Last updated 10th July 2024: Online ordering is currently unavailable due to technical issues. We apologise for any delays responding to customers while we resolve this. For further updates please visit our website https://www.cambridge.org/news-and-insights/technical-incident
We use cookies to distinguish you from other users and to provide you with a better experience on our websites. Close this message to accept cookies or find out how to manage your cookie settings.
This journal utilises an Online Peer Review Service (OPRS) for submissions. By clicking "Continue" you will be taken to our partner site
https://mc.manuscriptcentral.com/pdm.
Please be aware that your Cambridge account is not valid for this OPRS and registration is required. We strongly advise you to read all "Author instructions" in the "Journal information" area prior to submitting.
To save this undefined to your undefined account, please select one or more formats and confirm that you agree to abide by our usage policies. If this is the first time you used this feature, you will be asked to authorise Cambridge Core to connect with your undefined account.
Find out more about saving content to .
To save this article to your Kindle, first ensure coreplatform@cambridge.org is added to your Approved Personal Document E-mail List under your Personal Document Settings on the Manage Your Content and Devices page of your Amazon account. Then enter the ‘name’ part of your Kindle email address below.
Find out more about saving to your Kindle.
Note you can select to save to either the @free.kindle.com or @kindle.com variations. ‘@free.kindle.com’ emails are free but can only be saved to your device when it is connected to wi-fi. ‘@kindle.com’ emails can be delivered even when you are not connected to wi-fi, but note that service fees apply.
Federal [U.S.] law and the Joint Commission on the Accreditation of Healthcare Organizations mandate plans and mechanisms for response by hospitals to hazardous material incidents/accidents be developed and implemented. This paper describes the response of the University Hospitals of Cleveland to these regulations and to the anticipated needs of the community and local industiy. The physical plant constructed and its relationship to the emergency department personnel for staffing this unit are described. Utilization patterns since implementation of this program are presented.
To examine the effects of age, race, gender, and insurance status on utilization and times-to-transport (TTT) for interhospital air medical transfers from rural hospitals to tertiary care centers.
Design:
A retrospective review of interhospital transport records. The TTT was examined as a function of age, gender, race, and insurance status using the Student's t-test for unpaired samples. The Exact Binomial Test (alpha error at 0.05) was used to compare the observed versus expected transport rates for non-whites.
Setting/Participants:
A total of 268 patient transfers from hospitals within a two-county region in central Pennsylvania to tertiary care centers was analyzed. All records with sufficient demographic, TTT, or insurance data were included. Absence of data was the only exclusion.
Results:
The TTT (mean ± SD) was longer (2666 ± 3940 minutes (min.) versus 619 ± 909 min., respectively) for adult than pediatric patients (p <O1), and (2588 ± 4041 min. versus 640 ± 1301 min., respectively) for insured versus uninsured patients (p <.O1). The observed proportion of non-whites transported was less than expected (.41% versus 2.1 %) based on the proportion of non-whites in the region (p <.O5).
Conclusion:
The TTT was longer for adults than for children and for the insured than the uninsured. Non-whites were transported less frequently than predicted.
Concern for possible disease transmission during mouth-to-mouth resuscitation has decreased the incidence of bystander cardiopulmonary resuscitation (CPR). Barrier masks have become available that may be effective in CPR as well as protective against cross-contamination.
Hypothesis:
A silicone rubber barrier mask incorporating a one-way-valved airway (Kiss of Life [KOL]) designed to prevent contamination of the rescuer, permits satisfactory mouth-to-mouth ventilation of victims of cardiopulmonary arrest.
Methods:
Ten adult patients who did not survive non-traumatic cardiac arrest were ventilated with exhaled room air using a KOL barrier mask while external cardiac massage continued. Arterial blood gases were obtained every two minutes for a maximum of 10 minutes. The operator was blinded to the results of these blood tests.
Results:
Eight men and two women with ages from 55 to 99 years were studied. Four patients were edentulous and two of these had marked mandibular atrophy. The two patients with mandibular atrophy were poorly ventilated with the barrier mask. One other patient was not ventilated successfully. This patient had undergone multiple attempts at endotracheal intubation and had transtracheal needle ventilation performed prior to use of the barrier mask. One patient had elevated PaCO2 despite being well-ventilated clinically. Six patients were ventilated well clinically and had satisfactory PaCO2 and PaO2 values.
Conclusion:
The barrier mask studied appears to be an effective aid to ventilation in CPR Patients without facial support, as in edentulous patients with mandibular atrophy, are not ventilated well with this device.
The role of the base-hospital and on-line medical control in a disaster has not been investigated previously. This study assesses the roles of base-hospitals and the value and feasibility of on-line medical control during the 1989 Loma Prieta earthquake.
Methods:
The researchers studied five Bay Area counties most affected by the earthquake: San Francisco, Alameda, San Mateo, Santa Clara, and Santa Cruz. Researchers sent questionnaires to all 1,498 registered EMTs and paramedics in these counties; 620 were returned (41.4%). Respondents answered questions about activities performed, contacts with base-hospitals and other agencies, and problems encountered the night of the earthquake. Researchers selected 63 paramedics for in-depth interviews based on their performance of significant advanced life support (ALS) activities performed during the disaster. The coordinators of the 13 base-hospitals (BHCs) in the region also received and returned questionnaires about medical control, base-hospital roles during the disaster, and problems encountered. Researchers interviewed all five county emergency medical services (EMS) agency directors.
Results:
The surveys of EMS directors, base-hospital coordinators, and paramedics indicate that confusion existed over the status of medical control after the earthquake. There was general agreement among base-hospital coordinators (BHCs) that suspension of medical control is appropriate in a major disaster.
Three bases had appropriate equipment to function as back-up dispatch centers. Eight bases had adequate personnel, but only one BHC felt his personnel had adequate training to function in a dispatch capacity. Nine paramedics did not start or continue resuscitation on patients whom they ordinarily would have begun resuscitation.
Conclusion:
Emergency medical services should suspend medical control immediately following a major disaster and ensure that all prehospital and base personnel are notified. Disrupted communications protocols for prehospital personnel should reflect the skill and knowledge level of paramedics and the need for rapid, advanced practice in a disaster. Disaster planners should consider other roles for base hospitals in major disasters.
To examine the level of interest in paramedic upgrade education among a sample of intermediate-level emergency medical technicians, referred to as cardiac rescue technicians (CRT), to obtain education to upgrade to the paramedic level.
Method:
The design of this study was a descriptive, cross-sectional study utilizing a mailed survey instrument.
Results:
Most of the CRTs reported interest in advancement to the paramedic level with the most active CRTs significantly more interested in upgrading than were those with lower grade of activity. Preference was for the upgrade training to be offered as a single course, two nights per week. Respondents also indicated an interest in receiving college credits for the course.
Conclusion:
Active volunteer, intermediate-level emergency medical technicians (EMTs) in Maryland are interested in participating in the education necessary to advance them to the paramedic level.
On 14 July 1991, at 2150 h, a train derailment occurred near the Cantara rail curve about six miles above Dunsmuir in Northern California. The derailment spilled approximately 19,000 gallons of metam-sodium into the Sacramento River. When mixed with loater, metam-sodium degrades to methylisothiocyanate (MITC) and other gases. The contaminated river water passed the town of Dunsmuir and other occupied areas exposing residents to MITC gas.
From 15 July to 20 July (five days), a total of 360 people underwent triage. The majority of patients displayed minor exposure symptoms that did not require hospital care. Mercy Mt. Shasta Hospital, a small rural hospital close to Dunsmuir, received the majority of patients. As of 29 July, 15 days after the incident, Mercy Mt. Shasta Hospital had seen 244 exposed patients in its emergency department, and had admitted five. Three had symptoms that could have been spill-related. Three Regional Poison Control Centers provided medical toxicology advice.
Medical management of the emergency medical services (EMS) response to the event was piecemeal and weak. There did not appear to be a medical operations component at local Emergency Operations Centers (EOC). Most health care personnel interviewed complained about inadequate information about the substance and the situation. Local fire service mutual- aid agreements to obtain additional fire service and ambulance personnel worked well. It is important to emphasize that everyone who believed they had been exposed to the chemical underwent triage and received appropriate acute medical care.
Disaster managers should be familiar with certain technologies or sets of information used in disaster management. Among the more important are mapping, interpretation of aerial photography, communications, information management, logistics and computer applications, epidemiology, and preventive medicine.
Conventional emergency medical services (EMS) guidelines recommend that essentially every victim of any significant trauma be treated in the field as having an unstable spine injury. For example, any victim of any motor vehicle crash generally is assumed to have an unstable spine injury and is transported to the hospital in full-spine immobilization. This approach generally is reasonable and appropriate for the conventional EMS context of rapid transport, because patient symptoms and physical examination often are unreliable for the time period immediately following the event.
The specialized context of delayed or prolonged transport, however, requires a closer look at assessment criteria and treatment procedures for spine injury. Full-spine immobilization, if it is not required, can be unnecessarily difficult, impractical, impossible, and even dangerous during prolonged evacuation, especially in severe environments or when using improvized equipment. Prolonged transport also provides an opportunity to repeat patient surveys and to observe changes in the patient's condition over time.
Many states in the United States ‘have developed policies that enable prehospital emergency medical services (EMS) providers to withhold cardiopulmonary resuscitation (CPR) in the terminally ill. Several states also have policies that enable the implementation of do-not-resuscitate (DNR) orders.
Objectives:
1) assess which states have statutes governing DNR orders for the prehospital setting; 2) determine which states authorize DNR orders in ways other than by specific state statue; and 3) define those states that had regional protocols which address prehospital DNR orders.
Methods:
Survey of the state EMS directors in each of the 50 U.S. states, the District of Columbia, and Puerto Rico.
Results:
As of 1992, specific legislation authorizing the implementation of DNR orders was in place in 11 states. In addition, six others have a legal opinion or policy allowing the implementation of DNR orders. Fourteen additional states have either working groups or legislation pending that address prehospital DNR orders. In only five were there no existing regional protocols for implementation of DNR orders in the prehospital setting.
Conclusions:
There exists great variation in legal authorization by states for implementation of DNR orders in the prehospital setting. Despite the existence of enabling legislation, many state, regional, or local EMS systems have implemented policies dealing with DNR orders.
In 1966, a National Academy of Science's National Research Council white paper described inadequacies in the emergency health care available in the United States. Entitled “Accidental Death and Disability: The Neglected Disease of Modern Society,” this paper cited a diversity or lack of standards for many aspects of emergency medical services (EMS) and a general absence of a systemized approach.
Federal response in the early 1970s, through the National Highway Traffic Safety Administration and the EMS System Act of 1973, addressed the fragmented delivery of EMS, and set standards for planning and developing such services within the context of an EMS system. The System Act addressed the primary prevention of injury and acute, critical illness as well as methods for comprehensive intervention, from system access and prehospital care through stabilization and rehabilitation, in those cases where primary prevention fails.
Recent national and international disasters involving collapsed structures and trapped casualties (Mexico City; Armenia; Iran; Philippines; Charleston, South Carolina; Loma Prieta, California; and others) have provoked a heightened national concern for the development of an adequate capability to respond quickly and effectively to this type of calamity. The Federal Emergency Management Agency (FEMA) has responded to this need by developing an Urban Search and Rescue (US&R) Response System, a national system of multi-disciplinary task forces for rapid deployment to the site of a collapsed structure incident. Each 56person task force includes a medical team capable of providing advanced emergency medical care both for task force members and for victims located and reached by the sophisticated search, rescue, and technical components of the task force. This paper reviews the background and development of urban search and rescue, and describes the make-up and function of the Federal Emergency Management Agency (FEMA) Task Force medical teams.
Evaluate the experience of paramedic personnel at mass gatherings in the absence of on-site physicians.
Design:
Retrospective review of patients evaluated by paramedics with emergency medical services (EMS) medical control.
Setting:
First-aid facility operated by paramedics at an outdoor amphitheater involving 32 (predominantly rock music) concerts in accordance with the Chicago EMS System, June through September 1990.
Participants:
A total of 438 patients (≤0.1% on-site population) were evaluated.
Interventions:
Presentations to the first-aid facility were viewed as if the patient was presenting to an ambulance. Transportation to an emergency department was strongly recommended for all encounters. Time from presentation to the first-aid facility until disposition was limited to 30 minutes in the absence of on-line [direct] medical control. Refusal of care was accepted. On-line [direct] medical control with the EMS resource hospital was initiated as needed. Off-line [indirect] medical control consisted of weekly reviews of all patient records and periodic site visits.
Results:
Of the 438 patients, 366 (84%) refused further care, including 31 patients (7%) who refused advanced life support (ALS) level care. Seventy-two patients (16%) were transported; 37 by ALS and 35 by basic life support (BLS) units. On-line [direct] medical control was initiated in all ALS patients that were transported as well as for those who refused care. No known deaths or adverse outcomes occurred, based on lack of inquiries or complaints from the local EMS system, emergency departments receiving transported patients, law enforcement agencies, 9-1-1 emergency response providers, venue management, or security. No request for medical records from law firms have occurred. Problems noted initially were poor documentation and a tendency not to document all encounters (e.g., dispensing band-aids, tampons, earplugs, etc.). Concerns noted included: initial and subsequent vital signs, times of arrival, interventions, dispositions, and patient conditions of refusal. Specific problems with documentation of refusals at disposition included: appropriate mental status, speech, and gait; release with an accompanying family member or friend; and parental notification and approval of care for minors. There also was an initial tendency not to establish on-line [direct] medical control for ALS refusal or BLS medicolegal issues.
Conclusions:
The medical system configuration modeled after practices of prehospital care, demonstrates physicians did not need to be onsite when adequate EMS medical control existed with less than 30 minutes on-scene time.
The 82d Airborne Division, as the Army's worldwide contingency division, places unique demands on its medical personnel. This was true particularly during Operations Desert Shield and Desert Storm in 1990–1991. An unprecedented emergency medical training program was carried out in preparation for the Gulf War.
All levels of expertise were involved: non medical Combat Lifesavers, medics, physician assistants, and physicians. Courses provided included Combat Lifesaver provider and refresher training, Basic Trauma Life Support (BTLS) provider and instructor training, Chemical Casualty courses, and a Combat Surgical Skills course. Approximately 736 personnel, including 80 Saudi and allied physicians and medics, participated in these courses. Confidence and competence in handling war casualties at all levels was enhanced greatly. Prepackaged courses such as BTLS enabled the rapid training of large numbers of medical personnel under challenging conditions.
The need for quality assurance (QA) systems for review of prehospital advanced life support (ALS) care has long been recognized. However, there only have been limited published studies on the operation and cost of QA systems for prehospital care. A number of different systems currently are in use, and the relative effectiveness of different QA systems has not been well determined.
Objective:
The aim of this study was to compare the personnel work-time and costs of two different systems of QA for prehospital ALS services, and thereby determine which type of system was more cost-effective in the generation of QA reports.
Methods:
The quality assurance program (System 1) for three independent ALS services in a rural/suburban area and the QA program (System 2) for a nearby urban ALS service were compared. Data recorded included the training level and number of hours per year devoted exclusively to QA activities by different personnel. The annual costs for other aspects of the QA systems and apportioned salary costs for time spent on QA work were recorded.
Results:
System 1, a computer-based system, utilized 1,116 hours per year of personnel time and required [US]$17,662 in total costs per year (average cost per run reviewed of $4.38). System 2 (a manual system) utilized 569 hours per year of personnel time and had an annual cost of [US]$8,361 (or $2.15 per run reviewed). System 1 generated 852 reports per year (21 % of runs) about non-compliance with protocols or charting deficiencies. System 2 generated 284 reports per year (7.3% of runs) for similar events.
Conclusions:
Either a computer-based or “manual” system for QA of prehospital ALS services can be utilized. A computer-based system requires more personnel time and is more expensive, but generates more reports per year than does the manual system. A computer-based system more readily can retrieve run report data for further review.