Showing papers in "Prehospital and Disaster Medicine in 1999"

Health Disaster Management Guidelines for Evaluation and Research in the Utstein Style

Abstract: The ultimate objective of disaster management is to bring the probability that damage will occur from an event as close to zero as is possible. A conceptual model is proposed that uses a generic, non-quantitative, mathematical expression (formula) for relating the probability that damage will occur with specific hazards and with the risk posed by the hazard and vulnerabilities. Actions are subdivided into those that are implemented before a hazard becomes an event and those provided as a response to an event that is occurring or has occurred. In the former category are those actions that either augment or mitigate vulnerability by increasing or decreasing the absorbing capacity and/or buffering capacity of the population/environment at risk for an event. Responses to an event either may be productive or counterproductive. Use of this “formula” in disaster planning and analysis should assist in identification of the essential elements that contribute to a disaster. For example, application of the formula should facilitate the development of understanding why the occurrence of similar events produce a disaster in one setting but not in another. Numerous examples of its application are provided.

Effects of early prehospital life support to war injured: the battle of Jalalabad, Afghanistan.

Abstract: OBJECTIVE: To study the effects of early, advanced prehospital life support on the survival rate of war casualties during the battle of Jalalabad, Afghanistan from 1989-1992. METHOD: The outcomes of simple trauma care administered from 1989-1990 were compared to the outcomes of advanced trauma care administered from 1991-1992 in the combat zone. The outcomes were measured by the number of deaths at admission to the referral surgical hospitals in Pakistan. RESULTS: A total of 3,890 war casualties were treated in the combat zone by paramedics, and were evacuated through light, forward, field clinics to surgical hospitals in Pakistan. Advanced trauma care that was administered in the combat zone reduced the prehospital mortality rate from 26.1% to 13.6% (95% CI for difference = 9.7-15.4%). CONCLUSION: In scenarios with protracted evacuation, early and advanced trauma care should be included in the chain of survival. Local paramedics can provide such trauma care with a minimum of resources. Language: en

Health disaster management: Guidelines for evaluation and research in the utstein style: Executive summary

Abstract: Disasters always have been a part of life, whether caused by unavoidable natural events or by avoidable, man-made events. Being rendered helpless by such events has caused fear and concern in all periods of history. To some extent, a disaster is expected, but there are varying degrees of uncertainty as to how and when it will occur. The occurrence of a disaster creates varying degrees of chaos combined with a mismatch between resources and needs. Therefore, in order to restore an affected society back to its pre-event status requires extraordinary efforts.

Cardiovascular mortality--the hidden peril of heat waves

Abstract: OBJECTIVE: Define the mortality associated with extremely hot weather during the 04 July through 14 July, 1993 heat wave that struck the northeastern United States. METHODS: DESIGN--A rapid field assessment was used to compare mortality occurring during the heat wave to mortality occurring during a period in which there was no heat wave using copies of death certificates. The findings of the rapid field assessment were validated, and it was determined whether increases in mortality occurred in other metropolitan east-coast counties also affected by the heat wave, by reviewing computerized mortality files. SETTING--Information was collected on all deaths occurring in Baltimore City, Maryland; Baltimore County, Maryland; Essex County, New Jersey; Newcastle County, Delaware; and Philadelphia County, Pennsylvania; during these specified study periods: 08-18 June (comparison period) and 06-16 July (heat wave study period), 1993. MAIN OUTCOME MEASURES--Ratios for total mortality, cause-specific mortality, and variables such as age, sex, race, residence, and day and place of death, that were available from death certificates were calculated. RESULTS: From the rapid field assessment, the following were observed: a 26% increase in total mortality and a 98% increase in cardiovascular mortality associated with the heat wave in Philadelphia. Data from the computerized mortality files showed an increase in total mortality in four of five counties examined and an increase in cardiovascular mortality in all five counties. The risk for death for those dying from cardiovascular disease increased significantly for people older than 64 years, for both sexes, and all races. CONCLUSION: As initially indicated by the Philadelphia Medical Examiner, there was excess mortality associated with a heat wave in Philadelphia. All other nearby counties examined also experienced excess mortality associated with the heat wave, although this excess was not recognized by the local health officials. The true impact of a heat wave that causes excess preventable mortality must be appropriately and rapidly ascertained. Using a national standard to certify a death as heat-related will provide the needed information rapidly so that public health resources can be more effectively allocated and mobilized to prevent further heat-related illnesses and death. Language: en

Job stressors and job satisfaction in a major metropolitan public EMS service.

Abstract: Introduction: Behavioral and social science research suggests that job satisfaction and job performance are positively correlated. It is important that Emergency Medical Services managers identify predictors of job satisfaction in order to maximize job performance among prehospital personnel. Purpose: Identify job stressors that predict the level of job satisfaction among prehospital personnel. Methods: The study was conducted with in a large, urban Emergency Medical Services (Emergency Medical Services) service performing approximately 60,000 Advanced Life Support (Advanced Life Support) responses annually. Using focus groups and informal interviews, potential predictors of global job satisfaction were identified. These factors included: interactions with hospital nurses and physicians; on-line communications; dispatching; training provided by the ambulance service; relationship with supervisors and; standing orders as presently employed by the ambulance service. These factors were incorporated into a 21 item questionnaire including one item measuring global job satisfaction, 14 items measuring potential predictors of satisfaction, and seven questions exploring demographic information such as age, gender, race, years of experience, and years with the company. The survey was administered to all paramedics and Emergency Medical Technicians (Emergency Medical Technicians s) Results of the survey were analyzed using univariate and multivariate techniques to identify predictors of global job satisfaction. Results: Ninety paramedics and Emergency Medical Technicians participated in the study, a response rate of 57.3%. Job satisfaction was cited as extremely satisfying by 11%, very satisfying by 29%, satisfying by 45%, and not satisfying by 15% of respondents. On univariate analysis, only the quality of training, quality of physician interaction, and career choice were associated with global job satisfaction. On multivariate analysis, only career choice (p = 0.005) and quality of physician interaction (p = 0.05) were predictive of global job satisfaction Conclusion: Quality of career choice and interactions with physicians are predictive of global job satisfaction within this urban emergency medical service (Emergency Medical Technicians). Future studies should examine specific characteristics of the physician-paramedic interface that influence job satisfaction and attempt to generalize these results to other settings.

Differences in Mortality Rates Among Trauma Patients Transported by Helicopter and Ambulance in Maryland

Abstract: Introduction:A comprehensive state wide emergency medical services and helicopter transport system has been developed in the State of Maryland on the principle that early definitive care improves patient out comes. The purpose of this study was to determine if empirical data exist to support the theory that air medical transportation services provided by the Maryland State Police (Maryland State Police) Aviation Division contribute to an improved trauma patient survival rate in Maryland.Methods:A retrospective study was conducted on the records of all patients transported by helicopter or ground ambulance and admitted to the R Adams Cowley Shock Trauma Center (R Adams Cowley Shock Trauma Center of the University of Maryland Medical System) of the University of Maryland Medical System. Data were obtained from the Maryland Institute of Emergency Medical Services Systems (Maryland Institute for Emergency Medical Services Systems) Shock Trauma Clinical Registry for the period January 1988 through July 1995, covering 23,002 patients. Patients included those transported directly from the scene of injury to the Maryland Institute for Emergency Medical Services Systems as well as those from interfacility transfers. All patients were stratified by injury severity and compared by outcome (mortality) using Mantel-Haenszel statistics.Results:During the study period, 11,379 patients were transported by ground and 11,623 were transported by Maryland State Police helicopter. The mean Injury Severity Score (Maryland State Police) for patients transported by ground was 12.7 (standard deviation = 12.52) and the mean Injury Severity Score for patients transported by air was 14.6 (Injury Severity Score = 13.42), p <0.001. Among patients classified as having a high index of injury severity, the mortality rate was lower among those transported by Maryland State Police helicopter than among those transported by ambulance. The mortality rate was significantly lower for air transported patient with an Injury Severity Score higher than 31.Conclusion:The State of Maryland has demonstrated a commitment to its citizenry and invested heavily in its public safety air medical service. This study suggests the rapid air transport of victims of traumatic events by specialized personnel in Maryland has a positive effect on the outcome of severely injured patients. Further research is necessary to clarify the causal relationships in order to more fully elucidate the value of this resource.

Stop propagating disaster myths

Abstract: The international response to the recent tragic earthquakes in Turkey, Greece and Taiwan reinforces the need to reassess the myths and realities surrounding disasters, and to find ways to stop these destructive tales. Most of those myths cover the fear of epidemics and the place of external assistance in the rescue effort. It is urged that the media and donor community should work together to channelise the funds and use them effectively, particularly for planning and making sure that help reaches in the hour of need and not after the emergency has lapsed.

Predictors of demand for emergency prehospital care: An Australian study

Abstract: Determining the predictors of demand for emergency prehospital care can assist ambulance services in undertaking policy and planning activities. Demand for prehospital care can be explained by demographic, health status, and economic determinants. The study used a cross-sectional design to investigate the association of demographic, health status, and insurance factors with the use of prehospital, ambulance care. Core data items including age, gender, marital status, country of origin, triage score, diagnosis, time of presentation, method of arrival, and patient disposition were collected for every patient who pre-sented at the Emergency Department of the study hospital over a four-month period. Ambulance usage was analysed using Poisson regression. For the 10,229 patients surveyed, only a small number were triaged as having the highest level of urgent medical need (0.8%), but the majority of these used prehospital emergency medical care (90.2%). Predictors of ambulance use included age >65years (Prevalence Ratio [Prevalence Ratio] = 2.92; 95% confidence interval [ Confidence Interval]: 2.35–3.63), being married or in a defacto relationship (Prevalence Ratio = 0.69; 95% Confidence Interval: 0.60–0.79) or divorced, separated, or widowed (Prevalence Ratio = 0.83; 95% Confidence Interval: 0.70–0.98), triage score level 1 or 2 (Prevalence Ratio = 1.95; 95% Confidence Interval: 1.68–2.28), or triage score level 3 (Prevalence Ratio = 1.54; 95% Confidence Interval: 1.38–1.72), diagnosis involving either mental (Prevalence Ratio = 4.29; 95% Confidence Interval: 1.84–10.01), nervous (Prevalence Ratio = 2.74; 95% Confidence Interval: 1.19–6.31) or trauma (Prevalence Ratio = 2.33; 95% Confidence Interval: 1.03–5.27) conditions, and insurance status (Prevalence Ratio =1.54; 95% Confidence Interval: 1.40–1.71). Ethnicity, gender, and time of day were not associated with usage. Demand for ambulance services can be predicted by a number of demographic, medical status, and insurance variables. Age and triage levels are key influences on demand for ambulance services. Ambulance insurance status provides an economic incentive to use ambulance services regardless of the urgency of the medical condition.

Triage ability of emergency medical services providers and patient disposition: A prospective study

Abstract: Study objective:To determine the ability of emergency medical services (EMS) providers to subjectively triage patients with respect to hospital admission and to determine patient characteristics associated with increased likelihood of admission.Methods:A prospective, cross-sectional study of a consecutive sample of patients arriving by ambulance during the month of February 1997 at an urban, university hospital, Emergency Department. Emergency medical services providers completed a questionnaire asking them to predict admission to the hospital and requested patient demographic information. Predictions were compared to actual patient disposition.Results:A total of 887 patients were included in the study, and 315 were admitted to the hospital (36%). With respect to admission, emergency medical services providers had an accuracy rate of 79%, with a sensitivity of 72% and specificity of 83% (kappa = 0.56). Blunt traumatic injury and altered mental status were the most common medical reasons for admission. Variables significantly associated with high admission rates were patients with age > 50 years, chest pain or cardiac complaints, shortness of breath or respiratory complaints, Medicare insurance, and Hispanic ethnicity. The emergency medical services providers most accurately predicted admission for patients presenting with labor (kappa = 1.0), shortness of breath / respiratory complaints (kappa = 0.84), and chest pain (kappa = 0.77).Conclusion:Emergency medical services providers can predict final patient disposition with reasonable accuracy, especially for patients presenting with labor, shortness of breath, or chest pain. Certain patient characteristics are associated with a higher rate of actual admission.

Sensation seeking as it relates to burnout among emergency medical personnel: a Texas study.

Abstract: Introduction:Burnout among emergency medical personnel (emergency medical personne) is suspected, but largely unsupported in the literature. An investigation of the phenomenon of burnout and factors contributing to its existence are essential steps in designingeffective interventions.Research Questions:Three research questions were proposed: 1) Are EMP sensation seekers as measured by Arnett's Inventory of Sensation Seeking? 2) Are EMP burnt out as measured by Revicki's Work-Related Strain Inventory? 3) Is there a relationship between sensation seeking and burnout among EMP?Methods:Emergency medical personnel attending a statewide conference in Texas, USA in late 1996 completed 425 survey instruments measuring sensation seeking and burnout as well as demographic items. Survey instruments were included in each registrant's conference package. Completed surveys were deposited anonymously in labeled receptacles throughout the statewide conference site. Data collection ceased at the end of the conference.Results:Emergency Medical Personne had significantly higher sensation–seeking total and intensity sub–scale scores than the general public. Full–time employees reported more sensation–seeking than volunteers or part–time employees. The younger the Emergency Medical Personne, the greater were their reported sensation seeking tendencies. Emergency Medical Personne reported more burnout in 1996 than in 1991. The older the Emergency Medical Personne, the lower was the reported level of burnout. Emergency Medical Personne who sought counseling for a work–related event reported more burnout than those who did not. Paid full–time Emergency Medical Personne reported higher burnout than did volunteers. There was a weak but positive correlation between sensation seeking and burnout, suggesting that these two dimensions may be unrelated.Conclusion:The field of emergency medical services attracts sensation seekers, and Emergency Medical Personne today report more burnout than their counterparts did in 1991. Although Emergency Medical Personne appear to be high in sensation seeking, this dimension alone does not protect them from the effects of burnout.

A safety assessment of diaspirin cross-linked hemoglobin (DCLHb) in the treatment of hemorrhagic, hypovolemic shock.

Abstract: Objective: To determine the safety and possible efficacy of diaspirin cross-linked hemoglobin (DCLHb) in the treatment of patients in Class II-IV hemorrhagic, hypovolemic shock.Design: Multicenter, randomized, normal saline-controlled, dose-escalation study.Setting: Eleven hospitals in the U.S. and Belgium.Subjects: One hundred and thirty-nine (139) hospitalized patients with Class II-IV hemorrhagic, hypovolemic shock within the previous 4 hours who still were requiring therapy for shock.Interventions: Beginning with the lowest dose, patients were randomized to receive 50,100, or 200 mL of either 10% DCLHb or normal saline infused intravenously over 15 minutes. Following infusion of either treatment, further fluid resuscitation could be given, as necessary, to maintain perfusion. Vital signs, laboratory assessments, blood and fluid administration, complications, and adverse events were recorded at various times from the end of infusion through 72 hours after infusion.Results: A total of 29 (13 DCLHb- and 16 saline-treated) patients died during the study period. Adverse events were experienced by 61% of patients in the DCLHb group and 53% of patients in the saline group; serious adverse events occurred in 28% of DCLHb-treated patients and 30% of saline-treated patients. The incidence of prospectively defined, clinical complications, including renal insufficiency and renal failure, was similar between the treatment groups except for the occurrence of dysrhythmias/conduction disorders, which occurred significantly more frequently in the saline-treated patients than the DCLHb-treated patients (p = 0.041). At the highest dose level (200 mL), statistically significant between-group differences were observed with greater increases in serum amylase, LDH, the isoenzymes LD1,2,4 and 5, and CK-MB in the DCLHb group compared to the control group; none were of clinical significance. The volume of blood administered did not differ between the groups. Overall 24- and 72-hour survival rates were similar between treatment groups, although the hospital discharge rate was slightly higher in the DCLHb-treated patients (80%) compared with the saline-treated patients (74%).Conclusion: Administration of 50 to 200 mL of DCLHb to patients in hemorrhagic, hypovolemic shock was not associated with evidence of end organ toxuity or significant adverse events. Further studies involving larger doses and, perhaps, earlier administration of DCLHb are warranted. © World Association for Disaster and Emergency Medicine 1999.

Critical incident stress intervention after loss of an air ambulance: two-year follow up.

Abstract: Objective Following an air ambulance crash with five fatalities, critical incident stress debriefing (CISD) was provided for involved paramedics, physicians, and nurses. A study was conducted to evaluate the long-term effects of a critical incident with critical incident stress debriefing according to the Mitchell model. Methods Six months following the incident, empirically designed questionnaires were mailed to all transport paramedics and directly involved medical staff, and a random sample of both nurses from the dispatch/receiving institution and paramedics from around the province. Twenty-four months post-incident, all members of the transport paramedics completed the Impact of Events Scale and the General Health Questionnaires. Results There were no differences between groups on any scores, except for disturbed sleep patterns, bad dreams, and the need for personal counseling being greater among transport paramedics at one day. There was no correlation between how well the deceased individuals were known, amount of debriefing, and symptom severity. A trend was seen for those with pre-existing stress management routines to have less severe symptoms at six months (p = 0.07). At two years, 16% of transport paramedics still had significant abnormal behavior. Conclusions CISD did not appear to affect the severity of stress symptoms, whereas having pre-existing stress management strategies may. These findings give justification for proceeding to a randomized, controlled trial of different levels of critical incident stress intervention.

The international search and rescue response to the US Embassy bombing in Kenya: the medical team experience.

Abstract: On 07 August, 1998, a terrorist's bomb exploded outside of the United States Embassy in Nairobi, Kenya. The explosion caused severe damage to the Embassy and surrounding structures, including almost complete collapse of the Ufundi building adjacent to the Embassy. The U.S. response to this tragedy included the deployment of medical, rescue, and law enforcement personnel to assist the Kenyan government. An integral component of this response was the deployment of an Urban Search and Rescue Task Force to aid in the location, extrication, and rescue of entrapped victims. This Task Force was sponsored by the Office for Foreign Disaster Assistance (OFDA), a branch of the United States Agency for International Development (USAID). The Task Force included a medical team composed of two physicians and four paramedics, whose purpose was to define, create, and provide a medical care system for rescuers and victims in the austere environment at the bombsite. As an international event involving a multinational response, the characteristics and requirements of this event differed in some respects from domestic disaster emergency responses, and the medical team adjusted their operating procedures accordingly.

Racial and ethnic patterns in the utilization of prehospital emergency transport services in the United States

Abstract: INTRODUCTION: This descriptive research used a large, urban population-based data set for prehospital, emergency medical transports to examine racial/ethnic patterns of access and utilization for several broad categories of emergency medical transport services. METHODS: Fire department files of approximately 39,000 reports on service provision were used to establish rates of transport utilization per 1,000 population in 1990, the most recent year for which reliable city-level census data were available. Data were categorized by three age groups ( or = 65 years), three racial/ethnic groups (non-Hispanic whites, African-Americans, Hispanics), and gender. Transport rates were computed for total utilization, trauma incidents, and incidents due to medical conditions. Racial/ethnic rates were analyzed for each age and gender group and age- and gender-standardized rates were analyzed and presented in a graphical comparison. Statistical analyses of racial/ethnic differences were conducted using Tukey-type tests of multiple comparisons of proportions, with significant differences evaluated at the p = 0.001 level of significance. RESULTS: Significant differences between racial/ethnic groups in the utilization of emergency transport services existed for all pair-wise comparisons including comparisons by each of the three age groups and gender. For total utilization, unadjusted rates are highest for African-Americans (65.9/1,000) and lowest for Hispanics (25.8/1.000). Likewise, African-American rates were substantially higher for both gender groups and across all age groups. Categorized by gender and age group under age > or = 65 years, non-Hispanic whites are observed to have the lowest rates for both males and females under the age 65 years, while Hispanics have the lowest rates in the group 65 years old However, when rates are age- and gender-standardized, compared to African-Americans and Hispanics, rates for non-Hispanic whites are significantly lower for total transports and for trauma and medically related transports (p = 0.001). CONCLUSION: Age- and gender-standardized rates for emergency medical transport were found to be lowest for non-Hispanic, whites, moderately higher for Hispanics, and substantially higher for African-Americans, who experienced transport rates nearly three times higher than were the rates for non-Hispanic whites. Further research is required to establish the extent to which racial/ethnic differences observed in this geographically restricted study reflect variations between racial/ethnic groups in the underlying need for services. Language: en

The cost-benefit of pulse-oximeter use in the prehospital environment.

Abstract: Introduction:Pulse-oximetry has proven clinical value in Emergency Departments and Intensive Care Units. In the prehospital environment, oxygen is given routinely in many situations. It was hypothesized that the use of pulse oximeters in the prehospital setting would provide a measurable cost-benefit by reducing the amount of oxygen used.Methods:This was a prospective study conducted at 12 ambulance stations (average transport times >20 minutes). Standard care protocols and paramedic assessments were used to determine which patients received oxygen and the initial flow rate used. Pulse-oximetry measurements (oxygen-saturation measured by pulse oximetry) were then taken. If oxygen-saturation measured by pulse oximetry fell below 92% or rose above 96% (except in patients with chest pain), oxygen (O2) flow rates were adjusted. Costs of oxygen use were calculated: volume that would have been used based on initial flow rate; and volume actually used based on actual flow rates and transport time.Methods:A total of 1,907 patients were recruited. Oximetry and complete data were obtained on 1,787 (94%). Of these, 1,329 (74%) received O2 by standard protocol: 389 (27.5%) had the O2 flow decreased; 52 had it discontinued. Eighty-seven patients (6%) not requiring O2 standard protocol were hypoxemic (oxygen-saturation measured by pulse oximetry < 92%) by oximetry, and 71 patients (5%) receiving oxygen required flow rate increases. Overall, O2 consumption was reduced by 26% resulting in a cost-savings of $0.20 / patient. Prehospital pulse-oximetry allows unncessary or excessive oxygen therapy to be avoided in up to 55% of patients transported by ambulance and can help to identify suboptimally oxygenated patients (11%).Conclusion:Rationalizing the O2 administration using pulse-oximetry reduced O2 consumption. Other health care savings likely would result from a reduced incidence of suboptimal oxygenation. Oxygen cost-saving justifies oximeter purchase for each ambulance annually where patient volume exceeds 1,750, less frequently for lower call volumes, or in those services where the mean transport time is less than the 23 minute average noted in this study.

Care provided by VA mobile clinic staff during Northridge earthquake relief.

Abstract: Introduction: From 25 January 1994 to 02 February 1994, staff aboard four Veterans Affairs Mobile Clinics treated Northridge Earthquake victims. This study examined the types of conditions treated by Clinic staff during the disaster. Methods: A descriptive case series using 1,123 ambulatory encounter forms was undertaken. Case-mix was assessed by classifying diagnoses into 120 possible diagnostic clusters. Results: Forty-five percent of patients were infants or children and 60% were female. The primary diagnoses were characterize by acute conditions: 1) upper respiratory infection (34.6%); 2) stress reactions (11.9%); 3) otitis media (10.1%); and injuries (8%). Two-thirds of the infants and children either had an upper respiratory infection (46.4%) or otitis media (20.1%). Increasing age indicated an increased likelihood of stress and anxiety reactions. Conclusion: The results provide additional information for agencies involved in planning for and responding to disasters. Based on the types of conditions diagnosed at the United States Veterans' Administration mobile clinics (i.e., a high prevalence of acute conditions, including stress and anxiety reactions, and the large numbers of children), staff trained in primary care, mental health, and pediatrics should be considered for relief missions that begin several days after an event resulting in a disaster.

Trauma Scoring Systems Explained

Abstract: Objective: To list, describe and classify the extant trauma scoring systems found in the English language literature from the vantage of utility to emergency medicine. Each system is illustrated by a table and a hypothetical case study. Data Sources: Medline citations provided the data. The systems are classified as physiological, anatomical and combined trauma scoring systems. Results: We reviewed the Glasgow Coma Scale, the Paediatric Glasgow Coma Scale, the Trauma Score and Revised Trauma Score, the Circulation, Respiration, Abdominal/Thoracic, Motor and Speech Scale, the Acute Physiology and Chronic Health Evaluation System, Abbreviated Injury Scale, the Injury Severity Score, the Anatomical Profile, A Severity Characterization of Trauma, Revised Trauma Score and Injury Severity Score and its revisions, the Paediatric Trauma Score and the Drug-Rock Injury Severity Score. Conclusions: This compendium should help emergency physicians become familiar with trauma scoring systems which evaluate the extent and severity of injuries, facilitate inter-institutional comparisons and facilitate trauma research.

Glossary of new concepts in disaster medicine: a supplement to Gunn's Multilingual Dictionary of Disaster Medicine.

Abstract: The development of disaster medicine as a science is dependent on clear definitions of its language. This article proposes a set of definitions to supplement those currently accepted. (term-accident-vs-injury) Language: en

Short-term crystalloid fluid resuscitation in uncontrolled intra-abdominal bleeding in swine.

Abstract: Introduction: Fluid therapy in uncontrolled bleeding is controversial. In a previously used experimental animal model of aortic injury, the outcome often was impaired by re-bleeding that began at least 20 minutes after crystalloid fluid resuscitation was initiated. Therefore, it was hypothesized that re-bleeding might be avoided if volume loading is carried out for 20 minutes and then disconstinued. Methods: Ten minutes after a 5 mm laceration was produced in the infra-renal aorta on eight anesthetized pigs, they received a 20-minute intravenous infusion of Ringer's solution in the ratio of 1:1 to the expected blood loss. Hemodynamics were studied for 120 minutes using arterial and pulmonary artery catheters and blood flow probes placed proximal and distal to the aortic lesion and around the left renal artery and portal vein. Results: The bleeding stopped between three and four minutes after the onset of bleeding. The blood flow rate dropped to 38% (mean) of baseline in the splanchnic region, to 31% in the upper aorta, and to 13% in the kidney. The flow rates and the oxygen consumption increased transiently during fluid resuscitation, but never reached baseline levels. Re-bleeding amounted to about 15% of the initial bleeding and occurred in only three of the animals. Four of the pigs died of shock within 90 minutes (range 47–85 minutes) after the aortic injury. Conclusion: Short-term crystalloid fluid therapy in uncontrolled aortic hemorrhage transiently improved the hemodynamic status and the oxygen consumption following the initial bleeding. Furthermore, the infusion did not cause re-bleeding of more than 100 ml, which occurred in previously conducted experiments when the infusion was continued for more than 20 minutes.

Geriatric trauma patients at a suburban level-I trauma center in Japan.

Abstract: BACKGROUND: Despite the increases in the aged population in Japan, there are little data on geriatric patients with traumatic injuries. A prospective clinical study was carried out to evaluate the use of the emergency medical services (EMS) system, mechanisms of injury, and prehospital assessment and triage of elderly victims of trauma. PATIENTS AND METHODS: From July 1996 through June 1997, a group of geriatric trauma (Group G, n = 22) and a control group of younger trauma patients (n = 173) were compared with respect to transfer method to an Emergency Center (direct or indirect), Revised Trauma Scores on the scene of the accident (RTS-1) and on admission to the Emergency Center (RTS-2), and outcome (survival). RESULTS: The mean values for RTS-1 in the Control Group (Group C) were not different from those in Group G, but RTS-2 of the indirect-transfer patients (IP) in Group G were significantly lower than were those for Group C. Group G mortality rates were significantly higher than were the control rates (p = 0.0001). The mortality rate of the IP subgroup was significantly lower than that of the direct transfer subgroup (DP) (30/68 vs. 5/70, p Language: en

KAMEDO--a Swedish Disaster Medicine Study organization.

Abstract: Kamedo is a Swedish Disaster Medicine study organization that sends observers to disaster areas anywhere in the world to study recent events, collect useful information, and identify problems relative to the practice of Disaster Medicine. The results of these investigations are published in the KAMEDO Reports, and the English versions will be published in Prehospital and Disaster Medicine. Three of the recent reports follow: 1) KAMEDO Report 69: Ebolus Virus Epidemic in Zaire, 1995; 2) KAMEDO Report 70: The German Rescue and Emergency Organizations: a) Industrial Chemical Fire, Memmingen, Germany 23 January 1997; b) Fire at the Dusseldorf Airport, 01 April 1996; and c) Bus Accident on the Autobahn in Rosenheim, Germany; and 3) Terrorist Attack with Sarin, 20 March 1995. In addition, a catalog listing all of the KAMEDO Reports available in English is provided.

Current extent of disasters in Africa.

Abstract: The people oFf Africa are exposed to a wide range of disasters that seriously have aggravated the Continent's economic situation. Economic losses and human sufferings from drought, desertification, locust infestation, infectious diseases, epidemics, and armed conflicts are the dominant disasters that the people in the African countries face, and they have rendered the population utterly vulnerable. Disasters have aggravated Africa's economic situation. The cumulative effect of disasters include loss of property, injury, death, mounting food import bills, health hazards, environmental degradation, backward economic development, displaced people, refugees, and nutritional deficiency. Today, 175 million Africans out of a total population of 744 million people (23.5%) are suffering from chronic hunger; this is an increase of 50% from 25 years ago. In many African countries, up to half of the population suffers from absolute poverty. It is projected that Africa will be the only Continent to continue with the current level of poverty for another decade.

Complications from supervised mask use in post-operative surgical patients during the Gulf War.

Abstract: This is a report of three patients in a surgical ward of a hospital who developed complications seemingly related to the use of full-face-fitting masks associated with the first Scud Missile attack on Israel during the Gulf War. Patient 1 developed atrial fibrillation with an uncontrolled ventricular rate; Patient 2 redeveloped a gastrointestinal hemorrhage; and Patient 3 developed a severe anxiety attack. Each of the three was severely ill prior to the event. Special attention should be given to severely ill patients during such events.

Intubation with transillumination: nasal or oral?

Abstract: Transillumination-guided intubation is a useful back-up method when laryngoscopic intubation proves to be difficult or impossible. The Trachlight (Laerdal, N-4001 Stavanger, Norway) is suited for both nasal and oral use. Intubation times (IT) and success rates (SR) for nasal and oral intubation with the Trachlight were compared. Twenty-four medical students, inexperienced in intubation were instructed in the use of the Trachlight. A demonstration also was performed. Subsequently, they were asked to intubate a Laerdal Airway Management Trainer (Laerdal, Stavanger, Norway) using the Trachlight. Each student intubated 10 times orally and 10 times nasally (five times through the right and five times through the left nostril). The succession of the students was randomized. The intubation times were measured and the position of the tube noted. Nasal and oral intubation times for the tenth trial (steady state conditions) were compared using the rank-order test for paired observations. Oral and nasal success rates were compared using the sign test for paired observations. The differences between nasal and oral intubation concerning intubation time and the success rates were not significant. Nasal intubation with the Trachlight seems to be more difficult than the oral intubation.

Guidelines, Algorithms, Critical Pathways, Templates, and Evidence-based Medicine

Abstract: There are evolving in medicine a host of guidelines, algorithms, templates, and critical pathways. Each is a significant part of the Guidelines for Evaluation and Research in the Utstein Style, the Executive Summary of which was published in the last issue, and the complete work will be published as a Supplement to Volume 15 in 2000. Another templatelike document is the lead article in this issue. The development of such patterns for the delivery or analysis of medical care is hailed by some who believe these documents provide organization out of chaos. Others object to the structure provided as attempts to \"cookbook\" medical care. Others point out that the codification of such processes threatens the important role played by \"experience\" and \"logic\"; still others insist that such devices establish \"standards\" and that deviations from these standards present an increased risk for legal actions. Thus, confusion reigns relative to the meaning and utility of such documents. And, to confuse matters further, there now is a drive by some to evolve what they call, \"evidence-based medicine\". Are these all the same?

Utilization of military support in the response to hurricane Marilyn: implications for future military-civilian cooperation.

Abstract: INTRODUCTION: The past decade has been a period of evolution for the Federal disaster response system within the United States. Two domestic hurricanes were pivotal events that influenced the methods used for organizing Federal disaster assistance. The lessons of Hurricane Hugo (1989) and Hurricane Andrew (1992) were incorporated into the successful response to Hurricane Marilyn in the U.S. Virgin Islands in 1995. Following each of these storms, the Department of Defense was a major component of the response by the health sector. Despite progress in many areas, lack of clear communication between military and civilian managers and confusion among those requesting Department of Defense health resources may remain as obstacles to rapid response. METHODS: This discussion is based on an unpublished case report utilizing interviews with military and civilian managers involved in the Hurricane Marilyn response. RESULTS: The findings suggest that out-of-channel pathways normally utilized in the warning and emergency phase of the response remained operational after more formal civilian-military communication pathways and local assessment capability had been established. CONCLUSION: It is concluded that delays may be avoided if the system in place was to make all active pathways for the request and validation of military resources visible to the designated Federal managers located within the area of operations. Language: en