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Gas-powered resuscitators (ventilators) designed to be used primarily for resuscitation should be basic and simple to use. They offer many advantages over manual methods of ventilation during in-hospital cardiopulmonary resuscitation. Portable ventilators intended for critical care transport require additional, more sophisticated features such as: adjustable pressure limiting valves, air-mixing, airway pressure gauge, independent tidal volume and rate controls, and a Positive End-Expiratory Pressure (PEEP) valve. The performance of six gas-powered resuscitators/portable ventilators (TransPAC, Oxylog, Ambu Matic, ERA 2000, Uni-Vent, and MARS) was evaluated.
Methods:
The accuracy of volumes delivered to a test lung at three different compliance and resistance settings, was assessed for each ventilator prior to clinical evaluation during cardio-pulmonary resuscitation (CPR) and patient transport.
Results:
In each circumstance, measured tidal volumes and levels of minute ventilation decreased as resistance was increased and compliance reduced. Much of this loss of measured tidal volume occurred through inspiratory pressure relief valves that tended to start leaking at pressures below the preset level. Increasing levels of back-pressure resulted in further reductions in tidal volume when the ventilators were tested using the air-mix mode (available on three of the devices). In general, each resuscitator functioned well when used during CPR within the hospital.
Conclusions:
Each resuscitator tested failed to deliver the preset volumes and this must be considered during their use. Inspiratory pressure relief valves for all but one of the ventilators tested would not permit the delivery of adequate levels of ventilation in patients with low pulmonary compliance and/or high airway resistance.
Centralized dispatch data can provide useful information regarding the impact of major air medical system changes in a regional emergency medical services (EMS) system.
Methods:
Prospective evaluation of helicopter dispatch data from a centralized EMS dispatch agency. During the study period, four alterations in the total number of helicopters available to the system occurred (1,2,3,2,3). Statistical analysis consisted of Chi-Square with Yates' correction and comparison of sample proportions with p<.05 considered significant.
Results:
A total of 667 helicopter dispatches occurred during the 20-month study period from April 1989 through November 1990.
Conclusion:
Changes in dispatch patterns could result either from increased availability or alterations in the dispatchers' “threshold” for use based upon a perceived lessening of the need to save a “scarce” resource. Had the second possibility played a significant role, the rate of cancellation by ground personnel after arrival at the scene would be expected to have increased. Since this did not occur, it is likely that the increased use actually was a result of increased availability. In systems that dispatch helicopters prior to arrival of ground personnel, this method of evaluation may provide a useful model for analyzing the impact of major system alterations.
An emergency medical service (EMS) system is part of a broad health care system which no longer can be concerned exclusively with patient transportation. Integration of prehospital and in-hospital emergency care must be achieved to provide quality patient care. This article suggests modifications in the Joint Commission on Accreditation of Healthcare Organization's (JCAHO) 10-Step Model indicators that should help in an evaluation of the issues associated with the diversion of patients from Emergency Departments. The JCAHO model is one that can be used to help integrate prehospital and inhospital care.
The resuscitator bag has been considered the standard for prehospital, ventilatory managment. Recently, the Berg Resuscitation Apparatus (BRA) was developed as an alternative. Two devices were compared for their ability to deliver adequate tidal volumes and efficacy during simulated, single-rescuer CPR In the first phase, emergency care providers ventilated a test lung using a resuscitator bag, BRA, and demand valve. No significant differences between methods were found. During the second phase of the study, subjects performed single-rescuer CPR on a resuscitation mannikin for two minutes, using the bag-valve-mask and the BRA with a mask. The BRA delivered a volume of 0.81±0.26 liters compared to 0.35±0.19 liters using the resuscitator bag. The BRA allows ventilation to be performed as does the traditional equipment. When used in single rescuer CPR, it appears to provide a substantial increase in the tidal volumes delivered.
There are limited data available and no recognized standards or guidelines for providing emergency medical care at large public event The organizational planning of emergency medical care for the 1987 San Antonio Papal Mass was reviewed. Medical care was provided using a multi-tiered system. The San Antonio EMS system played a leading role in the design, administration, and implementation of this medical care.
An analysis of the types and frequencies of emergency medical problems encountered by health care providers is detailed. The total attendance was approximately 100,000, 1.5% (1553) required medical attention, and 241 were evaluated on-site by physicians. The majority of medical problems encountered were managed by non-physician, health care providers.
Severe environmental conditions with a heat index exceeding 102°F were responsible for 174 cases (72%) of heat-related illness. A total of 55 patients required transport to local emergency department. There were no cardiopulmonary arrests, major injuries, or deaths.
Since 1985, the state of Connecticut has been served by a hospital-based, advanced life support (ALS) helicopter air medical service. The service is stationed at a 1,000-bed, Level I, trauma center that is responsible for its operation. Connecticut statute requires the hospital to file operations reports with the Office of Emergency Medical Services, which reports to the Connecticut Department of Public Health. Operations include response to requests for transportation of severely ill or injured patients from the scene of an incident, and patient transport from one hospital to a higher level, definitive-care hospital.
This service also was charged to develop a disaster response plan to be integrated into the overall state plan for disaster responses. The helicopter disaster response involves all six New England states and the three hospital-based emergency medical helicopter programs that operate in the New England states.
This approach has allowed for joint planning and multi-agency, simulated drills. The helicopter emergency medical service has responded to 15 simulated emergencies (drills) and seven actual mass casualty incidents from May, 1985 to June, 1989. In Connecticut, the planning process conducted by the Department of Public Health and the Office of State EMS produced a coordinated, multi-jurisdictional, mass-casualty response plan.
Teaching hospitals (TH) can maintain the American College of Surgeons Committee on Trauma (ACSCOT) criteria for Level II trauma care more consistently than can community hospitals (CH).
Methods:
A retrospective analysis of 2,091 trauma system patients was done to determine if TH in an urban area are better able to meet the criteria for Level II trauma care than are CH. During the study period, a voluntary trauma plan existed among five hospitals; two TH and three CH. A hospital could accept patients that met trauma system entry criteria as long as, at that moment, it could provide the resources specified by ACSCOT. Hospitals were required to report their current resources accurately. A centralized communications center maintained a computerized, inter-hospital link which continuously monitored the availability of all participating hospitals. Trauma system protocols required paramedics to transport system patients to the closest available trauma hospital that had all the required resources available. Nine of the required ACSCOT Level II trauma center criteria were monitored for each institution emergency department (ED); trauma surgeon (TS); operating room (OR); angiogaphy (ANG); anesthesiologist (ANE); intensive care unit (ICU); on-call surgeon (OCS); neurosurgeon (NS); and CT scanner (CT) available at the time of each trauma system entry.
Results:
With the exception of OR, TH generally maintained the required staff and services more successfully than did CH. Further, less day to night variation in the available resources occurred at the TH. Specifically, ANE, ICU, TS, NS and CT were available more often both day and night, at TH than CH. However, OR was less available at TH than CH during both day and night (p<.01).
Conclusions:
In this community, TH provided a greater availability of trauma services than did CH. This study supports the designation of TH as trauma centers. A similar availability analysis can be performed in other communities to help guide trauma center designation.
A prospective study of 200 patients was conducted to evaluate the use of pulse oximetry as an adjunct to clinical monitoring of critically ill patients transported by rotary-wing aircraft with non-pressurized cabins. Thirty-four subjects (17%) were found to have significant hemoglobin desaturation of less than 90%, as defined by pulse oximetry (SpO2). Data were recorded continuously for later review. Desaturation often was noted prior to alterations in vital signs or clinical appearance. In 32 of the 34 hypoxemic subjects (94%), therapeutic interventions corrected the low SpO2. The use of pulse oximetry permitted measures for cardiorespiratory support to be instituted and assessed more rapidly than otherwise would have been possible. The availability of a continuous record of SpO2 facilitated detailed review of case management. It is concluded that the use of pulse oximetry is a practical and valuable adjunct for monitoring critically ill patients transported by rotary-wing aircraft.
While formal efforts have been made during the past quarter century in the United States to develop and coordinate emergency medical services (EMS) as a “system” of care, it was not until the past decade that we began to recognize and acknowledge the impact of stress on the lives of EMS and other public safety personnel, in both normal day-to-day response to emergencies as well as response to mass casualty incidents or disasters. The first significant writing on this complex issue, Emergency Response to Crisis, by Jeffrey T. Mitchell, PhD and H. L. P. Resnik, MD, provided a crisis intervention guidebook for emergency service personnel and early insight on crisis-worker stress and burnout. The most recent comprehensive discussion of this important area of concern can be found in Emergency Services Stress, by Mitchell and Grady Bray, PhD.
Few prearranged events provide better opportunities for emergency health system coordination and planned disaster management than does medical coverage of a major city marathon. No guidelines exist as to the appropriate level of care that should be provided for such an event.
Methods:
The medical coverage for 2,900 marathon runners and an estimated 500,000 spectators along a 26.2-mile course over city streets for the 1986 Pittsburgh Marathon was examined prospectively. Support groups included physicians, nurses, and medical students from area hospitals and emergency departments and podiatrists, physical therapists, athletic trainers, and massage therapists from the Pittsburgh area. Emergency medical services were provided by city and county advanced life support (ALS) and basic life support (BLS) units, the American Red Cross, and the Salvation Army. A total of 641 medical volunteers participated in the coverage. Data were collected by volunteers as to acute medical and sports medical complaints of all patients, their vital signs, and the treatment provided. Medical care was provided at 20 field aid-stations along the race route (including a station every mile afier the 12-mile mark, and at four stations at the finish line).
Results:
Race day weather conditions were unusually warm with a high temperature of 86°F (30°C), relative humidity of 64%, partly sunny with little ambient wind, and a high wet bulb-globe temperature of 78°F (25.6°C). Records were obtained on 658/2,900 (25%) runner-patients of which 52 (8%) required transportation to area hospitals after evaluation at aid-stations: three were admitted to intensive care units. Analysis showed that 379/658 (58%) of the patients were treated at the finish line medical areas, and of the remaining 279 patients treated on the course, 218/279 (78%) were seen at seven, mile-aid-stations between 16.2 and 22.8 miles. The conditions of heat and humidity constitute a near “worst-case” scenario and the numbers of medical personnel that should be available to deliver acute care of hyperthermia/hypothermia and fluid/electrolyte disorders are recommended. Also it is recommended that approximately 50% of medical personnel and equipment should be deployed in the finish line area and that 80% of the remaining resources on the race course be deployed in aid-stations located every mile between miles 16 and 23.
Some disasters produce circumstances that require the emergency removal of some or all of the citizens from a geographic area. Emergency or mass evacuation can be divided into immediate evacuation, in which the citizens are given no warning of their need to evacuate, and potential evacuation, in which citizens are given time (usually a day or two) to evacuate. The mass evacuation aspect of disaster planning frequently is neglected, but must be planned in detail. An essential ingredient of a plan is the designation of a person who has the authority to order an evacuation and that that person or an authorized alternate, is available instantly 24 hours a day. The plans should identify likely scenarios which could require emergency evacuation for a given community requiring, means of communicating with the citizens, evacuation routes, evacuation mechanisms, and shelter arrangements. All plans need to take into account human behavior during such a stressful situation.