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Pediatric disaster medicine (PDM) triage is a vital skill set for pediatricians, and is a required component of residency training by the Accreditation Council for Graduate Medical Education (ACGME). Simulation training is an effective tool for preparing providers for high-stakes, low-frequency events. Debriefing is a learner-centered approach that affords reflection on one's performance, and increases the efficacy of simulation training. The purpose of this study was to measure the efficacy of a multiple-victim simulation in facilitating learners’ acquisition of pediatric disaster medicine (PDM) skills, including the JumpSTART triage algorithm. It was hypothesized that multiple patient simulations and a structured debriefing would improve triage performance.
Methods
A 10-victim school-shooting scenario was created. Victims were portrayed by adult volunteers, and by high- and low-fidelity simulation manikins that responded physiologically to airway maneuvers. Learners were pediatrics residents. Expected triage levels were not revealed. After a didactic session, learners completed the first simulation. Learners assigned triage levels to all victims, and recorded responses on a standardized form. A group structured debriefing followed the first simulation. The debriefing allowed learners to review the victims and discuss triage rationale. A new 10-victim trauma disaster scenario was presented one week later, and a third scenario was presented five months later. During the second and third scenarios, learners again assigned triage levels to multiple victims. Wilcoxon sign rank tests were used to compare pre- and post-test scores and performance on pre- and post-debriefing simulations.
Results
A total of 53 learners completed the educational intervention. Initial mean triage performance was 6.9/10 patients accurately triaged (range = 5-10, SD = 1.3); one week after the structured debriefing, the mean triage performance improved to 8.0/10 patients (range = 5-10, SD = 1.37, P < .0001); five months later, there was maintenance of triage improvement, with a mean triage score of 7.8/10 patients (SD = 1.33, P < .0001).
Over-triage of an uninjured child with special health care needs (CSHCN) (67.8% of learners prior to debriefing, 49.0% one week post-debriefing, 26.2% five months post-debriefing) and under-triage of head-injured, unresponsive patients (41.2% of learners pre-debriefing, 37.5% post-debriefing, 11.0% five months post-debriefing) were the most common errors.
Conclusions
Structured debriefings are a key component of PDM simulation education, and resulted in improved triage accuracy; the improvement was maintained five months after the educational intervention. Future curricula should emphasize assessment of CSHCN and head-injured patients.
Cicero MX, Auerbach MA, Zigmont J, Riera A, Ching K, Baum CR. Simulation training with structured debriefing improves residents’ pediatric disaster triage performance. Prehosp Disaster Med. 2012;27(3):1-6.
Over the past two decades, Los Angeles County has implemented a Hospital Emergency Response Team (HERT) to provide on-scene, advanced surgical care of injured patients as an element of the local Emergency Medical Services (EMS) system. Since 2008, the primary responsibility of the team has been to perform surgical procedures in the austere field setting when prolonged extrication is anticipated. Following the maxim of “life over limb,” the team is equipped to provide rapid amputation of an entrapped extremity as well as other procedures and medical care, such as anxiolytics and advanced pain control. This report describes the development and implementation of a local EMS system HERT.
Scott C, Putnam B, Bricker S, Schneider L, Raby S, Koenig W, Gausche-Hill M. The development and implementation of a Hospital Emergency Response Team (HERT) for out-of-hospital surgical care. Prehosp Disaster Med. 2012;27(3):1-5.
During responses to disasters, the credibility of humanitarian agencies can be threatened by perceptions of poor quality of the responses. Many initiatives have been introduced over the last two decades to help address these issues and enhance the overall quality of humanitarian response, often with limited success. There remain important gaps and deficiencies in quality assurance efforts, including potential conflicts of interest. While many definitions for quality exist, a common component is that meeting the needs of the “beneficiary” or “client” is the ultimate determinant of quality. This paper examines the current status of assessment and accountability practices in the humanitarian response community, identifies gaps, and recommends timely, concise, and population-based assessments to elicit the perspective of quality performance and accountability to the affected populations. Direct and independent surveys of the disaster-affected population will help to redirect ongoing aid efforts, and generate more effective and comparable methods for assessing the quality of humanitarian practices and assistance activities.
Kirsch TD, Perrin P, Burkle FM Jr, Canny W, Purdin S, Lin W, Sauer L. Requirements for independent community-based quality assessment and accountability practices in humanitarian assistance and disaster relief activities. Prehosp Disaster Med. 2012;27(3):1-6.
During disasters and mass-casualty incidents (MCIs), there may be insufficient numbers of advanced life support (ALS) providers to provide intravenous (IV) access to all patients requiring parenteral fluids and/or medications. Enzyme-assisted subcutaneous infusion (EASI) access, in which human recombinant hyaluronidase (HRH) augments subcutaneous fluid dispersion and absorption, may be useful when ALS resources are insufficient to meet intravascular access needs. The utility of the use of the EASI lies, in part, in its ease of placement by ALS personnel.
Objectives
The objectives of this study were to document the feasibility, comfort, and speed/degree of infused-glucose uptake through EASI lines placed by basic-level emergency medical technicians (EMT-Bs).
Methods
Eighteen EMT-Bs instituted EASI access on each other. A total of 150 units (1 mL) of HRH were administered through the EASI line, followed by the administration of 250 mL of tracer-labeled D5W. Timed phlebotomy enabled gas chromatography/mass spectrometry characterization of glucose uptake. Enzyme-assisted subcutaneous infusion placement and comfort ratings were tracked and analyzed using non-parametric statistics and Fisher's Exact Test.
Results
In all 18 subjects, EASI access required only one attempt and was rated by the EMT-Bs as easy to accomplish. Glucose was absorbed quickly (within five minutes) in all subjects. The rate of infusion was rapid (median 393 mL/hour) and was comfortable for the recipients (median pain score 1/10).
Conclusions
The use of EASI may be viable as a fast, simple, and reliable method for the administration of fluid and glucose by EMT-Bs.
Soremekun OA, Shear ML, Connolly J, Stewart CE, Thomas SH. Basic-level emergency medical technician administration of fluids and glucose via enzyme-assisted subcutaneous infusion access. Prehosp Disaster Med. 2012;27(3):1-6.
This report of an aircraft crash at a major airport in Kingston, Jamaica examines the response of the local Emergency Medical Services (EMS). Factors that impacted the response are discussed, and the need for more disaster simulation exercises is highlighted. The objective of this case report was to document the response of EMS personnel to the crash of American Airlines Flight 331, and to utilize the information to examine and improve the present protocol.
While multiple errors can occur during a mass-casualty event, these can be reduced by frequent simulation exercises during which various personnel practice and learn designated roles. Efficient triage, proper communication, and knowledge of the roles are important in ensuring the best possible outcome. While the triage system and response of the EMS personnel were effective for this magnitude of catastrophe, more work is needed in order to meet predetermined standards. Ways in which this can be overcome include: (1) hosting more disaster simulation exercises; (2) encouraging more involvement with first responders; and (3) strengthening the links in the local EMS system. Vigorous public education must be instituted and maintained.
Dasgupta S, French S, Williams-Johnson J, Hutson R, Hart N, Wong M, Williams E, Espinosa K, Maycock C, Edwards R, McCartney T, Cawich S, Crandon I. EMS response to an airliner crash. Prehosp Disaster Med. 2012;27(3):1-4.
A principal strategy for the integration of mental health and psychosocial support in emergency settings is the training of front-line workers in international consensus-based guidelines.
Aim
This paper presents a pilot study evaluating changes in knowledge and understanding as a result of a brief training course in Nepal.
Method
Evaluation questionnaires were distributed to participants in two-day courses (n = 109) before, directly after, and at two months following completion.
Results
The course resulted in a post-training increase in correct answers of 21%, which further increased to 25% at two months.
Conclusion
A short training course based on widely endorsed guidelines to front-line staff can significantly increase mental health literacy for complex emergencies. While promising, the trend of knowledge gain is modest at most, and suggests a need for more intensive or more targeted training courses.
Jordans MJD, Luitel NP, Poudyal B, Tol WA, Komproe IH. Evaluation of a brief training on mental health and psychosocial support in emergencies: a pre- and post-assessment in Nepal. Prehosp Disaster Med. 2012;27(3):1-4.
Exposure to mass trauma has contributed to increasing concern about the well-being of children, families, and communities. In spite of global awareness of the dramatic impact of mass trauma on youth, little is known about how children and adolescents cope with and adapt to disasters and terrorism. While coping has yet to be fully conceptualized as a unified construct, the process of responding to stress includes recognized cognitive, emotional, and behavioral components. Unfortunately, research on the complex process of adaptation in the aftermath of mass trauma is a relatively recent focus. Further study is needed to build consensus in terminology, theory, methods, and assessment techniques to assist researchers and clinicians in measuring children's coping, both generally and within the context of mass trauma. Advancements are needed in the area of coping assessment to identify internal and external factors affecting children's stress responses. Additionally, enhanced understanding of children's disaster coping can inform the development of prevention and intervention programs to promote resilience in the aftermath of traumatic events. This article examines the theoretical and practical issues in assessing coping in children exposed to mass trauma, and includes recommendations to guide assessment and research of children's coping within this specialized context.
Pfefferbaum B, Noffsinger MA, Wind LH. Issues in the assessment of children's coping in the context of mass trauma. Prehosp Disaster Med. 2012;27(3):1-8.
This section of Prehospital and Disaster Medicine (PDM) presents reports and summaries of the 17th World Congress on Disaster and Emergency Medicine (WCDEM) held in Beijing, China in May and June of 2011. Included are reports and summaries that were submitted for publication in PDM.
Abstracts of Congress oral and poster presentations were published on September 1, 2011 as a supplement to PDM (Volume 26, Supplement 1). The 17th WCDEM was attended by 1,600 representatives from more than 57 nations, and the Congress included 315 oral and 211 poster presentations.
The editorial staff of PDM is pleased to present the following reports and session summaries of the Beijing 17th WCDEM.
Reports and session summaries of the 17th World Congress on Disaster and Emergency Medicine. Prehosp Disaster Med. 2012;27(3):1-11.
Despite intense public awareness campaigns, many patients with ST-elevation myocardial infarction (STEMI) do not utilize Emergency Medical Services (EMS) transportation to the Emergency Department (ED). Predictors for mode of transport by EMS versus private vehicle in patients with an acute STEMI were investigated.
Hypothesis
It was hypothesized that patient characteristics, specifically older age, male sex, and a history of a prior cardiac intervention, would be associated with a higher likelihood of EMS utilization.
Methods
A retrospective, observational cohort study was performed for all STEMI patients treated from April 1, 2007 through June 30, 2010 at an urban, academic ED with 24-hour cardiac catheterization available. Multivariable analyses with predetermined predictors (age, sex, prior cardiac intervention, weekend/evening arrival) were performed to investigate associations with mode of transport. Door-to-balloon (D2B) times were calculated.
Results
Of the 209 STEMI patients, 11 were excluded, leaving 198 for analysis. Median age was 60 years (IQR: 53-70), 138 (70%) arrived by private vehicle, and 60 (30%) by EMS. The primary analysis did not identify significant predictors for EMS, but a post-hoc model found that private insurance (OR 0.18; 95% CI, 0.07-0.45) was associated with fewer EMS transports. Although not statistically significant due to the great variability in time of arrival for STEMI patients transported by private vehicle, EMS transports had shorter D2B times. During business hours and weekend/evenings, EMS had D2B times of 50 (IQR: 42-61) and 58 minutes (IQR: 47-63), respectively, while private vehicle transports had median D2B times of 62 (IQR: 50-74) and 78 minutes (IQR: 66-106).
Conclusion
No associations between mode of transport and patient age, sex, weekend/evening presentation and history of a prior cardiac intervention were identified. Privately insured patients were less likely to use EMS when experiencing a STEMI. More effective ways are needed to educate the public on the importance of EMS activation when one is concerned for acute coronary syndrome.
Scherer TM, Russ S, Jenkins CA, Jones ID, Slovis CM, Cunningham BL, Barrett TW. Predictors of ambulance transport in patients with ST-elevation myocardial infarction. Prehosp Disaster Med. 2012;27(3):1-5.
The safety of personnel and resources is considered to be a cornerstone of prehospital Emergency Medical Services (EMS) operations and practice. However, barriers exist that limit the comprehensive reporting of EMS safety data. To overcome these barriers, many high risk industries utilize a technique called Human Factors Analysis (HFA) as a means of error reduction. The goal of this approach is to analyze processes for the purposes of making an environment safer for patients and providers. This report describes an application of this approach to safety incident analysis following a situation during which a paramedic ambulance crew was exposed to high levels of carbon monoxide.
Levy MJ, Seaman KG, Levy JL. A human factors analysis of an EMS crew's exposure to carbon monoxide. Prehosp Disaster Med. 2012;27(3):1-2.
This report details the background, planning, and establishment of a mass-casualty management area for the Durban Moses Mabhida Stadium at the Natal Mounted Rifles base, by the Department of Health and the eThekwini Fire and Rescue Service, for the Fédération Internationale de Football Association (FIFA) 2010 Soccer World Cup. The report discusses the use of the site during the seven matches played at that stadium, and details the aspects of mass-gathering major incident site planning for football (soccer).
The area also was used as a treatment area for other single patient incidents outside of the stadium, but within the exclusion perimeter, and the 22 patients treated by the Casualty Clearing Station (CCS) team are described and briefly discussed. A site-specific patient presentation rate of 0.48 per 10,000 and transport-to-hospital rate (TTHR) of 0.09/10,000 are reported. Lessons learned and implications for future event planning are discussed in the light of the existing literature.
HardcastleTC, SamlalS, NaidooR, HendrikseS, GlosterA, RamlalM, NgemaS, RoweM. A Redundant Resource: A Pre-Planned Casualty Clearing Station for a FIFA 2010 Stadium in Durban. Prehosp Disaster Med. 2012;27(2):1-7.
The Emergency Department (ED) is the triage, stabilization and disposition unit of the hospital during a mass-casualty incident (MCI). With most EDs already functioning at or over capacity, efficient management of an MCI requires optimization of all ED components. While the operational aspects of MCI management have been well described, the architectural/structural principles have not. Further, there are limited reports of the testing of ED design components in actual MCI events. The objective of this study is to outline the important infrastructural design components for optimization of ED response to an MCI, as developed, implemented, and repeatedly tested in one urban medical center.
Report
In the authors’ experience, the most important aspects of ED design for MCI have included external infrastructure and promoting rapid lockdown of the facility for security purposes; an ambulance bay permitting efficient vehicle flow and casualty discharge; strategic placement of the triage location; patient tracking techniques; planning adequate surge capacity for both patients and staff; sufficient command, control, communications, computers, and information; well-positioned and functional decontamination facilities; adequate, well-located and easily distributed medical supplies; and appropriately built and functioning essential services.
Discussion
Designing the ED to cope well with a large casualty surge during a disaster is not easy, and it may not be feasible for all EDs to implement all the necessary components. However, many of the components of an appropriate infrastructural design add minimal cost to the normal expenditures of building an ED.
Conclusion
This study highlights the role of design and infrastructure in MCI preparedness in order to assist planners in improving their ED capabilities. Structural optimization calls for a paradigm shift in the concept of structural and operational ED design, but may be necessary in order to maximize surge capacity, department resilience, and patient and staff safety.
Halpern P, Goldberg SA, Keng JG, Koenig KL. Principles of Emergency Department facility design for optimal management of mass-casualty incidents. Prehosp Disaster Med. 2012;27(2):1-9.
As the global population is concentrated into complex environments, rapid urbanization increases the threat of conflict and insecurity. Many fast-growing cities create conditions of significant disparities in standards of living, which set up a natural environment for conflict over resources. As urban slums become a haven for criminal elements, youth gangs, and the arms trade, they also create insecurity for much of the population. Specific populations, such as women, migrants, and refugees, bear the brunt of this lack of security, with significant impacts on their livelihoods, health, and access to basic services. This lack of security and violence also has great costs to the general population, both economic and social. Cities have increasingly become the battlefield of recent conflicts as they serve as the seats of power and gateways to resources. International agencies, non-governmental organizations, and policy-makers must act to stem this tide of growing urban insecurity. Protecting urban populations and preventing future conflict will require better urban planning, investment in livelihood programs for youth, cooperation with local communities, enhanced policing, and strengthening the capacity of judicial systems.
Patel RB, Burkle FM Jr. Rapid urbanization and the growing threat of violence and conflict: a 21st century crisis. Prehosp Disaster Med. 2012;27(2):1-4.
American Emergency Medical Services (EMS) agencies largely have been untouched by the dramatic health care reform efforts underway, although change seems imminent. Clarifying the role of the modern EMS system, and the yardsticks used to evaluate its performance, will be a challenge.
This paper introduces the concept of value (or outcomes to cost ratio) in EMS, and offers value assessment as a means by which reform decisions can be framed. The best reform decisions are those that optimize both costs and outcomes. This includes: (1) attention to the patient experience; (2) disallowing the provision of unhelpful, harmful or disproven prehospital care; and (3) expanding patient dispositions beyond Emergency Departments. Costs of care will need to be tracked carefully and acknowledged. Value generation should serve as the goal of ongoing EMS reform efforts.
Munk MD. Value generation and health reform in emergency medical services. Prehosp Disaster Med. 2012;27(2):1-4.