Prehospital and Disaster Medicine
Abstracts for
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Assessment Tool for Prehospital Emergency Curriculum in Eastern Europe
Objective: To assess effectiveness in improving patient outcomes of a new prehospital emergency care training curriculum paired with a quality assessment tool for prehospital care providers in Eastern Europe.
Introduction: A first responder curriculum that includes a mechanism for documenting clinical data and prompting critical interventions is planned for 14 EMS training centers in the CIS for 2001. Measuring effectiveness is critical for quality improvement and securing ongoing approval from the project stakeholders as well as support for similar projects in other parts of the world.
Methods: A dual phase evaluation process is proposed. In the first phase (precurriculum), prospective students will identify patients with an acute illness or injury most likely to benefit from field interventions with a standardized, validated case severity scale (CSS). The CSS categorizes patients on their initial level of severity and their interval status change upon arrival at the emergency department. The second phase (postcurriculum) would combine the CSS with a structured patient encounter data collection (quality assessment) tool, which would document clinical data and serve as a prompt for critical interventions. A cohort will be followed prospectively for 12 months to evaluate changes in CSS based on clinical interventions. Observed interventions will be controlled for a given locale's resources and prehospital infrastructure. The curriculum and quality assessment tool will be implemented in staggered intervals throughout the each center's jurisdiction allowing for comparisons between pre- and postcurriculum cohorts.
Conclusion: A combination severity scale and quality assessment instrument may be useful in measuring patient outcomes, and in addition, have universal applications for improving and reinforcing the performance of prehospital providers.
Key words: assessment; case severity scale; curriculum; emergency medical services; evaluation; prehospital; quality
E-mail: pdanders@caregroup.harvard.edu
Prehosp Disast Med 2001;16(2):s12.
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Objective: To determine the perceived usefulness of the Hospital Emergency Incident Command System (HEICS) and an assessment tool for hospital disaster response capabilities and needs inhospital disaster planning in Turkey.
Methods: During the conference, Turkish medical professionals and hospital staff members were introduced to HEICS via lectures, interactive discussions, and a tabletop disaster drill. They also were taught capabilities and needs assessment tool for hospital disaster response, modified from the Community Medical Disaster Planning and Evaluation Guide, via lectures and interactive hospital disaster planning sessions. At the conclusion of the conference, Turkish participants were surveyed regarding their attitudes about the usefulness of HEICS and this assessment tool for disaster planning in their hospitals. Descriptive statistics are used to present the results of this post-conference survey.
Results: Thirty-three Turkish medical professionals and hospital staff members participated in the survey. 31% of those responding reported that they had previous experience in hospital disaster planning; 100% stated that they intended to participate in hospital disaster planning in the future; and 43% of those responding stated that their hospitals already have a disaster plan. Of those whose hospitals have disaster plans, 54% reported that their hospitals already utilise some other type of command and control system in its disaster plan, and 46% reported that their hospitals previously used some other type of capabilities and needs assessment tool in hospital disaster planning. All of those responding, felt that HEICS would be useful in their hospital disaster response and planning, and 97% of those responding believed that the hospital disaster response capabilities and needs assessment tool they were taught in the conference would be useful for future disaster planning in their hospitals.
Conclusion: With disasters occurring more frequently and with greater impact around the world, an international search is under way for useful and appropriate strategies for hospital disaster planning. Concepts about HEICS and an assessment tool for hospital disaster response capabilities and needs can be taught to medical professionals and hospital staff in a developing country with relative ease. The vast majority of participants in this Turkish conference on hospital disaster planning felt that HEICS and the assessment tool they were taught would be useful in their future hospital disaster planning.
Key words: command; control; disaster; education; hospitals; incident command system; planning; training
E-mail: gurkan.ersoy@deu.edu.tr
Prehosp Disast Med 2001;16(2):s12.
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Japan Disaster Relief Medical Team Activity for the El Salvador Earthquake in 2001
Members of the Japanese Disaster Relief Medical Team were dispatched to the Republic of El Salvador in order to conduct relief activities for people affected by the earthquake that occurred on 13 January 2001. We report on this mission. The duration of the activities was from January 16 to January 25. The Japanese Medical Team for Disaster Relief (JMTDR) consisted of 18 members.
The place of activities was Hospital Nacional de Santiago de Maria and Colegio Santa Gema. Medical treatment rendered included first aid and primary health care. During the nine days, we treated 1,573 patients including 1,284 in Santiago de Maria and 289 in Santa Gema. There were 1,496 new patients and 77 revisits; 565 patients were <15 years old, 767 between 16 and 59 years, and 244 were 60 years old. The three most common final diagnoses were respiratory diseases in 716 (45.5%), acute stress syndrome in 322 (20.5%), and neurological/orthopedic diseases in 257 (16.3%).
The suggestions at the time of withdrawal were as follows: (1) to consider the preventive measures for infectionaffected by the earthquake, such as appropriate lavatories; (2) because many catch colds after staying or sleeping outside the home they need sufficient blankets and air mattresses (3) to maintain abdominal hygiene, the affected population should be supplied with insecticide; and (4) to keep conditions sanitary and to maintain good hygiene, menstruating women must obtain enough sanitary napkins.
Key words: demography; disasters; earthquake; public health; relief
Prehosp Disast Med 2001;16(2):s13.
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Homeostasis Correction in Burns Complicated by Blood Loss
Homeostatic changes have been studied, and some methods for correcting the revealed disturbances have been developed on the model of deep burns (IIIB,IV degree) of 10% of body surface and acute blood loss of 20–25 ml/kg in experiments on 50 dogs. The control series (no therapy) was noted to develop a hypodynamic syndrome, decompensated metabolic acidosis, hyperfermentemia, electrolytic shifts, and inhibition of myeloerythroproliferation. The resulting polyorganic pathology due to mutual aggravation syndrome caused death of all of the animals by the 4th–5th hour post-injury.
Intravenous infusive therapy with rheopolyglukin, isotonic solution of sodium chloride and antihypoxants (sodium oxybutyrate [SOB], 200 mg/kg, dimephosphonium, 1100 mg/kg, mexidol(e) 50 mg/kg) appeared to correct the principal parameters of homeostasis: it stabilized the central haemodynamics, normalizes the acid-base balance (ABD), reduced hyperfermentemia and endogenous intoxication along with a decrease in lipid peroxydation products. The therapeutic effect was noted to rise in intraosseous infusion of antihypoxants. Maximal antihypoxic effects of SOB was registered by 3 h after infusion, and that of dimephosphonium by the 6th h; the ABD normalizing effect of antihypoxants persisted for 24h. Intraosseous infusive therapy of combined injury in the presence of SOB helped to provide 100% survival rate within 24h; with dimephosphonium, the rate was 50%; mexidol (e) prolonged the life span to 72h.
Polycomponent infusive therapy in combined injury (deep burns complicated by acute blood loss) including antihypoxants seems to be valid and, should be taken into account in clinical practice.
Key words: antihypoxants; antioxidants; blood loss; burns; hemodynamics; hemostasis; hypodynamics; hypoxia; intoxication; survival; therapy
Prehosp Disast Med 2001;16(2):s13.
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Effect of Antihypoxants on Bone Marrow Blood Formation in Burns Complicated by Blood Loss
The efficacy of the use of antihypoxants in deep bum therapy (IIlB-IV degree), 10% of body surface, with acute blood loss 20@25 ml/kg has been studied in three series of experiments on 30 dogs, 10 animals in each. The control series received no therapy; the second group received intravenous infusions of rheopolyglukin, isotonic sodium chloride solution, sodium oxybutyrate (SOB, 200 mg/kg), and autoblood 1h post-trauma; and in the 3rd series, SOD was replaced by dimephosphonium (100 mg/kg).
The royelogram taken l h post injury, showed a sharp decrease in total myelokaryocytes (57% to the original level), increase in mature myeloid components, reduction of immature forms, and erythrokaryocytes. In the control series, mitosis increased in numbers along with the rise in erythrokaryocyte share by the 5th day post-injury. Leukoerythroblastic (l/e) ratio was 3:1 (4.5: l in the norm). The use of SOB was not observed to correct the mye1ogram: decrease of b1astic and immature forms along with rapid maturing of neurophils continued; the share of erythroid forms in the punctate was sharply decreased; the 1/e ratio became 27:1; the mitosis number went down to 2%. Signs of activation in erythropoesis of erythroblastic type swith predominant basophilic and polychromatophilic normocytes were noted after dimephosphonium infusion; the l/e ratio comprised 4.5:1. The number of mitoses returned back to the original level.
Combined injury (deep burns complicated by blood loss) causes inhibition of erythropoesis and speeds up neurophil maturation. The use of SOB provided a reversible picture of regenerative bone marrow, while diroephosphonium infusion tends to restore haemopoesis.
Keybwords: antihypoxants; blood loss; burns; erythrokaryocytes; erythropoesis
Prehosp Disast Med 2001;16(2):s13.
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Importance of Injury Signs and Indices in Prehospital Triage of Nonuniformly Irradiated Patients
In radiation accidents, people usually are exposed to general, nonuniform irradiation. In the Russian State Register of Radiation Accidents for 1950–1992, 119 cases of acute radiation sickness of uniform irradiation, 193 cases of acute radiation sickness from nonuniform irradiation, and 159 cases of severe, mainly local radiation injuries were registered. Clinics of injury in nonuniform irradiation may differ considerably from classical forms of acute radiation sickness seen with uniform irradiation. It impedes prognosis of injury severity, and thus, may influence the character and volume of medical-evacuation measures. In this connection, in the prehospital triage of the injured, it is necessary to take into account the prognostic importance of the signs of an injury from nonuniform exposure.
Study of absorbed dose distribution in a human body in typical situations showed that more often, it would be different variants of nonuniform irradiation with 2–5 times differences of dose. Depending on geometry of the irradiation, clinical signs of such injuries will vary considerably. The most important characteristic are (1) injuries with mostly head irradiation, when clinics of radiation sickness will be determined by oropharyngeal and in very high doses by cerebral syndromes; and (2) injuries with mostly abdomen irradiation with signs of modified intestinal syndrome. Some intermediate forms are possible with relatively small levels of nonuniform irradiation (dose fall off up to 3). In such cases, the signs of the corresponding syndromes will be expressed in vague form.
The triage of the injured in nonuniform irradiation must be carried out in accordance with the same process as for the injured in uniform irradiation. However, while estimating prognosis and establishing the evacuation priority in nonuniform irradiation, the relatively more favourable process of these forms of radiation pathologies must be taken into consideration. Signs of hemogenesis depression may be expressed in less degree, and may not correspond to the whole degree of severity of disease than should be expected from general ideas. During the primary reaction, the comparison of the disease symptoms with the dosimeter data and data on the body position during irradiation may be used to estimate the dose and its distribution. It also is necessary to compare the character and degree of local and general signs of an injury. Thus, distinct oropharingeal syndrome in presence of moderate dyspeptic disorders indicates to the sharply nonuniform irradiation with prevailing head irradiation. In moderate nonuniform irradiation ("intermediate forms"), clinical symptoms and the main laws of the disease process are close to the classical form of acute radiation sickness, caused by uniform irradiation. However, even in this case, correlation between expressed "classical" signs of acute radiation sickness (primary reaction, radiation bone marrow hypoplasia, etc.) and local signs reflect the morphological and functional changes of other critical bodies.
Key words: clinical signs; irradiation, non-uniform; irradiation, uniform; radiation sickness; syndromes; triage
E-mail: rcdm.org@g23.relcom.ru
Prehosp Disast Med 2001;16(2):nnn.
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Volunteers: An Essential Component
2001 is the International Year of the Volunteer. In any modern emergency response system, there always will be an incident in which the supply of emergency services and the demand do not match. No country can afford to have every emergency service on standby and reach every citizen within three minutes. Self-help and volunteers are essential in all societies, not just in the frequently televised disasters such as earthquakes or floods.
Professor E. L. Quarantelli of Chicago is an accepted master of recording human behaviour in disasters, and his 1960s model is readily extrapolated to more mundane emergency situations.1 In Australia, volunteers are an integral part of responses: they are used both in ordinary emergencies and disasters. The medical and ambulance emergency services routinely use volunteers from community emergency response teams (CERT), Red Cross, St. John, Surf Life Saving, Hatzolah, etc. through a coordinated central dispatch system.
The Australian prototype for volunteering is the rural fire services, each one is built around a local community, with state and regional levels of salaried staff providing infrastructure services, education, certification, or higher level coordination in very major incidents. In larger towns (population _25,000), there are full-time salaried, ambulance paramedics, but smaller townships may rely on paid casual or unpaid volunteers who have a similar training, but usually, lower level protocols. Using the Quarantelli template, when an incident occurs, firstly there is self-help by the victims or bystanders. Next, the professional services are alerted, and in rural and remote areas, they may use trained volunteers from ambulance, first aid, nursing, or medical resources as first or second line response. In a major event, the on-scene supervisor coordinates the volunteers to integrate them in tasks that are both safe and within their range of skill and fitness. Where the involvement may be prolonged, the sequence always must involve some form of supervision during every phase: assessing, briefing, equipping, deploying, communicating, reporting, debriefing, and stand down. Volunteers should not be left alone to "muddle on". Some volunteers may be exhausted or simply grateful to be relieved of their task and return to their families, others help for longer, then leave the scene to continue their normal routines.
By supporting volunteers, a skilled supervisor assists in rehabilitation of the affected individual and the whole community. Professionals arriving at the scene must recognise the part the volunteers have played prior to the arrival of the "authorities". Simple courtesies such as taking a handover, exactly as professionals do when taking over from a colleague, and if appropriate, keeping them involved during the remainder of the incident. At the conclusion, a debriefing to cover functional aspects of their role may allow hitherto unrevealed facts to become shared knowledge. In disaster situations, these debriefings may need to continue over several weeks as different aspects of the event and its consequences become the focus of mental and physicals needs. Finally, a thank you letter returns its own goodwill many times over, and, in a community affected by a disaster, also assists the individual to return to their normal psychological state and a normal life.
Reference
1.__Quarantelli EL: Organisational Responses & Problems in Disasters. Disaster Service Session, American Red Cross National Convention, Michigan, May 1965.
Key words: disaster; infrastructure; management; Quarantelli; responses; salary; self-help; supervision; volunteers
Prehosp Disast Med 2001;16(2):s15.
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Chemical Accidents in Urban Areas
Industry commonly makes more than 70,000 different chemicals. Chemical accidents represent the loss of control of a toxic product. The consequences affect people, animals, and the environment; they often are serious, immediate or delayed, and sometimes unknown. A chemical accident in an urban environment is characterised by: (1) its suddenness of onset and the initial localisation (industrial sites, public highways, railroad lines and sometimes planes or pipelines); (2) the number of poisonings; (3) the uncertainty as to the nature and toxicity of the products; (4) the important influence of the weather, the geography and the urbanisation features; (5) the number of casualties; (6) the organised influx (by rescue teams) or uncoordinated influx (spontaneous arrivals) of casualties; (7) the repetitive injuries (inhalations, burns, blasts, ocular lesions, cutaneous cuts or irritations, etc.); (8) a poor and often insufficient sanitary organisation (lack of medical knowledge and culture concerning the chemical accident even in developed countries); (9) logistical and therapeutic constraints; (10) risks for the rescue teams; and (11) immediate emotional media repercussions. The alert usually is precocious, but often indistinct. The first medical team on the scene, headed by a responsible physician, settles itself in a place without risk. The first damage assessment allows the assessment of the needs and of the emergency actions needed to be put into place by the relevant authorities. The collaboration should be limited among the rescuers (fire brigade, emergency medical services, poison centre, police, authorities, company, experts, medical psychological emergency unit), each having a part, but all working together. The usual missions of the Emergency Medical Service simultaneously are adapted to the human and logistical constraints connected with the exceptional event. Taking charge of the victims on-site (selection, first medical aid, evacuation) is based on the principles of emergency disasters, but a third level (potential emergency or victim who can present secondarily an acute and serious level of decompensation) is in addition to the two conventional emergency levels (absolute and relative levels). Equipped professionals must decontaminate each casualty before medical aid can be administered. Nevertheless, rescue teams should be protected to allow them to treat on-site. Everybody (patients of resuscitation, the injured, involved witnesses, rescuers) should be treated. The preparation of emergency rescue operations relies on the anticipation and evaluation of the potential industrial accidents in a region. Procedures taking account of risks and means (local chemical risks and local hospital structures) must be written and regularly updated. Real life exercises should be carried out. Finally, the information of the rescuers, patients, families, population and media should be clear, coherent, global, ethical, and not dramatised.
Key words: accidents; characteristics; chemicals; collaboration; control; exercises; information; levels; media; risks; toxicity; urban
Prehosp Disast Med 2001;16(2):15.
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Clinical Analysis of 1,076 Cases of Abdominal Injury
Objectives: To improve the level of early diagnosis and operating treatment of abdominal, multiple organ injuries .
Methods: A total of 1,076 patients with abdominal, multiple organ injuries were treated in our unit.
Results: The main causes of injuries were road traffic accidents, falls, and assaults. All Injury Severity Scores (ISS) of the patients were greater than 16; the highest ISS and the mean values for ISS were 60 and 29.5 respectively. Closed wounds were present in 893 cases, and open wounds in 183 cases. In this study, 969 cases underwent laparotomy. The main intraabdominal organ injuries included spleen, liver, kidney, stomach bowel, colon and rectum.. A total of 990 cases (92%) survived, 96 cases (8.9%) had no detectable blood pressure on admission and were brought back to life, 17 cases (1.6%) were reoperated due to missed injuries or inadequate management at the initial operation. The mortality rate was 8.0% (86 patients) and most of the deaths were due to hemorrhagic shock.
Conclusions: Under urgent conditions, consuming diagnostic procedures are not allowed when a patient's hemodynamics is stable. Modern diagnostic techniques should be used to avoid polytrauma. Laparotomy should be performed actively, for prolonged contamination due to gastrointestinal rupture is more harmful than is a negative exploration. An operative principle is that saving life is primary and remaining organ function is secondary.
Key words: abdominal injury; demography; diagnosis; laparotomy; outcome; results; shock; surgery; therapy; trauma
Prehosp Disast Med 2001;16(2):s15.
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Causes of Newborn Asphyxia in Pudong Zong
This study is an analysis of 69 cases of asphyxia of the newborn from 1994 to 1999. The findings indicate that there are a variety of factors that contribute to asphyxia of the newborn. Newborn asphyxia results mainly from the circulatory interruption of inner uterus, umbilical cord around the neck of the baby, and/or pollution and aspiration of amniotic fluid. Besides the maternal factors, newborn factors include abnormal fetal position and placental factors that contribute to the newborn asphyxia. CT tests of some of the newborn@s brains indicates that the incidence rate of hypoxic-ischemic encephalopathy (HIE) approaches 82.6%, and for intracranial hemorrhage, up to 73.9%. Thus, it is quite necessary to prevent newborn asphyxia, reduce the degree of asphyxia, and avoid the occurrence of sequellae, by virtue of the following: (1) monitoring the fetus inside the uterus early and prevent problems with the inner uterus; (2) having an immediate abdominal delivery in the necessary situations; (3) taking a B ultrasonic inspection, so as to make certain of the chances that the umbilical cord is not abnormal before childbirth; and (4) taking a CT test for the brain, under good conditions.
One particular concern is that immigrating workers are reluctant to see a medical professional before childbirth, and/or are willing to have a delivery at home due to financial hardship, or refuse to come to the hospital until they are in labor and are about to deliver the baby. This lack of medical care contributes to the rise in the newborn asphyxia and its sequellae. Thus, informing the public must be emphasized
Key words: asphyxia; causes; diagnosis; neonatal; newborn; obstetrics; prevention
Prehosp Disast Med 2001;16(2):s16.
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Anaesthetist Nurse on a Humanitarian Mission
The conflict in Burundi between the Tutsi power and the majority Hutu, which started in 1963, has escalated since 1993. Many factions have appeared, and a peace agreement has not been achieved. As the battles have become more intense over the recent years, the number of victims who have been entrusted to an already precarious health system has increased, justifying the need for medical help from Médecins sans Frontières (France). The daily medical needs (obstetrics, visceral, trauma) are augmented by the irregular, and, at times, massive influx of injuries as a result of the effects of constant war. The humanitarian assistance takes the shape of human resources (a team surgeon, an anaesthetist nurse or doctor, a field coordinator to negotiate with the provincial authorities, a coordinator for the general daily management), logistics (medicine, standard kits that include a sterilizer, a box of surgical instruments, an oxygen extractor, manual ventilation material, pulse oximeter, etc.) and medical know-how from 30 years of experience in difficult conditions. The medical team demonstrates its professional competencies and qualities of human relations by taking charge of any surgical casualties, adjusting to a minimal technical environment, partnership (work and formation) with the local health service, communication with the nursed populations, development of a team spirit (between expatriates who aren@t used to working together) and the constant control of security problems. The expatriate anaesthetist nurse or doctor is the only representative of this specialty, and controls the anaesthesia (general anaesthesia with or without intubation, spinal analgesia, regional intravenous anaesthesia, nerve block anaesthesia), postoperative care (hydro-electrolytic infusion, analgesia therapy, antibiotic therapy, antitetanus vaccination, medicine supply, dressing change, etc, control and management of anaesthetic and surgical equipment and sterilisation, involvement in the care and the hospital hygiene with local hospital staff, and monitoring this activity by weekly and monthly reports. Tense security issues forced the team to adjourn its activity on 22 May 2000. No governmental authority has yet permitted its reinstatement, in spite of very important medical civilian and military needs. The complex situation of this country in wartime shows the limits of the aide programs in crisis situations.
Key words: anaethetists; expatriates; Hutu; logistics; needs; security; supplies; team; Tutsi; war
Prehosp Disast Med 2001;16(2):s16.
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Systematic Radiologic Checking of Gastric Tubes in ICU and Emergency Services: Preliminary Results
Introduction: There is a professional agreement concerning the radiological checking of the position of gastric tubes (GT) after their installation in the field of continual enteral feeding for adults, that it is at hospital or at home.1 This research evaluated the relevance of this recommendation in emergencies and also sought predictive factors of difficulty encountered with the installation of GTs or anomalies of localization of the GT after its installation.
Methods: It is a prospective study. All patients admitted in our service and having profited from the installation of a GT, prehospital or not, were included. The data collected are: (1) demographic data of the patient, (2) admission data (antecedents, principal diagnosis, CGS, needs of intubation, tracheotomy or sedation), (3) mode of installation of the GT, (4) its type, and (5) existence of difficulties during this installation. Checking of the position of GT is achieved by injection of air and radiological control. The statistical tests used were Student's t-test for quantitative information and a chi-square test for qualitative data. A value of p <0.05 was considered statistically significant.
Results: 81 installations of GT were studied. The median age of patients is 58 years (19@94). 53% of patients were men, 32.5% of patients were sedated. Neurological or gastroenterologic antecedants were found in respectively 12.7% and 10.2%. 78% of the GT are passed by nurses and 23.5% by prehospital personnel. Characteristics of GT and tracheal tubes are included in the Table 1.
Table 1-Characteristics of GT and Tracheal Tubes
Gastric tubes Tracheal tubes
n 80 64 (80%)
Mode of Nasogastric Nasotracheal
Installation tube: 95% tube: 56.9%
Sizes 18 and 21: 76.5% 7 and 7.5: 80.3%
Types PVC: 97.5% Low pressure: 63%
Problems with 22% 24%
the installation
The results of the two tests used to check the position of the GT are presented in Table 2.
Table 2-Results of the Tests to Check GT Positioning
Air control Radiologic control
(%)(%)
In place 97.4 86.5
doubt or not 2.6 13.5
in place_
After their installation, 13.5% of the GTs are not in place after their installation (stops, 30%; pharynx, 20%; esophagus, 40%; trachea, 10%), and there exists a significant difference between the results of these two tests (p <0.05). There does not seem to exist any predictive criteria of difficulties during the installation or anomalies of position after the installation (p 0.05).
Conclusion: The recommendation of the systematic checking by a radiological control of the position of a GT must be extended to the fields of emergency medicine. The continuation of this study will allow the definition of predictive criteria.
Key words: feedings; enteral; gastric tubes; insertion; placement
References:
1. Health Care Practice Recommendations. ANAES. April 2000.
Prehosp Disast Med 2001;16(2):s17.
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The "Coordinating-Emergency Physician" in the German Rescue System: Mass Casualties and their Results over Five Years in a Midsize, Populated Region
Purpose: The aims of this analysis were to determine whether the German rescue system is prepared sufficiently to respond to mass casualty situations of degree two or higher 1 and to identify the incidence of these events in a midsize, population-dense region in the south of Germany.
Material: The rescue region of Augsburg covers a region of 4,100 km2 with a population of about 823,000 (city: 265,000; surroundings: 558,000 inhabitants). Since 1996, all mass casualty incidents (MCIs) that included the additional call of a coordinating emergency physician (CEP) have been registered separately by our Rescue Coordination Center (RCC). The indications used to call the CEP include: (1) 3 or more emergency physicians needed at the scene, (2) there are more than five severely injured victims, or (3) more than 10 injured persons.
Since 1999, there were 34 events, all of which were prospectively registered and reviewed to identify if the CEP Group-Augsburg is prepared to handle successfully future events, especially MCIs of third degree level that have been occurring with increasing frequency all over the country during the last few years.
Methods: To gain a good reliable documentation allowing quality control efforts, we applied some elements of Villareal`s quality control modules:[1]
1st degree (minor): Only parts of local resources involved
2nd degree (mutual aid): Managable with local facilities
3rd degree: Regional resources exceeded
Results: 34 calls occurred and all of them were analyzed: 20 calls happened during the night and 14 during the day (three in the morning, 11 in the afternoon). There were 19 fire alarms, six traffic accidents, four poisonings, three explosions, one mass gathering, and one natural disaster. In total, about 580 patients were served. The lowest number per event was two people landing a duck plane, and the highest number was about 150 people during a great outdoor event in the city. According to the seasonal distribution, there was an increase of events from six calls in spring to 12 calls in winter. There were 26 events classified at a 1st degree level; seven events at a 2nd degree level; and one at the 3rd degree level.
In each of the events, individual emergency medical care was provided to all of the victims, and none of these died due to triage reasons. Afterwards, each event was exactly analyzed for quality of the response and care delivered. From these results, we developed a new documentation sheet to facilitate the immediate, full, and standardized documentation at the scene.
Conclusion: All over Germany, the increasing number of MCIs requires specially trained physicians and coordination of the rescue in order to handle these events and to provide sufficient prehospital care to all of the victims. The establishment of official CEP groups with clearly defined tasks, rules of liability ,and fields of competence as indicated under German law will help to guarantee individual emergency medical care to all of the victims. In the future, further work must be done to be prepared for greater events. Excellent documentation and analysis of each event is necessary.
References:
1. Villareal M: QC module for mass casualties. Prehosp Disast Med 1997; 12(3):200-209.
Key words: coordinating emergency physician; management; multicasualty incident; rescue; system; victims
Prehosp Disast Med 2001;16(2):s17.
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Staff Qualifications for Providing Ventilation during Mass Toxicology Event
A toxicology event is one of the most frustrating events that can face a medical staff. There is difficulty in identifying the cause in real time, the influence on multi-organ systems, as well as the number of injuries. This creates a challenge for medical staff anywhere in the world.
The state of Israel, with its uncertain security situation, must deal with this issue, not only in theory, but also with an operational program that can be implemented in real time.
The Medical Center's management assumed that, with most of the scenarios of a mass toxicology event, the Medical Center may be short of workers, as well as technological devices such as respirators. Therefore, the Center for Resuscitation and Emergency Medicine Education (CREME) of the Tel Aviv Sourasky Medical Center (TASMC), developed a qualification program for non-medical staff in the Medical Center to be used as ventilators in emergencies situation. The program provides ongoing teaching and simulation for laboratory technicians to change their role. The course includes lectures and simulations of Basic Life Support and Airway Management. It continues one day, and is refreshed every three months. The participants include 180 laboratory workers of the Medical Center.
This paper presents the program as well as the evaluation of these activities after one year with updated knowledge.
Key words: curriculum; emergencies; evaluation; laboratory personnel; nonmedical staff; toxicological event; training; ventilation
E-mail: beningoren@yahoo.com
Prehosp Disast Med 2001;16(2):s 18.
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French Teaching Method to Export Disaster Medicine to Foreign Countries
Devastated by numerous disasters, Cameroun recognized its need for disaster planning and requested assistance from Doctor X. Emmanuelli, president of SAMU Social. SAMU Social is an organization in France that provides health care access to those for whom it is not usually available. SAMU then creates partnerships with faculties already involved in teaching Disaster Medicine, such as the Faculty of Créteil.
This team addressed the issues and developed a plan to identify the groups who must be involved. The course is open to doctors, nurses, technicians, and administrators. These groups are selected cooperatively by the SAMU Social International and the University of Yaoundé.
"Teaching the Teachers" is a two-year program that trains health care professionals to be the teachers of Disaster Medicine in a particular country. The program consists of 16 three-day sessions. Each session is similar in format. The morning program uses lectures to outline the goals of the three days and how the goals would be met. Step-by-step evaluation from research is carried out between sessions. The afternoon program is comprised of small group workshops. The workshops focus on problems that are specific to Cameroun. At the end of the three-day session, the participants are given tasks for the next session. After completing one year, participants are required to prepare a report on their area of expertise. During the second year, participants must attend a mock disaster drill in France. During these two years, other groups and organisations such as civil defense, Ordre de Malte, and/or the Ministry of Education may be invited to participate in specific sessions to create educational programs for a broader population. Certification takesplace at the completion of the two-year program.
It would be essential for international aid groups to assist Cameroun in making the transition from their dependence on France to independence.
Key words: certification; civil defense; curriculum; disaster; Disaster Medicine; course development; education; population; teachers; teaching
Prehosp Disast Med 2001;16(2):s18.
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Automated External Defibrillator Use during Cardiopulmonary Resuscitation in a Workplace
Introduction: Automated external defibrillation, a new link in the chain of survival, should reduce the mortality rate after prehospital cardiac arrest. In association with basic cardiac life support, automated external defibrillator can be used by individuals other than physicians during cardiopulmonary resuscitation. Early defibrillation can be performed by bystanders in a workplace as in the following case.
Case report: A 50 year-old man presented with sudden cardiac arrest in his workplace. Basic cardiac life support was performed by trained bystanders 3 minutes later. Defibrillation was delivered by automated external defibrillator 7 minutes later with successful conversion to spontaneous circulation. The patient was admitted to a cardiology intensive care unit. Angiography performed 1 hour after recovery diagnosed acute myocardial infarction, which was treated by angioplasty. Outcome was favorable, the patient was discharged home four days later with a discreet disorientation to time and place.
Conclusion: The time interval before the delivery of the first shock clearly is a determinant for survival after prehospital cardiac arrest. Use of an automated external defibrillator, by individuals other than physicians, in the chain of survival, can contribute to an earlier defibrillation. It can be useful in workplaces after specific and basic cardiac life support training.
Key words: automatic external defibrillator; cardiopulmonary arrest; chain of survival; defibrillation; nonphysicians; survival; training; workplace
Prehosp Disast Med 2001;16(2):s19.
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The CDC National Pharmaceutical Stockpile Program: An Overview
A release of selected biological or chemical agents targeting the United States civilian population will require rapid access to quantities of pharmaceuticals, antidotes, vaccines, and other medical supplies. In such an event, state, local, and private stocks of medical material will become depleted quickly. No one can anticipate exactly where a terrorist will strike, and few local governments have the resources to create sufficient stockpiles on their own.
With this in mind, the Centers for Disease Control and Prevention (CDC) have created the National Pharmaceutical Stockpile Program (NPSP). The NPSP is responsible for the purchase, storage, and deployment of pharmaceuticals, supplies, and equipment that localities will need in a chemical or biological terrorist incident. The NPSP can help bolster state and local response capacity, and be one of the keys in mitigating the results of a bioterrorist incident.
The broad role of the CDC is to ensure that Federal, State, and local levels of the public health partnership coordinate efforts and work with the medical and emergency response communities to prepare for acts of biological and chemical terrorism.
Attendees at this session will have an understanding of the role and capability of the National Pharmaceutical Stockpile Program.
Key words: bioterrorism; CDC; emergency response; stockpile
E-mail: sgb3@CDC.gov
Prehosp Disast Med 2001;16(2):s19.
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Peculiarities of Medical-Sanitary Provision of Peaceful Population in Conditions of Complicated Emergencies
The 20th century in the history of mankind will be judged not only by its scientific and technical achievements, but also for its tragic public and social phenomena, one of which is a local military conflict. The world permanently collides with considerable expansion of geography of interethnic, religious, and territorial conflicts. The experience with complex emergencies@ health relief operations proves that a great number of the civil population suffers in these emergencies. One of the most difficult problems is the fact that the public health system must organize and implement, in difficult conditions and in the shortest time, the provision of health services for a great number of displaced people.
At the same time, very often, some part of public health infrastructure on the territories where these people are mainly located, cannot satisfy the provision of their full medical necessities. While studying the experience of health provision of population in the Chechen Republic in 1999@2000, it was established that: (1) the population had moved to the nearest areas of the Russian Federation (98.2%); (2) the structure of temporary displaced population belonged, for the most part, to children and women (45 and 40% respectively), and to men, only 15%, and (3) the temporarily displaced population was located in specially equipped settlements (camps) and dwellings.
From available data, it may be assumed that population movement outside the zone of the conflict is a process that is difficult to control. Not the least of the factors that negatively impact public health rehabilitation is the absence (from the first days) of the administrative governmental bodies, as well as disorders of public health management system for the territory liberated from illegal military units. In organizing medical care to the peaceful population, it@s necessary to have data on medical-evacuation characteristics of sanitary losses among civil persons. However, this question hasn@t been solved theoretically, and it demands further scientific working out.
Key words: camps; complex emergencies; demography; displaced populations; management; military; public health
E-mail: rcdm.org@g23.relcom.ru
Prehosp Disast Med 2001;16(2):n19.
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Prehospital Management of Acute Myocardial Infarction: Role of a Medical Network
Corsica, one of the widest of the Mediterranean islands, has two difficult-to-manage specificities: (1) a rough topography with a lot of isolated villages in mountainous areas, and (2) one the highest rates of Acute Myocardial Infarction (AMI) in France. The cold and treacherous winter weather exacerbates the problems with both specificities and turns early AMI management into a challenge. In order to respond to "Time is Muscle", an Emergency Medical Network was developed in September 1999.This network is based on "first-line" private practitioners, some of them also being fire-brigade physicians, distributed across the countryside, and trained in emergency care, including the prehospital management of patients with an AMI.
The network, coordinated by the SAMU (Prehospital EMS), includes a Medical Rescue Helicopter as the spearhead of the system. Public advertising of the system was done. First-line physicians are activated by direct calls by the patients (private practice) or by SAMU regulation. As soon as they confirm the presence of an AMI, they start the first part of the thrombolytic protocol, while SAMU dispatches the medical rescue helicopter with an emergency physician and thrombolytic drugs to the scene. If the first line is outside a reasonable time line to reach the scene by the "first line" physician, SAMU will send the helicopter team as a first response. The objective is to start thrombolytic therapy wherever the patient is. So, easy to utilize drugs (e.g. as one-shot thrombolytic and LMWH), are the best choice in such difficult areas.
In the 20 months from implementation, the network has managed nearly 100 patients with an AMI, with an average time of less than 1 hour between alert and initiation of thrombolysis, and with good results.
Key words: acute myocardial infarction (AMI); helicopter; outcome; physicians; remote areas; responses; SAMU; system; team; thrombolysis
Prehosp Disast Med 2001;16(2):s20.
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Typhoon-Related Disasters
On 22 August 2000, Typhoon Bilis, by far the strongest of the season, approached Taiwan and left 14 people dead including 8 villagers buried in a mudslide in central Taiwan where a major earthquake had occurred just the previous year. Some people in a mountain climbing exploration were missing. On 28 August 2000, 6 days after Typhoon Bilis, a major bridge in southern Taiwan collapsed suddenly and injured 22 people. On 31 October, Typhoon Xangsane moved closer to Taiwan.
In the meantime, a Singapore Airlines Boeing 747 jetliner carrying 159 passengers and 20 crew bound for Los Angeles, crashed shortly after takeoff leaving 83 people dead and 56 injured.. Although the weather conditions at the airport were within safe takeoff tolerances, the visibility was very poor and the pilot chose the wrong runway. The next morning after the airplane crashed, flooding in northern Taiwan killed at least 61 people: some people were down in the basements, including 14 elderly people in a nursing home.
The impact of typhoons should not be underestimated. Serious damage can occur before, during, and even days after the arrival of typhoons. Preparedness in all aspects is needed to cope with these disasters. Loss of electricity, water supply, and telephone services including cellular phone dysfunction could be serious problems in a rescue work. Alternative measures must be planned.
Key words: air crashes; damage; events; flooding; infrastructure; mudslides; typhoons
Prehosp Disast Med 2001;16(2):s20.
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Surveillance and Care System for Abdominal Trauma
This is a description of a system for surveillance and care for victims of abdominal trauma. According to an objective assessment and score of the severity of the trauma to the abdomen, we classified the nursing care into three types, and drew up eleven principal nursing-care policies. In clinical practice, it has been effective both in improving the working initiatives and enhancing the comprehensive analytic ability of nurses. It has also increased the injured patient's survival rate.
Key words: abdomen; care; effects; injuries; nursing; policy; surveillance
Prehosp Disast Med 2001;16(2):s20.
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Disaster Medical Team Deployment for the Sydney 2000 Olympics
Sydney hosted the 2000 Olympics during September 2000. As part of the medical support of the Olympics, a number of disaster medical teams were organised and deployed. This presentation describes the organisation of these teams and their preparation for the Olympics. In particular, the findings of the first multiagency CBR exercise will be described, and how the health teams interfaced with the other agencies. The presentation also will describe what was learnt and will discuss and debate the challenges apparent in initiating such a deployment to an event as large as the Olympics in the city of Sydney.
Key words: deployment; interface; medical support; Olympics; organization; preparedness
E-mail: David_Cooper@wsahs.nsw.gov.au
Prehosp Disast Med 2001;16(2):s 20.
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Quality Care of Short Stay Unit Relevant to Critical Care and Emergency Services
Objective: Assess care indicators of a Short Stay Unit to: (1) to know care activity, and (2) to detect modifiable problems by care improvement measurements.
Methods: A retrospective observance study was conducted and included all patients attended in a Short Stay Unit (relevant to Critical Care and Emergency Services) at Virgen del Rocío Universitary Hospital (Sevilla), during the first semester of the year 2000. This Short Stay Unit is defined as a prolonged observation unit, basically a therapeutic, multifaceted unit for the care of patients that have low diagnostic and therapeutic complexity, and the stays are estimated initially at <3 days. We assessed age, gender, occupation grade, pathology by RGD, procedures, mortality, number of reentries, and medicament-taking. The data were provided by Clinical Documentation and Pharmacy Services of Virgen del Rocío Universitary Hospital.
Results: The number of admissions was 630, relative to 590 patients. The mean value for age was 75 years, and were predominantly female (59.3%). The mortality rate was 9%. The distributions of attended pathology was: shock and heart failure, 26.6%; angina pectoris, 10.6%; COPD, 11.5%; complicated simple pneumonia, 2.6%; breathing problems (excepting infections, asthma, and COPD) with main complications, 7.8%; uncomplicated heart attack (IM), 1.6%; complicated IM, 2.6%; congestive heart failure and pulse-rate alterations with main complications, 2.6%; and others, 34.4%. The mean value for a stay was 4.3 days, and the percentage of stays longer than 15 days was 5%. These patients had a high consumption of global stay (26.5%). These populations corresponding to stroke without family support, infected decubiti, retention of secretions and severe deterioration of patients with extenuating social problems. The hospital readmission rate was 3.2%. The resolution efficiency (discharge from hospital plus exitus) was 91.4%. The total cost of medicaments were 40,087e.
Conclusions: The Short Stay Unit is a highly productive unit that can be improved by using adaptation admission and has a great potential for growth.
Key words: activity; admission; critical care; emergency care; indicators; intensive care; pathology; short stay unit
E-mail: montilla@arrakis.es
Prehosp Disast Med 2001;16(2):s21.
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Diagnostics Agreement at Discharge from Hospital With Thoracic Pain in a Hospital Emergency Service
Objective: Identifying diagnostic agreement at discharges from the hospital of attended patients with atypical thoracic pain and stable angina pectoris at the Emergency Section relevant to Critical Care and Emergency Services.
Methods: Cross observance study about discharges with atypical thoracic pain and steady angina pectoris diagnostics, including resolved hemodynamic angina pectoris, for 7 weeks between 08 May and 25 June 2000. A database was designed to collect data from the clinic archives (vascular risk factors, complementary data requested, and destination of patient). Thirty days later, we conducted a telephone survey of all the patients included in the study. We assessed the decrease in cardiac causes or sudden death, admission by heart attack (IM), unstable angina pectoris, malignant pulse-rate alterations, consultation at the Emergency Service by the same reason with different diagnostics, and ischemic cardiopathy diagnoses at cardiology outpatient departments.
Results: 106 discharges were reviewed: 93 of these had atypical thoracic pain, 9 had stable angina pectoris, and 4 had hemodynamic angina pectoris. The mean age was 52 years. 52% (56 cases) had no vascular risk factors, and only 6 cases had four factors: tobacco habit, high blood pressure, diabetes, and lipidoses. Rx thoracic was done to 83 patients (78.3%). Measurement of CPK blood levels were performed in 63 patients, and troponin blood levels only for 4 patients. There were three events: previous consultation with different diagnosis of atypical thoracic pain group, unstable angina pectoris, and death. The death occurred in a senile patient who had premorbidity factors.
Conclusions: The small number of events collected indicates an acceptable level of diagnostic agreement for thoracic pain at our Emergency Service, but we noted that EKGs are underused in this type of patient.
Key words: angina; atypical; chest; diagnosis; ischemia; pain; risk factors
E-mail: montilla@arrakis.es
Prehosp Disast Med 2001;16(2):s21.
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Proposal of Standardization Protocol Care of Abdominal Pain in Emergency Room
Introduction: A patient arriving at the emergency room complaining of abdominal pain often represents a challenge for the physicians and the nursing staff. The most important aspect is the exclusion of certain pathologies and inclusion of others in order to establish the differential diagnosis.
Objectives: The objective of this work was to achieve a practical document regrouping the principal causes of abdominal pain, so as to orient the diagnosis in such a manners that is based on the anamneses of pain described.
Method: Theoretical research, inquiry in the opinion of patients suffering of abdominal pain, elaboration and testing of the anamneses document, and the gathering of commentaries from emergency nurses were used.
Results: The theoretical part of this work contains all of the pathologies that have an abdominal pain syndrome. The standard anamneses document for abdominal pain would permit one to target, in a structured manner, the appropriate questions to orient the diagnosis of a patient arriving at the emergency room for an abdominal pain syndrome.
Conclusions: This is a vast subject that is difficult to comprehend in a short period of time. However, the crucial basic analysis was brought into more easily understood proportions, by the nursing staff.
Key words: abdominal pain; diagnosis; differential; protocol; syndrome
Prehosp Disast Med 2001;16(2):s22.
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Difficulties with Identification of Living Patients after Fires in a Hospital
Introduction: Identification of patients in cases of disaster is a currently studied problem and most studies have been based on dead patients. Many identification systems have been suggested in order to centralize patient hospital files. However, in cases of an emergency or disaster event occurring in an hospital, some patients may still be alive but may not be identified, and their past medical history, treatments, and hospitalisation motives may remain unknown as is demonstrated in the following cases.
Case 1: A fire occurred at 03:00 hours, in a private hospital in the Seine-Saint-Denis area in France. Fifty-six persons were potentially poisoned by smoke inhalation including 4 patients with clinical signs of severity. The mean age was 72 years old. Six patients (11%) where not identified, including one comatose patient.
Case 2: A fire occurred at 04:00 hours, in a medicalised home for the elderly in the Seine-Saint-Denis area in France. Seventy-eight persons were potentially poisoned by smoke inhalation. Every patient was more than 71 years old; 7 patients died (9%), 12 patients were severely poisoned (15%) requiring intubation in 10 cases, and 14 more patients were admitted to the hospital. Ten patients (13%) were not identified, including 3 dead patients and 5 intubated patients.
In both cases, past medical history, treatments, and motives for hospitalisation were unknown because patient files were not accessible
Casualties_Unidentified
N Dead Intubated Others Total
Case 1 56 0 1 5 6
Case 2 78 3 5 2 10
Conclusion: In both cases, the identification of the patients was difficult even though patients were alive and conscious. Although reliable methods exist for the identification of dead patients in case of a disaster, identification of hospitalised patients remains difficult when the patients are not able to identify themselves. Impairment of consciousness is not the only reason for this difficulty. In elderly people, patients suffering dementia were not identifiable. Identity bracelets associated with a chip or a bar code could be helpful in these situations. Furthermore, this identification method would be even more useful if it could give access to the patient's medical file. Indeed, in case of a disaster occurring in a hospital, medical care must take into account a patient's past medical history, hospitalisation motive, and current treatments. Only an accessible hospital data system in association with this identification system would be able to optimise a patient's care in case of disaster occurring in a hospital.
Key words: disaster; elderly; hospital; identification; living; medical records; patients; system
Prehosp Disast Med 2001;16(2):s22.
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Salvador 2001
After a violent earthquake occurred in El Salvador (magnitude on the Richter scale, 7.9), the Salvadorian government requested international help. In response to their call for assistance, French and German teams were sent. The poster illustrates the cooperation with many teams in order to give help and assistance to the Salvadorian population.
Key words: assistance; earthquake; El Salvador; French; German; teams
E-mail: usc7@club-internet.fr
Prehosp Disast Med 2001;16(2):s23.
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Disaster and Airport: Boarding Area Sorting Center as an Advanced Medical Post (280 M2)
A sudden concentration of victims on an airport is not always due to a flying accident; air terminals are high risk areas (Hambourg = fire, Orly = armed attack, Marseille = hostages), and are important mechanisms used for transport during disasters or evacuations of the injured (Furiani = 300 patients in 6 hours). This eventuality justifies the creation of a "ready to use" structure.
In the last 15 years, SAMU and Marseille airport (6 millions passengers, 3rd airport of France) have a Medical Advanced Post or sorting center inside the airport. Its boarding area already is equipped and a new version will be finished in June 2001. It is 280 m2, on ground floor, and open on tracks. It contains 12 heavy emergency boxes, a zone for moving 20 to 50 injured, and a small emergency area. From this place, you can directly call police or the authorities. We@ve got different movable desks with telephone and radiophony.
Next, in this place, a 25 m2 tall section for equipment, drugs, water, shower, and everyday instructions. For the airport authorities and SAMU, the problem was to select an area and to foresee, when building, the oxygen/emptyness, and sound protection. However, this type of organization has a lot of advantages. First, for the airport, it is economical, since the area can be used everyday by passengers—it is not unusable space—and walls, equipment, oxygen, etc., are hidden from view. The general operation of the airport includes the maintenance of this area by employees and technical agents. For SAMU, it provides adapted and clean quarters near the tracks and terminals. Management requires doctors and nurses to verify all of the equipment once a month. In case of disaster, we will add to this equipment, one more PMA batch.
During last 10 years, we have managed eight serious incidents, and have conducted several simulations. It improves our concept and also encourages, if necessary, collaboration between airport direction and SAMU 13.
Key words: airport; cost; disasters; equipment; planning; preparedness; SAMU
Prehosp Disast Med 2001;16(2):s23.
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Clinical Evaluation of New Ways of Administration of Oxygen: Tusk Mask II and Double Trunk Mask
Objectives: Administration of oxygen in the emergency department or in the intensive care unit can be provided in different ways: (1) nasal oxygen cannula, (2) oxygen catheter, (3) normal mask, or (4) non-rebreathing mask(NRM). We compared the efficiency of each of these ways in relation to new systems: the Tusk Mask (TM II), and Double Trunk Mask (DTM)
Method: The TM II is a modification of the Tusk Mask described by Hnatiuk.1 It is composed of a normal mask in which a lateral hole of 22 mm is made on each side. A ringed tube, 19 cm long and 22 mm in diameter, is attached to each side. Thirty patients requiring the administration of oxygen in the intensive care unit were studied. Oxygen was given first through an oxygen catheter. Thereafter, oxygen was delivered by oxygen catheter and normal mask.
This then was replaced by a TM II. The data measured are the PaO2, the PaCO2, and the breathing rate. Oxygen was given at the rate of 3 litres per minute. The DTM is the same system with a ringed tube of 38 cm. The oxygen was given first through NRM and replaced by a DTM. Fifty patients were studied. The data measured are the same. Oxygen was given at the rate of 8 litres per minute.
Second part
Oxygen nasal cannula Normal mask TM II
PaO2 (mm Hg) 88.8 104.8 (+18%) 154.2 (+74%)
PaCO2 (mm Hg) 41.1 40.9(-1%) 42.6 (+4%)
Breathing rate 20 19 20
Third part
NRM DTM
PaO2 (mm Hg) 171.48 278.05 (+62%)
PaCO2 (mm Hg) 39.28 41.15 (+5%)
Breathing rate 17 17.5
Conclusion: The TM II and the DTM appear to be very efficient in increasing the PaO2 in patients without noticing any rise of the PaCO2.
Key words: administration; cannula; catheter; efficiency; masks; oxygen; double trunk mask; tusk mask
Prehosp Disast Med 2001;16(2):s23.
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The Role of NGOs in Management of Accident Victims in Nigeria
Nigeria, like so many other developing countries, has a history of poorly coordinated responses to accident and emergency victims. The rigorous policy of "pay-before-treatment", with attendant bureaucracy and an "out-of-stock" drug syndrome, have claimed the lives of several victims. Hence, a non-governmental organization (NGO), like SAVAN (Save Accident Victims In Nigeria) acts for the relations of the victims in the absence of their biological relations. In collaboration with designated hospitals, it has been documented that these organizations increase the chances of survival of accident victims. The saddest aspect is the often common incidence of unknown victims with consequences of mass burials of such victims, even without concrete efforts to trace the biological relations. Hence, the birth of SAVAN could not have come at a better time and several victims are known to have benefited.
In Nigeria, one out of every three accident victims dies, and since the civil war, no other pathology or phenomenon has claimed the lives of more Nigerians than have road traffic accidents. In short, the World Bank has described the roads in Nigeria as the most dangerous, yet the medical response to these accidents is abysmally poor. The complementary role of SAVAN can not be over-emphasized.
Key words: accidents, traffic; biological relations; developing countries; roads; SAVAN
E-mail: eddyenis@uniben.edu
Prehosp Disast Med 2001;16(2):s24.
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Correction of Gemostasis of Pregnant Women with Gestosis
Introduction: The effects of the administration of glucocorticoids as part of the treatment of pregnant women with gemostasis has not been defined.
Methods: This investigation was carried out with 102 pregnant women with severe gestosis (18@38 years old). They were allowed to give birth by means of Caesarian operation and were separated into two groups: Group I had correction of detected changes of gemostasis carried out by the use of dexon in a dose of 0.5 mg/kg/day intramuscularly; and Group II had no treatment. The investigation was carried out in two stages: (1) at the time when the women were received at the maternity home, and (2) on the 4th day after operative delivery. The fibrinogen level, prothrombin index, and a count of the number of thrombocytes in the blood was determined.
Results: It was shown that as the result of treatment, in Group I, the level of fibrinogen increased significantly by 21% (from 284 ±18 mg% to 343 ±21 mg%) (p <0.05). At the same time, in Group II, levels increased by 6% (to 301 ±16 mg%) and this was not significant statistically. It was possible to differentiate between the two groups (p <0.05). The protrombin index in both groups did not change significantly. In Group I, the number of thrombocytes increased by 38% (from 219 ±18*109/l to 302 ±23*109/l) and the change was significant statistically (p <0.05). For Group II, the thrombocytes increased only by 11% (to 243 ±21*109/l), and the between group difference was significant statistically (p <0.05).
Conclusion: Under the influence of glucocorticoids, the increases in the content of blood fibrinogen levels and in the number of thrombocytes are defined. They should be administered with other treatment for prophylaxis and treatment of bleeding in delivery and in early postdelivery periods.
Key words: fibrinogen; glucocorticoids; gemostasis; gestosis; pregnancy; prothrombin index; thrombocytes
E-mail: Elioutine@mail.ru
Prehosp Disast Med 2001;16(2):s24.
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Endogenous Intoxication in Women with Preeclampsia
Introduction: The aim of this research was to decrease the endogenic intoxication in women with sever levels of preeclampsia by use of a glucocorticoid (dexon).
Methods: Investigation was carried out with 169 pregnant women without preeclampsia (16-40 years old) and with 102 pregnant women with preeclampsia (18–38 years old). They were allowed to give birth by means of Caesarian operation and were separated into two groups: Group I had correction of endotoxicosis using dexon, 0.5 mg/kg/day intramuscularly; Group II did not receive dexon. The investigation was carried out in four stages: (1) at the time when the women arrived at the maternity home, and (2) on the 1st, 4th, and 7th day after surgical delivery. The Leukocyte Index of Intoxication (LII) was used as a criterion for endogenic intoxication.
Results: Women with preeclampsia in comparison with healthy women were marked with large LII increase in all stages of the investigation. This finding indicates hypersensitization of the organism. In healthy women and women with preeclampsia, either the LII levels became decreased by the 7th post-operational day. This change evidently was the result of pheto-placental complex elimination as the initial cause of autoimmunization. Dexon administration allowed the levels of LII to be reduced during all stages of investigation.
Conclusion: During preeclampsia, the cause of LII increase is due to surplus autoallergication resulting in prolonged subcompensating endotoxicosis. Dexon (5 mg/kg/day) reduces autoimmunization, which may be a reason for the cascading metabolic reaction, and the basis of a systemic inflammatory reaction during preeclampsia.
Key words: autoimmunization; glucocorticoids; intoxication; preeclampsia; pregnancy
E-mail: Elioutine@mail.ru
Prehosp Disast Med 2001;16(2):s24.
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Individual Psychological Profile of Women with Gestosis
Introduction: Pregnancy (leading to the immune conflict) and gestosis, which often appears as multiple organ dysfunction syndrome (MODS), cause the formation of an encephalopathia, and as a result, changes of the psychological peculiarities of a person. Their appraisal is very important while preparing pregnant women for delivery.
Methods: The psychological peculiarities were investigated with the help of the scale of alarm displays (J.Teylor) and the test of H. Eysenck. Twenty-four patients with severe level of gestosis were examined (age 18–36 years old). The patients were classified into two groups: Group I were treated with nootropil per os for 10 days (mid-day dose = 1,200 mg); and patients in Group 2 did not receive nootropil. The investigation was carried out in two stages: (1) on admission of the patient to the maternity home; and (2) at 10 days after operative delivery.
Results: At the first stage of a severe level of alarm (32.4 ±3.4 grades), high level of psychological instability: neuroticism, 19.3 ±1.6 grades) and introvertiveness, 5.4 ±0.9 grades); and a high level of psychotism, 13.8 ±1.5 grades) were detected. After the treatment, the level of alarm decreased to 22.1 ±2.8 grades), but without treatment, it remained elevated, 28.6 ±3.0 grades (p <0.05). The level of neuroticism in Group I reached a middle level (15.3 ±0.9 grades), but in Group II, it remained high (18.8 ±1.3 grades; p <0.05). In both groups, introvertiveness scores 6.2 ±08 grades and 5.9 ±0.4 grades in Groups 1 and 2 respectively were preserved. Psychotism in Group 1 was 11.4 ±2.1 grades, but in Group 2, they were greater than the average level (12.9 ±1.5 grades).
Conclusion: The psychophysical peculiarities of patients with gestosis that were revealed require prophylaxis and therapy including psychocorrection, a balanced diet, and noothropiltherapy.
Key words: alarm; gestosis; neurosis; pregnancy; profile; psychologic; psychosis; treatment
E-mail: Elioutine@mail.ru
Prehosp Disast Med 2001;16(2):s 25.
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Treatment Methods of Disorders of Contracting Uterus Activity
Introduction: The problem of treating the disorders of contracting uterus activity (DCUA) remains of topical interest in obstetrics.
Methods: In the first group consisting of 52 women (the age 16–40 years old) the correction of DCUA was carried out by injecting 20 mg of morphine intramuscularly. To the second group of 42 people (15–42 years old) epidural injections of 0.5 mg of morphine were given. The injections were prescribed after the diagnosis DCUA was confirmed. The effectiveness of treatment was checked clinically. The effects were checked by investigating the reaction of adrenal glands (on the grounds of the level of eosinophils), the reaction of thyroid glands (on the grounds of the general metabolism), by determining the vegetative index Kerdo in stages when the diagnosis DCUA was confirmed, and 10 days after the injection of morphine was given.
Results: Epidural injections of morphine decrease the stress activity of the cardiovascular system. The duration of the birth act was reduced to 52%, the checkup of newborn babies according to the scale APGAR had better results, the frequency of operative delivery was reduced to 39%, and the related complications to 35%.
Conclusion: Epidural injections of morphine are more effective (in comparison with the intramuscular) method of correction of DCUA.
Key words: epidural; morphine; intramuscular; obstetrics; uterus contractile disorders
E-mail: Elioutine@mail.ru
Prehosp Disast Med 2001;16(2):s25.
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Neuropsychological Status of Patients with Peritonitis
Introduction: Neuropsychological changes have been observed in some patients who have peritonitis. The nature and etiology of the changes have not been documented.
Methods: The neuropsychological status of 32 patients with peritonitis was studied by: (1) testing the attention (Shoolte), (2) testing the short-term and long-term memory using methodic "memory on shape", and (3) studying auditory-vocal memory, and testing mental abilities (IC Raven). Thirty-two patients with peritoneal intoxication in the stage of decompensation (age 18@46 years) were evaluated. Patients were separated into two groups: Group I had treatment for detected changes using nootropil administered for 21 days (mid-day dose = 1,200 mg); Group II did not receive nootropil therapy. Examination was carried on in two stages: (1) at the time of admission to the maternity home, and (2) at 21 days after the beginning of the treatment.
Results: Patients with decompensating endogenic intoxication showed weakness of attention. Short-term and auditory-vocal memory decreased to nonexistant and mental ability decreased (2.6 ±0.4 grades). After the treatment, attention was restored, and increasing memory and of mental abilities were demonstrated (to 5.4 ±0.7 grades) (p <0.05). In Group II, the second stage thinking decreased reaching 4.1 ±0.5 grades, and improvement of memory and attention were uncertain.
Conclusion: Neuropsyhological deviations required, in addition to main methods of treatments, specific therapy (psychocorrection, vasoactive, noothropic therapy) in cases of patients with endogenic intoxication in peritonitis.
Key words: attention; decompensation; intoxication; memory; mental abilities; nootropil; peritonitis; therapy; vasoactive
E-mail: Elioutine@mail.ru
Prehosp Disast Med 2001;16(2):s26.
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Postoperative Stress Reaction in Cases of Women with Gestosis
Introduction: The problem of intensive therapy of gestosis remains urgent in obstetrics. Here, both gestosis and surgery can be stressful agents that cause a definite reaction of the endocrine system.
Methods: The glucocorticoid function of the adrenal cortex and the thyroid reaction of 404 women (age 16-38 years) was assessed. The patients were allowed to give birth by means of Caesarian operation, and then were separated into two groups: Group I had severe gestosis; and Group II had moderate gestosis. The level of gestosis was determined on the basis of our own Vittlinger scale. Each group included two subgroups: (1) treatment with dexamethazone (0.5 mg/kg/day) intramuscularly, or (2) no dexamethazone. The aim was to determine the number of blood eosinophils and basic metabolism one day before the operation, and at 1, 4, and 7 days after the operation.
Results: The number of eosinophils was less during any stage in those subgroups of patients who received the dexamethazone than for those who did not. Basic metabolism was more indicated in either of the subgroups using dexamethazone.
Conclusion: Administration of glucocorticoids (dexamethazone) avoids glucocorticoid insufficiency that is related to failure of stress hormones (particularly adrenal glands cortex hormones), ensures a complete adaptive reaction from the combined stresses of both gestosis and surgery, and prevents depression of thyroid activity and its concomitant decrease a basic metabolism.
Key words: eosinophils; gestosis; glucocorticoids; metabolism; obstetrics; stress reactions; thyroid function
E-mail: Elioutine@mali.ru
Prehosp Disast Med 2001;16(2):s26.
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Verification Criterion of Preeclampsia: Creation of Autoantibodies
Introduction: The problem of searching for new methods of the earliest diagnostics of gestosis aimed at the coordinated correction of consequences of disturbances remains a central issue in obstetrics. In this work, an attempt was made to estimate the viability of a range of organs by determining a titer of specific antibodies.
Methods: The comparative inspection of 13 healthy women (age 18@30 years), and 18 patients with the severe form of gestosis (age 19-32 years) were carried out. Determination of the specific antibodies titer carried out one day before the operation and at 1, 4, and 7 days after the operation.
Results: The investigation indicated that a moderate increase or absence of specific antibodies in small titers (1:16-1:32) up to the 4th postoperative day. This is a reflection of moderate autosensitization. Women with gestosis had increases of antibodies in high titers (1:128-1:256) in one day, at days 1 and 4 after the operation. This proves the hypersensitization with the threat of transition to autoimmune depression. It was determined that gestosis causes the expressed degenerative processes covering mainly liver, kidneys, lungs, and retina.
Conclusion: The use of the specified methods allows early diagnosis of the organ disturbances.
Key words: autoantibodies; gestosis; preeclampsia; sensitization
E-mail: Elioutine@mail.ru
Prehosp Disast Med 2001;16(2):s26.
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Teaching the Teacher Disaster Medicine
The Faculty of Yaoundé has conducted a course in Disaster Medicine since May 2000. This is the result of cooperation between the Samu Social International and the University of Yaoundé. Cameroun has a unique situation because of its economical and social background. Cameroun has had many disasters that affected the whole population. The authorities realised that they had to both prevent as well as respond to disasters. Forthis reason, the course has had priority and is conducted by representatives from all French faculties involved in Disaster Medicine
Key words: Cameroun; disasters; Disaster Medicine; education; faculty; teachers; training
Prehosp Disast Med 2001;16(2):s26.
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Organization of an Emergency Service in Africa: The Case of Yaounde
Should services be adapted to the needs of the local population, and are we managing the services correctly? We found it necessary to create a local network working in Yaoundé. The result of this network is that they have become the central organisation.
Key words: emergency services; needs; organization; network
Prehosp Disast Med 2001;16(2):s26.
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Rapid Defibrillation: A Comparison of Prehospital Cardiac Arrest Victim Survival Rates
Introduction: In patients who suffer out-of-hospital cardiac arrest, the time from collapse to defibrillation is the single most important determinate that affects survival to hospital discharge. The purpose of this study was to compare the survival rates of cardiac arrest victims within an institution that has a rapid defibrillation program to those of its own urban community, with a tiered EMS system.
Methods: Logistic regression analysis of a retrospective data series (n = 23), and comparative analysis to a second retrospective data series (n = 724) were gathered for the study period September 1994 to September 1999. The first series consisted of all patients at Casino Windsor Ltd. who suffered cardiac arrest and the data abstracted included: (1) age, (2) gender, (3) death/survival (neurologically intact discharge), (4) presenting rhythm (VF, VT, other), (5) time of collapse, (6) time to security arrival, (7) time to CPR prior to defibrillation (if applicable), (8) time to nurse arrival, (9) time to defibrillation, and (10) time to return of spontaneous circulation (if any). Significantly, all arrests within this series were witnessed by the surveillance camera system, allowing time of collapse to be accurately determined rather than estimated. These data were compared on the basis of similar events, times, and intervals to a second series that consisted of all patients in the greater Windsor area who suffered cardiac arrest. This series was based upon the Ontario Prehospital Advanced Life Support (OPALS).1 The study database was coordinated by the Clinical Epidemiology Unit of the Ottawa Hospital, University of Ottawa.
Results: The Casino Windsor Ltd had 23 cardiac arrests, all were witnessed, 13 (56.5%) were male, 10 (43.5%) were female. The average age was 61.1 years, average of the time to defibrillation was 7.7 minutes from the collapse of patient, mean value of times of EMS to patient@s side 13.3 minutes of collapse, and VF/VT was the initial rhythm 91% of the time. Fifteen were discharged alive from hospital (65% survival).
The Greater Windsor Study Area had 668 out-of-hospital cardiac arrests: 365 (54.6%) were witnessed; 303 (45.4%) were unwitnessed; 410 (61.4%) were male, 258 (38.6%) were female. VF/VT was the initial rhythm in 34.3%. Thirty-seven were discharged alive from hospital (5.5% survival).
Conclusion: PAD Programs should be extended to any venue with large numbers of adults, and areas with difficult medical access. Device availability has proven to dramatically increase survival rates.
Key words: cardiac arrest; cardiopulmonary resuscitation (CPR); rapid; defibrillation; out-of-hospital
Prehosp Disast Med 2001;16(2):s27.
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EMS Under Fire: Activities during the Intifada—October 2000 to January 2001
Introduction: For the past 3 months, MDA treated 652 wounded persons in 253 Intifada events. Activities were conducted in hostile environment: 5 MDA crew members injured; 53 ambulances damaged; one was burned, and the rest stoned.
Results: Debriefing of treatments and evacuation covered 49 events comprising:
1) Injured, 194: 52 (30%), urgent, unstable; 18 (10%), urgent stable; 79 (45.5%), nonurgent; 25 (14.5%), pronounced dead on scene
2) Gun shot wounds, 60%; stabbing, 8%; explosions, 17%; and the rest MVA
3) Wounds distribution: Head and neck, 12.5; torso, 26%; extremities, 30%; burns, 9%; multitrauma, 18%
The military medical corps was involved in 21%.
Although most events were in rural areas, the average response time was 13 minutes; field treatment (including extrication time and delays due to environmental dangers) 22 minutes; and average time of transportation to hospitals, 18 minutes. Emergency lifesaving procedures in 70 urgent wounded: Intubation/ coniotomy, 36; Chest drain/ needle application, 18; Tourniquet for massive bleeding, 10.
Conclusions: Our main conclusions are: National EMS active and professional in every day activities (300,000, BLS; 90,000 ALS per year) operates equally well in emergency situations. The deployment and organization of MDA enable it to respond well to unexpected emergencies in hazardous locations. The professional skills in trauma treatment (as per PHTLS) of MDA staff at all levels saved the lives of many Intifada victims.
Key words: emergency medical services; Intifada; Israel; trauma; wounds
E-mail: medic@mdais.co.il
Prehosp Disast Med 2001;16(2):s27.
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CT in Diagnosis and Management of Patients with an Acute Abdomen
Objective: To emphazise the importance of CT in the diagnosis and management of patients with acute abdomen. Most of these cases were managed with the clinical findings and abdominal ultrasound, but when the diagnosis was unknown or more information was required, we performed a CT of the abdomen.
Methods: We retrospectively reviewed 403 CT of acute abdomen between January 1990 and August 2000. A final diagnosis was made by surgery. Early CT imaging was obtained within 6 hours after patient arrival.
Results: 403 patients with an acute abdomen were identified, and the underlying causes were as follows: diverticulitis in 87 (21.6%); appendicitis in 73 (18.1%); bowel obstruction in 63 (15.6%); gastrointestinal perforation in 35 (8.7%); acute cholecystitis in 31 (7.6%); pelvic inflammatory disease, 31 (7.6%); necrotyzing acute pancreatitis, 23 (5.7%); ileus in 23 (5.7%); cancer, 13 (3.2%); ischemic bowel, 10 (2.5%); aortic aneurysm rupture, 8 (2%); and hemorrhage, 6 (1.4%). These findings are similar to other studies.
Conclusion: CT is a useful tool to provide valuable information for the diagnosis of the cause of acute abdomen. It allows a rapid, cost-effective evaluation of these patients. CT represents a useful tool in the decision making for surgical or nonsurgical management.
Key words: acute abdomen; computerized tomography (CAT); diagnosis; differential; surgery
Prehosp Disast Med 2001;16(2):s28.
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Relationship of Pancreatic and Peripancreatic Fat Necrosis to Organ Failure in Acute Pancreatitis
Objective: A prospective study to determine the relationship of pancreatic and peripancreatic fat necrosis to organ failure in acute pancreatitis.
Methods: Fifty-six patients out of 275 (20.4%) with necrotizing pancreatitis from 1990 to 1999 .were reviewed Pancreatic necrosis was identified by characteristic findings on dynamic contrast-enhanced computerized tomography scan. Dysfunction was defined in accordance with the Atlanta symposium. We performed a univariant and multivariant statistical study with lineal discriminant analysis.
Results: The overall mortality was 17/275 (6.2%). Surgical treatment 24/275 (8.8%). Organ failure was present in 76.8% of 56 patients. There was statistically significant difference in the prevalence of organ failure in pancreatic necrosis compared with interstitial pancreatitis (p <0.01). The pancreatic head was affected in 9/275 (3.3%), body in 9/275 (18.97%), and the tail in 9/275 (10.2%). 5% had more than 50% of pancreas necrosed. 73/275 (26.5%) patients had peripancreatic fat necrosis.
Patients with increased amounts of necrosis did not have an increased prevalence of organ failure or infected necrosis. The anatomical site also did not correlate with overall clinical outcome. Patients with organ failure had an increased morbidity and mortality.
Conclusion: CT necrosis is not an indication for surgery or mortality. CT imaging helps to identify early, those patients who should be monitored closely to expedite the detection and treatment of complication.
Key words: computerized tomography; multiorgan system failure; necrosis; pancreatitis; peripancreatic fat
Prehosp Disast Med 2001;16(2):s28.
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A Drill as Part of the Training System: Training Hospital Staff to Cope with a Chemical Mass Casualty Event
Since chemical weapons and mass destruction events have a potentially catastrophic effect on civilization, all of the hospitals in Israel are committed by the Ministry of Health and the Medical Corp of the Israeli Defense Forces to prepare for the administration of optimal medical services for a large number of casualties. Successful coping mechanisms of the medical staff for such treatment necessitates special organization based on 5 phases: (1) establishing standing orders and instructions, (2) expansion of facilities and predesignated admitting sites, (3) designation of the hospital staff to the admitting sites and creation of special roles, (4) training programs to assure capabilities and skill performance of the staff, and (5) participating in drills.
These drills, which take place on an annual basis, are a crucial part of the training program. They simulate a realistic scenario, which requires the hospital to allocate the necessary staff (approximately 1,500) and equipment, update the instructions, the standing orders, and implement acquired knowledge. Videos recorded during these drills become a visual educational aid for future training, and even more importantly, for learning relevant lessons from the mistakes. Preparedness for a drill, is a long and complicated procedure that demands a substantial amount of time and resources. In this presentation, we would like to present our model of preparedness for a drill, step-by-step, from the moment we receive an announcement of a drill until the debriefing meetings. "War Games" [drills] are a very important part in the training program aimed to ensure the ongoing preparedness and alertness of the medical staff.
Key words: chemical weapons; disasters; drills; exercises; expenses; games; planning; preparedness; resources; standing orders; training; weapons of mass destruction
Prehosp Disast Med 2001;16(2):s28.
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Medical Opportunity of the Resort to Emergency Wards in the Auvergne
The medical service of the National State Health Insurance Office in the Auvergne, within the context of its mission determined by law, evaluated the medical opportunity of patients to use the 15 emergency wards of the region. A pragmatic method, based on joint opinions of doctors of the medical service and hospital section heads, indicated that a high percentage of patients—18%—who used the service did not need it. In most cases, these patients are rather young adults suffering from harmless diseases that can be treated by a general practitioner, or the elderly who need to be taken in care structures for health care and social welfare.
This overuse of emergency wards for non-emergency care, combined with the increasing overattending of emergency wards, indicated that the prehospital care structure was imperfect. Decision makers, who have in their charge to regulate the care system (Regional Union of the Social Security Offices [URCAM], Regional Hospitalization Agency [ARH]) used this study to establish an optimal organization for the use of emergency wards.
Key words: characteristics; emergency wards; patients; prehospital care; utilization
E-mail: ersm63.doc@wanadoo.fr
Prehosp Disast Med 2001;16(2):s29.
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Activities of JMTDR in Sumatra
Introduction: On 04 June 2000 at 23:28 hours, an earthquake of 7.4 magnitude on the Richter scale struck the southwest coast of Sumatra Island, Indonesia. The initial report said that more than 900 thousands people were involved, and that at least 58 persons lost their lives. Bengkulu City, the state capital of Bengkulu, and its surrounding area were affected. Entrance into the buildings of Yunus Hospital, the largest medical facility in the area and one of the class B hospitals of the nation, was prohibited for security reasons, and hence, all in-patients were accommodated in tents.
Methods: The Japanese Government dispatched its volunteer-based, medical team, JMTDR (Japan Medical Team for Disaster Relief), and the team arrived at the Bengkulu airport 81 hours after the eruption. The JMTDR established a field clinic in the front yard of Yunus Hospital in cooperation with the local headquarter. Information that many injured victims in a mountainous area could not come to see a doctor prompted us to start another field clinic in Tais, a suburb of Bengkulu. A Singapore army team came first and established a field clinic with minor surgery services in Yunus Hospital, and a Taiwanese team built its facility as well in Sukaraja village near Bengkulu. The JMDTR focused its activities on providing medical care for the most vulnerable, namely children and then, the elderly.
Results: The team saw a total of 526 patients (453 in Yunus, and 73 in Tais) within ten days. The frequency distribution of the medical problems seen in Yunus was: 28% respiratory diseases; 16% minor psychiatric disorders such as headache, sleeplessness, or fear sensation; 15% trauma; and 9% gastrointestinal diseases. On the other hand, we mainly saw trauma patients in Tais (88%) and in Yunus (86%). Eighty-two percent of them in Tais lived within 40 minutes distance on foot or by car, but some of the patients (1.2%) took more than 90 minutes to come to our clinics. The Indonesian Government declared that all medical services associated with the earthquake were free, but this announcement was unknown to most of the people. The JMTDR offered them free and accessible medical services in the acute phase.
Conclusion: The rapid establishment of a field clinic affords time to the local medical facilities to reorganize and restore their abilities in this kind of disastrous situation.
Key words: clinics; earthquake; field clinics; hospitals; infrastructure; Japan Medical Team for Disaster Relief (JMTDR); responses
Prehosp Disast Med 2001;16(2):s29.
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Ingestion of Major Caustic Substances by Children
Introduction: The ingestion of caustic substances constitutes more than a third of domestic accidents in developed countries: 80% of them concern children under the age of 5 years. Clinical signs either are atypical and limited, or missing half of the time, and lead to an underestimate of the seriousness of the ingestion.
Methods: This retrospective study (1984 to 2000) on 14 children hospitalised for accidental ingestion of major caustic substances in the intensive care unit of Edouard-Herriot Hospital in Lyon).
Results: The studies showed that these substances were various: 79% ingested bases; 14% acids, and 7% oxidisers (concentrated bleach). Most of the children were <5 years old (57% of them were between 1.5 and 3 years old). All of them showed, at sometime, discrete clinical signs: oral burns (43%), oral oedema (36%), hypersialorrhoea and vomiting (29%), dysphagia and thoracic pains (22%), and premature fevers (14%). A systematic fiberoscopy indicated 100% of digestive lesions, 50% of them being gastric lesions. Ingested bases involved 67% of stage II mucous lesions (as for endoscopic classification): ulcerations, and intense oedema. They also involved 33% of stage III mucous lesions: ulcerations, oedema and profuse bleedings. Acids caused 50% of the stage II lesions and 50% of stage III lesions. The only case caused by an oxidiser involved a stage II lesion. Every patient was treated: 55% of dilations and surgical procedures for stage II lesions, and 80% of them for stage III lesions. Complications occurred frequently (60%), either immediately (chemical epiglottitis) or occurring as long as one year later (lesional or iatrogenical affections). Anamnesia was difficult, practically speaking. Some procedures are dangerous: vomiting, drinks, neutralisations, and stomach tube insertion. The initial undertaking is symptomatic. The child is to be steered within a structure allowing the making of an oesophagogastric fiberoscopy, which always is necessary (50% of absence of correlation between causticity, ingested quantity, and clinical signs). A cervicothoracic x-ray must precede the fiberoscopy when a perforation is suspected. One-third showed the complications, 10% of which are related to stenosing aftereffects. The risk of later development of cancerisation is multiplied by 1,000.
Therefore, any ingestion of major caustic substances by children is serious. The clinical signs are to be accurately searched for, and a premature complication must be avoided. An endoscopic investigation in a specialised unit is necessary. More binding commercial legislation (as for dilution, presentation, and distribution) would be useful.
Key words: caustics; children; complications; endoscope; ingestions; pathology
Prehosp Disast Med 2001;16(2):s30.
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Rescue Clearing in Lyon in the Twentieth Century
Several dramatic landslides occurred in Lyon in the 20th century. Expert's reports were obtained on many of them. These catastrophes claimed 40 casualties in 1930, 30 casualties in 1932, and 3 in 1977. Other landslides occurred, but claimed no casualties.
The general interpretation of the accidents indicates that these landslides are not inevitable. The weak points are the nature of the ground, the age of the buildings, and the existence of 2,000-year-old subterranean galleries. Hence, more than 30 landslides occurred on Lyon hills in 1983, due to an exceptional amount of rainfall. As for prevention, some parameters—such as the maintenance of the walls and of the drainage network—can be mastered and the emptying of waters through cesspools also needs to be suppressed. On the other hand, since the catastrophe of 1930, a Technical Committee (Commission des Balmes) has been created. Its role is to check the solidity of the buildings on the concerned hills, and to define risk areas (setting of ground instability levels of assumption, granting of construction licenses).
Firemen are trained for rescue clearing at different levels: from elementary training to upgraded levels. There are several rescue units@a team unit, a group unit, and a section unit and their equipment includes ropes, pulleys, beams, and listening devices for searching for buried people. The vehicles all are appropriate: light colored for recognition and of average weight for first aid equipment, and large ones for logistical support. For large-scale catastrophes, specialized units are available to firemen: rescue clearing mobile column (by rail or road), and specialized airlifted detachments (for helping other countries). These particular rescue means can have quite short intervention delays and are autonomous on-site. When several rescue detachments are acting in a same area, an operating coordination advanced detachment ("Détachement avancé de coordination opérationnelle:" DACO) coordinates the intervention of the various units and communicates with local authorities. A medical support detachment ("Détachement d'appui médical"or DAM) is required, and takes charge of an advanced medical post that ensures the triage and the treatment of the victims who, once stabilized, are evacuated. The rapid medical intervention civil security element ("Elément de sécurité civile rapide d'intervention médicale",ESCRIM) is a surgical technical platform whose hospital staff aims at operating upon some of the victims coming from the DAM. Responding to the geological and geotechnical risks of Lyon hills and to experts@ reports, the firemen@s rescue operating seems to look appropriate, for local interventions as well as for external ones. Prevention, as a result of Lyon experiences, also seems effective: the number of catastrophes and their human effects have decreased.
Key words: casualty clearing; firefighters; interventions; landslides; logistics; preparedness; rescue; responses
Prehosp Disast Med 2001;16(2):s30.
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Construction of a Medical Evacuation System in Case of Air Raid on Cities
Introduction: A Medical Evacuation System refers to the organizing and operating a system for evacuating for the sick and wounded during wartime. When the number of the nonaffected is large, the rational deployment of the medical evacuation system, on one hand, determines whether medical treatment will be implemented fully; on the other hand, it plays an important role in speeding up medical rescue.
Hypothesis: In accordance with the features of contemporary, high-tech regional, war, air raid in cities, and taking such factors as city size, population density, and defense levels into account, the paper is devoted to the discussion on how to achieve a rational medical evacuation system. It proposes that in small cities a two-level medical rescue@rescue at the scene and treatment in medical organizations@is effective. In midsized or large cities, a three-level medical rescue@rescue at the scene, emergency treatment in medical stations and special treatment in hospitals@is effective. Moreover, the paper outlines the differences in the tasks of the respective levels of rescue.
In addition, in order to fulfill a rational deployment of medical organizations and to guarantee good quality of medical treatment, the following measures should be brought about:
1. Estimating nonaffected according to anti-air raid plan
2. Carrying out army-civilian joint rescue
3. Standardizing medical evacuation documents and checking accuracy of enrollment statistics of military medicine
4. Implementing military organization and equipment, performing stimulated training in order to reach a quick reaction
Key words: air raid; care levels; civilian; evacuation; military; records; rescue; war
Prehosp Disast Med 2001;16(2):30.
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High Speed Projectile Wounds: A Review of 22 Cases
Introduction: Wi