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Disaster medical team response by governmental and non-governmental responders is highly variable and poorly characterized. Each response is unique in terms of caseload, patient demographics, and medical needs encountered. This variability increases the difficulty of determining team member composition as well as supply and equipment needs. In an effort to demonstrate this issue, we have reviewed the National Disaster Medical Response to Hurricane Sandy.
This project was a retrospective chart review of Hurricane Sandy data abstracted from the National Disaster Medical System (NDMS) Health Information Repository (HIR) medical records from the NDMS system response, and were abstracted for data including vital signs, ages, sex, chief complaint, and final impressions. In addition, length of stay among other parameters was abstracted. The data was analyzed using Microsoft Excel and Access with descriptive statistics. In addition, the results were compared to similar indices in a community emergency department and prior NDMS responses.
The results indicate a wide range of patient ages, chief complaints, and final impressions. The vast majority of patients seen by Disaster Medical Assistance Teams (DMAT) were stable with relatively low acuity issues. The total number of charts reviewed were 7,905. Respiratory complaints were the most frequent at 845 patients followed by toxicology/injuries at 706 patients and mental health issues at 452 patients. In approximately 3,400 patients, no diagnosis was present in the chart. Length of stay averaged below 1 hour and peak patient ages were between 50-60 with a significant number of infants less than 2 years.
Characterization of NDMS responses by DMATs and comparison with prior events and community emergency department caseloads can provide an insight into the needs of DMATs and other response organizations in future responses.
In a 2015 report, the Institute of Medicine (IOM; Washington, DC USA), now the National Academy of Medicine (NAM; Washington, DC USA), stated that the field of Emergency Medical Services (EMS) exhibits signs of fragmentation; an absence of system-wide coordination and planning; and a lack of federal, state, and local accountability. The NAM recommended clarifying what roles the federal government, state governments, and local communities play in the oversight and evaluation of EMS system performance, and how they may better work together to improve care.
This systematic literature review and environmental scan addresses NAM’s recommendations by answering two research questions: (1) what aspects of EMS systems are most measured in the peer-reviewed and grey literatures, and (2) what do these measures and studies suggest for high-quality EMS oversight?
To answer these questions, a systematic literature review was conducted in the PubMed (National Center for Biotechnology Information, National Institutes of Health; Bethesda, Maryland USA), Web of Science (Thomson Reuters; New York, New York USA), SCOPUS (Elsevier; Amsterdam, Netherlands), and EMBASE (Elsevier; Amsterdam, Netherlands) databases for peer-reviewed literature and for grey literature; targeted web searches of 10 EMS-related government agencies and professional organizations were performed. Inclusion criteria required peer-reviewed literature to be published between 1966-2016 and grey literature to be published between 1996-2016. A total of 1,476 peer-reviewed titles were reviewed, 76 were retrieved for full-text review, and 58 were retained and coded in the qualitative software Dedoose (Manhattan Beach, California USA) using a codebook of themes. Categorizations of measure type and level of application were assigned to the extracted data. Targeted websites were systematically reviewed and 115 relevant grey literature documents were retrieved.
A total of 58 peer-reviewed articles met inclusion criteria; 46 included process, 36 outcomes, and 18 structural measures. Most studies applied quality measures at the personnel level (40), followed by the agency (28) and system of care (28), and few at the oversight level (5). Numerous grey literature articles provided principles for high-quality EMS oversight.
Limited quality measurement at the oversight level is an important gap in the peer-reviewed literature. The grey literature is ahead in this realm and can guide the policy and research agenda for EMS oversight quality measurement.
TaymourRK, AbirM, ChamberlinM, DunneRB, LowellM, WahlK, ScottJ. Policy, Practice, and Research Agenda for Emergency Medical Services Oversight: A Systematic Review and Environmental Scan. Prehosp Disaster Med. 2018;33(1):89–97.
Bioprospecting is the search for valuable products from natural sources. Given that most species are poorly known, a key question is where to search. Ethnodirected bioprospecting approaches use traditional knowledge in the process of selecting plants to screen for desired properties. A complementary approach is to utilize phylogenetic analyses based on traditional uses or known chemistry to identify lineages in which desired properties are most likely to be found. Novel discoveries of plant bioactivity from these approaches can aid the development of treatments for diseases with unmet medical needs. For example, neurological disorders are a growing concern, and psychoactive plants used in traditional medicine may provide botanical sources for bioactivity relevant for treating diseases related to the brain and nervous system. However, no systematic study has explored the diversity and phylogenetic distribution of psychoactive plants. We compiled a database of 501 psychoactive plant species and their properties from published sources. We mapped these plant attributes on a phylogenetic tree of all land plant genera and showed that psychoactive properties are not randomly distributed on the phylogeny of land plants; instead certain plant lineages show overabundance of psychoactive properties. Furthermore, employing a ‘hot nodes’ approach to identify these lineages, we can narrow down our search for novel psychoactive plants to 8.5% of all plant genera for psychoactivity in general and 1–4% for specific categories of psychoactivity investigated. Our results showcase the potential of using a phylogenetic approach to bioprospect plants for psychoactivity and can serve as foundation for future investigations.
To compare the state of chemical hazard preparedness in emergency departments (EDs) in Michigan, USA between 2005 and 2012.
This was a longitudinal study involving a 30 question survey sent to ED directors at each hospital listed in the Michigan College of Emergency Physician (MCEP) Directory in 2005 and in 2012. The surveys contained questions relating to chemical, biological, radiological, nuclear, and explosive events with a focus on hazardous material capabilities.
One hundred twelve of 139 EDs responded to the 2005 survey compared to 99/136 in 2012. Ten of 27 responses were statistically significant, all favoring an enhancement in disaster preparedness in 2012 when compared to 2005. Questions with improvement included: EDs with employees participating in the Michigan voluntary registry; EDs with decontamination rooms; MARK 1 and cyanide kits available; those planning to use dry decontamination, powered air purifiers, surgical masks, chemical gloves, and surgical gowns; and those wishing for better coordination with local and regional resources. Forty-two percent of EDs in 2012 had greater than one-half of their staff trained in decontamination and 81% of respondents wished for more training opportunities in disaster preparedness. Eighty-four percent of respondents believed that they were more prepared in disaster preparedness in 2012 versus seven years prior.
Emergency departments in Michigan have made significant advances in chemical hazard preparedness between 2005 and 2012 based on survey responses. Despite these improvements, staff training in decontamination and hazardous material events remains a weakness among EDs in the state of Michigan.
BelskyJB, KlausnerHA, KarsonJ, DunneRB. Survey of Emergency Department Chemical Hazard Preparedness in Michigan, USA: A Seven Year Comparison. Prehosp Disaster Med. 2016;31(2):224–227.
The microsporidian parasite Thelohania contejeani causes porcelain disease and has been implicated in mass mortalities in populations of the endangered European crayfish Austropotamobius pallipes. However, the route of parasite transmission is not known. This paper investigates the horizontal transmission of T. contejeani between A. pallipes hosts as well as its transmissibility to the invasive signal crayfish (Pacifastacus leniusculus). Field collected juvenile A. pallipes and P. leniusculus were assigned to 1 of 3 experimental treatments; fed heavily infected A. pallipes tissue, exposed to water from tanks housing heavily parasitized A. pallipes, and a control group to provide an estimate of the baseline infection levels in the field. After 26 weeks, abdominal muscle samples were screened by PCR for T. contejeani. Infection was significantly higher in the treatment groups (83% in the cannibalism treatment, 42% in the water exposure treatment) than in the control group (4%), providing evidence for horizontal transmission of the parasite between A. pallipes hosts. Cannibalism and scavenging are common amongst crayfish, providing transmission opportunities in the field. The study also provides the first direct evidence for transmission of the parasite from an indigenous European crayfish species to the invasive signal crayfish, with 50% of P. leniusculus in each treatment, and 8% of control animals infected. We discuss the possibility that high density populations of the invasive signal crayfish may serve either as reservoirs or sinks for the parasite.
The effect of soil properties and weather on herbicide persistence and injury to following crops were studied at a site near Lethbridge, Alberta, Canada, with undulating topography that included no-tillage and conventional tillage systems on adjacent fields. Soil pH ranged from 5.2 (lower slope no-tillage) to 7.8 (upper slope conventional tillage) and soil organic matter content ranged from 2.3% (upper slope conventional tillage) to 4.4% (lower slope no-tillage). During the years when the experiments were conducted rainfall ranged from < 50% of normal to > 150% of normal. During dry years atrazine and metsulfuron severely injured wheat and lentil crops, seeded 1 yr after herbicide application, on upper slope locations. The most severe injury occurred on the upper slope conventional tillage location. In years with high rainfall, no crop injury occurred 1 yr after atrazine and metsulfuron application on either upper or lower slope locations in both tillage systems. Imazamox plus imazethapyr caused almost 100% injury in the lower slope position in the no-tillage system (pH 5.2) in the driest year. Following-crop injury due to the imidazolinone herbicides decreased with increasing rainfall and increasing soil pH. The most severe injury to following crops seemed to occur when herbicide dissipation was dependent on microbial activity and rainfall was below normal.
Most accretion-powered relativistic jet sources in our Galaxy are transient X-ray binaries (XBs). Efforts to coordinate multiwavelength observations of these objects have improved dramatically over the last decade. Now the challenge is to interpret broadband spectral energy distributions (SEDs) of XBs that are well sampled in both wavelength and time. Here we focus on the evolution of the jet in their broadband spectra. Some of the most densely sampled broadband SEDs of a neutron star transient (IGR J00291+5934) are used to constrain the optically thick–thin break in the jet spectrum. For the black hole transient XTE J1550-564, infrared – X-ray correlations, evolution of broadband spectra and timing signatures indicate that synchrotron emission from the jet likely dominates the X-ray power law at low luminosities (~(2 × 10−4 − 2 × 10−3) LEdd) during the hard state outburst decline.
Three models were used to look at the Southern Ocean Ross Sea sector circulation and hydrography. Two were climate models of low (1°) to intermediate resolution (1/3°), and one was an operational high resolution (1/10°) ocean model. Despite model differences (including physics and forcing), mean and monthly variability aspects of off-shelf circulation are consistently represented, and could imply bathymetric constraints. Western and eastern cyclonic gyral systems separated by shallow bathymetry around 180°E redistributing water between the wider Southern Ocean and the Ross Sea are found. Some model seasonal gyral transports increase as the Antarctic Circumpolar Current transport decreases. Model flows at 900 m at the gyral eastern end compare favourably with float data. On-shelf model depth-averaged west–east flow is relatively consistent with that reconstructed from longline fishing records. These flows have components associated with isopycnal gradients in both light and dense waters. The climate models reproduce characteristic isopycnal layer inflections (‘V’s) associated with the observed Antarctic Slope Front and on-shelf deep water formation, and these models transport some 4 Sv of this bottom water northwards across the outer 1000 m shelf isobath. Overall flow complexity suggests care is needed to force regional Ross Sea models.
There is a great deal of potential third party liability created by activities in cyberspace. Partially this is due to the difficulty in holding persons responsible for their actions on the Internet, either because of international jurisdiction issues, or simply because of an inability to find them due to their anonymity or sheer numbers. As a result, third parties such as service providers and systems operators are often targeted instead. Employers, as well, are often targets of liability for actions of their employees.
Cases involving third party liability have been brought in a number of legal areas, including defamation, copyright infringement, trademark infringement, and unfair competition. Defamation and copyright, however, have been the primary source of third party liability claims in cyberspace.
Third Party Liability for Defamation
Liability of third parties for defamation traditionally depends on whether the court sees the third party as a “publisher,” “distributor,” or “common carrier.” A publisher is presumed to exercise control over the contents of what is published, and is therefore usually liable for those contents. A distributor is presumed not to have control over the contents of what is distributed and is therefore only potentially liable for those contents if the nature of the contents, and any alleged legal problems created by them, is brought to the distributor's attention and the distributor does nothing in response to notification.
“Common Law” is frequently characterized as “judge-made law.” It is the law of precedent, created through a process of constant evolution as courts interpret and apply previous judicial decisions. While it is true that, as many people insist, judges do not make laws (lower case “l”) but legislatures do, judges do shape society's legal fabric – its Law (upper case “L”) – through this interpretive process.
“Statutory Law” is the law of “statutes” or what we commonly refer to simply as “laws,” created by legislative bodies such as Congress, state legislative counterparts of Congress, or other such bodies. Unlike Common Law, Statutory Law is a product of attempts to take a broad view and, usually, to make major adjustments to the Law. Common Law is built in a more piece-by-piece fashion, one brick at a time, by practitioners who are not concerned with the big picture, but rather with the case at hand.
The U.S. Federal Court system is essentially a three-tiered system, resembling a pyramid. At the lowest level are the District Courts, scattered all over the country. There are currently ninety-four federal District Courts. Each state has at least one, as do the District of Columbia and Puerto Rico. Three Territories of the United States also have Federal District Courts – Puerto Rico, Guam, and the Northern Mariana Islands. The District Courts are usually the starting point for litigation or prosecution if federal courts have jurisdiction over a case (which will be discussed in Chapter 15).
The most common response to the question “What is a contract?” is “an agreement,” but a contract is more than that. The generally accepted legal definition of a contract is that it is a promise, or set of promises, that the law sees as a duty, for the breach of which the law will provide a remedy in the form of an action for damages. Thus a contract is a legally enforceable agreement.
Some Contracts Terminology
Promisee – A person to whom a promise is made
Promisor – A person who makes a promise
Offeree – A person to whom an offer is made
Offeror – A person who makes an offer
Contract Formation: Elements of a Contract
In order to make an agreement legally enforceable, three elements must be present – offer, acceptance, and consideration.
What is an offer? An offer is simply a manifestation of an intention to form a contract. The legal test of whether something is an offer is whether a reasonable person in the position of the offeree believes that acceptance creates a contract.
SIDEBAR: The reasonable person
The “reasonable person” is heavily relied upon by the law. No one can say with any specificity who this person is or what this person thinks, but the “reasonable person” might best be thought of as describing the “average” person, or perhaps the “normal” person. We will spend much more time examining this concept in the portion of this book that covers negligence.
A “trade secret” is information that is secret and has economic value by virtue of the fact that it is kept secret. Examples of the types of information that is commonly protected as trade secrets include customer lists, formulas for products, the contents of databases, and even software code itself.
One great advantage of using trade secrecy to protect intellectual property is that trade secrets can potentially last forever, unlike patents and copyrights. Patent protection now lasts for twenty years from the date the patent application is filed (although design patents expire fourteen years from the date the patent is issued); copyright protection, as we have seen in the previous chapter, now lasts for the life of the author plus seventy years or for a total of ninety-five years if the copyright is owned by a corporation.
Trade secrets do not require absolute secrecy. “Non-disclosure agreements” are used extensively to bar the recipients of trade secret information from disclosing the information. Non-disclosure agreements are simply another form of contract and, if properly executed, are binding on the individuals or entities agreeing to them.
Despite the fact that trade secrets do not require absolute secrecy, the owner of the trade secret must take reasonable steps to keep the secret in order to preserve the status of the information as a trade secret.