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Application of pressure infusion bags may increase intravenous (IV) flow rates three-fold. Commercially available pressure infusers, manual squeezing of the IV fluid bag, inflating a blood pressure (BP) cuff around the bag, and kneeling on the bag have been used by prehospital personnel attempting to augment fluid infusion rates. To test the efficacy of each these methods, seven experienced paramedics were asked to employ each method in two trials using a 1-liter bag of saline though a 14-gauge, 5.7cm catheter and a standard administration set. Gravity flow from 80cm served as the control.
Pressure infusers generated flow rates of 257±54 ml/min and 296±53 ml/min when inflated to 300 mmHg and maximum pressure respectively. This rate was 2–2.5 times that of gravity flow (123±2 ml/min) and significantly greater than those rates obtained by any other method (p<.0005). Manually squeezing the bag also was significantly better than was gravity flow with flow rates of 184±46 ml/min and 173±40 ml/min achieved by each of two different squeezing methods (p<.01). Neither blood pressure (BP) cuff application and inflation (135±28 ml/min) nor kneeling on the bag (125±36 ml/min) was better than gravity alone.
These results indicate that pressure infusers should be used to the exclusion of other field methods of supplying infusion pressure. If pressure infusers are not available, manually squeezing the bag is the only alternative acceptable in the field.
The study of disasters has become a new, applied science. The increasing global population is dependent on fragile links of communication and transportation, and the modern technology of weaponry has led to new forms of armed conflict. These combined factors have made our need to understand the process of disaster research ever more pressing. Similarly, workers and researchers in the field must reappraise their methodologies and their contributions to the literature of catastrophe. The end result of good research and its promulgation in journals, articles, and even press conferences should lead to the saving of lives, the protection of property, and the stability of our communities. Hastily performed research and misleading reporting can and does lead to unnecessary death and injury, and to the wasteful expenditure of scarce resources.
Prehospital and hospital emergency medical care providers frequently rely on the electrocardiogram (ECG) to assist them in the differential diagnosis of complex patient problems and as such, the ECG often constitutes a major determinant of the definitive treatment selected. The purpose of this exercise is to review a small portion of the vast area of ECG interpretation: specifically, those rules that guide the practitioner in the diagnosis of Premature Ventricular Complexes (PVCs).
Premature ventricular complexes (PVCs) occur in multiple individuals in multiple settings. Due to these differences, the causes, implications, and treatment of PVCs must be individualized. Thus, the scope possible for this discussion is huge. Consequently, this exercise will focus only on helping the practitioner correctly identify PVCs.
Superpower military competition has abated, but the specter of nuclear weapons still adds a completely new dimension to warfare. The destructive capacity of so-called conventional bombs was made cruelly evident in the Second World War. Yet, today, a single, thermonuclear bomb has the explosive power of a million times the largest conventional device, with not only devastatingly immediate consequences but also extremely harmful long-term effects, both at the site of the attack and far away, in time and space (Figure 1).
In Figure 2, the small central circle with a radius of 1.4mm represents the combined area which would have been affected by the total of all the explosives used in the Second World War. The larger circle, with a radius of 100mm, represents the relative destructive power of the nuclear arsenals stockpiled today. This is a terrible and, hopefully, a sobering image.
Local advanced life support (ALS) medical directors in North Carolina choose the skills and medications they want utilized in their jurisdiction from a list of options authorized by the State Board of Medical Examiners. We surveyed all 35 medical directors of paramedic providers in the state to determine which optional skills and medications local medical directors allow to be used and, therefore, how they tailor their prehospital practices. Information concerning the urban or rural status of the paramedic service area, annual call volume, and the specialty classification of the medical director also were obtained.
All of the medical directors surveyed responded. Twenty-one (60%) of the paramedic service areas were rural and 14 (40%) urban. Twenty-three physicians (66%) listed emergency medicine as their primary specialty. Annual call volumes ranged from 580 to 33,500. Skills allowed by >80% of the medical directors include: drawing blood, insertion of esophageal and endotracheal airways, defibrillation, cardioversion, and initiation of intravenous fluids prior to hospital contact. The majority permit the administration of bretylium, dopamine, NaCl injection, sodium bicarbonate, furosemide, sublingual nitroglycerin, diazepam, diphenhydramine, and morphine. The majority do not allow the use of positive-pressure ventilators and do not allow administration of dobutamine, nifedipine, procainamide, propranolol, local procaine, isoetharine, metaproterenol, nitroglycerin paste, 10% dextrose solution, methylprednisolone, mannitol, phenytoin, meperidine, or nitrous oxide. Nitroglycerin paste and dexamethasone were significantly (p<.05) more likely to be allowed in rural than in urban areas. No differences in utilization by medical director specialty classification or call volume were detected. The results suggest that, when given a choice, local ALS medical directors select a limited prehospital practice. Further study is warranted to determine why available skill and medication options are not utilized.
The National Disaster Medical System (NDMS) was formulated to provide medical care for casualties of future large-scale natural disasters and military conflicts. We sent questionnaires to the 59 emergency medical directors of North Carolina's participating hospitals in order to assess their views regarding the need for NDMS and the level of their hospital's preparedness. Responses were received from 78% (46) of the physicians surveyed. Of those responding, an overwhelming majority supported the need for a national plan like NDMS to treat casualties of a natural disaster or an overseas military conflict. Respondents also agreed that the participation of emergency department personnel, other physicians, and support personnel is essential for successful activation of NDMS. Responses to questions regarding level of preparedness, however, suggested that there is less than an optimal degree of preparedness for participation in NDMS.
This report from a member of the United Nations (UN) team of experts describes the investigations of the use of chemical weapons during the Iran-Iraq War. The UN-sponsored team of experts discovered evidence that clearly showed the use of three chemical weapon substances during that conflict—Yperite (Mustard Gas), Tabun (nerve gas), and Phosgene (respiratory irritant). The effects of these chemical agents and some means of treatment for victims are described.
Our experience suggests that even with standard definitions, information on ambulance report forms may be abstracted inconsistently.
Hypothesis:
The use of written decision rules will improve agreement between paramedics abstracting data from records of prehospital cardiac arrest.
Methods:
Sixty-three ambulance reports were selected by a random sample of all out-of-hospital cardiac arrests. Four paramedic abstractors each were given a set of definitions for use in abstracting data and one pair, randomly assigned, also was given a set of decision rules. Abstractors recorded whether there was: (1) underlying cardiovascular disease; (2) a witnessed arrest; (3) bystander CPR; and (4) the presenting rhythm. Agreement between pairs of abstractors was determined by computing kappa values.
Results:
Kappa values for each variable, for abstractors without and with decision rules were: (1) 0.23, 0.33; (2) 0.39, 0.41; (3) 0.43, 0.66; and (4) 0.65, 0.80. Kappa values consistently were higher for the pair of abstractors using decision rules. The degree of improvement varied with the difficulty of the decision required.
Conclusion:
The addition of decision rules to variable definitions is worthwhile but does not ensure good or excellent levels of agreement in data abstracted from records by paramedics.