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Introduction: A common reason for utilizing local paramedics and the emergency medical services is for the recognition and immediate treatment of chest pain, a complaint that has multiple possible etiologies. While many of those complaining of disease processes responsible for chest pain are benign, some will be life-threatening and will require immediate identification and treatment. The ability of paramedics to not only perform field electrocardiograms (ECGs), but to accurately diagnose various unstable cardiac rhythms has shown significant reduction in time to specific treatments. Increasing the overall accuracy of ECG interpretation by paramedics has the potential to facilitate early and appropriate treatment and decrease patient morbidity and mortality.
Methods: A convenient training device (flip book) on ambulances and in common areas in the fire station could improve field interpretation of certain cardiac rhythms. This training device consists of illustrated sample ECG tracings and their associated diagnostic criteria. The goal was to enhance the recognition and interpretation of ECGs, and thereby, reduce delays in the initiation of treatment and potential complications associated with misinterpretation.
This study was a prospective, observational study using a matched pre-test/post-test design. The study period was from November 2008 to December 2008. A total of 136 paramedics were approached to participate in this study. A pre-test consisting of 15 12-lead ECGs was given to all paramedics who agreed to participate in the study. Once the pre-tests were completed, the flip books were placed in common areas. Approximately one month after the flip books were made available to the paramedics, a post-test was administered.
Statistical comparisons were made between the pre- and post-test scores for both the global test and each type of rhythm.
Results: Using these data, there were no statistically significant improvements in the global ECG interpretation or on individual rhythm interpretations.
Conclusions: A flip book with multiple ECG rhythms and definitions without the benefit of any outside support was not effective in improving paramedic identification of ECG rhythms on a post-test. Suggestions for further research include repeating the study with a larger sample size; utilizing a lecturer to explain how to use the flip book in the most efficient manner; reiterating how to read and interpret ECGs; and answering questions. Comparing test scores of paramedic students, and newly certified paramedics as opposed to veteran paramedics also may indicate that the flip books are more suited for one group over another.
Introduction: Emergency medical services (EMS) systems are a central component of the healthcare system, particularly for older patients. As currently configured, EMS transport is fundamentally petroleum dependent. Petroleum scarcity is an emerging public health concern, particularly for patient transport. Little is known regarding EMS fuel use, potential impacts of scarcity on operations, or strategies to minimize these impacts.
Objective: The objective of this study was to characterize the fuel use of a large, urban, hospital-based, dynamically-deployed EMS system, and to identify broad optimization categories to minimize EMS’s petroleum dependence.
Methods: Fuel use was reviewed retrospectively using fuel purchasing and maintenance data from January 2007 through September 2008. Data on unit-hours, call volume, and patient transports also were collected. Data were processed using descriptive statistics.
Results: During the study period, a fleet of 35 diesel ambulances operated for 277,849 unit-hours and traveled 1,902,710 miles. Detailed mileage data were available for 66,527 unit-hours, 23.9% of the sample. Overall, vehicles averaged 6.6.89 (6.71, 7.08) miles per gallon (mpg), 11.5 (10.4, 12.6) miles were travelled per call, and 16.2 (14.8, 17.6) miles per transport; 2.7 (2.4, 2.9) gallons of fuel were used per transport.
Conclusions: In this EMS system, operations are fundamentally dependent on petroleum. Mileage estimates can serve as a baseline to evaluate interventions for reducing petroleum dependence and in contingency planning. As cost pressures increase and these interventions become more common, systematic evaluations will be important.
Once again, the politically volatile Middle East and accompanying rhetoric has escalated the risk of a major nuclear exchange. Diplomatic efforts have failed to make the medical consequences of such an exchange a leading element in negotiations. The medical and academic communities share this denial. Without exaggeration, the harsh reality of the enormous consequences of an imminently conceivable nuclear war between Iran and Israel will encompass an unprecedented millions of dead and an unavoidable decline in public health and environmental devastation that would impact major populations in the Middle East for decades to come. Nuclear deterrence and the uncomfortable but real medical and public health consequences must become an integral part of a broader global health diplomacy that emphasizes health security along with poverty reduction and good governance.
Introduction: Disasters and mass-casualty scenarios may overwhelm medical resources regardless of the level of preparation. Disaster response requires medical equipment, such as ventilators, that can be operated under adverse circumstances and should be able to provide respiratory support for a variety of patient populations.
Objective: The objective of this study was to evaluate the performance of three portable ventilators designed to provide ventilatory support outside the hospital setting and in mass-casualty incidents, and their adherence to the Task Force for Mass Critical Care recommendations for mass-casualty care ventilators.
Methods: Each device was evaluated at minimum and maximum respiratory rate and tidal volume settings to determine the accuracy of set versus delivered VT at lung compliance settings of 0.02, 0.08 and 0.1 L/cm H20 with corresponding resistance settings of 10, 25, and 5 cm H2O/L/sec, to simulate patients with ARDS, severe asthma, and normal lungs. Additionally, different FIO2 settings with each device (if applicable) were evaluated to determine accuracy of FIO2 delivery and evaluate the effect on delivered VT. Ventilators also were tested for duration of battery life.
Results: VT decreased with all three devices as compliance decreased. The decrease was more pronounced when the internal compressor was activated. At the 0.65 FIO2 setting on the MCV 200, the measured FIO2 varied widely depending on the set VT. Battery life range was 311-582 minutes with the 73X having the longest battery life. Delivered VT decreased toward the end of battery life with the SAVe having the largest decrease. The respiratory rate on the SAVe also decreased approaching the end of battery life.
Conclusion: The 73X and MCV 200 were the closest to satisfying the Task Force for Mass Critical Care requirements for mass casualty ventilators, although neither had the capability to provide PEEP. The 73X provided the most consistent tidal volume delivery across all compliances, had the longest battery duration and the least decline in VT at the end of battery life.
Introduction: Radiographic findings of dengue fever have not yet been clearly elucidated in relation to clinical and serological findings, despite the fact that two-fifths of the world population lives in areas where the virus is endemic. The current study is a retrospective analyzis of ultrasonographic (USG) features of patients presenting with probable dengue fever during the outbreak of DF of 2006 in North India.
Methods: Case records of a 169 patients with probable dengue fiver were included. Ten individual sonographic parameters were reviewed vis-à-vis ascites, hepatomegaly, splenomegaly, gall bladder wall edema (GBWE), pleural effusion (right or left or both), pericardial effusion, pericholecystic collection, perinephric collection. Subjects who had GB wall thickness >3 mm as measured on ultrasound were identified as positive for GBWE. The cases were analyzed in view of their serological profile.
Results: The mean age of the subjects was 27.9 +/− 13.4 years. The mean value of the platelet count was 57.4 +/− 22.3 x 103/cmm. The most common ultrasonographic feature was ascites (126, 74.6%) followed by gall bladder wall edema (122, 72%), hepatomegaly (78, 46.2%), splenomegaly (66, 39.1%) and pericholecystic collection (63, 37.3%); 48 (28.4%) subjects demonstrated evidence of pleural effusion on the right side, while 19 (11.2%) had bilateral effusion. None of the subjects had an isolated left pleural effusion. Twenty-seven (16%) subjects reported bleeding manifestations in the form of petechiae and five (3%) developed renal dysfunction. Presence of pleural and pericardial effusions was found to be specific while ascites and GBWE were identified as highly sensitive markers for seropositive Primary DF.
Conclusions: Ultrasonographic evidence of ascites, pleuro-pericardial effusion, and gallbladder wall edema are rapidly aquired, non-invasive markers of dengue and can be helpful before serological investigations become available. These findings may indicate severity and may herald the onset of bleeding (petechiae) or predict the development of acute renal dysfunction.
Introduction: This is the first study using national data to evaluate transportation risks among emergency medical technicians (EMTs) and paramedics (to be referred to hereafter as “EMTs”) in the United States.
Hypothesis: This epidemiological study compares the transportation risks for EMTs to the transportation risks for all workers in the US.
Methods: The rates, relative risks, and proportions associated with the 1,050 injury cases with lost work days, and 30 fatalities resulting from transportation incidents occurring to EMTs in the US between 2006 and 2008 are described.
Results: The risk of transportation-related injury for EMTs in the US is about five times higher than the national average. Females were the victims in 53% of the cases yet females only accounted for about 27% of employment in this occupation. Twenty percent of cases resulted in 31 or more lost work days. There were 30 transportation related fatalities.
Conclusions: The US national EMS system is built on the premise of having an unlimited supply of 20 year olds interested in, and dedicated to, the provision of EMS care. Not only do we not have an unlimited supply of 20 year olds, we may be rapidly losing our current workforce through clearly preventable risks such as transportation incidents.
Emergency medical services workers face a rate of occupational injury that is much higher than the national average and transportation-related events are a significant component of that risk. Resources must be devoted to further research, and to the development and evaluation of interventions designed to mitigate these transportation-related hazards.
Enclosed-space smoke inhalation is the fifth most common cause of all unintentional injury deaths in the United States. Increasingly, cyanide has been recognized as a significant toxicant in many cases of smoke inhalation. However, it cannot be emergently verified. Failure to recognize the possibility of cyanide toxicity may result in inadequate treatment. Findings suggestive cyanide toxicity include: (1) a history of an enclosed-space fire scene in which smoke inhalation was likely; (2) the presence of oropharyngeal soot or carbonaceous expectorations; (3) any alteration of the level of consciousness, and particularly, otherwise inexplicable hypotension (systolic blood pressure ≤90 mmHg in adults). Prehospital studies have demonstrated the feasibility and safety of empiric treatment with hydroxocobalamin for patients with suspected smoke inhalation cyanide toxicity. Although United States Food and Drug Administration (FDA)-approved since 2006, the lack of efficacy data has stymied the routine use of this potentially lifesaving antidote. Based on a literature review and on-site observation of the Paris Fire Brigade, emergency management protocols to guide empiric and early hydroxocobalamin administration in smoke inhalation victims with high-risk presentations are proposed.
Introduction: Globally, railway transport is increasing steadily. Despite the adoption of diverse safety systems, major railway incidents continue to occur. Higher speeds and increased passenger traffic are factors that influence the risk of mass-casualty incidents and make railway crashes a reality that merits extensive planning and training.
Methods: Data on railway disasters were obtained from the Centre for Research on the Epidemiology of Disasters (CRED), which maintains the Emergency Events Database (EM-DAT). This descriptive study consists of 529 railway disasters (≥10 killed and/or ≥100 non- fatally injured) from 1910 through 2009.
Results: The number of railway disasters, people killed, and non-fatally injured, has increased throughout the last hundred years—particularly during the last four decades (1970–2009), when 88% of all disasters occurred. In the mid-20th century, a shift occurred, resulting in more people being non-fatally injured than fatally injured. During 1970–2009, 74% of all railway disasters occurred in Asia, Africa, and South and Central America, combined. The remaining 26% occurred in Europe, North America, and Oceania, combined. Since 1980, railway disasters have increased, especially in Asia and Africa, while Europe has had a decrease in railway disasters. The number killed per disaster (1970–2009) was highest in Africa (n = 55), followed by South and Central America (n = 47), and Asia (n = 44). The rate was lowest in North America (n = 10) and Europe (n = 29). On average, the number of non-fatal injuries per disaster was two to three times the number of fatalities, however, in the African countries (except South Africa) the relation was closer to 1:1, which correlates to the relation found in more developed countries during the mid-20th century. The total losses (non-fatally and fatally injured) per disaster has shown a slight decreasing trend.
Conclusions: Despite extensive crash avoidance and injury reduction safety systems, railway crashes occur on all continents, indicating that this type of incident must be accounted for in disaster planning and training. Better developed safety, crashworthiness, and rescue resources in North America and Europe may be factors explaining why the number of crashes and losses has stabilized and why the average number of people killed per disaster is lowest on these continents.
Introduction: Earthquake exposure has been associated with adverse consequences for coronary heart disease. However, the natural history and prognostic significance of earthquake-related, new-onset angina have not been characterized.
Objective: The objective of this study was to evaluate the association between episodes of depressive symptoms and one-year prognosis after the first admission to the hospital among adults with new-onset angina before and after the Sichuan earthquake.
Methods: One hundred forty-one first hospitalized patients with new-onset angina before and after the Sichuan earthquake underwent psychological assessments during their first admission to the hospital following the earthquake. Patients were followed for 12 months to determine survival status. The independent relationships between baseline variables and readmission risk after the earthquake were examined. Baseline somatic and psychosocial variables were collected with the aid of standard, validated questionnaires.
Results: The proportion of patients with moderate/severe depression symptom in the earthquake-related group is higher than among their counterparts (23.7% vs. 8.9%, p = 0.026). Patients with new-onset angina after the Sichuan earthquake had a higher risk of readmission (22.4% vs. 8.9%, p = 0.041) and longer total hospitalization (average of 13.4 ±6.8 vs. 10.7 ±5.5 days, p = 0.015). The risks for readmission was associated with moderate/severe depression (adjusted hazard ratio, 9.18 [95% confidence interval (CI) = 3.09–27.23, p = 0.0000]) and low ejection fraction (adjusted hazard ratio, 6.66 [95%CI = 2.131–20.781, p = 0.001]).
Conclusions: Among patients diagnosed with new-onset angina, those with first episode after the Sichuan earthquake generated more moderate/severe depressive symptoms and had a higher risk for readmission and longer hospital stay. Depressive symptoms upon admission and low ejection fractions were significant predictors of 12-month risk for readmission, which indicates that antidepressants should be prescribed.
Introduction: The aim of this study was to describe the current state of disaster preparedness in hospitals in the public sector in the Western Cape, South Africa with the advent of the FIFA 2010 Soccer World Cup. The objectives included the completion of a self-reported assessment of readiness at all Western Cape public sector hospitals, to identify best practice and shortfalls in these facilities, as well as putting forward recommendations for improving disaster preparedness at these hospitals.
Methods: The National Department of Health, as part of the planning for the FIFA 2010 World Cup, appointed an expert committee to coordinate improvements in disaster medicine throughout the country. This workgroup developed a Self Reported Hospital Assessment Questionnaire, which was sent to all hospitals across the country. Data only were collected from public hospitals in the Western Cape and entered onto a purpose-built database. Basic descriptive statistics were calculated. Ethical approval was obtained from the Health Sciences Faculty Research Committee of the University of Cape Town.
Results: Twenty-seven of the 41 (68%) public hospitals provided completed data on disaster planning. The study was able to ascertain what infrastructure is available and what planning already has been implemented at these institutions.
Recommendations: Most hospitals in the Western Cape have a disaster plan for their facility. Certain areas need more focus and attention; these include: (1) increasing collaborative partnerships; (2) improving HAZMAT response resources; (3) specific plans for vulnerable populations; (4) contingency plans for communication failure; (5) visitor, media and VIP dedicated areas and personnel; (6) evacuation and surge capacity plans; and (7) increased attention to training and disaster plan exercises.
Background: Trauma is a major health issue worldwide, but especially so in developing countries such as Nigeria, where no comprehensive, national, injury data exist. There is a need to better define the epidemiology of injury as a basis for formulation of violence and injury prevention strategy.
Methods: This is a systematic analysis of published data on the epidemiology of injuries.
Objectives: The objective of this study was to describe the prevalent causes of injury among adults and children, and the causes of injury mortality.
Results: The medical records of 15,694 patients from the age of two weeks to 95 years formed the analysed data set. The mean value of their ages was 27 ±13 years and the gender ratio (M:F) 2:1. The injury burden is 11.2/100,000 population. The prevalent causes of injury are: (1) road traffic crashes (RTCs) = 68.4 % of 9939 patients; (2) fall = 5.5%; (3) gunshot injury = 3.2%; and (4) burns = 2.4%. Among children, the leading causes are: (1) RTC = 33.9% of 2,199 patients; (2) fall = 29.1%; (3) foreign body related = 5.5%; (4) bites = 4.9%; and (5) burns = 4%. Mortality resulted mainly from head injury, 26.6% of 575, and hemorrhage 8.3%.
Conclusions: Road traffic incidents are the leading cause of injury among adults and children. Falls are six times more prevalent among children than for adults. Burns and firearm injuries are relatively uncommon. Injury mortality results mainly from head injury and hemorrhage.
Objective: The objective of this study was to describe the injuries and distribution of casualties resulting from the crash of Turkish Airlines flight TK 1951 near Schiphol Airport in the Netherlands on 25 of February 2009.
Methods: This was a retrospective, descriptive study. Based on a review of the hospital records for all casualties of the airplane crash, triage at the scene, time to emergency department, Abbreviated Injury Scale (AIS) and Injury Severity Score (ISS), mortality, length of hospital stay and surgical procedures were abstracted.
Results: Of the 135 passengers, nine died on-scene. A total of 126 survivors were examined in 15 hospitals; data for all survivors were available for the study. Median time between crash and arrival at an emergency department was 3.5 hours (range 1.25-5.5 hours). Six passengers were uninjured and 66 were admitted to hospital. A total of 305 injuries were recorded. The majority were head and facial injuries (92), spinal injuries (35), and fractures of extremities (38). Eighteen percent of the patients had a spinal injury. The mean ISS was 6.3 (range = 1–57). The ISS score was >15 for 13 patients. Surgical procedures (80) were necessary in 23 patients. There was no in-hospital mortality.
Conclusions: Although the accident was in an urban area, there was a significant delay between the time of the accident and the arrival of the casualties at hospital emergency departments. The Turkish Airlines crash provides extensive information for research into mass-casualty or disaster management, triage, plane crash injuries, and survivability. The “Medical Research Turkish Airlines Crash” (MOTAC) study group currently is investigating several of these issues.
A disaster is a situation that overwhelms the local population’s capacity to respond, thus necessitating a request for assistance from outside the impacted area. In these circumstances, needs usually outweigh resources. The objective of response is to do the greatest good for the greatest number of people (the utilitarian principle). As such, some unique ethical considerations will arise that are not seen in day-to-day practice.
The adoption of medical ethics principles is important in such situations, but certain provisions must be accepted. In large-scale, complex disasters, it may be impossible to provide optimal care to each patient. This paper will discuss some of the challenges for healthcare personnel at “ground zero”, how training in preventive ethics may help, and what principles can be applied when working in disaster-affected areas or when responding to disasters.
Introduction: Due to recent disasters, disaster planners increasingly are focusing on healthcare worker preparedness and response in the event of a disaster. In this study, factors associated with pediatric healthcare workers’ willingness to respond are identified.
Hypothesis: It was hypothesized that personal factors may affect a pediatric healthcare worker’s willingness to respond to work in the event of a disaster.
Methods: Employees of a tertiary, pediatric care hospital in Los Angeles were asked to complete a brief, 24-question online survey to determine their willingness to respond in the event of a disaster. Information on demographics, employment, disaster-related training, personal preparedness, and necessary resources was collected. A logistic regression model was performed to derive adjusted odds ratios (OR) and their corresponding 95% confidence intervals (95% CI).
Results: Eight hundred seventy-seven pediatric healthcare employees completed the survey (22% response rate). Almost 50% (n = 318) expressed willingness to respond in the event of a disaster. Men were more likely to be willing to respond to a disaster than were women (OR = 2.4; 95%CI = 1.6–3.6), and single/divorced/widowed employees were more willing to respond than married or partnered employees (OR = 1.5; 95%CI = 1.1–2.1). An inverse relationship was observed between number of dependents and willingness to respond (OR = 0.45; 95%CI = 0.25–0.80, ≥3 dependents compared to 0). An inverse dose response relationship between commuting distance and number of necessary resources (ptrend = 0.0485 and 0.0001, respectively) was observed. There was no association between previous disaster experience, disaster training, or personal preparedness and willingness to respond.
Conclusions: Number of dependents and resources were major factors in willingness to respond. Healthcare facilities must clearly communicate their disaster plans as well as any provisions they may make for their employees’ families in order to improve willingness among hospital employees.
Introduction: The use of wireless, electronic, medical records and communications in the prehospital and disaster field is increasing.
Objective: This study examines the role of wireless, electronic, medical records and communications technologies on the quality of patient documentation by emergency field responders during a mass-casualty exercise.
Methods: A controlled, side-to-side comparison of the quality of the field responder patient documentation between responders utilizing National Institutes of Health-funded, wireless, electronic, field, medical record system prototype (“Wireless Internet Information System for medicAl Response to Disasters” or WIISARD) versus those utilizing conventional, paper-based methods during a mass-casualty field exercise. Medical data, including basic victim identification information, acuity status, triage information using Simple Triage and Rapid Treatment (START), decontamination status, and disposition, were collected for simulated patients from all paper and electronic logs used during the exercise. The data were compared for quality of documentation and record completeness comparing WIISARD-enabled field responders and those using conventional paper methods. Statistical analysis was performed with Fisher’s Exact Testing of Proportions with differences and 95% confidence intervals reported.
Results: One hundred simulated disaster victim volunteers participated in the exercise, 50 assigned to WIISARD and 50 to the conventional pathway. Of those victims who completed the exercise and were transported to area hospitals, medical documentation of victim START components and triage acuity were significantly better for WIISARD compared to controls (overall acuity was documented for 100% vs 89.5%, respectively, difference = 10.5% [95%CI = 0.5–24.1%]). Similarly, tracking of decontamination status also was higher for the WIISARD group (decontamination status documented for 59.0% vs 0%, respectively, difference = 9.0% [95%CI = 40.9–72.0%]). Documentation of disposition and destination of victims was not different statistically (92.3% vs. 89.5%, respectively, difference = 2.8% [95%CI = -11.3–17.3%]).
Conclusions: In a simulated, mass-casualty field exercise, documentation and tracking of victim status including acuity was significantly improved when using a wireless, field electronic medical record system compared to the use of conventional paper methods.