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Medical and epidemiological documentation in disasters is pivotal: the former for recording patient care and the latter for providing real-time information to the host country. Furthermore, documentation informs post-hoc analysis to improve the effectiveness of future deployments.
Although documentation is considered important and indeed integral to health care response, there are many barriers and challenges. Some of these challenges include: working without well-established standards for medical documentation; and working with international guidelines which provide minimal guidance as to how health data should be managed practically to ensure accuracy and completion. Furthermore, there is a shift in mindset in disaster contexts wherein most health care focus shifts to direct clinical care and diverts almost all attention from quality documentation.
This report distinguishes between the tasks of the epidemiologist and the data manager (DM) in an emergency medical team (EMT) and discusses the importance of data collection in the specific case of an EMT deployment. While combining these roles is sometimes possible if resources are limited, it is better to separate them, as the two are quite distinct. Although there is overlap, to achieve the goals of either role, preferentially they should be carried out by two people working closely together with complementary skill sets. The main objective of this report is to provide guidance and task descriptions to EMTs and field hospitals when training, recruiting, and preparing DMs and epidemiologists to work within their teams. Clear delineation of tasks will lead to better quality data, as it commits DMs to being concerned with the provision of real-time documentation from patient arrival through to compiling daily reports. It also commits epidemiologists to providing enhanced disease surveillance; outbreak investigation; and a source of reliable and actionable information for decision makers and stakeholders in the disaster management cycle.
Since 1945, the reasons for major crises and how the world responds to them have changed every 10-15 years or sooner. Whereas these crises vary greatly across global regions, their economic, environmental, ecological, social, and disease aspects are increasingly under the influence of widely integrated global changes and forces arising primarily from: climate extremes; rapid unsustainable urbanization; critical biodiversity losses; and emergencies of scarcity in water, food, and energy. These slow-moving but increasingly severe crises affect larger populations across many borders and lead to the emergence of increasing population-based, preventable public health emergencies related to water, sanitation, food, shelter, energy, and related health illnesses, and ultimately global health security. This report explores the impact of these crises on Asia and the Pacific region, and their potential for regional conflict.
Air medical transport of trauma patients from the scene of injury plays a critical role in the delivery of severely injured patients to trauma centers. Over-triage of patients to trauma centers reduces the system efficiency and jeopardizes safety of air medical crews.
Hypothesis:
The objective of this study was to determine which triage factors utilized by Emergency Medical Services (EMS) providers are strong predictors of early discharge for trauma patients transported by helicopter to a trauma center.
Methods:
A retrospective chart review over a two-year period was performed for trauma patients flown from the injury site into a Level I trauma center by an air medical transport program. Demographic and clinical data were collected on each patient. Prehospital factors such as Glasgow Coma Score (GCS), Revised Trauma Score (RTS), intubation status, mechanism of injury, anatomic injuries, physiologic parameters, and any combinations of these factors were investigated to determine which triage criteria accurately predicted early discharge. Hospital factors such as Injury Severity Score (ISS), length-of-stay (LOS), survival, and emergency department disposition were also collected. Early discharge was defined as a hospital stay of less than 24 hours in a patient who survives their injuries. A more stringent definition of appropriate triage was defined as a patient with in-hospital death, an ISS >15, those taken to the operating room (OR) or intensive care unit (ICU), or those receiving blood products. Those patients who failed to meet these criteria were also used to determine over-triage rates.
Results:
An overall early discharge rate of 35% was found among the study population. Furthermore, when the more stringent definition was applied, over-triage rates were as high as 85%. Positive predictive values indicated that patients who met at least one anatomic and physiologic criteria were appropriately transported by helicopter as 94% of these patients had stays longer than 24 hours. No other criteria or combination of criteria had a high predictive value for early discharge.
Conclusions:
No individual triage criteria or combination of criteria examined demonstrated the ability to uniformly predict an early discharge. Although helicopter transport and subsequent hospital care is costly and resource consuming, it appears that a significant number of patients will be discharged within 24 hours of their transport to a trauma center. Future studies must determine the impact of eliminating “low-yield” triage criteria on under-triage of scene trauma patients.
In the present world, International Consensus Frameworks, commonly called global frameworks or global agendas, guide international development policies and practices. They guide the development of all countries and influence the development initiatives by their respective governments. Recent global frameworks, adopted mostly post-2015, include both a group of over-arching frameworks (eg, the Sendai Framework for Disaster Risk Reduction [SFDRR]) and a group of frameworks addressing specific issues (eg, the Dhaka Declaration on Disability and Disaster Risk Management). These global frameworks serve twin purposes: first, to set a global development standard, and second, to set policies and approaches to achieve these standards. A companion group of professional standards, guidelines, and tools (ie, Sphere’s Humanitarian Charter and Minimum Standards) guide the implementation and operationalization of these frameworks on the ground.
This paper gathers these global frameworks and core professional guidelines in one place, presents an analytical review of their essential features, and highlights the commonalities and differences between and among these frameworks. The aim of this paper is to facilitate understanding of these frameworks and to help in designing development and resilience policy, planning, and implementation, at international and national levels, where these frameworks complement and contribute to each other.
This Special Report describes an important and evolving aspect of the discipline and provides core information necessary to progress the science. Additionally, the report will help governments and policy makers to define their priorities and to design policies/strategies/programs to reflect the global commitments. Development practitioners can pre-empt the focus of the international community and the assistance coming from donors to the priority sectors, as identified in the global agenda. This would then help governments and stakeholders to develop and design a realistic plan and program and prepare the instruments and mechanisms to deliver the goals.
Carbon monoxide (CO) poisoning is the most common cause of death and injury among all poisonings. Myocardial injury is detected in one-third of CO poisonings. In this Case Report, a previously healthy 41-year-old man was referred for CO poisoning. The initial electrocardiogram (ECG) showed 1mm ST segment elevation in leads DII, DIII, and aVF. As the patient did not describe chest pain and had no cardiac symptoms, ECG was repeated 10 minutes later and it was seen that ST segment elevation disappeared. As the patient had a transient ST segment elevation and elevated high-sensitive Tn-T (HsTn-T), the patient was transferred to the coronary angiography laboratory. The patient’s left coronary system was normal, but a thrombus image narrowing the lumen by approximately 60% was observed in the right coronary artery. Intravenous tirofiban was administered for 48 hours. Control coronary angiography showed continuing thrombus formation and a bare metal stent was successfully implanted. This is the first reported case with transient ST segment elevation associated with acute coronary thrombus caused by CO poisoning. It may be recommended that patients with CO poisoning should be followed-up with a 12-lead ECG monitor or 24-hour ECG Holter monitoring, even if they show no cardiac symptoms and echocardiography shows no wall motion abnormality. Early coronary angiography upon detection of such dynamic ECG changes in these recordings as ST segment elevation can reduce the risk of myocardial infarction (MI) and mortality in these patients.
Immersion of patients in a body bag filled with ice and water is recommended as prehospital management of severe hyperthermia. Experienced paramedics have raised a number of concerns about the use of this technique; particularly, whether cardiac monitoring equipment would remain functional once immersed. This test showed that monitoring equipment does remain functional and provides advice about safety considerations. The test should reassure practitioners that such an approach is feasible.
Severe trauma can lead to amputation of limbs. There is no golden standard or comprehensive evaluation indicator for amputation. It is difficult for the primary rescue organization to focus on the most essential indicators and to determine whether to perform amputation or take proper operation.
Problem:
For medical staff in first-line medical teams for disaster relief or in a common primary hospital, what indicators should they focus on to keep the patient’s limbs when they receive wounded patients with severe trauma?
Methods:
A retrospective case-control study was performed based on the patients with severe trauma from January 2013 through December 2018 in the emergency department of Southwest Hospital (Shapingba District, Chongqing, China), a Level I trauma center. A total of 165 cases were divided into amputation group (n = 79) and non-amputation control group (n = 86), which had severe skin and muscle injury but without amputation. The causes of trauma and the special cases were analyzed. Binary logistic regression models were used to find the essential indicators for amputation.
Conclusions:
Neurovascular injury with delayed treatment was the most decisive indicator leading to amputation, and time phase was also important for limb salvage. Preliminary treatment of disaster victims and patients with severe trauma should focus on neurovascular status and timely delivery.
Blood glucose level (BGL) is routinely assessed by paramedics in the out-of-hospital setting. Most commonly, BGL is measured using a blood sample of capillary origin analyzed by a hand-held, point-of-care glucometer. In some clinical circumstances, the capillary sample may be replaced by blood of venous origin. Given most point-of-care glucometers are engineered to analyze capillary blood samples, the use of venous blood instead of capillary may lead to inaccurate or misleading measurements.
Hypothesis/Problem:
The aim of this prospective study was to compare mean difference in BGL between venous and capillary blood from healthy volunteers when measured using a capillary-based, hand-held, point-of-care glucometer.
Methods:
Using a prospective observational comparison design, 36 healthy participants provided paired samples of blood, one venous and the other capillary, taken near simultaneously. The BGL values were similar between the two groups. The capillary group had a range of 4.3mmol/l, with the lowest value being 4.4mmol/l and 8.7mmol/l the highest. The venous group had a range of 2.7mmol/l, with the lowest value being 4.1mmol/l and 7.0mmol/l the highest.
For the primary research question, the mean BGL for the venous sample group was 5.3mmol/l (SD = 0.6), compared to 5.6mmol/l (SD = 0.8) for the capillary group. This represented a statistically significant difference of 0.3mmol/l (P = .04), but it did not reach the a priori established point of clinical significance (1.0mmol/l). Pearson’s correlation coefficient for capillary versus venous indicated moderate correlation (r = 0.42).
Conclusion:
In healthy, non-fasted people in a non-clinical setting, a statistically significant, but not clinically significant, difference was found between venous- and capillary-derived BGL when measured using a point-of-care, capillary-based glucometer. Correlation between the two was moderate. In this context, using venous samples in a capillary-based glucometer is reasonable providing the venous sample can be gathered without exposure of the clinician to risk of needle-stick injury. In clinical settings where physiological derangement or acute illness is present, capillary sampling would remain the optimal approach.
Cultural awareness can be defined as an understanding of the differences that exist between cultures. This understanding is a crucial first step towards the development of cultural sensitivity, a willingness to accept those differences as having equal merit, and becoming operationally effective when working within different cultures. The benefits of cultural awareness have become apparent in recent decades, including within governments, militaries, and corporations. Many organizations have developed cultural awareness training for their staffs to improve cross-cultural cooperation. However, there has not been a large movement toward cultural sensitivity training among non-governmental organizations (NGOs) who provide aid globally, across a number of countries and cultures. Cultural awareness can be a useful tool which enables an NGO to better serve the populations with which they engage.
Problem:
The goal of this study was to evaluate the presence of cultural awareness training for employees and volunteers working within international NGOs.
Methods:
Ten of the largest international NGOs were identified. Their websites were evaluated for any mention of training in cultural awareness available to their employees and volunteers. All ten were then contacted via their public email addresses to find out if they provide any form of cultural awareness training.
Results:
Of the ten NGOs identified, none had any publicly available cultural awareness training on their websites. One NGO dealt with cultural awareness by only hiring local staff, who were already a part of the prevalent culture of the area. None of the others who responded provided any cultural awareness training.
Conclusion:
Cultural awareness is a vital tool when working internationally. Large NGOs, which operate in a wide-range of cultures, have an obligation to act in a culturally aware and accepting manner. Most large NGOs currently lack a systematic, robust cultural awareness training for their employees and volunteers.
In January of 2010, North Carolina (NC) USA implemented state-wide Trauma Triage Destination Plans (TTDPs) to provide standardized guidelines for Emergency Medical Services (EMS) decision making. No study exists to evaluate whether triage behavior has changed for geriatric trauma patients.
Hypothesis/Problem:
The impact of the NC TTDPs was investigated on EMS triage of geriatric trauma patients meeting physiologic criteria of serious injury, primarily based on whether these patients were transported to a trauma center.
Methods:
This is a retrospective cohort study of geriatric trauma patients transported by EMS from March 1, 2009 through September 30, 2009 (pre-TTDP) and March 1, 2010 through September 30, 2010 (post-TTDP) meeting the following inclusion criteria: (1) age 50 years or older; (2) transported to a hospital by NC EMS; (3) experienced an injury; and (4) meeting one or more of the NC TTDP’s physiologic criteria for trauma (n = 5,345). Data were obtained from the Prehospital Medical Information System (PreMIS). Data collected included proportions of patients transported to a trauma center categorized by specific physiologic criteria, age category, and distance from a trauma center.
Results:
The proportion of patients transported to a trauma center pre-TTDP (24.4% [95% CI 22.7%-26.1%]; n = 604) was similar to the proportion post-TTDP (24.4% [95% CI 22.9%-26.0%]; n = 700). For patients meeting specific physiologic triage criteria, the proportions of patients transported to a trauma center were also similar pre- and post-TTDP: systolic blood pressure <90 mmHg (22.5% versus 23.5%); respiratory rate <10 or >29 (23.2% versus 22.6%); and Glascow Coma Scale (GCS) score <13 (26.0% versus 26.4%). Patients aged 80 years or older were less likely to be transported to a trauma center than younger patients in both the pre- and post-TTDP periods.
Conclusions:
State-wide implementation of a TTDP had no discernible effect on the proportion of patients 50 years and older transported to a trauma center. Under-triage remained common and became increasingly prevalent among the oldest adults. Research to understand the uptake of guidelines and protocols into EMS practice is critical to improving care for older adults in the prehospital environment.
ST-segment elevation myocardial infarction (STEMI) is a time-sensitive entity that has been shown to benefit from prehospital diagnosis by electrocardiogram (ECG). Current computer algorithms with binary decision making are not accurate enough to be relied on for cardiac catheterization lab (CCL) activation.
Hypothesis:
An algorithmic approach is proposed to stratify binary STEMI computerized ECG interpretations into low, intermediate, and high STEMI probability tiers.
Methods:
Based on previous literature, a four-criteria algorithm was developed to rule out/in common causes of prehospital STEMI false-positive computer interpretations: heart rate, QRS width, ST elevation criteria, and artifact. Prehospital STEMI cases were prospectively collected at a single academic center in Salt Lake City, Utah (USA) from May 2012 through October 2013. The prehospital ECGs were applied to the algorithm and compared against activation of the CCL by an emergency department (ED) physician as the outcome of interest. In addition to calculating test characteristics, linear regression was used to look for an association between number of criteria used and accuracy, and logistic regression was used to test if any single criterion performed better than another.
Results:
There were 63 ECGs available for review, 39 high probability and 24 intermediate probability. The high probability STEMI tier had excellent test characteristics for ruling in STEMI when all four criteria were used, specificity 1.00 (95% CI, 0.59-1.00), positive predictive value 1.00 (0.91-1.00). Linear regression showed a strong correlation demonstrating that false-positives increased as fewer criteria were used (adjusted r-square 0.51; P <.01). Logistic regression showed no significant predictive value for any one criterion over another (P = .80). Limiting physician overread to the intermediate tier only would reduce the number of ECGs requiring physician overread by a factor of 0.62 (95% CI, 0.48-0.75; P <.01).
Conclusion:
Prehospital STEMI ECGs can be accurately stratified to high, intermediate, and low probabilities for STEMI using the four criteria. While additional study is required, using this tiered algorithmic approach in prehospital ECGs could lead to changes in CCL activation and decreased requirements for physician overread. This may have significant clinical and quality implications.
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a percutaneous transfemoral balloon technique used in select centers for resuscitation and temporary hemostasis of bleeding patients. Several animal studies demonstrated that its application in non-traumatic cardiac arrest could enhance cerebral and coronary perfusion during cardiopulmonary resuscitation (CPR); despite this, there are few reports of its application in humans. This is a case report of REBOA application during a refractory out-of-hospital cardiac arrest in a 50-year-old man where Advanced Cardiac Life Support (ACLS) alone was unable to maintain a stable return of spontaneous circulation (ROSC) and Extracorporeal Cardiac Life Support (ECLS) was not available.
This paper discusses the need for consistency in mass-gathering research and evaluation from an environmental reporting perspective.
Background:
Mass gatherings occur frequently throughout the world. Having an understanding of the complexities of mass gatherings is important to inform health services about the possible required health resources. Factors within the environmental, psychosocial, and biomedical domains influence the usage of health services at mass gatherings. A minimum data set (MDS) has been proposed to standardize collection of biomedical data across various mass gatherings, and there is a need for an environmental component. The environmental domain includes factors such as the nature of the event, availability of drugs or alcohol, venue characteristics, and meteorological factors.
Method:
This research used an integrative literature review design. Manuscripts were collected using keyword searches from databases and journal content pages from 2003 through 2018. Data were analyzed and categorized using the existing MDS as a framework.
Results:
In total, 39 manuscripts were identified that met the inclusion criteria.
Conclusion:
In collecting environmental data from mass gatherings, there must be an agreed-upon MDS. A set of variables can be used to collect de-identified environmental variables for the purpose of making comparisons across societies for mass-gathering events (MGEs).
Disasters, such as cyclones, create conditions that increase the risk of infectious disease outbreaks. Epidemic forecasts can be valuable for targeting highest risk populations before an outbreak. The two main barriers to routine use of real-time forecasts include scientific and operational challenges. First, accuracy may be limited by availability of data and the uncertainty associated with the inherently stochastic processes that determine when and where outbreaks happen and spread. Second, even if data are available, the appropriate channels of communication may prevent their use for decision making.
In April 2019, only six weeks after Cyclone Idai devastated Mozambique’s central region and sparked a cholera outbreak, Cyclone Kenneth severely damaged northern areas of the country. By June 10, a total of 267 cases of cholera were confirmed, sparking a vaccination campaign. Prior to Kenneth’s landfall, a team of academic researchers, humanitarian responders, and health agencies developed a simple model to forecast areas at highest risk of a cholera outbreak. The model created risk indices for each district using combinations of four metrics: (1) flooding data; (2) previous annual cholera incidence; (3) sensitivity of previous outbreaks to the El Niño-Southern Oscillation cycle; and (4) a diffusion (gravity) model to simulate movement of infected travelers. As information on cases became available, the risk model was continuously updated. A web-based tool was produced, which identified highest risk populations prior to the cyclone and the districts at-risk following the start of the outbreak.
The model prior to Kenneth’s arrival using the metrics of previous incidence, projected flood, and El Niño sensitivity accurately predicted areas at highest risk for cholera. Despite this success, not all data were available at the scale at which the vaccination campaign took place, limiting the model’s utility, and the extent to which the forecasts were used remains unclear. Here, the science behind these forecasts and the organizational structure of this collaborative effort are discussed. The barriers to the routine use of forecasts in crisis settings are highlighted, as well as the potential for flexible teams to rapidly produce actionable insights for decision making using simple modeling tools, both before and during an outbreak.
Nowadays, extreme weather and atmospheric conditions are becoming more frequent and more intense. It seems obvious that together with climate change, the vulnerability of the public and of individual regions to the risks of various types of natural hazards also increases. This would increase the importance of organization concerning potential measures to protect against these extraordinary events, and to prepare for reducing their ramifications.
One such initiative is the creation of an early warning system for inhabitants of a given area of a country, to help guard against the extraordinary threat associated with a natural disaster; especially floods. The creation of such a system is aimed at increasing public safety and limiting losses caused by the occurrence of natural, technological, and synergistic hazards. Particular emphasis during the construction of a current system is placed on supporting flood risk management, which is aimed at increasing the safety of citizens and reducing losses caused by the occurrence of flooding in Poland. This would be possible by the identification of areas threatened by flooding throughout the country, and then limiting economic expansion in these areas.
Ultimately, the project aims to consolidate information regarding hazardous events and gather them in a professional Information Technology (IT) system, using an integrated database and a modern module for disseminating information to end users. The system is to provide access to this information for both the administration and the individual citizen.
This article presents the potential of a so called “IT System for the Country’s Protection Against Extreme Hazards,” which is currently being developed in Poland, with particular emphasis on reducing the risks related to natural disasters and minimizing the problems of crisis management in Poland. This article is also aimed at opening discussions and creating a basis for the exchange of information from countries implementing similar solutions, especially neighboring countries, with which joint action could be undertaken.
Provision of critical care and resuscitation was not practical during early missions into space. Given likely advancements in commercial spaceflight and increased human presence in low Earth orbit (LEO) in the coming decades, development of these capabilities should be considered as the likelihood of emergent medical evacuation increases.
Methods:
PubMed, Web of Science, Google Scholar, National Aeronautics and Space Administration (NASA) Technical Server, and Defense Technical Information Center were searched from inception to December 2018. Articles specifically addressing critical care and resuscitation during emergency medical evacuation from LEO were selected. Evidence was graded using Oxford Centre for Evidence-Based Medicine guidelines.
Results:
The search resulted in 109 articles included in the review with a total of 2,177 subjects. There were two Level I systematic reviews, 33 Level II prospective studies with 647 subjects, seven Level III retrospective studies with 1,455 subjects, and two Level IV case series with four subjects. There were two Level V case reports and 63 pertinent review articles.
Discussion:
The development of a medical evacuation capability is an important consideration for future missions. This review revealed potential hurdles in the design of a dedicated LEO evacuation spacecraft. The ability to provide critical care and resuscitation during transport is likely to be limited by mass, volume, cost, and re-entry forces. Stabilization and treatment of the patient should be performed prior to departure, if possible, and emphasis should be on a rapid and safe return to Earth for definitive care.