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The purpose of this discussion is to review the use of destinations other than the hospital emergency department, to transport patients injured as a result of a mass-casualty incident (MCI). A MCI has the ability to overwhelm traditional hospital resources normally thought of as appropriate destinations for the transport of injured patients. As a result, those with less severe injuries often are required to wait before they can receive definitive treatment. This waiting period, either at the scene of the incident or in the emergency department, can increase morbidity and drain resources that can be better directed toward the transport and care of those more severely injured. Potential alternate transport destinations include physician office buildings, ambulatory care centers, ambulatory surgery centers, and urgent care centers. By allowing for transport to alternate locations, these less severely injured patients can be removed rapidly from the scene, treated, and potentially released. This effort can decrease the strain on traditional resources within the system, better allowing these resources to treat more seriously injured patients.
In a populous city like Mumbai, which lacks an organized pre-hospital emergency medical services (EMS) system, there exists an informal network through which victims arrive at the trauma center. This baseline study describes the prehospital care and transportation that currently is available in Mumbai.
Methods:
A prospective trauma database was created by interviewing 170 randomly selected patients from a total of 454 admitted over a two-month period (July–August 2005) at a Level-I, urban, trauma center.
Results:
The injured victim in Mumbai usually is rescued by a good Samaritan passer-by (43.5%) and contrary to popular belief, helped by the police (89.7%). Almost immediately after rescue, the victim begins transport to the hospital. No one waits for the EMS ambulance to arrive, as there is none. A taxi cab is the most popular substitute for the ambulance (39.3%). The trauma patient in India usually is a young man in his late-twenties, from a lower socioeconomic class. He mostly finds himself in a government hospital, as private hospitals are reluctant to provide trauma care to the seriously injured. The injured who do receive prehospital care receive inadequate and inappropriate care due to the high cost of consumables in resuscitation, and in part due to the providers' lack of training in emergency care. Those who were more likely to receive prehospital care suffered from road traffic injuries (odds ratio (OR) = 2.3) and those transported by government ambulances (OR = 10.83), as compared to railway accident victims (OR = 0 .41) and those who came by taxi (OR = 0.54).
Conclusions:
Currently, as a result of not having an EMS system, prehospital care is a citizen responsibility using societal networks. It is easy to eliminate this system and shift the responsibility to the state. The moot point is whether the state-funded EMS system will be robust enough in a resource-poor setting in which public hospitals are poorly funded. Considering the high funding cost of EMS systems in developed countries and the insufficient evidence that prehospital field interventions by the EMS actually have improved outcomes, Mumbai must proceed with caution when implementing advanced EMS systems into its congested urban traffic. Similar cities, such as Mexico City and Jakarta, have had limited success with implementing EMS systems. Perhaps reinforcing the existing network of informal providers of taxi drivers and police and with training, funding quick transport with taxes on roads and automobile fuels and regulating the private ambulance providers, could be more cost-effective in a culture in which sharing and helping others is not just desirable, but is necessary for overall economic survival.
The aim of this qualitative, retrospective review is to identify and analyze the occurrence of recurrent problems in 20 processes that cover all relevant aspects of disaster health during the response phase. Consequently, an attempt is made to determine if there are generic themes of coherences in these problems.
Methods::
Eight after-action reports of five consecutive disasters in the Netherlands, between 1996 and 2005, were integrally analyzed in a structured manner. The analysis was confined to processes from the start of the event up to and including the initial stages of hospital admission.
Results::
Problems during all five disasters arose with eight processes: (1) submission of information to the ambulance dispatch center (ADC); (2) provision of information by the ADC to disaster response personnel; (3) scaling-up of prehospital response; (4) communication; (5) logistics; (6) registration; (7) multidisciplinary cooperation; and (8) preparation. Three generic themes of coherence were identified: (1) processes in which exchange of information among medical personal plays a major role are more likely to be affected by problems than processes in which this is less relevant; (2) processes in which disaster circumstances differ from day-to-day health care, or do not figure in day-to-day health care, are more likely to give rise to problems than processes that remain essentially similar; and (3) the existence of a protocol or disaster plan governing a process does not prevent problems.
Conclusions::
The method used enables a systematic analysis of the problems in health-related processes following five consecutive disasters. The analysis confirms that the majority of problems are repeated. The identified themes of coherences are in agreement with case reports and expert opinions. They are now supported with a higher level of evidence.
There has been much federal and local health planning for an influenza pandemic in the United States, but little is known about the ability of the clinical community to deal quickly and effectively with a potentially overwhelming surge of pandemic influenza patients.
Problem:
The attitudes and expectations of emergency physicians, emergency nurses, hospital nursing supervisors, hospital administrators, and infection control personnel concerning clinical care in a pandemic were assessed.
Methods:
Key informant structured interviews of 46 respondents from 34 randomly selected emergency receiving hospitals in Los Angeles County were conducted using an Institutional Review Board-approved protocol. The interview asked about supplies/resources, triage, quality of care, and decision-making. At the conclusion of each interview, the informant was asked to provide the contact information for at least two others within their respective professional group. Interviews were transcribed and coded for key themes using qualitative analytical software.
Results:
There was little salience that an influx of variably ill patients with influenza would force stratified healthcare decision-making. There also was a general lack of preparation to address the ethics and practices of triaging patients in the clinical setting of a pandemic.
Conclusions:
Guidelines must be developed in concert with public health, medical society, and legislative authorities to help clinicians define, adopt, and communicate to the public those practice standards that will be followed in a mass population, infectious disease emergency.