SPECIAL OFFER: - Limited Time Only!
(The ad below will not display on your printed page)
What kills a greater number of people in America than cancer or strokes? It's sudden cardiac arrest (SCA), when the heart abruptly stops beating and blood stops circulating through the body. Each year an estimated 310,000 Americans die from SCA, both in and out of hospitals.
Cardiopulmonary resuscitation (CPR), which consists of chest compressions and mouth-to-mouth breathing, can save lives if it's done in time, but the scary truth is that most people have no idea how to perform it or how to use the defibrillators, available in many public places, that can stop an abnormal heart rhythm and restore a normal one. Even more alarming, many EMS workers and healthcare providers may not perform CPR or defibrillation correctly. "Resuscitating someone in cardiac arrest is among the most stressful situations in healthcare," says Benjamin S. Abella, MD, MPhil, clinical research director of the Center for Resuscitation Science at the University of Pennsylvania School of Medicine. "It requires people to perform well under pressure without any warning or preparation." But ever since he was a resident, Dr. Abella was struck by how "disorganized and frantic" the process was. "It felt like we were reinventing the wheel every time." Now 38 and the father of three young children, he's playing a pivotal role in changing that picture by developing new recommendations for better CPR training and new technology to improve lifesaving care.
Over the past four years, to help hospital and EMS workers improve their skills, Dr. Abella helped develop and test a manual defibrillator known as the MRX Q-CPR that records various components of CPR, such as the depth and rate of chest compressions -- as a healthcare provider performs it -- and then provides a postcrisis assessment of how he or she did. "CPR has been around for over 50 years," Dr. Abella says. "Yet there have been no serious at attempts to evaluate performance or delivery of care during actual resuscitation until the last decade."
Now Dr. Abella's research has proved that feedback makes a notable difference. In his study, published in the May 26, 2008, issue of Archives of Internal Medicine, resident-level doctors who used the manual defibrillator on 123 patients were debriefed on the data the device had recorded. Analyzing what they'd done incorrectly let them improve their delivery of ventilation and chest compressions. Patients resuscitated after the debriefing had a more rapid return of heart rhythm, pulse, and measurable blood pressure than those treated earlier in the study.
"Dr. Abella has been a pioneer in measuring and recording CPR quality for in-hospital cardiac arrest," says Dana Peres Edelson, MD, director of clinical research in the emergency resuscitation center at the University of Chicago Medical Center, who has worked on several of his studies. "He truly is a visionary. He has opened our eyes to what we suspected: Because we are trained to perform CPR we thought we do it well, and that's just not the case."
Dr. Abella has also worked to improve how CPR is delivered before rescue crews arrive, when only 15 to 30 percent of victims receive it, probably because bystanders don't know what to do and don't realize how important prompt delivery of CPR can be. Since 2005 Dr. Abella has served on a team that revised the American Heart Association's CPR guidelines for laypeople and 911 dispatchers by emphasizing the need for chest compressions and reducing the emphasis on rescue breaths. He also helped develop a new defibrillator device that has voice prompts allowing good Samaritans to assess whether the person needing attention can benefit from a shock and leading rescuers through the steps of both defibrillation (if needed) and CPR. "He is doing incredible work," says Robert O'Connor, MD, chairman of emergency medicine at the University of Virginia in Charlottesville. "His efforts have the potential to save many lives."
For himself, Dr. Abella is optimistic that "with better CPR and more prompt defibrillation delivery, we can save more lives." The new tools he has pioneered are already making a difference.
Most of us know the reading that indicates an adult has high blood pressure: anything greater than 140/90. But until recently even doctors haven't given much thought to high blood pressure in children. When they have, it's complicated by age, gender, and height. A score considered normal for one 7- or 11-year-old may be considered high in another. Doctors have reference tables to consult, but wading through them can prove cumbersome. Diagnosis is further complicated because three abnormal readings over three doctor's visits are needed for a diagnosis, during which time a child will get older and height may have changed.
David C. Kaelber, MD, PhD, an internist and pediatrician at MetroHealth System, in Cleveland, has figured out how to get around these problems and has identified, for the first time, that high blood pressure is an undiagnosed chronic disease in children. According to his findings, published last August in the Journal of the American Medical Association, as many as 1.5 million American children may have undetected hypertension, a disorder in itself that can also be a sign of illnesses such as kidney or heart disease.
His new diagnostic tool is a computer software program, similar versions of which may soon be available to doctors treating kids everywhere. Using MetroHealth's electronic medical records (EMR) database, Dr. Kaelber's program evaluates a child's blood pressure reading, factors in gender, age, and height, and quickly determines whether it is normal or not. Dr. Kaelber discovered the high rate of undiagnosed high blood pressure by evaluating the 14,000 children whose records were already in MetroHealth's EMR database and extrapolating it.
This fall the American Academy of Pediatrics' (AAP) Information Technology Council will sponsor an EMR documentation challenge. Identifying elevated blood pressure will be one of the required tasks for EMR vendors who participate. Council members believe Dr. Kaelber's study helped demonstrate how available EMRs can be -- and helped raise awareness of hypertension as a significant health problem among children.
The idea for the study occurred to Dr. Kaelber, 39 and the father of a young daughter, in 2005, when as a medical director for a pediatric weight-management program he often had to tell parents that their child was hypertensive. "Usually parents would say, 'I didn't even know children could have high blood pressure,'" he recalls. "Then their reaction would quickly change to: 'Wait a minute. How come you're the first to tell me my child has hypertension?'"
"It is an extraordinarily important study," says pediatrician Eugenia Marcus, MD, of Pediatric Health Care at Newton Wellesley, in Massachusetts, and vice-chair of the Council on Clinical Information Technology of the AAP. "It can help doctors better recognize abnormalities and intervene before they develop into major disease." Following Dr. Kaelber's discovery the Certification Commission for Health Information Technology (CCHIT), which writes EMR standards, will require the ability to analyze a child's blood pressure for CCHIT certification starting this month, adds Dr. Marcus, who serves on the group's child-health panel.
Post-traumatic stress disorder (PTSD) can be life altering. Triggered by a traumatic event -- living through a natural disaster like Hurricane Katrina, experiencing military combat, or enduring sexual assault -- PTSD plagues half its sufferers for life, leaving them emotionally numb, subject to insomnia, nightmares, and flashbacks, and unable to face reminders of their trauma.
Though both men and women are at risk for PTSD, women are twice as likely to develop it, a fact that long predates the current conflicts in the Middle East but has become more urgent because of them. There are now more than 1.7 million women veterans, 177,000 of whom have served in Iraq or Afghanistan since September 2001. But while PTSD treatments had been evaluated in studies on male veterans, no one had done large-scale definitive research on the most effective PTSD treatment for female veterans and active-duty personnel.
Then, in February 2007, Paula P. Schnurr, PhD, deputy executive director of the National Center for PTSD for the Department of Veterans Affairs (VA), in White River Junction, Vermont, published groundbreaking research in the Journal of the American Medical Association. She and her team studied 284 veteran and active-duty women and found that PTSD symptoms were twice as likely to decrease dramatically in those treated with prolonged exposure therapy than in those women who received the other main treatment, present-centered therapy (PCT), which focuses on a patient's current problems. In prolonged exposure therapy, the patient repeatedly recounts the traumatic event until her emotional response eases. By contrast, PCT focuses on coping with issues that may be caused by PTSD.
Even more remarkable: Some women who benefited from the exposure therapy had been experiencing PTSD for more than 20 years. "With just 10 weekly 90-minute sessions, we improved their symptoms," says Dr. Schnurr, 52, who has two grown daughters. "It was a joy and a relief to have really good evidence that this treatment could make a difference."
Dr. Schnurr's findings drove the VA to support a national training program in prolonged-exposure therapy, which had not previously been widely used in its giant healthcare system or in civilian healthcare settings. "This is the most important clinical trial to date examining the psychological treatment of combat- related PTSD," says Terence M. Keane, PhD, director of the behavioral science division at the National Center for PTSD, in Boston. "It really is what drove the decision to implement the VA education efforts."
Experts don't know why women are more vulnerable to PTSD. Some research shows that, overall, women are likelier to experience the kind of traumatic events that would cause anyone -- male or female -- to develop PTSD, explains Dr. Schnurr. Next on her agenda? Finding a way to help primary-care providers manage PTSD in people who want to come to their family doctor for treatment and giving PTSD patients tools to make informed choices about care, such as details about the side effects from medication and benefits of different therapies. "I am very interested in doing the kind of research policy makers can use to help the men and women who sacrificed so much for their country," Dr. Schnurr says.
Paula P. Schnurr won the Marianne J. Legato Award for Gender-Specific Medicine (named in honor of Ladies' Home Journal's medical adviser, a pioneer in researching the different health needs of men and women).
Every 15 seconds, another American suffers a traumatic brain injury (TBI). That adds up to 1.2 million a year. Result: 235,000 hospitalizations, 80,000 new cases of long-term disability, and 50,000 deaths. Rehab experts have helped many patients recover from TBI damage, but for three decades there has been no new clinically available medical therapy to limit injury.
With a revolutionary new treatment that involves giving progesterone -- the hormone that protects a developing fetus -- intravenously to patients who have just suffered a TBI, researchers at the Emory University School of Medicine and the Morehouse School of Medicine are accomplishing the unimaginable: They not only are saving lives but also reducing the degree of post-injury disability, according to a study published in the Annals of Emergency Medicine in April 2007. In this study, only 13 percent of severely brain-injured patients who got natural progesterone -- extracted from the humble yam -- died, compared with 30 percent of those given a placebo. What's more, after 30 days, functioning had improved in nearly 56 percent of patients who received progesterone after a moderate TBI, including motor responses, opening their eyes, and communicating. Moderately injured patients who received the placebo did not improve nearly as much.
The study was done mainly to see how safe and effective progesterone is, but the results are a satisfying vindication of the vision and persistence of its lead investigator, Donald G. Stein, PhD, director of Emory's Department of Emergency Medicine Brain Research Laboratory. Dr. Stein, 69 and the father of two who credits the breakthrough to his team, including lead author David W. Wright, MD, labored for nearly four decades to find a treatment and, perhaps, a cure for brain injury.
He found his life's work as a doctoral candidate when he noticed that about one-third of rats whose severe brain injuries he was studying weren't much affected by the damage. Over the years, he doggedly researched why. Learning that female rats recovered from some injuries better than males, he homed in on the hormones estrogen and progesterone, eventually finding that rats of either gender "given a short course of progesterone after injury had less cerebral swelling and better functional outcomes," says Dr. Stein. Only when he went to Emory in 1995 and got the support of Arthur Kellermann, MD, chair of emergency medicine, could he test if his rat discoveries would help humans.
"What is wonderful about Dr. Stein is his persistence despite very little support," says Brent Masel, MD, a board member of the Brain Injury Association of America, and president and medical director of the Transitional Learning Center, in Galveston, Texas.
More research is needed before progesterone treatment becomes standard. Chinese researchers, building on Dr. Stein's work, recently reported that severely brain-injured patients who got the hormone had lower mortality than controls and continued to improve over six months. Dr. Stein is seeking federal and private funding for follow-up research. "I'd do all I could to get this treatment for someone in my family who was injured," he says. "But I understand the need for further clinical trials so people are absolutely convinced."
Originally published in Ladies' Home Journal, August 2008.