Life-saving Techniques Research Articles

Reflections and Visions: 50 Years of Presidential Addresses

Reflections and Visions: 50 Years of Presidential Addresses

Primary Percutaneous Coronary Intervention Without Nearby Surgical Capability: A Reassuring Response From Rural America

Primary Percutaneous Coronary Intervention Without Nearby Surgical Capability: A Reassuring Response From Rural America

Out-of-hospital cardiac arrest and survival: an epidemiological analysis of emergency service reports in a large city in Japan.

The factors that influence survival of out-of-hospital cardiac arrest in Japan have not been fully investigated. The official emergency service record was used to investigate 1,600 patients for whom cardiopulmonary resuscitation was attempted by the city's emergency personnel. Only 45 (2.8%) patients survived for 1 month. The survival rate was 9.8% in the patients under 20 years of age, with a marked decreasing trend to 0.8% in the patients aged 80 years or older. The rate peaked at 4.8% on Sunday and bottomed out at 0.5% on Thursday, forming a distinct sine curve. The survival rate was 9.9% when an ambulance arrived at the scene within 4 min, with a steep drop to 2.5% when 4-7 min elapsed. However, the rate was not significantly different by the interval to hospital. Although bystander resuscitation did not significantly affect the survival, paramedics on board significantly improved the rate (3.5% vs 1.6%). Multivariate analysis confirmed that age, day of the week, place, interval to ambulance's arrival, and personnel on board were independently associated with the probability of survival. Quick arrival of a paramedic team would improve the survival after out-of-hospital cardiac arrest. General education of lifesaving techniques would be another key factor.

Combat Medicine: A Model for Civilian Mass Casualty Managment?

Casualty management is vital in combat. Prior to World War I, the wounded soldier's outlook for survival was dismal. However, technological advances of the twentieth-century introduced combat medics, triage, and improved medicines to the front lines, as well as, paramedics, 9-1-1 response, and state and local emergency centers on the home front, reducing pain and saving lives. Emerging technology promises to bring further life-saving techniques to the future battlefield and civilian disasters. With the advent of digital networks and sophisticated information technology, the ability to assist the wounded and evacuate casualties from the combat zone and city emergency areas promises tremendous improvements in casualty management and subsequent patient survival. This paper provides a brief review of the evolution of battlefield medicine and extrapolates how combining applied human factors with emergent digital technology could enhance battlefield and disaster casualty management.

Methods of Medical Treatment Within Australian and United Kingdom Patents Law

The accommodation of methods of medical treatment within Australian and United Kingdom ('UK') patents law has been controversial since the first patent applications in respect of such methods were filed in the early 20th century. For the last 30 years that controversy has been accepted as having a moral basis, the issue being whether the public interest in encouraging research and innovation in the medical arena through the provision of patent-related incentives for creators of new and useful therapeutic methods on the one hand is outweighed, on the other, by the various public policy objections to permitting the monopolisation of such methods. Those objections include fears that the monopolisation of medical methods would: (a)hinder medical research by restricting the free availability of knowledge; (b) be inconsistent with the teaching of medical students and practitioners; (c)expose medical practitioners and patients who use and accept the use of a patented method without a licence to liability for patent infringement; and (d)enable patentees to exact unreasonable payments for life-saving or potentially life-saving techniques. The controversy regarding the patentability of methods of medical treatment has not always been understood as an ethical one. Prior to 1971 the inherent patentability of methods of medical treatment was expressly regarded by both Australian and UK decision makers as turning on the essentially black letter law question of the nature of an 'invention', a question that only arose in those jurisdictions after the introduction of modern patents legislation. Reconception of the issue from 1971 in moral terms can be attributed to a number of possible causes, including the recovery by decision makers from the initial shock caused by the prospect of allowing patents for potentially life-saving treatment, and the general increase in community (and judicial) interest in the morality of science and its implications for patents law. However, it can also be viewed as a recognition by the judiciary of the questions that have always laid at the heart of the issue concerning methods of medical treatment and patents law namely, whether methods of medical treatment should be patentable and, as a precursor to that question, to what extent (if any) legal constructions of the term 'invention' and patent eligibility generally can legitimately and openly accommodate ethical and other public policy considerations. There is a great deal of literature concerning the specific public policy arguments for and against the patenting of methods of medical treatment, and it is not the purpose of this article to review such arguments nor to argue for their resolution along particular lines. Rather, the purpose of the article is to consider by historical analysis the relationship between decision makers' responses to medical method patents and their conceptions of inherent patentability generally. The thesis advanced in the course of such consideration can be summarised as follows. First, for the last 100 years much of the important jurisprudence relating to inherent patentability in the UK and Australia has derived from cases involving methods of medical treatment. Secondly, those cases are distinguished by the failure of decision makers to resolve convincingly or consistently: (a) the basis for the exclusion from patentability of methods of medical treatment; and (b) the extent (if any) to which legal constructions of inherent patentability can legitimately accommodate ethical and other (non-commercial) public policy considerations. And thirdly, this failure is largely responsible for the unduly restrictive legal principles that governed inherent patentability in Australia and the UK until 1959 and methods of medical treatment until the 1970s. It is also responsible for the ongoing uncertainty on the part of Australian decision makers concerning the relevance of morality and public policy generally to inherent patentability. Central to this thesis are the issues noted above concerning what an 'invention' is and whether patents law, in its various 20th century guises, permits decision makers to consider moral issues when determining a subject matter's prima facie eligibility for patent protection. At a time of increasing public and legal debate regarding both the ability of certain new technologies to be treated as inventions and the moral implications of such treatment, an historical account of the development of decision makers' responses to these issues has never been more important. That account serves, among other things, as a reminder of the potential consequences for law of dressing public policy decisions in black letter principle, or of otherwise assuming inherent (un)patentability without proper consideration of the foundations for that assumption.

Pulmonary Infections in Ventilated Patients: Diagnostic and Therapeutic Options.

The diagnosis of pulmonary infections in the ventilated patient has threatened the foundations of medicine. Although the lifesaving techniques of endotracheal intubation (developed for the treatment of diphtheria) and artificial ventilation (developed for the management of poliomyelitis) contribute greatly to medical care, they have resulted in the production of the "progress"-related infection of ventilator-associated pneumonia (VAP). Modern ventilator therapy is a substantial technologic advance from earlier days and, as technology inherently does, has removed some of the human element, the main foundation of Oslerian medical practice. The time-honored clinical diagnosis based on physical examination by an experienced physician has been seriously compromised in the approach to VAP.

Cultivating Conscience: Learning to Make End-of-Life Decisions in the Emergency Department

Cultivating Conscience: Learning to Make End-of-Life Decisions in the Emergency Department

M. K. Bennett on Population and Food Supply

Post-World War II debate about the Malthusian race between population and food supply was elucidated in a 1949 article by an eminent agricultural economist. The deductions presented have been largely justified in the ensuring 40 years despite the assumption that global population would be 3.3 billion in the year 2000 a mark which was exceeded in 1965. Although global food production has exceeded this growth a wide difference in adequacy remains in per capita diets especially in countries that are unlikely to expand domestic food production. In 1948 academic and public officials were issued warnings about future global food shortages. Already the post=war baby boom was being felt and was outstripping population losses associated with war casualties. Conservationists of the day also recognized the effects of erosion and desertification resulting from mistreatment of the soil. Calls were made to improve diets through the consumption of more animal products even though it was recognized that such a move would place extra strains on resources. Another new idea was that fostering international use of lifesaving techniques would only condemn those saved to a life of misery. While these ideas were supremely pessimistic they were also vague and nonspecific. A review of the history of global food supplies or intake in the preceding 50 years when population increased by 750 million was made taking into account the average per capita intake of total calories and the proportion gleaned from grains and potatoes. A consideration was then given of what was preventing more food and more varied food from being produced and distributed to those who needed it. The current theory was that any acre of land has a maximum theoretical (economic) productivity dictated by the current state of technology which may or may not be presently achieved and will probably be increased as technological advances are made. The gap between agricultural practice and agricultural potential was mimicked by the gap between food harvested and food eaten which was caused by losses in storage and transportation. In conclusion the possibility of one of the direst calamities the reduction in per capita ingestion of animal products among the white races was conceded as was the possibility of mass starvation. However the possibility of permanent world wide hunger (with everyone hungry at once) within the foreseeable future was denied. If such a situation would occur it was thought that it would be caused by forces greater than overpopulation and soil degradation alone.

Give Industrial Policy a Second Chance

GIVE INDUSTRIAL POLICY A SECOND CHANCE Lee Price he American economy is facing its trade problems like a big family that is used to a swimming pool but has gone to the beach for a couple ofweeks and finds a rough surf. The service boys and girls are enjoying the sun, the sand, and watching the waves. The manufacturing boys and girls are great pool swimmers who have fun only in the water. But in the ocean many of them are struggling for air. They don't understand why, and want to go home to the pool. One manufacturing boy after another has to be rescued from the surf, yet no one else is disturbed. Those who know the number of rescues and how the expense is cutting into everyone's vacation budget are keeping it quiet. The family would be more likely to profit from its vacation if it examined how certain of its children got into trouble and why they had to be rescued, gave all the children lessons in surf swimming, learned some lifesaving techniques, and adopted new rules that were unnecessary back at the swimming pool. The boast that U.S. manufacturers could take on all challengers in international competition has been part of the American self-image since World War II. The rare industry that fell into dire straits was the victim of unfair foreign competition or overpaid and underactive labor and management . But given a level playing field, hard-working and properly paid American management and labor could handle any foreign competition. In fact, as discussed below, American manufacturers—even the best-managed high-technology industries with below-average pay Lee Price is an economist for the subcommittee on Economic Stabilization of the House Committee on Banking, Finance, and Urban Affairs. The views expressed are the author's alone. 39 40 SAIS REVIEW scales—face mounting difficulties competing in the world economy. As the United States adapts to cope with this new environment, a new and more activist framework for trade policy in manufacturing is taking shape. The federal government increasingly aids troubled American manufacturers in difficulty by providing them with import restraint, export assistance, tax relief, regulatory lenience, government purchases, and direct subsidies. Although the government's decision to assist an industry hinges on the industry's economic conditions (macro- or firmspecific ) and political clout, the rationale stated for public consumption is almost always the need to counter foreign unfairness. Consonant with the country's outdated self-image, American officialdom propagates the myth that the government assists specific industries only to offset foreign unfairness. This "unfairness only" myth persists because it serves the interests of the heads of corporations and the government . The corporations find they can obtain unconditional assistance with trade problems by invoking the bogeyman of foreign unfairness. The government, for its part, finds the doctrine ofunfairness a useful diplomatic figleaf for its inability to force adjustment on industries with political clout. At the moment Americans seem preoccupied with finding external actors and circumstances to blame for the nation's trade deficits. Before proceeding, we should situate our argument within the long-running debate over trade and industrial policy. The debate too often seems to pit against each other two sets of mythmakers: those who castigate or praise clever foreigners in defense ofindustrial policy, versus those who pretend the United States has a free market that is working fine. In fact, the United States has little prospect of either changing foreigners or emulating them—nor would it help us substantially if we could. The U.S. government is heavily involved in assisting specific industries but is doing a poor job. Industrial assistance will intensify in coming years but would have greater success with the political participation and support of the American public. The unfairness doctrine in trade policy fits neatly with the prevailing governmental philosophy that counsels against sector-specific intervention in the economy. In this view, government should emphasize economy-wide incentives to encourage industries to invest, research and develop new technology, and pursue export markets. In the recent debate over the Reagan administration's trade policy both sides seem comfortable with the unfairness doctrine. Until recently the administration belittled...

Advances in clinical management of acute myocardial infarction in the past 25 years

The management of acute myocardial infarction in the past 25 years has emerged from a state of masterful inactivity to one of intensive care based on a new discipline of aggressive management. This has increased the chances of survival of the victim of infarction and cquld well be one of the major reasons for the decline in mortality due to coronary heart disease in the United States since 1968. Because resuscitative techniques must be instituted within 4 minutes after the onset of cardiac arrest, the attendant nurse had to learn (he new emergency lifesaving techniques and assume a crucial role as a physician's assistant. The various stages in the evolution of coronary care discipline began with cardiopulmonary resuscitation and were followed by pacemaker application, arrhythmia prophylaxis and insertion of pulmonary venous flow-directed catheters and arterial lines that permit monitoring and control of ventricular filling pressures. Other developments in better management of the failing heart have included methods to salvage jeopardized myocardium, strategies for the prevention of sudden death, the application of revascularization techniques after acute coronary occlusion and new noninvasive computerized technology to provide enhanced contrast images of cardiac perfusion that can be directly integrated with measurement of function.

Training in Advanced Trauma Life Support

The lack of a standardized method for the initial assessment of the trauma patient's condition and the skills to perform emergency lifesaving surgical techniques in rural Nebraska has led to the development of an Advanced Trauma Life Support (ATLS) course. There has been a direct correlation between the presentation of the course in several rural areas of Nebraska and the improved quality of trauma care apparent when the patients arrive at a definitive care hospital. The national development of a standardized ATLS course will improve the survival of trauma patients as has been experienced with the Advanced Cardiac Life Support course and cardiac patients.

A free clinic approach to drug abuse

The Haight-Ashbury Free Medical Clinic was founded in 1967 as a social statement of community need by the particular population of disenfranchised young people who flocked to the Haight-Ashbury district of San Francisco. Since that time we have responded to this need and have provided comprehensive drug abuse prevention and detoxification programs as well as a wide spectrum of health and psychosocial care unavailable through conventional public health facilities of the City. Fundamental to our delivery of care is the basic philosophy of nonpunitive, nonjudgmental free medical and psychosocial care to all who apply. Specifically, the HAFMC provides counseling and drug detoxification facilities, including a 24-hour resuscitation squad and intensive psychological services. Our personnel are widely recognized for their professional knowledge and street expertise in their effectiveness in dealing with the addicted individual. In this study the epidemiology, sociology, and pharmacology of the various commonly encountered drugs are described, as well as some specific and oft times life-saving techniques.

Comprehensive regional approach to the chronic renal failure problem.

COMPREHENSIVE REGIONAL APPROACH TO THE CHRONIC RENAL FAILURE PROBLEM FRED L. SHAPIRO, M.D.* Introduction Although chronicintermittenthemodialysis and renalhomotransplantation have been effective forms oftreatment for several years, most patients with end-stage renal disease are allowed to die without the opportunity of receiving either ofthese treatments. An even more distressing fact is that most patients with advanced chronic renal failure are not even given the benefit ofa trial ofappropriate medical management prior to their death. This includes the use ofthe newer renal diets, proper control offluid and electrolyte balance, appropriate blood-pressure regulation, treatment of infection and control ofcongestive heart failure. Whenthe individualwith end-stage renaldisease canno longer be maintained by conservative management, hemodialysis and renal transplantation offer him another chance of life—an opportunity to regain a near normal state ofhealth and activity. Both treatments are complicated and require specializedknowledge, training, and facilities. Theyare demanding of the medical staff and are very extravagant with personnel time and money. Dialysis and transplantation patients may develop medical problems and complications which are seldom "routine" and usually require extensive study and investigation to define the problem before appropriate treatment can be instituted. Nevertheless, the favorable clinical results achieved so far with hemodialysis and transplantation are convincing support for the wider application of these lifesaving techniques. In this paper various aspects ofchronic hemodialysis, particularly pertaining to the many problems encountered in applying the treatment and thesolutionswhichwehavefoundtobeacceptable to afew ofthemultiple dilemmas and problems, will be discussed. * Department of Internal Medicine, Hennepin County General Hospital, Fifth and Portland South, Minneapolis, Minnesota 55415. 597 NEED FOR TREATMENT Reliable statistics are not available, but it is estimated that between 35,000 and 55,000 patients die of chronic renal failure each year in the United States. Accurate vital statistics are available in Sweden where the incidence is about fifty-five people per million population per year dying of renal failure. Various reports estimate that from 20 to 50 percent of patients dying of chronic renal failure would significantly benefit from treatment with renal transplantation or dialysis. The potential patient load is dependent upon numerous factors, including available facilities, personnel , money, education both ofthe lay public and physicians, the selection criteria utilized, and where the patients live. In reality, most patients with end-stage renal disease could benefit to some extent from dialytic therapy iffacilities, personnel, and money were available. In 1969 approximately 3,000 patients in the United States were being treated by hemodialysis after ten years ofexperience with this treatment. A similar number of patients have received transplants over the past six years, so that there still remains considerable disparity between need and applied therapy. The reasons for the appallingly slow rate ofapplication of this lifesaving technique include insufficient numbers offacilities, lack of trained personnel, and most important, the lack offinancial support. Another major factor is a reluctance on the part of many nephrologists to devote the necessary time and effort to dialysis-related activities and associated problems. These physiciansjustifiably prefer to spend more time practicing clinical nephrology, teaching, and performing research. Our Program In an attempt to find a more tolerable answer to the marked disparity between need for treatment and available facilities, we have developed a regional program during the past three years designed to provide treatment for patients dying ofkidney failure. The program utilizes conservative medical management for as long as is reasonable. When medical management can no longer maintain the patient, then dialysis or a kidney transplant is made available. Our chronic dialysis program is unique in that dialysis treatments are performed in several different locations, including the parent center at Hennepin County General Hospital (HCGH), the patient's own home, in small satellite units in private hospitals throughout the region [1] and in a recently opened large twenty-bed chronic dialysis 598 nem Fred L. Shapiro · Chronic Renal Failure Proble, Perspectives in Biology and Medicine · Summer 1970 facility located in a small rehabilitation hospital one mile from the parent center [2]. This facility will be referred to as the MRU (Metropolitan Rehabilitation Unit). These several methods ofproviding dialysis are integrated with each other and also serve as maintenance and back-up facilities for a renal homotransplantation program. The parent center located...

The Emergency Medical Care System

Medicine's lifesaving techniques and the system organized to deliver them are in sharp contrast. Progress in medicine's lifesaving techniques is dramatic. Today there are cardiac monitors and pacemakers, exquisite surgical techniques, drugs of great potency, institutions splendidly equipped and superbly staffed. These are available for many. Emergency medical systems in most cities and nearly all rural areas, however, do not often enough bring the patient at the right time to the right place; nor is there assurance the patient will get the proper treatment by the proper professional. Progress in this system is not dramatic. An emergency need exists in a patient's mind until he is convinced by a health professional that his life or well-being or that of a loved one is not threatened. When an emergency exists, professional decisions are required to determine the time, the type, the amount and the place of treatment. The child with a

Life Saving vs Population Explosion

To the Editor:— A magazine recently published a cartoon showing a lifeguard being rebuked for suggesting that drowning might be an acceptable solution for the population problem. Apparently the extreme competition for resources that will eventually follow exponential population growth has produced the paradox that life-saving techniques offer a threat to humanity. A paradox implies a fallacy. Perhaps the fallacy in this instance is the popular assumption that a lifeguard works for humanity when in fact he works for the individual swimmer. This swimmer and his descendants will consume resources that could be used to maintain the well-being of other individuals. Thus the lifeguard has aided the swimmer in competition against the rest of humanity. Normally the lifeguard will continue to work for the swimmer for he knows that ultimately he is working for himself. If a physician insists on working for the good of all living humanity he might