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The Medical Priority Dispatch System (MPDS) is an emergency medical dispatch system widely used to prioritize 9-1-1 calls and optimize resource allocation. This study evaluates whether the assigned priority predicts a Delphi process-derived level of prehospital intervention in each emergency medical dispatch category.
Methods:
All patients given a MPDS priority in a suburban California county from 2004–2006 were included. A Delphi process of emergency medical services (EMS) professionals in another system developed the following categories of prehospital treatment representing increasing acuity, which were adapted for this study: advanced life support (ALS) intervention, ALS–Stat, and ALS–Critical. The sensitivities and specificities of MPDS priority for level of prehospital intervention were determined for each MPDS category.
Results:
A total of 65,268 patients met inclusion criteria, representing 61% of EMS calls during the study period. The overall sensitivities of high-priority dispatch codes for ALS, ALS-Stat, and ALS-Critical interventions were 83% (95% confidence interval 83–84%), 83% (82–84%), and 94% (92–96%). Overall specificities were: ALS, 32% (31–32%); ALS-Stat, 31% (30–31%); and ALS-Critical 28% (28–29%). Compared to calls assigned to a low priority, calls with high-priority dispatch codes were more likely to receive ALS interventions by 22%, ALS-Stat by 20%, and ALS-Critical by 32%. A low priority dispatch code decreased the likelihood of ALS interventions by 48%, ALS-Stat by 45%, and ALS-Critical by 80%. Among high-priority dispatch codes, the rates of interventions were: ALS 26%, ALS-Stat 22%, and ALS-Critical 1.5%, all of which were significantly greater than low-priority calls (p <0.05) [ALS 13%, ALS-Stat 11%, and ALS-Critical 0.2%]. Major MPDS were categories with high sensitivities (>95%) for ALS interventions included breathing problems, cardiac or respiratory arrest/death, chest pain, stroke, and unconscious/fainting; these categories had an average specificity of 3%. Medical Priority Dispatch System categories such as back pain, unknown problem, and traumatic injury had sensitivities for ALS interventions <15%.
Conclusions:
The MPDS is moderately sensitive for the Delphi process derived ALS, ALS-Stat, and ALS-Critical intervention levels, but non-specific. A low MPDS priority is predictive of no prehospital intervention. A high priority, however, is of little predictive value for ALS, ALS-Stat, or ALSCritical interventions.
Falls are one of the most common types of complaints received by 9-1-1 emergency medical dispatch centers. They can be accidental or may be caused by underlying medical problems. Though not alert” falls patients with severe outcomes mostly are “hot” transported to the hospital, some of these cases may be due to other acute medical events (cardiac, respiratory, circulatory, or neurological), which may not always be apparent to the emergency medical dispatcher (EMD) during call processing.
Objectives:
The objective of this study was to characterize the risk of cardiac arrest and “hot-transport” outcomes in patients with “not alert” condition, within the Medical Priority Dispatch System (MPDS®) Falls protocol descriptors.
Methods:
This retrospective study used 129 months of de-identified, aggregate, dispatch datasets from three US emergency communication centers. The communication centers used the Medical Priority Dispatch System version 11.3–OMEGA type (released in 2006) to interrogate Emergency Medical System callers, select dispatch codes assigned to various response configurations, and provide pre-arrival instructions. The distribution of cases and percentages of cardiac arrest and hot-transport outcomes, categorized by MPDS® code, was profiled. Assessment of the association between MPDS® Delta-level 3 (D-3) “not alert” condition and cardiac arrest and hot-transport outcomes then followed.
Results:
Overall, patients within the D-3 and D-2 “long fall” conditions had the highest proportions (compared to the other determinants in the “falls” protocol) of cardiac arrest and hot-transport outcomes, respectively. “Not alert” condition was associated significantly with cardiac arrest and hot-transport outcomes (p < 0.001).
Conclusions:
The “not alert” determinant within the MPDS® “fall” protocol was associated significantly with severe outcomes for short falls (<6 feet; 2 meters) and ground-level falls. As reported to 9-1-1, the complaint of a “fall” may include the presence of underlying conditions that go beyond the obvious traumatic injuries caused by the fall itself.
Medical care is a highly regulated field in nearly every country. Therefore, it is not surprising that legal issues regularly arise in cross-border disaster operations that have with the potential to profoundly impact the effectiveness of international assistance. Little attention has been paid to preparing for and addressing these kinds of issues. This paper will report on research by the International Federation of Red Cross and Red Crescent Societies (IFRC) on International Disaster Response Law, and discuss new developments in the international legal framework for addressing these issues.
For seven years, the IFRC has studied legal issues in cross-border disaster assistance. Its activities have included several dozen case studies, a global survey of governments and humanitarian stakeholders, and a series of meetings and high-level conferences.
The IFRC has found a consistent set of regulatory problems in major disaster relief operations related to the entry and regulation of international relief. These include some issues specific to the health field, such as the regulation of drug donations and the recognition of foreign medical qualifications. To address the gaps in domestic and international regulatory structures, the IFRC spearheaded the development of new international guidelines.
The legal risks for international health providers in disaster settings are real and should be better integrated into program planning. Governments must become more proactive in ensuring that legal frameworks are flexible enough to mitigate these problems.
The objective of this study was to identify the factors that lead to increased use of emergency medical services (EMS) by patients ≥65 years of age in an urban EMS system.
Methods:
Retrospective, case-control study of frequent EMS use among elderly patients transported during one year in an urban EMS system. Three distinct groups were examined for transports that took place in 1999: (1) 1–3 transports per year (low use); (2) 4–9 times per year (high use); and (3) those transported 10+ times (very high use). This frequency-use indicator variable is the primary outcome measurement. Predictors included age, gender, preexisting medical diseases, ethnicity, number of medications, number of medical problems, primary physician, psychiatric diagnosis, and homelessness. Analysis of predictors was done using ordinal logistic regression model, and a global test of interaction terms.
Results:
Male gender, black ethnicity, homelessness, and a variety of types of medical problems were associated with increased use of EMS resources. The strongest single predictor of case status remained homelessness, which was nearly eight times as commonly associated with frequent EMS use than for the controls. The number of medical problems and medications also were significantly associated with EMS use in this patient population. There was a lack of association of alcohol, substance abuse, and psychiatric disorders with EMS use. Patients with asthma who did not have a primary care physician were more likely to use EMS services than were those who had a physician.
Conclusions:
This analysis highlights homelessness as being strongly associated with frequent EMS use among the elderly and downplays other associated factors, such as psychiatric disease and substance use. Medical illness severity, particularly asthma when no primary care physician is available, also appears to drive frequent EMS use. Both findings have implications in terms of targeting of public resources; providing housing to medically ill elderly and primary care to asthmatics in particular, may provide dividends not only in terms of social welfare and medical care, but in preventing frequent EMS use by the elderly.
The Pre-Traumatic Vaccination Intervention (PTV) has been developed in an attempt to help rescue personnel cope with anticipated and non-anticipated disasters, and to prevent trauma-related mental disorders during and after a traumatogenic exposure. Contrary to the generally accepted approach of treating trauma after it has occurred, the PTV has been designed to be administered prior to the potentially traumatic event. Based on empirical findings, the PTV training techniques were designed to prepare the participants for distressful situations. Trainees were gradually exposed to increasingly severe sights using cognitive-behavioral techniques along with foreseen situations relating to their profession. Various interventions were aimed at normalizing using personal resources and implementing relaxation techniques. The PTV was administrated as part of the Israeli Defense Forces rescue personnel's and military police training courses. The results of an uncontrolled, preliminary study suggest that the intervention reduced the level of dissociation leading to more awareness to the traumatic event's details, less suffering, lower probability of making mistakes, and increased likelihood of returning to normal functioning. Lower dissociation may suggest a lower probability to be diagnosed with post-traumatic stress disorder among rescue personnel.
The earthquake that struck the central coast of Peru on 15 August 2007 was a disaster that mobilized international humanitarian assistance to address the needs of the affected people in the regions of Huancavelica, Ica, and Lima. It also was an opportunity to prove the effectiveness of regulations and procedures to facilitate the entry and distribution of donations and medical goods during a major emergency. In the first month after the earthquake, the national government approved new regulations that aimed to reduce waiting time while reducing the number of requisites required by customs. More than 5,500 tons of international donations arrived in Peru in a short period of time. Many donated medicines arrived unsorted, without an international non-proprietary (generic) name on the label, and some medicines did not have any relationship with the diseases that would appear in the aftermath of the event.
Large-scale events may overwhelm the capacity of even the most advanced emergency medical systems. When patient volume outweighs the number of available emergency medical services (EMS) providers, a mass-casualty incident may require the aid of non-medical volunteers. These individuals may be utilized to perform field disaster triage, lessening the burden on EMS personnel.
Objective:
The purpose of this study was to evaluate the accuracy of triage decisions made by newly enrolled first-year medical students after receiving a brief educational intervention.
Methods:
A total of 315 first-year medical students from two successive classes participated in START triage training and completed a paper-based triage exercise as part of orientation. This questionnaire consisted of 15 clinical scenarios providing brief but sufficient details for prioritization. Subjects assigned each scenario a triage category of Red, Yellow, Green, or Black, based on the START protocol and were allowed four minutes to complete the exercise. Participants from the Class of 2009 were provided with printed START reference cards, while those from the Class of 2008 were not. Two test types varying in the order of patient age values were created to determine whether patient age was a factor in triage assessment.
Results:
The mean accuracy score of triage assignment by medical student volunteers after a brief START training session was 64.3%. The overall rate of over-triage was 17.8%, compared to an under-triage rate of 12.6%. There were no significant differences in triage accuracy between subjects with and without printed materials (63.9% vs. 64.6%, p = 0.729) or those completing the age-variant test types (64.4% vs. 64.1%, p = 0.889).
Conclusions:
First-year medical students who received brief START training achieved triage accuracy scores similar to those of emergency physicians, registered nurses, and paramedics in previous studies. Observed rates of underand over-triage suggest that a need exists for improving the accuracy of triage decisions made by medical and non-medical personnel. This study did not find that printed materials significantly improved triage accuracy, nor did it find that patient age affected the ability of participants to correctly assign triage categories. Future research might further evaluate disaster triage by non-medical volunteers.
The increase in adverse health impacts of disasters has raised awareness of the need for education in the field of emergency public health. In the past, most traditional models of graduate education in schools of public health have not incorporated the theory and practice of disaster public health into their curricula. This paper describes the development of a curriculum in emergency public health within a US masters program in public health, and provides a description of the courses that comprise an area of specialization in the field. The interdisciplinary nature of the faculty, close ties with public health practitioners, and practical applications of the nine courses in this program are highlighted. The curriculum is presented as one model that can be used to meet the educational needs of professionals who will assume the responsibility for planning for and responding to the public health impacts of mass-populations disasters.
Clostridium botulinum toxins, the most poisonous substance known to humankind, are considered to be a [US] Centers for Disease Control and Prevention Category A bioterrorist agent. Despite this concern, little has been published with regard to the tactical aspects of triaging a mass-casualty event involving botulism victims arriving at an emergency department. Because neuromuscular-ventilatory failure is a principal reason for botulism's early morbidity and mortality, using a quick and sensitive test to evaluate this possibility is imperative. The purpose of this article is to propose the adoption of the Single-Breath-Count Test (SBCT). The ease and validity of the use of the SBCT in evaluating complications associated with various neuromuscular disorders make it an attractive adjunct for triage during a mass-casualty incident due to botulism. While education, immune globulin, antitoxin, and invasive airway techniques are well-recognized steps in treating botulism, incorporating a time-honored technique such as the SBCT, will be an important addition to the triage process.
The devastating Haiti earthquake rightly resulted in an outpouring of international aid. Relief teams can be of tremendous value during disasters due to natural hazards. Although nobly motivated to help, all emergency interventions have unintended consequences. In the immediate aftermath of the earthquake, many selfless individuals committed to help, but was this really all in the name of reaching out a helping hand? This case report illustrates that medical disaster tourism is alive and well.
After more than three decades of preoccupation with wars and internal political conflicts, the humanitarian community has the opportunity to re-evaluate what humanitarian crises will dominate both policy and practice in the future. In reality, these crises are already active and some are over the tipping point of recovery. These crises share the common thread of being major public health emergencies which, with a preponderance of excess or indirect mortality and morbidity dominating the consequences, requires new approaches, including unprecedented improvements and alterations in education, training, research, strategic planning, and policy and treaty agendas. Unfortunately, political solutions offered up to date are nation-state centric and miss opportunities to provide what must be global solutions. Public health, redefined as the infra-structure and systems necessary to allow communities, urban settings, and nation-states to provide physical and social protections to their populations has become an essential element of all disciplines from medicine, engineering, law, social sciences, and economics. Public health, which must be recognized as a strategic and security issue should take precedence over politics at every level, not be driven by political motives, and be globally monitored.
Tehran, Iran, with a population of approximately seven million people, is at a very high risk for a devastating earthquake. This study aims to estimate the number of units of blood required at the time of such an earthquake.
Methods:
To assume the damage of an earthquake in Tehran, the researchers applied the Centre for Earthquake and Environmental Studies of Tehran/Japan International Cooperation Agency (CEST/JICA) fault-activation scenarios, and accordingly estimated the injury-to-death ratio (IDR), hospital admission rate (HAR), and blood transfusion rate (BTR). The data were based on Iran's major earthquakes during last two decades. The following values were considered for the analysis: (1) IDR = 1, 2, and 3; (2) HAR = 0.25 and 0.35; and (3) BTR = 0.05, 0.07, and 0.10. The American Association of Blood Banks' formula was adapted to calculate total required numbers of Type-O red blood cell (RBC) units. Calculations relied on the following assumptions: (1) no change in Tehran's vulnerability from CEST/JICA study time; (2) no functional damage to Tehran Blood Transfusion Post; and (3) standards of blood safety are secure during the disaster responses. Surge capacity was estimated based on the Bam earthquake experience. The maximum, optimum, and minimum blood deficits were calculated accordingly.
Results:
No deficit was estimated in case of the Mosha fault activation and the optimum scenario of North Tehran fault. The maximum blood deficit was estimated from the activation of the Ray fault, requiring up to 107,293 and 95,127 units for the 0–24 hour and the 24–72 hour periods after the earthquake, respectively. The optimum deficit was estimated up to 46,824 and 16,528 units for 0–24 hour and 24–72 hour period after the earthquake, respectively.
Conclusions:
In most Tehran earthquake scenarios, a shortage of blood was estimated to surge the capacity of all blood transfusion posts around the country within first three days, as it might ask for a 2–8 times more than what the system had produced following the Bam earthquake.
World Youth Day (WYD) and its associated activities were held in Sydney, Australia from 15–20 July 2008. The aims of this research were to pilot the use of postcards at mass gatherings and to collect baseline data of how young people (age 16–25 years) identify factors that may affect their health and safety when attending mass gatherings.
Hypothesis:
The concerns of young people in relation to their health and safety at mass gatherings are poorly understood. It was decided that postcards would be an effective method of data collection in the mobile mass gathering environment.
Methods:
The research setting was the Pilgrim Walk at WYD. Participants on this walk were young people. To measure their health and safety concerns, a postcard was developed using a Likert scale to rank their attitudes on a continuum.
Results:
Young people stated that staying hydrated, having enough to eat, and being safe in a crowd were important to them. They also indicated that they perceived, overcrowding, getting to and from an event, and violent behavior as the greatest risks to their health and safety at a mass gathering.
Conclusions:
The problems with postcard distribution at a “mobile” mass gathering have been identified. Even so, results gathered showed that young people were focused on “in the moment” aspects of their health; such as access to food and water. They also had concerns for their safety due to potential overcrowding and/or violent behavior.
Limited data exist on the standard of care provided for children at mass gatherings and special events (MGSE). Some studies provide valuable insight into the proportion of pediatric patients that can be expected at various types of MGSEs, but an accurate breakdown of the range of pediatric conditions treated at major events has yet to be produced. Such data are essential for the preparation of MGSEs so that the health and safety of children at such events can be adequately safeguarded. The aim of this study is to examine the care requirements for children at a large, outdoor music festival in the United Kingdom.
Methods:
A retrospective review of all patient report forms (PRFs) from a large, outdoor music festival held in Leeds (UK) in 2003. Data were extracted from the PRFs using a standardized proforma and analyzed using an Excel computer program.
Results:
Pediatric cases contributed approximately 15% to the overall workload at the event. Children presented with a range of conditions that varied from those seen in the adult population. Children were more likely than adults to present for medical attention following crush injuries (OR = 2.536; 95% CI = 1.537–4.187); after a collapse/syncopal episode (OR = 2.687; 95% CI = 1.442–5.007); or complaining of nausea (OR = 3.484; 95% CI = 2.089–5.813). Alcohol/drugs were less likely to be involved in the precipitating cause for medical attention in children compared to adults (OR = 0.477; 95% CI = 0.250–0.912). No critical care incidents involving children were encountered during the event.
Conclusions:
Mass gatherings and special events in the UK, such as outdoor music festivals, can involve a large number of children who access medical care for a different range of conditions compared to adults. The care of children at large, outdoor music events should not be overlooked. Event planning in the UK should include measures to ensure that appropriately trained and equipped medical teams are used at music festivals to safeguard the welfare of children who may attend. Further research into this exciting area is required.
Simple Triage and Rapid Treatment (START) and more recently developed prehospital casualty triage algorithms are widely used, in part because they are easy to teach and learn, and can be performed rapidly. Every rapid triage protocol has inherent, significant limitations: (1) no mechanism of injury (MOI) considerations; (2) limited assessment points; and (3) no refinement in truly mass-casualty situations where transport of “minor” or “moderate” patients may be delayed.
Hypothesis:
When rapid initial triage protocols are utilized, a significant triage deficiency (“under-triage”) may occur when “minor” or “moderate” casualties actually are more severely injured than initially triaged. Some MOI produce casualties with subtle or latent (i.e., hidden or delayed) signs and symptoms not considered in the commonly used prehospital triage algorithms. This research did not focus on START or other initial triage screening methods. Instead, it focuses on developing follow-on triage guidance to more specifically prioritize “delayed transport” casualties based upon signs and symptoms related to their MOI.
Methods:
Using expert opinion and accepted clinical criteria, triage algorithms were developed to re-evaluate patients triaged to “minor” and “moderate” cohorts. A detailed literature search produced a draft list of relevant signs and symptoms for each selected MOI. The lists then were evaluated by a multi-disciplinary panel of experts via an anonymous, mail-based Delphi method. The input shaped triage algorithms for each selected MOI, which then were subjected to a second stage Delphi process.
Results:
Consensus was achieved using the Delphi method. The algorithms extend patient assessment beyond the rapid initial triage protocols and incorporate triage criteria specific to each selected injury mechanism or condition: (1) penetrating injuries; (2) unconventional MOI (burns, blast, chemical, radiation); (3) smoke and other inhalation exposure; and (4) injuries with concomitant pregnancy. The full list of triage protocols is designated by the acronym “-PLUS”.
Conclusions:
“-PLUS” Prehospital Casualty Triage may supplement the strengths of already existing, widely accepted mass-casualty triage strategies. It does not displace START or other rapid initial triage protocols, but in mass-casualty situations with extensive delays in transport, it provides a method to identify under-triage of seriously injured casualties. “-PLUS” also presents a framework for capturing the triage considerations used by experienced medical providers, and so may provide a valuable teaching tool for training future triage professionals. Further research and field assessment is required.