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Heat waves pose a serious public health risk to particular patient populations, especially in urban areas. Emergency Medical Services (EMS) in many urban areas constitute the first line of regional preparation and response to major heat wave events; however, little is known on heat wave operational impact to the EMS system, such as call volume or demand.
Objective
To examine the effect of heat wave periods on overall urban EMS system call volume and transport volume as well as the nature of the call types.
Methods
Retrospective review of all emergency medical calls to an urban, two-tiered EMS system performed over a 5-year period from 2006–2010. Heat wave days (HWD) defined as two or more consecutive days of hot weather >32.2°C (90°F) were compared with similar non-heat wave days (nHWD) of the previous year to also include two calendar days prior to and after the heat wave. National Weather Service (NWS) temperature data, daily EMS call volume data, and call type codes were collected and underwent descriptive analysis.
Results
Thirty-one HWD were identified and compared with 93 nHWD. The mean maximum temperature for HWD was 34°C (93.2°F) compared with 25.3°C (77.6°F) for nHWD (P < .001). Average daily medical emergency calls (318.4 vs 296.3, P < .001) and actual patients transported per day (247.5 vs 198.3, P < .001) were significantly higher during HWD. There was no difference in daily medical emergency call volume or EMS transports between weekdays or weekend days. No significant differences on various call types were observed between HWD and nHWD except for “heat” related calls (7.7 vs 0.5, P < .001).
Conclusion
Emergency Medical Services call volumes were significantly increased during heat waves, however there was minimal change in the types of calls received.
KueRC, DyerKS. The Impact of Heat Waves on Transport Volumes in an Urban Emergency Medical Services System: A Retrospective Review. Prehosp Disaster Med. 2013;28(6):1-6.
The treatment of hunger strikers is always contentious, chaotic and complex. The management is particularly difficult for health professionals as it raises unprecedented clinical, ethical, moral, humanitarian, and legal questions. There are never any easy answers. The current situation of prisoners from the Iraq and Afghanistan Wars currently at the Guantanamo Bay Detention Center in Cuba demands unprecedented transparency, accountability and multilevel coordination to ensure that the rights of the strikers are properly met. There are scant references available in the scientific literature on the emergency management of these tragedies. This historical perspective documents the complex issues faced by emergency physicians in Hong Kong surrounding refugee camp asylum seekers from Vietnam in 1994 and is offered as a useful adjunct in understanding the complex issues faced by emergency health providers and managers.
BurkleFMJr., ChanJTS, YeungRSD. Hunger Strikers: Historical Perspectives from the Emergency Management of Refugee Camp Asylum Seekers. Prehosp Disaster Med. 2013:28(6);1-5.
Physicians and other licensed health professionals are involved in force-feeding prisoners on hunger strike at the US Naval Base at Guantanamo Bay (GTMO), Cuba, the detention center established to hold individuals captured and suspected of being terrorists in the wake of September 11, 2001. The force-feeding of competent hunger strikers violates medical ethics and constitutes medical complicity in torture. Given the failure of civilian and military law to end the practice, the medical profession must exert policy and regulatory pressure to bring the policy and operations of the US Department of Defense into compliance with established ethical standards. Physicians, other health professionals, and organized medicine must appeal to civilian state oversight bodies and federal regulators of medical science to revoke the licenses of health professionals who have committed prisoner abuses at GTMO.
DoughertySM, LeaningJ, GreenoughPG, BurkleFMJr. Hunger Strikers: Ethical and Legal Dimensions of Medical Complicity in Torture at Guantanamo Bay. Prehosp Disaster Med. 2013;28(6):1-9.
Successful oxygenation and ventilation can mean the difference between life and death in the prehospital setting. While airway challenges can be numerous within the confines of the emergency department, there are many additional confounding difficulties in the prehospital setting, which include limited access to equipment, poor lighting, extreme environments, limited personnel to assist, no immediate backup, and limited rescue airway options. The concept of an easy, reliable, and rapidly deployable alternative rescue airway device is critical, especially when considering the addition of rapid sequence intubation protocols in the prehospital setting.
Hypothesis
The primary objective of this study was to ascertain whether paramedics can be trained to deploy this alternative airway device with an acceptable success rate in a simulated critical care airway scenario. The secondary objective was to determine whether the previously-trained paramedics were able to retain their ability to deploy the device successfully at one year.
Methods
This was a prospective, observational, single-group, descriptive cohort, educational trial. Forty paramedics were trained in the use of the Intubating Laryngeal Mask Airway (I-LMA) in a simulation medicine curriculum culminating in a simulated critical care difficult airway scenario requiring urgent oxygenation and ventilation after failed traditional endotracheal intubation. An emergency medicine physician proctor determined successful airway management. Repeat testing was then performed at approximately one year out, challenging the medics to intubate a mannequin using the I-LMA during an unrelated training session.
Results
Of the 40 paramedics who underwent complete simulation training, 39 were able to intubate and ventilate the simulated difficult airway using the I-LMA during the critical care scenario. This yields a success rate of 97.5% (95% CI, 87.1%-99.4%). At approximately one year out, 35 out of 35 medics were able to intubate the mannequin using the I-LMA, resulting in a success rate of 100% (95% CI, 91.4%-100%).
Conclusions
In this study, paramedics were able to deploy the I-LMA with a high degree of success in a simulated difficult airway, with a high degree of skill retention at one year out.
ByarsD, LoB, YatesJ. Evaluation of Paramedic Utilization of the Intubating Laryngeal Mask Airway in High-Fidelity Simulated Critical Care Scenarios. Prehosp Disaster Med.2013;28(6):1-2.
Heat waves have significant impacts on mortality and morbidity. However, little is known regarding effects on pre-admission health outcomes such as ambulance attendances, particularly in subtropical regions.
Problem
This study investigated both main temperature effects and the added effects of heat waves on ambulance attendances in Brisbane, a subtropical city in Australia.
Methods
Daily data relating to 783,935 ambulance attendances, along with data on meteorological variables and air pollutants, were collected for the period 2000-2007. Ambient temperature (main) effects were assessed using a distributed lag nonlinear approach that accounted for delayed effects of temperature, while added heat wave effects were incorporated separately using a local heat wave definition. Effect estimates were obtained for total, cardiovascular and respiratory attendances, and different age groups.
Results
Main effects of temperature were found for total attendances, which increased by 50.6% (95% CI, 32.3%-71.4%) for a 9.5°C increase above a reference temperature of 29°C. An added heat wave effect on total attendances was observed (18.8%; 95% CI, 6.5%-32.5%). Significant effects were found for both respiratory and cardiovascular attendances, particularly for those aged 65 and above.
Conclusion
Ambulance attendances can be significantly impacted by sustained periods of high temperatures, and are a valid source of early detection of the effects of extreme temperatures on the population. The planning of ambulance services may need to be adapted as a consequence of increasing numbers of heat waves in the future. Ambulance attendance data also should be utilized in the development of heat warning systems and climate change adaptation strategies.
TurnerLR, ConnellD, TongS. The Effect of Heat Waves on Ambulance Attendances in Brisbane, Australia. Prehosp Disaster Med. 2013;28(5):1-6.
To clarify the factors and reasons for the differences in the outcomes of rescue and relief efforts in Hiroshima and Nagasaki, mainly focusing on the numbers of rescue/relief staffs and casualties in the period within 72 hours of the atomic bombings in August 1945.
Methods
By retrieving the data and information from the records and reports concerning the disasters in the two cities, together with other publications as to the damages by the atomic bombings and subsequent rescue-relief activities, and restoration activities.
Results and Conclusions
It seems that there was less damage in Nagasaki, where a stronger atomic bomb was used than in Hiroshima. There were crucial geographic factors that led to the different effects in terms of the numbers of victims; however, systematic organization and mobilization of rescue and relief staffs, maintenance of functional transportation, and advanced medical knowledge and public warning with regard to disaster all may have contributed to a lower death toll and increase in survivors in Nagasaki.
MatsunariY, YoshimotoN. Comparison of Rescue and Relief Activities Within 72 Hours of the Atomic Bombings in Hiroshima and Nagasaki. Prehosp Disaster Med. 2013;28(6):1-7.
Despite their popularity and unique characteristics, county shows, also known as agricultural fairs, are amongst the least-studied mass-gathering events. Suffolk Show is one of the biggest such events in the UK, attracting tens of thousands of people annually over a 2-day period. In addition to trade stands and livestock displays, the 2011 show included top international show jumping and other sport activities.
Problem
Due to the range of activities and large number of attendees of different ages and medical backgrounds, combined with a lack of objective data about medical contacts made during these events, medical officers and local emergency services find planning an appropriate level of medical coverage for county shows particularly challenging. This study involved analyzing the characteristics of medical contacts during a major county show and assessing the level of medical coverage provided.
Methods
Data collected from St John Ambulance (SJA) and British Red Cross standard medical records of all contacts on the show ground over the two days were analyzed in terms of demographics, presenting complaints, medical history, and discharge destination. The Event Safety Guide by the Health and Safety Executive (HSE) was the agreed standard for the level of medical coverage.
Results
More than 90,000 people visited the show, with a total of 180 medical contacts recorded. Patient presentation rate (per 1,000 attendees) was 2.0 and the transport to hospital rate (per 1,000 attendees) was 0.1.
Of the 112 cases handled by SJA, 74 (66%) were women and 49 (44%) were 18-64 years of age. Wounds, lacerations and abrasions made up 26 (23.2%) of all presentations to SJA, followed by foot and lower limb blisters at 20 (17.8%). Hypertension was the most common medical history in presentations to SJA (11 cases, 10%), followed by asthma in 7 (6%).
Conclusion
The majority of presentations were due to minor injuries or ailments. An understanding of the event characteristics, demographics, and nature of medical contacts will provide organizers, medical officers, and local emergency services with information about the level of coverage and resources required. This data can further help advance knowledge of mass-gathering medicine across the various types of events.
PakravanAH, WestRJ, HodgkinsonDW. Suffolk Show 2011: Prehospital Medical Coverage in a Mass-gathering Event. Prehosp Disaster Med. 2013;28(5):1-4.
On June 29, 2012, mid-Atlantic storms resulted in a large-scale power outage affecting up to three million people across multiple (US) states. Hemodialysis centers are dependent on electricity to provide dialysis care to end-stage renal disease patients. The objective of this study was to determine how the power outage impacted operations in a sample of hemodialysis centers in the impacted regions.
Methods
The sample consisted of all hemodialysis centers located in the District of Columbia and a total of five counties with the largest power losses in West Virginia, Virginia, and Maryland. A semi-structured interview guide was developed, and the charge nurse or supervisor in each facility was interviewed. The survey questions addressed whether their centers lost power, if so, for how long, where their patients received dialysis, whether their centers had backup generators, and if so, whether they had any problems operating them, and whether their center received patients from other centers if they had power.
Results
Calls were placed to 90 dialysis centers in the sampled areas and a 90% response rate was achieved. Overall, hemodialysis operations at approximately 30% (n = 24) of the centers queried were impacted by the power outage. Of the 36 centers that lost power, 31% (n = 11) referred their patients to other dialysis centers, 22% (n = 8) accommodated their patients during a later shift or on a different day; the rest of the centers either experienced brief power outages that did not affect operations or experienced a power outage on days that the center is usually closed. Some centers in the study cohort reported receiving patients from other centers for dialysis 33% (n = 27). Thirty-two percent (n = 26) of the centers queried had backup generators on site. Eleven percent (n = 4) of the centers experiencing power outages reported that backup generators were brought in by their parent companies.
Conclusions
Comprehensive emergency planning for dialysis centers should include provisions for having backup generators on site, having plans in place for the timely delivery of a generator during a power outage, or having predesignated backup dialysis centers for patients to receive dialysis during emergencies. Most dialysis centers surveyed in this study were able to sustain continuity of care by implementing such pre-existing emergency plans.
AbirM, JanS, JubeltL, MerchantR, LurieN. The Impact of a Large-Scale Power Outage on Hemodialysis Center Operations. Prehosp Disaster Med. 2013;28(6):1-4.
High-dose intravenous nitroglycerin is a common in-hospital treatment for respiratory distress due to congestive heart failure (CHF) with hypertension. Intravenous (IV) nitroglycerin administration is impractical in the prehospital setting. In 2011, a new regional Emergency Medical Services (EMS) protocol was introduced allowing advanced providers to treat CHF with high-dose oral nitroglycerin. The protocol calls for patients to be treated with two sublingual tabs (0.8 mg) when systolic blood pressure (SBP) was >160 mm Hg, or three sublingual tabs (1.2 mg) when SBP was >200 mm Hg, every five minutes as needed.
Hypothesis/Problem
To assess the protocol's safety, the incidence of hypotension following prehospital administration of multiple simultaneous nitroglycerin (MSN) tabs by EMS providers was studied.
Methods
This study was a retrospective cohort study of patients from a single commercial EMS agency over a 6-month period. Records from patients with at least one administration of MSN were reviewed. For each administration, the first documented vital signs pre- and post-administration were compared. Administrations were excluded if pre- or post-administration vital signs were missing.
Results
One hundred case-patients had at least one MSN administration by an advanced provider during the study period. Twenty-five case-patients were excluded due to incomplete vital signs. Seventy-five case-patients with 95 individual MSN administrations were included for analysis. There were 65 administrations of two tabs, 29 administrations of three tabs, and one administration of four tabs. The mean change in SBP following MSN was -14.7 mm Hg (SD = 30.7; range, +59 to -132). Three administrations had documented systolic hypotension in the post-administration vital signs (97/71, 78/50 and 66/47). All three patients were over 65 years old, were administered two tabs, had documented improved respiratory status, and had repeat SBP of at least 100. The incidence of hypotension following MSN administration was 3.2%.
Discussion
High-dose oral nitroglycerin administration is a practical alternative to IV nitroglycerin in the prehospital setting when administered by advanced providers. The prehospital protocol for high dose oral nitroglycerin was demonstrated to be safe in the cohort of patients studied. Limitations of the study include the relatively small sample size and the inability to identify hypotension that may have occurred following the cessation of data collection in the field.
Conclusion
Hypotension was rare and self-limited in prehospital patients receiving MSN.
Hospitals are expected to continue to provide medical care during disasters. However, they often fail to function under these circumstances. Vulnerability to disasters has been shown to be related to the socioeconomic level of a country. This study compares hospital preparedness, as measured by functional capacity, between Iran and Sweden.
Methods
Hospital affiliation and size, and type of hazards, were compared between Iran and Sweden. The functional capacity was evaluated and calculated using the Hospital Safety Index (HSI) from the World Health Organization. The level and value of each element was determined, in consensus, by a group of evaluators. The sum of the elements for each sub-module led to a total sum, in turn, categorizing the functional capacity into one of three categories: A) functional; B) at risk; or C) inadequate.
Results
The Swedish hospitals (n = 4) were all level A, while the Iranian hospitals (n = 5) were all categorized as level B, with respect to functional capacity. A lack of contingency plans and the availability of resources were weaknesses of hospital preparedness. There was no association between the level of hospital preparedness and hospital affiliation or size for either country.
Conclusion
The results suggest that the level of hospital preparedness, as measured by functional capacity, is related to the socioeconomic level of the country. The challenge is therefore to enhance hospital preparedness in countries with a weaker economy, since all hospitals need to be prepared for a disaster. There is also room for improvement in more affluent countries.
DjalaliA, CastrenM, KhankehH, GrythD, RadestadM, OhlenG, KurlandL. Hospital Disaster Preparedness as Measured by Functional Capacity: a Comparison between Iran and Sweden. Prehosp Disaster Med.2013;28(5):1-8.
The Bandar Bushehr, Iran earthquake of April 9, 2013 gravely illustrates how disaster-prone areas of the world are compounding their risk of disaster and major public health emergencies when there is a geographical convergence of natural and technological hazards. Scientists must emphasize to policy makers that ever-increasing regional industrialization and the broader introduction of nuclear facilities, especially in the Middle East, must parallel sound prevention and community-level public health preparedness planning.
ArdalanA, MowafiH, BurkleFM, Jr. Iran's Disaster Risk: Now is the Time for Community-based Public Health Preparedness. Prehosp Disaster Med. 2013;28(5):1-2.
In Italy, administration of medications or advanced procedures dictates the prehospital presence of a physician to initiate treatment. Nursing staff is often used as dispatchers in Italian emergency medical ambulance services. There is little data about nursing dispatch performance in detecting high-acuity patients who need prehospital medications and procedures.
Objective
To determine the ability of a dispatch center staffed by emergency ambulance nurses to detect prehospital need for physician interventions in the context of a semi-rural area Emergency Medical Services system.
Methods
A retrospective analysis of 53,606 calls from the Rovigo Emergency Ambulance Services’ database was undertaken. Physician prehospital interventions were defined as the administration of medications or procedures (advanced airway management and ventilation, pneumothorax decompression, fluid replacement therapy, external defibrillation, cardioversion and pacing). The dispatch codes (assigned by a subjective decision-making process as Red, Yellow, or Green) of all transported prehospital patient calls were matched with an out-of-hospital triage system staffed by clinicians to determine the number of correctly identified prehospital need of physician interventions. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated.
Results
The sensitivity of subjective experience-based nursing dispatch in detecting the need for physician interventions was 78.0% (95% CI, 76.9%-79.1%), with a PPV of 36.6% (95% CI, 35.8%-37.5%). Specificity was 83.8% (95% CI: 83.4%-84.1%), with an NPV of 96.9% (95% CI, 96.8%-97.1%).
Conclusion
A dispatch center staffed by nurses with six years of experience and three months of training correctly identified when not to send a doctor to the scene in the absence of need for physician interventions, using a subjective decision-making process. The nurses staffing the dispatch center also worked in the field. Dispatch center staff were not able to predict when there was no need for physician interventions in high-acuity dispatch code patients, resulting in an over-triage and use of emergency physicians on scene.
LeopardiM, SommacampagnaM.Emergency Nursing Staff Dispatch: Sensitivity and Specificity in Detecting Prehospital Need for Physician Interventions During Ambulance Transport in Rovigo Emergency Ambulance Service, Italy. Prehosp Disaster Med. 2013;28(5):1-6.
Police officers often serve as first responders during out-of-hospital cardiac arrests (OHCA). Current knowledge and attitudes about resuscitation techniques among police officers are unknown.
Hypothesis/problem
This study evaluated knowledge and attitudes about cardiopulmonary resuscitation (CPR) and automated external defibrillators (AEDs) among urban police officers and quantified the effect of video self-instruction (VSI) on these outcomes.
Methods
Urban police officers were enrolled in this online, prospective, educational study conducted over one month. Demographics, prior CPR-AED experience, and baseline attitudes were queried. Subjects were randomized into two groups. Each group received a slightly different multiple-choice test of knowledge and crossed to the alternate test after the intervention, a 10-minute VSI on CPR and AEDs. Knowledge and attitudes were assessed immediately before and after the intervention. The primary attitude outcome was entering “very likely” (5-point Likert) to do chest compressions (CC) and use an AED on a stranger. The primary knowledge outcomes were identification of the correct rate of CC, depth of CC, and action in an OHCA scenario.
Results
A total of 1616 subjects responded with complete data (63.6% of all electronic entries). Randomization produced 819 participants in group 1, and 797 in group 2. Groups 1 and 2 did not differ significantly in any background variable. After the intervention, subjects “very likely” to do CC on a stranger increased by 17.2% (95% CI, 12.5%-21.8%) in group 1 and 21.2% (95% CI, 16.4%-25.9%) in group 2. Subjects “very likely” to use an AED on a stranger increased by 20.0% (95% CI, 15.3%-24.7%) in group 1 and 25.0% (95% CI, 20.2%-29.6%) in group 2. Knowledge of correct CC rate increased by 59.0% (95% CI, 55.0%-62.8%) in group 1 and 64.8% (95% CI, 60.8%-68.3%) in group 2. Knowledge of correct CC depth increased by 44.8% (95% CI, 40.5%-48.8%) in group 1 and 54.4% (95% CI, 50.3%-58.3%) in group 2. Knowledge of correct action in an OHCA scenario increased by 27.4% (95% CI, 23.4%-31.4%) in group 1 and 27.2% (95% CI, 23.3%-31.1%) in group 2.
Conclusion
Video self-instruction can significantly improve attitudes toward and knowledge of CPR and AEDs among police officers. Future studies can assess the impact of VSI on actual rates of CPR and AED use during real out-of-hospital cardiac arrests.
AldeenAZ, HartmanND, SequraA, PhullA, ShawDM, ChiampasGT, CourtneyDM. Video Self-instruction for Police Officers in Cardiopulmonary Resuscitation and Automated External Defibrillators. Prehosp Disaster Med. 2013;28(5):1-6.
Emergency Medical Services (EMS) providers face many ethical issues while providing prehospital care to children and adults. Although provider judgment plays a large role in the resolution of conflicts at the scene, it is important to establish protocols and policies, when possible, to address these high-risk and complex situations. This article describes some of the common situations with ethical underpinnings encountered by EMS personnel and managers including denying or delaying transport of patients with non-emergency conditions, use of lights and sirens for patient transport, determination of medical futility in the field, termination of resuscitation, restriction of EMS provider duty hours to prevent fatigue, substance abuse by EMS providers, disaster triage and difficulty in switching from individual care to mass-casualty care, and the challenges of child maltreatment recognition and reporting. A series of ethical questions are proposed, followed by a review of the literature and, when possible, recommendations for management.
BeckerTK, Gausche-HillM, AsweganAL, BakerEF, BookmanKJ, BradleyRN, De LorenzoRA, SchoenwetterDJ for the American College of Emergency Physicians’ EMS Committee. Ethical Challenges in Emergency Medical Services: Controversies and Recommendations. Prehosp Disaster Med. 2013;28(5):1-10.