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Obesity is a growing epidemic in the United States with increasing burden to the health care system. Management and transport of the morbidly obese (MO) pose challenges for Emergency Medical Services (EMS) providers. Though equipment and resources are being directed to the transport of the obese, little research exists to guide these efforts. To address this, the author of this study sought to assess EMS providers’ perspectives on the challenges of caring for MO patients.
Methods
An anonymous, web-based survey was distributed to all active providers of prehospital transport of a large, urban, fire-based EMS system to evaluate the challenges of MO patients. The definition of MO was left up to the provider. This survey looked at various components of transport: lifting, transport time, airway management, establishing intravenous access, drug administration, as well as demographics, equipment, and education needs. The survey contained yes/no, rank-order, and Likert scale questions. Data were analyzed using descriptive statistics. The study was approved by the University of Miami (Miami, Florida USA) Institutional Review Board.
Results
Of survey participants, 71.9% felt the average weight of their patients had increased, and 100% reported to have transported a MO patient. Of calls made to EMS, 25% were only for assistance in the house and another 25% were for non-emergent transport to a health care facility; shortness of breath was the most common emergent complaint. Of specific challenges to properly care for MO patients, 94.4 % ranked lifting and/or moving the patient highest, followed by airway management, intravenous access, and measuring vital signs. A total of 43.8% of respondents felt that MO patients require at least six to eight EMS personnel to transport patients while 31.8% felt more than eight providers were necessary. Greater than 81.3% felt it would be beneficial to receive more training and 90.4% felt more equipment was needed. Of participants, 68.8 % felt that MO patients did not receive the same standard of care.
Conclusions
Surveyed participants reported that patient’s weights are increasing with all having transported a MO patient. Despite the majority of transports being for non-emergent problems, providers felt more training would be beneficial, that equipment available does not meet needs, and that the MO pose challenges to appropriate patient care.
CienkiJJ. Emergency Medical Service Providers’ Perspectives towards Management of the Morbidly Obese. Prehosp Disaster Med. 2016;31(5):471–474.
Accidental hypothermia can lead to untoward cardiac manifestations and arrest. This report presents a case series of severe accidental hypothermia with cardiac complications in three emergency patients who were treated with extracorporeal membrane oxygenation (ECMO) and survived after re-warming. The aim of this discussion was to encourage more clinicians to consider ECMO as a re-warming therapy for severe hypothermia with circulatory collapse and to prompt discussion about decreasing the barriers to its use.
NiehausMT, PechulisRM, WuJK, FreiS, HongJJ, SandhuRS, GreenbergMR. Extracorporeal Membrane Oxygenation (ECMO) for Hypothermic Cardiac Deterioration: A Case Series. Prehosp Disaster Med. 2016;31(5):570–571.
Emergency medical technicians (EMTs) and paramedics are at serious risk for work-related injuries (WRIs) during work hours. Both EMTs and paramedics have higher WRI rates, according to the literature data. This study was designed to investigate causes and characteristics of WRIs involving EMTs and paramedics staffed in Western Turkey.
Methods
All health care personnel staffed in Emergency Medical Services (EMS) in the city were interviewed face-to-face in their off-duty hours to inform them about the study. Excluded from the study were those who declined to participate in the study, those who were not on duty during the two-month study period, and those who had been working in the EMS for less than one year. The subjects were asked to answer multiple-choice questions.
Results
A total of 163 personnel (117 EMTs and 46 paramedics) comprised the study sample. Eighty-three personnel (50.9%) were female and mean age was 29.7 years (SD=8.4 years). The most common mechanisms of WRI, as reported by the personnel, were motor vehicle accidents (MVAs; 31.9%), needlestick injuries (16.0%), ocular exposure to bodily fluids (15.4%), and sharp injuries (9.8%), respectively. Needlestick injuries commonly occurred during intravenous line procedures (59.4%) and inside the cruising ambulance (n=20; 62.5%). Working inside the cruising ambulance was the most commonly accused cause of the WRI (41.3%).
Conclusion
Paramedic personnel and EMTs are under high risk of WRI. Motor vehicle accidents and needlestick injuries were the most common causes of WRI. Strict measures need to be taken to restructure the interior design to protect personnel from all kinds of WRIs.
YilmazA, SerinkenM, DalO, YaylacıS, KarciogluO. Work-related Injuries Among Emergency Medical Technicians in Western Turkey. Prehosp Disaster Med. 2016;31(5):505–508.
The objective of this report was to show how the Center for Humanitarian Emergencies (the Center) at Emory University (Atlanta, Georgia USA) has trained graduate students to respond to complex humanitarian emergencies (CHEs) through innovative educational programs, with the goal of increasing the number of trained humanitarian workers. Natural disasters are on the rise with more than twice as many occurring from 2000-2009 as there were from 1980-1989. In 2012 alone, 144 million people were affected by a natural disaster or displaced by conflict worldwide. This has created an immense need for trained humanitarian workers to respond effectively to such disasters. The Center has developed a model for educational programming that targets learners along an educational continuum ranging from the undergraduate level through continuing professional education. These programs, based in the Rollins School of Public Health (RSPH) of Emory University, include: a competency-based graduate certificate program (the Certificate) in humanitarian emergencies; a fellowship program for mid-career professionals; and funded field practica. The competency-based Certificate program began in 2010 with a cohort of 14 students. Since then, 101 students have received the Certificate with 50 more due for completion in 2016 and 2017 combined. The fellowship program for mid-career professionals has hosted four fellows from conflict-affected or resource-poor countries, who have then gone on to assume leadership positions with humanitarian organizations. From 2009-2015, the field practicum program supported 34 students in international summer practicum experiences related to emergency response or preparedness. Students have participated in summer field experiences on every continent but Australia. Together the Certificate, funded field practicum opportunities, and the fellowship comprise current efforts in providing innovative education and training for graduate and post-graduate students of public health in humanitarian response. These modest efforts are just the beginning in terms of addressing the global shortage of skilled public health professionals that can coordinate humanitarian response. Evaluating existing programs will allow for refinement of current programs. Ultimately, these programs may influence the development of new programs and inform others interested in this area.
EvansDP, AndersonM, ShahparC, del RioC, CurranJW. Innovation in Graduate Education for Health Professionals in Humanitarian Emergencies. Prehosp Disaster Med. 2016;31(5):532–538.
There were 5,385 deceased and 710 missing in the Ishinomaki medical zone following the Great East Japan Earthquake that occurred in Japan on March 11, 2011. The Ishinomaki Zone Joint Relief Team (IZJRT) was formed to unify the relief teams of all organizations joining in support of the Ishinomaki area. The IZJRT expanded relief activity as they continued to manually collect and analyze assessments of essential information for maintaining health in all 328 shelters using a paper-type survey. However, the IZJRT spent an enormous amount of time and effort entering and analyzing these data because the work was vastly complex. Therefore, an assessment system must be developed that can tabulate shelter assessment data correctly and efficiently. The objective of this report was to describe the development and verification of a system to rapidly assess evacuation centers in preparation for the next major disaster.
Report
Based on experiences with the complex work during the disaster, software called the “Rapid Assessment System of Evacuation Center Condition featuring Gonryo and Miyagi” (RASECC-GM) was developed to enter, tabulate, and manage the shelter assessment data. Further, a verification test was conducted during a large-scale Self-Defense Force (SDF) training exercise to confirm its feasibility, usability, and accuracy. The RASECC-GM comprises three screens: (1) the “Data Entry screen,” allowing for quick entry on tablet devices of 19 assessment items, including shelter administrator, living and sanitary conditions, and a tally of the injured and sick; (2) the “Relief Team/Shelter Management screen,” for registering information on relief teams and shelters; and (3) the “Data Tabulation screen,” which allows tabulation of the data entered for each shelter, as well as viewing and sorting from a disaster headquarters’ computer. During the verification test, data of mock shelters entered online were tabulated quickly and accurately on a mock disaster headquarters’ computer. Likewise, data entered offline also were tabulated quickly on the mock disaster headquarters’ computer when the tablet device was moved into an online environment.
Conclusions
The RASECC-GM, a system for rapidly assessing the condition of evacuation centers, was developed. Tests verify that users of the system would be able to easily, quickly, and accurately assess vast quantities of data from multiple shelters in a major disaster and immediately manage the inputted data at the disaster headquarters.
IshiiT, NakayamaM, AbeM, TakayamaS, KameiT, AbeY, YamaderaJ, AmitoK, MorinoK. Development and Verification of a Mobile Shelter Assessment System “Rapid Assessment System of Evacuation Center Condition Featuring Gonryo and Miyagi (RASECC-GM)” for Major Disasters. Prehosp Disaster Med. 2016;31(5):539–546.
Primary triage in a mass-casualty event setting using low-visibility tags may lead to informational confusion and difficulty in judging triage attribution of patients. In this simulation study, informational confusion during primary triage was investigated using a method described in a prior study that applied Shannon’s Information Theory to triage.
Hypothesis
Primary triage using a low-visibility tag leads to a risk of informational confusion in prioritizing care, owing to the intermingling of pre- and post-triage patients. It is possible that Shannon’s entropy evaluates the degree of informational confusion quantitatively and improves primary triage.
Methods
The Simple Triage and Rapid Treatment (START) triage method was employed. In Setting 1, entropy of a triage area with 32 patients was calculated for the following situations: Case 1 – all 32 patients in the triage area at commencement of triage; Case 2 – 16 randomly imported patients to join 16 post-triage patients; Case 3 – eight patients imported randomly and another eight grouped separately; Case 4 – 16 patients grouped separately; Case 5 – random placement of all 32 post-triage patients; Case 6 – isolation of eight patients of minor priority level; Case 7 – division of all patients into two groups of 16; and Case 8 – separation of all patients into four categories of eight each. In Setting 2, entropies in the triage area with 32 patients were calculated continuously with each increase of four post-triage patients in Systems A and B (System A – triage conducted in random manner; and System B – triage arranged into four categories).
Results
In Setting 1, entropies in Cases 1-8 were 2.00, 3.00, 2.69, 2.00, 2.00, 1.19, 1.00, and 0.00 bits/symbol, respectively. Entropy increased with random triage. In Setting 2, entropies of System A maintained values the same as, or higher than, those before initiation of triage: 2.00 bits/symbol throughout the triage. The graphic waveform showed a concave shape and took 3.00 bits/symbol as maximal value when the probability of each category was 1/8, whereas the values in System B showed a linear decrease from 2.00 to 0.00 bits/symbol.
Conclusion
Informational confusion in a primary triage area measured using Shannon’s entropy revealed that random triage using a low-visibility tag might increase the degree of confusion. Methods for reducing entropy, such as enhancement of triage colors, may contribute to minimizing informational confusion.
AjimiY, SasakiM, UchidaY, KanekoI, NakaharaS, SakamotoT. Primary Triage in a Mass-casualty Event Possesses a Risk of Increasing Informational Confusion: A Simulation Study Using Shannon’s Entropy. Prehosp Disaster Med. 2016;31(5):498–504.
In resource-constrained environments, appropriately employing triage in disaster situations is crucial. Although both case-based learning (CBL) and simulation exercises (SEs) commonly are utilized in teaching disaster preparedness to adult learners, there is no substantial evidence supporting one as a more efficacious methodology. This randomized controlled trial (RCT) evaluated the effectiveness of CBL versus SEs in addition to standard didactic instruction in knowledge attainment pertaining to disaster triage preparedness.
Methods
This RCT was performed during a one-day disaster preparedness course in Lucknow, India during October 2014. Following provision of informed consent, nursing trainees were randomized to knowledge assessment after didactic teaching (control group); didactic plus CBL (Intervention Group 1); or didactic plus SE (Intervention Group 2). The educational curriculum used the topical focus of triage processes during disaster situations. Cases for the educational intervention sessions were scripted, identical between modalities, and employed structured debriefing. Trained live actors were used for SEs. After primary assessment, the groups underwent crossover to take part in the alternative educational modality and were re-assessed. Two standardized multiple-choice question batteries, encompassing key core content, were used for assessments. A sample size of 48 participants was calculated to detect a ≥20% change in mean knowledge score (α=0.05; power=80%). Robustness of randomization was evaluated using X2, anova, and t-tests. Mean knowledge attainment scores were compared using one- and two-sample t-tests for intergroup and intragroup analyses, respectively.
Results
Among 60 enrolled participants, 88.3% completed follow-up. No significant differences in participant characteristics existed between randomization arms. Mean baseline knowledge score in the control group was 43.8% (standard deviation=11.0%). Case-based learning training resulted in a significant increase in relative knowledge scores at 20.8% (P=0.003) and 10.3% (P=.033) in intergroup and intragroup analyses, respectively. As compared to control, SEs did not significantly alter knowledge attainment scores with an average score increase of 6.6% (P=.396). In crossover intra-arm analysis, SEs were found to result in a 26.0% decrement in mean assessment score (P < .001).
Conclusions
Among nursing trainees assessed in this RCT, the CBL modality was superior to SEs in short-term disaster preparedness educational translation. Simulation exercises resulted in no detectable improvement in knowledge attainment in this population, suggesting that CBL may be utilized preferentially for adult learners in similar disaster training settings.
AluisioAR, DanielP, GrockA, FreedmanJ, SinghA, PapanagnouD, ArquillaB. Case-based Learning Outperformed Simulation Exercises in Disaster Preparedness Education Among Nursing Trainees in India: A Randomized Controlled Trial. Prehosp Disaster Med. 2016;31(5):516–523.
As one of the largest marathons worldwide, the Bank of America Chicago Marathon (BACCM; Chicago, Illinois USA) accumulates high volumes of data. Race organizers and engaged agencies need the ability to access specific data in real-time. This report details a data visualization system designed for the Chicago Marathon and establishes key principles for event management data visualization. The data visualization system allows for efficient data communication among the organizing agencies of Chicago endurance events. Agencies can observe the progress of the race throughout the day and obtain needed information, such as the number and location of runners on the course and current weather conditions. Implementation of the system can reduce time-consuming, face-to-face interactions between involved agencies by having key data streams in one location, streamlining communications with the purpose of improving race logistics, as well as medical preparedness and response.
HankenT, YoungS, SmilowitzK, ChiampasG, WaskowskiD. Developing a Data Visualization System for the Bank of America Chicago Marathon (Chicago, Illinois USA). Prehosp Disaster Med. 2016;31(5):572–577.
Hospitals play a critical role in providing health care in the aftermath of disasters and emergencies. Nonetheless, while multiple tools exist to assess hospital disaster preparedness, existing instruments have not been tested adequately for validity.
Hypothesis/Problem
This study reports on the development of a preparedness assessment tool for hospitals that are part of the US Department of Veterans Affairs (VA; Washington, DC USA).
Methods
The authors evaluated hospital preparedness in six “Mission Areas” (MAs: Program Management; Incident Management; Safety and Security; Resiliency and Continuity; Medical Surge; and Support to External Requirements), each composed of various observable hospital preparedness capabilities, among 140 VA Medical Centers (VAMCs). This paper reports on two successive assessments (Phase I and Phase II) to assess the MAs’ construct validity, or the degree to which component capabilities relate to one another to represent the associated domain successfully. This report describes a two-stage confirmatory factor analysis (CFA) of candidate items for a comprehensive survey implemented to assess emergency preparedness in a hospital setting.
Results
The individual CFAs by MA received acceptable fit statistics with some exceptions. Some individual items did not have adequate factor loadings within their hypothesized factor (or MA) and were dropped from the analyses in order to obtain acceptable fit statistics. The Phase II modified tool was better able to assess the pre-determined MAs. For each MA, except for Resiliency and Continuity (MA 4), the CFA confirmed one latent variable. In Phase I, two sub-scales (seven and nine items in each respective sub-scale) and in Phase II, three sub-scales (eight, four, and eight items in each respective sub-scale) were confirmed for MA 4. The MA 4 capabilities comprise multiple sub-domains, and future assessment protocols should consider re-classifying MA 4 into three distinct MAs.
Conclusion
The assessments provide a comprehensive and consistent, but flexible, approach for ascertaining health system preparedness. This approach can provide an organization with a clear understanding of areas for improvement and could be adapted into a standard for hospital readiness.
DobalianA, SteinJA, RadcliffTA, RiopelleD, BrewsterP, HagigiF, Der-MartirosianC. Developing Valid Measures of Emergency Management Capabilities within US Department of Veterans Affairs Hospitals. Prehosp Disaster Med. 2016;31(5):475–484.
To aid in preparation of military medic trainers for a possible new curriculum in teaching junctional tourniquet use, the investigators studied the time to control hemorrhage and blood volume lost in order to provide evidence for ease of use.
Hypothesis
Models of junctional tourniquet could perform differentially by blood loss, time to hemostasis, and user preference.
Methods
In a laboratory experiment, 30 users controlled simulated hemorrhage from a manikin (Combat Ready Clamp [CRoC] Trainer) with three iterations each of three junctional tourniquets. There were 270 tests which included hemorrhage control (yes/no), time to hemostasis, and blood volume lost. Users also subjectively ranked tourniquet performance. Models included CRoC, Junctional Emergency Treatment Tool (JETT), and SAM Junctional Tourniquet (SJT). Time to hemostasis and total blood loss were log-transformed and analyzed using a mixed model analysis of variance (ANOVA) with the users represented as random effects and the tourniquet model used as the treatment effect. Preference scores were analyzed with ANOVA, and Tukey’s honest significant difference test was used for all post-hoc pairwise comparisons.
Results
All tourniquet uses were 100% effective for hemorrhage control. For blood loss, CRoC and SJT performed best with least blood loss and were significantly better than JETT; in pairwise comparison, CRoC-JETT (P < .0001) and SJT-JETT (P = .0085) were statistically significant in their mean difference, while CRoC-SJT (P = .35) was not. For time to hemostasis in pairwise comparison, the CRoC had a significantly shorter time compared to JETT and SJT (P < .0001, both comparisons); SJT-JETT was also significant (P = .0087). In responding to the directive, “Rank the performance of the models from best to worst,” users did not prefer junctional tourniquet models differently (P > .5, all models).
Conclusion
The CRoC and SJT performed best in having least blood loss, CRoC performed best in having least time to hemostasis, and users did not differ in preference of model. Models of junctional tourniquet performed differentially by blood loss and time to hemostasis.
KraghJFJr, LunatiMP, KharodCU, CunninghamCW, BaileyJA, StockingerZT, CapAP, ChenJ, AdenJK3d, CancioLC. Assessment of Groin Application of Junctional Tourniquets in a Manikin Model. Prehosp Disaster Med. 2016;31(4):358–363.
To assess the performance of two pediatric length-based tapes (Broselow and Handtevy) in predicting actual weights of US children.
Methods
In this descriptive study, weights and lengths of children (newborn through 13 years of age) were extracted from the 2009-2010 National Health and Nutrition Examination Survey (NHANES). Using the measured length ranges for each tape and the NHANES-extracted length data, every case from the study sample was coded into Broselow and Handtevy zones. Mean weights were calculated for each zone and compared to the predicted Broselow and Handtevy weights using measures of bias, precision, and accuracy. A sub-sample was examined that excluded cases with body mass index (BMI)≥95th percentile. Weights of children longer than each tape also were examined.
Results
A total of 3,018 cases from the NHANES database met criteria. Although both tapes underestimated children’s weight, the Broselow tape outperformed the Handtevy tape across most length ranges in measures of bias, precision, and accuracy of predicted weights relative to actual weights. Accuracy was higher in the Broselow tape for shorter children and in the Handtevy tape for taller children. Among the sub-sample with cases of BMI≥95th percentile removed, performance of the Handtevy tape improved, yet the Broselow tape still performed better. When assessing the weights of children who were longer than either tape, the actual mean weights did not approximate adult weights; although, those exceeding the Handtevy tape were closer.
Conclusions
For pediatric weight estimation, the Broselow tape performed better overall than the Handtevy tape and more closely approximated actual weight.
LoweCG, CampwalaRT, ZivN, WangVJ. The Broselow and Handtevy Resuscitation Tapes: A Comparison of the Performance of Pediatric Weight Prediction. Prehosp Disaster Med. 2016;31(4):364–375.
Physicians are key disaster responders in foreign medical teams (FMTs) that provide medical relief to affected people. However, few studies have examined the skills required for physicians in real, international, disaster-response situations.
Problem
The objectives of this study were to survey the primary skills required for physicians from a Japanese FMT and to examine whether there were differences in the frequencies of performed skills according to demographic characteristics, previous experience, and dispatch situations to guide future training and certification programs.
Methods
This cross-sectional survey used a self-administered questionnaire given to 64 physicians with international disaster-response site experience. The questionnaire assessed demographic characteristics (sex, age, years of experience as a physician, affiliation, and specialty), previous experience (domestic disaster-relief experience, international disaster-relief experience, or disaster medicine training experience), and dispatch situation (length of dispatch, post-disaster phase, disaster type, and place of dispatch). In addition, the frequencies of 42 performed skills were assessed via a five-point Likert scale. Descriptive statistics were used to assess the participants’ characteristics and total scores as the frequencies of performed skills. Mean scores for surgical skills, health care-related skills, public health skills, and management and coordination skills were compared according to the demographic characteristics, previous experience, and dispatch situations.
Results
Fifty-two valid questionnaires (81.3% response rate) were collected. There was a trend toward higher skill scores among those who had more previous international disaster-relief experience (P=.03). The more disaster medicine training experience the participants had, the higher their skill score was (P<.001). Physicians reported involvement in 23 disaster-relief response skills, nine of which were performed frequently. There was a trend toward higher scores for surgical skills, health care-related skills, and management and coordination skills related to more disaster medicine training experience.
Conclusion
This study’s findings can be used as evidence to boost the frequency of physicians’ performed skills by promoting previous experience with international disaster relief and disaster medicine training. Additionally, these results may contribute to enhancing the quality of medical practice in the international disaster relief and disaster training curricula.
NoguchiN,
InoueS,
ShimanoeC,
ShibayamaK,
MatsunagaH,
TanakaS,
IshibashiA,
ShinchiK. What Kinds of Skills Are Necessary for Physicians Involved in International Disaster Response?Prehosp Disaster Med. 2016;31(4):397–406.