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Decisions to send an ambulance with or without lights and siren are made every day. While travel with lights and siren is presumed to have relatively more risk associated with it than travel without, little epidemiologic analysis has been conducted to compare the two modes of travel or to characterize collisions in general.
Objective:
To characterize ambulance collisions and assess the risk of traveling with lights and siren in an urban 9-1-1 environment.
Methods:
Retrospective analysis of all consecutive ambulance collisions of the Paramedic Division of the San Francisco Department of Public Health during a 27-month period.
Results:
The overall collision rate for lights and siren (LS) travel was higher than that for non-lights and siren travel, although the difference was not statistically significant (45.9 collisions per 100,000 LS patient travels, 95% confidence limits 29.7, 62.1, versus 27.0/100,000 for non-LS travel, 95% confidence limits 18.3, 35.7). However, the rates of resulting injuries displayed a statistically significant difference (22.2 injuries per 100,00 LS patient travel, 95% confidence limits 11.0, 33.5, versus 1.5/100,000 for non-LS travel, 95% confidence limits −0.6, 3.5). While the majority of collisions (60.0%) occurred during patient-related travel, 35.6% occurred while the ambulance was available awaiting assignment, and 4.4% in a hospital parking lot. The majority of collisions were due to inattention, failure of on-coming traffic to yield, or unsafe parking; unsafe speed was an infrequent cause. Most crashes occurred during daylight, in dry weather, and involved another vehicle.
Conclusion:
There is some elevated risk for collision and added injury during lights and siren travel compared to travel without LS. The causes for these collisions suggest that interventions designed to improve driver skills and increase citizen awareness of an approaching ambulance could help reduce the number of collisions.
With the growth of hospice and home health care, more patients with terminal illness are electing to avoid hospitalization until the final stages of illness. Many of these patients, as well as others with advanced chronic illnesses, have decided with the help and support of their attending physicians, that they do not wish to be resuscitated in the event of cardiac or respiratory arrest. However, as death draws near, well-meaning family or friends, or perhaps the patient, may call emergency medical services (EMS) personnel to transport the dying patient to the hospital; the prehospital providers who respond to these calls may be the last medical persons to attend terminally ill patients at home or in nursing homes. In many cases, these calls to EMS personnel are intended only to obtain transportation or comfort measures for the loved one. However, unless the state provides statutory authority for EMS personnel to honor a “do not resuscitate” (DNR) order, there may be a requirement for such personnel to attempt resuscitation, regardless of the patient's wishes and the physician's directive.
The State Hospital of Sarajevo has a tradition that is 127 years old. It is located on the spot where the first Turkish Army hospital—the first hospital on the territory of Bosnia and Herzegovina—was established in 1865. Through the ages, military health institutions in the city of Sarajevo always have been located on this spot. In its time, that first hospital was a modern health facility with its own running water and sewage system. It was used for the treatment of Turkish soldiers. Civilians had their facility built in 1866— the so-called Vakuf Hospital, the operation of which was aided occasionally by two military physicians.
As a physician and aid worker for the World Health Organization (WHO), I spent some months during the winter (1992-1993) in the besieged city of Sarajevo and another month during the spring (1993) in northeastern Bosnia.
Impressions from such an experience, in the middle of a war in Europe, naturally mark one's mind. As one who has seen Sarajevo's people desperately fight to survive the winter, during constant bombardment, and with lack of everything associated with basic needs such as fuel, food, water, and drugs, I will never forget. I could speak a long time about the hardship, as well as the helpfulness, friendship, and even happiness amid grief and misery. There were joyful parties with Bosnian songs and music, dinners with food made of almost nothing at all and held in homes seriously damaged by shelling. Sarajevo, that magic city, became a mysterious attraction to us foreigners. Once we had been there, we had to go back to see how the city was surviving. We all had the “Sarajevo Syndrome.”
Anecdotal observations about prehospital emergency medical care in major natural and human-made disasters, such as earthquakes, have suggested that some injured victims survive the initial impact, but eventually die because of a delay in the application of life-saving medical therapy.
Methods:
A multidisciplinary, retrospective structured interview methodology to investigate injury risk factors, and causes and circumstances of prehospital death after major disasters was developed. In this study, a team of United States researchers and Costa Rican health officials conducted a survey of lay survivors and health care professionals who participated in the emergency medical response to the earthquake in Costa Rica on 22 April 1991.
Results:
Fifty-four deaths occurred prior to hospitatization (crude death rate = 0.4/1,000 population). Seventeen percent of these deaths (9/54) were of casualties who survived the initial impact but died at the scene or during transport. Twenty-two percent (2/9) were judged preventable if earlier emergency medical care had been available. Most injuries and deaths occurred in victims who were inside wooden buildings (p <.O1) as opposed to other building types or were pinned by rubble from building collapse. Autopsies performed on a sample of victims showed crush injury to be the predominant cause of death.
Conclusions:
A substantial proportion of earthquake mortality in Costa Rica was protracted. Crush injury was the principal mechanism of injury and cause of death. The rapid institution of enhanced prehospital emergency medical services may be associated with a significant life- saving potential in these events.
To investigate surgical blood usage during the siege of Sarajevo.
Methods:
Data on blood usage and pre-transfusion hematocrit (Hct) values from blood transfusion request forms in 250 wartime emergency surgical procedures during August through October 1992 (experimental group), and in 146 peacetime elective surgical procedures (control group) during April through June 1991 at the State Hospital of Sarajevo, were reviewed.
Results:
The mean number of blood units transfused per patient (blood usage rate) was 1.13 in the experimental group versus 2.56 in the control group (p <0.001). During the war, for blood conservation, normovolemic hemodilution was practiced widely. A significantly lower mean pre-transfusion Hct value of 0.21 was observed in the experimental group versus 0.27 in the control group (p <0.001).
Conclusion:
Blood-usage rate was lower during emergency surgical procedures in war than during elective surgical procedures in peacetime without apparent adverse patient outcome. This decrease in blood-usage rate in the face of increased numbers of trauma victims was the result of a planned blood-conservation program which included: stringent blood-usage criteria, and widespread implementation of casualty resuscitation using normovolemic hemodilution with colloid and crystalloid plasma substitutes.
The use of warning lights and siren (L&S) by prehospital emergency medical services (EMS) vehicles is a basic component of emergency response and patient transport. This public-safety practice predates modern EMS by 50 years. Despite the long-term reliance on L&S, it is not a risk-free practice. There are many reports of emergency medical vehicle (EMV) collisions during L&S responses and transports. These collisions often result in tragic consequences for the EMV occupants and those in other vehicles, and may cause significant delays to medical care for the patient the EMV was responding to or transporting. While there is no systematic collection of EMV collision data, some authors have suggested that the available information underestimates the extent of the problem. In addition, to date there have been few published analyses regarding the effectiveness of L&S as a modality that improves response times or, more important, patient outcome.
The safe and timely provision of blood is of crucial importance in the prevention and mitigation of morbidity and mortality due to trauma. The use of blood in the treatment of war casualties, soldiers as well as civilians, was analyzed retrospectively and the impact of massive blood transfusion on blood banking services and reserves of blood during the war in Sarajevo was assessed.
Methods:
A retrospective analysis of 3,215 war casualties (1,815 civilians plus 1,400 military) who arrived to the casualty reception center of the State Hospital of Sarajevo during the period 11 May through 31 October 1992 was performed. Blood usage was reviewed in three stages: within 24 hours (h) of admission, after seven days of hospitalization, and after 30 days of hospitalization. The types of injury, survival rate, and blood-usage rate in a sample of 37 war casualties who required massive blood transfusions (MBT) during the period 11 May through 31 December 1992 was examined.
Results:
The civilian casualty rate in this series of patients was 56.5%. A total of 1,217/3,215 (37.9%) casualties were hospitalized. In this study, 16% (504/3,215) of total number of persons wounded received blood transfusion. Of these patients, 504/1,217 (41.4%) were transfused. A total of 971.1 liters of blood were transfused through 31 October 1992; 68% within 24 h of admission, 91% within the first seven days, and 100% within the first 30 days. From a total of 37 MBT recipients, 36 (97%) were injured by firearms. Survival rate among MBT patients was 30%. The MBT recipients comprised 2% of total hospitalized patients and 6% of total number of patients transfused. The amount of blood needed during episodes of MBT was 15% of total blood used through 31 December 1992.
Conclusions:
Based on these data, prospective requirements for blood usage should take into account casualty triage, as follows: for each casualty transported to the hospital, hospitalized, or transfused, 0.302, 0.796, and 1.912 liters of blood respectively, will be needed for the first 30 days of treatment. Recipients of massive blood transfusions are a significant drain on blood reserves in war. This experience can be utilized in the development of revised guidelines for blood usage for an entire population affected by war.
An epidemic of surgical wound infections observed at the State Hospital of Sarajevo during June-September 1992 is reported.
Methods:
A cross-sectional survey of 138 surgical patients with wound infection treated by the Department of Surgery of the State Hospital of Sarajevo was performed in mid-September and again in mid-November 1992. A preliminary evaluation of the bactericidal effectiveness of a new antiseptic preparation called DI-ASEPT also was done.
Results:
The frequency of wound infection was 24.4% in September and 19.2% in November. Pseudomonas species was the primary etiologic agent in this epidemic. DI-ASEPT was as effective as povidone-iodine in producing wound asepsis.
Conclusions:
Because of limited resources large numbers of casualties, and an extremely adverse environment as a result of war that has affected hygienic conditions at the State Hospital of Sarajevo, a high frequency of contaminated or dirty operations were performed. This was the primary reason for the observed increase in wound infections. After hygienic conditions were restored, the epidemic of wound infections was terminated.
In war, abdominal injuries constitute a significant proportion of the total injuries. These injuries are associated with high mortality and their treatment poses dianostic, surgical, and therapeutic dilemmas. This article presents the epidemiology of abdominal war injuries during the siege of Sarajevo, and briefly describes the surgical techniques and therapeutic practices used in their treatment.
Methods:
A retrospective medical record review was performed of 273 war casualties with trauma to visceral and vascular structures in the abdomen inflicted during a 7.5 month period in 1992.
Results:
Most patients underwent exploratory laparotomy. Six percent had negative laparotomies, and there were no deaths in this group. In 18.3%, injuries were limited to one organ system, while 81.7% sustained combined injuries to multiple-organ systems. The crude mortality rate was 26.0%. Mortality rate excluding deaths within 24 hours of injury was 10.3%. Injuries were caused by metal fragments from artillery shrapnel, mortar and contact mines, or hand grenades. Because of a shortage of colostomy bags, resections of the colon with primary end-to-end anastomoses rather than colostomy were performed in 72% of the cases.
Conclusions:
Mortality was highest in those victims with four or more injured organ systems (81.3%) or with major vascular injuries (64.7%). The primary cause of death within the first 24 hours was prolonged hemorrhagic shock.
The proliferation of air medical transport in the 1980s and 1990s has been accompanied by minimal investigation into the appropriateness of transport. A strong foundation has been developed regarding adult trauma. However, important issues in pediatric and general medical patients have not been addressed. The health care crisis in America mandates air medical transport systems to provide appropriate access to medical technology and resources in a cost-effective manner while maintaining quality of care. We must identify the patients whose outcomes will benefit from air medical transport.
The National Association of State EMS Directors (NASEMSD) held its annual meeting in Austin, Texas, in October 1993. The Association expressed its support and concern for several issues at that meeting. In Austin, seven resolutions were approved.