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Background: In April 2004, the US Army Medical Department approved the use of the Army Knowledge Online (AKO) electronic e-mail system as a teleconsultation service for remote teledermatology consultations from healthcare providers in Iraq, Kuwait, and Afghanistan to medical subspecialists in the United States. The success of the system has resulted in expansion of the telemedicine program to include 11 additional clinical specialty services: (1) burn-trauma; (2) cardiology; (3) dermatology; (4) infectious disease; (5) nephrology; (6) ophthalmology; (7) pediatric intensive care; (8) preventive and occupational medicine; (9) neurology; (10) rheumatology; and (11) toxicology. The goal of the program is to provide a mechanism for enhanced diagnosis of remote cases resulting in a better evacuation system (i.e., only evacuation of appropriate cases). The service provides a standard practice for managing acute and emergent care requests between remote medical providers in austere environments and rear-based specialists in a timely and consistent manner.
Methods: Consults are generated using the AKO e-mail system routed through a contact group composed of volunteer, on-call consults. The project manager receives and monitors all teleconsultations to ensure Health Insurance Portability and Accountability Act compliance and consultant's recommendations are transmitted within a 24-hour mandated time period. A subspecialty “clinical champion” is responsible for recruiting consultants to answer teleconsultations and developing a call schedule for each specialty. Subspecialties may have individual consultants on call for specific days (e.g., dermatology and toxicology) or place entire groups on-call for a designated period of time (e.g., ophthalmology).
Results: As of May 2007, 2,337 consults were performed during 36 months, with an average reply time of five hours from receipt of the teleconsultation until a recommendation was sent to the referring physician. Most consultations have been for dermatology (66%), followed by infectious disease (10%). A total of 51 known evacuations were prevented from use of the program, while 63 known evacuations have resulted following receipt of the consultants' recommendation. A total of 313 teleconsultations also have been performed for non-US patients.
Conclusions: The teleconsultation program has proven to be a valuable resource for physicians deployed in austere and remote locations. Furthermore, use of such a system for physicians in austere environments may prevent unnecessary evacuations or result in appropriate evacuations for patients who initially may have been “underdiagnosed.”
Introduction: Low education levels may limit community-based health worker (CHW) efforts in rural Afghanistan. In 2004, LeapFrog Enterprises and the United States Department of Health and Human Services developed the Afghan Family Health Book (AFHB), an interactive, electronic picture book, to communicate public health messages in rural Afghanistan. Changes in health knowledge among households exposed to the AFHB vs. CHWs were compared.
Methods: From January–June 2005, baseline and follow-up panel surveys were administered in Pashto-speaking Laghman and Dari-speaking Kabul provinces. Within each province, an AFHB and a CHW district were randomly sampled using a stratified, 2-staged cluster sample design (total 98 clusters and 3,372 households). Surveys tested knowledge of 17 health domains at baseline and on follow-up at three months. For each domain, multivariate logistic regression was used to assess the effect of the AFHB on follow-up pass rates, controlling for demographics and differences in baseline knowledge.
Results: Both AFHB and CHW resulted in statistically significant changes in pass rates on follow-up, although there were greater gains among AFHB users for five domains among Pashto-speakers (micronutrients, malaria, sexually transmitted diseases, postpartum care, and breast-feeding) and seven domains among Dari-speakers (diet, malaria, mental health, birth-spacing, and prenatal/neonatal/postpartum care). Community-based health workers effected greater knowledge gains only for the Dari breast-feeding module. Participants favored CHW over the AFHB, which they found poorly translated and difficult to use.
Conclusions: The AFHB has potential to improve public health knowledge among rural Afghans. Future efforts may benefit from involvement of local health agencies and the integration of interactive technology with traditional CHW approaches.
Introduction: Trauma is a leading cause of death and disability in Mexico. Unintentional injuries, along with diabetes and heart disease, contribute to >35% of the country's total mortality. Effective and efficient prehospital care of the conditions may improve outcomes.
Objective: The objective of this paper was to determine if prehospital field experience (PFE) correlated with higher passing rates among candidates for the paramedic registry in Mexico City.
Methods: This was a retrospective, cohort study using data from the Voluntary Registry of Prehospital Care Professionals (VRPHP) in Mexico City.
Results: The mean value for candidate age was 30.6 years and mean value for the years of PFE was 6.8 years (CI = 9–13 years). Most of the applicants were male and almost 90% were basic emergency medical services providers. Sixty-five percent of the candidates were from private, non-profit organizations, 73% were volunteers, and 19% had obtained a university degree. More than 57% had ≥5 years of PFE, but the experience level did not correlate significantly with higher passing rates for the registry evaluation (χ2 = 1.66, p = 0.43).The results differed between the two years that the examination was offered (χ2 = 32.98, df = 1, p <0.001, γ = 0.54), regardless of gender, education, and years of experience.
Conclusions: Previous field experience showed no correlation with passing rates, although the correlations improved between examination periods. The results may be used to support appropriate implementation of future health policies for prehospital emergency services.
Introduction: A set of symptom-based, all-hazards, decision-making algorithms was designed to aid the first-contact provider during early patient presentations after a terrorist incident.
Objective: The primary objective was to assess the usability of these algorithms. A secondary objective was to assess the psychometric properties of the testing scenarios.
Methods: This was a written, usability assessment of the algorithms employing a convenience sample of hospital-based, healthcare providers who had not taken any specific training in the use of the algorithms. A series of 26 paragraph-length, moderately difficult scenarios was created to reflect possible agents, means of attack, and types of patients. Each of the 26 scenarios requires that one make a triage choice on the “attack” algorithm (the trunk algorithm), then proceed to one of four other branch algorithms (dirty resuscitation, chemical agents, biological agents, bomb/blast/radiation dispersal device) to make a final triage choice. Conditional scores based on getting both the attack and final card correct were calculated for each algorithm.
Results: Nineteen attending physicians, 50 emergency medicine residents, and 41 nurses took the assessment. The total score was 45% correct for all participants. The score on the attack algorithm was 66% correct. Dirty resuscitation, biological, chemical, and bomb/blast scores were 46%, 54%, 46%, and 51% respectively. The probability of guessing the correct answer on the attack algorithm was 1/7 or 14%. The conditional probability of guessing both the attack algorithm and the final card correct ranged from 4.7% for the biological, chemical, and bomb/blast algorithms to 2.4% for the dirty resuscitation algorithm. Item discrimination, item difficulty, and Cronbach's alpha were acceptable for the overall test. Certain individual items had item difficulty levels suggesting they were too difficult and should be replaced in future versions of the test.
Conclusions: Performance on the test suggests that participants did substantially better than would have been expected by chance alone. Future efforts will revise the algorithms with the goal of simplification. Revision of the testing instrument and testing algorithm use after instruction also are needed.
Introduction: Millions of vulnerable, elderly individuals live in coastal areas susceptible to hurricanes and are at risk for adverse health outcomes. The purpose of this study was to determine the status of preparedness for and possible health consequences of a hurricane on a vulnerable, but experienced, elderly population.
Problem: Preparedness guidelines have been published, but it is unclear how well-prepared elderly individuals are for hurricanes, and what impact hurricanes may have on their health.
Methods: Five hundred forty-seven ambulatory patients who attended an urban teaching hospital's geriatrics clinic in Florida were surveyed. A 25-question survey that asked whether subjects followed the American Red Cross guidelines for hurricane preparation was developed. The participants were asked what hurricane supplies they had, and whether they would need to evacuate or utilize storm-proof window shutters. They also were queried about definitions and their understanding of hurricane warnings. Three possible health impacts during the two weeks following Hurricane Wilma in 2005 were asked: (1) falls; (2) missed medication; and (3) missed doctor's appointments. An additional 105 patients in the same clinic were asked about the same three health outcomes one and one-half years after the hurricane struck.
Results: Two-thirds of respondents were missing at least one supply item. A multivariate analysis indicated that there was no relationship between the subjects' demographic characteristics and the possession of the suggested disaster supplies. Although 36% would need to evacuate, only 56% of these 36% had a plan. Only 63% had storm-proof windows or shutters, and of these, only 46% could install them. Gasoline-powered electrical generators can be useful, but also a source of morbidity or mortality following a hurricane. For example, this study found that 28% of respondents had generators, but only 46% knew how to use them. Subjects immediately after the hurricane rmsstd fewer doses of medication than at other times (3.4% vs. 6.7%; p <0.0001) and fell slighdy less often (8.8% vs. 12.9%; p <0.0001). However, there were significandy more missed doctors appointments after the hurricane (11.6% vs. 0.1%, p <0.0001).
Conclusions: The survey indicated that even a well-experienced population lacks adequate hurricane preparation. Most still are vulnerable in at least one aspect of preparation. The elderly may be more likely to miss medical appointments immediately following a hurricane. Interventions to improve hurricane preparedness should be piloted.
Introduction: This study intended to describe the types of organizations and communities in which Nationally Registered First Responders (NRFR) perform their duties. Also, it aimed to estimate the number of NRFR who received disaster preparedness training. It was hypothesized that NRFR participation in disaster preparedness training was related to the types of organizations and communities in which they performed their duties.
Methods: The NRFR re-registering in 2006 were asked to report the organization type and community size in which they work. They also were asked to report the amount and content of preparedness training received during the last 24 months. Multivariable logistic regression modeling was utilized to describe the relationship between NRFR organizational characteristics and the receipt of disaster preparedness training.
Results: The analysis included 872 (59%) individuals who completed the survey and reported working for one or more emergency medical services (EMS) organizations. The majority of NRFR performed work in rural areas (75%) and more NRFR reported working for fire departments (61%) than for any other organization type. In all categories of service type, participants who reported working in urban areas had higher odds of receiving disaster preparedness training than those working in rural areas. Additionally, regardless of community size, individuals working in fire departments were more likely to receive disaster preparedness training.
Conclusions: This study indicated that the majority of NRFR perform EMS duties for fire departments and work in rural communities. In this sample of NRFR, more than one-quarter did not receive disaster preparedness training within a 24-month period. Finally, a statistical model was constructed that indicated a relationship between service type, community size, and the participation in disaster preparedness training.
Introduction: On 24 September 2005, Hurricane Rita made landfall in eastern Texas, resulting in the mandatory evacuation of 16 counties and declaration of disaster areas in 22 counties afterward.
Hypothesis: This study tested whether the evacuation and hurricane landfall affected the pattern of Texas poison center calls.
Methods: Texas poison center calls received from the 22 disaster-area counties were identified for three time periods: (1) 10–20 September 2005 (pre-evacuation); (2) 21–25 September 2005 (evacuation and hurricane landfall); and (3) 26 September–08 October 2005 (post-evacuation). The numbers of calls reviewed during the two latter time periods were compared to a baseline range (BR) derived from the number of calls received during corresponding time periods in 2002, 2003, and 2004. This comparison was made for total calls, as well as calls involving pill identifications, other information, total exposures, carbon monoxide exposures, gasoline exposures, food poisoning, water contamination, and other information.
Results: The daily call volume was relatively stable during the pre-evacuation period (mean = 291), declined during the evacuation period (mean = 191), and returned to normal volume during the post-evacuation period (mean = 283). During the evacuation and landfall period, only gasoline exposure calls were higher than expected (n = 68, BR = 11–30). During the post-evacuation period, the only higher than expected call volumes were for carbon monoxide exposures (n = 11, BR -2–10) and gasoline exposures (n = 40, BR = 12–28).
Conclusions: During an evacuation, total poison center call volume in the affected area may decline, although certain calls such as those involving gasoline exposures might increase. After a hurricane, the total call volume returns to normal, but certain calls such as those involving carbon monoxide and gasoline exposures may increase. This information allows for poison centers and public health providers to prepare their response to hurricanes and to educate the population before such events occurs.
Introduction: On 26 December 2003, a catastrophic earthquake measuring 6.6 on the Richter scale devastated large areas of the city of Bam in south-eastern Iran. More than 40,000 people died, tens of thousands were injured, and almost 20,000 homes were destroyed.
Many national and international search-and-rescue teams were dispatched to the area to provide medical and health services and assist in the evacuation of survivors to undamaged areas.
Problem: The purpose of the study was to evaluate the opinions of survivors about medical responses provided, and the process of reconstruction of health infrastructures.
Methods: This was a descriptive study performed two years after the earthquake. Stratified, two-stage area sampling was used to enroll 211 survivors into the survey. A designed questionnaire was applied to evaluate the respondents' opinions about medical and health responses. The respondents were asked to score their satisfaction on a variety of services on a five-point scale, with 1 being “very poor” and 5 being “very good”.
Results: Family members and relatives comprised the majority of first responders for those injured or trapped (127, 60.2%). Field hospitals deployed by the Red Crescent, international relief teams, and military forces were the first medical facilities for 98 (46.4%) of the casualties. As denoted by the mean values for the satisfaction scores, transportation by aircraft to the backup hospitals received the highest score (4.2), followed by international assistance (4.1), first medical care (3.5), search and rescue (3.3), primary transportation (3.1), and reconstruction and the quality of access to the infrastructures of the city (2.6). Two years after the earthquake, 151 (71.5%) respondents still were living in connexes (temporary accommodations or shelters for victims to live in; resemble a small hotel), only 33 (15.6%) had access to safe drinking water, and 44 (20.9%) did not have sufficient supplies of sanitary food.
Conclusions: In addition to reinforcing the medical and health infrastructures of a society in accordance with geographical and architectural characteristics, effective air evacuation and relief missions carried out by experienced international relief teams can play an important role in the appropriate management of approximately 30,000 casualties after a catastrophic event, such as experience with the Bam Earthquake.
Introduction: In the prehospital setting, optimal endotracheal tube (ETT) depth may be approximated using the patient's sex or height, and assessed by auscultation. Even when using these methods, the ETTs still may be placed at inappropriate depths.
Problem: This study assessed the inter-rater reliability and accuracy of manual cuff palpation (ballottement) at excluding an improperly placed ETT depth in adult patients.
Methods: This is a prospective, observational, pilot study in a convenience sample of adults recently intubated in the prehospital, medical floor, intensive care unit, or emergency department settings of an urban, teaching hospital. Two physician participants separately performed ballottement on each intubated subject and rated the ballottement as none, weak, or strong prior to assessment of appropriate depth using a chest radiograph (CXR). Results were compared for simple agreement and compared to the CXR to estimate accuracy.
Results: Of 163 patients, 27 (17%) had an inappropriate ETT depth. Physician assessments of ballottement agreed in 79% of patients (95% CI = 72-85%). Chest radiograph assessment found the ETT in the “strong” ballottement group properly placed in 93%, as compared to 77% in the “weak”, and 42% in the “none” groups. Combining “weak” and “strong” ballottement, the sensitivity was 96% (95% CI = 93–100%), specificity was 26% (95% CI = 9–43%), and accuracy was 85% (95% CI = 79–90%).
Conclusions: Manual cuff palpation is a simple and reproducible technique that is sensitive, but nonspecific, in identifying intubations of appropriate depth.
This article reviews the literature describing four chemical and nuclear accidents and the lessons learned from each regarding the evacuation of civilian populations. Evacuation may save lives however, if poorly orchestrated, it may cause serious problems. For example, an inaccurate assessment of danger may lead to the evacuation of the same population twice, as the area requiring evacuation becomes larger than originally expected. Evacuation programs should focus on the vulnerable components of the populations, such as the elderly, children, and the disabled, and also should include plans for the care of pets and other animals. Training programs for civilians living near industrial centers and other high-risk areas should be considered. Finally, pre-event planning and preparation can improve the evacuation process and prevent panic behavior, and thus result in fewer casualties.
Background: The 14 neighborhoods surrounding University of Chicago Hospitals (UCH) have both Chicago's highest “ambulatory-care-sensitive condition” hospitalization rates and lack of community-based care. To address these problems, in 2004, the Southside Medical Homes (SMH) Network began linking emergency department (ED) patients with 18 community providers. The ED-based patient navigator (patient advocate) is an integral component of this network, and both their current and developing roles will be discussed.
Methods: Six navigators worked in the UCH-ED approached eligible patients that are flagged by the ED electronic tracking system. Patients were offered the services provided by primary-care referral and appropriate dental, mental health, and substance abuse facilities. Appointments were scheduled, and pertinent ED medical data was faxed to the outlying sites. Navigator roles were expanding with SMH to include: (1) focus on frequent user/chronic disease populations such as sickle cell disease where advocates will expedite a multidisciplinary clinic referral; (2) navigator training to better inform patients of the specific benefits a “medical home” provides for preventive and psychosocial care; (3) and improving navigator, and secondarily, patient knowledge, of community resources: health-education sites, vocational programs, advocacy agencies, support groups, etc.
Results/Conclusions: Data through 01 July 2007 show a monthly average of 950 ED patients surveyed and 80% of these accepting follow-up referral services. Of those patients with ED-scheduled appointments (43%) in community clinics, network data shows patients returning to their referred providers: 39% of patients have been ≥2 times. The navigator role is evolving with the expansion of SMH to include: (1) frequent-user population referrals; (2) preventive health education; and (3) utilization of community resources.
Improving public awareness through education has been recognized widely as a basis for reducing the risk of disasters. Some of the first disaster just-in-time (JIT) education modules were built within 3–6 days after the south Asia tsunami, Hurricane Katrina, and the Bam, Pakistan, and Indonesia earthquakes through a Supercourse. Web monitoring showed that visitors represented a wide spectrum of disciplines and educational levels from 120 developed and developing countries. Building disaster networks using an educational strategy seizes the opportunity of increased public interest to teach and find national and global expertise in hazard and risk information. To be effective, an expert network and a template for the delivery of JIT education must be prepared before an event occurs, focusing on developing core materials that could be customized rapidly, and then be based on the information received from a recent disaster. The recyclable process of the materials would help to improve the quality of the teaching, and decrease the time required for preparation. The core materials can be prepared for disasters resulting from events such as earthquakes, hurricanes, tsunamis, floods, and bioterrorism.