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To investigate the adequacy of hospital disaster preparedness in the Osaka, Japan area.
Methods:
Questionnaires were constructed to elicit information from hospital administrators, pharmacists, and safety personnel about self-sufficiency in electrical, gas, water, food, and medical supplies in the event of a disaster. Questionnaires were mailed to 553 hospitals.
Results:
A total of 265 were completed and returned (Recovery rate; 48%). Of the respondents, 16% of hospitals that returned the completed surveys had an external disaster plan, 93% did not have back-up plans to accept casualties during a disaster if all beds were occupied, 8% had drugs and 6% had medical supplies stockpiled for disasters. In 78% of hospitals, independent electric power generating plants had been installed. However, despite a high proportion of power-plant equipment available, 57% of hospitals responding estimated that emergency power generation would not exceed six hours due to a shortage of reserve fuel. Of the hospitals responding, 71% had reserve water supply, 15% of hospitals responding had stockpiles of food for emergency use, and 83% reported that it would be impossible to provide meals for patients and staff with no main gas supply.
Conclusions:
No hospitals fulfilled the criteria for adequate disaster preparedness based on the categories queried. Areas of greatest concern requiring improvement were: 1) lack of an external disaster plan; and 2) self-sufficiency in back-up energy, water, and food supply. It is recommended that hospitals in Japan be required to develop plans for emergency operations in case of an external disaster. This should be linked with hospital accreditation as is done for internal disaster plans.
A study was done with EMS personnel to determine the ease of use and accetance of a saline lock (SL), intermittent infusion device in place of traditional intravenous tubing and fluid bags for prehospital intravenous (IV) maintenance.
Study Hypotheses:
Saline lock, intermittent infusion device use in specific clinical scenaios is easier, less expensive, and as effective traditional TV tubing and fluid bags. The emergency medical technician-paramedic (EMT-P) would accept the implementation of saline locks in the emergency medical servics (EMS) system.
Methods:
This was a prospective, non-blinded study with the EMS providers under the medical command of a suburban community hospital's emergency department. Patients were included if prophylactic IV access or medication administration was required by clinical protocols. Excluded from the study were those patients requiring IV access for fluid infusion, constant drug infusion, cardiac arrests, or transport to another hospital's emergency department (ED). Intravenous access was achieved with the usual catheter over needle cannulation techniques. The device (Interlin Injection Site SL) was attached to the hub of the IV cannula and flushed with 2 cc of 0.9% saline from prefilled carpujects.
Results:
There were completed questionnaires for 79 successful SL initiated in 98 attempts of IV access on 80 patients over a four-month period. When compared to traditional IV fluid bags, SL were judged by the paramedics to be less time-consuming to initiate and maintain (55 of 79 or 70%), easier to use (51 of 79 or 65 %) and facilitated patient transportation (73 of 79 or 92%). Medications were administered according to protocol or command dirtion in the prehospital setting through 20 (25%) SL. Intravenous access was maintained by 52 of 79 SL (65 %), and seven (9%) SL were converted to fluid infusions in the prehospital setting after contact with the medical command physician. In the ED, two (3%) SL were judged by nurses to be nonpatent and 17 (22 %) were converted to maintenance fluid infusions. Systemwide use of SL was favored by 73 of 79 (92.4%) EMS providers. Each device and 2 ml 0.9% saline flush carpuject cost [U.S.]$1.62 versus the cost of IV tubing and a 250 cc bag of lactated Ringer's at $2.11, resulting in a cost savings of 23.2%.
Conclusion:
The saline lock, intermittent infusion device is an effective method of maintaining prehospital IV access. When compared to traditional IV fluid bags, EMT-Ps judged the device to be easier and less time-consuming to initiate, and facilitated patient transportation. A cost savings was realized when SL usage was compared to traditional IV fluid bag infusion. Systemwide implementation of the saline lock was desired.
On 9 April 1991, the Republic of Georgia proclaimed its independence from the Soviet Union. Sviat Gamsakhurdia, an anti-communist leader of the Georgian Nationalist movement, was elected President by an overwhelming majority. Soon after the election, however, Gamsakhurdia's popularity began to plummet. He was accused of suppressing any opposition, and he and his supporters accused the opposition of being in league with Moscow and seeking to sabotage Georgian independence. Demonstrators in Tbilisi, the capital city, demanded the resignation of the new government, and the government relied increasingly upon armed forces to maintain power.
To identify risk factors for adverse events that occur during interfacility transfers by advanced life support (ALS).
Design:
A four-year, retrospective, case series.
Setting:
Three ALS units in a rural/suburban emergency medical services (EMS) system.
Participants:
351 transports to or from twelve acute care facilities; two patients records could not be located.
Interventions:
Patients were classified by illness/injury, transporting staff, and ongoing therapy; these were correlated with frequency of ALS intervention and patient deterioration.
Results:
During the study period, the number of transfers as a percentage of total calls (1.1%–5.2%) rose consistently. There were 11 illness/injury categories; the largest was cardiac (44%, 154 patients). Hospital staff accompanied the patient in 15% (52). Advanced life support (ALS) therapy was required in 4.9% (17): one monitored cardiac arrest was defibrillated successfully, 13 patients required unanticipated medication therapy, and three were noted to have clinical deterioration en route. The upper 95% confidence limit for cardiac arrest is 12.9/1,000 transfers or 20.8/1,000 hours. Patient deterioration and the need for ALS intervention were associated with the presence of medication infusions (p <.O5), but not with hospital staff (p >.40).
Conclusions:
Interfacility transfers of a heterogeneous group of patients in this series involve a low risk of cardiac arrest. Patients with medication infusions are at higher risk of deterioration and more frequently require ALS intervention en route. The presence of hospital staff had no measurable effect. These findings have implications for the development of ALS transfer protocols.
This self-study course will meet the needs of people involved in disaster management for both sudden-onset natural disasters (i.e., earthquakes, floods, hurricanes) and slow-onset disasters (i.e., famine, drought). The course is designed for government personnel, representatives of private, voluntary agencies, and other individuals interested in disaster management.
The nine lessons for the course will be published successively in Prehospital and Disaster Medicine. Self-assessment tests will accompany each lesson. There also is a final examination offered for those who wish to earn continuing education units (CEUs) through the University of Wisconsin—Disaster Management Center (UW-DMC).
On 28 March 1982, El Chichon, a volcanic peak located in southern Mexico, began an eruptive phase of activity. Four major eruptions occurred within the next eight days, culminating in a cataclysmic eruption on 4 April. When the dust had settled, an estimated 200 million tons of ash blanketed more than 200 square kilometers of southern Mexico and neighboring Central American countries. Forty thousand villagers were left homeless and several thousand people may have lost their lives. Fifty thousand head of cattle were destroyed outright with many more succumbing to lack of water and pasture. Millions of hectares of crops were destroyed (Figure 1).
Current paramedic training mandates complete immobilization of all patients, symptomatic or not, whose mechanism of injury typically is viewed as conducive to spinal trauma. It is common to observe confrontations between paramedics and walking, asymptomatic accident victims who fail to understand why they should “wear that collar and be strapped to that board.” Immobilized, frustrated patients then may wait for hours in a busy emergency department until a physician declares them to be without spinal injury. Patients frequently refuse treatment and transport.
Hypothesis:
Algorithms exist for physicians to “clear” the cervical spine (C-spine) without radiography. It was hypothesized that paramedics routinely assess and document these indicators in their patient evaluations.
Methods:
A retrospective chart review was conducted on 161 patients (Group 1) admitted to a regional medical center with a diagnosis of C-spine injury over a 52-month period. The charts of 225 motor vehicle accident (MVA) victims (Group 2) transported by ambulance to the emergency department over a five-month period then were studied. Indicators for C-spine injury documented by emergency medical service (EMS) personnel were abstracted.
Results:
All patients underwent mental status assessment and full spinal immobilization (neck and back) by EMS crews prior to transport to the hospital. Two or more indicators of possible C-spine injury were documented on each prehospital care report (PCR).
Conclusion:
Paramedics already assess most, if not all, of the criteria standard to C-spine clearance algorithms, but are inconsistent in their documentation of the presence or absence of all of the relevant findings.
Proper airway control in trauma patients who have sustained cervical spine fracture remains controversial.
Purpose:
This study was undertaken to survey the preferred methods of airway management in cervical spine fracture (CSF) patients, to evaluate the experience of handling such patients at a level-I trauma center, and to contrast the findings with recommendations of the American College of Surgeons Committee on Trauma.
Hypothesis:
The methods used for control of the airway in patients with fractures of their cervical spine support the recommendation of the American College of Surgeons (ACS) Committee on Trauma.
Methods:
The study consisted of two parts: 1) a survey; and 2) a retrospective study. Survey questionnaires were sent to 199 members of the Eastern Association for the Surgery of Trauma and to 161 anesthesiology training programs throughout the United States. Three resuscitation scenarios were posed: 1) Elective airway—CSF—breathing spontaneously, stable vital signs; 2) Urgent airway—CSF—breathing spontaneously, unstable vital signs; and 3) Emergent airway—CSF—apneic, unstable. In addition, a three-year retrospective study was conducted at a level-I trauma center to determine the method of airway control in patients with cervical spine fractures.
Results:
Responses to the questionnaires were received from 101 trauma surgeons (TS) and 58 anesthesiologists (ANESTH). Respondents indicated their preference of airway methods: Elective airway: Nasotracheal intubation: TS 69%, ANESTH 53%. Orotracheal intubation: TS and ANESTH 27%. Surgical airway: TS 4%. Intubation with fiberoptic bronchoscope (FOB): ANESTH 20%. Urgent airway: Nasotracheal intubation: TS 48%, ANESTH 38%. Orotracheal intubation: TS 47%, ANESTH 45%. Surgical airway: TS 4%. FOB: ANESTH 16%. Emergent airway: Orotracheal intubation: TS 81 %, ANESTH 78%. Surgical Airway: TS 19%, ANESTH 7%. FOB: ANESTH 15%.
The retrospective review at the trauma center indicated that 102 patients with CSF were admitted; 62 required intubation: four (6%) on the scene, seven (11%) en route, five (8%) in the emergency department, 42 (67%) in the operating room, and four (6%) on the general surgery floor. Airway control methods used were nasotracheal: 14 (22%); orotracheal: 27 (43%); FOB: 17 (27%); tracheostomy: one (2%); unknown: three (4%). No progression of the neurological status resulted from intubation.
Conclusion:
The choice of airway control in the trauma patient with CSF differs between anesthesiologists and surgeons. However, the method selected does not have an adverse affect on neurological status as long as in-line stabilization is maintained. The methods available are safe, effective, and acceptable. The recommendations of the American College of Surgeons Committee on Trauma for airway control with suspected cervical spine injury are useful. The technique utilized is dependent upon the judgment and experience of the intubator.
The developments of emergency medicine and emergency medical services (EMS) have occurred simultaneously although at times on parallel paths. The recognition of EMS providers as physician surrogates and emergency care resources as an extension of emergency department care has mandated close physician involvement. This intimate physician involvement in EMS activities is now well accepted. It has, however, pointed out the need for in-depth training of physicians in the subspecialty of EMS.
To assess the accuracy of paramedic estimates of adult body weights in cardiac arrest cases.
Hypothesis:
Paramedics could accurately estimate the weights of out-of-hospital cardiac arrest patients.
Design:
Retrospective data analysis of a 15-month, multicenter study involving nontraumatic out-of-hospital cardiac arrest patients. Paramedic estimates of body weights were compared to weights measured in the hospital. Patients were included in the analysis only if both a paramedic weight and a measured in-hospital weight were recorded.
Setting:
Six urban emergency medical services systems.
Participants:
The study population included adults with return of spontaneous circulation who subsequently were admitted to the hospital.
Measurements:
Pearson correlation analysis of paramedic-estimated weights and measured weights.
Results:
Among the 133 study patients, the correlation coefficient (R) for paramedic estimates and the actual measured weight was 0.93. Paramedic estimates of weight were within 10% of the measured weights in 74% of the patients, and within 20% of measured weights in 93% of the patients.
Conclusion:
Paramedic weight estimates correlated well with measured weights.
Direct physician observation of advanced life support (ALS) personnel is rare in a demographically diverse state.
Study Population:
Twenty ALS agencies from throughout Arizona.
Methods:
A board-certified emergency physician performed on-site interviews with the emergency medical services (EMS) supervisor of each agency to approximate the number of days per year that physicians observe ALS personnel in the field.
Results:
Only 11 agencies (55%) reported that physicians ever observed ALS personnel. Among all agencies, an estimated total of 84 observer-days occurred per year. The agencies staffed a total of 86 ALS units, resulting in an estimated 0.98 observer-days/unit/year (84/86). On the average, it took 3.4 ALS personnel to staff a given unit over time and the probability that an ALS provider would be on a unit on any given day was 0.29 (1/3.4). The probability of a given provider being observed during one year was approximately 0.29 (0.98 x 0.29). Thus, on the average, an ALS provider would be observed by a physician approximately once every 3.5 years (1/0.29). Among urban agencies, the “average” ALS provider would be observed once every 2.9 years. This compared to a likelihood of in-field observation of only once every 6.7 years for non-urban providers (p = .036).
Conclusions:
The skills of ALS providers in Arizona are observed by a physician in the field very infrequently. Although an uncommon occurrence in urban agencies, observation of non-urban ALS personnel occurs even less frequently. In addition, nearly one-half of the agencies surveyed never had a physician-observer. Although a variety of skills evaluation methods exist, it remains unclear whether any method is as useful as direct observation. Future investigations are needed to evaluate whether in-field physician observation impacts skills, patient care, or outcome in EMS systems.
The standard of practice and teaching for prehospital pediatric endotracheal intubation (PETI) in the United States currently is unknown. The accepted practice of prehospital PETI is of interest because it has contradictory support in the medical literature.
Hypothesis:
PETI is an accepted method of prehospital airway control in the United States.
Methods:
Nationwide mail survey (June 1991 to March 1992) of each state emergency medical service (EMS) agency and all known paramedic training sites.
Results:
The use of PETI is supported by 100% of state EMS agencies and the American Virgin Islands. Ninety-seven percent (339 of 349) of the responding (349 of 523) paramedic training sites reported that PETI was taught in their programs. The results of the survey did not identify a predominate method for instructing paramedics in PETI. Lectures, mannequins, operating room demonstration, animal models, and cadavers were used in various ways for teaching the skill.
Conclusion:
Endotracheal intubation is an accepted standard in prehospital pediatric care. This standard exists with marginal support in published literature and study of prehospital PETI is needed to define the benefits, risks, and optimal instruction methods for the procedure.