BackgroundThis prospective, randomized double-blind study, conducted over 19 months in a tertiary care ED, sought to determine if a fascia-iliaca regional anesthetic block provides better and safer pain relief than does parenteral analgesia.AimsThis study also aimed to determine the effectiveness of parenteral NSAID analgesia for acute hip fractures.MethodsPatients >65 years old presenting at an adult ED with acute hip fractures were randomized upon presentation to the ED into two groups (A and B) using numbers generated by the EPI-INFO™ (Atlanta, GA: Centers for Disease Control and Prevention) program. The randomization list was kept by one of the authors who did not interact with the patients. Two groups of patients were to receive either (A) a fascia-iliaca block with bupivacaine and parenteral saline injection, or (B) the same block with saline and an IV NSAID injection. Upon admission to the study, vital signs such as blood pressure, mean blood pressure (MAP), heart rate (HR), respiratory rate (RR) and pain-intensity measurements [using the Visual Analogue Scale (VAS)] were obtained and repeated at 15 min, 2 h and at8 h. The occurrence of complications was registered.ResultsOne hundred seventy-five patients were randomized, and 21 were excluded from participation. The remaining 154 patients were grouped as: group A (n = 62) or group B (n = 92). The mean pain level on admission to the ED for all patients, assessed with the VAS, was 8.21 ± 0.91 (CI 95%: 6.43–9.99); in group A the VAS was 7.6 ± 0.22 and in group B 8.5 ± 0.72 (p = 0.411). At 15-min evaluation, values were: group A 6.24 ± 0.17 and group B 2.9 ± 0.16 (p < 0.001). At the 2-h assessment, values were: group A 1.78 ± 0.11 and group B 2.3 ± 1.16 (p = 0.764). At 8 h the VAS for group A was 2.03 ± 0.12 and for group B 4.4 ± 0.91 (p = 0.083).ConclusionThis study demonstrates that: (1) parenteral NSAIDs are very effective as analgesics after hip fractures in elderly patients, (2) fascia-iliaca regional blocks are nearly as effective for up to about 8 h after administration and (3) regional fascia-iliaca blocks effectively control post-hip fracture pain. (4) Fascia iliaca regional block has a rapid onset.
Most disaster plans depend on using emergency physicians, nurses, emergency department support staff, and out-of-hospital personnel to maintain the health care system's front line during crises that involve personal risk to themselves or their families. Planners automatically assume that emergency health care workers will respond. However, we need to ask: Should they, and will they, work rather than flee? The answer involves basic moral and personal issues. This article identifies and examines the factors that influence health care workers' decisions in these situations. After reviewing physicians' response to past disasters and epidemics, we evaluate how much danger they actually faced. Next, we examine guidelines from medical professional organizations about physicians' duty to provide care despite personal risks, although we acknowledge that individuals will interpret and apply professional expectations and norms according to their own situation and values. The article goes on to articulate moral arguments for a duty to treat during disasters and social crises, as well as moral reasons that may limit or override such a duty. How fear influences behavior is examined, as are the institutional and social measures that can be taken to control fear and to encourage health professionals to provide treatment in crisis situations. Finally, the article emphasizes the importance of effective risk communication in enabling health care professionals and the public to make informed and defensible decisions during disasters. We conclude that the decision to stay or leave will ultimately depend on individuals' risk assessment and their value systems. Preparations for the next pandemic or disaster should include policies that encourage emergency physicians, who are inevitably among those at highest risk, to "stay and fight."
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