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The siege of Sarajevo is a longterm, human-made, medical disaster of international significance. The delivery of emergency health care provided to the large civilian population held captive in that war zone for an extended time was studied.
Methods:
In May 1993, a humanitarian and fact-finding visit to Sarajevo was conducted. Physicians, administrators, and public health officials were interviewed; epidemiological data were acquired—the resuscitation of war casualties at the two largest hospitals were observed; and local published reports and videotaped footage on the organization and delivery of prehospital and hospital care were reviewed. The videotapes also served to document war crimes.
Results:
Daily bombardment and sniper fire directed at civilians have caused a steady stream of casualties (64,130, or an average of 119 killed or injured per day in 18 months). Eighty percent of the victims were civilian. Despite hazardous conditions from direct shelling, disruption of vital lifelines, and shortage of supplies, medicines, oxygen, and anesthetics, the physicians continue to provide at least a minimum standard of resuscitative care. Seventy percent of all war victims were transported to hospitals in private vehicles. Most casualties (93%) received some form of prehospital, basic first-aid from lay bystanders or first responders. From November 1992 to February 1993, 27,733 patients were treated in hospitals, resulting in 2,139 major surgical procedures. The primary cause of death in 71 of 273 victims was prolonged hemorrhagic, hypovolemic shock. Sixty-one percent of these victims died within 24 hours of injury.
Conclusions:
Continuous needs assessment be accompanied by rapid delivery of outside aid. International “peacekeeping” forces should protect hospitals and their staffs, and ensure the entry of supplies and evacuation of some patients. A public trained in life-supporting first-aid, and physicians and paramedics with experience in advanced life support may have enhanced lifesaving efforts in Sarajevo.
Supplying an adequate amount of drinking water to a population is a complex problem that becomes an extremely difficult task in war conditions. In this paper, several simple methods for obtaining individual supplies of drinking water by filtration of atmospheric water with common household items are reported.
Methods:
Samples of atmospheric water (rain and snow) were collected, filtered, and analyzed for bacteriological and chemical content. The ability of commonly available household materials (newspaper, filter paper, gauze, cotton, and white cotton cloth) to filter water from the environmental sources was compared.
Results:
According to chemical and biological analysis, the best results were obtained by filtering melted snow from the ground through white cotton cloth.
Conclusions:
Atmospheric water collected during war or in extreme shortage conditions can be purified with simple improvised filtering techniques and, if chlorinated, used as an emergency potable water source.
This paper is being composed on Olympic Day 1994, exactly 10 years after its historic flame illuminated the skies of Sarajevo for a festival of peace and friendship. Today, the flames sadly come from incendiary bombs, shell streaks, and fratricide hatred. Against this tragic degradation, the role of the military and the international community has been changing from that of aggressive interference to one of humanitarian assistance and negotiated settlement. In this new setting, disaster and emergency medicine have a special opportunity to prove a noble calling and obligation.
Conflict, unfortunately, and help, fortunately, are as old as humanity. The thoughts expressed herein concern the latter aspect with special reference to the military. As long as man has had a heart, some adrenaline, and the physiological reflex for protection, he has had compassion and an urge to bring succor to those who suffer. The sufferer may be a friend or he may be an enemy, but in humanitarian medical actions, there is no foe.
The 1991 earthquake in the Limón area of Costa Rica presented the opportunity to examine the effectiveness of a decade of disaster preparedness.
Hypothesis:
Costa Rica's concentrated work in disaster preparedness would result in significantly better management of the disaster response than was evident in earlier disasters in Guatemala and Nicaragua, where disaster preparedness largely was absent.
Methods:
Structured interviews with disaster responders in and outside of government, and with victims and victims' neighbors. Clinical and epidemiologic data were collected through provider agencies and the coroner's office.
Results:
Medical aspects of the disaster response were effective and well-managed through a network of clinic-based radio communications. Nonmedical aspects showed confusion resulting from: 1) poor government understanding of the roles and responsibilities of the central disaster coordinating agency; and 2) poor extension of disaster preparedness activities to the rural area that was affected by the earthquake.
Conclusion:
To be effective, disaster preparedness activities need to include all levels of government and rural, as well as urban, populations.
To analyze the characteristics of fatal ambulance crashes to assist emergency medical services (EMS) directors in objectively developing their EMS system's policy governing ambulance operations.
Hypothesis:
No difference exists between the characteristics of fatal ambulance crashes during emergency and nonemergency use.
Design:
Retrospective, cross-sectional, comparative analysis of ambulance crashes resulting in fatalities reported to the Fatal Accident Reporting System (FARS) from 1987 to 1990.
Methods:
Twenty variables, representing characteristics of fatal ambulance crashes, were selected from the National Highway Traffic Administration FARS Codebook and were evaluated using tests of significance for categorical data grouped by emergency use and nonemergency use. Crash variable categories examined included demographics, accident configuration, accident severity, vehicle description, and ambulance operator action.
Results:
During the four-year study period, 109 fatal ambulance crashes occurred producing 126 deaths. Four states, New York, Michigan, California, and North Carolina, accounted for 37.5% of all fatal crashes. Seventy-five fatal crashes (69%) occurred during emergency use (EU) and 34 fatal crashes (31%) occurred during nonemergency use (NEU). The total number of fatal crashes varied in a downward trend (1987:32; 1988:24; 1989:28; 1990:25). The number of fatal EU crashes also varied in a downward trend (1987:28; 1988:16; 1989:19; 1990:12), while the number of fatal NEU crashes increased each year [1987:4; 1988:8; 1989:9; 1990:13](p = .016). Most EU fatal crashes occurred between 1200 h and 1800 h (p = .009). Most NEU fatal crashes occurred during times when light conditions were poor (p = .003). When a violation was charged to the ambulance driver (17 cited), the vehicle was more likely to be in EU (p = .056). No statistically significant differences between EU and NEU were identified by: 1) day of week; 2) season; 3) atmospheric conditions; 4) roadway surface type; 5) roadway surface condition; 6) speed limit; 7) roadway alignment; 8) relationship to junction; 9) manner of collision; 10) year manufactured; 11) vehicle role; 12) vehicle maneuver; 13) manner leaving scene; 14) extent of deformation; 15) violations charged; or 16) number of persons killed in accident.
Conclusion:
Few characteristics differentiate between fatal ambulance crashes during EU and NEU. The difference between EU and NEU were statistically significant in only three out of the 20 variables examined: 1) year occurred; 2) time of day; and 3) light condition. These data provide few objective measures that may be used to develop ambulance operation policies to decrease fatal ambulance crashes.
Each of us has witnessed news reports and graphic television scenes of the willful targeting of innocent noncombatants by military forces; the displacement of tens of thousands of men, women, and children; and the diabolical genocidal tactics of “ethnic cleansing” of the war in Bosnia and Herzegovina. An international effort to establish a United Nations war crimes tribunal is being developed, but even this plan is running out of steam for lack of funding. These events are unfolding in “civilized” and “enlightened” Europe. We all know what is happening, yet world leaders have been reluctant to intervene.
This course is an introduction to the topic of natural hazards, their causes and their consequences. The subject is so vast that this course cannot begin to provide a definitive treatment of all aspects of these hazards. Instead, it seeks to present an overview of the general subject.
The course begins with a definition of each major natural hazard that disaster managers may encounter in developing countries. Historical examples are presented to give perspective to the potential scope of these natural events and their actual effects within a community or country. The geographical distribution of the hazard type, indicating the possibility of its occurrence in all parts of the world, is shown. The natural pre-conditions that must exist for the phenomenon to occur are described. The actual event is described in its physical/natural manifestation, with a detailed account of what happens and why, before, during, and after the event. The impact on the natural and human-produced environment—the reason it becomes a “disaster” rather than simply a natural phenomenon—is reviewed. Each lesson then discusses what disaster managers, in particular, and the public, in general, can do to respond.
Motor vehicle injuries are a major public health problem. They are a primary cause of: 1) death and injury in the United States; and 2) result in a substantial loss of productive life. These injuries and fatalities have serious social and economic consequences for the injured individual, their families, and society. This report focuses on the portion of health care expense borne by the public and the tax revenue implications of these injuries and fatalities.
Methods:
The relationship between motor vehicle injuries and fatalities, health care costs, and income taxes was analyzed for four situations: 1) 1990 baseline; 2) achievement of modest goals for safety improvements; 3) population growth with constant injury and fatality rates; and 4) the effect of higher injury and fatality rates. Total health care costs, publicly funded health care costs, lost income tax revenue, and increased public assistance were estimated at the [U.S.] federal level, and at the state and local level.
Results:
Study of these relationships indicate that: 1) the lifetime economic cost of motor vehicle injuries, fatalities, and property damage that occurred in 1990 is $137.5 billion. American taxpayers will pay $11.4 billion of that total to cover publicly funded health care ($3.7 billion), reduced income tax revenue ($6.1 billion), and increased public assistance expenses ($1.6 billion); 2) the lifetime economic cost of alcohol-related, motor vehicle injuries, fatalities, and property damage that occurred in 1990 was $46.1 billion. Of this, the American taxpayer will pay $1.4 billion to cover publicly funded health care and $3.8 billion to cover reduced income tax revenue and increased public assistance; 3) reducing the percentage of the alcohol-related portion of these fatalities from 45% to 43% (1,200 lives saved), and alcohol-related injuries by a proportionate amount, would save American taxpayers $73 million in publicly funded health care and $208 million in income taxes and public assistance; 4) by increasing observed safety-belt usage in passenger cars from 62% to 75%, (1,700 lives saved plus a proportionate reduction in injuries), publicly funded health care costs would be reduced by $180 million, and $328 million would be saved in the combination of increased income tax revenues and reduced public assistance; 5) Further reductions in publicly funded health care, increases in income tax revenues, and reductions in public assistance are possible as a result of reasonable gains in other areas, such as increased safety-belt usage in light trucks, increased usage of motorcycle helmets, increased correct usage of child safety seats, and reducing the number of speeding drivers; 6) if injury and fatality rates remain at the 1992 level, population increases alone would result in 3,300 more fatalities in the year 2000. Economic costs from these fatalities and a proportionate increase in injuries would increase by an estimated $7.4 billion, including a $277 million increase in publicly funded health care costs, and $573 million in reduced income tax revenue and increased public assistance; and 7) if injury and fatality rates increase from the 1992 level, injuries, fatalities, and costs will increase. In one scenario, with 5,800 more fatalities than the population growth scenario, economic costs would increase by $13 billion, including a $350 million increase in publicly funded health care, and an additional $1 billion in taxes to cover lost income tax revenue and increased public assistance.
Conclusions:
It is obvious that inaction is a costly alternative and that anticipated population gains will require further reductions in injury and fatality rates just to maintain current injury and fatality rates. Fortunately, countermeasures are to be available that can accomplish this. Lack of vigilance that would result in deterioration of safety levels would be even more costly.
Use of an oxygen-powered demand-valve to ventilate through an endotracheal tube is considered inappropriate due to concern regarding excessive airway pressure.
Hypothesis:
It was hypothesized that ventilation through an endotracheal tube using a bag-valve (BV) device and the recently modified demand-valve (DV) would produce similar tidal volumes (Vt), minute ventilation (MV), and peak airway pressures (PAP).
Methods:
This is a prospective, randomized vitro experimental model. Subjects were blinded to volume and pressure gauges. Thirty-nine EMTs (mean age 27 years with mean experience five years) volunteered to ventilate a mechanical test lung through an endotracheal tube for 10 minutes. Each subject was randomized to BV or DV and to either normal (0.1 L/cm H2O) or poor (0.04 L/cm H2O) lung compliance. This DV delivers set flow of 40 L/min at maximum 50±5 cm H2O. Subjects were instructed to use their “usual” technique for an average size adult in respiratory arrest with normal heart rate and blood pressure. The Vt and PAP were recorded for each breat; the MV and maximum PAP (PAP-max) for each minute was noted. Data were analyzed using repeated measures ANOVA and Tuke multiple comparisons with alpha set at 0.05.
Results:
Overall average tidal volumes and minute ventilations were acceptable with both ventilalory devices at both normal and poor compliance for the first, fifth, and 10th minute of continuous ventilation. Average airway pressures and peak airway pressures during the first, fifth, and 10th minute of ventilation all were significantly higher with those of the bag-valve than with the use of the demandvalve at both normal and poor compliance.
Conclusion:
In this model, ventilation with bag-valve and demand-valve both provided more than adequate Vt and MV; values wer similar except for higher Vt with BV at normal compliance. However, DV yielded significantly lower PAP and PAPmax at both poor and normal compliance. These findings need corrobration in an in vivo model, but suggest that with proper training, demand-valve ventilation through an endotracheal tube may be preferable.
A mechanism was initiated for conveying quality improvement (QI) results to paramedics as a means of improving chart documentation in difficult-to-correct areas. This study examines the impact of this QI feedback loop on charting, resuscitation rates from cardiac arrest, endotracheal intubation (ETI) success rates, and trauma scene times.
Design:
Paramedic trip sheets were reviewed before and after the institution of the QI feedback hop in this interrupted time series design.
Setting:
The New Castle County, Delaware, Paramedic Program.
Participants:
All New Castle County paramedics participated in the study.
Interventions:
In January 1990, the medical director began to circulate a QI summary among the paramedics in an effort to improve performance and chart documentation. The summary focused on the management of respiratory distress or arrest, cardiac arrest, and major trauma. The success rate for ETI was compared with the rate of field resuscitation from cardiac arrest, the percentage of unjustified prolonged trauma scene times (longer than 10 minutes), and the percent compliance with minimum endotracheal intubation documetation (ETID) requirements from a six-month period before institution of the QI feedback mechanism with data obtained from a six-month period after the program had been operational for one year.
Results:
Comparing results from before with after the initiation of the QI program, the ETI success rate was 273 of 295 (92.5%) before and 300 of 340 (88.2%) after (X2 = 3.04, p <.1, ns); field resuscitations totaled 26 of 187 (13.9%) before and 44 of 237 (18.6) after (X2 = 1.40, p <.25, ns); ETID rate was 249 of 295 (84.4%) before and 336 of 340 (98.8%) after (X2 = 44.24, p <.001), and unjustified prolonged trauma scene times were 69 of 278 (24.8%) before and seven of 501 (1.4%) after (X2 = 320.5, p <.001).
Conclusion:
The use of QI feedback had little effect on psychomotor skills such as the ETI success rate or resuscitation rate, but had a dramatic effect on chart documentation, as evidenced by ETID rate, and behavior, as evidenced by the reduction in prolonged trauma scene times. The use of QI feedback is recommended as a means of correcting charting deficiencies or modifying behavior.