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By defining the chain of medical care and the capacities of the successive phases within this chain, an attempt is made to analyze and grade the determinants of these capacities. In this way, calculations that indicate overall disaster preparedness can be expressed in a figure ranging from 1–5. The capacity of the system is taken as the lowest score obtained for the components of the system. The methodology used for this assessment of pre-paredness is described and an example is used to show the efficacy of this methodology.
Osborne and Gaebler's Reinventing Government has sparked discussion amongst elected officials, civil servants, the media, and the general public regarding advantages of privatizing government services. Its support stems from an effort to provide services to municipalities while reducing taxpayer expenditure. Many echo the sentiment of former New York Governor Mario Cuomo, who said, “It is not government's obligation to provide services, but to see that they're provided.” Even in the area of public safety, privatization has found a “market.”
In many localities, privatizing Emergency Medical Services (EMS) is a popular and successful method for providing ambulance services. Privately owned ambulance services staff and respond to medical emergencies in a given community as part of the 9–1–1 emergency response system. Regulations for acceptable response times, equipment, and other essential components of EMS systems are specified by contract. This allows the municipality oversight of the service provided, but it does not provide the service directly. As will be discussed, this “contracting-out” model has many benefits.
Privatizing EMS services is a decision based not only on cost-savings, but on accountability. A thorough evaluation must be utilized in the selection process. Issues of efficiency, effectiveness, quality, customer service, responsiveness, and equity must be considered by the government, in addition to cost of service.
The uncertain future of health care in the United States has led those in EMS to look beyond the field's internal market to explore additional opportunities for expanding and redefining its roles beyond emergency care. It is important, however, to consider how emergency medical care, the original role of EMS, can be best delivered. Responding to emergencies is not just one of the functions involved in this field, it is the principal function from which public perception of EMS is formed, and from which support for entering other markets can be fostered.
The purpose of this paper is to present several important concepts and considerations that public officials, medical directors, and the public must be aware of when contemplating the possibility of privatizing their Emergency Medical Services. A review of the general concepts of privatization and issues of accountability will be presented, referencing policy experts, followed by an examination of how advocates of privatization might see these issues as they relate to providing EMS. The conclusion will present prescriptions for both municipal and commercial ambulance providers.
A multiple patient incident involving a commercial airliner is a challenge for any community EMS system. When the community is on a remote island in the North Pacific Ocean, where there is no hospital and only a small clinic staffed by just one physician and several nurses and technicians, the challenge is much greater. The incident described herein necessitated providing emergency care at the airport, and at the same time, activating a response capability from hundreds of miles away to transport the patients to definitive care. The situation was compounded further by the fact that most of those injured spoke little or no English. This paper reviews the events that occurred and the lessons learned..
Objective:
To identify the events that occurred when a commercial airliner, with more than 250 passengers and crew aboard, experienced an in-flight “upset” that resulted in many being injured. What was learned may help other areas be better prepared for such events.
Study Population:
A commercial airliner incident that occurred in April, 1993 resulted in the need for emergency medical care at the remote island location of Shemya, Alaska initially, and fixed-wing transport of the injured to definitive care in Anchorage, Alaska, USA, which is about 1,300 miles (2,130 km) from Shemya.
Methods:
A case review methodology was used that included interviews with key persons involved in the response to this incident to learn first-hand what occurred; by review of the National Transportation Safety Board (NTSB) reports, and by having agencies involved in the event review draft report materials to ensure accuracy.
Results:
This study showed how a remote site with a small cadre of medically trained personnel could organize and effectively provide initial emergency care for >200 persons, an have them transported more than a thousand miles to definitive care.
Conclusion:
Valuable lessons were learned from this incident that may help other areas be better prepared, particularly in remote areas, for large multiple patient events.
When a disaster occurs, a major difficulty is knowing where to find accurate information, and how to help coordinate efforts to share accurate information in a quick and organized manner. The establishment of a global information network, that is in place before a disaster occurs, could link all the communication efforts for relief. We propose that a Global Health Unit for Disaster and Relief Coordination be set up as part of the Global Health Network, utilizing the Internet as its backbone. This Unit would establish the links for the disaster information mosaic.
This report includes the preparations for and the medical impact of the missile attacks launched by Iraq on Israel. It includes the authorization language for the preparations, the preparations undertaken, the perceived threat to the civilian population of Israel, the operational plans activated, the attacks and the medical impact of these attacks, the number and types of casualties, the damage to property, and the initial and subsequent protection times. There occurred a total of 18 missile attacks with 40 conventional missiles launched against Israeli civilians. They resulted in an 4.4 times overall increase in the number of ambulance responses, 228 civilians injured; and two deaths. In addition, five persons died of myocardial infarction related to these attacks. Eight persons died of suffocation due to use of the gas masks.
There has been relatively little attention paid to the mid- and long-term effects of large-scale disasters, particularly their effects on children and young people. At the present time, the impact of the Chernobyl catastrophe on the daily lives of the affected population may include one of strong psychological stress due to uncertainty about ultimate health outcomes. Persons in the Chernobyl region in specific areas of low contamination may be affected similarly. This investigation assesses radiation concerns and attitudes about health and government information, nine years after the disaster, in a group of adults and adolescents residing in a relatively uncontaminated village in the Chernobyl area.
Methods:
Questionnaires were administered to 94 adults and 50 adolescents. Items assessed beliefs about extent of radiation exposure, health concerns regarding oneself and family members, past and current pre-occupation about the disaster, and trust in the accuracy of government information about health effects.
Results:
Considerable uncertainty was demonstrated in both adults and adolescents about the extent of their and their families exposure to radiation. Marked distrust of past and current government information about health effects was evident. A large proportion of subjects reported that they still thought frequently about the Chernobyl accident. They worried about health problems related to radiation exposure whenever they or their family members exhibited physical symptoms or complaints, and they urged family members to go to a medical clinic for evaluation to assess these symptoms.
Conclusion:
The extent of long-term concerns about the personal and family health effects of the Chernobyl disaster in this population residing in a relatively uncontaminated village is striking: the psychological impact on adolescents is considerable. The stress generated is maintained by the realistic uncertainty about the ultimate health consequences to the overall population as a result of radiation exposure and distrust in government information about contamination levels in this particular village. The level of stress and its effects on physical and mental health may increase over time if there is a rise in morbidity in the area. The continuing health needs of the extremely large population affected by the Chernobyl disaster need to be addressed.
More than 2 million refugees, 2–3 million displaced persons internally, thousands of unaccompanied children, and a total number of reported fatalities of 48,347 in Goma, Zaire.
Priorities for International Relief:
International relief support started with coordination provided by the United Nations High Commissioner for Refugees (UNHCR). In the first phase, availability of potable water was the highest priority. Current priorities are to intensify repatriation of Rwandan refugees under conditions that will guarantee human rights and allow for dignified daily living.
Conclusion:
Education beginning at childhood, to overcome conflicts, social inequality, and overpopulation should be promoted by assisting governments, instead of pursuing policies aimed largely at forwarding their own national interests.
Rapid transport from scene to closest trauma center requires optimal use of public safety first responder (FR), basic life support (BLS), advanced life support (ALS), and transport resources (ground or air). In some parts of this regional emergency medical services (EMS) system, on-scene ALS requires contact with on-line medical command (OLMC) to obtain authorization for air medical helicopter (AMH) dispatch, because some EMS medical directors believe that this may decrease overutilization of AMH services.
Hypothesis:
The hypothesis of this study was that requiring prior OLMC for AMH dispatch prolongs mean time to a trauma center versus either FR or BLS request for AMH.
Methods:
Computer mapping programs were used to model the most rapid driving time to the closest trauma center from 167 actual AMH responses to the scene of a motor vehicle accident. In an OLMC-ALS model, only OLMC-ALS can request an AMH. In a BLS model, BLS units arrive on the scene and the crew requests simultaneous dispatch of an ALS response and an AMH. In the FR model, on arrival at the scene, a FR requests simultaneous dispatch of a BLS unit, an ALS unit, and an AMH.
Results:
The OLMC-ALS model resulted in a longer mean value for time to trauma center by an AMH than did the computer model for all ground transport settings. The FR model yielded a shorter mean time for AMH compared with the mean values for time to trauma center for all settings. Differences in mean values for time in urban settings were small (ground: 42 minutes, air: 36 minutes), whereas those for the suburban (ground: 52 minutes, air: 41 minutes), and those for rural (ground: 69 minutes, air: 47 minutes) were significant clinically. For the BLS model, these differences persisted, but were significant clinically only in the rural setting (ground: 68 minutes, air: 53 minutes).
Conclusions:
Optimal use of AMH requires balancing the need for early helicopter dispatch to fully exploit its speed advantage with the disadvantage of expensive overutilization. This computer model indicates that the best person to request AMH varies by venue: in urban settings, the OLMC physician should request AMH dispatch; in suburban venues, BLS should request AMH dispatch; and in rural venues, FRs should request AMH dispatch.
To determine characteristics of continuing education programs for paramedics in large metropolitan areas, and to make recommendations for changes in the Chicago Emergency Medical Services (EMS) system.
Design:
A survey of 95 metropolitan areas from each state in the United States.
Participants:
EMS medical directors, coordinators, and administrators.
Results:
The survey population included 56 respondents. Within this group, 23% were from areas of 1 million people or more, 61% in areas with populations of 100,000 to 1 million and 16% from areas populated by < 100,000 people. Several system types were represented in the survey. In the systems surveyed, 98% mandate didactic continuing education requirements. Clinical continuing education was required by 34% of the systems. Ten systems (18%) awarded continuing education hours for documented in-field experience. This method did not have a specific structure by the majority of users. Both written and skills testing were used by most EMS systems to evaluate paramedic competency. No statistically significant differences (p >0.05) could be found among population subgroups or EMS system types when evaluating the use of these various methods.
Conclusion:
EMS systems primarily use didactic sessions to meet their continuing education requirements. Nearly half of the systems requiring clinical continuing education use in-field credit to fulfill these requirements. In-field credit systems are poorly developed to date. This mechanism may be an effective alternative to usual clinical experiences for paramedics and deserves further investigation.
Many colleges and universities appear to exist in relative isolation from community-based emergency medical services (EMS) systems. In response, some have developed their own EMS systems.
Objective:
To determine the extent of this phenomenon and to delineate the characteristics of these systems.
Design/Methods:
Questionnaires were mailed to 1,503 colleges/universities in the United States and Canada. The questionnaire asked whether the institution had an EMS system and included 19 questions about the characteristics of the system.
Results:
A total of 919 (61 %) responses were received. Of the institutions responding, 234 (25%) had an EMS system and 31 (3.4%) were considering starting a system. Characteristics of the systems were as follows: 1) Types of patients—the two most common call types were medical and trauma/surgical; 134 (57%) reported one-fourth of calls to be medical and 91 (39%) reported one-fourth of calls to be trauma/surgical. 2) Type of service—133 (57%) services transport patients; 195 (83%) respond only to the campus or other university property; the remainder also respond to the community; and 135 (58%) function all year. 3) Dispatch—178 (76%) are dispatched by the campus police, although most services are dispatched by several sources; 46 (20%) use 9-1-1. 4) Personnel—two systems (0.85%) exclusively employ paramedic; 141 systems (60%) have at least one emergency medical technician; the remainder use emergency care attendants and first-aid providers; 118 (50%) have medical directors, of these 76 (64 %) are student health physicians and 21 (18%) are community physicians. 5) Demographic Information—The majority of the campus-based EMS systems exist on small campuses in urban areas.
Conclusions:
A significant number of colleges/universities have EMS systems and one-half transport patients. However, the level of training of the personnel and medical direction may be below the standard for the EMS systems in the communities in which these campus-based systems exist.
The capnometric demonstration of end-tidal carbon dioxide (CO2) is a reliable method of differentiating between a correct endotracheal tube position and an accidental misplacement of the tube into the esophagus. Recently, several CO2 detectors have been introduced for monitoring end-tidal CO2 in the “out-of-hospital” setting, where quantitative capnometry with capnography is not yet available.
Hypothesis:
These devices are not influenced by carbon monoxide (CO) present in lethal concentration.
Methods:
A heated (37°C) 2.3 L reservoir bag filled one-third full with water (representing the stomach in esophageal misintubation) was machine ventilated (tidal volume: 450 ml; frequency: 16/min) with the following mixtures for three minutes each: 1) 95% O2, 5% CO; 2) 45% O2 5% CO, 50% N2O; and 3) 44% O2 5% CO, 50% N2O, 1% halothane. The presence of end-tidal CO2 was monitored with each of the following devices: 1) MiniCAP™ III CO2 Detector; 2) StatCAP™ CO2 Detector; 3) EasyCAP™ CO2 Detector; PediCAP™ CO2 Detector; and 5) Colibri™ CO2 Detector.
Results:
In none of the cases was the presence of CO2 signaled by the detector.
Conclusion:
The presence of 5% CO does not interfere with infrared spectrometry detection (MiniCAP™ and StatCAP™) or chemical detection (EasyCAP™, PediCAP™, and Colibri™) of CO2. The devices can be used safely in patients with CO poisoning for monitoring of endotracheal tube position.
Many state and local emergency medical services (EMS) systems may wish to modify provider levels and their scope of practice to align their systems with the recommendations of the National Emergency Medical Services Education and Practice Blueprint. To determine any changes that may be needed in a typical EMS system, the knowledge and skills of EMS providers in one rural area of North Carolina were compared with the knowledge and skills recommended in the National Emergency Medical Services Education and Practice Blueprint.
Methods:
A survey listing 175 items of patient care-oriented knowledge and skills described in the National Emergency Medical Services Education and Practice Blueprint was developed. EMS providers from five rural eastern North Carolina counties were asked to identify on the survey those items of knowledge and skills they believed they possessed. The skills and knowledge selected by the respondents at the five different North Carolina levels of certification were compared with the knowledge and skills listed for comparable provider levels delineated by the National Emergency Medical Services Education and Practice Blueprint. The proportions of the recommended skills reported to be possessed by the respondents were compared to determine which North Carolina certification levels best correlate with the Blueprint.
Results:
One hundred forty-five EMS providers completed the survey. The proportion of recommended skills and knowledge reported to be possessed by Emergency Medical Technicians (EMTs) ranked significantly lower than did the skills and knowledge reported to be possessed by respondents at other levels in five of the 10 Blueprint elements. The proportion of recommended skills and knowledge reported to be possessed by EMT-Defibrillator-level personnel ranked lower than did those reported to be possessed by respondents at other levels in seven of the 10 Blueprint elements. The proportion of recommended skills and knowledge reported to be possessed by EMT-Intermediates ranked lower than did those reported to be possessed by respondents at other levels in nine of the 10 Blueprint elements. The proportion of recommended skills and knowledge reported to be possessed by EMT-Advanced Intermediates ranked lower than were the skills and knowledge reported to be possessed by respondents at other levels in two of the 10 Blueprint elements. Finally, the proportion of recommended skills and knowledge reported to be possessed by EMT-Paramedics ranked lower than were those reported to be possessed by respondents at other levels in one of the 10 Blueprint elements.
Conclusion:
In North Carolina, combining the EMT and EMT-Defibrillator levels and eliminating the EMT-Intermediate level would create three levels of certification, which would be more consistent with levels recommended by the Blueprint. The results of this study should be considered in any effort to revise the levels of EMS certification in North Carolina and in planning the training curricula for bridging those levels. Other states may require similar action to align with the National Emergency Medical Services Education and Practice Blueprint.