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The literature of disaster planning and management makes frequent reference to disaster drills and exercises as a fundamental training tool. Such exercises have been variously described as ranging from full-scale, all-day events involving many agencies and resources to table-top simulations using models and prepared scenarios. Because of this large gamut of disaster training activities, often it is difficult for trainers to select the most appropriate model. The purpose of this paper is to place various types of disaster training exercises in a hierarchial order based on fundamental educational principles.
Accompanying the graying of America is the increased incidence of Alzheimer's Disease (AD) and the need to teach prehospital personnel how to manage these patients. The purpose of this project was to develop an instructional strategy to teach prehospital personnel about AD and some basic management techniques. This information includes: causes of acute and gradual onset confusion in the elderly; symptoms and course of AD; mental status exam; methods to facilitate communication; techniques to avoid confrontation; and means to identify personal feelings about the elderly and AD.
Teaching methodology includes instructional objectives, videotape presentation of didactic/clinical material, videotape situations demonstrating patient management techniques, role playing exercises, and discussion groups.
The videotape presentation portion of the teaching methodology was shown to be effective as a single instructional strategy. One hundred and thirty-four EMS personnel were given a sixteen item exam before and after the videotape presentation. Pre-test to post-test difference was significant at p=.001. The additional instruction components may further impact the knowledge of AD and positive delivery of care to the elderly.
Once ignored by health care and management theorists, emergency medical service (EMS) has begun to attract attention to its traditional policies and practices. Long-standing notions about job qualifications, job responsibilities, organizational structure, and operations control are being challenged by alternative approaches such as System Status Management (SSM), Computer-Aided Dispatch (CAD), and Emergency Medical Dispatch (EMD). One important characteristic of these new models is their emphasis on the role of the communications center in controlling operations. Convincing arguments for these systems have been advanced, and they have been implemented successfully in many areas.
Despite these developments, variations of the traditional model which minimizes the importance of the communications center and emphasizes control by field supervisors still characterize many, if not most, EMS systems in the United States. While this probably is due to a natural resistance to change and local political concerns, data supporting the new systems unfortunately are only anecdotal. Except for superficial comparisons, the traditional and alternative approaches have not been examined in light of accepted management theory and principles. Therefore, this paper will analyze the communications center and operations control from a theoretical standpoint to determine where in an EMS organization, control is exercised most naturally, and how these findings could impact on management effectiveness.
To evaluate the seroconversion rate of EMS personnel given the hepatitis B virus (HBV) recombinant deoxyribonucleic acid (DNA) vaccine series.
Design:
Retrospective review of paramedics and firefighters consecutively completing the HBV recombinant DNA vaccine program.
Setting:
Urban, non-prof it, private, regional EMS Resource Hospital. The Chicago North EMS System is under contract with the Chicago Fire Department. This contract allows for the voluntary vaccination of EMS personnel with recombinant DNA-HBV vaccine and treatment and follow-up of paramedics and firefighters possibly exposed to HBV.
Population:
Initial 68 EMS personnel completing HBV recombinant DNA vaccine program (48 primary prophylaxis and 20 post-exposure prophylaxis).
Intervention:
HBV recombinant DNA vaccine series was administered voluntarily to Chicago EMS System paramedics and firefighters per manufacturers recommendations. Two weeks after completion of the vaccination series, blood samples for HBV antibody titres were drawn to determine reactivity and the need for further immunization.
Results:
Of the 68 vaccinated individuals, only two had negative titres (3%). These two individuals were given a fourth dose of vaccine with successful seroconversion.
Conclusions:
Prehospital care personnel are known highrisk, health-care workers for acquiring HBV and should be vaccinated prophylactically. There is a high seroconversion rate (97%) utilizing HBV recombinant DNA vaccine. However, post-vaccination antibody titres must be performed to identify those rare individuals that do not seroconvert.
Casualty Collection Points (CCPs) are sites predesignated by county officials for the congregation, triage, austere medical treatment, holding, and evacuation of casualties following a major disaster. A CCP (and the simulation) is made up of a series of discrete, interrelated steps that collectively result in medical care being provided to a casualty.
Methods:
A series of computer simulations was run comparing differences in personnel, supplies, and evacuation configuration for a jurisdiction that has plans in place to establish a CCP, and for one that does not. Each simulation was for 650 earthquake-related casualties.
Results:
Generally, it was found that: 1) mortality appears to be related directly to performance of triage of casualties and to where they are directed for care. The least injured did not need to be treated at a CCP; 2) survival is related directly to arrival time, mix of medical staff, and the ability to form “care teams” on-site; 3) the sudden, massive arrival of casualties will result in a “snowball” mortality effect if staff numbers are low or do not include the proper mix of training to form care teams well before the peak arrival time of casualties; 4) holding ambulances until they are filled completely before evacuation may increase mortality; 5) during the first four hours, more lives may be saved by using transportation assets to move medical staff and supplies to a CCP, if large numbers of casualties are expected to congregate there. Generally, the local jurisdiction must be prepared to mobilize a significant number of medical staff and supplies to a predesignated CCP within 4–6 hours after an event.
Conclusions:
The simulation produced useful information. In particular, local disaster response planners need to develop rapid response methods to ensure that the best combination of medical staff are available early to care for casualties.
In recent years, several authors have begun to address the medical and legal risks associated with patients refusing or being refused transport by emergency medical services (EMS) systems. However, data regarding patient outcomes still are lacking.
Purpose:
The purpose of this study was to determine: 1) why patients are not transported; and 2) the subsequent outcome of these patients.
Setting:
A busy, suburban, volunteer EMS service with indirect medical control, but no guidelines for non-transport of patients.
Methods:
A retrospective review of the records of 158 consecutive EMS incidents in which an ambulance was called, but the patient was not transported. Follow-up was attempted by telephone contact with the patient and/or family.
Results:
Telephone follow-up was established successfully for 93 cases (59%). Of the 93 patients, 60 (64.5%) subsequently sought care from a physician, 15 of whom (25%) later were admitted. The mean hospital stay was 6.6±7.9 days (median=3 days) with a range of 1–30 days. Two were admitted to an intensive care unit (ICU) and two others died. Of the 93 study cases, 43 (46%) involved situations in which the patient refused transport. Paramedics declined transport or mutually agreed not to transport in 50 cases (54%). This latter category accounted for 11 (73%) of the 15 hospitalizations. Ten percent of patients (or their families) stated that they were dissatisfied with the non-transport decisions.
Conclusions:
Serious, even fatal outcomes were identified in the follow-up of patients not transported by EMS. Although a direct causal relationship was not established within the context of this study, situations in which EMS personnel either denied transport (or mutually agreed with the patient not to transport by ambulance) were twice as likely to result in hospitalization than were those cases in which the patients declined transportation against the advice of the EMS personnel.
To study the natural outcome of patients refusing prehospital transportation (PT).
Methods:
A total of 188 consecutive patients who refused PT in an urban, advanced life support (ALS), emergency medical services (EMS) system were studied. Of these, 77 (41 %) were male, and the average age was 51 years. Patients were entered into the study group only once.
Results:
Only 94 (50%) patients could be reached by telephone follow-up. Seven (7%) of these 94 patients had abnormal vital signs, 33 (35%) had cardiopulmonary complaints, 16 (17%) had an altered level of consciousness, nine (10%) were involved in accidents, and eight (8%) had abdominal pain. Six (6%) patients were admitted to the hospital, two (2 %) received ALS-level treatment by the paramedics and then refused conveyance, and 31 (33 %) either saw or contacted a physician. Consultation with an EMS physician was initiated for nine (5%) refusals. Of all the patients contacted, six (6%) needed PT for hospitalization.
Conclusion:
As only 50% of the patients refusing prehospital transportation could be reached using follow-up telephone calls, the 6% figure probably underestimates the true number of patients requiring PT. Telephone follow-up is an inadequate means of determining the natural outcome for this patient population. The ALS nature of many of the complaints combined with the lack of consistent physician consultation, exposes the EMS system to an undefined medico-legal liability risk.
National medical responses to catastrophic disasters have failed to incorporate a resuscitation component.
Purpose:
This study sought to determine the lifesaving potentials of modern resuscitation medicine as applied to a catastrophic disaster situation. Previous articles reported the preliminary results (I), and methodology (II) of a structured, retrospective interview study of the 1988 earthquake in Armenia. The present article (III) reports and discusses the definitive findings, formulates conclusions, and puts forth recommendations for future responses to catastrophic disasters anywhere in the world.
Results:
Observations include: 1) The lack of adequate construction materials and procedures in the Armenian region contributed significantly to injury and loss of life; 2) The uninjured, lay population together with medical teams including physicians in Armenia were capable of rapid response (within two hours); 3) Due to a lack of Advanced Trauma Life Support (ATLS) training for medical teams and of basic first-aid training of the lay public, and scarcity of supplies and equipment for extrication of casualties, they were unable to do much at the scene. As a result, an undetermined number of severely injured earthquake victims in Armenia died slowly without the benefit of appropriate and feasible resuscitation attempts.
Recommendations:
1) Widespread adoption of seismic-resistant building codes for regions of high seismic risk; 2) The lay public living in these regions should be trained in life-supporting first-aid (LSFA) and basic rescue techniques; 3) Community-wide emergency medical services (EMS) systems should be developed world-wide (tai-lored to the emergency needs of each region) with ATLS capability for field resuscitation; 4) Such systems be prepared to extend coverage to mass casualties; 5) National disaster medical system (NDMS) plans should provide integration of existing trauma-EMS systems into regional systems linked with advanced (heavy) rescue (public works, fire, police); and 6) New techniques and devices for victim extrication should be developed to enable rapid extrication of earthquake casualties within 24 hours.
Workers, managers, occupational health and safety inspectors, and the general community can be trained to detect and promote action by the use of sentinel markers for detecting industrial disasters. A sentinel marker is a pre-disaster warning sign of impending failure in prevention. Administration sentinel markers are: weak occupational health and safety programs; lack of spontaneous access to top management; failure to accept responsibility for sub-contractors; absence of written disaster plans and drills for emergency response in the factory and in the adjacent community; non-investigation of prodromal leaks, exposures, spills, or injuries; punishment of “trouble-some” individuals (“whistleblowers”) reporting prodromal events; non-use or misuse of data on illness, injury, and absenteeism; and sub-optimal work conditions and supervision of shift workers. Information sentinel markers are: absence of worker and community right-to-know programs; non-use of data on earlier mishaps from similar technologies; and failure to provide toxicologic data to hospitals in the pre-disaster phase. Technological sentinel markers include the absence of fail-safe controls, interlocks, and automated alarm systems driven by real-time monitoring. Transportation sentinel markers include sub-optimal vehicle standards, alcohol and drug abuse, and fatigue in drivers. Preventive programs based on identification of all sentinel markers by workers and others outside a narrow spectrum of specialists are suggested to be more effective than are selective actions based on risk assessment analysis.
The Santa Cruz County 9-1-1 emergency response system was taxed severely with over 1,000 calls during the first seven hours following the Loma Prieta earthquake. It remained functional and responsive, making 229 ambulance runs in the 72-hour period following the earthquake. Initially, the demand was very high compared to normal, but decreased to slightly greater than normal levels during the second day. A fewer than normal number of advanced life support transports were required, and the number of vehicular accident cases were fewer than normal following the earthquake. The 9-1-1 center adopted an abbreviated procedure and only attempted to determine if the call was a medical emergency and the location for dispatch. During the initial emergency period, there were an unusually low proportion of transports and an unusually high number of cases in which the patient was not located. The medical system in Santa Cruz County was able to accommodate the injury load: the health care system was extensive; its three community hospitals were not damaged severely; and there was light demand.
Based on this experience, a revised 9-1-1 emergency medical services (EMS) procedure is recommended for disaster periods: 1) the dispatcher inquires whether the patient can be transported by other means; 2) the caller is asked to explain the need for an ambulance in order to assign a priority to the request; and 3) the caller is asked to cancel the call if there no longer is a need. This procedure is expected to improve disaster management of limited ambulance resources during and following a disaster, while maintaining rapid call processing.