Showing papers in "Prehospital and Disaster Medicine in 1997"

Mass gathering medicine: a review.

Abstract: The provision for emergency medical care for spectators and participants at large events is a growing area of interest. This article describes the definition and characteristics of medical care at mass gatherings. The literature is reviewed with regard to the planning, organization, personnel, and staffing required at these events. The equipment and transportation assets needed are also discussed. Disaster and mass casualty planning implications also are described.

Mass gathering medical care: a twenty-five year review.

Abstract: INTRODUCTION: The purpose of this study was to critically review the provision of medical care at mass gatherings as described in 25 years of case reports. Specifically measured was the relationship between the size of a mass gathering and the frequency of patients seeking medical aid and the effects of certain event characteristics on this relationship. METHODS: Data were obtained through a retrospective literature review. Medline and CINHAL computerized databases were searched for English language articles using several keywords: "mass gathering", "concert", "festival", "Olympics", "crowd"; "riot", "stadium", "sports", "games", "papal", and "football". Only articles containing complete information on the number of spectators, number of patients, type, location, and duration of the mass gathering were included in the primary analysis. As available, additional information was added including the described weather patterns, number of patients transported to a hospital, and number of patients suffering a cardiac arrest. Thirty-five of the approximately 100 articles reviewed, met these criteria. RESULTS: A Spearman Rank Correlation Coefficient was calculated for number of spectators and patients and a significant relationship was identified (p = 0.0001). Mann-Whitney U-tests indicated that papal masses (p = 0.04), rock concerts (p = 0.005), hot climatic conditions (p = 0.03), and events held in the British Commonwealth (p = 0.03) had a significantly higher frequency of patient visits. Significantly more cardiac arrests occurred at papal masses (p = 0.04) and sporting events (p = 0.0002). CONCLUSIONS: Type of event, country, weather, and the size of the mass gathering had a significant effect on the numbers of spectators seeking medical care. A uniform classification scheme is necessary for future prospective studies of mass gatherings. Language: en

The wake-effect--emergency vehicle-related collisions.

Abstract: INTRODUCTION: Emergency medical vehicle collisions (EMVCs) occurring during initial response and with patient transport have been a long-standing problem for emergency medical services (EMS) systems. Experience suggests "wake-effect" collisions occur as a result of an EMS vehicle's transit, but do not involve the emergency medical vehicle (EMV). Substantiating the existence and magnitude of wake-effect collisions may have major implications regarding the manner of EMV response. HYPOTHESIS: Paramedics will report that wake-effect collisions do occur and that they occur more frequently than do EMVCs. METHODS: Design: Survey analysis. Participants: Thirty paramedics employed by the Salt Lake City (Utah) Fire Department and 45 paramedics employed by Salt Lake County Fire Department. Geographic Area: Service area has population of 650,000 and is urban, suburban, and rural. Measurements: The survey consisted of three open-ended questions concerning years on the job, EMVCs, and wake-effect collisions. Analysis: The mean value for the number of EMVCs and wake-effect EMVCs, along with the 0.95 confidence intervals (0.95 CI) were determined. RESULTS: Seventy-three surveys were analyzed. Sixty EMVCs and 255 wake-effect collisions were reported. Overall, the mean value for the number EMVCs per respondent was 0.82 (0.60-1.05) and for wake-effect collisions 3.49 (2.42-4.55). The mean values for EMVC's for each service were 0.86 (0.50-1.38); 0.80 (0.50-11.0). For wake-effect collisions the mean values were 4.59 (2.83-6.35); and 2.76 (1.46-4.06) respectively. CONCLUSIONS: This study suggests that the wake-effect collision is real and may occur with greater frequency than do EMVCs. Significant limitations of this study are recall bias and misclassification bias. Future studies are needed to define more precisely wake-effect collision prevalence and the resulting "cost" in regards to injury and vehicle/property damage. Language: en

The EMS response to the Oklahoma City bombing.

Abstract: This is a descriptive study of the Emergency Medical Services response to a bombing of a United States Federal Building in Oklahoma City, Oklahoma on 19 April 1995. The explosion emanated from a rented truck parked in the front of the building. The force of the explosion destroyed three of the four support columns in the front of the building and resulted in a pancaking effect of the upper floors onto the lower floors. There were three distinct phases of the medical response: 1) Immediately available local EMS ambulances and staff; 2) Additional ambulances staffed by recalled, off-duty personnel; and 3) mutual-aid ambulances and personnel from the surrounding communities. There were 361 persons in the building at the time of the explosion, 163 of these perished. Within the first hour of the explosion, 139 patients were transported to area hospitals. Of these, 32% were in critical condition. During the day of the explosion, 444 persons were treated for physical injuries: 410 of these were related to the explosion and 14, including one with fatal injuries, were sustained during search and rescue attempts. A total of 354 (80%) were treated and released from emergency departments, and 90 (20%) were admitted to hospitals. Six of the transported victims either were dead on arrival to the emergency department or died after admission to the hospital. Of those who died, 95% of the deaths were related to blunt trauma associated with the collapse of the structure. Only three persons were extricated alive after the first five hours following the explosion. The scene became flooded with volunteers who, although their intentions were to provide help and aid to those injured, created a substantial logistical problem for Incident Command. Several other lessons were learned: 1) Telephone lines and cells became overloaded, but the Hospital Emergency Administrative Radio system was operational only in three of the 15 hospitals; 2) Volunteer personnel should have responded to the hospitals and not to the scene; and 3) Training was an essential for the success of such a response. Thus, the success of this operation was a function of the intense training, practice, and coordination between multiple agencies.

Stress, job satisfaction, coping, and psychological distress among emergency medical technicians.

Abstract: Introduction:Although several studies link job-related stressors with adverse reactions among emergency medical technicians (EMTs), more standardized research is needed, since much remains unknown about stress responses, coping styles and their consequences for EMTs. This paper presents the results of two studies. Study I investigated the relation between job-related stressors, job satisfaction, and psychological distress, while Study II investigated how coping is related to occupational burnout, job-related stress, and physiological arousal.Hypothesis:Study I: Those EMTs experiencing greater job-related stressors are less satisfied with their jobs and more psychologically distressed.Objective, Study II:To obtain preliminary information about which coping strategies are associated with greater feelings of stress and burnout and more intense autonomic nervous system reactivity.Methods:For both studies, EMTs from a large, urban, public EMS organization in the southern United States were asked to participate. Study I: Subjects completed an informed consent document, a demographics questionnaire, a measure of job stress (the Stress Diagnosis Inventory), a measure of job satisfaction (Job-in-General), and a measure of psychological symptomatology (Symptom Checklist-90, Revised). Pearson product-moment correlations were computed between the measures. Study II: Subjects completed an informed consent document, a demographics/information sheet, the Maslach Burnout Inventory (MBI), and the Ways of Coping Scale (WOCS). They then completed 30 days of monitoring using the Daily Stress Inventory (DSI) and the Daily Autonomic Nervous System Response Inventory (DANSRI). Pearson product-moment correlations were computed between the measures.Results:Study I: Those EMTs who experienced greater job-related stress also were significantly more dissatisfied with their jobs, more depressed, anxious, hostile, and endorsed greater global psychological distress. Study IT. The Depersonalization subscale on the MBI correlated significantly with the following WOCS subscales: Accepting Responsibility, Confrontive Coping, Distancing, and Escape/Avoidance. Emotional Exhaustion on the MBI correlated significantly with Confrontive Coping, Escape/Avoidance, and Social Support, while data obtained on the 40 subjects who completed the daily monitoring revealed that DSI-Impact, DANSRI-Number, and DANSRI-Impact scores each correlated significantly with Accepting Responsibility, Confrontive Coping, and Escape/Avoidance.Conclusion:A significant portion of an EMT's job satisfaction and psychological well-being is associated with the degree to which they are experiencing job-related stress, and, furthermore, this distress level appears to be clinically elevated. This implies that in-service programs and psychological support services designed to help EMTs manage their job-related stress may improve job satisfaction and decrease psychological distress. The coping styles most consistently associated with maladaptive outcomes were: Accepting Responsibility, Confrontive Coping, and Escape/Avoidance. Thus, subjects who were more likely to handle stress with self-blame, aggression, hostility, and risk taking or with wishful thinking, escape tendencies, and avoidance were more likely to endorse more negative outcomes.

Stress levels in EMS personnel: a national survey.

Abstract: Objective:The purpose of this study was to evaluate stress levels in emergency medical services personnel across the United States.Design:Confidential, 20-question survey tool, Medical Personnel Stress Survey-Abbreviated (MPSS-R). A total score of 50 indicates average stress levels. A score of 12.5 on the subset measurements of somatic distress, job dissatisfaction, organizational stress, and negative attitudes towards patients indicates average levels of stress. Data were analyzed using ANOVA and t-test.Interventions:None.Results:A total of 658 of 3,000 emergency medical technicians (EMTs) (22%) completed the survey. The mean value of 69.3±6.3 for the total stress scores was very high Mean values for the subset scores were: somatic distress = 19.6±3.3; organizational stress = 17.3±2.4; job dissatisfaction = 17.0±2.6; negative attitudes towards patients = 15.5±2.3. Characteristics predicting higher stress were EMT-basic (A) licensure, basic life support (BLS) only service provider, volunteer status, new employee working in a small EMS organization, and providing service to a small town.Conclusion:Stress levels in EMS personnel were very high, were manifested primarily as somatic distress, secondarily as organizational stress and job dissatisfaction, and lastly as negative patient attitudes. Stress levels and subset manifestations of occupational stress among EMS personnel varied depending on gender, marital status, age, level of training and function, on salaried or volunteer status, length of time as an EMT, and size of the organization, city, and population served. Care should be taken to address stresses peculiar to individual EMS system needs.

Epidemiologic assessment of mortality, building collapse pattern, and medical response after the 1992 earthquake in Turkey. Disaster Reanimatology Study Group (DRSG).

Abstract: BACKGROUND Post-earthquake engineering and epidemiologic assessments are important for the development of injury prevention strategies. This paper describes mortality and its relationship to building collapse patterns and initial medical responses following the 1992 earthquake in Erzincan, Turkey. METHODS The study consisted of: 1) background data collection and review; 2) design and implementation of a field survey; and 3) site inspection of building collapse patterns. The survey included: 1) national (n = 11) and local (n = 17) officials; 2) medical and search and rescue (SAR) workers (n = 38); and 3) a geographically stratified random sample of lay survivors (n = 105). The survey instruments were designed to gather information regarding location, injuries, initial actions and prior training of survivors and responders, and the location, injuries, and management of dead and dying victims. A case-control design was constructed to assess the relationship between mortality, location, and building collapse pattern. RESULTS There was extensive structural damage throughout the region, especially in the city where mid-rise, unreinforced masonry buildings (MUMBs) incorporating a "soft" first floor design (large store windows for commercial use) and one story adobe structures were most vulnerable to collapse. Of 526 people who died in the city, 87% (n = 456) were indoors at the time of the earthquake. Of these, 92% (n = 418) died in MUMBs. Of 54 witnessed deaths, 55% (n = 28) of victims died slowly, the majority of whom (n = 26) were pinned or trapped (p < 0.05). Of 42 MUMB occupants identified through the survey, those who died (n = 25) were more likely to have been occupying the ground floor when compared with survivors (n = 28) (p < 0.01). Official medical and search and rescue responders arrived after most deaths had occurred. Prior first-aid or rescue training of lay, uninjured survivors was associated with a higher likelihood of rescuing and resuscitating others (p < 0.001). CONCLUSIONS During an earthquake, MUMBs with soft ground floor construction are highly lethal, especially for occupants on the the ground floor, suggesting that this building type is inappropriate for areas of seismic risk. The vulnerability of MUMBs appears due to a lack of lateral force resistance as a result of the use of glass store front windows and the absence of shear walls. The prevalence of this building type in earthquake-prone regions needs to be investigated further. A large portion of victims dying in an earthquake die slowly at the scene of injury. Prior public first-aid and rescue training programs increase participation in rescue efforts in major earthquakes and may improve survival.

Review of disaster definitions.

Abstract: Researchers need accurate, explicit definitions of terms in order to discuss, search for or identify the consequences of any particular phenomenon. The term "disaster" is no exception. The many definitions used for definition of disaster are outlined in general and by the discipline using them in this paper. Although the definitions used still seem somewhat specific to the discipline, there is one common element accepted by all: a disaster is seen to occur at a well-defined and easily identified time. It is not feasible to formulate a universally acceptable definition of disaster that will satisfy all practitioners, but common and agreed upon definitions must be formulated in the various fields and areas concerned with disasters, and where there exist recognizable, common sets of objectives.

The efficacy of integrating "smart simulated casualties" in hospital disaster drills.

Abstract: Introduction: Full-scale disaster drills are complex, expensive, and may involve hundreds or thousands of people. However, even when carefully planned, they often fail to manifest the details of medical care given to the casualties during the drill. Objective: To assess the feasibility of integrating physicians among the simulated casualties of a hospital disaster drill. Methods: A total of 178 physicians graduating an Advanced Trauma Life Support (ATLS) course participated in eight hospital disaster drills during 1994 as “Smart Victims.” The participants were given cards with descriptions of their injury and detailed instructions on how to manipulate their medical condition according to the medical care provided in the hospital. They also were given coded questionnaires to fill out during the process of the drill. Conclusions were drawn from analysis of the questionnaires and from a roundtable discussion following each drill. Results: The “smart casualties” made comments on the following topics: 1) triage (over-triage in 9%, and under-triage in 4%); 2) treatment sites; 3) medical equipment usage (i.e., shortage of ventilators and splinting devices); 4) medical knowledge and care rendered by the hospital staff; 5) evacuation and escorting of the wounded; 6) management of patients with post-traumatic stress disorder; and 7) medical documentation. Their comments contributed valuable information on the quality of medical care and organization, and identified obstacles that otherwise would have been overlooked. The “smart casualties” were very cooperative and indicated that their participation in the drill contributed to their understanding of disaster situations in hospitals. Conclusion: Integrating physicians among the simulated casualties in a hospital disaster drill may contribute to achieving the objectives of hospital disaster drills and add to disaster management education of the simulated casualty physicians.

Epidemiologic Assessment of Mortality, Building Collapse Pattern, and Medical Response after the 1992 Earthquake in Turkey

Abstract: Background:Post-earthquake engineering and epidemiologic assessments are important for the development of injury prevention strategies. This paper describes mortality and its relationship to building collapse patterns and initial medical responses following the 1992 earthquake in Erzincan, Turkey.Methods:The study consisted of: 1) background data collection and review; 2) design and implementation of a field survey; and 3) site inspection of building collapse patterns. The survey included: 1) national (n = 11) and local (n = 17) officials; 2) medical and search and rescue (SAR) workers (n = 38); and 3) a geographically stratified random sample of lay survivors (n = 105). The survey instruments were designed to gather information regarding location, injuries, initial actions and prior training of survivors and responders, and the location, injuries, and management of dead and dying victims. A case-control design was constructed to assess the relationship between mortality, location, and building collapse pattern.Results:There was extensive structural damage throughout the region, especially in the city where mid-rise, unreinforced masonry buildings (MUMBs) incorporating a “soft” first floor design (large store windows for commercial use) and one story adobe structures were most vulnerable to collapse. Of 526 people who died in the city, 87% (n = 456) were indoors at the time of the earthquake. Of these, 92% (n = 418) died in MUMBs. Of 54 witnessed deaths, 55% (n = 28) of victims died slowly, the majority of whom (n = 26) were pinned or trapped (p <0.05). Of 42 MUMB occupants identified through the survey, those who died (n = 25) were more likely to have been occupying the ground floor when compared with survivors (n = 28) (p <0.01). Official medical and search and rescue responders arrived after most deaths had occurred. Prior first-aid or rescue training of lay, uninjured survivors was associated with a higher likelihood of rescuing and resuscitating others (p <0.001).Conclusion:During an earthquake, MUMBs with soft ground floor construction are highly lethal, especially for occupants on the ground floor, suggesting that this building type is inappropriate for areas of seismic risk. The vulnerability of MUMBs appears due to a lack of lateral force resistance as a result of the use of glass store fiont windows and the absence of shear walls. The prevalence of this building type in earthquake-prone regions needs to be investigated further. A large portion of victims dying in an earthquake die slowly at the scene of injury. Prior public first-aid and rescue training programs increase participation in rescue efforts in major earthquakes and may improve survival.

Comparison of a colorimetric end-tidal CO2 detector and an esophageal aspiration device for verifying endotracheal tube placement in the prehospital setting: a six-month experience.

Abstract: INTRODUCTION Hand held, colorimetric, end-tidal CO2 detector devices are being used to verify correct endotracheal tube (ETT) placement. The accuracy of these devices has been questioned in situations of cardiac arrest. The use of the esophageal detector device (EDD) is an easy alternative for detection of ETT placement, and may be more accurate in situations of cardiac arrest. HYPOTHESIS The use of the esophageal aspiration device in comparison with a colorimetric end-tidal CO2 detector is more accurate in detecting proper ETT placement and easier to use in the prehospital setting than is the colorimetric end-tidal CO2 detection device. METHODS This was prospective alternating weeks, 6-month study in a prehospital setting. Participants included all patients older than 18 years who were intubated by the Portsmouth, Virginia Emergency Medical Services (EMS) personnel from 01 July 1993 through 31 December 1993. The aspiration device used, also known as an esophageal detector device (EDD), was a 60 ml, luer-lock syringe attached to a 15 mm ETT adapter. Its efficacy was compared with an already accepted method of ETT position detection, the colorimetric end-tidal CO2 detector. Each device was used on alternating weeks, and correct ETT placement was determined by the receiving emergency department physician using standard techniques. Chi-square analysis and Fisher's Exact test were used to compare parameters, time of device use, and ease of use. Sensitivity and specificity were calculated, and provider preference was assessed using a survey instrument administered following completion of the study. RESULTS There were 49 patients who met the inclusion criteria, but six were excluded because of situational circumstances rendering use of the device a possible compromise of patient care. Twenty-five patients were in the EDD group, and 18 were in the end-tidal CO2 detector group. There was no statistically significant difference detected between groups for the gender ratio, underlying condition, CPR in progress, perceived difficulty of intubation, or percentage of nasotracheal intubation. The EDD was significantly easier to use (p < 0.005). There was no statistically significant difference in time required for use of end-tidal CO2 detector device versus the EDD. The sensitivity and specificity for correct tracheal placement using the EDD was 100%, and the sensitivity for correct tracheal placement using the end-tidal CO2 detector device was 78%. Use of the EDD was preferred over use of the end-tidal CO2 detector device by 75% of participating EMS providers. One case of nasotracheal intubation with an ETT placement above the cords raised the question of accuracy of this device in situations where direct visualization is not utilized. CONCLUSION The EDD was accurate in all cases of orotracheal intubation, and was easier to use than was end-tidal CO2 detector device. It was preferred by 75% of participating EMS providers. In cases in which the ETT may be above the vocal cords, caution must be used with interpreting the results obtained by use of the EDD.

The psychosocial aftermath of the Chernobyl disaster in an area of relatively low contamination.

Abstract: INTRODUCTION There has been relatively little attention paid to the mid- and long-term effects of large-scale disasters, particularly their effects on children and young people. At the present time, the impact of the Chernobyl catastrophe on the daily lives of the affected population may include one of strong psychological stress due to uncertainty about ultimate health outcomes. Persons in the Chernobyl region in specific areas of low contamination may be affected similarly. This investigation assesses radiation concerns and attitudes about health and government information, nine years after the disaster, in a group of adults and adolescents residing in a relatively uncontaminated village in the Chernobyl area. METHODS Questionnaires were administered to 94 adults and 50 adolescents. Items assessed beliefs about extent of radiation exposure, health concerns regarding oneself and family members, past and current preoccupation about the disaster, and trust in the accuracy of government information about health effects. RESULTS Considerable uncertainty was demonstrated in both adults and adolescents about the extent of their and their families exposure to radiation. Marked distrust of past and current government information about health effects was evident. A large proportion of subjects reported that they still thought frequently about the Chernobyl accident. They worried about health problems related to radiation exposure whenever they or their family members exhibited physical symptoms or complaints, and they urged family members to go to a medical clinic for evaluation to assess these symptoms. CONCLUSIONS The extent of long-term concerns about the personal and family health effects of the Chernobyl disaster in this population residing in a relatively uncontaminated village is striking: the psychological impact on adolescents is considerable. The stress generated is maintained by the realistic uncertainty about the ultimate health consequences to the overall population as a result of radiation exposure and distrust in government information about contamination levels in this particular village. The level of stress and its effects on physical and mental health may increase over time if there is a rise in morbidity in the area. The continuing health needs of the extremely large population affected by the Chernobyl disaster need to be addressed.

Patients who refuse transportation by ambulance: a case series.

Abstract: Introduction Patients refusing hospital transportation occurs in 5% to 25% of out-of-hospital calls. Little is known about these calls. This study was needed to determine the demographics, inherent risks, and timing of refused calls. Methods This was a prospective review of all run sheets of patients who refused transportation were collected for a two month period. Demographic data and medical information was collected. Each run was placed into one of three categories of need for transport and further evaluation: 1) minimal; 2) moderate; and 3) definite. The Greater Elgin Area Mobile Intensive Care Program (GEA-MICP) based at Sherman Hospital in Elgin, Illinois, was the setting. The GEA-MICP is an Emergency Medical Services (EMS) system comprised of 17 advanced life support (ALS) ambulance agencies servicing northeastern Illinois. Study subjects were all patients who refused transportation to a hospital by ALS ambulance during July 1993 and February 1994. Paramedics were required to complete a run sheet for all calls. Results Overall, 30% (683 of 2,270) of all runs resulted in refusal of transportation. Patients who most commonly refused transportation were asymptomatic, 11-40 years old and involved in a motor vehicle crash. They usually had no past medical history, normal vital signs, and a normal mental status. Patients generally signed for their own release after evaluation. The average time to arrival was 4.2 minutes and average time spent on scene by paramedics was 18.4 minutes. Of the patients, 72% were judged to have minimal need, 25% were felt to have a moderate need, and 3% were felt to definitely need transport to a hospital for further evaluation and/or treatment. Conclusion There are many cases when EMS are activated, but transportation is refused. Most refusals occur after paramedic evaluation. Providing paramedics with primary care training and protocols would standardize care given to patients and provide a mechanism for discharge instructions and follow-up for those who chose not to be transported to a hospital. Patients judged to require further treatment had unique characteristics. These data may be useful in identifying potentially sicker patients allowing a concentrated effort to transport this subset of patients to a hospital.

How to cope with a visit from the Pope.

Abstract: A mass gathering always presents a challenge to the medical providers of a city since preparations must be made to cover any potential disasters, big or small. With a prediction of several hundred thousand people coming to the New York City area to participate in the Papal Masses, the New York City-Emergency Medical Services readied its forces of physicians, paramedics, and emergency medical technicians from throughout the region. Extensive multi-agency planning involving a Total Quality Management process was integral to the success of covering the events. Language: en

Does number of beds reflect the surgical capability of hospitals in wartime and disaster? The use of a simulation technique at a national level.

Abstract: INTRODUCTION: The raw number of hospital trauma beds and occupancy has been used to assess the surgical capability of hospitals in wartime and disaster situations. The goal of this study was to examine and offer a better tool to determine the load of casualties that a hospital would be able to absorb and treat effectively during these situations. METHODS: Simulation software was applied to various wartime scenarios. It assessed the usefulness of a computerized simulation of operating room (OR) function under loading of "standard wartime casualties." Comparison of the functioning of similar hospitals was undertaken in order to identify possible methods to optimize the care delivered. A "what-if" module was used to define the optimal way to absorb mass casualties within the known resources of a given healthcare system. Each hospital was tested under different loading of "standard casualties." Average waiting time for surgery was used as a marker of the constant decay in the standards of care with the increasing patient load. RESULTS: Different, unique patterns of strategies for optimizing waiting periods were identified. Not all trauma centers responded by shortening waiting time by diverting the lightly injured patients from them either before or after triage. The reaction to alternate days' shift was unexpected. The temporal course of matching a patient with a functional operating room was more indicative of a hospital's capability to absorb casualties requiring surgery than was the pre-set number of beds available in the hospital. RECOMMENDATIONS: The use of simulation techniques might be useful method to assess the nationwide surgical capability. This is a complex dilemma that cannot be predicted with trivial guessing, even when combined with previous experience of triaging. Analyzing the weak points and bottlenecks at a national level might help in creating preparedness protocols. Language: en

Medical Outreach After Hurricane Marilyn

Abstract: INTRODUCTION Many geographical areas are subject to devastating disasters that leave the citizens not only without homes, but also without their local medical systems. Now medical-aid stations consisting of personnel, supplies, and equipment quickly can be deployed when needed to such areas under the aegis of the National Disaster Medical System (NDMS). Such teams can provide emergent medical care as well as daily medical care. However, these aid stations are of no help for the home-bound or nursing home patients too infirm to reach them. Thus, these citizens only can obtain medical care if medical teams make planned outreach excursions to reach them. OBJECTIVE To describe a planned outreach program that was implemented for such patients on St. Thomas Island after it was devastated by Hurricane Marilyn in 1995. RESULTS Over a five-day period, the outreach team provided medical care for 67 patients ranging in age from 11 days to 90 years. Play and art therapy was provided for non-injured children. The most common needs in the elderly were anti-hypertensive medications and insulin-loaded syringes. CONCLUSIONS For outreach efforts of this nature, membership of the team should include a registered nurse, a paramedic, a respiratory therapist, a public health specialist, and a local authority familiar both with the area and its inhabitants. A physician does not need to be assigned to the team, but should be available by radio.

A model for a statewide critical incident stress (CIS) debriefing program for emergency services personnel.

Abstract: PURPOSE Emergency services personnel are highly vulnerable to acute and cumulative critical incident stress (CIS) that can manifest as anger, guilt, depression, and impaired decision-making, and, in certain instances, job loss. Interventions designed to identify such distress and restore psychological functioning becomes imperative. METHODS A statewide debriefing team was formed in 1988 through a collaborative effort between an academic department of emergency medicine and a social work department of a teaching hospital, and a metropolitan area fire department and ambulance service. Using an existing CIS debriefing model, 84 prescreened, mental health professionals and emergency services personnel were provided with 16 hours of training and were grouped into regional teams. Debriefing requests are received through a central number answered by a communicator in a 24-hour communications center located within the emergency department. Debriefings are conducted 48-72 hours after the event for specific types of incidents. Follow-up telephone calls are made by the debriefing team leader two to three weeks following a debriefing. The teams rely on donations to pay for travel and meals. RESULTS One hundred sixty-eight debriefings were conducted during the first four years. Rural agencies accounted for 116 (69%) requests. During this period, 1,514 individuals were debriefed: 744 (49%) firefighters, 460 (30%) EMTs, and 310 (21%) police officers, dispatchers, and other responders. Deaths of children, extraordinary events, and incidents involving victims known to the responders (35%, 14%, and 14% respectively) were the most common reasons for requesting debriefings. Feedback was received from 48 (28%) of the agencies that requested the debriefing. All of those who responded felt that the debriefing had a beneficial effect on its personnel. Specific individuals identified by agency representatives as having the greatest difficulty were observed to be returned to their pre-incident state. CONCLUSIONS CIS debriefings are judged as beneficial. A statewide response team is an effective way to provide these services at no cost to agencies.

Prehospital severity scoring at major rock concert events.

Abstract: INTRODUCTION: Rock and contemporary music concerts are popular, recurrent events requiring on-site medical staffing. STUDY OBJECTIVE: To describe a novel severity score used to stratify the level of acuity of patients presenting to first-aid stations at these events. METHODS: Retrospective review of charts generated at the first-aid stations of five major rock concerts within a 60,000 spectator capacity, outdoor, professional sports stadium. Participants included all concert patrons presenting to the stadium's first-aid stations as patients. Data were collected on patient demographics, history of drug or ethanol usage while at the concert event, first-aid station time, treatment rendered, diagnosis, and disposition. All patients evaluated were retrospectively assigned a "DRUG-ROCK" Injury Severity Score (DRISS) to stratify their level of acuity. Individual concert events and patient dispositions were compared statistically using chi-square, Fisher's exact, and the ANOVA Mean tests. RESULTS: Approximately 250,000 spectators attended the five concert events. First-aid stations evaluated 308 patients (utilization rate of 1.2 per 1,000 patrons). The most common diagnosis was minor trauma (130; 42%), followed in frequency by ethanol/illicit drug intoxication (98; 32%). The average time in the first-aid station was 23.5 +/- 22.5 minutes (+/- standard deviation; range: 5-150 minutes). Disposition of patients included 100 (32.5%) who were treated and released; 98 (32%) were transported by paramedics to emergency departments (EDs); and 110 (35.5%) signed-out against medical advise (AMA), refusing transport. The mean DRISS was 4.1 (+/- 2.65). Two-thirds (67%) of the study population were ranked as mild by DRISS criteria (score = 1-4), with 27% rated as moderate (score = 5-9), and 6% severe (score > 10). The average of severity scores was highest (6.5) for patients transported to hospitals, and statistically different from the scores of the average of the treated and released and AMA groups (p < 0.005). CONCLUSION: The DRISS was useful in stratifying the acuity level of this patient population. This severity score may serve as a potential triage mechanism for future mass gatherings such as rock concerts. Language: en

Quality management tool for mass casualty emergency responses and disasters.

Abstract: Introduction and background Quality management (QM) principles generally have not been applied to multi-casualty and disaster situations. Quality management incorporates quality assurance (QA) and quality improvement (QI) supported by a management information system (MIS). Since responders to disasters and multi-casualty incidents generally operate on standing orders and/or protocols, the character of the responses lends itself to quality management methods. Standards and indicators of performance readily can be developed for these situations. Objectives 1) to format disaster medical records as data collection instruments; 2) to develop appropriate tools that are easy to use for rapid assessments; 3) to develop a mechanism for determination of causes of injuries; and 4) to develop methods to: a) track patients; b) document response and recovery; and c) document the circumstances associated with the event. Methods Model tools using checklists and short, fill-in answers are provided. These tools are designed to be incorporated into the trauma or EMS registries. Emergency medical technicians, nurses, physicians, and medical students scored the same disaster scenario for the functional areas of calling the state of the disaster, triage, and field stabilization. Results Testing indicated that the checklists are completed in less than one minute, and produce objective data per patient in each functional area evaluated. In one instance, data were compiled for 38 patients from one bus accident in less than 10 minutes. The same data were reproduced, without variation, in the same amount of time, by three different providers of varied professional backgrounds.

Adenosine for the treatment of PSVT in the prehospital arena: efficacy of an initial 6 mg dosing regimen.

Abstract: Objective:To confirm the efficacy of pre-hospital administration of adenosine, using a 6 milligram (mg) initial dosing regimen, for the treatment of paroxysmal supraventricular tachycardia (PSVT).Methods:Urban, suburban, rural emergency medical services (EMS) system in Clark County, Washington with advanced life support (ALS) patient transports. Concurrent, paramedic Medical Incident Report (MIR) review was conducted for 102 patients receiving prehospital adenosine during a 42-month period. Patients were administered 6 mg of adenosine using an intravenous (IV) bolus followed by 10 ml of balanced salt solution flush. If the patient's rhythm remained unchanged, the dosing regimen was increased to 12 mg followed by a 10 ml flush. This was repeated once more if the rhythm remained unchanged, to a total maximum dose of 30 mg. Medical direction for administration of adenosine was in the form of standing orders rather than direct (on-line) medical control.Results:Seventy-four of 102 patients had PSVT as determined by physician analysis of the initial six-second electrocardiographic rhythm strip (ECG) recording. Sixty-six of these patients converted their cardiac rhythm from PSVT using adenosine; 46 (70%) converted with the initial 6 mg bolus. Fifteen patients converted after receiving the second dose (12 mg); and five patients required 30 mg.Conclusion:These results show that for paramedics, adenosine is an effective treatment for PSVT. An initial bolus of 6 mg converts the majority of cases. Eighty-nine percent of cases of confirmed PSVT converted with adenosine administration.

Automatic external defibrillation and its effects on neurologic outcome in cardiac arrest patients in an urban, two-tiered EMS system.

Abstract: OBJECTIVE To describe the use of the Automatic External Defibrillation (AED) device in an urban, two-tiered Emergency Medical Service (EMS) response setting with regard to its potential effects on cardiac arrest patient survival and neurologic outcome. METHODS A retrospective and descriptive design was utilized to study all cardiac arrest patients that had resuscitations attempted in the prehospital environment over a 30-month period. The study took place in a two-tiered EMS system serving an urban population of 368,383 persons. The first tier of EMS response is provided by the City Fire Department, which is equipped with a standard AED device. All first-tier personnel are trained to the level of Emergency Medical Technician-Basic. The second tier of EMS response is provided by personnel from one of two ambulance services. All second-tier personnel are trained to the level of Emergency Medical Technician-Paramedic. RESULTS 271 cardiac arrest patients were identified for inclusion. One-hundred nine of these patients (40.2%) had an initial rhythm of either ventricular fibrillation or pulseless ventricular tachycardia and were shocked using the AED upon the arrival of first-tier personnel. Forty-two patients (38.5%) in this group had a return of spontaneous circulation in the field and 22 (20.2%) survived to hospital discharge. Of the survivors, 17 (77.3%) had moderate to good neurologic function at discharge based on the Glasgow-Pittsburgh Cerebral Performance Categories. Faster response times by the first-tier personnel appeared to correlate with better neurologic outcomes. CONCLUSION First responder-based AED usage on patients in ventricular fibrillation or pulseless ventricular tachycardia can be applied successfully in an urban setting utilizing a two-tiered EMS response. In this study, a 20.2% survival to hospital discharge rate was obtained. Seventy-seven percent of these survivors had a moderate to good neurologic outcome based on the Glasgow-Pittsburgh Cerebral Performance Categories.

The Dynamic Nature of ST-Segment and T-Wave Changes During Acute MI

Abstract: Obtaining a prehospital 12-lead electrocardiogram (ECG) diagnostic of acute myocardial injury has been demonstrated to hasten the administration of thrombolytic agents in the emergency department. This case demonstrates that a prehospital electrocardiogram diagnostic of acute anterior wall infarction can become non-diagnostic following routine administration of oxygen, nitroglycerin, and morphine by paramedics. Although this phenomenon has been observed in the in-hospital setting, it has not been reported in patients with a prehospital ECG.

Evaluation of intravenous tramadol for use in the prehospital situation by ambulance paramedics.

Abstract: Introduction:An evaluation of the opioid analgesic tramadol (Zydol, Searle United Kingdom) was carried-out by ambulance paramedics to assess its efficacy in providing pain relief in the prehospital situation.Methods:Type of subjects—Patients suffering severe pain from any cause uncontrolled by other simple methods.Number of subjects—101 patients received tramadol and 41 patients served as a control. Study design—Random, open study.Statistical tests—Pain score at scene and on arrival at hospital were compared using Fisher's exact tests (2 sides). Logistic regression analyses also were applied to other factors.Results:Pain scores improved for 93.1% of the tramadol treated patients and for 44.0% of the controls. A total of 30.7% of patients treated with tramadol complained of nausea after treatment compared with 17.1% before treatment and with 12.2% of the control patients.Conclusion:Pain was significantly decreased by the administration of tramadol. It was safe with only minimal side effects, the major one being nausea. Suggestions are made for areas of further study.

Identifying victims of elder abuse and neglect: a training video for prehospital personnel.

Abstract: INTRODUCTION: The majority of prehospital emergency medical services (EMS) personnel lack specific training relating to elder abuse and neglect. OBJECTIVES: To develop and test an audio-visual training program that focuses on the identification and reporting of domestic violence in the elderly. METHODS: A videotape was designed to be used as a 45-minute training course for prehospital personnel using one-half inch, super-VHS recording. A convenience sample of 60 EMS personnel working in Kent County then were asked to evaluate the videotape program. Each volunteer completed a pre-test on elder abuse and neglect, watched the 45-minute videotape, and then answered 12 questions on a post-test. RESULTS: Participants had an average of 12.4 years (range: 1-30 years) prehospital emergency-care experience. Only four (7%) could recall any previous training relating to elder abuse or neglect during their careers. Although the prevalence of elder abuse in their community was described as "rather rare" by most (60%) of the subjects, 85% (51/60) had seen a suspected case of elder abuse or neglect during their careers; 47% (28/60) had seen a case during the past six months. Only 29% of these suspected cases were reported to county authorities. Approximately 40% of the questions on the pre-test were answered correctly (mean score, 4.8 +/- 3.0). In comparison, 83% of the questions on the post-test were answered correctly (10.0 +/- 3.0). Although participants had a number of suggestions to improve the video program, 78% (47/60) expected this material to change the way they will evaluate elderly patients in the future. CONCLUSION: Prehospital personnel do not feel confident identifying or reporting victims of elder abuse or neglect. A videotape training program may be an effective way of presenting this information as a means of continuing education. Language: en

Domestic violence: efficacy of health provider training in Utah.

Abstract: The purpose of this project was to improve the identification, treatment, and referral of domestic violence victims by prehospital care providers (Emergency Medical Technicians (EMTs) and paramedics) and emergency department personnel. The training focused on the definition of domestic violence, procedures to use when questioning patients about abuse, Utah's mandatory reporting law, and the referral of victims to community resources. While the training did improve the participant's knowledge concerning referral options and the law, health care providers still did not believe that domestic violence was a problem in their community. Although providers felt confident asking questions about abuse, the providers did not question patients unless they suspected domestic violence was the cause of the injury. Further training needs to be offered to staff to encourage regular screening for all adult patients.

Assessment of a scenario-based approach to facilitating critical thinking among paramedic students.

Abstract: Introduction Paramedic practice is shifting from [direct] on-line medical control to protocol-driven care initiated on the paramedic's judgment of the patient's problem(s). Teaching in most paramedic training programs remains grounded in technical rationality. This does not adequately prepare practitioners for current day practice. Medical conditions often present as ill-defined problems. To deal with these situations, practitioners need problem solving and reflective-thinking skills. Methodologies incorporating the use of these skills in a contextual situation similar to actual practice may help paramedics develop these skills. Hypothesis This study sought to determine the impact of written scenario exercises in the context of clinical problems as a means of learning in order to foster higher level thinking skills and self-directed tendencies. It involved three hypotheses: 1) Post-test scores would correlate with scores attained on the traditional, multiple choice, final examination; 2) Post-test scores would correlate with scores on the critical thinking sub-test of the final examination; and 3) Scores would be better on the post-test compared to the pre-test. Methods This two year, longitudinal, prospective study was conducted with 55 paramedic students using a pre- and post-test. Post-test scores were compared with final examination scores and scores of the subset of higher level thinking questions within that examination using the Pearson r-test. The relationship between the pre- and post-test scores was analyzed using a one-tailed dependent t-test. Post-hoc analysis of the variables of age, experience, and education was conducted using one-way analysis of variance. Results The correlation between post-test scores with final examination scores was positive and modestly significant. There was no correlation of post-test scores with sub-test scores. Comparison of pre- and post-test scores was significant. Effects for age, experience, and education were not significant statistically. Conclusions Using written scenarios increases ability to utilize reflective thinking and self-directed tendencies. However, this ability may not be demonstrated consistently on traditional written examinations. A multi-site study using large numbers and a control group or alternative methods appears to be indicated to demonstrate more accurate effects of the methodology.

An eight-year review of legal cases related to an urban 9-1-1 paramedic service.

Abstract: Introduction An eight year retrospective analysis was conducted to determine the type and outcome of lawsuits related to the provision of 9-1-1 paramedic service in an urban environment. Methods For the evaluation period of May 1986 to March 1994, all litigation cases related to Ambulance Service or paramedics were collected and analyzed. This urban 9-1-1 Paramedic Service has an estimated call volume of > 60,000 assignments resulting in > 30,000 patient encounters during the evaluation period. Results Seven lawsuits were filed against the service. No lawsuits were related to tardy response, failure to transport, or patient care negligence of any kind. All of the litigation was related to motor vehicle collisions (MVC). Conclusions The data suggest that motor vehicle collisions are a significant medical-legal risk to the EMS community. In addition, it was found that the use and lack of use of seatbelts was an important component in many of the suits.

The need for a global health disaster network.

Abstract: When a disaster occurs, a major difficulty is knowing where to find accurate information, and how to help coordinate efforts to share accurate information in a quick and organized manner. The establishment of a global information network, that is in place before a disaster occurs, could link all the communication efforts for relief. We propose that a Global Health Unit for Disaster and Relief Coordination be set up as part of the Global Health Network, utilizing the Internet as its backbone. This Unit would establish the links for the disaster information mosaic.