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Americans are living longer and are more likely to be chronically or terminally ill at the time of death. Although surveys indicate that most people prefer to die at home, the majority of people in the United States die in acute care hospitals. Each year, approximately 400,000 persons suffer sudden cardiac arrest in the US, the majority occurring in the out-of-hospital setting. Mortality rates are high and reach almost 100% when prehospital care has failed to restore spontaneous circulation. Nonetheless, patients who receive little benefit or may wish to forgo life-sustaining treatment often are resuscitated. Risk versus harm of resuscitation efforts can be differentiated by various factors, including cardiac rhythm. Emergency medical services policy regarding resuscitation should consider its utility in various clinical scenarios. Patients, family members, emergency medical providers, and physicians all are important stakeholders to consider in decisions about out-of-hospital cardiac arrest. Ideally, future policy will place greater emphasis on patient preferences and quality of life by including all of these viewpoints.
Exsanguination from a femoral artery wound can occur in sec-onds and may be encountered more often due to increased use of body armor. Some military physicians teach compression of the distal abdominal aorta (Abdominal Aorta) with a knee or a fist as a temporizing measure.
Objective:
The objective of this study was to evaluate if complete collapse of the Abdominal Aorta was feasible and with what weight it occurs.
Methods:
This was a prospective, interventional study at a Level-I, academ-ic, urban, emergency department with an annual census of 80,000 patients. Written, informed consent was obtained from nine male volunteers after Institutional Research Board approval. Any patient who presented with abdominal pain or had undergone previous abdominal surgery was excluded from the study. Subjects were placed supine on the floor to simulate an injured soldier. Various dumbbells of increasing weight were placed over the distal Abdominal Aorta, and pulsed-wave Doppler measurements were taken at the right common femoral artery (CFA). Dumbbells were placed on top of a tightly bundled towel roughly the surface area of an adult knee. Flow measurements at the CFA were taken at increments of 20 pounds. This was repeated with weight over the proximal right artery iliac and distal right iliac artery to eval- uate alternate sites. Descriptive statistics were utilized to evaluate the data.
Results:
The mean velocity through the CFA was 75.8 cm/ sec at 0 pounds. Compression of the Abdominal Aorta ranging 80 to 140 pounds resulted in no flow in the CFA. A steady decrease in mean flow velocity was seen starting with 20 pounds. Flow velocity decreased more rapidly with compression of the prox- imal right iliac artery, and stopped in all nine volunteers by 120 pounds of pressure. For all nine volunteers, up to 80 pounds of pressure over the distal iliac artery failed to decrease CFA flow velocity, and no subject was able to tolerate more weight at that location.
Conclusion:
Flow to the CFA can be stopped completely with pressure over the distal Abdominal Aorta or proximal iliac artery in catastrophic wounds. Compression over the proximal iliac artery worked best, but a first responder still may need to apply upward of 120 pounds of pressure to stop exsanguination.
Percutaneous, transtracheal jet ventilation (percutaneous transtracheal jet ventilation) is an effective way to ventilate both adults and children. However, some authors suggest that a resuscitation bag can be utilized to ventilate through a cannula placed into the trachea.
Hypothesis:
Percutaneous transtracheal ventilation (percutaneous transtracheal ventilation) through a 14-gauge catheter is ineffective when attempted using a resuscitation bag.
Methods:
Eight insufflation methods were studied. A 14-gauge intravenous catheter was attached to an adult resuscitation bag, a pediatric resuscitation bag, wall-source (wall) oxygen, portable-tank oxygen with a regulator, and a jet ventilator (JV) at two flow rates. The resuscitation bags were connected to the 14-gauge catheter using a 7 mm adult endotracheal tube adaptor connected to a 3 cc syringe barrel. The wall and tank oxygen were connected to he 14-gauge catheter using a three-way stopcock. The wall oxygen was tested with the regulator set at 15 liters per minute (LPM) and with the regulator wide open. The tank was tested with the regulator set at 15 and 25 LPM. The JV was connected directly to the 14-gauge catheter using JV tubing supplied by the manufacturer. Flow was measured using an Ohmeda 5420 Volume Monitor. A total of 30 measurements were taken, each during four seconds of insufflation, and the results averaged (milliliters (ml) per second (sec)) for each device.
Results:
Flow rates obtained using both resuscitation bags, tank oxygen, and regulated wall oxygen were extremely low (adult 215 ±20 ml/sec; pediatric 195 ±19 ml/sec; tank 358 ±13 ml/sec; wall at 15 l/min 346 ±20 ml/sec). Flow rates of 1,394 ±13 ml were obtained using wall oxygen with the regulator wide open. Using the JV with the regulator set at 50 pounds per square inch (psi), a flow rate of 1,759 ±40 was obtained.These were the only two methods that produced flow rates high enough to provide an adequate tidal volume to an adult.
Conclusions:
Resuscitation bags should not be used to ventilate adult patients through a 14-gauge, transtracheal catheter. Jet ventilation is needed when percutaneous transtracheal ventilation is attempted. If jet ventilation is attempted using oxygen supply tubing, it must be connected to an unregulated oxygen source of at least 50 psi.
It is important to identify what kinds of drugs are required by disaster-affected populations so that appropriate donations are allocated. On 26 December 2003, an earthquake with an amplitude of 6.3 on the Richter scale struck southeastern Iran, decimating the city of Bam. In this study, the most frequently utilized and prescribed drugs for Bam outpatients during the first six months after the Bam Earthquake were investigated.
Methods:
In this descriptive, cross-sectional study, the data were collected randomly from 3,000 prescriptions of Bam outpatients who were examined by general practitioners from Emergency Medical Assistance Teams in 12 healthcare centers during the first six months after the Bam Earthquake. The data were analyzed for: (1) patient sex; (2) number of drugs/prescriptions; (3) drug category; (4) drug name (generic or brand); (5) route of administration; (6) percent of visits where the most frequent drug categories were prescribed; and (7) the 25 most frequently prescribed drugs, using World Health Organization (WHO) indicators of drug use in health facilities.
Results:
Male patients represented 47.4% and females 52.6% of the total number of outpatients. The mean number of drugs/prescriptions was 3.5 per outpatient. Oral administration was the most frequent method of administration (81.7%), followed by injections (10.9%). Respiratory drugs were the most frequently used drugs (14.2%), followed by analgesics/non-steroidal anti-inflammatory drugs (non-steroidal anti-inflammatory drugs) (11.3%), antibacterials (11.2%), gastroinestinal (GI) drugs (9.6%), and central nervous system drugs (7%). Penicillins (6.8%), cold preparations (8%), and systemic anti-acids (ranitidine and omeprazole) were among the 25 most frequently used drugs by outpatients and inhabitants of Bam during the first six months after the Bam Earthquake.
Conclusion:
Respiratory, analgesic, antibacterial, gastrointestinal, and psychiatric medications were among the most commonly prescribed pharmaceuticals after the catastrophic Bam Earthquake.The results of this study may help to predict the needs of patients during future disasters and prevent unnecessary donations of medicine.
Physicians and nurses are integral components of the public health bioterrorism surveillance system. However, most published bioterrorism preparedness surveys focus on gathering information related to selfassessed knowledge or perceived needs and abilities.
Objective:
A survey of physicians and nurses in Hawaii was conducted to assess objective knowledge regarding bioterrorism agents and diseases and perceived response readiness for a bioterrorism event.
Methods:
During June and July 2004, an anonymous survey was mailed up to three times to a random sample of all licensed physicians and nurses residing in Hawaii.
Results:
The response rate was 45% (115 of 255) for physicians and 53% (146 of 278) for nurses. Previous bioterrorism preparedness training associated significantly with knowledge-based test performance in both groups. Only 20% of physicians or nurses had had previous training in bioterrorism preparedness, and <15% felt able to respond effectively to a bioterrorism event. But, >70% expressed willingness to assist the state in the event of a bioterrorist attack.
Conclusions:
Additional bioterrorism preparedness training should be made available through continuing education and also should become a component of both medical and nursing school curricula. It is important to provide the knowledge necessary for physicians and nurses to improve their ability to perform in the event of a bioterrorist attack.
Latex allergy first was recognized early in the 20th Century, but was not a matter of concern until the last decade of that Century. The reported incidence of latex allergy in different occupations varies considerably. It has been documented in dental workers, operating theater staff, anesthetists, and laboratory technicians. However, little data specifically related to those involved in patient care in the emergency prehospital setting are available.
Methods:
A questionnaire was distributed to a sample of both volunteer and salaried first responders from St. John Ambulance Australia in South Australia and Western Australia, and the South Australian AmbulanceService. The first responders were surveyed to: (1) determine the incidence of latex allergy; (2) consider possible factors associated with its development; (3) compare characteristics of the surveyed groups; and (4) reinforce the development of an educational program.
The study tool had predetermined statistical qualities. Data were collated and processed using standard statistical procedures. Surveys were collected anonymously.
Results:
Of the 2,716 forms distributed, 1,099 were returned, resulting in an overall response rate of 40.5%. Atopy was identified in 14.9% of participants, hand dermatitis in 9.4%, and latex allergy in 6.4%. In the group of full-time ambulance officers, there was a significantly higher incidence of hand dermatitis and latex allergy. There also was a significant relationship between latex allergies and both dermatitis and glove usage (as measured by frequency and duration).
Conclusion:
In a group of first responders assessed by an anonymous, voluntary questionnaire, the subset of full-time, salaried ambulance officers was identified as having a higher incidence of hand dermatitis and latex allergy than their volunteer co-workers. These results require further assessment to substantiate the frequency of latex allergy and determine the predisposing factors. All personnel must learn about hand care. Non-powdered, natural rubber latex gloves should be supported for general use in this setting.
The ECHO Team was the second Australian team to arrive to Banda Aceh, Indonesia in response to the Southeast Asia Earthquake and Tsunami. The ECHO Team continued the work of the first Australian Team which consisted of members of the Alpha and Bravo Teams. The ECHO team left Australia on 08 January 2005. The following describes some of the more significant logistical challenges encountered by the ECHO Team.The issues the ECHO Team confronted were those expected during a mission to help to manage a disaster.
Reading the Bracha and Burkle article gave me a flashback to a military course I took early in my career:the Combat Casualty Care Course (C4), an exercise of mass-casualty triage and management. Triaging and treating the severely injured–all types of blunt and penetrating injuries–proved relatively manageable with practice. However, what I distinctly remember as the most challenging, were those cases of stress-induced psychosis that the course leaders periodically threw at us. Dazed “soldiers” with the “hundred mile stares” and predictably unpredictable thoughts and behaviors, drained our valuable resourcesas they required constant vigilance in addition to their “three hots and a cot” (three meals and a place to sleep).
On 26 December 2004, an earthquake (9.0 Richter, 10 kilometers below the sea) near Sumatra, Indonesia, triggered a tsunami, which traveled at approximately 800 km per hour to strike the Indian coastline. The disaster response at a 100-bed hospital situated on the beach front (2,028 km from the epi-center) is described.This paper underlines the benefit of the Pan-American Health Organization (PAHO)/World Health Organization (WHO) Guidelines for Natural Disasters in the Indian setting.
Methods:
The demand on the healthcare system in the affected study area (50 km2, 40,000 population) was assessed in terms of preparedness, response time, casualties, personnel, and resources. Other disaster issues studied included: (1) the disposal of the dead; (2) sanitation; (3) water supply; (4) food; (5) the role of the media; and (6) rehabilitation. Two hospital paramedics administered a disaster-related questionnaire in the local language to the victims (or an accompanying person) upon arrival at the hospital. Personalinterviews with administrative officials involved in incident management, aid, volunteers, and response, also were conducted.The outreach programs consisted of medical camps, health education, re-chlorination of contaminated drinking water, and spraying bleaching powder on wet floor areas.
Results:
The total death toll in the area was 62 (with 56, four, and two bodies being recovered on Day 1, 2, and 3 respectively). There were 17 deceased males and 45 females. The bodies immediately were handed over to the relatives upon identification or sent to the mortuary. The attendance in the makeshift accident-and-emergency department on the day of the Tsunami was 219, surged to 339 patients on Day 2, and returned to baseline census on Day 7. Essentially, injuries were minor, and two children with pulmonary edema secondary to salt-water drowning recovered fully. The hospital was cleaned of debris and seaweed on Day 3 and the equipment was restored, but it remained only partially functional. This is because many staff members did not come to work because of rumors that another tsunami was imminent.There were no outbreaks of water-borne illnesses. Post-traumatic stress disorder (PTSD) symptoms such as panic attacks, nightmares, insomnia, fear of water, being startled by loud sounds, and palpitations were detected in 17% of the patients.
Conclusions:
After an event, medical rescue personnel often are instructed by well-meaning authorities to conduct interventions and response, which have high visibility in the media. However, strictly adhering to the Pan-American Health Organization/World Health Organization guidelines proved to be cost-effective in terms of resource allocations and disaster responses in the Tsunami-affected areas. Unnecessary mass vaccinations, mass disposal of dead bodies without identification, and an influx of untrained volunteers were avoided. Inappropriate aid by developed nations often is unmindful of the victims'needs and self-esteem. The survivors demonstrated natural coping mechanisms and resilience, which only required time and psychosocial support.
Threats of bioterrorism and emerging infectious disease pandemics may result in fear-related consequences. If left undetected and untreated, fearbased signs and symptoms may be extremely debilitating and lead to chronic problems with a risk of permanent damage to the brain's locus coeruleus and stress response circuits. The triage management of susceptible, exposed, and infectious victims seeking care must be sensitive and specific enough to identify individuals with excessive levels of fear in order to address the nuances of fear-based symptoms at the initial point of contact. These acute conditions, which include hyper-vigilant fear, are managed best by timely and effective information, rapid evaluation, and possibly medications that uniquely address the locus-coeruleus-driven noradrenalin over-activation. It is recommended that a Fear and Resilience (FR) Checklist be included as an essential triage tool to identify those most at risk. The use of this checklist facilitates an enhanced capacity to respond to limitations brought about by surge capacity requirements. Whereas the utility of such a checklist is evident, predictive validity studies will be required. In addition to identifying individuals who are emotionally, medically, and socially hypo-resilient, the fear and resilience Checklist simultaneously identifies individuals who are hyper-resilient and can be asked to volunteer, and thus, rapidly expand the surge capacity.
This Supplement is a Report of the Conference convened by the Regional Office for South East Asia (SEARO) of the World Health Organization (WHO). The Conference was a follow-up to the WHO Conference of May 2005 in Phuket, Thailand on the Earthquake and Tsunami of 26 December 2004. The invitational meeting brought together representatives of 11 countries impacted by the events. The goal of the Conference was to produce a plan of action that meets the specific needs of the countries and ensure that the countries of the Region will be better equipped to cope with any future event.
Objectives:
The objectives of the Conference were to: (1) identify gaps in the health needs of the affected and vulnerable populations for preparedness, responses, recovery, and rehabilitation; (2) determine the next steps in addressing these gaps; and (3) develop benchmarks and a corresponding framework for action that must be achieved to solidify the capacities and capabilities of the health sector to meet emergencies.
Methods:
Presentations of background papers, panel discussions, and Working Groups were used. Based, in part, on the materials presented, the Working Groups drafted benchmarks that could mark the progress in achieving the overall goal and proposed strategies that could be used to reach the benchmarks. Representatives of the participating countries summarized the current status of their respective countries relative to each of the defined benchmarks.
Results:
The benchmarks relate to: (1) legal framework for preparedness and response; (2) national disaster plan for preparedness and response; (3) budget; (4) rules of engagement for external actors; (5) community plan based on risk identification and vulnerability assessment; (6)community-based capacities; (7) local capacity for provision of essential services and supplies; (8) awareness and advocacy programs; (9) identification of hazards, risks, and vulnerabilities; (10) education and training; (11) “safe” health facilities; and (12) surveillance and early warning systems.
There exists a wide range in the levels of preparedness at all levels in the affected countries particularly at the community level. The country representatives agreed that community-level preparedness, legal frameworks, local and national disaster plans, surveillance and early warning systems, and advocacy and awareness programs demand more attention.
The strategies and mechanisms that will facilitate achievement of the benchmarks were grouped into seven categories: (1) monitoring, evaluation, surveillance, and assessments; (2) education and training (human resource development); (3) information and communications; (4) legislation, policies, and authority; (5) funding; (6) planning and preparedness; and (7) coordination and control. Any or all of the strategies suggested could be implemented by the countries in the Region.
Conclusion:
The Conference delivered an important set of benchmarks and strategies that, when implemented, will facilitate the countries and the communities within them reaching better levels of preparedness and response to future events. Attaining the benchmarks will decrease the number of lives lost and minimize the pain and suffering associated with such events.
On the morning of 25 April 2005, a Japan Railway express train derailed in an urban area of Amagasaki, Japan. The crash was Japan's worst rail disaster in 40 years.This study chroniclesthe rescue efforts and highlights the capacity of Japan's urban disaster response.
Methods:
Public reports were gathered from the media, Internet, government, fire department, and railway company. Four key informants, who were close to the disaster response, were interviewed to corroborate publicdata and highlight challenges facing the response.
Results:
The crash left 107 passengers dead and 549 injured. First responders, most of whom were volunteers, were helpful in the rescue effort, and no lives were lost due to transport delays or faulty triage. Responders criticized an early decision to withdraw rescue efforts, a delay in heliport set-up, the inefficiency of the information and instruction center, and emphasized the need for training in confined space medicine. Communication and chain-of-command problems created confusion at the scene.
Conclusions:
The urban disaster response to the train crash in Amagasaki was rapid and effective.The KobeEarthquake and other incidents sparked changes that improved disaster preparedness in Amagasaki. However, communication and cooperation among responders were hampered, as in previous disasters, by the lack of a structured command system. Application of an incident command system may improve disaster coordination in Japan.
The Bam Earthquake caused one of the most destructive disasters from naturally occurring hazards in recent years. Children are one of the most vulnerable age groups during disasters, in terms of both physical and psychological injuries. The assessment of pedatric injuries in the aftermath of the Bam Earthquake is discussed is this article. Within one week of the Earthquake, 119 patients <16 years of age were admitted to three tertiary-level referral hospitals in Tehran, Iran. Extremity, chest, and abdomen, and head and spinal column injuries were present in 83, 17, and 36 patients, respectively. Lower extremity injuries were morecommon than upper extremity injuries. A total of 65 operations were performed: 52 (80%) orthopedic, eight (12.3%) general, and five (7.7%) neurosurgical.
Quarantelli established criteria for evaluating the effectiveness of disaster management.
Objectives:
The objectives of this study were to analyze the response of the healthcare system to the Tsunami disaster according to the Quarantelli principles, and to validate these principles in a scenario of a disaster due to natural hazards.
Methods:
The Israeli Defense Forces (IDF) Home Front Command Medical Department sent a research team to study the response of the Thai medical system to the disaster. The analysis of the disaster management was based on Quarantelli's 10 criteria for evaluating the management of community disasters. Data were collected through personal and group interviews.
Results:
The three most important elements for effective disaster management were: (1) the flow of information; (2) overall coordination; and (3) leadership. Although pre-event preparedness was for different and smaller scenarios, medical teams repeatedly reported a better performance in hospitals that recently conducted drills.
Conclusions:
In order to increase effectiveness, disaster management response should focus on: (1) the flow of information; (2) overall coordination; and (3) leadership.
This Panel Session consisted of three country reports (Democratic People's Republic of Korea; Sri Lanka; and Timor-Leste) and the common issues identified during the Panel discussions relative to industrial accidents and conflicts in the Southeast Asia Region. Important issues identified included the needs for: (1) use of medical technology; (2) stockpiling of essential supplies; (3) human resource development; (4) surveillance systems for disease detection; (5) coordination; and (6) emergency funding.