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The increasing openness (glastnost) of the Soviet authorities has brought about a new era of accountability but sadly has coincided with a series of disasters, both natural and manmade. Chernobyl, the Armenian earthquake, and recently a gas explosion which involved two passenger trains have been reported widely and medical teams from the West were invited to assist with the care of the injured. We were part of a multidisciplinary team involved in the care of victims of the train disaster.
The ability to deliver large volumes of intravenous (IV) fluids may be critical to the successful prehospital resuscitation of hypovolemic patients. We compared the time required to deliver one liter of crystalloid solution, using an administration set-up consisting of a 16-guage (g), 1.25 inch, intravenous cannula, a pneumatic pressure bag, and either conventional intravenous tubing (3.2 mm internal diameter [ID]) or large bore (4.4 mm internal diameter [ID]) “shock” tubing. With the fluid bag positioned at 110cm (46 inches) above the level of the cannula, the mean elapsed time to deliver 1,000ml using the conventional tubing set-up was 6.0 minutes, while the same volume could be delivered in only 2.7 minutes with the shock tubing configuration. This time was reduced to 1.8 minutes when the intravenous cannula size was increased to 14g. By attaching a liter of fluid to each arm of the “Y” adapter of the shock tubing, virtually uninterrupted fluid flow may be maintained at this rate. We feel this intravenous configuration could enhance greatly the ability of paramedics to provide fluid resuscitation in the field setting. When such IVs are established en route to a receiving hospital, this technique may prove to be an important adjunct to improving patient outcome from hypovolemic shock.
On July 19,1989, at 1515h, United Airlines flight 232 with 297 passengers and crew on board, experienced disintegration of the number 2 engine (in the tail section) while at 40-thousand feet above Alta, Iowa (Map 1). The DC-10, en route from Denver to Chicago, was diverted to Sioux City, Iowa's Gateway Airport. The disabled jet made a crash landing on an unused runway, burst apart, and caught fire upon impact. Due to the advanced warning of the potential crash, local crash-fire-rescue (CFR) units from the Air National Guard stationed at Gateway Airport, local and regional paramedic and fire units, an advanced life-support EMS helicopter service, and the two Sioux City hospitals were on alert and ready. Firefighters and Air National Guard personnel fought the fire and EMS personnel performed triage, provided emergency care in the field, and transported victims from the crash scene to local health care facilities in Sioux City. Injured victims in critical condition were transported first followed by those with lesser injuries. All were being treated within one hour and 45 minutes of the event. Of the 297 passengers and crew, 59 were admitted to local hospitals in critical condition, and 124 were treated for less severe injuries and later released.
In order to identify the study designs andthe type of pre-trial peer review in published EMS research, we reviewed three refereed emergency medicine journals during the period from 1985 through 1988. All original scientific manuscripts utilizing human subjects in prehospital care were analyzed. Ninety-six issues were examined, and 79 manuscripts met the criteria for analysis. The research design was cross-sectional in 7.5%, retrospective in 51%, and prospective in 41.5%. Pre-trial peer review had been sought in nine (11%). Each was performed by a hospital or university-based Institutional Review Board (IRB). Only four (5%) manuscripts contained statements about pre-trial peer review. All reviewed trials were prospective in design (9/33, 27%). A follow-up telephone survey of the authors of the non-reviewed prospective trials indicated that 96% were unaware of the potential need for pre-trial review, 16% anticipated difficulty obtaining approval from traditional IRB committees, and 11% feared that the protocol would be interfered with by the review committee.
We conclude that 92.5% of the current published EMS research is retrospective or prospective in design, and that pre-trial peer review is not obtained in the majority of prehospital EMS research. Guidelines should be developed to educate EMS researchers about the need for and the value of pre-trial peer review. Journal editors should clearly state and enforce policies about manuscripts lacking information about pre-trial peer review when human subjects are involved.
An earthquake with the destructive magnitude of 6.9 on the Richter scale struck Armenia on Wednesday, 7 December 1988 at 1142 local time. It devastated an area 80 km in diameter in the northern part of the Armenian Soviet Socialist Republic (SSR), encompassed the towns of Leninakan, Spitak, Stepanovan, and Kirovakan, and killed some 25,000 persons (Table 1). Almost 15,000 persons were rescued alive. The load placed on medical facilities and transport capabilities was profound. Many Armenian nurses and physicians died during the earthquake and most of the hospitals and clinics within the disaster area were destroyed (Tables 1,2). More than 31,000 persons required some form of medical assistance in hospitals. Some 12,000 (38%) were conveyed by some form of ambulance. Of these, 82% were received by hospitals within the Armenian SSR and 22% still were hospitalized at the beginning of the newyear. Only 13% of those who received care at a hospital died in the hospital. More than 100-thousand victims had to be transported from the scene.
The Basic Trauma Life Support (BTLS) course was developed to teach prehospital providers a rapid, prioritized approach to assess and manage the trauma victim. Little data currently are available relative to the retention of the cognitive and psychomotor skilk taught in the course. To examine this question, thirteen paramedics were retested on identically moulaged trauma scenarios and written examinations 14–16 months after initial training in BTLS. No advanced notification of the re-test was given. Written test scores decreased from an initial mean of 93.0±6.6 to a mean of 64.9±11.8 (p<0.001) 14–16 months later. Similarly, the trauma scenario test scores declined from 71.6±10.4 to 61.3±16.2 (p<0.05). The results suggest that there is significant loss of both didactic information and practical skills from the BTLS course 14–16 months after training. Frequent BTLS refresher training in the form of supplemental readings, lectures, and repeated exposures to trauma simulations is needed.