On 17 October 1989, the Loma Prieta Earthquake shook the San Francisco Bay area, home to more than 6 million people. This study examined the effectiveness and function of emergency medical services (EMS) communications after this event.

The six Bay area counties most affected by the Loma Prieta Earthquake were surveyed using a 156-part questionnaire. This study examined the functioning of the primary 9-1-1 county dispatch centers. Paramedics involved in a set of defined activities during the period after the earthquake also were surveyed. Emergency medical services directors also were questioned by telephone using an interview tool developed for this purpose. All areas concerning disaster response were not queried. Ten specific areas were considered, including: 1) preparation for disaster; 2) the impact of the earthquake; 3) reconnaissance; 4) call volume; and 5) others.

Coordination among the various agencies responsible for disaster response and mitigation needs more study. Uniform response plans for medical mutual aid need development. Government support similar to police and fire department arrangements for mutual aid are not in place. Additional planning and training for disasters at all levels need reassessment. The communication-center personnel indicated that they did not call for more resources, but instead accepted volunteers at dispatch centers and extra assistance. Once engaged, however, most communications centers (CCs) had great difficulty tracking and controlling all the units under their jurisdiction. In some large urban counties, some ambulances were idled awaiting calls but lost their communications centers, while other ambulance personnel were trying to handle multiple patients and requests for services.

Significant help from a state or federal agency likely will be unavailable for a substantial period after a catastrophic regional event. Important coordination among EMS agencies for disaster response is poor or absent. Although fatalities and casualties were limited compared to what could have occurred, great confusion reigned for varying periods of time after the earthquake. Communications among local agencies, counties, and the state were problematic. Information flow to hospitals was cited frequently as a problem, making it difficult for hospitals to prepare adequately. Medical mutual-aid help was disorganized and inadequately controlled. The training of personnel and the method of recall for disaster response need to be examined.

Prehospital providers regularly encounter patients with obstetrical emergencies. This study determined the frequency and outcome of out-of-hospital deliveries in an urban, all advanced life support (ALS) emergency medical services (EMS) system.

Retrospective review of all out-of-hospital records that involved women delivering babies in the care of prehospital providers from 1984–1988. The EMS system answered an average of 62,000 calls during the study period. The records of these patients were identified through a computer database.

A total of 81 out-of-hospital deliveries (1.4/month) occurred during the study years. The average age of the mothers was 24 years, and the average gestation period was 30 weeks. The women had an average of three previous pregnancies and two previous deliveries, and 10 were primagravida. Seventy-two (89%) of the deliveries occurred in the home. The paramedia encountered a variety of obstetrical and neonatal complications in 34% of the patient encounters. Nine neonates were delivered prior to the arrival of the paramedic team. Twenty-four neonates had Apgar scores calculated, and the one- and five-minute scores averaged eight and nine respectively. Five of the mothers had no prenatal care. Maternal complications included four patients noted to be hypertensive with the delivery, nine patients had some degree of vaginal bleeding, and in 33 patients, the prehospital providers did not deliver the placenta in the field. An EMS physician was in attendance for only two of the out-of-hospital deliveries.

In this urban EMS system, out-of-hospital deliveries, especially pre-term deliveries, are a common event. There appears to be a significant number of neonatal complications that confront paramedics. Generally, the paramedics were deficient in their documentation of the neonatal assessment. Continuing educational programs for paramedics should include reviewing normal and complicated vaginal deliveries as well as ALS measures for neonates. Protocols for obstetrical emergencies need to be developed and subjected to quality improvement measures.

Paramedics, especially those in urban settings, are likely to encounter obstetrical and neonatal emergencies and a significant number of associated complications. Emergency medical services systems and medical directors should have in place continuing educational programs, patient-care protocols, and continuous quality improvement measures to evaluate the care rendered to patients having out-of-hospital deliveries.

Although general discussions of legal claims against emergency medical services (EMS) have been published, there is no literature that examines legal claims that specifically have involved base-station contact for direct medical control.

A review of case law through July 1994 was conducted to identify cases that involved radio communications between a prehospital provider and a physician or nurse under the direction of a physician.

Only eight cases could be identified. Each case is described in terms of the event, selected pertinent legal issues, and the opinions rendered by the court.

These few cases illustrate some important observations that indicate that there will occur an increase in the detail, role delineation, and clarification of the prehospital providers, medical directors, base-station physicians, and others who provide direct medical control to prehospital EMS providers. These findings have important implications for EMS medical directors.

In recent years, controversy has surrounded the issue of whether infectious disease should be considered a serious potential consequence of natural disasters. This article contributes to this debate with evidence of a significant outbreak of malaria in Costa Rica's Atlantic region after the 1991 earthquake and subsequent floods.

This study is an epidemiologic investigation of the incidence of malaria for the periods of 22 months before the April 1991 Limon earthquake and for 13 months afterward. Data were obtained from the Costa Rican Ministry of Health's malaria control program.

Some of the cantons in the region experienced increases in the incidence of malaria as high as 1,600% and 4,700% above the average monthly rate for the pre-earthquake period (p ≤0.01). Causal mechanisms are postulated as relating to changes in human behavior (increased exposure to mosquitoes while sleeping outside, and a temporary pause in malaria control activities), changes in the habitat that were beneficial to mosquito breeding (landslide deforestation, river damming, and rerouting), and the floods of August 1991.

It is recommended that there be enhanced awareness of the potential consequences of disaster-wrought environmental changes.

Date of Event: 22 April 1991; Type: Earthquake, 7.4 Richter scale; Location: Costa Rica; Number of deaths and casualties: 54 deaths and 505 moderate to severe injuries.

To characterize the types of occupational exposures and injuries reported by emergency medical service (EMS) workers.

A blinded review of accidents/exposures among EMS workers employed by a Baltimore County fire department was conducted. Medical records for 1992 were reviewed.

Two hundred and twenty-six reports were filed by EMS workers (n = 197) employed by a large, urban fire department in 1992. The most commonly reported injuries were sprains (23%), strains (20%), and exposure to blood and body fluids (15%). The body site most commonly injured was the back (20%) followed by the respiratory system (10%). Most incidents were treated at the employee health clinic, and 13% of the incidents resulted in a hospital visit. Fifteen percent of the injuries resulted in more than seven lost work days. Most incidents were caused by stretcher mishaps, especially during transport of heavy patients. Walkway impediments (e.g., icy steps, wet leaves, broken and uneven pathways) also played an important role in creating slipping and tripping hazards.

These results suggest a variety of prevention strategies aimed at reducing accidents and exposures among EMS workers.

To document the existence and nature of variation in times to trauma care between urban and rural locations; to assess the impact of identified variations on outcome.

Retrospective case review

Washington state, 1986

Motor-vehicle-collision fatalities

Previously unreported definitions of urban and rural location and possibly preventable death were used to conduct a comparative analysis of urban and rural fatalities. Trauma care times in the prehospital and the emergency department (ED) phases of care were abstracted. Their relationships to corresponding crude death rates and possibly preventable death rates also were examined.

Prehospital times averaged two times longer in rural locations than in urban areas. First-physician contact in the ED averaged six times longer in rural locations than in urban settings. Concomitantly, the crude death rate in rural settings was three times that of the urban areas. The overall possibly preventable death rate was double the urban rates in rural incidents. When stratified by phase of care, rate of possibly preventable death showed no urban/rural variation for the prehospital phase, but was three times greater for the ED phase in rural areas than in urban ones.

Trauma care times and adverse outcome appear to be associated. Allocation of resources to decrease length of and geographic variation in time to definitive care, particularly in the ED phase, seems appropriate.

Previous evaluations of prehospital devices intended for spinal immobilization have focused on the device's ability to restrict motion only. This study defines six relevant criteria for evaluation of cervical immobilization device (CID) performance.

To suggest relevant criteria for evaluation and use available technology to improve measurements for performance testing of prehospital-care devices.

Six parameters (motion restriction, access, ease of application, environmental performance, radiolucency, and storage size) were used to evaluate three types of CIDs: Device A—a single-use corrugated board; Device B—a reusable foam-block CID; and Device C—hospital towels and adhesive tape. To test motion restriction, the most frequently compared parameters for immobilization devices, 20 volunteers were asked to move their heads and necks through a series of motions (flexion, extension, lateral bending and rotation). Their movements were videotaped, still images of each movement were generated, and the degrees of deflection recorded from these still images. To ensure a consistent level of force, electromyography (EMG) of the sternodydomastoid and extensor muscles was employed.

Data were produced for each parameter and presented for comparison. The use of video to determine deflection proved to be a useful and highly accurate (±1°) method for measurement. The use of EMG technology enabled force to be controlled indirectly when the subjects used moderate levels of exertion. Overall, Devices A and C restricted motion better than Device B. Although Device C required the shortest time for application, it took the longest to prepare for application. The total time required for preparation and application of A and B essentially were equivalent, with A requiring no preparation time but taking the longest for application, and B having an intermediate interval for application. Device A allowed for the best examination of the head and neck. No differences were detected in performance in extreme environmental conditions or in radiolucency for cervical spine X-ray examinations. Device A consumed the smallest storage volume, B the greatest storage volume, and C an intermediate volume substantially greater than that required for A.

Device evaluation should include examination of all relevant performance parameters using the most accurate and meaningful methods possible.