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To describe the types of surgical procedures performed by emergency medical teams (EMTs) with general surgical capability in the aftermath of sudden-onset disasters (SODs) in low- and middle-income countries (LMICs).
A search of electronic databases (PubMed, MEDLINE, and EMBASE) was carried out to identify articles published between 1990 and 2018 that describe the type of surgical procedures performed by EMTs in the impact and post-impact phases a SOD. Further relevant articles were obtained by hand-searching reference lists.
16 articles met the inclusion criteria. Articles reporting on EMTs from a number of different countries and responding to a variety of disasters were included. There was a high prevalence of procedures for extremity soft tissue injuries (46.8%) and fractures (28.3%). However, a significant number of genitourinary/obstetric procedures were also reported.
Knowledge of the types of surgical procedures most frequently performed by EMTs may help further determine the necessary prerequisite surgical skills required for the recruitment of surgeons for EMTs. Experience in basic plastic, orthopedic, urological, and obstetric surgery would seem desirable for surgeons and surgical teams wishing to participate in an EMT.
Clinical diagnostics in sudden-onset disasters (SOD) has historically been limited. With poor supply routes, lack of a cold chain, and challenging environmental conditions, many diagnostic platforms are unsuitable.
We set out to design, implement, and evaluate a mobile diagnostic laboratory accompanying a type II emergency medical team (EMT) field hospital.
Available diagnostic platforms were reviewed and selected against infield need. Platforms included HemoCue301/WBC DIFF, i-STAT, BioFire multiplex RT-PCR, Olympus BX53 microscopy, ABO/Rh Grouping, and specific rapid diagnostic tests (RDT). This equipment was trialed in Katherine, Australia and Dili, Timor-Leste.
During the initial deployment, validation of FilmArray rt-PCR multiplex tests was successful on blood culture, gastrointestinal, and respiratory panels. HemoCue301 (n = 20) haemoglobin values were compared on Sysmex XN 550 (r = 0.94). Analysis of HemoCue WBC DIFF samples had some variation when compared to Sysmex XN 550, (neutrophils r = 0.88, lymphocytes r = 0.49, monocytes r = 0.16, eosinophils r = 0.70, basophils r = 0.16). i-STAT showed non-significant differences for CHEM4 (n=10), CG8 (n = 10), and TnI (n = 5) against Vitros 250. A further trial of BioFire rt-PCR testing in Dili, Timor-Leste diagnosed 117 causative pathogens on 168 FilmArray test cartridges.
This mobile laboratory represents a major advance in SOD. Setup of the service was quick (<24hr) and transport to site rapidly. Training was simple and performance consistent. Future deployment in fragmented health systems after sudden onset disasters with EMT2 will now allow broader diagnostics.
Emergency medical teams (EMTs) have helped to provide surgical care in many recent sudden onset disasters (SODs), especially in low- and middle-income countries (LMICs). General surgical training in Australia has undergone considerable change in recent years, and it is not known whether the new generation of general surgeons is equipped with the broad surgical skills needed to operate as part of EMTs.
To analyze the differences between the procedures performed by contemporary Australian general surgeons during training and the procedures performed by EMTs responding to SODs in low- and middle-income countries (LMICs).
General surgical trainee logbooks between February 2008 and January 2017 were obtained from General Surgeons Australia. Operating theatre logs from EMTs working during the 2010 earthquake in Haiti, 2014 typhoon in the Philippines, and 2015 earthquake in Nepal were also obtained. These caseloads were collated and compared.
A total of 1,396,383 procedures were performed by Australian general surgical trainees in the study period. The most common procedure categories were abdominal wall hernia procedures (12.7%), cholecystectomy (11.7%), and specialist colorectal procedures (11.5%). Of note, Caesarean sections, hysterectomy, fracture repair, specialist neurosurgical, and specialist pediatric surgical procedures all made up <1% of procedures each. There were a total of 3,542 procedures recorded in the EMT case logs. The most common procedures were wound debridement (31.5%), other trauma (13.3%), and Caesarean section (12.5%). Specialist colorectal, hepato-pancreaticobiliary, upper gastrointestinal, urological, vascular, neurosurgical, and pediatric surgical procedures all made up <1% each.
Australian general surgical trainees get limited exposure to the obstetric, gynecological, and orthopedic procedures that are common during EMT responses to SODs. However, there is considerable exposure to the soft tissue wound management and abdominal procedures.
Sudden onset disasters exceed the capabilities of local health services. Emergency Medical Teams (EMTs), including the Australian Medical Assistance Team (AUSMAT), are a vital element of the Australian Governments capacity to respond to regional and international sudden-onset disasters. AUSMAT has the capacity to deploy an EMT Type 2 surgical field hospital and has been successfully verified by the World Health Organisation (WHO). All AUSMAT members must complete AUSMAT Team Member training. The National Critical Care and Trauma Response Centre, Darwin, Australia is responsible for all AUSMAT training.
To educate and train the Surgical Team (perioperative nurses, surgeons, and anesthetists) in preparation for AUSMAT deployments in the austere environment.
Prior to 2015, the surgical AUSMAT training was conducted via two courses: one for perioperative nurses and a separate course for surgeons and anesthetists. In 2015, the course was redesigned with the aim of collaborative training with all the Surgical Team Members. The new Surgical Team Course (STC) engages all three professions to learn alongside each other and discuss potential difficulties in techniques, the daily running of the operating room, and ethical discussions.
Since the rejuvenation of the STC, 15 surgeons, 17 anesthetists, and 18 perioperative nurses have completed the course. The attendees are familiarized with operational and clinical guidelines, the surgical field hospital, and operating room equipment including CSSD. A pivotal component of the course focuses on the essentials of medical records and Minimum Data Set reporting for EMTs as defined by WHO.
Since 2015, the NCCTRC has successfully run two courses. The revised collaborative model for AUSMAT STC has enhanced the quality of the program and subsequent learning experiences for participants.
Sudden onset disasters (SODs) have affected over 1.5 billion of the world’s population in the past decade. During the same time, developing nations have faced a sustained increase in the burden of non-communicable disease (NCD) with extra pressure placed on health systems. The combined increase in SODs and the NCD epidemic facing the world’s most disaster-prone nations will present new challenges to emergency medical teams (EMTs) during disaster response. This report details the experience as an EMT during the Typhoon Haiyan disaster of 2013, with particular reference to the challenges of diabetic management in a surgical field hospital. The incidence of diabetes in this surgical cohort exceeded that of the population by a factor of four. The steps to prepare for and treat diabetes in the field provide a useful model for the management of NCD in the deployed field hospital environment after a disaster.
McDermottKM, HardstaffRM, AlpenS, ReadDJ, CoatsworthNR. Management of Diabetic Surgical Patients in a Deployed Field Hospital: A Model for Acute Non-Communicable Disease Care in Disaster. Prehosp Disaster Med. 2017;32(6):657–661.
Reintroduction practitioners must often make critical decisions about reintroduction protocols despite having little understanding of the reintroduction biology of the focal species. To enhance the available knowledge on the reintroduction biology of the warru, or black-footed rock-wallaby Petrogale lateralis MacDonnell Ranges race, we conducted a trial reintroduction of 16 captive individuals into a fenced predator and competitor exclosure on the An̲angu Pitjantjatjara Yankunytjatjara Lands in South Australia. We conducted seven trapping sessions and used radio-tracking and camera traps to monitor survival, reproduction and recruitment to the population over 36 months. Blood samples were collected pre-release and during two trapping sessions post-release to assess nutritional health. The survival rate of founders was 63%, with all losses occurring within 10 weeks of release. Post-release blood biochemistry indicated that surviving warru adapted to their new environment and food sources. Female warru conceived within 6 months of release; 28 births were recorded during the study period and 52% of births successfully recruited to the population. Our results suggest that captive-bred warru are capable of establishing and persisting in the absence of introduced predators. However, the high mortality rate immediately post-release, with only a modest recruitment rate, suggests that future releases into areas where predators and competitors are present should use a trial approach to determine the viability of reintroduction. We recommend that future releases of warru into unfenced areas include an intensive monitoring period in the first 3 months post-release followed by a comprehensive long-term monitoring schedule to facilitate effective adaptive management.
The paper reports on the fourth (2010) season of fieldwork of the Cyrenaican Prehistory Project, and on further results of analyses of artefacts and organic materials collected in the 2009 season. Ground-based LiDar has provided both an accurate 3D scan of the Haua Fteah cave and information on the cave's morphometry or origins. The excavations in the cave focussed on Middle Palaeolithic or Middle Stone Age ‘Pre-Aurignacian’ layers below the base of the Middle Trench beside the McBurney Deep Sounding (Trench D) and on Final Palaeolithic ‘Oranian’ layers beside the upper part of the Middle Trench (Trench M). Although McBurney referred to the upper part of the Deep Sounding as more or less sterile, the 2010 excavations found evidence for small-scale but regular human presence in the form of stone artefacts and debitage, though given the sedimentary context the latter are unlikely to represent in situ knapping. The excavations of Trench M extended from the basal Capsian layers investigated in 2009 through Oranian layers to the transition with the Dabban Upper Palaeolithic. Some 17,000 lithic pieces have been studied from the Capsian and Oranian layers excavated in Trench M, in an area measuring less than 2 m by 1 m by 1.1 m deep, along with numerous animal bones, molluscs, and macrobotanical remains, as well as occasional shell beads. Preliminary studies of the lithics, bones, molluscs, and plant remains are revealing the changing character of late Pleistocene (Oranian) and early Holocene (Capsian) occupation in the Haua Fteah. Alongside the work in the Haua Fteah, the project continued its assessment of the Quaternary and archaeological sequences of the Cyrenaican coastland and completed a transect survey of surface lithic materials and their landform contexts from the pre-desert across the Gebel Akhdar to the coast, with a new focus on the al-Marj basin. Significant differences are emerging in patterns of Middle Palaeolithic and later hominin occupation and palaeodemography.
In the past, research on social stratification focused primarily on the independent contributions of race, socioeconomic status (SES), and gender to status attainment. However, contemporary research in the field recognizes that race, SES, and gender interact to create complicated systems of inequality that go beyond conventional models of stratification. Increasingly, studies add categories such as religion and nativity to the mix and uncover even more complex patterns of inequality, ones that rarely fit conventional explanations for stratification outcomes, particularly for women (Fitzgerald and Glass 2008, 2012; Glass and Jacobs 2005; Lehrer 1999a; Sherkat and Darnell 1999). Consider these examples: Education is highly correlated with U.S. women's employment and earnings (England, Garcia-Beaulieu, and Ross 2004), but is much more so for native-born white and black women than for immigrant women (Read and Cohen 2007). Religion is negatively associated with women's human capital acquisition among conservative Christians (Lehrer 1999b), whereas the opposite is true among U.S. Jews (Gold 2002), and among Arab Americans, women evidence a pattern of high educational attainment, but very low labor force participation (Read and Oselin 2008).
These patterns can create theoretical and empirical conundrums for researchers focused on the relationship between any single identity (e.g., race, class, gender) and social inequality. In this chapter, we examine where the presence of multiple group identities results in status attainment outcomes that do not fit neatly within conventional stratification models. We use Arab American women as a case study. This group provides a useful case because it lies at the intersection of religion and ethnicity, where the cultural dynamics shaping women's achievements are especially acute (Read 2004). Arab American women also constitute a population that exhibits a paradoxical pattern of high educational attainment but low employment (U.S. Bureau of the Census 2000). They provide a rich repository of information to examine how multiple identity categories intersect to shape outcomes.
Background: Randomized controlled trials have established that individual cognitive therapy based on the Clark and Wells (1995) model is an effective treatment for social anxiety disorder that is superior to a range of alternative psychological and pharmacological interventions. Normally the treatment involves up to 14 weekly face-to-face therapy sessions. Aim: To develop an internet based version of the treatment that requires less therapist time. Method: An internet-delivered version of cognitive therapy (iCT) for social anxiety disorder is described. The internet-version implements all key features of the face-to-face treatment; including video feedback, attention training, behavioural experiments, and memory focused techniques. Therapist support is via a built-in secure messaging system and by brief telephone calls. A cohort of 11 patients meeting DSM-IV criteria for social anxiety disorder worked through the programme and were assessed at pretreatment and posttreatment. Results: No patients dropped out. Improvements in social anxiety and related process variables were within the range of those observed in randomized controlled trials of face-to-face CT. Nine patients (82%) were classified as treatment responders and seven (64%) achieved remission status. Therapist time per patient was only 20% of that in face-to-face CT. Conclusions: iCT shows promise as a way of reducing therapist time without compromising efficacy. Further evaluation of iCT is ongoing.
We report the results of tensile tests of thin films of Al-0.5 % Cu deposited on bare silicon. This material was subjected to the complete CMOS fabrication process, including a high-temperature heat treatment. Contact metal makes the electrical connection between the metal wiring and the silicon transistors in a chip. Room-temperature values of yield strength, ultimate tensile strength, and elongation were all lower than the corresponding values found previously for pure electron-beam-evaporated aluminum films. The strengths and elongation decreased slightly as the specimen temperature was raised from 25 to 150°C. The slopes of the stress-strain curves from unloading-reloading runs were lower than the accepted Young's modulus of bulk polycrystalline aluminum. The results are interpreted with the help of scanning and transmission electron microscopy.
A tensile test procedure that accommodates specimens with gage section 25 μm thick, 70 μm wide and 360 μm long was developed and demonstrated. The instrumentation and technique were adapted from those previously developed and used to test thin films, by increasing both the force capacity of the load cell and the stiffness of the pull rod. Specimens with bow-tie geometry were fabricated by photolithography from nominally 25 μm thick full hard stainless steel 302 foil. A silicon test frame fabricated by bulk micromachining techniques included tapered grips in the form of recesses in its top surface that accepted and retained the specimen grip sections. One grip was on the fixed outer portion of the frame. The other grip was on a plate suspended in the center of the frame by long slender silicon beams. Force was imposed on this plate by pin loading. The force was measured by use of a custom load cell. The displacement was measured by sub-pixel digital image correlation to surface features on the two ends of the gage section, applied to images with a resolution of approximately 0.8 μm per pixel. Yield and ultimate strengths and elongation values consistent with vendor-provided information were obtained. The values of Young’s modulus were scattered but within the range of expected behavior for the specimen material.
An approach to measuring the mechanical properties of thin films with in—plane and thickness dimensions comparable to those of films in VLSI electronic devices and in multi—chip modules is being developed. The guiding principles are to utilize as much as possible the technology of microelectronic fabrication and to make the design downward—scalable in size so that eventually the very smallest films and structures can be tested. The necessary components have been designed; we are in the process of building and testing them.
The specimen and associated instrumention are fabricated by semiconductor techniques on a 50 mm—diameter silicon wafer. Piezoresistors arranged as strain—sensitive Wheatstone bridges are fabricated by diffusion. One bridge, located on a grip section, is the load cell. After opening contact windows and metallization, the thin—film specimen is deposited. Then the silicon wafer is patterned and etched, leaving the specimen hanging between two instrumented grip sections linked by flexible silicon springs. Relative displacement of the grip sections is imposed by either a micrometer or a micro—stepper motor and measured by a scanned laser beam and by additional strain—sensitive bridges.
A series of trial assessments are being undertaken within the United Kingdom to rehearse procedures for post-closure radiological risk analysis of low and intermediate level radioactive waste disposal sites. These trial or “Dry Run” studies draw together workers from a variety of scientific disciplines allowing simultaneous rather than isolated development of assessment procedures. This paper illustrates the use of chemical codes and data within a probabilistic risk assessment framework through a demonstration exercise performed on a hypothetical repository located beneath Harwell, Oxfordshire. The implications for risk assessment practices reliant on the assumption of “conservative” parameters are highlighted by comparison with a more mechanistic approach which takes into account competitive effects.
We demonstrate the evolution of microstructure and deformation associated with the use of electrical methods for evaluating mechanical reliability of patterned interconnects on rigid substrates. Thermomechanical fatigue in aluminum and copper interconnects was induced by means of low frequency (100 Hz), high density (> 10 MA/cm2) alternating currents, which caused cyclic Joule heating and associated thermal expansion strains between the metal lines and oxidized silicon substrate. The failure mechanism involved formation of localized plasticity, which caused topography changes on the free surfaces of the metal, leading to open circuit eventually taking place by melting at a region of severely reduced cross-sectional area. Both aluminum and copper responded to power cycling by deforming in a manner highly dependent upon variations in grain size and orientation. Isolated patches of damage appeared early within individual grains or clusters of grains, as determined by a quasi in situ scanning electron microscopy and automated electron backscatter diffraction measurement. With increased cycling, the extent of damage became more severe and widespread. We document some examples of the types of damage that mechanically confined interconnects exhibited when subjected to thousands of thermal cycles, including growth and re-orientation of grains in a systematic manner. We observed in the case of Al-1Si certain grains increasing by nearly an order of magnitude in size, and reorienting by greater than 30°. The suitability of electrical methods for accelerated testing of mechanical reliability is also discussed.
The AC fatigue test technique, which uses cyclic joule heating to apply thermal cycles to thin-film structures, was applied to copper lines and vias in damascene dielectric structures on silicon substrates. Specimen chips with two different types of dielectric, oxide and low-k, were tested. The lines were 300 nm wide; various via widths were tested. At 100 Hz, cyclic temperature ranges from 400 to 900 °C produced line lifetimes between 10 and 1 million seconds. Similar lifetimes were reached in the vias for temperature ranges between 100 and 500 °C. The data were plotted as number of load reversals to failure against cyclic temperature range; the data trends for the two different types of dielectric were indistinguishable. When the line data were fit to the Basquin equation for mechanical fatigue, the temperature ranges for both dielectrics at the one1-reversal intercept were above 1000 °C. The via data were more scattered, but trended toward a lower intercept temperature.