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Hazardous material (HAZMAT) protocols require health care providers to wear personal protective equipment (PPE) when caring for contaminated patients. Multiple levels of PPE exist (level D - level A), providing progressively more protection. Emergent endotracheal intubation (ETI) of victims can become complicated by the cumbersome nature of PPE.
The null hypothesis was tested that there would be no difference in time to successful ETI between providers in different types of PPE.
This randomized controlled trial assessed time to ETI with differing levels of PPE. Participants included 18 senior US Emergency Medicine (EM) residents and attendings, and nine US senior Anesthesiology residents. Each individual performed ETI on a mannequin (Laerdal SimMan Essential; Stavanger, Sweden) wearing the following levels of PPE: universal precautions (UP) controls (nitrile gloves and facemask with shield); partial level C (PC; rubber gloves and a passive air-purifying respirator [APR]); and complete level C (CC; passive APR with an anti-chemical suit). Primary outcome measures were the time in seconds (s) to successful intubation: Time 1 (T1) = inflation of the endotracheal tube (ETT) balloon; Time 2 (T2) = first ventilation. Data were reported as medians with Interquartile Ranges (IQR, 25%-75%) or percentages with 95% Confidence Intervals (95%, CI). Group comparisons were analyzed by Fisher’s Exact Test or Kruskal-Wallis, as appropriate (alpha = 0.017 [three groups], two-tails). Sample size analysis was based upon the power of 80% to detect a difference of 10 seconds between groups at a P = .017; 27 subjects per group would be needed.
All 27 participants completed the study. At T1, there was no statistically significant difference (P = .27) among UP 18.0s (11.5s-19.0s), PC 21.0s (14.0s-23.5s), or CC 17.0s (13.5s-27.5s). For T2, there was also no significant (P = .25) differences among UP 24.0s (17.5s-27.0s), PC 26.0s (21.0s-32.0s), or CC 24.0s (19.5s-33.5s).
There were no statistically significant differences in time to balloon inflation or ventilation. Higher levels of PPE do not appear to increase time to ETI.
Patients with respiratory failure are usually mechanically ventilated, mostly with fraction of inspired oxygen (FiO2) > 0.21. Minimizing FiO2 is increasingly an accepted standard. In underserved nations and disasters, salvageable patients requiring mechanical ventilation may outstrip oxygen supplies.
The hypothesis of the present study was that mechanical ventilation with FiO2 = 0.21 is feasible. This assumption was tested in an Acute Respiratory Distress Syndrome (ARDS) model in pigs.
Seventeen pigs were anesthetized, intubated, and mechanically ventilated with FiO2 = 0.4 and Positive End Expiratory Pressure (PEEP) of 5cmH2O. Acute Respiratory Distress Syndrome was induced by intravenous (IV) oleic acid (OA) infusion, and FiO2 was reduced to 0.21 after 45 minutes of stable moderate ARDS. If peripheral capillary oxygen saturation (SpO2) decreased below 80%, PEEP was increased gradually until maximum 20cmH2O, then inspiratory time elevated from one second to 1.4 seconds.
Animals developed moderate ARDS (mean partial pressure of oxygen [PaO2]/FiO2 = 162.8, peak and mean inspiratory pressures doubled, and lung compliance decreased). The SpO2 decreased to <80% rapidly after FiO2 was decreased to 0.21. In 14/17 animals, increasing PEEP sufficed to maintain SpO2 > 80%. Only in 3/17 animals, elevation of FiO2 to 0.25 after PEEP reached 20cmH2O was needed to maintain SpO2 > 80%. Animals remained hemodynamically stable until euthanasia one hour later.
In a pig model of moderate ARDS, mechanical ventilation with room air was feasible in 14/17 animals by elevating PEEP. These results in animal model support the potential feasibility of lowering FiO2 to 0.21 in some ARDS patients. The present study was conceived to address the ethical and practical paradigm of mechanical ventilation in disasters and underserved areas, which assumes that oxygen is mandatory in respiratory failure and is therefore a rate-limiting factor in care capacity allocation. Further studies are needed before paradigm changes are considered.
Manual ventilation with a bag-valve device (BVD) is a Basic Life Support skill. Prolonged manual ventilation may be required in resource-poor locations and in severe disasters such as hurricanes, pandemics, and chemical events. In such circumstances, trained operators may not be available and lay persons may need to be quickly trained to do the job.
The current study investigated whether minimally trained operators were able to manually ventilate a simulated endotracheally intubated patient for six hours.
Two groups of 10 volunteers, previously unfamiliar with manual ventilation, received brief, structured BVD-tube ventilation training and performed six hours of manual ventilation on an electronic lung simulator. Operator cardiorespiratory variables and perceived effort, as well as the quality of the delivered ventilation, were recorded. Group One ventilated a “normal lung” (compliance 50cmH2O/L, resistance 5cmH2O/L/min). Group Two ventilated a “moderately injured lung” (compliance 20cmH2O/L, resistance 20cmH2O/L/min).
Volunteers’ blood pressure, heart rate (HR), respiratory rate (RR), and peripheral capillary oxygen saturation (SpO2) were stable throughout the study. Perceived effort was minimal. The two groups provided clinically adequate and similar RRs (13.3 [SD = 3.0] and 14.1 [SD = 2.5] breaths/minute, respectively) and minute volume (MV; 7.6 [SD = 2.1] and 7.7 [SD = 1.4] L/minute, respectively).
The results indicate that minimally trained persons can effectively perform six hours of manual BVD-tube ventilation of normal and moderately injured lungs, without undue effort. Quality of delivered ventilation was clinically adequate.
On April 15, 2013, two improvised explosive devices (IEDs) exploded at the Boston Marathon and 264 patients were treated at 26 hospitals in the aftermath. Despite the extent of injuries sustained by victims, there was no subsequent mortality for those treated in hospitals. Leadership decisions and actions in major trauma centers were a critical factor in this response.
The objective of this investigation was to describe and characterize organizational dynamics and leadership themes immediately after the bombings by utilizing a novel structured sequential qualitative approach consisting of a focus group followed by subsequent detailed interviews and combined expert analysis.
Across physician leaders representing 7 hospitals, several leadership and management themes emerged from our analysis: communications and volunteer surges, flexibility, the challenge of technology, and command versus collaboration.
Disasters provide a distinctive context in which to study the robustness and resilience of response systems. Therefore, in the aftermath of a large-scale crisis, every effort should be invested in forming a coalition and collecting critical lessons so they can be shared and incorporated into best practices and preparations. Novel communication strategies, flexible leadership structures, and improved information systems will be necessary to reduce morbidity and mortality during future events. (Disaster Med Public Health Preparedness. 2015;9:489–495)
The Emergency Department (ED) is the triage, stabilization and disposition unit of the hospital during a mass-casualty incident (MCI). With most EDs already functioning at or over capacity, efficient management of an MCI requires optimization of all ED components. While the operational aspects of MCI management have been well described, the architectural/structural principles have not. Further, there are limited reports of the testing of ED design components in actual MCI events. The objective of this study is to outline the important infrastructural design components for optimization of ED response to an MCI, as developed, implemented, and repeatedly tested in one urban medical center.
In the authors’ experience, the most important aspects of ED design for MCI have included external infrastructure and promoting rapid lockdown of the facility for security purposes; an ambulance bay permitting efficient vehicle flow and casualty discharge; strategic placement of the triage location; patient tracking techniques; planning adequate surge capacity for both patients and staff; sufficient command, control, communications, computers, and information; well-positioned and functional decontamination facilities; adequate, well-located and easily distributed medical supplies; and appropriately built and functioning essential services.
Designing the ED to cope well with a large casualty surge during a disaster is not easy, and it may not be feasible for all EDs to implement all the necessary components. However, many of the components of an appropriate infrastructural design add minimal cost to the normal expenditures of building an ED.
This study highlights the role of design and infrastructure in MCI preparedness in order to assist planners in improving their ED capabilities. Structural optimization calls for a paradigm shift in the concept of structural and operational ED design, but may be necessary in order to maximize surge capacity, department resilience, and patient and staff safety.
Halpern P, Goldberg SA, Keng JG, Koenig KL. Principles of Emergency Department facility design for optimal management of mass-casualty incidents. Prehosp Disaster Med. 2012;27(2):1-9.
The number of paramedics in Israel is increasing. Despite this growth and important role, the emergency medical organizations lack information about the characteristics of their work.
The objective of this study was to examine the characteristics of the paramedics' work, the quality of their working lives, the factors that keep them in the profession, or conversely, draw them away from it.
Cross-sectional study conducted through telephone interviews of a random sample of 50% of the graduates of paramedic courses in Israel (excluding conscripted soldiers).
The factors that attract paramedics to the profession have much to do with the essence of the job—rescuing and saving—and a love of what it involves, as well as interest and variety. Pressures at work result from having to cope with a lack of administrative support, paperwork, long hours, imbalance between work and family life, and salary. They do not come from having to cope with responsibility, the pressure of working under uncertain conditions, and the sudden transition from calm situations to emergencies. Dissatisfaction at work is caused by burnout, work overload, and poor health. Physical and mental health that impedes their ability to work is related to a sense of burnout and the intention to change professions.
The findings about the relationships between health, job satisfaction, and burnout, coupled with the fact that within a decade, half of the currently employed paramedics will reach an age at which it is hard for them to perform their job, lead to the conclusion that there is a need to reconsider the optimum length of service in the profession. There also is a need to form organizational arrangements to change the work procedures of aging paramedics.
We sought to document the adequacy of acute pain management in a high-volume urban emergency department and the impact of a structured intervention.
We conducted a prospective, single-blind, pre- and postintervention study on patients who suffered minor-to-moderate trauma. The intervention consisted of structured training sessions on emergency department (ED) analgesia practice and the implementation of a voluntary analgesic protocol.
Preintervention data showed that only 340 of 1000 patients (34%) received analgesia. Postintervention data showed that 693 of 700 patients (99%) received analgesia, an absolute increase of 65% (95% CI 61%–68%), and that delay to analgesia administration fell from 69 (standard deviation [SD] 54) minutes to 35 (SD 43) minutes. Analgesics led to similar reductions in visual analog pain scale ratings during the pre- and postintervention phases (4.5 cm, SD 2.0 cm, and 4.3 cm, SD 3.0 cm, respectively).
Our multifaceted ED pain management intervention was highly effective in improving quality of analgesia, timeliness of care and patient satisfaction. This protocol or similar ones have the potential to substantially improve pain management in diverse ED settings.
The events of 11 September 2001 became the catalyst for many to shift their disaster preparedness efforts towards mass-casualty incidents. Emergency responders, healthcare workers, emergency managers, and public health officials worldwide are being tasked to improve their readiness by acquiring equipment, providing training and implementing policy, especially in the area of mass-casualty decontamination. Accomplishing each of these tasks requires good information, which is lacking. Management of the incident scene and the approach to victim care varies throughout the world and is based more on dogma than scientific data. In order to plan effectively for and to manage a chemical, mass-casualty event, we must critically assess the criteria upon which we base our response.
This paper reviews current standards surrounding the response to a release of hazardous materials that results in massive numbers of exposed human survivors. In addition, a significant effort is made to prepare an international perspective on this response.
Preparations for the 24-hour threat of exposure of a community to hazardous material are a community responsibility for first-responders and the hospital. Preparations for a mass-casualty event related to a terrorist attack are a governmental responsibility. Reshaping response protocols and decontamination needs on the differences between vapor and liquid chemical threats can enable local responders to effectively manage a chemical attack resulting in mass casualties. Ensuring that hospitals have adequate resources and training to mount an effective decontamination response in a rapid manner is essential.
This article reviews the implications of mass-casualty, terrorist bombings for emergency department (ED) and hospital emergency responses. Several practical issues are considered, including the performance of a preliminary needs assessment, the mobilization of human and material resources, the use of personal protective equipment, the organization and performance of triage, the management of explosion-specific injuries, the organization of patient flow through the ED, and the efficient determination of patient disposition. As long as terrorists use explosions to achieve their goals, mass-casualty, terrorist bombings remain a required focus for hospital emergency planning and preparedness.
This article characterizes the epidemiological outcomes, resource utilization, and time course of emergency needs in mass-casualty, terrorist bombings producing 30 or more casualties.
Eligible bombings were identified using a MEDLINE search of articles published between 1996 and October 2002 and a manual search of published references. Mortality, injury frequency, injury severity, emergency department (ED) utilization, hospital admission, and time interval data were abstracted and relevant rates were determined for each bombing. Median values for the rates and the inter-quartile ranges (IQR) were determined for bombing subgroups associated with: (1) vehicle delivery; (2) terrorist suicide; (3) confined-space setting; (4) open-air setting; (5) structural collapse sequela; and (6) structural fire sequela.
Inclusion criteria were met by 44 mass-casualty, terrorist bombings reported in 61 articles. Median values for the immediate mortality rates and IQRs were: vehicle-delivery, 4% (1–25%); terrorist-suicide, 19% (7–44%); confined-space 4% (1–11%); open-air, 1% (0–5%); structural-collapse, 18% (5–26%); structural fire 17% (1–17%); and overall, 3% (1–14%). A biphasic pattern of mortality and unique patterns of injury frequency were noted in all subgroups. Median values for the hospital admission rates and IQRs were: vehicle-delivery, 19% (14–50%); terrorist-suicide, 58% (38–77%); confined-space, 52% (36–71%); open-air, 13% (11–27%); structural-collapse, 41% (23–74%); structural-fire, 34% (25–44%); and overall, 34% (14–53%). The shortest reported time interval from detonation to the arrival of the first patient at an ED was five minutes. The shortest reported time interval from detonation to the arrival of the last patient at an ED was 15 minutes. The longest reported time interval from detonation to extrication of a live victim from a structural collapse was 36 hours.
Epidemiological outcomes and resource utilization in mass-casualty, terrorist bombings vary with the characteristics of the event.