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Limited information exists concerning physician staffing at mass gathering events.
Methods:
A retrospective review of the preparation, planning, and provision of medical care for the United States Air Show was performed. Patient encounters from the air show for the years 1981–1991 also were evaluated.
Results:
The frequency rate of overall encounters was 8.45 patients/10,000 spectators and hospital transport rate was 0.6/10,000 spectators. The majority of complaints were related to heat or minor injuries. During this period, emergency physicians played a vital role in both medical planning and on-site staffing. Emergency medicine residents also participated. A small patient population received direct benefit from on-site physician intervention.
Conclusion:
The on-site emergency physician is of benefit in event preplanning and reducing the burden on the EMS system during mass gathering events.
The atrocities committed by Nazi physicians and scientists, in the name of furthering medical science, is an appalling page of the history of medical research. In the wake of World War II, the scientific community strived to develop regulations to guard against future abuses in medical research. However, a particularly sobering thought is that the atrocities in Germany were being carried out in a country that had specific regulations for protecting human research subjects: Nazi Germany was the only European country to have such regulations. A more in-depth look at these regulations reveals institutional or department heads were held accountable, but not the individual researcher. The lesson from this analysis is clear: individual investigators must bear the responsibility of conducting ethical research. Governmental regulations and Institutional Review Boards never can replace investigators who are advocates for the protection of human subjects.
The purpose of this paper is to address issues broadly regarding ethics and prehospital research, with a focus on the topic of informed consent.
The purposes of this study are to quantify the use of nitroglycerin (NTG) in prehospital care, to detect deviations from the Standing Medical Orders (SMO), to determin the effectiveness of its administration, and the incidence of clinically significant adverse reactions (hypotension, bradycardia).
Method:
Retrospective review of 7683 Advanced Life Support (ALS) telemetry, base-station contacts over a three month period (June, July, Auguest 1990) to identify all prehospital patient contacts in which NTG was utilized.
Setting:
The Resource Hospital/Telemetry Base-Station a two community hospitals/Telemetry Base-Stations for the Chicago North EMS System.
Results:
There were 445 runs in which NTG was indicated as per SMO. Two hundred eighty-eight patients (64.7%) received NTG for appropriate indications as per SMO, 203 for ischemic chest pain (45.6%), 79 for pulmonary edema (17.7%), and six for both (1.3%). There were 157 (35.5%) runs in which NTG was indicated, but not administered. There were 22 patients who received NTG for indications that deviated from the SMO. Reassessment data concerning the subjective symptom was completed on 118 patients (40.9%), 92 (45.3%) patients with chest pain and 26 with dyspnea (32.9%). Following the administration of NTG, 21 patients (10.1%) with chest pain were unchanged, while 13 with dyspnea (15.3%) improved, 13 patients (15.3%) were unchanged, and none worsened. In 121 patients, the systolic blood pressure (SBP) decreased, while 24 were unchanged (5.4%), and 28 had an increase (6.3%). The mean initial value SBP was 176±44 mmHg and the repeat mean SBP was 164±41 mmHg with a mean decrease of 12±22 mmHg. The diastolic blood pressure (DBP) decreased in 87 patients, was unchanged in 53 (11.9%), and increased in 33 (7.4%). The initial mean DBP was 97±24 mmHg, the repeat mean DBP was 92±23 mmHg, a mean decrease of 5±15 mmHg. Only one patient became hypotensive with the administration of NTG and was successfully resusticated with a fluid bolus of 300 ml normal saline.
Conclusions:
In this EMS system, NTG is under-utilized based on the indications delineated by this system's SMOs. Reassessment is documented infrequently, but when completed, clinically significant adverse reactions are rare. Since the incidence of hypotension and bradycardia are rare, the inability to establish an IV line should not preclude the administration of NTG.
Exposure to radiation induces a reduction in the number of gastrointestinal, anaerobic bacterial flora, and an increase in the number of Enterobacteriaceae that are associated with sepsis and mortality. Antimicrobials that suppress anaerobic flora have a deleterious effect on survival by promoting earlier enterobacterial sepsis. In contrast, in studies of animals and immunosuppressed patients, antimicrobials that inhibit gram-negative enteric bacteria and preserve the anaerobic flora have shown a beneficial effect by preventing bacterial translocation and fatal sepsis. The quinolone antimicrobials hold potential for therapy of endogenous and exogenous infection after irrodiation.
To characterize the prevalence and morbidity of injuries to emergency medical technicians EMTs) in New England [United States].
Design:
A survey was mailed to a 2% random sample of all registered EMTs in the six New England States. The identity of the EMTs remained anonymous, and a second mailing was used to improve return rate. The EMTs were requested to recall events that occurred during the previous six months.
Results:
A total of 439 of the 786 (56%) surveys were returned representing 13,875 hours of duty time in the six-month period. Seventy one percent of the EMTs were male with a mean age of 35 years. Sixty-six percent were basic-EMTs. Injury attack rates (number of injuries/100 EMTs/6 months) were: stress, 11.2; back, 10.5; extremity, 9.8; assault, 8.4; ambulance collision, 4.1; hearing loss, 2.5; and eye injury, 1.4. Twelve percent of the EMTs were injured more than once in the six-month period. The paramedics more frequently were involved in ambulance collisions, suffered from stress, and were less likely to injure their back. There were minor interstate differences. Disability due to back injury affected 2.5% of those surveyed, four EMTs lost duty time secondary to an assault, and 0.5% of the EMTs were out of work due to stress.
Conclusions:
This survey begins to characterize the occupational risks of EMTs. The prevalence of back injuries, assault, stress, and extremity injuries seems to be too high. Educational programs and preventive interventions should be designed to minimize back injuries, stress, and assault. There is a need for more research nationwide in order to better characterize these injuries.
Privately transported, major trauma patients made up approximately 4% of the total trauma patients population at a major, regional trauma center which treats over 90% of all major trauma victims in the geographic area. This study was undertaken to evaluate the patient profile of those individuals who did not access 9-1-1 for transport to a trauma center, including their reasons for such non-use.
Methods:
Data on all major trauma occurring within Dade County, Florida, were collected by the county trauma registry.
Results:
In the last six months of 1989, 1,672 patients were entered into the trauma registry. One-thousand-six-hundred-thirteen (1,613) were transported by professional ground or air services, 59 by private vehicle. For those patients transported directly from the Emergency Department to the Operating Room, only 35% of private vehicle patients entered surgery within 90 minutes of presentation compared to 57% of those who gained access to the 9-1-1 system and used emergency medical services (EMS). One-half of those patients who did not use 9-1-1 did not have telephone access. Patient acuity was similar for those transported by private vehicle compared to those transported by basic or advanced life support units. Private vehicle transport often delayed patient triage and assessment. Thus, for a number of lower income patients, 9-1-1 access was difficult.
Conclusion:
Underestimation of the severity of the injury or fear of delay in rescue response were prominent reasons for non-use of 9-1-1. While educational efforts should concentrate on decreasing inappropriate 9-1-1 use for nonemergencies, the causes of underutilization should not be ignored.
For more than two decades, emergency medical services (EMS) systems have proliferated primarily based upon governmental impetus and funding at the federal, state, and local levels. Although many of the foundations of patient care rendered in these systems have been based upon intuitive logic, the understanding of the impact on patient outcome is poor, at best. The reasons for the current status are varied, but five issues are preeminent:
1) The authority for the development of these medical systems has been based primarily in political and bureaucratic institutions which have little or no medical expertise;
2) Little attention has been paid to system evaluation, particularly in the area of cost-effectiveness;
3) Few academic medical institutions have become involved in EMS research;
4) Traditional approaches to medical research primarily are disease-specific and are not multidisciplinary. Thus these are not useful for evaluating and understanding the highly complex and uncontrolled environmental interactions that typify EMS systems; and
5) The process of efficiently and reliably collecting accurate data in the prehospital setting is extremely difficult.
The following recommendations and suggestions are gleaned from my experience as EMS section editor for an emergency medicine journal. I do not pretend that they are definitive or objective. Nevertheless, to the extent it is helpful to know what passes through the consciousness of one editor, I offer these to individuals wishing to make the transition from aspiring author to published author. May you be successful in adding your contribution to the knowledge of our specialty and profession.
For the past two decades, prehospital trauma care has been addressed almost generically in terms of the related approaches to epidemiology, research, and management. However, evolving directions in research have helped emergency medical services (EMS) practitioners to delineate more focused treatment strategies according to the mechanism of injury, anatomic involvement, and the patient's clinical condition. Recent studies in the areas of trauma-associated circulatory arrest, severe blunt head injury, and post-traumatic hemorrhage following penetrating truncal injury suggest that current standard approaches to patient care should be reconsidered. In turn, this need for re-examination of trauma management strategies calls for the development of appropriate evaluation tools within EMS systems. Proper research design is dependent upon several key issues including: 1) the type of study (system study versus examination of a specific intervention); 2), the population under study; 3) physiological and anatomical scoring method; 4) prospective definitions of interventions and meaningful outcome variables (both morbidity and mortality; 5) relative outcome compared to known standards; and 6) prospective determination of statistical requirements.
The principal reason to conduct medical research is twofold: 1) to provide an answer to some question that is important to the investigator(s); and 2) to affect the behavior of others involved in the practice of medicine. In order to accomplish the latter of these two objectives, the results of your labors must be published in a reputable medical Journal so that it can impact upon the practice of your peers. To accomplish this, it is necessary to conform to certain rules in the development of the manuscript, and then have the paper evaluated for its relative merits for publication by a panel of your peers. These issues are addressed in this paper.
We all tend to be somewhat naive about the need to write in terms that can be understood and appreciated by our peers. Without clarity and understanding, our work has little impact on others. All that will be accomplished is the knowledge that you think you have gained from what you have done. There are several benefits associated with submission of your hard-earned work for review by your peers. Perhaps the most significant is that the process of peer review constitutes a learning process for the reviewers as well as the authors.
The Telemedicine Spacebridge, a satellite-mediated, audio-video-fax link between four United States and two Armenian and Russian medical centers, permitted remote American consultants to assist Armenian and Russian physicians in the management of medical problems following the December 1988 earthquake in Armenia and the June 1989 gas explosion near Ufa.
Methods:
During 12 weeks of operations, 247 Armenian and Russian and 175 American medical professionals participated in 34 half-day clinical conferences. A total of 209 patients were discussed, requiring expertise in 20 specialty areas.
Results:
Telemedicine consultations resulted in altered diagnoses for 54, new diagnostic studies for 70, altered diagnostic processes for 47 and modified treatment plans for 47 of 185 Armenian patients presented. Simultaneous participation of several US medical centers was judged beneficial; quality of data transmission was judged excellent.
Conclusion:
These results suggest that interactive consultation by remote specialists can provide valuable assistance to on-site physicians and favorably influence clinical decisions in the aftermath of major disasters.