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It is crucial to predict and prevent re-bleeding from ruptured intracranial aneurysms in patients with subarachnoid hemorrhage (SAH). During the prehospital period and on arrival to the hospital, blood glucose and serum potassium levels, as well as changes in levels of consciousness were assessed in patients in the acute stage of spontaneous subarachnoid hemorrhage. These assessments were analyzed as possible risk factors for re-bleeding and as potential contributors to the prevention of re-bleeding, both in prehospital care and after hospital admission.
Methods:
Upon the arrival of 202 patients with spontaneous subarachnoid hemorrhage, the following indications were examined retrospectively: (1) presence/absence of re-bleeding; (2) time interval between the onset of SAH and re-bleeding; (3) level of consciousness using the Glasgow Coma Scale (GCS) score before and on arrival; (4) amount and distribution of subarachnoid blood using Fisher's Computerized Tomography Classification; (5) blood pressure; (6) blood glucose concentration; and (7) serum potassium concentration. The patients were hospitalized in the Yokohama City University Critical Care and Emergency Center (Yokohama, Japan) between January 1991 and December 2000. The re-bleeding rate was analyzed using the chi-square ([X]2 test, and the averages and standard deviations of hematological data were compared using the Mann-Whitney U-test. The level of statistical significance was set at p <0.05.
Results:
The overall re-bleeding rate was 20.8%. Among 119 patients with a GCS score of 3–7 before arrival, 42 (35.3%) had re-bleeding, but none of the 83 patients with a GCS score of 8–15 before arrival had re-bleeding. Of 105 patients with a GCS score of 13–15 on arrival, 14 (51.8%) of 27 patients whose consciousness level was a GCS score of 3–7 before arrival experienced re-bleeding. The re-bleeding rate of this group was high. Moreover, this rebleeding group had a significantly higher blood glucose concentration than did the patients whose GCS score was 13–15 both before and on arrival. Between the patients with or without re-bleeding, there was no significant difference in the blood pressure on arrival or in distribution according to Fisher's Computerized Tomography Classification
Conclusion:
Since the re-bleeding rate is high in patients who have hyperglycemia and a history of a level of consciousness as low as a GCS score of 3–7, a detailed assessment of level of consciousness and blood glucose tests performed on arrival provide important information that will contribute to predicting and preventing re-bleeding. This may be extended to the prehospital phase, because blood glucose tests are simple and safe when performed by paramedics.
The psychosocial impacts of disasters are profound. In recent years, there have been too many reminders of these impacts and the dire needs of the people involved. The purpose of this article is to present the following themes from the psychosocial literature on disasters and emergency management: (1) differential impacts of disasters according to gender and age; (2) prevention efforts to reduce racial discrimination, rape, and other forms of abuse; (3) readiness for cultural change toward prevention and preparedness; and (4) the need to involve aid beneficiaries as active partners in relief strategies, particularly during reconstruction of communities and critical systems. Psychosocial needs change throughout the disaster cycle, particularly as social support deteriorates over time. It is important to anticipate what psychosocial needs of the public, emergency responders, support staff, and volunteers might emerge, before advancing to the next stage of the disaster. Particular consideration needs to be directed toward differential impacts of disasters based on gender, age, and other vulnerabilities.
The primary mission of the military physician assigned to a combat-arms unit is to sustain the unit's fighting strength through prevention, primary medical care, and trauma resuscitation. Technical and organizational details of civic action assistance are not emphasized routinely during training. Real-world deployment, however, presents challenges approachable only with flexibility and improvisation. Historically, combatant commanders have recognized the health of civilians in their operational area as a target through which local acceptance of United States (US) intervention may be achieved. The medium-unit (battalion and brigade) physician may be charged with providing care to the host-nation populace. Because the mission's emphasis is one of public relations and not sustainable development, lasting medical benefits are not attained. This article addresses the challenge of on-the-spot military civic assistance. The experience of the 173d Airborne Brigade (Bde) Medical Section is used to color concepts with real events. The unit attempted to reach beyond the immediate directive in order to create a program of lasting results.
Collegiate-based emergency medical systems (CBEMS) are a unique model for the delivery of prehospital care. The National Collegiate Emergency Medical Services Foundation (NCEMSF) was founded to serve as a resource for CBEMS groups. The purpose of this investigation is to describe the current state of CBEMS organizations.
Methods:
The NCEMSF maintains a Web-based, data collection system to gather data on CBEMS organizations. Collegiate-based emergency medical services are defined as emergency medical services in a university or college campus setting. The abstracted data from the NCEMSF registry were analyzed using descriptive statistics.
Results:
The NCEMSF registry contained data on 175 groups, and 145 groups were identified as providing CBEMS. The levels of service provided by the groups were: (1) first responder, 8.3%; (2) basic life support (BLS) 66.2%; (3) intermediate life support (ILS) 4.8%; (4) advanced life support (ALS), 9.7%; and (5) combination BLS/ALS, 8.3%. Transport capabilities were provided by 31.7% of the CBEMS. The average response time was estimated at 2.6 minutes (95% confidence interval (CI), 2.35–2.91 minutes). Early defibrillation using a automated external defibrillator (AED) or ALS was available by 75.9% (95% CI, 68.8–83.0) of CBEMS. Service to the community beyond the campus was provided by 21.3% of CBEMS groups. Forty-eight percent of the services operate 24 hours/day, seven days/week. The average call volume per year was 568 responses (95% CI, 315–820), and the groups averaged 29 (95% CI, 25–34) members. During the past five years, an average of 4.3 new CBEMS groups were formed per year. Eleven of the CBEMS are based at international schools.
In Australia, cardiac arrest kills 142 out of every 100,000 people each year; with only 3–4% of out-of-hospital patients with cardiac arrest in Melbourne surviving to hospital discharge. Prompt initiation of cardiopulmonary resuscitation (CPR), defibrillation, and advanced cardiac care greatly improves the chances of survival from cardiac arrest. A critical step in survival is identifying by the emergency ambulance dispatcher potential of the probability that the person is in cardiac arrest. The Melbourne Metropolitan Ambulance Service (MAS) uses the computerized call-taking system, Medical Priority Dispatch System (MPDS), to triage incoming, emergency, requests for ambulance responses. The MPDS is used in many emergency medical systems around the world, however, there is little published evidence of the system's efficacy.
Objective:
This study attempts to undertake a sensitivity/specificity analysis to determine the ability of MPDS to detect cardiac arrest.
Methods:
Emergency ambulance dispatch records of all cases identified as suspected cardiac arrest by MPDS were matched with ambulance, patient-care records and records from the Victorian Ambulance Cardiac Arrest Registry to determine the number of correctly identified cardiac arrests. Additionally, cases that had cardiac arrests, but were not identified correctly at the point of call-taking, were examined. All data were collected retrospectively for a three-month period (01 January through 31 March 2003).
Results:
The sensitivity of MPDS in detecting cardiac arrest was 76.7% (95% confidence interval (CI): 73.6%–79.8%) and specificity was 99.2% (95% CI: 99.1–99.3%). These results indicate that cardiac arrests are correctly identified in 76.7% of cases.
Conclusion:
Although the system correctly identified 76.7% of cardiac arrest cases, the number of false negatives suggests that there is room for improvement in recognition by MPDS to maximize chances for survival in out-of-hospital cardiac arrest. This study provides an objective and comprehensive measurement of the accuracy of MPDS cardiac-arrest detection in Melbourne, as well as providing a baseline for comparison with subsequent changes to the MPDS.
On 11 September 2001, two hijacked airplanes collided with the World Trade Center in New York. Both towers collapsed, spreading smoke and debris for miles. Rescue personnel arrived rapidly, but the collapse of the towers made the scene too dangerous for these teams to rescue all those trapped inside. Although this collapse was impossible to predict, fires occurring in skyscrapers can cause the structures to collapse. When a fire erupts in the upper levels of the building, it is even more difficult for those trapped inside to escape. Communications systems were shut down. In future incidents with large numbers of injured victims, the injured should be transported to hospitals by non-traditional medical transport vehicles (taxis, cars, etc.). If future disasters occur in the vicinity of a hospital, the most severely injured victims should go to the hospital instead of congregating at assembly points. These victims often are already at hospitals before substantial aid arrives at the assembly points. On-scene care must be documented, and easy-to-read triage tags should be used. Reserve power supplies in major cities should be maintained in preparation for emergencies. Both victims and rescue personnel are susceptible to post-traumatic, psychosocial reactions.
During October and November 2005, the National Norwegian Tsunami Support Association organized a journey to the disaster area for survivors. The aim of this study was to investigate whether the Tsunami affected the participants' psychological problems.
Methods:
Twenty-nine adults and 19 children made the journey. Steps were taken to enable each individual to acquire an overall understanding of the catastrophic event. Various forms of antiphobic training were provided. At the end of the stay, 28 adults replied to a questionnaire. The questions concerned: (1) motives for traveling; (2) benefits experienced; (3) psychological problems before departure; and (4) problems at the end of the stay. Parents with children were asked to assess their children's psychological problems at the same points in time.
Results:
Considerable improvements in anxiety symptoms were reported and observed in both the adults and children. No certain cases of retraumatization occurred.
Discussion:
The improvements can be understood in the light of psychodynamic, cognitive, and behavioral theory approaches. The duration of the improvement in symptoms remains to be documented. There appears to be grounds for encouraging traumatized patients to return to a disaster area as part of the treatment process if they so wish.
The potential for domestic or international terrorism involving cyanide has not diminished and in fact may have increased in recent years. This paper discusses cyanide as a terrorist weapon and the current state of readiness for a cyanide attack in the United States. Many of the factors that render cyanide appealing to terrorists are difficult to modify sufficiently to decrease the probability of a cyanide attack. For example, the relative ease with which cyanide can be used as a weapon without special training, its versatile means of delivery to intended victims, and to a large degree, its ready availability cannot be significantly modified through preparedness efforts. On the other hand, the impact of an attack can be mitigated through preparedness measures designed to minimize the physical, psychological, and social consequences of cyanide exposure. Although the nation remains ill-equipped to manage a cyanide disaster, significant progress is being realized in some aspects of preparedness. Hydroxocobalamin—a cyanide antidote that may be appropriate for use in the prehospital setting for presumptive cases of cyanide poisoning—currently is under development for potential introduction in the US. If it becomes available in the US, hydroxocobalamin could enhance the role of the prehospital emergency responder in providing care to victims of a cyanide disaster. Additional progress is required in the areas of ensuring local and regional availability of antidotal treatment and supportive interventions, educating emergency healthcare providers about cyanide poisoning and its management, and raising public awareness of the potential for a cyanide attack and how to respond.
A growing number of golfers are senior citizens, and it may be predicted that the number of golf-related medical emergencies, including the incidence of cardiac arrest, will increase. This study was designed to survey the level of preparedness of golf courses in Southeastern Pennsylvania to respond to cardiac arrest among their members.
Methods:
A telephone survey of all of the 180 golf courses in the area was conducted to determine their type (public/private), volume in rounds per year, presence of automated external defibrillator (AED) devices, number of employees, and percentage of employees with cardiopulmonary resuscitation (CPR) training. Participants also were asked to estimate the time needed to reach the farthest point on their course in order to estimate a maximum time to the application of an AED device.
Results:
A total of 131 of 180 golf courses completed the survey (53 private, 78 public) for an overall response rate of 73%. Private courses reported a greater average number of employees with CPR training [private = 9.1, public = 3.6; p = 0.001] and in AED presence [public = 9%, private = 58.5%; p = 0.0001]. Public courses support a higher volume of play than do private courses [public = 32,000, private = 24,000; p = 0.001], yet have far fewer employees [public = 25, private = 44; p = 0.004]. The longest time necessary to reach the most remote point on the course was between four and five minutes in all courses. Analysis was performed using the Student's t-test and Pearson's Chi-square as appropriate.
Conclusion:
Neither public nor private golf courses are well equipped to respond to cardiac arrest, but outcomes on public courses likely are to be far worse.
Aspirin is administered to patients with acute coronary syndromes (ACSs), but prehospital providers do not administer aspirin to all patients with chest pain that could be secondary to an ACS.
Objective:
To identify reasons prehospital providers fail to administer aspirin to all patients complaining of chest pain.
Methods:
A convenience sample of prehospital providers was surveyed as they transported patients with a chief complaint of chest pain to the emergency department. The providers were asked if they had given aspirin, nitroglycerin, or oxygen, or if they utilized a monitor. If the medications had not been administered, the paramedic was asked about the reason. The patient's age and previous cardiac history also was recorded.
Results:
A total of 52 patients with chest pain who were transported were identified over eight weeks, and all of the providers agreed to participate in the study. Only 13 of the patients (25%) received aspirin. Reasons given for not administering aspirin to the other 39 patients included: (1) chest pain was not felt to be cardiac in 13 patients (33%); (2) 10 patients already had taken aspirin that day (26%); (3) the medical provider was a basic-level emergency medical technician (EMT)-Basic and could not administer aspirin to six patients (15%); (4) pain subsided prior to arrival of emergency medical services (EMS) in these three patients; and (5) other reasons were provided for the remaining seven patients.
Conclusions:
The most common reason that paramedics did not administer aspirin was the paramedic's belief that the chest pain was not of a cardiac nature. Another common reason for not giving aspirin was the inability of EMT-Basic providers to administer aspirin.
A European Union (EU) Summit in Göteborg, Sweden, was held 15–16 June 2001. This meeting presented various security and medical concerns to city officials. In preparation for a large meeting such as the EU Summit, a plan should be established that includes basic facts, management organization, and guidelines. Clear communication beteween city agencies also must be established. Hospital inventories should be recorded daily and reported to medical staff. A command center must be in place for police and medical command. An emergency medical provider should ride in each police vehicle, so in case of a riot situation, victims can be treated quickly. An information officer should be assigned with the task of providing information regarding the injured to the media.
Mexico City has one of the highest mortality rates in Mexico, with non-intentional injuries as a leading cause of death among persons 1–44 years of age. Emergency medical services (EMS) in Mexico can achieve high levels of efficiency by offering high quality medical care at a low cost through adequate system design.
Objective:
The objective of this study was to determine whether the prehospital EMS system in Mexico City meets the criteria standards established by the American Ambulance Association Guide for Contracting Emergency Medical Services (AAA Guide) for highly efficient EMS systems.
Methods:
This retrospective, descriptive study, evaluated the structure of Mexico City's EMS system and analyzed EMS response times, clinical capacity, economic efficiency, and customer satisfaction. These results were compared with the AAA guide, according to the social, economic, and political context in Mexico. This paper describes the healthcare system structure in Mexico, followed by a description of the basic structure of EMS in Mexico City, and of each tenet described in the AAA guide. The paper includes data obtained from official documents and databases of government agencies, and operative and administrative data from public and private EMS providers.
Results:
The quality of the data for response times (RT) were insufficient and widely varied among providers, with a minimum RT of 6.79 minutes (min) and a maximum RT of 61 min. Providers did not define RT clearly, and measured it with averages, which can hide potentially poor performance practices. Training institutions are not required to follow a standardized curriculum. Certifications are the responsibility of the individual training centers and have no government regulation. There was no evidence of active medical control involvement in direct patient care, and providers did not report that quality assurance programs were in place. There also are limited career advancement opportunities for EMS personnel. Small economies of scale may not allow providers to be economically efficient, unit hours are difficult to calculate, and few economic data are available.There is no evidence of customer satisfaction data.
Conclusions:
Emergency medical services in Mexico City did not meet the AAA requirements for high-quality, prehospital, emergency care. Coordination among EMS providers is difficult to achieve, due, in part, to the lack of: (1) an authoritative structure; (2) sound system design; and (3) appropriate legislation. The government, EMS providers, stakeholders, and community members should work together to build a high quality EMS system at the lowest possible cost.
Over-triage of patients by emergency medical services (EMS) dispatch is thought to be an acceptable alternative to under-triage, which may delay how quickly life-saving care reaches a patient. Previous studies have looked at advanced life support (ALS) misutilization in urban- and county-based EMS systems and have attempted to analyze how dispatch methods either contribute to or alleviate this problem.1–5
Objective:
The purpose of this study is to assess the relationship between dispatches of a cardiac nature in a Medical Priority Dispatch (MPD) system, and the actual clinical diagnosis as determined by an emergency department physician.
Methods:
Calls for emergency medical assistance in a suburban community outside of a major metropolitan area were surveyed over a three-month period. Medical Priority Dispatch protocols determined that 104 of these calls were cardiac-related. Of these emergency calls, 56 (53.8%) patients were transported to the local community hospital and treated by the emergency physician. A retrospective review of the medical records was conducted to determine whether the patient had a cardiac-related discharge diagnosis from the emergency department.
Results:
Sixteen (28.6%) of the patients in this cohort were diagnosed with a cardiac-related condition upon discharge from the emergency department. Forty (71.4%) were diagnosed with a non-cardiac-related condition. The positive, predictive value of the dispatch protocol for the detection of an actual cardiac emergency in this EMS system was 28.6%.
Conclusion:
In this suburban community, the MPD system may over-triage emergency medical responses to cardiac emergencies. This can result in the only ALS (paramedic) unit in the community being unavailable in certain situations. Future studies should be conducted to determine what level (in any) of over-triage is appropriate in EMS systems using a MPD system.
Effective management of cyanide poisoning from chemical terrorism, inhalation of fire smoke, and other causes constitutes a critical challenge for the pre-hospital care provider. The ability to meet the challenge of managing cyanide poisoning in the prehospital setting may be enhanced by the availability of the cyanide antidote hydroxocobalamin, currently under development for potential introduction in the United States. This paper discusses the causes, recognition, and management of acute cyanide poisoning in the prehospital setting with emphasis on the emerging profile of hydroxocobalamin, an antidote that may have a risk:benefit ratio suitable for empiric, out-of-hospital treatment of the range of causes of cyanide poisoning. If introduced in the US, hydroxocobalamin may enhance the role of the US prehospital responder in providing emergency care in a cyanide incident.
A break in safety locks resulted in the release of high quantities of gamma and neutron radiation directly exposed three workers and indirectly exposed as many as 310,000 other persons. The two persons who received the highest doses ultimatley succumbed due to the latent effects of the radiation on the skin and mucous membranes. Improved protection of workers and responders as well as dosimeters are needed in areas where such events may occur. Careful attention must be paid to providing accurate information to the media and to the provision of competent psychosocial support.
A train traveling at 200 kilometers per hour carrying 300 passengers crashed into a bridge. At leaset 85 doctors and 1,889 persons were involved in the emergency response. A total of 101 persons were killed, 108 were injured, and 87 were transported to a hospital (27 by helicopter; 60 by land ambulance). Eighty percent of the severely injured were trasported to a hosptial within two hours of the crash. Coordination of the activities of the hoards of responders was an issue, as was the lack of a formal organization to provide psychosocial support. Preparedness plans should include management of the dead and for the provision of psychosocial support.
The train crash that occurred in London in 1999 resulted in 31 dead and almost 300 injured persons. Mobilized resources allowed for the application of normal treatment principles. Available resources were in excess of what was needed. The procedures implemented were judged as adequate. Responses followed the management plan formulated over many years and experiences. The rotating command procedures used worked well. Multiple communications systems were used, including landline telephones, mobile telephones, and radios. Plans should include caring for both adults and children. Well-planned psychosocial services and functional compute services are essential components.