Article: TME200151 Date: January 24, 2012 Time: 17:12

Advanced Emergency Nursing Journal

Vol. 34, No. 1, pp. 75–81
Copyright 
C 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins

Hypothermia in the Trauma Patient

How Vital Is This Sign?
Christopher D. McLarty, MSN, ACNP-BC, CEN, TNS

Abstract
Recognizing the adverse impact that trauma has on a patient’s overall well-being and hemodynamic
stability is key to successful management and improved outcomes for this patient population. It
is well established that trauma is accompanied by deadly pathophysiological sequelae, referred to
as the “trauma triad.” This triad is characterized by hypothermia, acidosis, and coagulopathy. This
triad is cyclic and, moreover, each element of the triad builds upon one another to exacerbate the
next. Hence, evidence demonstrates that it is important to recognize the cycle and intervene early
to reduce or prevent negative outcomes. Key words: advanced practice, hypothermia, trauma,
trauma triad

T
RAUMATIC INJURY is a significant
threat to the well-being of Americans.
As reported by the Centers for Disease
Control and Prevention (CDC), of the 123.8
million emergency department (ED) visits
recorded for 2008, a total of 42.4 million visits
were injury related (CDC, 2008). In terms of
economic burden, trauma costs the U.S. econ-
omy $406 billion a year, a sum that accounts
for both health care costs and lost productiv-
ity (Finklestein & Alam, 2010).
Life years lost is a term used to measure the
impact of trauma on society. This measure
takes into account the age at which deaths
occur, giving a greater weight to deaths oc-
curring at younger ages and lesser weight to
Author Affiliations: Division of Trauma and Emer-
gency Surgery, The University of Arizona Medical Cen-
ter, Tucson, Arizona; and AeroCare Medical Transport
Systems, Scottsdale, Arizona.
Disclosure: The author reports no conflicts of interest.
Corresponding Author: Christopher D. McLarty, MSN,
ACNP-BC, CEN, TNS, Division of Trauma and Emer-
gency Surgery, The University of Arizona Medical Cen-
ter, 1501 N Campbell Avenue, Tucson, Arizona 85724
(christopher.mclarty@gmail.com).
DOI: 10.1097/TME.0b013e3182437d01
those deaths occurring later in life. The life
years lost indicator measures the projected
years of life lost by the patient due to a partic-
ular cause of death in proportion to the total
life years lost due to premature mortality of all
causes in the population at large (Finklestein
& Alam, 2010). In fact, unintentional injury is
the leading cause of death for persons aged 1–
44 years and is considered the fifth most com-
mon cause of death for all ages (CDC, 2008).
Health care providers and dedicated clini-
cians work tirelessly to save trauma patients.
Regardless of what particular level of trauma
center a physician, nurse, or other provider
works in, trauma basics share a common ap-
proach involving primary and secondary sur-
veys. Needless to say, just the mere presence
of vital signs in a trauma patient portends a
better outcome for the patient. However, of
those vital signs, which require particular at-
tention? No doubt, nonlabored respirations,
a normal sinus rhythm, and a normal blood
pressure are all positive signs that bode well
for the patient. What consideration should
be given to the patient’s temperature? Is it
necessary to maintain core temperature for

75

Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 Article: TME200151 Date: January 24, 2012
76
every patient? Furthermore, what is con-
sidered to be a normal temperature range?
Finally and most importantly, does hypother-
mia have an independent effect on the
outcome?
PATHOPHYSIOLOGY
Physiologically, the impact of hypothermia
alone is significant. When hypothermia oc-
curs in the setting of trauma, it has been noted
that a “core temperature decrease of 0.3 ◦ C is
associated with as much as a 7% increase in
oxygen consumption” (Moore, 2008, p. 62).
Hemorrhage commonly accompanies trauma
and reduces a patient’s circulating blood vol-
ume. This results in decreased availability of
oxygen for cellular aerobic metabolism. In
the presence of traumatic injury and hem-
orrhage, the excess oxygen consumption in-
duced by hypothermia further compromises
the patient’s ability to maintain cellular func-
tion. Moreover, the increased oxygen con-
sumption combined with the reduced circu-
lating volume further disrupts electrophysio-
logical signaling and inotropic properties of
the heart (Moore, 2008). This results in a fur-
ther reduction in systemic oxygenation and
tissue perfusion.
Hypothermia also has a direct detrimental
effect on the hematological system, specif-
ically hemostasis. Vascular injury frequently
accompanies trauma and results in activation
of the clotting cascade both to stem blood
loss and to initiate vascular repair. Early in
the clotting cascade, platelets provide pri-
mary hemostasis, or initial closure of the vas-
cular injury. This is followed by activation of
clotting factors that function as part of the ex-
trinsic clotting pathway to provide secondary
hemostasis. This process initiates a more sub-
stantial repair to the tissue through the for-
mation of fibrin. The intrinsic and extrinsic
pathways eventually merge into the common
pathway, resulting in platelet aggregation and
fibrin substantiation of the clot. In the pres-
ence of hypothermia, both the intrinsic and
extrinsic pathways of the clotting cascade are
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Time: 17:12
Advanced Emergency Nursing Journal
inhibited, leading to development of coagu-
lopathy (Mallet, 2002).
Volume loss and decreased availability of
oxygen lead to inadequate cellular perfusion.
These changes in cellular perfusion induce
anaerobic metabolism at the cellular level, in-
creasing lactic acid production, which leads
to profound metabolic acidosis. Although aci-
dosis has little effect on clotting under con-
ditions of normothermia, it intensifies the
adverse effects of hypothermia and syner-
gistically worsens clotting times (Dirkmann,
Hanke, Görlinger, & Peters, 2008). Working
independently of one another, “hypothermia
primarily inhibits thrombin generation in the
initiation phase, whereas acidosis severely
impair thrombin generation in the propaga-
tion phase” (Martini, 2009b, pp. 207–208).
In the presence of trauma, hypothermia in-
hibits the synthesis of fibrinogen, thereby pre-
venting the formation of fibrin, while acidosis
contributes to advanced fibrinogen degrada-
tion. This quickly results in ineffective clot-
ting, leading to a state of coagulopathy. As
a result, this defense against blood loss is
compromised, further contributing to the vi-
cious cycle. In addition, much like hypother-
mia, increasing acidosis resulting from anaer-
obic metabolism not only affects the clotting
cascade but it also has detrimental effects
on myocardial performance, reducing cardiac
effectiveness, increasing oxygen debt, and ex-
acerbating this detrimental pathological re-
sponse (Martini, 2009a).
In summary, trauma alters fibrinogen
metabolism in a variety of ways that accelerate
fibrinogen breakdown and allow for further
coagulopathy-facilitated volume depletion.
Hypothermia inhibits fibrinogen synthesis
and increases oxygen consumption, which
leads to anaerobic metabolism and metabolic
acidosis. In turn, acidosis accelerates fibrino-
gen breakdown and disturbs cardiac electro-
physiological signaling, which compromises
cardiac function. Independently and collabo-
ratively, hemorrhage, hypothermia, and aci-
dosis lead to what is referred to as the trauma
triad of death (Figure).
 Article: TME200151
January–March 2012 r Vol. 34, No. 1
Figure. The cyclical trauma triad presents with
each factor exacerbating and compounding upon
the next.
METHODS
A review of literature was conducted to ex-
amine studies that evaluated the influence of
hypothermia on the outcome of the trauma
patient. The selection of literature for this re-
view was completed with due consideration
of quality indices. Multiple CINAHL, Ovid, and
PubMed searches were performed using key-
words including but not limited to trauma,
hypothermia, trauma triad, rewarming, pre-
hospital trauma care, and trauma outcomes.
The primary searches were limited to those
studies published within the past 10 years
preceding initial research, with queries later
expanded to cover the past 20 years in an ef-
fort to include classical works. For inclusion,
articles were required to be published in a
reputable, peer-reviewed nursing, medical, or
scientific journal. Preference was given to pri-
mary research. Studies were evaluated on the
basis of population, noted citations, sample
size, rigor of the research design, and data
analysis and interpretation. All works cited
were deemed to contribute in a meaningful
and relevant manner to understanding the
relationship between hypothermia and out-
comes in trauma patients. On the basis of
these selection criteria, findings from four key
studies are reviewed and discussed in the fol-
lowing text.
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Date: January 24, 2012 Time: 17:12
Hypothermia in Trauma 77
LITERATURE REVIEW
Mizushima, Wang, Cioffi, Bland, and Chaudry
(2000) conducted a key study in which the
effect of hemorrhage was evaluated using a
rat model. This experimental model permit-
ted the assessment of cardiac performance
and organ blood flow following induced hem-
orrhage in the animals under conditions of
normothermia, hypothermia, and rewarming.
Differences (p < 0.05) were determined by
use of a one-way analysis of variance followed
by Tukey’s test. Findings revealed that both
the maintenance of normothermia during
hemorrhage as well prolonged hypothermia
following successful resuscitation resulted in
reduced left ventricular performance, car-
diac output, and suboptimal blood flow in
various organs. On the contrary, the results
demonstrated that rewarming a previously hy-
pothermic patient to a normothermic state
during resuscitation significantly improved
overall cardiac performance, cardiac output,
and end-organ perfusion (Mizushima et al.,
2000). These data demonstrate a correlation
between a subject’s temperature and the sub-
ject’s improved physiological function and
overall recovery once rewarming occurs fol-
lowing trauma. In this animal model of injury,
hemorrhage was experimentally induced.
Although this is not typical of the human
trauma patient who would usually suffer spon-
taneous, multisystem traumatic injury, the
study provides a well-controlled model to
evaluate the effect of body temperature and
rewarming on cardiovascular outcomes. In ad-
dition, the level of precision in measurement
of the experimental animal’s hemodynamic
function relative to trauma and associated hy-
pothermia lends to the rigor of study design
and hence the validity and trustworthiness of
the results.
The second study by Wang, Callaway,
Peitzman, and Tisherman (2005) used a ret-
rospective, cross-sectional design in which
a convenience sample of trauma cases from
Pennsylvania’s statewide trauma registry was
evaluated. The primary study outcome was
death at hospital discharge. The variable of
note was hypothermia, which was defined as
 Article: TME200151 Date: January 24, 2012
78
body temperature less than 35◦ C upon ad-
mission. The findings revealed a direct cor-
relation between admission hypothermia in
the trauma patient and mortality. That is, hy-
pothermia in patients upon admission was in-
dependently associated with increased rate of
mortality in both the full cohort and a sub-
set cohort limited to those patients with re-
ported “severe head injury.” For the full co-
hort, the odds ratio for fatality to occur was
3.03, with a 95% confidence interval (range
= 2.62–3.51). For the head injury subset, the
odds ratio for fatality to occur was 2.21, with
a range of 1.62–3.03. The study results were
adjusted for age, severity, and mechanism of
injury, and the recorded route of temperature
measurement and the findings remained con-
sistent, which strengthen the conclusion that
hypothermia independently increases risk for
mortality due to posttraumatic injury. Despite
the fact that this study employed a retrospec-
tive analysis of a convenience sample, the
large sample size and significant confidence
interval add to the validity of the results and
conclusions.
A third related study by Martin, Kilgo,
Miller, Meridith, and Chang (2005) used exist-
ing data to evaluate the effect of hypothermia
on mortality using a convenience sample ac-
cessed from the National Trauma Data Bank. A
cross-sectional correlational design was used.
Findings showed a correlation between core
body temperature and mortality, such that as
patients’ core temperature decreased, their
mortality rate increased. Mortality rate was
39% at a core temperature of 32◦ C, and this
correlation remained constant at lower tem-
peratures. Of these patients, 477 (59.5%) with
admission core temperatures less than 32◦ C
survived. Logistic regression analysis revealed
that hypothermia significantly and indepen-
dently contributed to patient mortality even
when adjustment was made for confound-
ing variables such as unavoidable environ-
mental temperature extremes. Limitations to
the study include use of records that origi-
nated from numerous trauma centers, which
increases the chance for variability in care as
well as inconsistencies in data entry, which
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Time: 17:12
Advanced Emergency Nursing Journal
can confound the results. Yet, the large sam-
ple size is a notable strength of this study
(Martin et al., 2005).
The fourth and final primary research study
reviewed was authored by Taylor et al. (2008)
and evaluated intravascular rewarming in the
hypothermic patient. Data were collected ret-
rospectively by reviewing the records of pa-
tients treated with the CoolGard system at a
Level I trauma center in Texas from May to Oc-
tober 2007. Patient temperature, rewarming
data, demographic, injury pattern and sever-
ity, laboratory values, transfusion status, and
outcomes were collected and reviewed. The
patients’ mean core temperature noted at the
initiation of rewarming was 33.6 ± 1◦ C, and
the mean rate of rewarming was 1.5 ± 1◦ C
per hour. Despite rewarming measures, six of
11 patients died: two (18%) expiring of acute
exsanguination and four (36%) of unsurviv-
able traumatic brain injuries. In addition, one
patient developed a deep vein thrombosis at
the site of the femoral catheter and experi-
enced a nonfatal pulmonary embolus.
Of the five survivors, four had rewarming initiated
early in the course of treatment, either in the ED
or operating room. Only one fatality, due to non-
survivable brain injury, occurred in a patient whose
rewarming began prior to ICU arrival. Of note, the
two patients with the lowest ED arrival temper-
atures, both with extensive penetrating injuries,
had intravascular rewarming begun immediately
and survived. (Taylor et al., 2008, p. 122)
The research team concluded that based
upon their findings, the data demonstrated
that active intravascular balloon-catheter re-
warming demonstrated an effective and es-
sentially automated technique for the timely
treatment of hypothermia in trauma patients.
This study was chosen to highlight the po-
tential for improved outcome because it re-
lates to proper identification and management
of hypothermia in the trauma patient. From
the perspective of study rigor, utilization of
one particular rewarming device adds to the
study’s reliability in that there should be no
variation attributed to different devices. Al-
though this study is valid and has potential to
 Article: TME200151
January–March 2012 r Vol. 34, No. 1
impact nursing practice, future studies should
employ a larger sample size and enroll sub-
jects from multiple centers so as to improve
general applicability and confidence in the
conclusions drawn. This should be accom-
plished prior to universal implementation of
this practice.
The physiological effects of primary hy-
pothermia are well documented, and most
clinicians understand the impact that hy-
pothermia can have on a patient. In fact, the
care of the patient with primary hypother-
mia is typically well understood by those
experienced in emergency care. For exam-
ple, one study reported a mortality rate of
17.1% in patients presenting with the chief
complaint of primary hypothermia without
other injury (Martin et al., 2005). This is re-
lated to the significant multiorgan system ef-
fects attributed to hypothermia, including de-
pressed cardiac function, which decreases
perfusion and gives rise to shock. Further-
more, hypothermia leads to myocardial ir-
ritability, which can precipitate potentially
fatal arrhythmias (Peng & Bongard, 1999).
Although these same physiological changes
can occur in the patient with no injuries,
the patient with a significant traumatic injury
is more vulnerable and should therefore be
protected to the best of the trauma team’s
ability.
Traumatic injury, by nature, puts a patient
at significant risk for heat loss. In fact, hy-
pothermia accompanies injury subsequent to
exposure, which increases heat loss from con-
duction and convection; also, decreased mo-
tor activity further reduces heat production
(Moore, 2008). Traditionally, hypothermia is
defined as a core temperature less than 35◦ C
(American College of Surgeons, Committee
on Trauma, 2008). However, in a study that
surveyed 96 trauma team members includ-
ing both nurses and physicians found that
36.4% incorrectly identified break point for
hypothermia as either 33◦ C or 34◦ C (Ireland
et al., 2006). This is concerning because cur-
rent literature readily identifies hypothermia
as a significant determinant of the outcome of
a patient presenting with significant traumatic
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Date: January 24, 2012 Time: 17:12
Hypothermia in Trauma 79
injury. In fact, a previously referenced study
concluded that not only is hypothermia a sig-
nificant factor in patient outcome but “hy-
pothermia is independently associated with
increased adjusted odds of death after major
trauma” as well (Wang et al., 2005, p. 1300).
Patients with traumatic injury frequently
sustain significant blood loss and their care
often includes aggressive fluid resuscitation.
While infusing large volumes of intravenous
fluids and blood products into the patient, the
efficient trauma team also concurrently strips
victims of any clothing to complete very nec-
essary primary and secondary trauma surveys.
Moreover, temperatures in the ED and oper-
ating room are typically 21◦ C–22◦ C (Taylor
et al., 2008). Collectively, this culminates in
conditions that almost make hypothermia in-
evitable. In fact, it has been documented that
“mild (33◦ C–35◦ C) to moderate (30◦ C–33◦ C)
hypothermia frequently occurs during fluid
resuscitation of trauma victims” (Mizushima
et al., 2000, p. 58). The same study further
emphasizes, “Studies have shown that hy-
pothermic trauma victims have a higher mor-
tality rate than those patients who are kept
warm” (Mizushima et al., 2000, p. 58). Related
studies recommend that hypothermic trauma
patients be rewarmed rapidly (Gentilello &
Rifley, 1991).
Interventions as basic as keeping the pa-
tient covered have been used for years and
assumed to be sufficient in many situations.
If more intervention is thought to be neces-
sary, warmed blankets as well as warmed in-
travenous fluids have been used (Ireland et al.,
2006). Such measures do assist in preventing
further heat loss, but the question is whether
they are sufficient to adequately rewarm the
injured patient. As previously mentioned, one
method of more aggressive rewarming now
being evaluated is intravascular rewarming,
whereby a central catheter is introduced into
the femoral vein. The rewarming device uses
a balloon tip that circulates warmed fluid
in a closed loop fashion to deliver heat to
the bloodstream. In addition, the balloon de-
vice has the capacity to monitor the patient’s
core temperature. According to Taylor et al.
 Article: TME200151 Date: January 24, 2012
80
(2008), a study using this intravascular equip-
ment reported the average rewarming rate to
be 1.5◦ C/hr. Despite the fact that the technol-
ogy is relatively new and the study had a very
small sample size (N = 11), it seems that this
may be a promising technology for rewarming
trauma patients (Taylor et al., 2008).
DISCUSSION AND IMPLICATIONS
As is evident by the data previously discussed,
core temperature in the trauma patient is a
very vital sign. Although it is important to fo-
cus on ensuring adequate breathing and cir-
culation of the critically injured patient, the
physiological and metabolic damage that hy-
pothermia can cause must also be considered.
When rewarming should begin and just how
aggressive rewarming measures should be are
still a matter of debate; however, the data con-
sistently show that rewarming that is safe, ef-
fective, and efficient would serve the patient
best (Mizushima et al., 2000). It is essential to
ensure that nurses and physicians have fun-
damental knowledge of the normal limits for
core temperature, the methods of taking and
recording accurate core temperatures, and an
understanding of appropriate interventions to
improve overall quality of care and patient
outcomes. Beyond that, protocols to prevent
and treat hypothermia should be addressed at
an institutional level in order to empower the
trauma team to effectively combat hypother-
mia and related sequelae.
Dissemination of findings is an integral part
of the research continuum, ensuring that ev-
idence translates to patient care. These prac-
tice changes facilitate improvements in stan-
dards of practice, which ultimately and most
importantly improve the patients’ outcomes.
As previously reviewed, hypothermia in the
trauma patient is a critical problem and it
is clear that the traumatically injured pa-
tient almost immediately becomes at risk for
heat loss. Consequently, it is may be con-
cluded that patient temperature preservation
and related interventions should begin with
pre-hospital care and be maintained and/or
augmented from that point forward. This
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Time: 17:12
Advanced Emergency Nursing Journal
requires education of pre-hospital care
providers inclusive of air and ground staff
who care for patients prior to arrival at
the trauma center. In addition, it is impor-
tant to review and reinforce the significance
of temperature monitoring and hypothermia
management with all trauma team members.
Finally, equipment procurement and the cre-
ation and implementation of algorithms to
prevent and treat hypothermia should be con-
sidered as a part of an institution’s standard
trauma care practices.
CONCLUSION
All aspects of care of the trauma patient are
important and no part of the primary or sec-
ondary assessment, including a patient’s tem-
perature, should be overlooked. Providers
must understand the impact of hypothermia
as a part of the trauma triad of death if the
cyclic events are not interrupted quickly and
effectively. Accomplishing this requires edu-
cated staff members who recognize the signs
and symptoms of compromise in the trauma
patient and who effectively align their prac-
tice with current evidence. Patients who have
incurred traumatic injury are a vulnerable pa-
tient population. As patient advocates, nurses
must work to ensure that the patient is cared
for to the utmost of the health care team’s
ability in an effort to ensure the best possible
outcome.
REFERENCES
American College of Surgeons, Committee on Trauma.
(Ed.). (2008). Advanced trauma life support for
doctors: Emergency management of severe trauma
(EMST) Faculty manual. (8th ed). Chicago, IL:
Author.
Centers for Disease Control and Prevention, Ambulatory
and Hospital Care Statistics Branch. (2008). National
hospital ambulatory medical care survey: 2008
emergency department summary tables. Retrieved
from http://www.cdc.gov/nchs/fastats/ervisits.htm
Dirkmann, D., Hanke, A. A., Görlinger, K., & Pe-
ters, J. (2008). Hypothermia and acidosis syn-
ergistically impair coagulation in human whole
blood. Anesthesia & Analgesia, 106(6), 1627–1632.
doi:10.1213/ane.0b013e31817340ad
 Article: TME200151 Date: January 24, 2012
January–March 2012 r Vol. 34, No. 1
Finklestein, R., & Alam, H. (2010). Induced hypothermia
for trauma: Current research and practice. Journal
of Intensive Care Medicine, 25(4), 205–226.
doi:10.1177/0885066610366919
Gentilello, L. M., & Rifley, W. J. (1991). Continuous arte-
riovenous rewarming: Report of a new technique for
treating hypothermia. The Journal of Trauma, 31,
1151–1154.
Ireland, S., Murdoch, K., Ormrod, P., Saliba, E., Endacott,
R., Fitzgerald, M., & Cameron, P. (2006). Nursing
and medical staff knowledge regarding the monitor-
ing and management of accidental or exposure hy-
pothermia in adult major trauma patients. Interna-
tional Journal of Nursing Practice, 12, 308–318.
Mallet, M. L. (2002). Pathophysiology of accidental
hypothermia. QJM, 95, 775–785. Retrieved from
qjmed.oxfordjournals.org
Martin, R. S., Kilgo, P. D., Miller, P. R., Meridith, J. W., &
Chang, M. C. (2005). Injury-associated hypothermia:
An analysis of the 2004 National Trauma Data Bank.
Shock (Augusta, Ga), 24(2), 114–118.
Martini, W. (2009a). Fibrinogen metabolic responses
to trauma. Scandinavian Journal of Trauma,
Resuscitation & Emergency Medicine, 17(1), 2.
doi:10.1186/1757-7241-17-2
Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Time: 17:12
Hypothermia in Trauma 81
Martini, W. Z. (2009b). Coagulopathy by hypothermia
and acidosis: Mechanisms of thrombin generation
and fibrinogen availability. The Journal of Trauma,
67(1), 202–209. doi:10.1097/TA.0b013e3181a602a7
Mizushima, Y., Wang, P., Cioffi, W. G., Bland, K. I.,
& Chaudry, I. H. (2000). Should normothermia be
restored and maintained during resuscitation after
trauma and hemorrhage? The Journal of Trauma,
48(1), 58–65.
Moore, K. (2008). Hypothermia in trauma. Journal of
Trauma Nursing, 15(2), 62–64.
Peng, R. Y., & Bongard, F. S. (1999). Hypothermia in
trauma patients. Journal of the American College of
Surgeons, 188, 685–696.
Taylor, E. E., Carroll, J. P., Lovitt, M. A., Petrey,
L. B., Gray, P. E., Mastropieri, C. J., & Fore-
man, M. L. (2008). Active intravascular rewarming
for hypothermia associated with traumatic injury:
Early experience with a new technique. Proceed-
ings (Baylor University Medical Center), 21(2),
120–126.
Wang, H. E., Callaway, C. W., Peitzman, A. B., & Tisher-
man, S. A. (2005). Admission hypothermia and out-
come after major trauma. Critical Care Medicine,
33(6), 1296–1301.