Does Depression Affect Cardiac Care?

Stress Training
Wolmer L, Hamiel D, Laor N. Preventing children’s post-traumatic stress after disaster with teacher-based intervention: A controlled study. J Am Acad Child Adolesc Psychiatry. 2011;50(4):340—348.

Critical Incident Stress Management (CISM) is common practice in EMS. Its advocates and recipients (including me) swear by its therapeutic effects. But the research to support CISM in EMS has been the subject of some debate over the years. This newly published Israeli study implemented a teacher-run “Stress Inoculation Training” (SIT) program with nearly 1,500 fourth- and fifth-grade students.

The students were attending school in the Gaza Strip, an area where war was likely. A group of schools was selected based on convenience, and teachers provided 14 training sessions, 45 minutes each. I particularly like that the training was focused on building resiliency skills, included some interpersonal and crisis communication skills, and also involved safety-drill simulation. These skills are useful in everyday situations–not just during extreme stress. As predicted, war broke out in that area, and the children were subjected to months of continuous rocket attacks with the threat of chemical weapons. They had a one-minute warning before the first missiles hit.

Three months after the conflict ended, these researchers compared post-traumatic stress disorder (PTSD) rates in children who had SIT training versus those who hadn’t. The SIT group reported significantly fewer symptoms than the control group, which had 57% more cases of PTSD. The number needed to treat to prevent one additional adverse outcome was 24. For unknown reasons, the therapy also proved more successful for boys than girls.

My hope in reporting on this study is that some of you may consider duplicating it in EMS. Imagine the benefits of providing stress inoculation training for new EMS providers “¦ and just as importantly, prove with research that it works.

Depression & Cardiac Care
Atzema C, Schull M, Tu J, et al. The effect of a charted history of depression on emergency department triage and outcomes in patients with acute myocardial infarction. CMAJ. 2011;183(6):663—639.

This review comes with a friendly reminder: Proving an association doesn’t necessary imply we found a cause-and-effect relationship. This retrospective study used electronic records to compare initial triage scores, door-to-ECG time, cardiac catheterization lab activation and door-to-balloon inflation times in patients who had a charted history of depression.

The authors do a good job bringing our attention to the previously established link between coronary artery disease and depression. They show that in the emergency department, the 680 patients with depression in their charts received lower triage scores, had delayed ECGs (three minutes longer) and delayed reperfusion times (140 minutes longer). One has to wonder, did the triage nurse know about the depression? Where’s the bias? Because only slight delays in ECG times occurred but huge delays in reperfusion were recorded, I ask myself: Was the problem in the cardiac cath lab?

The study excluded patients who arrived by ambulance because they were already “triaged.” But in the full paper (another reason to read full papers and not just the abstracts), researchers include statistics showing that patients who arrived by ambulance had a 35% greater chance of being properly triaged and cared for more rapidly. Although the statistics in this paper seem to confirm previous findings linking a history of depression to poor cardiac care, one can’t assume that one causes the other.

However, Ontario EMS can be proud that their patients with a history of depression were cared for faster than those who arrived at the front door of the hospital. This proves again that EMS makes a difference in patient outcomes. JEMS

Control: This research term refers to a group of subjects who are purposefully not exposed to the therapy or process being tested.

Watch Box IO Placement in Hazmat Suits

Borron S, Arias J, Bauer C, et al. Intraosseous line placement for antidote injection by first responders and receivers wearing personal protective equipment. Am J Emerg Med. 2011;29(4):373—381.

The makers of the EZ-IO recently conducted a laboratory trial on the use of hydroxocobalamin in goats. Look for their full paper on this project coming soon. They also reported the feasibility of intraosseous (IO) insertion while donning various types of hazmat suits. The paramedics in the study were 100% successful in placing the IO, and most took less than one minute for insertion. The authors propose the idea that antidotal treatments for cyanide-exposed patients might be possible in the hot zone before decontamination.

This article originally appeared in July 2011 JEMS as “Cause & Effect: Studies examine role of psychological factors.”

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