The grant is to study whether patients with renal stones can be treated as effectively with ultrasound as radiation-delivering CT scans.

Rebecca Smith-Bindman, UC San Francisco

As concerns mount about unregulated radiation dosages from CT scans, Rebecca Smith-Bindman’s study will examine if ultrasound is a viable alternative for patients with renal stones.

Smith-Bindman, MD, a professor of radiology at UCSF, recently received a $9.2 million comparative effectiveness award through the federal economic stimulus package known as the American Recovery and Reinvestment Act (ARRA).

The ARRA grant is to study whether emergency room patients with renal stones can be treated as effectively with ultrasound as radiation-delivering CT scans. The grant follows Smith-Bindman’s research published last December that found radiation doses from common CT procedures vary widely and are higher than generally thought, raising concerns about increased risk for cancer.

That research reviewed procedures performed on 1,119 patients at four San Francisco Bay Area institutions over five months and found a 13-fold variation between the highest and lowest radiation dose for each type of CT procedure.

“Dose awareness has increased profoundly in the last six months, and at UCSF, we’re really making a concerted effort to try and reduce the doses associated with a large number of CT scan types,” said Smith-Bindman. “That’s resulted in improved safety by lowering the dose for the same study type. “

The grant is among more than 45 awards UCSF has received through ARRA that have been targeted towards understanding of what works – and doesn’t – in real-life hospital and clinic practice settings. Known as comparative effectiveness research, the projects involve multiple medical centers throughout the nation, assessing actual clinical practice and patient outcomes in areas ranging from prenatal testing and children’s oral health to treating stroke and traumatic brain injuries.

The grants are particularly significant in the ongoing debate over health care reform, with the increasing scrutiny on both the cost of health care and the quality provided. In that context, comparative effectiveness research – or identifying the best practices among different health care models in preventing, diagnosing, treating, and monitoring disease — has been touted as one possible solution to rising health care costs.

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C. Eric McCoy, Christy Carroll will serve two-year terms.

(Left) C. Eric McCoy and Christy Carroll, UC Irvine

A UC Irvine physician and nurse will join the Orange County Emergency Medical Services Quality Assurance Board, which monitors and studies how to enhance the level of care provided by the county’s EMS system.

Dr. C. Eric McCoy, assistant clinical professor of emergency medicine, and Christy Carroll, trauma injury prevention coordinator, were among eight people recently appointed to two-year terms by county supervisors.

“The EMS Quality Assurance Board is extremely important to the operation of the county’s emergency medical system,” said Laurent Repass, EMS coordinator for the agency. “It takes a specialized group of people to help evaluate and recommend ways to improve our system and better serve the county.”

Orange County EMS oversees pre-hospital and emergency medical care administered by ambulances, emergency medical technicians, paramedics and hospital emergency departments.

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A wound that fails to heal is a serious health issue. Complications range from ongoing pain to severe infection or even amputation. UC San Diego Health System’s Department of Emergency Medicine is expanding treatment options in the San Diego region by opening a new Hyperbaric Medicine and Wound Healing Center in Encinitas.

“The field of hyperbaric medicine is on a sharp incline in terms of both its clinical use and awareness among members of the medical community,” said Caesar Anderson, MD, director of UCSD’s Hyperbaric Medicine and Wound Healing Center, Encinitas.  “Practicing competent wound care does not mean treating a wound in isolation; it means keeping the complete patient in mind.”

The UCSD Hyperbaric Medicine and Wound Healing Center, located at 477 N. El Camino Real, Ste. D-204, Encinitas, specializes in the treatment of difficult-to-heal wounds, including those resulting from an operation, radiation exposure, diabetes, bone infection, or trauma. The all-inclusive center provides all the necessary services, including expert evaluation, individual therapy plans and support tailored for each patient.

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Hospital emergency departments need to be better adapted to the needs of terminally ill patients who are increasingly seeking palliative care in the emergency room, according to a study led by a physician at the San Francisco VA Medical Center.

“At first blush, palliative care in the emergency department sounds like a contradiction in terms,” says lead author Alexander Smith, MD, MS, MPH, a palliative medicine physician at SFVAMC and an assistant professor of medicine in the Division of Geriatrics at the University of California, San Francisco. “Palliative care seeks to treat symptoms and bring comfort to patients. In the emergency room, the goals are patient stabilization and disposition – either admission to the hospital or release back into the community.”

Smith notes that other studies have shown that emergency departments have become “common sites of care at the end of life,” yet emergency room crowding has increased severely over the past 20 to 30 years. “Waiting times to see an emergency department physician have increased over that time as well, which has left many patients frustrated, uncertain, waiting, and in pain.”

The study authors observe that in spite of mounting interest in improving palliative care in emergency departments, little research has been done in this area.

Smith says the goal of the study, which appears in the June 2010 issue of the Journal of Pain and Symptom Management, was to “understand more about the experience of patients with very serious illness who were seen in the emergency department.”

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In a perspective published online June 30 in the New England Journal of Medicine, Garen Wintemute, UC Davis Violence Prevention Research Program director, urges Congress to pursue making all private-party gun sales subject to the same screening and record-keeping requirements that apply to sales by licensed gun retailers.

Wintemute, a professor of emergency medicine in the UC Davis School of Medicine, said the approach would be more effective and have more support than requiring criminal background checks of private-party sales at gun shows.

“Gun owners gave stronger support to this all-inclusive approach than to a gun-show-only proposal in a 2009 poll conducted for the advocacy organization Mayors Against Illegal Guns,” Wintemute said.

Since such a requirement would be more effective, and either approach would face “tough sledding” on Capitol Hill, moving forward with the one most likely to reduce rates of firearm-related violence is the preferable course.

In 2007, 12,632 people in the United States were murdered with firearms, and an estimated 48,676 were treated in hospitals for gunshot wounds received in assaults. Eighty-five percent of all guns used in crimes have been sold at least once by private parties, the commentary relates.

Wintemute describes two systems of legal retail gun commerce in the United States. In one, sales by federally licensed gun retailers require purchasers to show identification and certify that they do not fall into any categories barred from purchasing firearms, including felons, controlled-substances addicts or domestic-violence offenders. A criminal background check is conducted and the retailer must keep a permanent record of the purchase. In the other, none of those safeguards apply. You can legally buy as many guns as you want from a private party with no identification, background check or record-keeping. The sale can remain anonymous and undocumented, despite the fact that perhaps 40 percent of all gun sales nationwide are made by private parties. Moreover, private parties can sell handguns to persons as young as 18 years of age. Licensed retailers cannot sell handguns to anyone under 21.

“The private-party gun market, sometimes called the informal gun market, has long been recognized as a leading source of guns used in crimes,” Wintemute says in the perspective. “Such sales are the principal option when the prospective purchaser is a felon, a domestic-violence offender, or another person prohibited by law from owning a gun.”

Gun shows are the “big-box retailers” of gun commerce, where both systems of gun sales exists side-by-side. But they account for only a small percentage of gun sales in the U.S. — between 4 and 9 percent — and only 3 to 8 percent of private-party sales. Six states, including California, already make private-party gun sales subject to the same requirements as sales by licensed retailers. The screening works, Wintemute said.

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UC Irvine doctors Kristi L. Koenig and Carl H. Schultz are not just world-renowned experts in disaster medicine. They have, quite literally, written the book on the subject.

Published last fall by Cambridge University Press in association with the American College of Emergency Physicians, Koenig & Schultz’s Disaster Medicine: Comprehensive Principles & Practices is intended for anyone who manages or trains people involved in disaster response, including public health officials, paramedics, hospital staff and medical school students.

“Emergency responses to Hurricane Katrina and recent earthquakes in Haiti and Chile emphasize the need for expertise in disaster management,” says Koenig , UCI’s director of public health preparedness. “It’s an emerging science, and up until now, there have been no comprehensive texts on it.”

Their book is being well received. “This mix of operational, academic and governmental influences results in chapters that are incredibly detailed and fresh, with current developments in this field,” writes Dr. Scott R. Lillibridge, executive director of Texas A&M’s National Center for Emergency Medical Preparedness & Response.

The publication comes amid debate over the way medical care is delivered during disasters. Prompted by the recent H1N1 scare, the prospect of a catastrophic earthquake in California, and this month’s attempted car bombing in New York’s Times Square, caregivers, ethicists and local, state and national public health officials are re-examining emergency response systems.

“The big issue is how to allocate scarce resources,” says Koenig. “In a truly catastrophic event, we won’t have the resources to save everyone, so we need policies and procedures governing crisis care that will maximize benefit to the affected population.”

This requires a shift in attitude and an agreement on basic terminology. “Crisis standard of care” – the phrase adopted by the federal Institute of Medicine – was coined by Koenig, Schultz and their colleague Dr. Tareg A. Bey to describe emergency guidelines when resources are scarce.

“The usual standard of care is based on doing everything possible for the individual,” says Schultz , UCI’s director of disaster medical services. “But what’s the standard during a widespread disaster?”

He and Koenig want to see a uniform approach to resource management under such circumstances. They believe, for example, that after an earthquake, all Orange County hospitals should offer similarly injured patients the same treatment.

“Problems occur when you leave it up to each site to determine how to ration its resources,” Schultz says. Discussion of this issue will continue within the public health community until a consensus emerges.

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Hurricane Katrina. The Southeast Asian tsunami. Now the killer earthquake in Haiti, which has claimed upwards of 50,000 lives. In each case, the response to a natural disaster has been further complicated by the difficulty delivering medical care in a chaotic environment where the communications infrastructure on the ground is seriously damaged or completely destroyed.

To address that problem, researchers at UC San Diego have launched a project to find better ways for emergency officials and first responders to talk to each other and share data on the ground at the scene of a natural or man-made disaster — even when the local communications infrastructure is out of commission.

Approximately $1.5 million annually over two years in “stimulus” funding under the American Recovery and Reinvestment Act (ARRA) from the National Library of Medicine (NLM) will underwrite the WIISARD SAGE project. NLM is one of the National Institutes of Health (NIH).

The new project picks up where the original Wireless Internet Information System for Medical Response in Disasters (WIISARD) left off. That four-year project (2004-08) developed a testbed consisting of devices and software for use by first responders and command center personnel dealing with triage and other medical decisions after a disaster.

Building on the WIISARD testbed, the new project (SAGE stands for “Self-scaling Architecture for Group and Enterprise Computing”) will explore group or collaborative computing in mobile environments, as well as self-scaling systems for disaster management (no matter how many personnel and agencies respond to a disaster).

The new project brings together an interdisciplinary team of faculty — most of whom also worked on the original WIISARD — from computer science, cognitive science, electrical engineering and emergency medicine in the UC San Diego division of the California Institute for Telecommunications and Information Technology (Calit2).

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A substantial percentage of children who get CT scans after apparently minor head trauma do not need them, and as a result are put at increased risk of cancer due to radiation exposure. After analyzing more than 42,000 children with head trauma, a national research team led by two UC Davis emergency department physicians has developed guidelines for doctors who care for children with head trauma aimed at reducing those risks.

Their findings appear in an article published online in the journal The Lancet.

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