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Recent studies demonstrate that early, in-field, basic life support by paramedics improves trauma survival where prehospital transport times are long. So far, no case-control studies of the effect of layperson trauma first responders have been reported. It was hypothesized that trained layperson first responders improve trauma outcomes where prehospital transit times are long.
Methods:
A rural prehospital trauma system was established in the mine and war zones in Iraq, consisting of 135 paramedics and 7,000 layperson trauma first responders in the villages. In a non-randomized clinical study, the outcomes of patients initially managed in-field by first-responders were compared to patients not receiving first-responder support.
Results:
The mortality rate was significantly lower among patients initially managed in-field by first responders (n = 325) compared to patients without first-responder support (n = 1,016), 9.8% versus 15.6%, 95% CI = 1.3−10.0%.
Conclusions:
Trained layperson first responders improve trauma outcomes where prehospital evacuation times are long. This finding demonstrates that simple interventions done early—by any type of trained care provider—are crucial for trauma survival. Where the prevalence of severe trauma is high, trauma first-responders should be an integral element of the trauma system.
The 12 January 2010 earthquake that struck Port-au-Prince, Haiti caused >200,000 deaths, thousands of injuries requiring immediate surgical interventions, and 1.5 million internally displaced survivors. The earthquake destroyed or disabled most medical facilities in the city, seriously hampering the ability to deliver immediate life- and limb-saving surgical care. A Project Medishare/University of Miami Miller School of Medicine trauma team deployed to Haiti from Miami within 24 hours of the earthquake. The team began work at a pre-existing tent facility in the United Nations (UN) compound based at the airport, where they encountered 225 critically injured patients. However, non-sterile conditions, no means to administer oxygen, the lack of surgical equipment and supplies, and no anesthetics precluded the immediate delivery of general anesthesia. Despite these limitations, resuscitative care was administered, and during the first 72 hours following the event, some amputations were performed with local anesthesia. Because of these austere conditions, an anesthesiologist, experienced and equipped to administer regional block anesthesia, was dispatched three days later to perform anesthesia for limb amputations, debridements, and wound care using single shot block anesthesia until a better equipped tent facility was established. After four weeks, the relief effort evolved into a 250-bed, multi-specialty trauma/intensive care center staffed with >200 medical, nursing, and administrative staff. Within that timeframe, the facility and its staff completed 1,000 surgeries, including spine and pediatric neurological procedures, without major complications. This experience suggests that when local emergency medical resources are completely destroyed or seriously disabled, a surgical team staffed and equipped to provide regional nerve block anesthesia and acute pain management can be dispatched rapidly to serve as a bridge to more advanced field surgical and intensive care, which takes longer to deploy and set up.
Incident monitoring has been shown to improve patient care and has been adopted widely in the hospital care setting. There are limited data on incident monitoring in the prehospital setting.
Hypothesis:
A high-yield, systems-oriented, incident monitoring process can be implemented successfully in a prehospital setting.
Methods:
This prospective, descriptive study outlines the implementation of an incident monitoring process in a regional prehospital setting. Both trauma care and non-trauma care were monitored by a system of anonymous reporting and chart review with debriefing for trauma cases that met major trauma criteria. A committee reviewed all identified cases and coded and logged all incidents and provider recommendations.
Results:
There were 454 incidents identified from 230 cases (mean = 2.0; 95% CI 1.8−2.1 per case). Anonymous reporting resulted in the identification of 113 incidents from 69 cases (1.6l per case 95% CI = 1.4−1.9 per case) Major trauma cases generated 266 incidents from 134 cases (mean = 2.0; 95% CI = 1.8−2.2 per case), and there were 74 incidents from 26 combined cases (mean = 2.9; 95% CI = 2.2−3.5 per case). One incident was uncategorized. There were 315 (69.4%) incidents categorized as management problems and 123 (27.1%) were system problems. Prolonged scene time was the most common incident in both management and system categories; 56 (17.8%) and 18 (14.6%) respectively. Mitigating circumstances were found in 111 (24.4%) incidents. The most common incident-related patient outcome was none/near miss (127 (28%)). Incident monitoring most commonly led to generalized feedback (105 (23.1%)) or specific trend analysis (140 (30.8%)). Reports to higher or external bodies occurred in 18 incidents (4.0%).
Conclusions:
The project has been implemented successfully in a regional prehospital settling. The methodology, utilizing a number of incident detection techniques, results in a high yield of incidents over a broad range of error types. The large proportion of “near miss” type incidents allows for incident assessment without demonstrable patient harm. Many incidents were mitigated and the majority represented management-type issues.
The purpose of this study was to evaluate the ability of first-year paramedic students to identify ST-segment elevation myocardial injury (STEMI) on 12-lead electrocardiograms (ECGs) following a three-hour presentation by a board-certified emergency medicine physician experienced in ECG interpretation.
Methods:
Thirty-three first-year paramedic students with minimal to no experience in evaluating 12-lead ECGs were administered a pretest with 20 12-lead ECGs and were asked to evaluate each for: (1) presence of STEMI (STEMI identification); (2) if STEMI presents, ECG leads demonstrating ST-elevation (LEAD identification); and (3) if STEMI present, the anatomic distribution of the STEMI (ANATOMY identification). The students were randomized into two groups. Group 1 (16 students; control group) received a handout describing the evaluation of ECGs for STEMI, while Group 2 (17 students; experimental group) received the handout plus a threehour presentation on the evaluation of ECGs for STEMI. Following randomization, distribution of the STEMI handout and ECG STEMI presentation, a posttest with 20 new ECGs was administered to all participants. The pretest and posttest mean scores were compared between the two groups to determine if attendance at the presentation improved the paramedic students' abilities to evaluate and identify STEMI ECGs. Following the STEMI posttest, students in Group 1 were provided with the STEMI lecture. Students were retested with 20 new ECGs five months following the initial study to examine retention of the information taught.
Results:
The mean pre-test scores for the two groups (Group 1 vs Group 2, respectively) in STEMI identification (74.4 vs 75.6%; p = 0.79), lead identification (50.0 vs. 51.2%; p = 0.8) and anatomy identification (49.4 vs 51.8%; p = 0.60) were similar in all three categories. Post-test scores between Group 1 and Group 2 demonstrated statistically significant differences in STEMI identification (85.6 vs 92.4%; p <0.02), lead identification (73.4 vs 85.2%; p <0.02), and anatomy identification (65.9 vs 87.1%; p <0.01), with Group 2 demonstrating higher mean scores relative to Group 1 in all three categories. Comparison of mean initial pre-test and five-month retest scores for all students demonstrated statistically significant differences in STEMI identification (75.0 vs 87.4%; p <0.0001), lead identification (50.6 vs 82.2%; p <0.0001), and anatomy identification (50.6 vs 76.6%; p <0.0001).
Conclusions:
The ability of first-year paramedic students to accurately detect STEMI on prehospital 12-lead ECGs is enhanced by a structured ECG STEMI presentation provided by an emergency medicine physician, and these students maintained excellent retention of STEMI ECG skills over a five-month period.
The Darfur region of Sudan has been an intense focus of humanitarian concern since rebellions began there early in 2003. In 2004, the US Secretary of State declared that conflict in Darfur represented genocide. Since 2003, many sample surveys and various mortality estimates for Darfur have been made. Nonetheless, confusion and controversy surrounding mortality levels and trends have continued. For this project, results were reviewed from the highest quality field surveys on mortality in Darfur conducted between 2003 and 2008. Trend analysis demonstrated a dramatic decline in mortality over time in Darfur. By 2005, mortality levels had fallen below emergency levels and have continued to decline. Deaths directly due violence have declined as a proportion of all of the deaths in Darfur. Declining mortality in Darfur was not associated with other proximate improvements in well-being, such as improved nutrition. Without large-scale, humanitarian intervention, continuing high rates of mortality due to violence likely would have occurred. If mortality had continued at the high rate documented in 2004, by January 2009, there would have been 330,000 additional deaths. With the humanitarian assistance provided through the United Nations and non-governmental organizations, these people are alive today. A focus on excess deaths among non-combatants may draw attention away from other needs, such as establishing better security, improving service delivery to the displaced, and advocating for internally displaced persons to be reached today and to re-establish their lives and livelihoods tomorrow.
All events that result in disasters are unique, and it is impossible to become fully prepared. However, through thorough planning and preparedness, it is possible to gain a better understanding of the typical injury patterns and problems that arise from a variety of hazards. Such events have the potential to claim many lives and overwhelm local medical resources. Burn disasters vary in scope of injury and procedures required, and are much more labor and resource intensive than non-burn disasters.
This review of the literature should help determine whether, despite each event having its own unique features, there still are common problems disaster responders face in the prehospital and hospital phases, what recommendations were made from these disasters, and whether these recommendations have been implemented into practice and the current disaster planning processes.
The objective of this review was to assess: (1) prehospital and hospital responses used during past burn disasters; (2) problems faced during those disaster responses; (3) recommendations made following those disasters; (4) whether these recommendations were integrated into practice; and (5) the key characteristics of burn disasters and how they differ from other disasters. This review is important to determine why, despite having disaster plans, things still go wrong.
Standard gauze field dressings and direct pressure occasionally are inadequate for the control of hemorrhage. QuikClot® Combat Gauze™ (QCG) combines surgical gauze with an inorganic material and is approved by the Food and Drug Administration and by the Israeli Standards Institute for external hemorrhage control. The purpose of this article is to report clinical use of this dressing during Operation Cast Lead in the Gaza strip during January 2009.
Methods:
QuikClot Combat Gauze and the QCG guidelines were issued to advanced life support (ALS) providers during the preparations for the Operation.
All cases of injuries involving hemorrhage were reviewed, as well as interviews with the ALS providers (physicians and paramedics) and injured soldiers.
Results:
Fourteen uses of QCG were reported and reviewed (out of a total of 56 hemostatic interventions in 35 cases). Dressings were applied to injuries to the head, neck, axilla, buttocks, abdomen, back, and pelvis in 10 cases, and to extremities in four cases. In 13 cases (93%), injuries were caused by blast or gunshot mechanisms. The success rate was reported as 79% (11/14). Failure to control hemorrhage was reported in three cases in three different locations: neck, buttock, and thigh. All failures were attributed to severe soft tissue and vascular injuries. No complications or adverse events were reported.
Conclusions:
This report on the clinical field use of the QCG dressing by ALS providers suggests that it is an effective and safe product, and applicable for prehospital treatment of combat casualties. This report further suggests that QCG should be issued to medics as well as ALS providers. Larger clinical investigations are needed to confirm these findings.
Terrorist bombings continue to remain a risk for local jurisdictions, and retrospective data from the United States show that bombings occur in residential and business areas due to interpersonal violence without political motives. In the event of a mass-casualty bombing incident, prehospital care providers will have the responsibility for identifying and managing blast injuries unique to bombing victims. In a large-scale event, emergency medical services personnel should be required to provide prolonged medical care in the prehospital setting, and they will be able to deliver improved care with a better understanding of blast injuries and a concise algorithm for managing them. Blast injuries are categorized as primary, secondary, tertiary, and quaternary, and these injuries are related to the mechanism of injury from the blast event. After an initial evaluation, the emergency healthcare provider should consider following a universal algorithm to identify and treat blast injuries within these categories to prevent further morbidity or mortality in the prehospital setting.
On 13 September 2008, Hurricane Ike made landfall near Galveston, Texas, resulting in an estimated 74 deaths statewide and extensive damage in many counties. The Texas Department of State Health Services, US Public Health Service, and the Centers for Disease Control and Prevention conducted assessments beginning 12 days following hurricane landfall to identify the public health needs of three affected communities. The results of the assessment are presented, and an example of a type of public health epidemiological response to a disaster due to a natural hazard is provided.
Methods:
A one-page questionnaire that focused on household public health characteristics was developed. Using a two-stage cluster sampling methodology, 30 census blocks were selected randomly in three communities (Galveston, Liberty, and Manvel, Texas). Seven households were selected randomly from each block to interview.
Results:
The assessments were conducted on 25, 26, and 30 September 2008. At the time of the interview, 45% percent of the households in Galveston had no electricity, and 26% had no regular garbage collection. Forty-six percent reported feeling that their residence was unsafe to inhabit due to mold, roof, and/or structural damage, and lack of electricity. Sixteen percent of households reported at least one member of the household had an injury since the hurricane. In Liberty, only 7% of the household members interviewed had no access to food, 4% had no working toilet, 2% had no running water, and 2% had no electricity. In Manvel, only 5% of the households did not have access to food, 3% had no running water, 2% had no regular garbage collection, and 3% had no electricity.
Conclusions:
Post-Ike household-level surveys conducted identified the immediate needs and associated risks of the affected communities. Despite the response efforts, a high proportion of households in Galveston still were reportedly lacking electricity and regular garbage pickup 17 days post-storm. The proportion of households with self-reported injury in Galveston suggested the need to enhance public education on how to prevent injuries during hurricane cleanup. Galveston public health officials used the assessment to educate local emergency and elected officials of the health hazards related to lack of basic utilities and medical care in the community. This resulted in the provision of an extensive public health outreach education program throughout the island. The Liberty and Manvel assessment findings suggest that most households in both communities were receiving the basic utilities and that the residents felt “safe”. The assessments reassured local health officials that there were no substantial acute public health needs and provided objective information that services were being restored.
Mass gatherings have a higher patient presentation rate than is found within the general population. Despite this fact, many mass gatherings are occurring without suitable medical coverage. South Africa has had no standard approach or model to determine the number of medical personnel needed to deploy to an event. The awarding of the FIFA (Federation International de Football Association) 2010 World Cup to South Africa has provided the impetus for the development of such a model. The model presented in this paper is based on existing recommendations that originate from the United Kingdom.
This paper outlines the modifications that have been made to this model to ensure that adequate medical resources still are provided, albeit in a developing country where medical resources may not be as plentiful.