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The outcome of survivors within disaster areas largely depends upon the quick reallocation and operation of logistic and medical support systems. Enthusiastic media equipped with advanced communication systems, reveal mass human suffering in real time. But, the response period required for the organization of rescue systems is much slower and is most frustrating. In this article, we present our experience in quick deployment and operation of airborne field hospitals gained following the earthquake disaster in Armenia in 1988 and the civil war in Rwanda in 1994.
Deployment of improvised, volunteer-based, military field hospitals was feasible within 24 hours after the decision was made. A multi-disciplinary structure enabled an effective, flexible mode of operation and reduced the dependency on meticulous, time-consuming assessments of requirements prior to deployment.
These missions are a paradigm for the successful incorporation and integration within the capabilities of military infrastructure of volunteer professionals drafted from civil medical facilities. Such field hospitals could provide backup for primary care medical systems in disaster areas and substitute or take some pressure off of local hospitals, particularly when evacuation systems are insufficient.
An earthquake with a magnitude of 7.6 struck the town of Neftegorsk (population about 3,000) on 27 May, 1995. This paper describes the devastation and the human aspects of the catastrophe of the first week following the quake. A total of 1,995 persons were found dead under the rubble, including 268 children less than 16 years of age. There were 1,144 survivors. A total of 406 person were rescued alive from under the rubble of which an additional 37 persons died in a hospital following rescue. Most of the survivors have been relocated, but some remain in the area. There remains a need for psychological support for the survivors and rescuers.
Introduction: A case is presented in which a 43-year-old man suffering from a severe asthma attack, had ventilatory arrest during a hoisting procedure. Based on this experience, the influence of three hoisting techniques on lung function was tested.
Methods: The ventilatory capacity of 12 healthy volunteers was tested during three commonly used hoisting techniques: 1) single sling; 2) double sling; or 3) strapped to a stretcher.
Results: The vital capacity (VC) and the one-second, forced expiratory volume (FEV1) were reduced significantly during all hoisting techniques compared to the standing position. The reduction was significantly more pronounced on a stretcher than in either sling position. There were no differences in the FEV1 to VC ratio between the positions.
Conclusion: The small reduction in ventilatory capacity during hoisting procedures is tolerated easily by healthy individuals, but should be taken into account when planning such procedures on patients with severe pulmonary disease.
From its beginnings, the provision of emergency medical services in the United States has been a male-dominated occupation. The objective of this exploratory study was to determine if and how such issues might influence partner preferences of male and female emergency medical technicians (EMTs).
Methods:
Initially, unstructured interviews were conducted with 10 EMS workers enrolled in a paramedic training program in order to see whether and how such issue might affect partner preferences. From the data obtained during these interviews, a questionairre was developed and distributed to participants in an annual meeting of Louisiana Association of Nationally Registered EMTs. Participation was voluntary and uncompensated.
Results:
A total of 49 EMTs (22 women, 27 men) completed the questionairre. The major gender-related issues could be class fied into three dimensions: 1) physical strength; 2) assumption of authoritative roles; and 3) structural (organizational) preparedness to implement gender-friendly working environments. In general, the gender of a partner now “makes no difference”.
Conclusion:
Overall, the EMS work worlds are reflective of the larger society of which they are a part. Now is the time for EMS systems to examine the gendered nature of their organization and of the issues of gendered expectations prevalent in EMS work. Future research should document the changes now due in the field of emergency medical services.
To use the clinical activities of an ambulance service as a tool to assess the residual and unmet medical need of a city in the aftermath of a major earthquake and to apply that assessment to the development of a training curriculum for the prehospital personnel.
Methods:
The researchers conducted structured interviews with health care workers at all levels of the emergency health care delivery system in Gyumrii, Armenia, and carried out a retrospective frequency analysis of 29,010 ambulance runs for an 11-month period from February through December 1992. Runs first were assigned into the broad categories of: 1) Adult Medical; 2) Pediatric Medical; or 3) Trauma, and then, according to diagnosis. The runs then were classified further as: 1) Primary Care; 2) Basic Life Support (BLS); or 3) Advanced Life Support (ALS).
Results:
Adult Medical calls represented 24,684 (85%), Pediatric Medical calls 459 (1.6%), and Trauma calls 3,867 (13%). Only 12% of all ambulance calls resulted in transport to a medical facility, although this percentage was higher in children. Thirty percent of Adult Medical patients were diagnosed by the emergency medical providers as having exclusively a psychiatric problem.
Conclusion:
In the late aftermath of a devastating earthquake, the ambulance service in Gyumrii, Armenia has been delivering a substantial proportion of non-emergency, primary care services. They have adopted this unconventional role to compensate for the deficit in health care facilities and personnel created by the disaster. The training program that the investigators developed reflected the actual work activities of the prehospital personnel demonstrated in their assessment.
Jurisdictions throughout the United States and some other parts of the world have invested substantial time and resources into creating and sustaining a prehospital advanced life support (ALS) system without knowing whether the efficacy of ALS-level care had been validated scientifically. In recent years, it has become fashionable for speakers before large audiences to declare that there is no scientific evidence for the clinical effectiveness of ALS-level care in the out-of-hospital setting. This study was undertaken to evaluate the evidence that pertains to the efficacy of ALS-level care in the current scientific literature.
Methods:
An extensive review of the available literature was accomplished using computerized and manual means to identify all applicable articles from 1966 to October, 1995. Selected articles were read, abstracted, analyzed, and compiled Each article also was categorized as presenting evidence supporting or refuting the clinical efficacy of ALS-level care, and a list was constructed that pointed to where the preponderance of the evidence lies.
Results:
Research in this field differs widely in terms of methodological sophistication. Of the 51 articles reviewed, eight concluded that ALS-level care is not any more effective than is basic life support, seven concluded that it is effective in some applications but not for others, and the remainder demonstrated effectiveness. The strongest support for ALS-level care was in the area of responses to victims of cardiac arrest, whereas somewhat more divergent findings related to trauma or non condition-specific studies.
Conclusion:
While not unanimous, the predominant finding of recent research into the clinical effectiveness of advanced life support demonstrates improved effectiveness over basic life support for patients with certain pathologies. More outcomes-based research is needed.
The majority of prehospital emergency medical services (EMS) personnel lack specific training relating to elder abuse and neglect.
Objectives:
To develop and test an audio visual training program that focuses on the identification and reporting of domestic violence in the elderly.
Methods:
A videotape was designed to be used as a 45-minute training course for prehospital personnel using one-half inch, super-VHS recording. A convenience sample of 60 EMS personnel working in Kent County then were asked to evaluate the videotape program. Each volunteer completed a pre-test on elder abuse and neglect, watched the 45-minute videotape, and then answered 12 questions on a post-test.
Results:
Participants had an average of 12.4 years (range: 1–30 years) prehospita emergency-care experience. Only four (7%) could recall any previous training relating to elder abuse or neglect during their career. Although the prevalence of elder abuse in their community was described as “rather rare” by most (60%) of the subjects, 85% (51/60) had seen a suspected case of elder abuse or neglect during their careers; 47% (28/60) had seen a case during the past six months. Only 29% of these suspected cases were reported to county authorities. Approximately 40% of the questions on the pre-test were answered correctly (mean score, 4.8 ± 3.0). In comparison, 83% of the questions on the post-test were answered correctly (10.0 ± 3.0). Although participants had a number of suggestions to improve the video program, 78% (47/60) expected this material to change the way they will evaluate elderly patients in the future.
Conclusion:
Prehospital personnel do not feel confident identifying or reporting victims of elder abuse or neglect. A videotape training program may be an effective way of presenting this information as a means of continuing education.
Medical disaster preparedness (MDP) of Rotterdam-Europort has been estimated by grading personnel, materials, and methods utilized in the chain of medical care, from the disaster site to the hospital. On a scale from 1 to 5, this MDP was set at 2.8: the disaster site is the weakest link, which determines the strength of the whole chain. This, in turn, was the result mainly of the methods utilized for which the personnel were not properly educated and trained.
By applying the methodology as described in an earlier paper, the MDP of cities, airports, harbors, industrial plants, etc. can be determined in a standardized way. This methodology should facilitate epidemiologic research in the public health aspects of disaster preparedness.
To describe the use of the Automatic External Defibrillation (AED) device in an urban, two-tiered Emergency Medical Service (EMS) response setting with regard to its potential effects on cardiac arrest patient survival and neurologic outcome.
Methods:
A retrospective and descriptive design was utilized to study all cardiac arrest patients that had resuscitations attempted in the prehospital environment over a 30-month period. The study took place in a two-tiered EMS system serving an urban population of 368,383 persons. The first tier of EMS response is provided by the City Fire Department, which is equipped with a standard AED device. All first-tier personnel are trained to the level of Emergency Medical Technician-Basic. The second tier of EMS response is provided by personnel from one of two ambulance services. All second-tier personnel are trained to the level of Emergency Medical Technician-Paramedic.
Results:
271 cardiac arrest patients were identified for inclusion. One-hundred nine of these patients (40.2%) had an initial rhythm of either ventricular fibrillation or pulseless ventricular tachycardia and were shocked using the AED upon the arrival of first-tier personnel. Forty-two patients (38.5%) in this group had a return of spontaneous circulation in the field and 22 (20.2%) survived to hospital discharge. Of the survivors, 17 (77.3%) had moderate to good neurologic function at discharge base on the Glasgow-Pittsburgh Cerebral Performance Categories. Faster response times by the first-tier personnel appeared to correlate with better neurologic outcomes.
Conclusion:
First responder-based AED usage on patients in ventricular fibrillation or pulseless ventricular tachycardia can be applied successfully in an urban setting utilizing a two-tiered EMS response. In this study, a 20.2% survival to hospital discharge rate was obtained. Seventy-seven percent of these survivors had a moderate to good neurologic outcome based on the Glasgow-Pittsburgh Cerebral Performance Categories.
Abstract: Recertification requirements and new curricula place increased importance on continuing education (CE) for emergency medical services (EMS) personnel. To be effective, continuing education not only must be accessible to EMS personnel, but it must be also acceptable. Journal-based continuing education was selected to improve accessibility, but questions were raised about its acceptance. Although there were some significant differences found between the feelings of basic and advanced EMS personnel, a study conducted on six articles showed that participants overall liked this method. The study also found that some articles significantly generated more reader response than others.
Although several studies link job-related stressors with adverse reactions among emergency medical technicians (EMTs), more standardized research is needed, since much remains unknown about stress responses, coping styles and their consequences for EMTs. This paper presents the results of two studies. Study I investigated the relation between job-related stressors, job satisfaction, and psychological distress, while Study II investigated how coping is related to occupational burnout, job-related stress, and physiological arousal.
Hypothesis:
Study I: Those EMTs experiencing greater job-related stressors are less satisfied with their jobs and more psychologically distressed.
Objective, Study II:
To obtain preliminary information about which coping strategies are associated with greater feelings of stress and burnout and more intense autonomic nervous system reactivity.
Methods:
For both studies, EMTs from a large, urban, public EMS organization in the southern United States were asked to participate. Study I: Subjects completed an informed consent document, a demographics questionnaire, a measure of job stress (the Stress Diagnosis Inventory), a measure of job satisfaction (Job-in-General), and a measure of psychological symptomatology (Symptom Checklist-90, Revised). Pearson product-moment correlations were computed between the measures. Study II: Subjects completed an informed consent document, a demographics/information sheet, the Maslach Burnout Inventory (MBI), and the Ways of Coping Scale (WOCS). They then completed 30 days of monitoring using the Daily Stress Inventory (DSI) and the Daily Autonomic Nervous System Response Inventory (DANSRI). Pearson product-moment correlations were computed between the measures.
Results:
Study I: Those EMTs who experienced greater job-related stress also were significantly more dissatisfied with their jobs, more depressed, anxious, hostile, and endorsed greater global psychological distress. Study IT. The Depersonalization subscale on the MBI correlated significantly with the following WOCS subscales: Accepting Responsibility, Confrontive Coping, Distancing, and Escape/Avoidance. Emotional Exhaustion on the MBI correlated significantly with Confrontive Coping, Escape/Avoidance, and Social Support, while data obtained on the 40 subjects who completed the daily monitoring revealed that DSI-Impact, DANSRI-Number, and DANSRI-Impact scores each correlated significantly with Accepting Responsibility, Confrontive Coping, and Escape/Avoidance.
Conclusion:
A significant portion of an EMT's job satisfaction and psychological well-being is associated with the degree to which they are experiencing job-related stress, and, furthermore, this distress level appears to be clinically elevated. This implies that in-service programs and psychological support services designed to help EMTs manage their job-related stress may improve job satisfaction and decrease psychological distress. The coping styles most consistently associated with maladaptive outcomes were: Accepting Responsibility, Confrontive Coping, and Escape/Avoidance. Thus, subjects who were more likely to handle stress with self-blame, aggression, hostility, and risk taking or with wishful thinking, escape tendencies, and avoidance were more likely to endorse more negative outcomes.
Development of competence in exercising therapeutic judgment skills represents the goal of clinical education. Time (clock hours) is not a valid predictor of attainment of competence in paramedic clinical education. Quantity of patient contact experiences facilitates development of judgment skills, and offers a valid measure of progress toward competence. This project uses national survey data from accredited programs to describe the availability and accessibility of patient contact experiences within paramedic clinical education. Data from this local program supplements the national survey results. The components of clinical judgment are enumerated, and strategies to teach and evaluate clinical judgment skills are discussed.
Obtaining aprehospital 12-lead electrocardiogram (ECG) diagnostic of acute myocardial injury has been demonstrated to hasten the administration of thrombolytic agents in the emergency department. This case demonstrates that aprehospital electrocardiogram diagnostic of acute anterior wall infarction can become non-diagnostic following routine administration of oxygen, nitroglycerin, and morphine by paramedics. Although this phenomenon has been observed in the in-hospital setting, it has not been reported in patients with a prehospital ECG.
The pressures facing emergency medical services (EMS) in Wisconsin and their effects on the delivery of prehospital emergency medical care were not known by the Wisconsin EMS Board. In an effort to assess these pressures and the needs of the emergency medical services in the State as perceived by the services, the Board undertook a survey of the EMS providers in Wisconsin.
Methods:
A survey instrument was developed and approved by the EMS Board and distributed to all of the licensed emergency medical services in Wisconsin.
Results:
Of the 453 survey instruments distributed, 323 (71.3%) were completed and returned. Intermediate- and paramedic-level services were more likely to respond than were the basic services, but 235 (72.8%) of the respondents identified their service levels as basic. In addition to providing information about the service characteristics, each responding service also rated the importance of their perceived needs. Lack of medical direction was perceived as the greatest need by all levels of service. However, the second greatest area of need for basic and intermediate services related to difficulty in recruiting new staff. For paramedic services, the second greastest need was associated with dispatching. When comparing services by rural versus urban, difficulty in recruiting new staff and collecting ambulance fees were seen as second and third to lack of a medical director by rural services, whereas urban services noted local training to be in the top three. In the assessment of educational needs, patient-care issues dominated. A review of written comments also demonstrated a difference between rural and urban services, but both noted Medicare and Medicaid reimbursement issues more commonly than any other problem.
Conclusion:
In the restructuring of health care, it will be important to consider the various needs of prehospital providers and recognize that such needs may be unique to the providers' location and level of service.