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The staff of accident and emergency departments in the United Kingdom are realizing their increasing role in teaching the elements of emergency care. This paper highlights some recent developments which have influenced the way in which emergency medicine is taught.
First Aid instruction aims to impart the universally agreed and accepted principles to a wide ranging audience. Traditionally these principles have been embodied in the combined manual of the St. John Ambulance Service, St.
Evaluation of the traumatized patient frequently involves consideration of possible cervical spine injury. When neurological deficits, unconsciousness, alcoholic intoxication, severe maxillofacial or head trauma, or local neck pain are present, it is an easy decision to obtain cervical spine x-rays. The dilemma arises in the patient without neck pain who has mild to moderate scalp or facial injuries. Such a patient usually arrives in the emergency department with a cervical collar placed by pre-hospital personnel because of the mechanism of injury and the associated head or facial soft tissue trauma. Due to the association of cervical spine fractures with “significant” facial trauma, neck x-rays have been recommended. What, however, constitutes “significant” facial trauma To delineate such facial injuries, a retrospective analysis of 30 patients with cervicalspine fractures hospitalizedin a five year period at the University of Nebraska Medical Center was performed. Seventeen patients had head, scalp or facial injuries ranging from skull fractures and scalp hematomas to minor abrasions and lacerations. To determine if cervical spine films are being over utilized, a current prospective study of patients undergoing this evaluation will be presented, detailing the facial and head injuries, location, degree of severity, and detection of cervical spine injuries.
Retrospective studies of the mechanisms of drowning are difficult to make for a number of reasons. First, the severity of the immersion incident is hard to classify; therefore, conclusions drawn from the outcome of a number of incidents grouped together may be erroneous. Second, confusion results from traditional attempts to separate victims into those who immerse in salt water from those who immerse in fresh. This is an analysis of 61 individual cases of immersion published in the last 20 years, but not previously subjected to group analysis such as those published by Modell, Conn and Simcock.
Results
In 61 cases reviewed, males outnumbered females by almost 4 to 1 (48/13), 17 died and 44 survived (Table 1). When placed in age groups, those most at risk fell into the 0–5 years old group, comprising 43% of the total; but this group also contained the greatest proportion of survivors (Figure 1).
Research on acute dying processes, emergency resuscitation (cardiopulmonary-cerebral resuscitation, CPCR) and long-term resuscitation (intensive therapy) have the potential of leading to so far unimagined restoration of total body function, including human mentation, after sudden cardiac death from ventricular fibrillation, asphyxia or exsanguination; and also after prolonged terminal states from trauma or other insults—conditions which have so far been considered irreversible. Since the 1950's, an increasing number of investigators have embarked on resuscitation-related research.
The eruption of Mount Saint Helens in the Cascade Mountain Range of Washington State on 18 May 1980 resulted in a life-threatening and economically disruptive natural disaster that required the mobilization of supportive agencies from the State and Federal government for control. Because of the potential for further eruptions, the mechanism of death for those persons exposed to the initial blast was examined to aid in contingency planning.
Fatalities as a result of the eruption could be attributed to lack of understanding of the danger in the area of the mountain. Although several scientists were killed during the eruption, most were sight-seers who ignored the warning seismic activity and the precautionary blockade of the area. A few were outside of the well-publicized danger zone, but were caught in the rapidly moving mudslides or the ash cloud.
Treatment of severe hemorrhage with adequate concurrent administration of plasma substitutes leads to acute normovolemic hemodilution (NVHD). Advantages of hemodilution include: l) reduced risk of infection; 2) decreased thromboembolic phenomena; 3) improved microcirculation; and 4) less use of banked blood resulting in reduced patient cost.
In the 1960's, Takaori and Safar described the types of response to various degrees of hemodilution (HD) and demonstrated that dogs survived when hemodiluted with dextrans to a hematocrit (hct) of 10%. In contrast, HD with Lactated Ringers (LR) was unable to support survival.
The discipline of emergency medicine includes the field of disaster medicine. Unfortunately, little actual emphasis is placed upon this vital area of training in emergency medical residency programs aside from nominal involvement in mock hospital-community disaster drills and triage exercises. In addition to these important areas of disaster medicine, physicians must be knowledgeable in field medical sanitation, environmental illnesses, ground and aero-medical evacuation, epidemiology and logistics in addition to hands on emergency medical casualty care. To better serve this important neglected area of the emergency medicine residency curriculum, we developed a one-month block of instruction.
The operational medicine course is composed of separate instructional modules. The emphasis of the field medical training is obviously a military one; however, that emphasis is easily translated into a field medical environment, one that is commonly employed in military disaster relief operations. The American armed forces, particularly the US Army, frequently come to the aid of victims of both civil and natural disasters. This humanitarian assistance also serves the readiness training goals of the Army Medical Department during peacetime.
Since oil was found under the North Sea in the mid 1960's, oil production now plays an important part in Norwegian economy. A major oil field is Ekofisk, between Norway and Britain (Figure 1). The Alexander Kielland, one of the rigs at Ekofisk, was a mobile platform of the pentagon type, floating on 5 columns, 150 nautical miles of f the Norwegian coast. It was developed and built as a drilling rig, but was used as an accommodation platform since delivery in July 1976. OnMarch27,1980, the Alexander Kielland rig lay at anchor on the Ekofisk field, close to the production platform EDDA.
The relatively young scientific field of health services research, whose practitioners are still struggling to establish legitimacy within the vast domain of health care, owes much to Michael Pozen. Indeed, Michael must be counted as one of the founders of this new speciality in that his brief but incredibly productive career began as the field of health services research took form and emerged as a distinct career specialty. His very significant contributions to health care can be assessed from two perspectives.
The most visible perspective upon Michael Pozen's professional work can be obtained from a review of his research as reported in his published articles and presented papers. Michael clearly established himself as a creative and resourceful scholar and researcher who had a particular interest in improving the design and delivery of emergency medical services as well as the clinical aspects of emergency medical care.
In preparation for the visit of Pope John Paul II on Oct. 5, 1979 to Chicago, Illinois, a multi-departmental committee met for a number of months prior to the Pope's visit to prepare for possible mass casualties at the outdoor papal mass held in Grant Park. Data taken into consideration in preparation for this mass gathering included predictions of the number of people to attend the event, calculations by the National Safety Council of the possible number of victims and type of casualties, a review of the literature and the experience of others at outdoor events of the same scale.
On this basis, it was predicted that aproximately 3,000 to 3,500 casualties would occur simply as a result of a mass gathering of one million individuals. The actual total number of casualties was 400, with twenty being transported to the hospital and no deaths. On the basis of this experience a formula was described to predict the number of casualties based on total attendance figures.
A strong earthquake occurred in the Tangshan-Fengnan area in Hopei Province of North China at 03:42 hours on July 28, 1976. A general headquarter was set up immediately to perform the functions of organization and administration. This was the most essential authority in keeping everything in order in such a disaster area. Mine Rescue Corps and mobile medical teams from many parts of the country were called and rushed to the scene. Critical care was organized into 3 stages: (1) digging and rescue; (2) preliminary treatment and transfer; and (3) treatment after transfer.
The Mine Rescue Corps, existing normally in every coal mine, was the most efficient and valuable element in digging out victims and carrying out the most urgent resuscitative management. They dug and rescued, and also patrolled in the pits. They cleared the way for the coal miners. More than 10,000 miners, who were working in the pits during their night shift, were less able to return to the ground safely. As it was very difficult to locate every working group in such a labyrinth pits system, some coal miners had been left in the pits for long periods of time. There were, for instance, five coal miners who were working 850 meters underground and could not find their way out because the pits were badly damaged.
Resuscitation and acute respiratory care must be taught to all personnel involved in the management of everyday emergencies and mass casualties. Personnel range from the lay public to physician specialists. In deciding who should be taught what and how one must consider the limitations of learning ability of trainees and of resources. Mouth-to-mouth ventilation can be learned by laymen merely from viewing pictures, but better with manikin practice to perfection. CPR steps A-B-C can be effectively taught to non-physicians including laymen with instructor-coached manikin practice to perfection. but also with self-practice coached by audiotape, and to some extent even by frequent film viewing only without manikin practice. In 1972, A. Laerdal invented a CPR steps A-B-C self-training system consisting of a recording manikin, flipcharts and the coaching audiotape. We added a demonstration film to be shown before manikin practice.
The growing number of nuclear power, research, and industrial facilities places increasing numbers of people and places at risk from an accident involving radioactive material. Fortunately, such accidents are infrequent. Unfortunately, this rarity often results in very limited hospital and physician interest and awareness. The incident at the nuclear facility at Three Mile Island (TMI) in Pennsylvania, USA, has demonstrated that despite its rarity, a radiation accident may not only occur, but occur on a scale large enough to require more than the radiation accident protocol which each hospital is required to have. There is a need, therefore, for the incorporation of radiation accidents into disaster planning and triage systems. We address the considerations to be made in planning an emergency medical system's response to a large radiation accident. We describe the application of a triage team in such a plan.
From many recent publications and also from a pathophysiologic standpoint, it has become abundantly clear that probably the most important factor determining the outcome of any attempt at resuscitation is the period of time elapsed between the onset of the calamity and the initiation of “CPR.” In most of the reports on the effects of time-related variables the initiation of effective cardiopulmonary resuscitation is usually not clearly defined.
What exactly is meant by “initiation of CPR?” Since 1966 CPR has been instructed according to the “A-B-C-schedule.”
To emphasize the importance of pathologic studies to physicians and biomedical scientists should be “preaching to the converted.” Unfortunately there are disturbing signs that this is not so, particularly in clinical medicine. The autopsy rate is declining globally and some authors have even unwisely implied in print that modern diagnostic techniques render the autopsy and other pathologic studies superfluous. Fortunately, pathologists continue to expose and resist such attitudes by means of analytical discussion of the problem. The role of pathologic study remains an essential one in both clinical and experimental studies of therapy of all types.
The term pathologic studies includes: pathologic anatomy (the autopsy and surgical biopsy); clinical pathology (hematology, chemistry, microbiology, immunologyl and experimental pathology.
Cardiopulmonary Resuscitation (CPR) lessens mortality and morbidity following cardiac arrest and has gained widespread acceptance. However, the cognitive and psychomotor skills achieved at the initial training sessions tend to deteriorate fairly quickly. Experience or retraining can help to preserve these skills. The authors felt that repetitive exposure to the principal facts might achieve the same purpose. Furthermore they viewed the time spent in the bathroom (lavatory) as an untapped educational resource for instructing a group of individuals; a suitable poster taped on a bathroom wall would repeatedly present the key information to a captive audience. Judging by the graffiti already present, the audience is presumably accustomed to reading in this environment. This paper reports two trials: in the first, posters were displayed in an undergraduate dormitory followed by a test of theoretical knowledge; in the second, the posters were displayed in hospital bathrooms used by nurses followed by a test of theoretical and practical ability.
A good deal of controversy currently surrounds the role of collars and extrication devices in the on-site immobilization of suspected injuries to the cervical spine. The plethora of manufactured items readily available for this purpose reinforces the general impression that no one device is universally acceptable.
In his book, Spinal Cord Injuries – Comprehensive Management and Research, Sir Ludwig Guttman stressed the importance of keeping all cervical movements to a minimum. Flexion, hyperextension and rotatory movements are particularly dangerous. The most difficult circumstances are those in which an unconscious front-seat occupant requires extrication from a damaged motor vehicle. Here the strict first-aid drill of gentle lifting by a six man team maintaining rigid traction in the line of the spine becomes impracticable and the rescuers have to resort to the use of aids.
The Royal Victoria Hospital, Belfast, over a four-year period, used its disaster plan more than 100 times due to the civil disturbances in Northern Ireland. The concept of classifying these patients into three or four triage categories made me critical of assumed methods and articles dealing with triage. None of it measured up to my own experience. What is triage? Triage is the French word for “sorting.” I, therefore, addressed myself to the kind of sorting I had seen, where it was done and what categories were used.
Due to the development of modern resuscitation during anesthesia and surgical operations, methods of intensive therapy have been introduced in clinical medicine. Efforts, through cardiopulmonary resuscitation (CPR), to give any patient in need the chance to survive resulted in systems of emergency medical services (EMS). A short account of the present state of CCM in the CSSR is given here. The principle of “differentiated patient care” is outlined, with accepted definitions of resuscitative and intensive care. The terminology of different steps in CCM is offered for discussion.
In Czechoslovakia, the Constitution of 1960 proclaims the right to health care for every citizen. Medical care is provided to all citizens free of charge by the State. The State took over the responsibility for planning, organizing and providing medical care on the highest attainable contemporary level. In the last ten years, special programs have been launched in order to cover most actual health areas such as neonatal and maternal health care, cardiovascular disease programs, oncology, geriatric care, and, last but not least, the care of patients with acute organ systems' failure.