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To determine the reliability of ST-segment interpretation by paramedics from lead-II rhythm strips obtained in the prehospital setting.
Design:
Prospective, blinded study of 127 patients transported by an urban/rural emergency medical services system with complaints consistent with ischemic heart disease.
Methods:
Emergency department physicians asked emergency medical technician-paramedics (EMT-P) via radio to evaluate ST-segments for elevation or depression and grade it as “mild,” “moderate,” or “severe.” Then, this rhythm strip was interpreted blindly by emergency physicians who also interpreted the lead-II obtained from a 12-lead electrocardiogram (ECG) obtained in the emergency department (ED). The field interpretation was compared with the subsequent readings and the final in-patient diagnosis using positive predictive value (PPV), negative predictive value (NPV), and the Kappa statistic. Markedly discrepant interpretations were analyzed separately.
Results:
Using physician interpretation as the reference standard, paramedic interpretation of the lead-II ST-segments obtained in the prehospital setting was correct (within ±1 gradation) in 113 out of 127 total cases (89%). Of 105 patients for whom final hospital diagnosis was available, the ST-segment on the rhythm strip obtained in the prehospital setting, had a positive predictive value of 74% and a negative predictive value of 85% for myocardial ischemia or myocardial infarction (MI) (p <0.001, Kappa = 0.59). Discordant interpretations between the paramedics and emergency physicians often were related to a basic misunderstanding of rhythm strip morphology.
Conclusion:
Field interpretation of ST-segments by paramedics is fairly accurate as judged both by emergency physicians and correlation with final patient outcome, but its clinical utility is unproved. A small but clinically significant number of outliers, consisting of markedly discrepant false positives, reflects paramedic uncertainty in identifying the deviations of the ST-segment.
The pivotal role of anesthesiologists in the implementation of disaster plans is not widely appreciated.
Objective:
To describe the role of anesthesiologists as managers in the operating room (OR) especially during hospital disaster management.
Methods:
On 25 February 1991, King Fahd Hospital of the University in Eastern Saudi Arabia, was alerted, received, triaged, and treated the victims of a Scud missile attack on a United States military barracks which killed 28 and injured more than 100 service personnel.
Results:
There were 47 males and 15 females admitted to the hospital. Their initial triage categories of injuries were: 1) red, 23; 2) yellow, 27; and 3) green, 7. The flow of patients through the main operating rooms occurred in two peaks: 1) treated within nine hours (60%); and 2) during the next 11 hours (40%). A total 101 units of blood and blood products were consumed.
The role of the Chief of Anesthesiology was vital in the dynamics of the situation regarding appropriate deployment of staff and ensuring an orderly throughput of victims in the operating room. He also was required to keep track of resources and supply levels in the operating room, so that he could advise the hospital administration appropriately.
Conclusion:
The successful management of a large multi-casualty incident, which involved use of the operating rooms, depended upon the efficient coordination of clearly defined functions with the Chief of Anesthesiology Service as the team leader.
There is a huge need for access to information in the areas of disaster relief disaster medicine, and humanitarian assistance. The extraordinarily rapid increase in the literature in these subject areas attests to this need. However, use of the printed word has substantial limitations that are even more profound in the developing world.
Currently, the information available tends to be fragmented and sequestered by the specific interests of the organizations and governments involved. The evolving electronic methods for the storage, organization, and retrieval of information makes coordination between organizations concerned with disasters within our grasp.
This paper discusses the Center of Excellence in Disaster Management and Humanitarian Assistance and describes the World Wide Web and the implications it has in disaster management and medicine. It describes methods for obtaining user input to the techniques used for the development of the world wide web for the areas of disaster management and disaster medicine. The implementation of an on-line Internet reference desk that will provide: 1) a list of “experts;” 2) a searchable disaster database; and 3) on-line simulation courses and training exercises also is discussed.
To determine the type and frequency of immediate unsolicited feedback received by emergency medical service (EMS) providers from patients or their family members and emergency department (ED) personnel.
Methods:
Prospective, observational study of 69 emergency medical services providers in an urban emergency medical service system and 12 metropolitan emergency departments. Feedback was rated by two medical student observers using a prospectively devised original scale.
Results:
In 295 encounters with patients or family, feedback was rated as follows: 1) none in 224 (76%); 2) positive in 51 (17%); 3) negative in 19 (6%); and 4) mixed in one (<1%). Feedback from 254 encounters with emergency department personnel was rated as: 1) none in 185 (73%); 2) positive in 46 (18%); 3) negative in 21 (8%); and 4) mixed in 2 (1%). Patients who had consumed alcohol were more likely to give negative feedback than were patients who had not consumed alcohol. Feedback from emergency department personnel occurred more often when the emergency medical service provider considered the patient to be critically ill.
Conclusion:
The two groups provided feedback to emergency medical service providers in approximately one quarter of the calls. When feedback was provided, it was positive more than twice as often as it was negative. Emergency physicians should give regular and constructive feedback to emergency medical services providers more often than currently is the case.
This paper examines the considerable medical and psychological problems that ensue after disasters in which massive populations are affected for extended and sometimes unknown time periods. The organization of disaster response teams after large-scale disasters is based on experiences as a medical specialist at Chernobyl immediately after this catastrophe. Optimal ways of dealing with the immediate medical and logistical demands as well as long-term public health problems are explored with a particular focus on radiation disasters. Other lessons learned from Chernobyl are explained.
Issues:
Current concerns involve the constant threat of a disaster posed by aging nuclear facilities and nuclear and chemical disarmament activities. The strategies that have been used by various groups in responding to a disaster and dealing with medical and psychological health effects at different disaster stages are evaluated. The emergence of specialized centers in the former Soviet Union to study long-term health effects after radiation accidents are described. Worldwide, there has been relatively little attention paid to mid- and long-term health effects, particularly the psychological stress effects. Problems in conducting longitudinal health research are explored.
Recommendations:
The use of a mobile diagnostic and continuously operating prehospital triage system for rapid health screening of large populations at different stages after a large-scale disaster is advisable. The functional systems of the body to be observed at different stages after a radiation disaster are specified. There is a particularly strong need for continued medical and psychosocial evaluation of radiation exposed populations over an extended time and a need for international collaboration among investigators.
Automatic external defibrillators (AED) have enabled the medical act of defibrillation to be performed in the community by a number of non-physician providers. However, these portable, battery-powered units are costly to maintain and service. This study examines the life of AED batteries and provides a battery replacement protocol.
Design:
Prospective diagnostic testing of 191 field batteries to determine their ability to deliver shocks at 360 joule.
Setting:
Ottawa General Hospital Paramedic Program.
Outcomes:
Using a battery analyzer, battery capacity and the number of shocks delivered were determined for each battery (at room temperature and in a controlled, refrigerated setting). In addition, the reliability of the testing method was assessed using the interclass correlation coefficient (ICC).
Results:
High reliability of blinded technical assessment of the batteries was achieved (ICC = 0.85). A strong correlation between the battery's capacity and the number of shocks it can deliver was obtained. For example, a battery with a measured capacity of 75% is capable of delivering more than 30 consecutive 360 joule shocks. This compares to a battery with a capacity of 20%, which is capable of delivering only 12 consecutive 360 joule shocks.
Conclusion:
While manufacturers' recommendations on battery replacement always have been based on an assumed technical threshold, these recommendations are not based on individual battery performance. The system for testing batteries described in this paper, should provide significant cost savings and improve quality assurance within a prehospital AED program.
An eight year retrospective analysis was conducted to determine the type and outcome of lawsuits related to the provision of 9-1-1 paramedic service in an urban environment.
Methods:
For the evaluation period of May 1986 to March 1994, all litigation cases related to Ambulance Service or paramedics were collected and analyzed. This urban 9-1-1 Paramedic Service has an estimated call volume of >60,000 assignments resulting in >30,000 patient encounters during the evaluation period.
Results:
Seven lawsuits were filed against the service. No lawsuits were related to tardy response, failure to transport, or patient care negligence of any kind. All of the litigation was related to motor vehicle collisions (MVC).
Conclusion:
The data suggest that motor vehicle collisions are a significant medicallegal risk to the EMS community. In addition, it was found that the use and lack of use of seatbelts was an important component in many of the suits.
Full-scale disaster drills are complex, expensive, and may involve hundreds or thousands of people. However, even when carefully planned, they often fail to manifest the details of medical care given to the casualties during the drill.
Objective:
To assess the feasibility of integrating physicians among the simulated casualties of a hospital disaster drill.
Methods:
A total of 178 physicians graduating an Advanced Trauma Life Support (ATLS) course participated in eight hospital disaster drills during 1994 as “Smart Victims.” The participants were given cards with descriptions of their injury and detailed instructions on how to manipulate their medical condition according to the medical care provided in the hospital. They also were given coded questionnaires to fill out during the process of the drill. Conclusions were drawn from analysis of the questionnaires and from a roundtable discussion following each drill.
Results:
The “smart casualties” made comments on the following topics: 1) triage (over-triage in 9%, and under-triage in 4%); 2) treatment sites; 3) medical equipment usage (i.e., shortage of ventilators and splinting devices); 4) medical knowledge and care rendered by the hospital staff; 5) evacuation and escorting of the wounded; 6) management of patients with post-traumatic stress disorder; and 7) medical documentation. Their comments contributed valuable information on the quality of medical care and organization, and identified obstacles that otherwise would have been overlooked. The “smart casualties” were very cooperative and indicated that their participation in the drill contributed to their understanding of disaster situations in hospitals.
Conclusion:
Integrating physicians among the simulated casualties in a hospital disaster drill may contribute to achieving the objectives of hospital disaster drills and add to disaster management education of the simulated casualty physicians.
Devices used for support of patients requiring air rescue or conveyance are subjected to severe environments that may affect their ability to function when needed or may affect other systems within the transporting vehicle.
Methods:
The ability of four portable ventilators, a suction device, and plastic and rubber tracheal tubes to withstand changes in temperature, vibration, sudden deceleration, and electromagnetic fields was studied in the laboratory setting. In addition, the effects of the operation of these devices on the flight instrumentation was investigated.
Results:
All of the ventilators tested delivered stable minute volumes at temperatures above zero, but in sub-zero temperatures problems were encountered with the driving gas. Vibrations produced alterations in the performance of two of the ventilators, and resonant frequencies were detected that are identical to those produced by the rotors of the helicopter used.
Suctioning became difficult at temperatures below −5° C as the mucus froze in the collecting tubing. The motor produced electromagnetic fields that interfered with the aircraft instrumentation, and resonant frequencies had a deleterious effect on the circuit boards. Plastic tubes were adversely affected by cold, and these chilled tubes were excessively sensitive to vibration and shocks.
Conclusion:
The devices used in various aircraft influence certain vital maneuver systems of the craft. Studies on portable ventilators, a suction device, and tracheal tubes showed that, under specific conditions, the equipment was safe to patients and was not hazardous to the aviation safety. However, under certain conditions commonly encountered during air rescue operations, the equipment became dys-functional or presented safety hazards to the aircraft, and, hence, the crew. The Swedish Air Force has adopted three different criteria constellations: 1) operative; 2) storing; and 3) transport environment.
Researchers need accurate, explicit definitions of terms in order to discuss, search for or indentify the consequences of any particular phenomenon. The term “disaster” is no exception. The many definitions used for definition of disaster are outlined in general and by the discipline using them in this paper. Although the definitions used still seem somewhat specific to the discipline, there is one common element accepted by all: a disaster is seen to occur at a well-defined and easily identified time.
It is not feasible to formulate a universally acceptable definition of disaster that will satisfy all practitioners, but common and agreed upon definitions must be formulated in the various fields and areas concerned with disasters, and where there exist recognizable, common sets of objectives.
The provision for emergency medical care for spectators and participants at large events is a growing area of interest. This article describes the definition and characteristics of medical care at mass gatherings. The literature is reviewed with regard to the planning, organization, personnel, and staffing required at these events. The equipment and transportation assets needed are also discussed. Disaster and mass casualty planning implications also are described.
Hand held, colorimetric, end-tidal CO2 detector devices are being used to verify correct endotracheal tube (ETT) placement. The accuracy of these devices has been questioned in situations of cardiac arrest. The use of the esophageal detector device (EDD) is an easy alternative for detection of ETT placement, and may be more accurate in situations of cardiac arrest.
Hypothesis:
The use of the esophageal aspiration device in comparison with a colorimetric end-tidal CO2 detector is more accurate in detecting proper ETT placement and easier to use in the prehospital setting than is the colorimetric end-tidal CO2 detection device.
Methods:
This was a prospective alternating weeks, 6-month study in a prehospital setting. Participants included all patients older than 18 years who were intubated by the Portsmouth, Virginia Emergency Medical Services (EMS) personnel from 01 July 1993 through 31 December 1993. The aspiration device used, also known as an esophageal detector device (EDD), was a 60 ml, luer-lock syringe attached to a 15 mm ETT adapter. Its efficacy was compared with an already accepted method of ETT position detection, the colorimetric endtidal CO2 detector. Each device was used on alternating weeks, and correct ETT placement was determined by the receiving emergency department physician using standard techniques. Chi-square analysis and Fisher's Exact test were used to compare parameters, time of device use, and ease of use. Sensitivity and specificity were calculated, and provider preference was assessed using a survey instrument administered following completion of the study.
Results:
There were 49 patients who met the inclusion criteria, but six were excluded because of situational circumstances rendering use of the device a possible compromise of patient care. Twenty-five patients were in the EDD group, and 18 were in the endtidal CO2 detector group. There was no statistically significant difference detected between groups for the gender ratio, underlying condition, CPR in progress, perceived difficulty of intubation, or percentage of nasotracheal intubation. The EDD was significantly easier to use (p<0.005). There was no statistically significant difference in time required for use of end-tidal CO2 detector device versus the EDD. The sensitivity and specificity for correct tracheal placement using the EDD was 100%, and the sensitivity for correct tracheal placement using the end-tidal CO2 detector device was 78%. Use of the EDD was preferred over use of the end-tidal CO2 detector device by 75% of participating EMS providers. One case of nasotracheal intubation with an ETT placement above the cords raised the question of accuracy of this device in situations where direct visualization is not utilized.
Conclusion:
The EDD was accurate in all cases of orotracheal intubation, and was easier to use than was end-tidal CO2 detector device. It was preferred by 75% of participating EMS providers. In cases in which the ETT may be above the vocal cords, caution must be used with interpreting the results obtained by use of the EDD.
The purpose of this project was to improve the identification, treatment, and referral of domestic violence victims by prehospital care providers (Emergency Medical Technicians (EMTs) and paramedics) and emergency department personnel. The training focused on the definition of domestic violence, procedures to use when questioning patients about abuse, Utah's mandatory reporting law, and the referral of victims to community resources. While the training did improve the participant's knowledge concerning referral options and the law, health care providers still did not believe that domestic violence was a problem in their community. Although providers felt confident asking questions about abuse, the providers did not question patients unless they suspected domestic violence was the cause of the injury. Further training needs to be offered to staff to encourage regular screening for all adult patients.
Until now, the public health response to the threat of an epidemic has involved coordination of efforts between federal agencies, local health departments, and individual hospitals, with no defined role for prehospital emergency medical services (EMS) providers.
Methods:
Representatives from the local health department, hospital consortium, and prehospital EMS providers developed an interim plan for dealing with an epidemic alert. The plan allowed for the prehospital use of appropriate isolation procedures, prophylaxis of personnel, and predesignation of receiving hospitals for patients suspected of having infection. Additionally, a dual notification system utilizing an EMS physician and a representative from the Office of Infectious Diseases from the hospital group was implemented to ensure that all potential cases were captured. Initially, the plan was employed only for those cases arising from the Centers for Disease Control and Prevention (CDCJ/Public Health Service (PHS) quarantine unit at the airport, but its use later was expanded to include all potential cases within the 9–1–1 system.
Results:
In the two test situations in which it was employed, the plan incorporating the prehospital EMS sector worked well and extended the “surveillance net” further into the community. During the Pneumonic Plague alert, EMS responded to the quarantine facilities at the airport five times and transported two patients to isolation facilities. Two additional patients were identified and transported to isolation facilities from calls within the 9–1–1 system. In all four isolated cases, Pneumonic Plague was ruled out. During the Ebola alert, no potential cases were identified.
Conclusion:
The incorporation of the prehospital sector into an already existing framework for public health emergencies (i.e., epidemics), enhances the reach of the public safety surveillance net and ensure that proper isolation is continued from identification of a possible case to arrival at a definitive treatment facility.