The training of New Jersey emergency service first responders in autism awareness

This study investigated the extent and adequacy of training among New Jersey first responders (e.g. police, firefighters, emergency medical technicians) specifically as relates to a 2008 state law mandating that autism and hidden disability recognition and response training be conducted. The results show that a significant percentage of emergency service personnel have not completed the state mandated training. Recommendations for improving the training, such as by involving parents, advocates, and field and training personnel as a part of the training process, are discussed.     

Special report on patient care. The new federal patient-dumping regulations: some commonly asked questions and answers

Until both providers and government surveyors become more familiar with the new EMTALA regulations, there will be an uncomfortable period of adjustment, and perhaps some turmoil as well, particularly regarding the new requirement that facilities who receive suspicious transfers report those transfers to HCFA. Providers should carefully examine their internal policies on discharge and transfer of emergency patients to assure that those policies are consistent with the new regulations. Particular attention should be given to inservice training for medical and support personnel in the emergency department, because they must precisely comply with the law and their errors can subject the hospital to costly investigations and potential fines of $50,000 for each violation.     

Medical Ethics at Guantanamo Bay and Abu Ghraib: The Problem of Dual Loyalty

Although knowledge of torture and physical and psychological abuse was widespread at both the Guantanamo Bay detention facility and Abu Ghraib prison in Iraq, and known to medical personnel, there was no official report before the January 2004 Army investigation of military health personnel reporting abuse, degradation or signs of torture. Military medical personnel are placed in a position of a "dual loyalty" conflict. They have to balance the medical needs of their patients, who happen to be detainees, with their military duty to their employer. The United States military medical system failed to protect detainee's human rights, violated the basic principles of medical ethics and ignored the basic tenets of medical professionalism.     

海淀区托儿所幼儿园医疗资质现状及对策研究

海淀区大部分托儿所、幼儿园(以下简称托幼园所)按照卫生部,国家教委联合发布的《托儿所、幼儿园卫生保健管理办法》(以下简称《卫生保健管理办法》)和北京市人民政府文教办公室,北京市卫生局、北京市教育局制定的《北京市托儿所、幼儿园卫生保健管理实施细则》(以下简称《卫生保健管理实施细则》)成立了保健室并配备了儿童保健人员。同时,国家对于医疗机构开展诊疗活动和医疗卫生人员从事执业活动作出了严格的规定。通过对海淀区托幼园所保健机构和人员现状分析及对策的研究,为政府有关部门解决存在的问题提供依据。     

Anterior thoracic wall trauma in elderly homicide victims. The "CPR defense"

During the course of medicolegal postmortem examinations, forensic pathologists often encounter the sequelae of cardiopulmonary resuscitation (CPR) that was administered by medical and paramedical personnel. A wide variety of CPR-related injuries have been described since the institution nearly 30 years ago of this now common-place emergency technique. The forensic pathologist must be aware of both typical and unusual CPR-related trauma patterns in order to differentiate between injury produced during emergency therapy procedures and injury sustained through other mechanisms (for example, during an assault or an accident). This article describes two recent separate and unrelated incidents in which an elderly woman was murdered. In each instance, bony injuries of the anterior thoracic wall structures were identified during the autopsy. Defense attorneys in each case attempted to use these injuries as proof that their accused clients had performed external cardiac massage on their victims, thus indicating that the homicides had not been intentional, and that the perpetrators showed remorse. These cases are presented, with a discussion of the typical features of CPR-related thoracic wall trauma as compared with willfully inflicted injury.     

Acute effects of carbon monoxide and cyanide on hepatic mitochondrial function

The effects of carbon monoxide and cyanide on the hepatic redox state and energy charge were investigated. Rats were used for the experiment under pentobarbital anesthesia. Immediately after laparotomy, a rat was placed in an animal chamber made of a transparent plastic box and exposed to a test gas for 3 min. Every test gas was produced in a gas chamber connected to the animal chamber with a flexible tube. HCN was produced from NaCN and H2SO4. In the CO inhalation experiment, various amounts of CO were introduced into the gas chamber. Immediately after an exposure, about 2 g liver was frozen in situ with a precooled clamp. Oozed blood from the wound surface was sampled. Concentrations of ATP, ADP, AMP, acetoacetate, and beta-hydroxybutyrate in hepatic mitochondria were determined, and the redox state and the energy charge were calculated. For cyanide as well as CO, significant negative correlations were found between the concentration in the blood and the redox state. The same held true for the energy charge. The redox state showed a slight increase at low concentrations of both gases; however, thereafter it began to decrease sharply with increases in concentrations. When concentrations of the toxicant in the blood reached certain levels, a kind of turning point, beyond which the redox state does not decrease any more, was observed. It was about 40% for HbCO and about 2.0 micrograms/ml for cyanide, and the points seemed to be related to the concentrations, beyond which cells are irreversibly damaged. On the other hand, the energy charge did not change at low concentrations. With an increase in toxicant concentrations, the energy charge decreased drastically. The rate of decrease in the energy charge became higher when blood concentrations exceeded certain levels. It was about 40% for HbCO and 2.0 micrograms/ml for cyanide. The presence of low levels of blood cyanide did not affect the relationship between the energy charge and the HbCO concentration.     

Sudden and unexpected death from pituitary tumor apoplexy

Pituitary tumor apoplexy refers to a clinical syndrome precipitated by the expansion of a pituitary adenoma by hemorrhage or infarction. Individuals may present with myriad signs, including sudden onset of severe headache, visual changes, altered mental status, cranial nerve palsies, and hormonal dysfunction. This disorder constitutes a medical emergency and warrants an expedited evaluation, diagnosis, and treatment to prevent the potential sequelae of permanent visual loss, endocrine abnormalities, or death. We report a case of sudden death from undiagnosed pituitary tumor apoplexy. The decedent was evaluated by medical personnel on three occasions in the week prior to her death for severe headache, nausea, vomiting, and photophobia. Postmortem examination demonstrated a hemorrhagic infarction of a pituitary adenoma with necrosis and expansion out of the sella turcica. The recognition of and treatment for a patient with pituitary tumor apoplexy requires a rapid multidisciplinary effort. Failure of prompt diagnosis may be fatal and require a medico-legal death investigation for sudden and unexpected death.     

Toxicological findings in 889 fatally injured obese pilots involved in aviation accidents

Prevalence of drugs in fatally injured obese pilots involved in aviation accidents has not been evaluated. Therefore, toxicological findings in such pilots (body mass index ≥30 kg/m(2) ) were examined in a data set derived from the Civil Aerospace Medical Institute's (CAMI's) Scientific Information System for 1990-2005. Aeromedical histories of these aviators were retrieved from the CAMI medical certification and toxicology databases, and the cause/factors in the related accidents from the National Transportation Safety Board's database. In 311 of the 889 pilots, carbon monoxide, cyanide, ethanol, and drugs were found, and glucose and hemoglobin A(1c) were elevated. Of the 889 pilots, 107 had an obesity-related medical history. The health and/or medical condition(s) of, and/or the use of ethanol and/or drugs by, pilots were the cause/factors in 55 (18%) of the 311 accidents. Drugs found were primarily for treating obesity-related medical conditions such as depression, hypertension, and coronary heart disease.     

The court for sexual offences: perceptions of the professionals involved

This article evaluates the functioning of the Court for Sexual Offences in Bloemfontein, Free State, South Africa at the hand of the perceptions of those professionals most frequently involved with the Court. The findings suggest that professionals involved with this court tend to be positive in their appraisals of the sex-court system. However, the ability of the sex-court to remain objective and to reduce secondary victimization is called into question. Misconceptions with regard to the Court's current ability to contribute to the rehabilitation of offenders and the emotional recovery of the victims were exposed. The operational difficulties facing sex-court personnel are discussed and directions for future research are identified.     

The role of coronial autopsies in a context of decreasing hospital autopsies: an investigation of the issues

This article scrutinises the argument that decreasing hospital autopsy rates are outside the control of medical personnel, based as they are on families' unwillingness to consent to autopsy procedures, and that, as a consequence, the coronial autopsy is the appropriate alternative to the important medical and educational role of the autopsy It makes three points which are well supported by the research. First, that while hospital autopsy rates are decreasing, they have been doing so for more than 60 years, and issues beyond the simple notion of consent, like funding formulae in hospitals, increased technology and fear of litigation by doctors are all playing their part in this decline. Secondly, the issue of consent has as much to do with families not being approached as with families declining to give consent. This is well supported by recent changes in hospital policy and procedures which include senior medical personnel and detailed consent forms, both of which have been linked to rising consent rates in recent years. Finally, the perception that coronial autopsies are beyond familial consent has been challenged recently by legislative changes in both Australia and the United States of America which allow objections based on religion and culture to be heard by coroners. For these reasons, it is argued that medical personnel need to focus on increasing hospital autopsy rates, while also addressing the complex ethical issues associated with conducting medical research within the context of the coronial autopsy.     

Participation of children in clinical trials: UK, European and international legal perspectives on consent

The Declaration of Helsinki was, until recently, the leading international code on the conduct of clinical trials on human subjects. The Council of Europe's Convention on Human Rights and Biomedicine (1997) and the ICH guidelines for Good Clinical Practice (1996) represent a significant step towards increased harmonization of standards in the conduct of medical experiments on human subjects. But in spite of emerging areas of consensus, there remain important areas of unclarity and divergence. Medical practitioners involved in paediatric research in the UK are concerned about the lack of certainty in the law, particularly on the application of consent rules to emergency research. This paper examines UK, European and International norms on the participation of children in medical research and compares the circumstances under which consent rules may be waived under each normative regime.     

Cyanide ingestion. Case studies of four suicides.

Deliberate ingestion of cyanides is relatively rare, as reflected in the Registrar General's figures. There are no pathognomonic specific autopsy findings and even the distinctive smell may be missed by some individuals. We present four cases of cyanide ingestion, one of which appears to be the first reported case of magnesium cyanide poisoning in humans. The problems involved in investigating deaths from cyanide ingestion are discussed.     

A study on house fire victims: age, carboxyhemoglobin, hydrogen cyanide and hemolysis.

Correlation among age, concentrations of carboxyhemoglobin and hydrogen cyanide, oxygen density and hemolysis were studied in 120 house fire victims. Victims aged over 60 years comprised approximately 50% of the pooled subjects. Blood samples were mainly collected from the left ventricle, but sometimes from both the right and left ventricles. The concentration of carboxyhemoglobin ranged from 1-95%, of which 71 persons (59.7%) died with carboxyhemoglobin concentrations below 60%. Carboxyhemoglobin concentrations below 10% were found in 9 persons (7.5%). Most of these cases involved the elderly persons. In this paper, we report on the death of elderly victims as a result of low carboxyhemoglobin concentrations. A significant correlation of blood carboxyhemoglobin concentrations existed between the right and left ventricles. The concentration of carboxyhemoglobin in the left ventricle was significantly higher than that in the right. Two out of 31 victims whose hydrogen cyanide concentrations were determined, succumbed to hydrogen cyanide poisoning, having a high concentration of hydrogen cyanide and a low concentration of carboxyhemoglobin. On analysis, oxygen density was found to be low in 13 persons. A negative correlation was shown between carboxyhemoglobin concentration and hemolysis. Inasmuch as hemolysis may indicate the extent of heat dissociation, hemolysis should provide an index of carbon monoxide dissociation from carboxyhemoglobin. In the present study of victims, possible causes of death i.e., carbon monoxide gas poisoning, hydrogen cyanide poisoning, oxygen deprivation, burning, shock due to burns and others were estimated. The survival time for elderly victims was considered to be short.     

Lack of observable intoxication in humans with high plasma alcohol concentrations

Judging the degree of human alcohol intoxication is an important clinical, social, and medicolegal matter. Assessing the degree of intoxication is not always easy by direct patient observation. Observational instruments have been used in forensic science, medical, and social situations in an endeavor to measure alcohol intoxication. The validity of these observational instruments must be questioned. In this study, twenty-one patients with alcohol related complaints presenting to major city emergency departments were studied using one such observational instrument, the Alcohol Symptom Checklist (ASC). Three independent emergency medicine physicians applied the criteria of ASC to the twenty-one patients and obtained a plasma alcohol concentration (PAC) for correlation purposes. Individual correlation coefficients (r = 0.182, r = 0.202, r = 0.200) and a composite correlation coefficient (r = 0.235) demonstrated lack of correlation between PAC and ASC. This lack of correlation is supported by clinical observations of experienced emergency department personnel.     

Medicolegal death investigator workplace safety hazards: A scoping review of the literature

In the United States, medicolegal death investigation practices and policies pertaining to sudden unexpected deaths are mandated by state government. Practices vary across states, which contributes to inconsistency in job prerequisites and training. In preparation for a study focused on occupational safety and health of medicolegal death investigators in their on-scene and follow-up activities, a scoping review was conducted to document known occupational safety risks and health-related conditions associated with death investigation. Searches used Boolean and subject heading operators both broad and narrow in scope, and search terms included scene responder, hazard, investigator, forensic pathology, injury, and safety. Twenty-five articles met inclusion criteria, which included seventeen survey-mixed method designs, two systematic reviews, five quasi-experimental designs, and one case study. Twelve articles addressed mental health and eleven focused on risks associated with infectious disease. One article addressed the risk of chemical exposure from cyanide among autopsy personnel (including forensic pathologists) and nine included a wide range of employees within the setting of medical examiner or coroner offices. One article, addressing burnout, included employees in a forensic science laboratory setting as well as medicolegal death investigators and two articles included forensic pathologists and medicolegal death investigators. Only one article addressed medicolegal death investigators specifically. Articles addressing occupational and environmental hazards of medicolegal death investigators associated with musculoskeletal, respiratory, cardiovascular, radiological, nuclear, electrical, or explosive threats were not identified. There is little published about safety risks inherent in conducting death investigations. Research is needed to adequately inform health promotion and injury prevention strategies.     

The role of hydrogen cyanide and carbon monoxide in fire casualties: a prospective study

Determinations of blood cyanide and carboxyhemoglobin concentrations were performed in 18 victims found dead in buildings after fires during a 2-year period. The results indicated that 50% of the victims had been exposed to toxic levels of hydrogen cyanide and 90% to toxic levels of carbon monoxide. Lethal concentrations of carbon monoxide were found in 83% of the victims. In one case a lethal blood cyanide but a non-toxic blood carboxyhemoglobin value was found. It is concluded that carbon monoxide appears to be more important than hydrogen cyanide as a toxic agent in the fire atmosphere, but cyanide poisoning without carbon monoxide poisoning may, under certain circumstances, be the cause of death in fire victims.     

Penal harm medicine: state tort remedies for delaying and denying health care to prisoners

In prison and jail subcultures, custodial personnel are committed to the penal harm movement, which seeks to inflict pain on prisoners. Conversely, correctional medical personnel are sworn to the Hippocratic Oath and are committed to alleviating prisoners' suffering. The Hippocratic Oath is violated when correctional medical workers adopt penal harm mandates and inflict pain on prisoners. By analyzing lawsuits filed by prisoners under state tort law, this article shows how the penal harm movement co-opts some correctional medical employees into abandoning their treatment and healing mission, thus causing denial or delay of medical treatment to prisoners. This revised version was published online in July 2006 with corrections to the Cover Date.