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: With the rising incidence of urban violence related events, we observed a proportional rise in the incidence of victims of High-Speed-Projectile-caused wounds.
Methods: This is a retrospective study of 22 cases of High Speed Projectile-caused wounds attended at the Miguel Couto Municipal Hospital Emergency Ward (Rio de Janeiro, Brazil) between March 1993 and June 1999.
Results: Eleven patients were dead on arrival, three presented with severe lesions and died before or during the surgical procedures, and eight patients were operated and survived.
Conclusion: Because of the high destructive power of this kind of projectiles, the majority of these patients do not survive to be treated (do not arrive to the hospital in time). Those who are submitted for surgical treatment usually have multiple associated lesions, requiring complex treatment and high skilled surgeons. This study shows the urgency of investigating and proposing new therapeutic procedures for the treatment of this kind of wounds, that are far more severe and lethal than are the ordinary gunshot wounds.
Key words: projectiles, high speed; mortality; surgery; violence; wounds
E-mail: lucanunes@dr.com
Prehosp Disast Med 2001;16(2):s31.
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Summary Gas Pressures in Plasma and Spinal Fluid in "Normal" Humans
Introduction: In Disaster Medicine, homeostasis of the respiratory gases takes part in the development of polyorganic pathology. Therefore it is desirable to study "normal" homeostasis.
Method: Tests on pO2 and pCO2 (mmHg), SO2, pH, etc. and arterio-venous gradients (D(a-v)) are used commonly to study human respiratory gas homeostasis. Beginning from 1987, we used tests on the summary gas pressure (SGP, pS in mmHg) pS = pO2+pCO2. The D(a-v) on SGP are denoted as "gas functionals" [DpS = pSa-pSv] in mmHg. SGP tests neither exclude nor substitute conventional (pO2 and pCO2) tests, but include them as a part choosing only additive characteristic pressure. The knowledge of "normal" values for these tests are helpful for gas homeostasis.1 The investigation has been carried out during air respiration in supine position from the "normal" persons. Blood samples were taken from aortae (a), s. coronarius (sC), bulbus v. jugularis int.(vJ), v. hepaticae (vH), a. pulmonalis (aP), v. renalis (vR), v. cava inf. (vC), cerebrospinal fluid liquor (L). Cases with pO2= 70-100 and pCO2= 30-45 mmHg.
Results:
pO2 pCO2 pS
a 91.7 ±0.54 36.6 ±0.21 128.3 ±0.60
sC 23.8 ±0.30 47.5 ±0.34 71.3 ±0.60
D(a-sC) 67.9 ±0.43 -10.9 ±;0.26 57.0 ±0.42
a 85.7 ±0.65 37.4 ±0.23 123.1 ±0.67
vJ 38.0 ±0.57 47.0 ±0.24 84.9 ±0.54
D(a-vJ) 47. ±0.63 9.6 ±0.26 38.2 ±0.58
a 90.4 ±0.56 39.4 ±0.31 129.8 ±;0.70
vH 43.6 ±0.49 44.9 ±0.34 88.5 ±0.54
D(a-vH) 46.8 ±0.55 -5.5 ±;0.25 41.3 ±0.60
a 86.7 ±0.52 37.6 ±0.26 124.3 ±0.60
aP 43.0 ±0.40 41.9 ±0.30 84.8 ±0.50
D(a-aP) 43.8 ±0.47 -4.3 ±0.21 39.5 ±0.45
a 88.1 ±0.81 36.5 ±0.45 124.1 ±;0.8
VC 42.8 ±0.39 45.3 ±0.42 88.1 ±0.71
D(a-aC) 45.5 ±1.22 -8.8 ±0.79 36.7 ±1.21
a 88.8 ±0.56 38.4 ±0.23 127.2 ±0.60
VR 59.4 ±0.80 41.4 ±0.24 100.7 ±0.80
D(a-vR) 29.4 ±0.54 -2.9 ±0.16 26.5 ±0.50
a 83.0 ±1.8 38.8 ±0.56 121.7 ±1.4
L 81.3 ±1.97 46.3 ±0.76 107.5 ±1.11
D(a-L) 21.7 ±0.22 -7.4 ±0.67 14.3 ±0.31
Results:
pH SO2
a 7.396 ±0.003 96.7 ±0.07
sC 7.345 ±0.005 38.0 ±0.70
D(a-sC) 0.051 ±0.002 58.7 ±0.73
a 7.391 ±0.004 96.7 ±0.10
vJ 7.353 ±0.003 68.2 ±0.74
D(a-vJ) 0.038 ±0.002 28.5 ±0.74
a 7.385 ±0.003 96.8 ±0.13
vH 7.360 ±0.003 76.8 ±0.62
D(a-vH) 0.025 ±0.002 20.0 ±0.58
a 7.395 ±0.003 96.3 ±0.10
aP 7.372 ±0.003 76.8 ±0.42
D(a-aP) 0.023 ±0.001 19.5 ±0.41
a 7.395 ±;0.002 96.6 ±0.91
vC 7.389 ±0.002 77.1 ±1.19
D(a-aC) 0.015 ±0.002 19.6 ±0.73
a 7.388 ±0.003 96.5 ±0.10
VR 7.375 ±0.003 87.8 ±0.46
D(a-vR) 0.013 ±0.001 8.8 ±0.40
a 7.408 ±0.004 -
L 7.324 ±0.004 -
D(a-L) 0.084 ±0.007 -
Discussion: The "normal" pO2, SO2, pS levels are: (1) maximal in plasma of vR blood and L (with pO2pCO2); and (2) minimal in plasma of sC blood (with pO2<pCO2). In other regions, the levels are found between vR and maximal ones, where pO2 and pCO2 relationships can be different. The evaluation of pO2 and pCO2 relationships promotes more complete understanding of each organ@s role in regulation of oxyhemoglobin regional dissociation process through their metabolism.
References
Gebel GY, Kruglov AG, et al: 7th World Cong. Int. Soc. Cardiothor. Surgery, Dusseldorf, Germany, 1997; 348
Gebel GY, Kruglov AG et al. 12th World Congr. Anaesthesiol., Montreal, Canada, 2000, p.14, 220, 284.
Key words: organs; partial pressures; plasma; respiratory gases; spinal fluid
Prehosp Disast Med 2001;16(2):s31
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Management of Disaster Medicine Service
Due to the increasing number of emergencies and severity of their medical aftermath, one of the most urgent problems in the efficiency of achievement for a Disaster Medicine service remains the problem of adequate formation of a structure and the mechanisms used for management. In this context, it is important to consider, on one hand, the experience accumulated in the course of practical management directly in emergencies from previous tasks. On the other hand, the task of developing such a model with its national (or federal) structure remains rather complicated. It should provide the optimal level of its emergency preparedness and sufficiency of resources and manpower as some certain basic factors for adequate emergency responses.
The objectives of this presentation are: (1) to demonstrate the chief practical lessons learned by the All-Russian Disaster Medicine Service (ARSDM), and (2) to examine the All-Russian Centre for Disaster Medicine (ARCDM), the research arm of the scientific and practical Centre, that provides the main terms of reference and hierarchy of management.
The primary echelons of ARCDM management and the five levels of its organization are given federal, regional, territorial, local, and on-site-as well as the mechanisms of vertical taxonomy and horizontal cooperation. Technologies of coordination of ARCDM subsystems, beginning from international cooperation and up to interdepartmental relations in the practice of medical care delivery in emergency, are discussed. Quantitative indices or parameters of the Service's activity in emergencies are proposed as a pattern of criteria for evaluating its efficiency. The guidelines of the concept of civil and military cooperation are considered as the most technological and adequate components of management processing for different types of medical care delivery in emergencies. It is stated that the adequate model of ARSDM's structural and functional organization includes mechanisms of management employed in international practice under the auspices of EHA/WHO, OCHA/UN, but taking into account, the national characteristics typical for our various regions. An example of cooperation of Disaster Medicine services in CIS countries is provided as one of the most efficient tools of interaction in transboundary and national major emergencies in the Eurasian region. The possibility of using the Russian experience in formation of similar Disaster Medicine services in the regions (countries) prone to emergency impact is discussed.
Key words: disaster management; emergencies; experiences; model; organization
E-mail: rcdm.org@g23.relcom.ru
Prehosp Disast Med 2001;16(2):s32.
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Teaching Disaster Medicine in Lublin, Poland
The first course on Disaster Medicine in Lublin, Poland started in February 1992. The curriculum for Disaster Medicine was developed by the president of The Polish Emergency Medicine and Disaster Society and was based on the Curriculum for Education and Training of the Scientific Committee of the International Society of Disaster Medicine (ISDM). The accomplishment of the curriculum of Disaster Medicine belongs to the interfaculty chair and The Department of Public Health at the Medical University of Lublin. The aim of the study was to disseminate our ten years of experience in teaching Disaster Medicine. The curriculum includes 30 hours of theoretical lectures, and 45 hours of practical training. High tech medical equipment has been used in teaching the course. The medical students avail themselves of interactive computer programs to obtain knowledge relative to triage. Use of a videotape training program is a way to analyze and evaluate every major accident or disaster. Our intention was to introduce flexibility into Disaster Medicine education, and to present actual needs (postgraduate training) in Disaster Medicine in Poland.
Key words: course; curriculum; disaster medicine; education; ISDM; medical students; training
E-mail: mikula@rekt.pol.lublin.pl
Prehosp Disast Med 2001;16(2):s32.
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Field Evacuation Patterns of Humanitarian Relief Workers
Objective: Emergency evacuation of humanitarian relief workers from field operations not only may be detrimental to the workers themselves, but for the nongovernmental organizations (NGOs), which depend upon their work. Several studies to date, have examined causes of mortality in humanitarian relief workers, yet none so far, have looked at causes of morbidity prompting evacuation. A study that delineates risk factors for emergency evacuation would allow NGOs to plan preventive strategies designed to protect their workers, and keep their operations cost-effective.
Methods: We surveyed 30 large NGOs for personnel records documenting reasons for emergent evacuation of their humanitarian workers from the field during the interval 1990–2000.
Results: Preliminary data demonstrate that over three-quarters of evacuations occur due to infectious diseases, notably malaria and dengue, while a significant percentage of the remainder of the evacuations are due to trauma-related injury.
Discussion and Conclusion: By knowing risk factors for emergent evacuation, NGOs can better educate prospective workers as part of the orientation process as well as initiate preventive approaches for personnel already in the field. Such interventions could include preventive measures for infectious diseases, personal protection measures, and surveillance of personnel health markers.
Key words: diseases; evacuation; field workers; humanitarian; nongovernmental organizations (NGOs); patterns; preventive strategies; relief; trauma
E-mail: ggreenou@jhsph.edu
Prehosp Disast Med 2001;16(2):s33.
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Acute Hemolytic Crises in Patients with G6PD Deficiency: A Case Series
Glucose-6-phosphate dehydrogenase deficiency is the most common human enzyme deficiency. It affects approximately 400 million people worldwide. Acute hemolytic crises are well-described, but uncommon presentations for patients seen in emergency departments have not been described. This paper presents a case series of five pediatric patients, four males and one female, aged from seven months to two years and ten months, who presented acutely ill and jaundiced in a general emergency department over a period of one year.
The patients@ hemoglobin concentrations on presentation ranged between 37 and 50 g/L, all had evidence of acute hemolysis, and all received transfusions as part of the treatment. Ingestion of fava beans were implicated in each episode.
Key words: acute hemolytic crisis; children; clinical manifestations; emergency department; glucose-6-phosphate dehydrogenase deficiency; hemolysis; incidence
E-mail: agrunfeld@hotmail.com
Prehosp Disast Med 2001;16(2):s33.
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Malaria in the Emergency Room
We observed 38 patients with 44 cases of malaria seen in the emergency room between 1997 and 1999:
1. 36 came from subsaharian Africa, only one from Asia, and one from Arabia
2. 13 were residents in their country, and 25 were back from a trip that lasted from 1 to 13 weeks
3. Half of them had taken appropriate chemoprophylaxis: most of them by chloroquine-proguanil combination
4. Symptoms appeared between 1 and 120 days after leaving the endemic area, usually within two weeks
5. Nevertheless in 25% of the cases, they appeared after more than 2 months later
6. Those patients with late reviviscence had previously taken medicine: quinine or halofantrine
7. The classic rhythmic accesses usually did not appear
8. Splenomegaly was present in 38.6 % of the cases, even in case of primo-invasion
9. Three cases of pernicious accesses were observed: one of them died, another one had neuropaludism, and the last one a serious anemia
10. The diagnosis was made by blood smear examination in 38/44 cases and by searching parasitic antigen (HRP) in 3 cases. It was only presumptive in the last three cases
11. The mean parasitaemia was 2%, with one case at 17 and another at 25% (the last one died)
12. All patients (except for the one who died) recovered quickly with quinine or halofantrine in less than 36 hours in _ of the cases, but never more than 4 days
13. Six patients suffered a reviviscence after treatment
The main original observations concern: (1) the poor preventive activity of correct chemoprophylaxis, (2) the late apparition of symptoms, possibly until four months after leaving endemic area, particularly after previous treatment, (3) the frequency of splenomegaly in primo-invasion accesses, contrasting with the rareness of classic rhythmic accesses, and (4) the dramatic importance of rapid blood smear diagnosis.
Importance should be accorded to the single equation: ´fever after leaving an endemic area = malaria = immediate blood smear examinationª so that death by severe malaria can be avoided.
Key words: chemoprophylaxis; diagnosis; emergency department; malaria; presentation; reviviscence
Prehosp Disast Med 2001;16(2):s33.
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Pain in Adults Presenting to the Emergency Room: Evaluation and Treatment
Objective: Our objective was to to measure the frequency and the intensity of pain in patients in an emergency room, to validate different methods of measuringpain for emergencies, and to evaluate the treatment of pain in this service.
Methods: The survey was conducted over 21 days on 983 consecutive patients. The questionnaire queried: (1) demographic data, (2) patient@s own pain evaluation, (3) nurse@s evaluation of the patient@s pain, (4) the doctor's evaluation, (5) diagnosis classification, and (6) the nature, time, and effectiveness of the intervention against pain.
Results: The panel is similar to the usual population of this emergency room concerning the number of patients, age, gender, arrival time, and kinds of diseases. 60.3% of the patients experience pain. Medical patients and nonpainful patients are older than are surgical patients (trauma).
Using an analog visual scale (AVS), the pain reaches an average evaluation by the patients of 52.7/100; 41.7/100 by the nurses; and 37.2 by the doctors. The difference between these three evaluators is highly significant statistically, but they all correlate (r = 0.60). Using a simple verbal scale, the average was 4.1/7. It correlated with the AVS (r = 0.61). The average score of the objective signs was 1.28/18. It did not correlated well with AVS (r = 0.34).
All of the patients felt better when they left the emergency room with an AVS from 20 to 30 points lower. The intervention time was 45 minutes for traumatic patients, and 81 minutes for patients with abdominal pain and visceral surgery. The effectiveness time on pain is 86 minutes on the average after admission: it has absolutely nothing to due with the initial pain intensity. It is linked directly with the initiating time of treatment.
Discussion: It is difficult to evaluate the levels of pain in an emergency room because: (1) it relies on different kinds of pains and pathologies, (2) treatment needs to be initiated quickly, and (3) it concerns numerous kinds of medical staffs with different backgrounds. If the AVS remains the reference, the use of a simple verbal scale is enough in an emergency room. This immediate evaluation should allow a quick initiation of analgesic treatments (analgesic drugs, physical means) with a short action time.
The current effort will concentrate on the simple, but immediate, evaluation of the pain, and on the analgesic treatment (pharmacological as well as physical).
Key words: analgesia; evaluation; nurses; pain; patients; physicians; treatment
Prehosp Disast Med 2001;16(2):s34.
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Principles of a Multilevel Preparation System for an Extreme Situation
Disaster Medicine (DM) is a constituent of a state system emergency reaction in extreme situations (ES). In a complete approach to a disaster, DM is invoked to take preventive measures following the occurrence of a hazard that produces massive sanitary losses and for the prevention of negative medical consequences of accidents and failures. Training of the population is required for survival, with the population being responsible for rendering first medical care in ES.
For this difficult task (both for the state, and for the society), the Novosibirsk Regional Center for Disaster Medicine provided the following methodological principles for a multilevel system to prepare the population to be able to understand the psychology of conduct, the determinants of survival, and render first aid to themselves as important actions in ES.
This package approach to the training a population that may or may not have a medical education proved that the optimal approach is the combined programs of initial and a continuous process of training with gradual escalation of the information during life (up to school, the educational institutions, army, etc.). In addition, it also presents uniform criteria as algorithms of actions and also of a rating of knowledge of the population, and will facilitate the development of a continual skill set under the preset program.
The system examines the complex decision making of the tasks, and must be taken before a service, as it will be a required condition for the safety of vital activities and the shaping of personal safety.
Key words: disasters; population; safety; self-care; survival; training
Prehosp Disast Med 2001;16(2):s34.
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A Simulation Model of Biological Hazard or Widespread Infectious/ Biological Disaster Focusing on the Characteristics of the Spread of Disease by the Percolation-Diffusion Theory
Objective: The aim of this study is to create a simulation model of widespread biological hazard and to review its significance.
Methods: The simulation model is created by using the percolation-diffusion theory. The contagion rate, incubation period, infectious period, diseased period, and mortality are arbitrary. In this model, it is premised that no treatment is applied.
Results and Conclusions: This study is preliminary. The results are quite complex. However, parameters that result in an increase in the number of infected patients (infinitely) are a high contagion ratio and long infectious period. However, the number of infected patients will be depressed if mortality rate is high.
Key words: hazard, bioloigical; computer; contagion rate; infection; incubation period; model; mortality; percolation-diffusion theory
E-mail: akisatoh@mxm.mesh.ne.jp
Prehosp Disast Med 2001;16(2):s34.
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Stroke Patients in the Emergency Medical Services (EMS)
Introduction: Stroke represents one of the major health care challenges in the world today. Early initiation of therapy can improve outcome. There is increasing interest in the role of the EMS in early stroke therapy, in view of the fact that time is one of the critical factors in stroke treatment. The aim of our study was to analyze time intervals of stroke treatment in the EMS.
Methods: First, all advanced life support units and basic ambulances of a German community EMS-system were equipped with questionnaires that were completed after prehospital treatment of patients with suspected stroke. Secondly, patients with suspected stroke were surveyed by a member of our group. The relevant time intervals and anamnestic and clinical data were documented.
Results: Data of 700 patients were obtained: 38% of patients suffered an acute ischemic stroke; in 12%, symptoms were due to intracranial hemorrhage. Thirty-eight percent were treated by an emergency physician at the scene; 50% received EMS treatment within 2 hours; and 63% within the first 6 hours after onset of symptoms. The median time interval from EMS alarm to hospital admission was 42 minutes (16-105 min). Cranial computerized tomography was performed within a median time interval of 228 minutes after EMS alarm (47-1,408 min), and within 188 minutes (3-1,385) after hospital admission, respectively.
Conclusion: Early initiation of treatment is crucial regarding prognosis and outcome in stroke patients. Starting therapy in the EMS provides the possibility of early treatment, thus enabling time limited therapeutic regimens like neuroprotection and thrombolysis. Parallel to advanced trauma life support algorithms (ATLS), in-hospital treatment of stroke patients should be optimized to reduce time delays.
Key words: diagnosis; emergency medical services; scans; stroke; time intervals; outcome; prognosis; treatment
E-mail: heid@mail.uni-mainz.de
Prehosp Disast Med 2001;16(2):s35.
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Efficacy of MEBO Bandaging in Treating Second-degree Burns
Objective: To observe the efficacy of MEBO bandaging method in treating burn wounds.
Methods: Patients with second-degree burns who were hospitalized during the same period were selected for treatment with MEBO bandaging.
Results: 180 cases of superficial and deep second-degree burns all were cured. Wounds healed without any hyperplastic scar.
Conclusion: MEBO bandaging method for treating second-degree burns gives very reliable efficacy and is easy to apply. It is worthy of adoption.
Key words: bandaging; burns; healing; second degree; MEBO; scar; wounds
Prehosp Disast Med 2001;16(2):s35.
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Improving Capabilities in Prehospital Trauma Life Support
Introduction: Prehospital Trauma Life Support (PHTLS) is the action taken on the injured before entering medical service such as at a firstaid station. China is one of unfortunate countries where various disasters happen everyday. Therefore, it is necessary to perfect PHTLS.
Hypothesis: Based on the analysis of the current situation of PHTLS in Shanghai, the authors hold that the best approach for improving the capabilities for PHTLS are as follows:
1. The most important measure is to increase the speed of the critical care response to disaster. This is of great importance for lowering the incidence of disability and mortality of the injured. This may be accomplished by bettering the personal mental status, communication apparatus, first-aid station distribution, vehicles, and so on
2. Increasing the level of critical care provided at the scene of the disaster also is vital. This demands incorporating the concept of taking action without sophisticated medical support, counterplans, a transient conduct system, practiced skills for critical care, essential medicines and medical instruments in the ambulances, and practice during peacetime.
Conclusion: A strategy for enhancing the delivery of PHTLS during a disaster is proposed.
Key words: China, critical care; life support; prehospital; responses; speed; trauma
Prehosp Disast Med 2001;16(2):s35.
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Effects of Noradrenaline on Absorption of Organophosphorus Pesticides during Animal Lavage
Objective: To look for an effective substance to use for lavage.
Methods: After pouring different concentrations of noradrenaline into a rat's stomach, we observed the change of the rat's gastric mucous membrane. We also poured DDVP into dog stomachs. The dogs were allocated into three groups: the model group (no lavage), the experimental group (lavage using adrenaline) and the control group (lavage using NS). Cholinesterase activity, blood pressure, and heart rate were monitored.
Results: When using noradrenaline, maximum concentration (0.03%), there was no change in the rat@s gastric mucous membrane. The cholinesterase activity decreased in the model group, and was minimal in the experimental group (p <0.01).
Conclusions: Lavage using noradrenaline (0.008-0.016%) may be safe and may decrease the continuous absorption quantity of poison. Lavage using a 0.008% noradrenaline solution provided the best results. Lavage using a solution of noradrenaline (0.008%) for organophosphorus pesticide poisoning shows promise for clinical use.
Key words: cholinesterase; lavage; noradrenaline; organophosphates; poisoning
Prehosp Disast Med 2001;16(2):s35.
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Analysis of Serious Organophosphate Poisoning
From June 1995 to September 1999, 67 serious cases of organophosphate poisoning were rescued. Of all of the cases, 7 cases (10.4%) were male, 60 cases (89.6%) were female. The average of the ages was 29.5 years. These cases were poisoned by digestive tract, 47 cases (70.1%) by Metham, 7 cases (10.4%) by Folimat, 11 cases (16.4%) by Atgard. The dosage taking ranged from 50 to 250 ml, with an average of the doses of 120 ml. The main presenting symptoms and signs were: coma, vomiting, urinary incontinence, drooling, difficulty breathing, hypertension, face muscle trembling, miosis, and rales in both lungs. The serum cholinesterase action ranged from 0 to 8 Units.
Key words: organophosphate poisoning; rescue; signs; symptoms
Prehosp Disast Med 2001;16(2):s36.
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The Value of Initial Serum Levels of Drugs as Predictors of Complication Risks in Intentional Intoxications
Introduction: Intentional intoxications are encountered frequently in emergency services, and the medical management of these patients depends on the initial clinical status of the patient and the local poison unit@s advice. Managing these patients can be very expensive due to the fact that the clinical status may vary dramatically within a short period. The aim of the present study is to assess the role of initial serum level of the drugs as a sign of complication risks to these patients in order to improve the cost-effectiveness of their management.
Methods: Clinical and biological findings from a sample of 200 consecutive patients (128 females and 72 males, aged between 17 to 79 years, with an average age of 35 years) were managed in our institution from January 2000 to December 2000. All victims of intentional intoxication (except pure or mixed alcohol and addicts) were reviewed retrospectively. The initial clinical status, the management duration, and the complications were used to assess and establish the effectiveness of each drug on a five-point scale score. Curves between these scores and each drug initial serum level were established and correlation coefficients calculated.
Results: Most of the intoxications were due to intentional benzodiazepin overdose. We did not find any statistically significant correlation between drugs' initial serum level and the effectiveness score of drugs included in the patient's usual drug regiment such as antidepressive agents. Some correlation was found for some uncommon drugs such as paracetamol.
Key words: complication risks; cost; effectiveness; intoxication; overdose; prediction; serum levels
Prehosp Disast Med 2001;16(2):s36.
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Hemorrhagic Shock and Antioxidants: Influence of Timing on Survival
Introduction: Hemorrhagic shock (HS) is associated with the generation of reactive oxygen species (ROS). Interventions that reduce the generation of ROS exert beneficial effects on the acute mechanisms in HS models. Spin trapping nitrones or tempol (4-hydroxy-2,2,6,6-tetramethyl-4-piperidine-N-oxyl), which acts as an antioxidant and membrane-permeable scavenger of superoxide anions, improved short-term outcome in models of hemorrhagic or endotoxic shock. We hypothesized that poly-nitroxylated, albumin-bound tempol (PNA+Tempol), which increases half-life of free tempol, improves process and outcome variables during and after HS in rats.
Methods: Study 1. HS was induced by blood withdrawal of 3 ml/100 g over 15 min. Mean arterial pressure (MAP) was maintained at 40 mmHg with normal saline or blood withdrawal from 20 to 90 minutes. Resuscitation (90 to 270 minutes) was with infusion of shed blood. Observation was to 72 hours. At HS 45 minutes, albumin (ALB, n = 3D 10) or PNA+Tempol (n = 3D 10) was infused (1 ml/100g/h) until 120 minutes.
Study 2. Same as in Study 1 (n = 3D 6 per group), but terminated at 150 minutes.
Study 3. Same as Study 1, but started with ALB or PNA+Tempol (n = 3D 7 per group) at 20 minutes. Primary endpoints in Studies 1 and 3 were survival and biochemical markers, endpoints in Study 2 were antioxidant reserve (serum and tissue) and inflammation (tissue).
Results: Study 1. 72 hour survival was 1/10 (ALB) vs. 2/10 (PNA+Tempol). At 90 minutes, pHa was lower in the ALB group vs. the PNA+Tempol group (p = 3D, 0.02) and remained low. Arterial lactate increased to 8.9 = B1 3.2 vs. 6.5 =B1 1.8 mmol/l (p = 3D, 0.04) and base excess was -9.6 = B1 4.3 vs. -5.2 = B1 3.2 mmol/l (p = 3D 0.01) (ALB vs. PNA+Tempol, respectively).
Study 2. Antioxidant reserve in the serum was threefold lower in the ALB group vs. the PNA+Tempol group (p = 3D 0.002). There were no differences between groups in antioxidant reserve in the small intestines or low molecular weight thiols in liver, kidney, and small intestine. Expression of pro-inflammatory cytokines in liver and gut was similar in both groups.
Study 3. 72 hour survival was 0/7 (ALB) vs. 5/7 (PNA+Tempol), p=3D 0.02. Heart rate and systolic blood pressure at end of HS were higher in the ALB group (p <0.05).
Conclusion: When infused early in HS, PNA+Tempol can increase survival. When given late, it significantly improves acid-base and antioxidant status, without an effect on survival. Early resuscitation with the antioxidant PNA+Tempol may attenuate ROS-mediated injury and the progression toward multiple organ failure and death after HS. The results suggest that antioxidant therapy should be part of the initial resuscitation for HS.
Key words: antioxidants; hemorrhage; outcome; reactive oxygen species; scavengers; shock survival; tempol; timing
E-mail: kentner@mail.uni-mainz.de
Prehosp Disast Med 2001;16(2):s36.
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Treatment of Children with Severe Road Trauma at the Prehospital Stage
Mortality analyses of children with severe road trauma indicate that nearly half died during the prehospital stage and 34.4% of them died even before the arrival of the medical brigades. The main mortality factors during the prehospital stage were shock and bleeding (38.2%). Destruction of vital function regulation caused death in 16.3% of injured, and respiratory insufficiency in 15.8%. Factors incompatible with life were present only in 30%; 70% of the injured could have survived had professional medical aid arrived in time.
Drivers and policemen are the first to reach the victims, but their medical skills are very low. At the same time, our legislation forbids them to render even first aid. To lower children's mortality rate, it is necessary to improve medical training of drivers and policemen, and make alterations in the present legislation.
Key words: children; legislation; prehospital; roads; survival; traffic; trauma
Prehosp Disast Med 2001;16(2):s37.
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Co-Ordination of Transboundary Collaboration in Emergencies
The history of formation of an international system for preparedness and adequate response to major emergencies extends for more than 30 years. From our point of view, the principal component of this system is the delivery of prompt, medical, humanitarian care, as only in this particular case, can one really speak about rescue of human lives or relief of human sufferings.
At present, the only central coordinating mechanism of humanitarian care delivery is based in the UN Office for Coordination of Humanitarian Affairs (OCHA), but the medical aspects of humanitarian assistance are managed mainly in the WHO Department of Emergency Humanitarian Affairs (EHA).
The goal of the presentation is to demonstrate how the OCHA coordinating levels, namely-strategic, tactical, and operational-determine the mechanisms and tools of coordination in different countries and regions when delivering humanitarian medical care. Our presentation emphasizes detailed practical models promoting the analysis of prolonged activity of Disaster Medicine service, primarily in complex emergencies (situations complicated by local armed conflicts). It is stated that in the initial phase of forming contingents of refugees (or temporarily displaced persons), the adequacy of response influences the levels of morbidity, mortality in temporary camps, and the subsequent dynamics of the public health of the affected population. Specific field practice examples are given, as well as processes of continuity, succession, and adequacy of delivery of different types of humanitarian medical care. The mission of peacemaking activity, presuming the formation of a temporary demilitarized zone in complex emergencies (as it is clear from field experience), can be realized adequately only in the obligatory presence of hospitals (temporally medical posts), where medical treatment and delivery of all types of medical care are organized.
Humanitarian medical care is considered a triggering mechanism for a temporary armistice between conflict parties. The feasibility of developing principles of humanitarian medical pacifism irrespective of political and other interests of parties in conflict, and organization of participants delivering humanitarian aid is discussed. Ethical postulates of paramount importance for the priority of the health of displaced persons in complex emergencies are suggested as a principles reflecting priority of health importance.
Key words: care, medical; complex emergencies; coordination; displaced persons; ethics; humanitarian; public health
E-mail: rcdm.org@g23.relcom.ru
Prehosp Disast Med 2001;16(2):s37.
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Epidemiological Status of the Baltic Region as a Potential Challenge for the Onset of a Crisis Situation
Statistical data on dynamics of contagious diseases in the countries of Baltic region demonstrate their unstable epidemiological status and the presence of the latent threat in case it becomes impossible to take organizational and practical measures to stabilize the situation. A group of experts from 11 countries, created by an initiative of the Norwegian government, analyzed the situation, and identified five basic problems of international importance for which decision-making could promote the epidemiological welfare of the Northern Europe as well as of its other regions. The decision-making process is connected with a considerable increase of statistical data on morbidity and the factors provoking its spread, in particular@with an increase of a number of migrants from those region where the given forms of diseases spread to a major degree. Finally, proceeding from the experience and assessment of the situation, there now exists a certain latent "biosocial threat" for the emergence of a critical situation, which is likely to develop into a prolonged catastrophe.
The goal of this presentation is to provide a brief description of the problem and some step technologies for its resolution. This aim has global significance as the given example of the situation analysis represents a model of coordinating administrative and organizational decisions and launching international executive mechanisms for realization of medical humanitarian assistance in the field of emergency epidemiology. The main problems of the Baltic region epidemiology are the following: (1) a great number of HIV-infected patients and sexually-transmitted diseases, (2) pronounced increase in antibiotic resistant organisms and an urgent necessity to improve the control of inhospital infections, (3) profound and targeting extension of epidemiological surveillance and vaccination control of the lay public (4) considerable spread of tuberculosis (TB) as compared with the mean level for Europe, including drug resistant forms of TB, and (5) modernization of primary medical care (WHO definition) in the treatment of communicable diseases.
A model scenario for the preparatory response stage, a process of making strategic decisions, and tactics of their implementation in the system of the Baltic Sea countries' readiness for predictable, ecosocial, epidemiological threat have been developed as a result of the situation analysis.
Key words: assessment; Baltic countries; biological threat; communicable diseases; critical situations; data; epidemiological threats; epidemiology; HIV; primary care; sexual transmission; surveillance; tuberculosis; vaccination
E-mail: rcdm.org@g23.relcom.ru
Prehosp Disast Med 2001;16(2):s38.
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Management Development Process in 2001 Disaster Medicine
Substantial growth of new technologies, the dynamics of society, and macroecological shifts connected with these processes, give rise to a great number of disasters. The main strategy of human "survival" in the next century inevitably will be associated with the formation of an international, sufficiently effective system for coping with emergencies and the provision of adequate preparedness for disasters. Otherwise, all accumulated income of the community would not be enough for emergency relief, including medico-sanitary relief and emergency aftermath operations.
The main goal of this presentation is to discuss in principal improvements in management technologies in 2001-Disaster Medicine. A brief history of international management in humanitarian responses to emergency is provided. The most effective response structures and coordination hierarchy in large-scale emergencies are given when emergency relief operations are performed under the auspices of the UN Office for Coordination of Humanitarian Operations with involvement of the EHA/WHO experience, expertise, and medical humanitarian aid.
A hierarchy of strategies at the international level of emergency humanitarian assistance and their brief characteristics is described. An original form of strategy for donation engaging, allocation, and formation of permanent committees providing management in the disaster prone countries is proposed. It also is discussed in each specific case to confirm the necessity to appoint at the level of a Prime Minister's Office, a permanent representative or coordinator-in-chief on emergency problems who is capable of managing preparedness processing and decision-making on strategies for safety promotion in emergencies. The establishment of regional task forces consisting of such representatives and working groups responsible for different regions and main aspects of medico-sanitary prevention and emergency response is proposed. This procedure would promote a higher level of mitigation, preparedness, and mobilization of resources and manpower in the urgent phase of emergency response. Decision-making of the problem at the initial stage by incorporation of appropriate items in the conference memorandum is discussed. The possibility of developing a principal fundamental document, that can constitute a basis for the "Code of International Humanitarian Support for Medical Care in Emergencies" as a preamble in the "Guidelines on the Use of Military and Civil Defence Assets in Disaster Relief" is proposed and discussed.
Key words: care, medical; code; disasters; hierarchy; humanitarian assistance; international; management; organization; phases; strategies; technologies
E-mail: rcdm.org@g23.relcom.ru
Prehosp Disast Med 2001;16(2):s38.
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Infectious Diseases during the Flood Disaster in Mozambique 2000
Introduction: The types of medical care that are predominantly needed after a disaster vary and depend on its cycle or its nature. After a flood disaster, it has been pointed out that diarrhea-characterized diseases such as cholera, dysentery, and malaria are likely to break out. Therefore, accurate information to identify any occurrence of infectious diseases is essential for effective relief activities in flood disasters.
Methods: The Japan Disaster Relief (JDR) Medical Team was sent to Mozambique where the flood disaster occurred during a period from January to March 2000. Taking this opportunity, the Team tried to collect information that could be useful for elucidating the post-flood epidemic of the infectious diseases through the use of medical care activities, epidemiological investigation, and laboratory testing. The JDR Medical Team executed its operation for two weeks in the Hokwe region of the State of Gaza, in the mid-south section of Mozambique where the damage was the greatest. Through medical care activities, the information was collected from medical records. Through epidemiological investigation, the information was collected by accessing the data at local medical facilities, by interviewing habitants/evacuees, and by conducting water analysis. Through laboratory testing, information was collected on items related to malaria and diarrhea-characterized diseases.
Results: The number of patients who underwent medical care was enormous as shown by a figure of 2,611 patients in 9 days. Infectious diseases were detected in 85% of all patients, among them, patients with malaria, respiratory infectious diseases, and diarrhea-characterized diseases predominated. To the contrary, there was no outbreak of the cholera and dysentery.
Through epidemiological investigation, self-recognition of healthiness decreased among the flood victims after the disaster. The incidence of malaria increased between four to five-fold over non-disaster periods and the quality of drinking water deteriorated after the disaster.
Conclusions: The incidence of the diarrhea-characterized diseases likely to become an epidemic, such as cholera and dysentery, was not high, although the incidence of infectious diseases, particularly malaria, and diarrhea-characterized diseases was increased and the risk of infectious diseases was also increased. The medical care activities, epidemiological investigation and laboratory testing executed in the frame of the international emergency aid program were found to be a useful means to track a post-disaster trend of the outbreak of infectious diseases.
Key words: cholera; disaster; diarrhea; dysentery; epidemic; epidemiology; floods; infectious diseases; Japan Disaster Relief (JDR) Medical Team; malaria; medical care; risk
E-mail: kondou@nirs.go.jp
Prehosp Disast Med 2001;16(2):s39.
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Hypermagnesemia Common in CPAOA Patients in Japan
Introduction: Only in ionized form, can magnesium be physiologically active in the human body. But current discussions of hypomagnesemia in critically ill or severely injured patients and clinical trials of magnesium administration for these patients mainly depend upon the data with serum total magnesium concentration. As for ionized magnesium (Mg2+), to our knowledge, reliable data in such patients are limited. We hypothesized that the Mg2+ concentration of critically ill or severely injured patients in our facility might be distributed widely.
Methods: We retrospectively studied serum Mg2+ concentration and clinical features of patients who presented in the emergency room (ER) of our critical care medical center during six months. In 215 consecutive critically ill or severely injured adult patients with age 15 years (males, 124; females, 92), we measured serum Mg2+ concentration as a part of our routine biochemical assessment concomitant with arterial blood gas analysis immediately after arrival. The Mg2+ measurement was determined using NOVA Stat Profile Ultra (NOVA Biomedical, Waltham, MA, USA) with reference interval of 0.45-0.60 mmol/L. Clinical features of the patients also were examined.
Results: The mean age of the patients was 55.1 ±21.2 (mean ±SD) years, and the mean value of Mg2+ was 0.531 ±0.115 mmol/L (range: 0.23 to 1.40 mmol/L). 148 patients (68.8%) showed Mg2+ values within reference range, whereas 30 (14.0%) were with hypo-magnesemic, and 37 17.%) were hyper-magnesemic. In 47 patients (21.9%) with cardiopulmonary arrest on arrival (CPAPA), Mg2+ (0.575 ±0.140 mmol/L) was significantly higher than for the non-CPAOA patients (0.519 ±0.103 mmol/L) (Student's t-test: p <0.05). Patients with hypermagnesemia had 17 of the CPAOA (45.9%), which was significantly more frequent than for normomagnesemic (16.2%) and hypomagnesemia (20%) patients (chi-square test: p <0.05). Regression analysis showed no significant correlation between Mg2+ and Ca2+, Na+, or K+ concentrations.
Conclusion: In critically ill or severely injured patients, especially in CPAOA patients, who presented in our ER, hypermagnesemia was common. Blind administration of magnesium to such patients is not advisable.
Key words: cardiopulmonary arrest; critically ill; emergency room; magnesium administration; magnesium levels
E-mail: qq-kubo@hyo-med.ac.jp
Prehosp Disast Med 2001;16(2):s39.
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Major Aviation Disasters: EMS Strategies and Tactics
Many airplane accidents are initially survivable. People die in the subsequent fire, smoke, and heat conditions. If a major cargo or passenger jet crashes, either on airport premises or miles away into a municipality, the final decision of life or death for the plane's occupants and people on the ground is made by fast, skilled responses. Considering that fire, rescue, and EMS responders will have only minutes to start successful lifesaving operations, it is crucial that even local emergency departments are prepared.
Using recent aviation disasters, the presentation demonstrates Comprehensive Emergency Management, Fire/Rescue/EMS Response Strategies and Tactics, Recovery and Investigative Operations, Airport-Community Disaster Planning, "Working Together TM," Common Challenges and Specific Hazards. The Family Assistance Act and the rules of different parties (i.e., hospitals, air carrier, Red Cross, NTSB, Law enforcement, aviation authority, coroner) are explained.
Key words: aircraft; aviation; crashes; fire; heat; lifesaving; responses; smoke; strategies; tactics
E-mail: gjk@emergency-management.net
Prehosp Disast Med 2001;16(2):s39.
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Meeting the Challenge of Catastrophic Domestic Terrorism: A Systems Approach to Local Jurisdiction Preparedness, and Development of Stand-alone Capabilities
Introduction: History clearly illustrates that catastrophic terrorism can occur in any community at any time. Incidents such as the sarin releases in Matsumoto and Tokyo, Japan; bombings at the World Trade Center in New York City, the federal building in Oklahoma City, and the American Embassy in Kenya; and the recent interdiction of terrorists attempting to enter the United States, provide enough evidence to suggest that strong local terrorism preparedness and response programs are needed.
Planning for terrorism must go beyond training courses and drills. Terrorism readiness requires an in-depth, multilevel, comprehensive approach geared to the nuances and intricacies of terrorism involving chemical warfare agents and industrial materials, and biological pathogens and toxins.
Objective: To provide attendees a detailed overview of effective metropolitan terrorism preparedness in order to effect similar programs in their home communities.
Briefing topics include: (1) planning assumptions and developing a baseline from where to begin the process, (2)_threat analysis, targets, and vulnerability; (3) capability assessment@emergency medical service, fire and hazardous materials, law enforcement, public health, health and medical; and (4) program initiatives including training, equipment, enhancements, and exercises. Responses to terrorism start at the local level. Federal response assets will not arrive for hours, perhaps even days after an incident. Local jurisdictions must develop a stand-alone capability to react to a terrorist incident while awaiting the arrival of the authorities.
Key words: assessments; capabilities; initiatives; planning; responses; terrorism; threat analysis
Prehosp Disast Med 2001;16(2):s40.
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NBC Programme of the Swedish National Board of Health and Welfare
Introduction: The Swedish National Board of Health and Welfare is a national authority under the government tasked with the supervision of medical and social care with respect to quality, safety, the rights of the individual, mediation of expertise, and participation in development and training. Within the programme of national defence, actions to manage threats from N, B and C agents have high priority. In this concept N, B and C agents include both warfare agents and agents occurring in peacetime (e.g., accidents with nuclear material, pandemics, and chemical accidents). During the last decade, the Swedish National Board of Health and Welfare has developed a programme meeting the demands of threats from N, B and C agents.
Medical expert groups (MEG): The first medical group established was the medical expert group for N agents (N-MEG) in 1986 after the Chernobyl incident when medical information in many cases was quite confusing. This group of medical experts is at the disposal of the Swedish National Board of Health and Welfare and the Swedish Government. Corresponding medical expert groups for C agents (C-MEG) were established in 1998 and for B agents (B-MEG) in 2000.
Guidelines: The Board has published guidelines in order to standardise planning and preparedness for emergency situations in the country. These guidelines are "Chemical Accidents and Disasters" and "Nuclear Accidents and Disasters Due to Release of Radioactive Materials". Guidelines on "Pandemics and Bioterrorism" are under preparation.
Centres of Research and Expertise: In order to guarantee knowledge, research, education, and training within the N, B, and C fields, special centres of research and expertise are being contracted and supported financially.
Highly contagious patients: In order to be able to take care of and transport highly contagious patients, financial support is given to Linköping University Hospital for equipment and for education and training of personnel in treating and transporting (especially equipped ambulance and aircraft) highly contagious patients.
Decontamination and personal protective equipment: In order to manage situations of chemical incidents, a programme for decontamination and personal protective clothing has been developed. This programme includes equipment for decontamination of exposed persons at accident site and at hospital as well as personal protective equipment (including respiration protection) for ambulance and medical personnel. Research on decontamination procedures is also included in this programme and focusses on when, how, and why decontamination of persons exposed to chemicals must be performed.
Key words: accidents; biologics; chemicals; decontamination; disasters; education; knowledge; nuclear materials; programmes; research; responses; threats; training
Prehosp Disast Med 2001;16(2):s40.
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Health Information Team in a Congolese Refugee Camp of Tanzania
Background: The persisting conflicts in the Great Lakes regions of Africa continue to cause refugees to flee into the United Republic of Tanzania. As of February 2000, the UNHCR has provided protection and assistance to some 415,000 refugees from Burundi, 285,000; DRC, 118,000; Rwanda, 7,600; and Somalia, 4,200. The Health Information Team (HIT), whose members were selected from refugee communities, has played a pivotal role in the provision of health services for refugees in Tanzania since February 1997.
Objectives: This study aimed at illustrating the role of the Health Information Team, and the gap between expected and achieved work in a Congolese refugee camp of Tanzania.
Methods: We conducted face-to-face, structured interviews with 50 members of the HIT and with 500 refugees. Focus group interviews also are given to both HIT members and refugees.
Results: We are scheduled to complete the survey by the end of March, 2001, and will present the results during the 12th WADEM.
Key words: camp; health information; health services; information; refugees; team
E-mail: kuniio@attglobal.net
Prehosp Disast Med 2001;16(2):s41.
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Quebec's Integrated Trauma System
This poster summarizes the interactions between the 14 components of the chain of services in this trauma system model. Each link has received from the Quebec Automobile Insurance Board, a conceptual or an operational input in order to reach the preset goals for each specific service. In this presentation, the authors will inform the readers on the outcomes resulting from the implementation of this integrated approach, and especially on the support systems that permit the evaluation and improvement of the end product quality.
Key words: chain; evaluation; goals; integration; quality; services
Prehosp Disast Med 2001;16(2):s41.
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Measurement of Carbon Monoxide in Expired Breath: An Experimental Study
Introduction: Carbon monoxide (CO) detectors currently are used as an alert method by emergency rescue teams. Some of these detectors also can measure expired breath CO concentrations. This method of measurement has been studied only for low concentration of CO in smokers.
Objective: To validate the measurements performed with CO detectors by comparing the results with the gold standard method (infrared spectrophotometry).
Methods: This was an experimental study using the FIM CO-detector. CO gas was obtained from Cosma. Infrared spectrophotometric measures were performed with IR Beryl 100 Cosma. A bag was filled with a gas mixture of air and CO concentration from 100 to 500 ppm. Manual pressure was performed to reproduce expired breath. The CO concentration was measured with the CO-detector, and two samples of gas were obtained: (1) at the beginning; and (2) the end of the simulated expired breath. These samples had to be diluted (with air) to allow spectrophotometric measures. The dilution method as tested with a reference CO gas (80 ppm). A total of 21 measurements were performed.
Results: Dilution method was validated with a SD of 2.7%.
Conclusion: Despite a difference with the reference in measurements for high CO concentrations, the linearity of these results is satisfactory for clinical practice. A CO detector is a efficient and reliable method to measure CO in expired breath
Key words: air; exhaled; assessment; carbon monoxide; detectors
Prehosp Disast Med 2001;16(2):s41.
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Practical Experience Inquiry on Emergency Endotracheal Intubation in Emergency Departments in France
Introduction: In France, Emergency Medicine is not a recognized speciality. Endotracheal intubation usually is learned during a specific training ("Capacité de Médecine d'Urgence") with an apprenticeship on a mannequin or on human beings during anaesthesia. However, this training also is necessary for the emergency care of critically ill or injured patients. The objective of this study was to evaluate endotracheal intubation knowledge and practice of physicians working in emergency departments in France.
Methods: A questionnaire was sent to emergency practitioners in France. The collected data included a physician's knowledge of intubation procedures, their use of medicaments for intubations, and the options available for difficult airway management.
Results: 816 questionnaires received from general practitioners (48%), emergency physicians (28%), or anaesthesiologists (12%) were analysed. Among them: 64% received the training "Capacité de Médecine d'Urgence"; 50% work in an out-of-the-hospital emergency medical system ("SMUR"), and 15% work in an intensive care unit. Seventeen percent work in a hospital emergency department for <2 years, and 20% for more than 10 years. In emergency rooms, 88% of questioned physicians already had intubated patients, but 40% had not practised this act during the last month; 25% of emergency practitioners have made less 5 intubations during the last year, and 29% performed 15 intubations during the same period in emergency rooms. Predictors of difficult airway management (anatomic hurdles, anatomic techniques, Cormack, Mallampati score) never are used by 31% of emergency practitioners, while 51% of questioned physicians have been confronted at least once with an impossible intubation. In cases of impossible intubation, ventilation with bag-valve-mask is the method most often employed while waiting for assistance (63%). In their practical experience, a small number of physicians have used fibroscope (16.4%), intubating laryngeal mask airway (14.3%), kit for cricothyroidotomy (13.7%), and catheters for percutaneous transtracheal ventilation (10.9%). Rapid sequence intubation is used in more than 50% of intubations by 23% of emergency physicians. Among anaesthesic drugs, midazolam is the most frequently used (95%), then fentanyl (78.7%), etomidate (68.5%), succinylcholine (45.5%), and propofol (39.6%). 98.7% of physicians believe that the endotracheal intubation practice does not need to be done by an anaesthesiologist, but 7% think that the rapid sequence intubation must be managed only by anaesthesiologists; 5.3% of physicians are stressed at the time of intubation, and 11% are not.
Conclusion: The practice of endotracheal intubation is unequally distributed among the emergency practitioners. These differences depend on the training and, probably, of the activity in France, specifically, out-of-hospital emergency medical system ("SMUR").
Key words: anesthetics; emergency departments; emergency physicians; endotracheal intubation; performance; practice; rapid sequence; SMUR; training
Prehosp Disast Med 2001;16(2):s42.
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High School Students Assisting the Hospital
The Israeli Medical System is committed to administrating optimal medical services to casualties during conventional and nonconventional mass casualty events. The operation of the hospital in such events, necessitates expansion of facilities, predesignation of admitting sites and operation of special roles such as decontamination teams, stretcher-bearers, and so on. This obligates expansion of our manpower and the operation of ancillary and voluntary teams. In this poster we will present a model initiated by our hospital, which displays a unique cooperation program with one of our neighboring high schools.
Approximately 300 students from the tenth to twelfth grades are integrated into our personnel during mass casualty events, in order to assist the hospital. The students serve as stretcher-bearers and other necessary tasks. Once each year, they participate in a training program and drills, and in real life during mass casualty events. As a result of the ongoing relationship between the hospital management and the director of the school over the last 10 years, the students are available to us every moment, day and night, throughout the whole year. This project has been supported by the Municipality Emergency Law and is recognized by the Israeli Defense Forces and the Ministry of Health.
Summary: This unique model has many benefits, both, to the community and to the hospital, but, mainly for the students themselves, because the most important education a student can receive is the ability to donate to others.
Key words: assistance; hospital; mass casualty events; schools; students
Prehosp Disast Med 2001;16(2):s42.
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Risk Analysis Model for Health Care and Medical Service
Objectives: We found that conventional methods and tools for risk assessment do not include requirements from the medical service. To tackle these problems, we have developed a new risk analysis methodology. The objectives of the work were to develop a new model for risk analysis for the health care and medical service in the Stockholm County.
Methods: Based upon studies of literature and risk analysis models from the municipal rescue services in the Stockholm County, we have developed a new model for risk analysis with a number of new parameters specific for the health and medical service. The model was presented and discussed during the 4th Nordic Congress on Emergency and Disaster Medicine in Copenhagen 2000.
Summary: Dimensioning of disaster medical resources should be based upon an analysis of risks and threats and assessment of probability and consequences of every possible scenario. In the model presented, we have defined scenarios with consideration taken to casualties and their priority for emergency care. The probability calculus describes how many times a scenario probably will occur in a specific period of time. The calculus is based on statistics and current development in the region.
To describe consequences, we analyze the capacity of the medical services to take care of casualties in the various scenarios, and if the medical services must activate the disaster medical plans. Using a simple matrix diagram, we can identify the scenarios with high probability and large consequences for the emergency medical services. According to the results, decisions can be made concerning prevention, and measures can be taken to reduce the consequences or increase the capacity of the medical service.
The model will be used in the assessment of risks and dimensioning of medical resources during the EU Conference in Stockholm at the end of March 2001.
Key words: assessments; capacity; dimensioning disaster; medical services; mitigation; model; prevention; risks
Prehosp Disast Med 2001;16(2):s42.
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Percutaneous Puncture Intervertebral Incision and Exsuction in Treatment of Prolapse of Lumbar Intervertebral Disc
Objective: To assess percutaneous puncture intervertebral incision and exsuction (APLD) as a treatment for patients with prolapse of lumbar intervertebral disc.
Methods: Fifty-one patients with prolapse of a lumbar intervertebral disc received the treatment by national APLD with follow-up from 3 to 24 months.
Results: Treatment efficacy was classified according to improved Mac-nab criterion as excellent (25 cases), good (21 cases), normal (4 cases), and poor (1 case). The effectiveness rate was 90%.
Conclusion: It indicated that APLD technique had the characteristics of less injury, quick recovery, avoiding the vertebral canals, maintaining the stability of spinal column, and less and slight complications. If indication is present, APLD is an effective treatment for prolapse of lumbar intervertebral disc.
Key words: effectiveness; efficacy; intervertebral disk displacement; lumbar vertebrae; percutaneous; removal of vertebral disc
Prehosp Disast Med 2001;16(2):s43.
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Alarm Situation in Castellon Due to Floods: "Cold Front" Meteorological Phenomenon
The "cold drop" phenomenon, favoured by the peculiar orographical and hydrographical features of Castellon Province, is the combination of cold wind at the highest levels of the atmosphere with the warm wind over the Mediterranean Sea. It produces torrential and heavy rains with the risk of floods. Consequently, a special plan in case of floods is enacted (P.E.I = plan especial de inundaciones) Resolution 156/1999.
Objective: Analysis of the application of the P.E.I. in an actual situation occurred during October 2000 in Castellon and comparing it with rainfall from the last 10 years.
Methods: A qualitative study of the situation occurred 20th to 26th October 2000 due to torrential rainfalls (superior to 30 l/m2/h ) causing harm to people and properties. Information is provided by means of the following sources: (1) National Meteorological Institute, (2) Civil Protection, Hydrographical Confederation of "the Jucar and Ebro", and (3) Centre of Information and Coordination Health Emergency Institute from the Province of Castellon and images from the local newspaper "Mediterraneo" (local press).
Results: The maximum rainfall in 24 hours took place in "la Puebla de Benifassar" with 315.80 l/m2/24h; being the average on the 20th/26th October 2000 of 86.61 l/m2/24h. The maximum rainfall in 24 hours in the last 10 years was 163 l/m2 in 1994, the average rainfall of the last 10 years was 35.6 l/m2 in 24 hours. This rainfall affected altogether 48 roads in the local net, and three from the national net, 4 dams, and 4 rivers. The railway sustained no damage, 13 townships were without electrical power, 3 without drinking water, 3 without telephones, and 95 people were evacuated, 5 people were rescued, and 11 warning to townships were given facing the possibility of a break in Mª Cristina dam. Health emergencies were at their most intense point on the 24th, the most common pathology being the traumatic injuries. The availability of sanitary resources was of 6 units of emergency assistance, 50 conventional ambulances, 2 air rescue units, 183 hospitable beds, and 11 for critics.
Conclusions: The development of the emergency, the management and the supervision was carried out under the resolution P.E.I. 156/1999 and allowed all of the involved services to act in coordination so as to activate and mitigate the consequences of the emergency.
Key words: alarm; "cold-drop" phenomenon; floods; rain
E-mail: ifuster@wanadoo.es
Prehosp Disast Med 2001;16(2):s43.
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Medical Education of CPR in Mexico
Medical education in cardiopulmonary resuscitation is one of the most important aspects of learning to recognize and treat medical emergencies for the Facultyof Medicine in the national, free University of Mexico. We have developed a very comprehensive program about the process of learning of Emergency Medicine, specifically with young students who arrive at the first courses in their medical career.
The training program is based on the Pan-American Health Organization's program for medical education. The goal of the education and training is the preparedness in emergency skills of the medical students. Cardiopulmonary resuscitation is emphasized in these program. The course extends for six months and is divided into theoretical sessions and practice stations.
Our office had been pleased with the results obtained using a microlearning system that is based on problem solving. By the end of the course, the students can apply what they have learned to the realities they will face, whether it be in the hospital emergency room or in the field.
Key words: cardiopulmonary resuscitation, emergency care; medical students; skills; training
E-mail: kev97@latinmail.com
Prehosp Disast Med 2001;16(2):s43.
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Comprehensive Evaluation of Interventions for Injuries of Primary and Middle School Students
Objective: To explore the intervention measures for prevention and control of injuries and evaluation of their effectiveness in students of middle and primary school.
Methods: The effectiveness of the intervention was evaluated by comparison of the incidence of injuries before and after interventions in 3,896 students of nine middle and primary schools. These findings were compared with a nonintervention group of 651 students of four primary schools in Jiangmen City, Guangdong Province, during January to December 1999.
Results: The incidence of injuries dropped from 50.6% before intervention in the intervention group to 11.8% after intervention, a 76.7% reduction. The proportion of severe injuries dropped from 7.8% before intervention to 0.65% after intervention. The incidence of multiple injuries dropped from 19.2% to 3.2%, an 83.6% reduction. However, in the control group, the incidence of injuries dropped from 52.7% to 49.0%, a reduction of only 6.8%, with a ratio of reduction of intervention to control of 11.2%, and a ratio of cost to benefit of 1:13.9.
Conclusion: Intervention measures focusing on health promotion can prevent and control the occurrence of injury in students of middle and primary schools in a cost-effective manner.
Key words: benefit; children; cost; incidence; health promotion; injuries; prevention; students
Prehosp Disast Med 2001;16(2):s44.
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The Effect of rhGH on Protein Metabolism of Patients with Abdominal Trauma
Objective: To study the effects of rhGH on protein metabolism of patients with abdominal trauma. Methods: Forty-eight patients with abdominal trauma were enrolled in the study: 20 into the control group, and 28 into the treatment group. All cases accepted operation and treatment with TPN; rhGH was administered in the treatment group; 24 hours after operation for five or seven days, albumin, globulin, prealbumin, transferrin, IgG, IgA, IgM Amc, TSF, hepatic and renal functions, and glucose were measured respectively. In the fifth and tenth days, POF was observed.
Results: POF, TSF, AMC, albumin, globulin, prealbumin, transferrin, IgG, IgA, IgM decreased in the control group (p =0.05), and were unchanged in the treatment group. Hepatic and renal functions and glucose levels remained unchanged for both groups.
Conclusion: Protein synthesis is increased by the administration of rhGH; decomposition of protein and POF decreased. The tissue injury recovered quickly.
Key words: abdomen; organ function; protein metabolism; rhGH; trauma
Prehosp Disast Med 2001;16(2):s 44.
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New Approaches to Diagnosis and Rehabilitation of Patients with Posttraumatic Stress Disorders
Introduction: In many countries of the world, standards for the diagnosis of Posttraumatic Stress Disorder (PTSD) are the criteria being proposed by American Association of Psychiatrists (DSM-4), including criteria by A, B, C, D, and E groups. However, the use of these criteria doesn't allow the identification of earlier vegetative signs and, therefore, the ability to carry out timely medical rehabilitation.
Methods: We@ve studied peculiarities of the formation of the PTSD syndrome, and the efficiency of programs of medical rehabilitation for 234 participants in the antiterrorist operations in the Chechen Republic during a period of 3-8 months in 1999@2000 after their return from the scene of action. The examination program for each person included: DSM-4 testing, estimation of vegetative functions with the help of modern computer system "BHC-Specter", express-estimation of cerebral alpha rhythm by the method "Unifac-EEG" (developed by the authors), and estimation of psychological status of a person with the help of special questionnaires.
Results: According to the data from the DSM-4 test, the syndrome was revealed in 24% of the participants. At the same time, a syndrome of recurrent trauma emotional experience was identified in 78 % of cases, symptoms of increased anxiety in 67%, and vegetative signs in the form of different emotional disturbances in 34% of cases. Use of special test programs as well as estimation of vegetative nervous system with the help of quantitative indices allowed identification of earlier signs of PTSD in 37% of the cases. A syndrome of recurrent trauma experience was shown in 82%, and vegetative signs in 67% of the cases. The most apparent were changes from the side of cerebral alpha potential, which revealed desynchronism in 46%.
A total of 123 PTSD patients underwent special programs of medical rehabilitation, which included transpersonal psychotherapy, mesodyencephaly modulation (by our method), and microwave resonance therapy by the small doses method. The control group included 11 persons, who underwent standard group psychotherapy. The use of the complex of modern programs of medical rehabilitation gave a positive effect in 88% of cases; for the control group, it was only in 52%.
Conclusions: These data show the necessity to include additional diagnostic programs for the early diagnosis of PTSD, as well as the use of modern methods of medical rehabilitation that allow correction of the above mentioned changes in 88%.
Key words: diagnosis; discovery; interventions; post-traumatic stress syndrome (PTSD); rehabilitation; treatment
E-mail: rcdm.org@g23.relcom.ru
Prehosp Disast Med 2001;16(2):s44.
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Seat Belt Use by Pregnant Women: A Necessity, or a Risk?
In most countries, seat belts and head restraints are the only elements of vehicle equipment the use of which is defined by the Traffic Code. The analysis of car accident statistics and of survival statistics of their victims indicates the necessity to use seat belts by all people in the car (the driver and all passengers). The use of seat belts by pregnant women should also be considered necessary, despite the fact that the Polish Traffic Code exempts them from this requirement. The risk of injury to the pregnant woman and the fetus induced by properly used (fastened) seat belts is much lower that is the risk of injury caused by sudden deceleration resulting from abrupt braking or a collision of the vehicle which she is in. The paper also presents the current legal status relating to seat belt use in Poland and in the world, and presents the criteria of safe child transport in the car.
Key words: children; code; fetus; pregnancy; restraints; seat belt; traffic; utilization; women
E-mail: wmanesth@ld.onet.pl
Prehosp Disast Med 2001;16(2):s45.
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Mass Gathering Medical Care in the Stockholm Area: A Review
Introduction: Festivals, fairs, concerts, parades, and rallies are some of the many events that cause large numbers of people to gather in one place. Whether the event lasts a day or a week, it is evident that the people attending may require organized medical care. Most of the medical needs are minor, but cardiac arrests and other serious medical problems, including trauma, must be dealt with by the medical team. Careful planning and integration of emergency physicians efforts with local hospitals and the emergency medical services system allow for an optimal delivery of health care, from the routine incident to a mass-casualty event.
Objective: The purpose of this report was to try to critically review the provision of medical care at mass gatherings in the Stockholm area. Specially measured was the relationship between the size of a mass gathering and the frequency of patients seeking medical aid and the effects of certain event characteristics on the relationship.
Conclusions: Type of event, weather conditions and the size of the mass gathering have a significant effect on the numbers of spectators seeking medical care. Mass casualty incidents provide valuable lessons for the prehospital provider. A reevaluation of large-scale rescue operations that require a complex network of agencies, communications, and on-scene triaging, frequently exposes common weaknesses and errors. The report tries to provide guidelines for more effective mass casualty management.
Key words: evaluation; management; mass gathering; medical care; planning; prehospital; rescue
E-mail: lennart.malmstrom@ks.se
Prehosp Disast Med 2001;16(2):s45.
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River Navigation Disasters and First Aid Organization
River traffic has been constantly increasing in the area of Lyon. The transportation of goods especially in petrochemistry, remains the most significant part of this traffic, because of the important economic activity. Additionally, other types of leisure and tourism activities- riverboat tours, cruises, boat rentals, pubs, and disco boats-have expanded greatly. Thus, the probability of a river disaster involving a large number of victims must be considered.
Firemen are responsible for victim evacuation. In case of such an accident, the victims could be dispatched on the riverbanks at an appropriate distance down river. Outside of urban areas, access to the site might be difficult for assistance coming from land.
The location of the first aid post is of considerable importance, so that early first treatment can be delivered. It should be situated close to a place where boats can moor alongside, near the crash spot, and also should have an easy access by way of land. It should be next to a bridge down river. A second first aid post should be located at the opposite of the first one, on the other bank and so, reducing the waiting period before first medical treatment can be given. It also might be useful that a medical team be dispatched further down stream, close to a bridge. The Evacuation Medical Center should be located, if possible, next to the bridge on the evacuation way to the different hospitals. Without a prepared emergency plan, a previous coordination meeting should be organized. The rescue teams must be given the opportunity to evaluate the topography of the area where the first aid post and the Evacuation Medical Center should be installed.
Key words: accidents; evacuation; first aid; planning; rescue; river; teams; transportation
Prehosp Disast Med 2001;16(2):s45.
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Disaster Medicine in a European Perspective
The Major Project "Disaster Medicine" is an initiative of the European Commission as part of the action programme on Civil Protection
Disaster Medicine plays an meaningful role as one of the key entities of civil protection, based on the principles of regular health care, and in most cases, using existing means and infrastructure.
Disaster Medicine demands a multidisciplinary approach, and therefore, requires national coordination and communication involving all organisations. The key for success in the working area of Disaster Medicine is to stimulate this process. Significant questions aimed at the multidisciplinary approach, the principle of chain management, quality management, information exchange, and a continuous cycle of lessons learned are ahead of us.
By its contents and its process, the Disaster Medicine project contributes to the formation of national policies, keeping in mind that the development of a policy in Disaster Medicine is seen as a responsibility of national authorities. On a union-wide level, the Disaster Medicine programme can help reduce national differences in the organisation, quality, and availability of help; it is a good example of how they can be bridged. It will focus on relevant policymakers and experts, while seeking to influence the longer term quality of Disaster Medicine. It will bridge the gap between national interests.
The programme for 2000-2002 will focus on three key items: (1)Cross-border/mutual (DisMed) assistance between member states, (2) psychosocial care, and (3) (Dismed) preparation for major accidents and disasters.
In this programme, it is foreseen the publication of policy papers, virtual discussion groups, workshops, and cross-border exercises. These activities will be followed by policy papers and recommendations on the policymaking and political levels. The real challenge will be to bridge the differences in culture, organisation, and resources without falling back to the old principles of "standardisation and harmonisation." Struck by a large-scale accident or disaster, people living or travelling in European Union Member States should receive the same high quality medical care.
Key words: accident; cross-border; disaster; Disaster Medicine; European Union; mutual assistance; policy; preparation; programme; psychosocial
Prehosp Disast Med 2001;16(2):s46.
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Mission Statement for The Major Project on Disaster Medicine from 2000 to 2002
Mieke Martens; Dick Fundter
The Major Project on Disaster Medicine is an initiative of the European Commission as part of the action programme on Civil Protection
Modern European society is expanding quickly and, as a consequence, increasing the risks of large-scale accidents or disasters. It raises the economic costs for society as well as the impact on victims, families, and the social environment. Therefore, EU citizens will be expecting a high quality of protection and care in this matter. The Major Project on Disaster Medicine will be responsible for this part of Civil Protection. Differences as well as similarities@geographic, demographic, and risk levels@can be assessed between the different member states. Because of the complexity and diversity of the national policies on disaster management, the Disaster Medicine programme aims at creating networks, including national authorities, umbrella organisations, and local policymakers on the long run, so national differences can be bridged. At the same time, standardisation of practices and methods will be stimulated.
The long-term goal of the Disaster Medicine project is to ensure that people living or travelling in European Union member states struck by a large-scale accident or disaster should receive an equal level of quality care.
Objective: For the programme 2000@2002, the Project will focus on the following three main items, for which policy papers will be developed, guidelines will be published, and information will be disseminated.
First, cross-border mutual assistance between member states will be a priority. Special interest will be shown for clarification on subjects such as common nomenclature, legal restrictions of personnel and equipment, communications, training needs, common markings of emergency personnel, and the expectations on the quality of assistance. Also, cross-border exercises will be organised in order to get an overall view of the problems of cross-border actions.
Second, psychosocial care will be examined and efforts in this matter must lead to a professional network of experts and a European guideline on the organisation of psychosocial care. Third, preparedness for large-scale accidents and disasters will be developed. Subjects like the development of performance indicators, quality of care, management of the medical chain, and the development of scenarios will be handled.
To come to workable and pragmatic outcomes of the Major Project on Disaster Medicine, the Project will try to establish a small task force at the central level. This task force will make maximum use of the expertise of the Core Group and the available groups of experts. For the dissemination of information, the working parties will make use of new techniques such as the Disaster Medicine domain on the EU/Circa system. The organisation of a task force as well as the coordination on the work of the Disaster Medicine Project are conducted by the Netherlands.
Key words: accidents; authorities; costs; cross-border; disaster; Disaster Medicine; European Union; management; networks; organisation; policy; preparedness; psychosocial; quality of care
Prehosp Disast Med 2001;16(2):s46.
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An Outcome Evaluation for Prehospital Cardiopulmonary Arrest Patients Using the Utstein Template: A Japanese Experience
Introduction: Publication of Utstein Style Template made it possible to perform a national hospital based evaluation, and compare Emergency Medical Service systems. This research was done as a national investigation to identify present outcome data for prehospital cardiopulmonary arrest (CPA) patients in Japan.
Methods: The records of 3,029 CPA patients who were transported to 10 Emergency Critical Care Medical Centers from November 1997 to April 1999, were abstracted according to the Utstein style, and the data for outcomes were analyzed using logistic regression.
Results: 109 out of 3,029 cases (3.6%) were found dead. The remaining 2,920 cases (96.4%) underwent CPR by emergency medical technicians (EMT) and were included in this study. Bystander CPR was performed in 28.4% of witnessed cardiogenic CPA. The discharge rate was 4.0% of witnessed cardiogenic CPA, and 18.4% of witnessed ventricular fibrillation or ventricular tachycardia (VF/VT). A comparison of resuscitation rates indicated that a success of 7.9% in prehospital phase and 28.4% in in-hospital phase: this is more than 3 times of former results. Outcome analysis indicated that a discharge rate of witnessed cardiogenic CPA was 49.1% of prehospital resuscitation cases which was 6.6 times higher than for hospital resuscitation cases (7.4%). The latter from an emergency telephone call to defibrillation, the lower one month survival rate, it reached almost 0% in 30 minutes (min). Follow-up evaluation after discharge indicated that the survival rate rapidly decreased from 24 hoursto 3 months, then, it reached a plateau in the cardiogenic group; for the noncardiogenic group, the survival rate decreased rapidly from 24 hours to 1 month, then became nearly constant.
Conclusion: To improve the resuscitation rate in prehospital phase, we must develop a prehospital medical control system, and then expand management items provided at the scene by Japanese paramedics, such as endotracheal intubation, administration of emergency drugs, and early defibrillation using standing orders. Educating and cultivating a first responder will be needed, and every effort should be concentrated on improving the bystander CPR rate. It may be possible to change the Utstein style statistics in a follow-up period of one year to 3 months after an onset of CPA.
Key words: cardiopulmonary arrest; cardiopulmonary resuscitation; discharge; emergency medical technicians; in-hospital; outcome; paramedics; prehospital; resuscitation; Utstein style
E-mail: Fmashiko@nms.ac.jp
Prehosp Disast Med 2001;16(2):s47.
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Interactive Tactical Simulation Program
It is very important and informative to test individual tactical preparedness using an interactive simulation program. On the individual level, tactical preparedness can be assessed by proceeding logically through the primary survey and in making sharp priority decisions between casualties and in optimal utilisation of available personal and material resources. It also would be essential to utilise recorded logbooks for evaluation of systemic weak points in tactics. Thus, one could become aware of common deficiencies in tactical entities, and conclude if there are certain components in teaching that should obtain more emphasis and attention.
The collected experiences over last eight years in teaching, training, and testing with my own interactive simulation program, Matimed, will be presented. This PC program produces an accident scene and gives the trainee the task of leading an emergency group to provide prehospital care of casualties. The trainee is obligated to make all decisions and delegate all tasks to the other members of the group. The leader's performance is recorded in a logbook in detailed form, and hence, it is possible to reconstruct the performance step-by-step. Thus, the tutor can draw conclusions about the weak points in the decision-making.
Although there are several casualties at the scene, many trainees stop at the first victim for a long time and start to provide optimal emergency procedures for the first casualty encountered. The importance of primary survey of all casualties cannot be overemphasised.
It also seems to be very difficult to make logical decisions on a priority order of casualties and emergency procedures, although prioritisation of tasks is the key component of triage. There also are deficiencies in utilisation of available resources.
We conclude that there are obvious needs to provide more individual tactical training and improve tactical teaching.
Key words: decision-making; multicasualty incidents; individual; prehospital; preparedness; simulation; tactics; teaching; testing; training
E-mail: matti.mattila@matimed.pp.fi
Prehosp Disast Med 2001;16(2):s47.
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Simulation and Computer-Aided Training
In an emergency patient situation as well as in a major accident with multiple injured casualties, the action of medical groups is based on knowledge and experiences. It is relatively easy to obtain theoretical knowledge, but it is much more difficult to collect enough personal experience in action of real accident situations. It also is difficult to represent accident situations with casualties represented by live players, because different traumas and symptoms are nearly impossible to be vividly and correctly simulated. Thus, there is an urgent need to provide easily available and truly interactive methods for large-scale training for both individual members as well as for emergency groups and ensembles.
Interactivity, problem solving, decision-making, immediate evaluation, and feedback are the key elements of a simulation program for training actions for medical emergency care.
There are two totally different applications available to provide adequate training. The first is to construct a simulation training centre with giant computers to create integrated group training sessions or even virtual reality circumstances. The other way is to provide large-scale individual training with software running in a normal PC. The tactics and cooperation at the site of an accident are so multidimensional that it has only been in recent years that the more advanced computer technology has made it possible to create this type of simulation program for PCs. With these programs, it is possible to create challenging scenes with naturally acting casualties having different injuries. Because the program "memorizes" the performance step by step, it can be scored and evaluated. This immediate feedback is essential for learning and progressing successfully to more difficult situations. This individual training later can be completed in much more advanced and technically demanding group sessions. We can expect that interactive training software production will accelerate, and thus, provide modern useful training and testing methods for emergency care.
Key words: computers; emergency care; groups; feedback; individual; interactive; learning; simulations
E-mail: matti.mattila@matimed.pp.fi
Prehosp Disast Med 2001;16(2):s48.
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Municipal Contingency Plans
During the last century, disaster prevention has become the focus of attention in emergencies administration. Knowing clearly and accurately the possible effects of a disaster, and who commands the responses in case of emergency, can facilitate the civil protection authorities and the general population to develop specific mechanisms to reduce the impact of calamitous events.
Municipal Contingency Plan (MPC) develops community protection actions and includes action organizations, services, people, and resources available to attend to disasters. It also contains specific risk identification, community preparedness, local capabilities for response, risk planning, and establishment of the structure for organization (authorities, agencies, offices, volunteers) to respond at the emergency. Each element knows their respective role@what to do, what not to do, and how to participate in a team effort.
The state of Oaxaca is situated in the southeast portion of Mexico and presents a complex geography that makes access to basic emergency services difficult. The state is also at high risk for earthquakes: Of the total number of earthquakes in Mexico, 40% strike in Oaxaca. Additionally, the Tehuantepec Isthmus Region occupies the first matrix point for generating hurricanes.
Today more than ever before, both the urban and rural population in Oaxaca know the effects of disasters. The government and society are now more inclined to promote and practice self-protection and the prevention of the most traumatic consequences.
Development of the proposed MPC forces decision-makers to plan and execute preventive actions and emergency projects, by developing effective formulas that can improve the stability factors and response mechanisms. Our goal is the generation of organizational schemes based on natural community leadership.
In order to develop prevention strategies, we must facilitate collaborative activities between municipal institutions, like education and health, promoting natural schemes of organization. This organization should be based in the society and not in government offices because if programs are applied by official means, they may have only a short-term effect. However, if its implementation is developed and adopted by the local community, its effect may be more long-term.
The Civil Protection Office in Oaxaca, has implemented this formula and it is clearly effective. Where the population has been adopted these systems, especially in the hazardous places, they have been able to prevent the most common causes of disasters and promote a culture of prevention.
Key words: collaboration; contingency planning; disaster; municipal; planning; prevention; risk; roles
Prehosp Disast Med 2001;16(2):s48.
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Cardiac Arrest: The Case Against Public Access Defibrillation
Objective: The aim of this study was to determine the location of out-of-hospital cardiac arrests in Melbourne, Australia, and to determine if public access defibrillation may be of benefit.
Methods: A retrospective case note review of all out-of-hospital cardiac arrests that presented to the Metropolitan Ambulance Service (Melbourne, Australia) for 1997, was performed with the use of the Utstein Criteria.
Results: 1,064 victims of out-of-hospital cardiac arrests were identified: (1) age, 66.5 ±15.3 years; (2) gender, 64% male; (3) response time, 9.1 ±4.2 minutes; (4) witnessed, 57.5%; (5) documented call to 000, 87.7%; (6) bystander CPR, 34.7%; and (7) location: private home, 915/1,064 (93.7%), public place, 62/1,064 (5.8%).
Conclusions: These results indicate that out-of-hospital cardiac arrests occur mainly in the victim's home. From these data, there appears little evidence to support large-scale deployment of public access defibrillators.
Key words: arrest; cardiac; defibrillators; homes; out-of-hospital; public access; public places; Utstein style
E-mail: alastaie.meyer@mh.org.au
Prehosp Disast Med 2001;16(2):s49.
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Asystole Cardiac Arrest in Melbourne, Australia
Introduction: Out-of-hospital cardiac arrest (OHCA) claims approximately 2,000 victims in Metropolitan Melbourne each year. Ventricular fibrillation (VF) and ventricular tachycardia (VT) are the common presenting rhythms found by the EMS-providers for Melbourne, the Metropolitan Ambulance Service (MAS). Asystole is less commonly encountered. International studies have shown that the survival rate of OHCA presenting as asystole is very poor. This study investigated victims of OHCA who presented to the MAS in asystole.
Results: In a 12-month period, 778 patients met the entry criteria. The mean value for age was 67.2 years, 36% were female, 64% male. Response time was a mean of 9.8 minutes. Resuscitation was commenced on 37% of patients. There was one survivor (0.12%).
Conclusion: Adult victims of OHCA presenting as asystole should not receive treatment.
Key words: arrest; asystole; cardiac; out-of-hospital; survival
E-mail: alastair.meyer@mh.org.au
Prehosp Disast Med 2001;16(2):s49.
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Advanced Life Support Skills of Emergency Department Staff
Introduction: Cardiac arrest is a common event in emergency departments. Survival from cardiac arrest can be used as a measure of performance of an emergency department (ED), and can be used as a tool for comparing emergency departments. In the prehospital setting, ventricular fibrillation (VF) is the most commonly recorded rhythm. There are no Australian data that indicate the most common cardiac rhythm found in patients who arrest in the emergency department. Prompt, safe defibrillation is the treatment most likely to improve survival after VF. Optimum effect from defibrillation occurs within 90 seconds of onset of VF. The aim of this study was to determine whether VF could be identified and managed adequately in an ED setting in accordance with the resuscitation protocol prescribed by the hospital.
Methods: The ED staff of a tertiary referral hospital were assessed as to their ability to manage patients with VF. The subjects for this study were staff volunteers from the medical and nursing staff from the ED. The subjects were asked to manage, without warning and apparent prior knowledge, a simulated patient in VF. The study took place in the hospital setting known to the subject.
Results: The time to defibrillation varied between staff type and appointment level with the majority of subjects achieving defibrillation within the 90 second time frame.
Conclusion: The results suggest that teaching, training, and testing of ED staff in the management of VF be improved, and that there may be a role for the use of Automated External Defibrillators in the ED setting.
Key words: automatic external defibrillator; ability; defibrillation; emergency department; staff; training; treatment; ventricular fibrillation
E-mail: alasatir.meyer@mh.org.au8
Prehosp Disast Med 2001;16(2):s49
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Earthquake in Armenia of 1988
A total of 3,232 children have suffered from the earthquakes in Armenia in 1988. Of these, 2,007 (62.1%) sustained various damages to the locomoto apparatus. Of these, 653 (32.5%) sustained closed fractures, 286 (14.2%) sustained open fractures, and 377 (18.8%) children had crush-syndrome.
The medical care was provided in two stages: (1) prehospital first aid (control of bleeding, application of aseptic bandages, anesthesia, immobilization, and transport) was implemented at the place of incident; and (2) The full complement of the aid to victims at the site not always was implemented because the crews providing the first aid did not have adequate supplies of medical equipment. In this series of cases, some victims were delivered to a hospital without having any first aid.
The greatest difficulty with the treatment has arisen for those victims not treated in specialized clinics. The errors in treatment for this group of the patient have resulted in development of contractures of joints, high-gravity palsy of extremities, deformity of segments, and quite often, led to amputations. Many errors were made at rendering assistance to children with high-gravity, open fractures, and with the syndrome long-time compression (LTC). The vast cuts of extremities made in last cases, complicated the condition of the patients due to secondary wound infections and padding intoxication. We were forced to perform amputation in five of them. We performed fasciotomies only when ischemia of extremities was threatening and definte intoxication from several small approach. Three patients with the high-gravity form of LTC developed of an aseptic necrosis the head of the hip.
Analysis of results of treatment LTC of extremities has shown the ineffectiveness of using during the first days, compression-distraction apparatus or fulfilment of a submerged osteosynthesis in connection with increased swelling of an extremity.
Key words: amputations; aseptic necrosis; crush syndrome; earthquake; fractures; infections; treatment
E-mail: arnaz@mail.ru
Prehosp Disast Med 2001;16(2):s50
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Being on the Alert in Hospital Services: Estimate of Preparation of the Emergency Staff for Facing an Influx of Victims
Introduction: In the anticipation of a great number of victims following a catastrophic event, every hospital has an intervention plan ready to face that exceptional situation. The aim of that plan of alert of in-hospital services (MASH plan) is to optimize the reception and the treatment of the victims of that particular catastrophe, and take care of the usual emergencies at the same time. It also must allow for the reception of the victims' families. The emergency staff represents the first line in the good development of an exceptional situation. Every member of that staff, whichever his/her charge is, should know the existence of the MASH plan, how it works, what has to be reorganized in his/her service, and the part s/he has to play, as modest as it can be.
Methods: A survey was conducted in February 2001, among the emergency staff of Saint-Vincent, a 170 bed General Hospital in Lille, to identify what knowledge of the MASH plan they had. That survey consisted of 20 simple questions essentially aiming at four main points: (1) the alert, (2) the practical organisation of the emergency service, (3) the reception of the victims, families, and people involved, and (4) the part everyone must play.
Results: The survey was completed by 92.8% of the emergency staff (65/70). The average longevity was 4.7 years. The name "MASH" was unknown to 16.9% of the staff; 36.9% of the staff had no idea where the reception of the victims is, and 90.8% had no idea where the reception of the families is. A large majority (87.7%) of the respondents didn't know their part in case the MASH plan is started, and only 7.7% know how to reorganize the emergency service in that case.
Conclusion: Considering these points, information sessions have been organized to improve the efficiency of the staff in case of an influx of victims. The staff will be reevaluated using the same questionnaire, the objective being to get 50% right answers for each question. The members of the emergency team will be asked to update and improve the Saint-Vincent hospital MASH plan.
Key words: emergency department; families; hospital; MASH; multiple casualties; organization; plan; preparedness; training
Prehosp Disast Med 2001;16(2):s50.
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The Impact of Euro 2000 on Activities of All Emergency Departments of the City of Brugge
Introduction: Organization of huge sports events always is associated with an increase in medical risks. Public authorities warn hospitals to increase the number of medical doctors and nurses in the Emergency Departments during these events. Political authorities are put under high public pressure to ensure an increased medical deployment.
In the city of Brugge, three qualifying football matches and one quarter final were played. No game was considered risky by the organizing committee. A literature review defined the expected risks, and hence, the resources that needed to be deployed. Prior football games with severe mass riots were analysed regarding the effective hospital admission rate. This analysis helped us decide to use the daily emergency medical care to provide the backbone for medical deployment. Three mobile intensive care units were deployed in the stadium. In addition, we used the usual provincial disaster plan to upgrade our medical supplies in case of mass casualty emergencies.
Methods: During the whole tournament, both emergency departments of the city of Brugge collected data about Euro 2000-related pathology. Data regarding the pathology treated in the stadium as well as for all patients admitted to the hospital were reviewed.
Results: These data confirm that the organization of a European football tournament does not increase significantly the activities in the emergency departments of a "play-city". Only 24 Euro 2000-related patients visited the emergency departments during the whole tournament. The majority of their pathologies were alcohol-related. The daily increase in patients never exceeded 8%. Only two patients had to stay in the hospital for a period of more than 12 hours. Even analysis of the data of the days that the home nation, Belgium, was playing did not show any statistical increase in admittance rate of patients.
Conclusion: We conclude that political instances as well as public opinion put high pressure on the medical authorities during major sports events. However, the data collected proved that preparedness and a higher level of alertness is sufficient to guarantee a high level of medical safety.
Key words: alcohol; emergency departments; mass gatherings; patient loads; sports events
Prehosp Disast Med 2001;16(2):s50.
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Do Computer Programs Perform Better Than Human Regulators in Mass Casualty Disasters?
Introduction: An on-site observation of an actual Red Cross mass casualty disaster by one of the authors of this article who specialized in "Industrial Logistics Management" aroused doubts about the regulator's efficiency, both from a medical as well as from a logistics point of view. During a postexercise discussion session, the authors decided to form a small study group with the primary aim to formalize the important task of the mass casualty disaster regulator within a framework of a decision sciences and management approach.
Methods: A case game "Dis_Strat" was developed, describing an oxygen-tank explosion on a factory site at the precise moment that one of the company's busses leaves the industrial site. The explosion is supposed to have injured some 40 shift-workers. For didactical purposes, however, the simulated task of the candidate regulator has been limited to the 12 U1 and 13 U2 victims. They have to be evacuated by a certain, but not a priori, fixed number of ambulances to a set of 16 possible hospitals with known medical specialties and specific admittance characteristics. The pedagogical aspects were tested and improved through several trial runs at three different universities by staff members, all specializing in the field of industrial logistics management. As the case game was clearly conceived as a highly sensitive multicriteria problem with only vaguely described strategy objectives, the authors were compelled to develop also a computer program "Dis_Strat_Eva" to evaluate the results of the trainees' respective possible dispatching approaches. Furthermore, the study's aim intended to compare and benchmark the trainees' performances with "Best Practices" obtained by medical specialists of the regulator's task in cases of mass casualty disasters.
Results: The case game has been organized five times for participants of the European "Leonardo Community" program in "Logistics Management". The preliminary results of our experiments in the manual simulation of the human regulator's task, show an unexpected high disparity of solutions, this due to: (1) first time confrontation by the participant with such an assignment; (2) the differences in the perceived policy criteria; (3) the difficulties to agree on concrete measurement means of commonly accepted policy criteria; (4) the existence of a high number of variety of theoretically well-known dispatching heuristics; and (5) the lack of a trainees' capability to transfer and use knowledge from well-known fields of applications for unexpected or even apparently unrelated problems.
Conclusions: The multicriteria assignment of the regulator's task in mass casualty disaster problem has to be more clearly defined and imposed by the competent authorities, if one does not want to leave the initiative for the choice of the dispatching strategies to a regulator. Training in the use of appropriate dispatching heuristics seems essential. An expert-like computer simulation is an inevitable necessity and a pedagogically valuable tool for the debriefing session.
Key words: computers; control; coordination; decisions; disaster; dispatching; exercise; mass casualties; regulators; simulations
Prehosp Disast Med 2001;16(2):s51.
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Experience in International Relief Activities for Gujarat Earthquake 2001 in India
Introduction: Kobe University dispatched its medical team, KUMT, which consisted of two emergency doctors, to Gujarat, India from February through December, 2001 to provide medical advice and assistance to Gujarat Earthquake victims. In this video session, we will share our experiences in this catastrophe.
Results: KUMT visited two municipal hospitals in Ahmedabad, where many trauma patients were transported from neighboring cities and hospitalized. Some of them needed splinting for bone fractures and treatment for wound infections and sepsis. KUMT provided suggestions and advice based upon its knowledge from experience in the Kobe earthquake of 1995.
From 03 through 07 February, an ad hoc team named "Play It By Ear" comprised of the two medical doctors of KUMT, a firefighter paramedic from the USA, an Indian pharmacologist as interpreter, and a car driver, investigated medical care in the most devastated area in Gujarat state. The team contacted control centers and/or hospitals in cities and towns such as Bachau, Rapar, Gandhi Dham, Anjar and Bhuj, and interviewed them regarding problems they had at the time. Their official response was that everything was under control; the supplies of food, water, and manpower for medical care were sufficient, and that no village was left without medical service. Many NGO groups contributed to the disaster medical relief for the victims. However, better coordination is required to coordinate the functions of many NGO teams properly. More appropriate supply distribution was required.
At Bachau, the team joined Indian Medical Association to check remote villages, where several days had passed since one medical team had checked the residents by using a mobile hospital. We treated approximately 30 patients who suffered from sickness, bone fractures, and infected wounds. Hospitalization or more frequent medical care such as dressing changes and debridement for wounds were essential.
The devastated area that should be covered from the point of medical care was scattered and was more widespread than was present following the Kobe earthquake.
Conclusion: KUMT has achieved its initial goals with collaboration of Gujarat Government. Domestic and foreign medical relief by GO and NGO teams were well-mobilized and activated. Better coordination is needed for them as is the more efficient supply distribution should have been carried out.
The first priority for the government must be to provide temporary houses for victims to sleep and live. More frequent health care surveying and checkups are required, especially in remote areas, in order to avoid preventable diseases, deaths, and epidemic outbreak.
Key words: coordination; India; hospital; international; Kobe; KUMT; NGO; relief; shelter; supplies; team
Prehosp Disast Med 2001;16(2):s52.
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Advance Deployment and Organization of Activities of a Field Multiprofile Hospital (FMH) in Local, Armed Conflicts
In health responses to military operations, one must deal with the particularly specific role of a Multiprofile Hospital (FMH) in health response under these conditions. First, this is the structure of casualties, characteristic properties of the affected people cohort, and capacity for evacuation. The specific nature of medical care delivery to the affected in armed conflicts is not a general practice with civilian medical units, while the Field Multiprofile Hospital (FMH) belongs to the ARCDM "Zaschita", and the FMH has had a unique experience of such activity during military conflict in the Chechen Republic in 1994-1995. In those years, the FMH teams worked in such localities as Mozdok, Tolstoi-Yurt, Znamensky, and Grozny; took part in health response activities following terrorist acts in Budenovsk, on the Chechen-Daghestan border (Pervomajsky); and in military operations within the area of Sunzhi station (1996). During the period of its work depending on the specific medico-tactical situation, the FMH's tasks, principles of its operation, and variants of deployment have been amended correspondingly.
Summarizing the experience gained, one may determine three basic variants of FMH's operation during armed conflict: (1) deployment of a surgical hospital on the basis of a local medical facility, (2) deployment of a self-supported surgical hospital, and (3) deployment of a self-supported multiprofile hospital
Our experience demonstrates that the FMH of ARCDM "Zaschita" is well-adjusted for operation under such conditions, as its organizational and staff structure and medical equipment promote the delivery of any type of medical care, including secondary care. The FMH is capable of urgent response to changing situations, and can timely amend the task set to that medical unit.
Key words: adaptability; armed conflict; experience; field; hospital; medical care; multiprofile; uses
E-mail: rcdm.org@g23.relcom.ru
Prehosp Disast Med 2001;16(2):s52.
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Dissolving and Eliciting Technique Applied to Cerebral Hemorrhage Associated with Hypertension
Objective: To investigate whether use of the dissolving and eliciting technique applied to a wound that is not serious is or not feasible for treating cerebral hemorrhage associated with hypertension.
Methods: From July 1998 to October 1998, we applied the technique to treat cerebral hemorrhage associated with hypertension on 23 patients.
Results: Hematomas were eliminated in more than 50% of patients within 24 hours. Of the group, 3 patient@s hematomas were smaller than 10 ml, the next day they were drawn by tube. Otherwise, in 12 patients, hematomas were eliminated in more than 70% of patients and were able to be drawn by tube.
Conclusions: The technique to apply to a wound that is not serious is simple and feasible, adaptability is broad, and is not restrictive. The effects of the hemolytic medicament "two in one" is remarkable.
Key words: cerebral hemorrhage; dissolving and eliciting technique; hematoma; hypertension
Prehosp Disast Med 2001;16(2):s52.
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Floods in Mozambique 2000: Analysis of the MSF Emergency Response
Introduction: Heavy, torrential rains during the rainy season 1999@2000, caused serious flooding in many parts of Southern Africa. Mozambique was the worst affected country with an estimated 1,000,000 people affected directly, and around 300,000 people temporarily displaced. All southern provinces of Mozambique were affected to a varying extent; the coastal regions as well as the population along the main rivers of Gaza, Sofala, and Inhambane Provinces suffered most the consequences of the flooding.
MSF response and activities: Medecins sans Frontieres (MSF) launched an emergency intervention on 6 February, two days before the Mozambican government declared anational state of emergency. A large MSF stock of drugs and material in Mozambique facilitated the rapid initiation of an assistance program. At the peak of the disaster, four MSF sections (operational centers) were involved in the management of the emergency. MSF-Switzerland in a joint mission with MSF-Luxembourg, focused its intervention on Maputo and Gaza Provinces. Collaboration with the Mozambican authorities and other aid organizations was satisfactory. In Maputo and Matola, the Mozambican authorities assured primary and secondary health care and MSF focused on cholera control. In the identified zones in Gaza province@Chokwe, Chaquelane, Macia@MSF was involved in assisting approximately 100,000 displaced persons. The main activities were the following:
1. Primary health care through the installation or reinforcement of health posts
2. Introduction of an adapted epidemiological surveillance system
3. Provision of potable water and improvement of sanitary conditions in displaced camps
4. Cholera preparedness and outbreak control (9,587 cholera cases in Maputo and Matola with cumulative attack rates = 0.70 and 0.69 respectively, and overall case fatality rate = 1.4, and 241 cases in Gaza province [CFR = 1.24])
5. Management of malnourished children (rehabilitation of 468 severely malnourished children and temporary involvement in supplementary feeding)
During the inundation of Chokwe town, MSF was involved in Search and Rescue activities (SAR) saving more than 100 individuals from immediate drowning, and evacuating inpatients from the flooded district hospital. Despite the pressure of the provincial authorities, who evacuated Chokwe, MSF remained in the flooded town assisting the 8,000 of the remaining residents, who were unwilling to leave.
The MSF emergency program ended in the month of July. The overall cost of the operation figured at approximately 4,000,000 Swiss Francs. Transport by air was the one of the largest cost factors.
Conclusion: A MSF-emergency intervention followed the disastrous floods in Southern Mozambique in early 2000. Experts estimated that the destruction caused by the floods annihilated 10 years of development in southern Mozambique.
The main difficulties, when facing such a complex situation involving hundreds of thousands of victims, are the coordination of activities between the different actors, the dimensioning of the respective interventions, and the availability of reliable information, in particular, in situations when the access to the populations at risk is heavily impaired. Anticipation of the evolution of the situation is crucial for providing rapid assistance.
Key words: cholera; coordination; floods; health care; interventions; malnourishment; Medicins sans Frontiere; Mozambique; rain; responses; sanitation; surveillance; water
E-mail: Thomas Nierle@geneva.msf.org
Prehosp Disast Med 2001;16(2):nnn.
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Medicine in the Global Village
The advent of the information super highway permits us virtually unlimited access to public information. Shopping over the Internet now is commonplace. If you can buy groceries, why not medical supplies? If you can organise custom-made furniture, why not custom-made medical equipment?
Bohica medical is a microindustry specialising in innovative medical equipment. We are able to compete within the global market place. I had a vision, developed a plan, and made it happen. If you have ever had a dream, or wanted to make a difference, listen to my story.
Key words: equipment; Internet; manufacture; plan; vision
E-mail: nobledrdg@hotmail.com
Prehosp Disast Med 2001;16(2):s53.
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Bioterrorism: Challenges for Public Health Action
Four components of the public health response to disease outbreaks are also important to address acts of terrorisrn in a coordinated fashion: detection of usual events, investigation and containment of potential threats, laboratory capacity, and coordination and communication.
The public health effort to combat infectious diseases is based on the early detection of unexpected cases or clusters of illnesses, so that small outbreaks can be stopped before they become big ones. In the case of a bioterrorist attack, the initial detection of a disease is likely to take place at the local level. It is essential to work with members of the medical community who may be the first to recognize unusual diseases, and who are most likely to mount the initial response-especially if the intentional nature of the outbreak is not immediately apparent. Strong communication links between clinicians, emergency responders, and public health personnel are important.
As is the case for any naturally occurring infectious disease outbreak, the initial response to an outbreak caused by an act of bioterrorism, is likely to take place at the local level. Once the cause of a terrorist-sponsored outbreak has been determined, specific drugs, vaccines, and antitoxins may be needed to treat the victims and to prevent further spread.
In the event of a bioterrorist attack, rapid diagnosis will be critical to the immediate implementation of prevention and treatment measures.
In the event of an intentional release of a biological agent, rapid and secure communications will be especially crucial to ensure a prompt and coordinated response. Each hour of delay will increase the probability that another group of people will be exposed, and the outbreak will spread both in number and in geographical range. Because of the ease and frequency of modern travel, an outbreak caused by a bioterrorist could quickly become an international problem.
Key words: bioterrorism; communication; coordination; detection; investigation; laboratory support; public health; response
Prehosp Disast Med 2001;16(2):s 54
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Centres of Research and Expertise for Disaster Medicine in Sweden
The National Board is a central authority under the government, and is responsible for supervising quality and performance in Medical Care, Social Welfare, and Public Health. On the national level, the Board has the responsibility to ensure the medical preparedness for large-scale disasters and wartime medical care in Sweden. The responsibility for providing medical care to the population lies in the 21 Regional parliamentary organisations (County councils). The Board receives money from the defence budget to support the preparedness of the Country Councils for medical disasters. New threats lead to increased need of scientific knowledge in various fields. Therefore, the Board has decided to establish special centres of research and expertise in several fields of Disaster Medicine. These centres are set up as special research groups connected to university institution/equivalent in close connection with the medical/clinical society. The main aims of these centres are to perform scientific research in their respective fields, to act as experts and to participate in education. A special steering group for each centre with representatives from relevant authorities decides about the aim of the work and follows up the results.
The following centres are planned or established (through 2000): General Disaster Medicine, Psychosocial Preparedness, and Radiation Medicine in Disasters (at the Cancer Centre, Karolinska Hospital, Stockholm), Microbiological Preparedness (at the Swedish Institute for Infectious Disease Control), Disaster Toxicology and Public Health in International Disasters.
Key words: centers; county councils; Disaster Medicine; education; public health; preparedness; research; Sweden
Prehosp Disast Med 2001;16(2):s54.
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Clinical Audit of Hypertensive Crisis
Introduction: The term "hypertensive crisis" (HC) suggests a rapid reduction of the arterial blood pressure. The aim of this work was an assessment of therapeutic efficiency and evaluation of results in terms of hospital mortality relative to the blood pressure (BP) at the admission of the patients, and the magnitude of its reduction during the first 24 hours.
Methods: This prospective study included 125 patients admitted to emergency room for a stroke. The patients had the benefit of indirect monitoring of the BP. Variance analysis and odds ratio calculation were been used (p <0.05).
Results: At admission, the mean values for systolic blood pressure (SBP) was of 216.2 ±29.07 mmHg, for diastolic blood pressure (DBP) was 121.8 ±19.51 mmHg, and for mean blood pressure (MBP) was of 151.8 mmHg. After 24 hours of hospitalisation, arterial blood pressure reduction was of 38% for the DBP and the MBP, and of 39% for the SBP. No statistical relationship was demonstrated between the reduction in DBP and the mortality; this relation for MBP was weak. Concerning the SBP, the relation is highly significant: the SBP above 220 mmHg at the time of admission increased mortality (p <0.003) as was a reduction of more than 35% during the first 24 hours (p <0.005).
Conclusion: The DBP proposed for the diagnosis of a HC and its therapeutic follow-up does not seem to be a deciding factor of outcome for our patients. The outcome of these patients who present with a cerebral suffering seems more dependant on the SBP in which the rapid and the important reduction is the origin of progression of the cerebral injury.
Key words: blood pressure; hypertensive crisis; emergency room; stroke
E-mail: imas@mail.wissal.dz
Prehosp Disast Med 2001;16(2):s 54.
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Crisis Management: A Possible Improvised Operational Approach
In cases of mass casualties, the French hospital and prehospital health organization requested the implementation of a field "structure", the Forward Medical Post (FMP). The objective of this structure is to triage, maintain life, and dispatch the victims in order to permit their evacuation in the best possible medical condition and in the shortest time to the nearest appropriate hospital.
In the Bataillon de Marins Pompiers de Marseille (BMPM), we define a Forward Medical Post not as a physical structure, but as a working organization. This organization articulates itself around six functions: a secretary, triage, an Immediate Emergency care function (IE), a Relative Emergency care function (RE), a regulation, and an evacuation. Therefore, every structure, that includes all of these functions and is set up in the field to cope with an influx of victims, can be defined as a forward medical post (whichever its physical form is.)
The organization of a FMP relies on unavoidable rules: (1) the site is decided upon in cooperation with the On-site Commanding Officer; (2) it must be situated in the "safe zone", at the vicinity of the incident as near as possible to evacuation roads and on enough ground surface to receive at least a third of the total number of victims (if known); and (3) the FMP is organized into six zones (one for each function). Various guidelines also apply but they usually are summarized by "Think but think simple."
Other factors influencing set up include climatic conditions, existent structures, communication axes, security, and safety. Frequently encountered errors are from neglecting to adhere to the guidelines and the space is too small an area to permit a later enlargement of the post.
This working organization is nothing without the people. The FMP leader is a medic who relies on a Logistic Officer, a Triage Medic, a Regulation Medic, and on a variable number of medics and paramedics (ideally 1 medic for 2 IE victims and 1 medic for 10 RE victims). Distinctive white chasubles or armbands identify them.
A "crisis" implies for managers an immense amount of pressure. The usual approach for coping with a crisis relies on three things: (1) prevention, (2) planning, and (3) training. However, what if your team is unavailable or what if your plans are useless, because they are not adapted to this situation? We propose here an operational crisis approach centred around chaos reduction and casualties reduction.
Chaos reduction is the first unavoidable step resumed in the acronym IRIT: Information, Reinforcement, Immediate action, and Team set up. Information is the first concern; find who is in charge, what's happening, what has been done, what resources are there, verify the sources, make a synthesis. Reinforcements should be requested: remember that more is better, immediate actions denote the use standard operational procedures, and team set up establishes the chain of command. If communication protocols are not predefined, nominate a communication manager who will establish communication network and protocols, nominate a logistic manager who will establish logistic follow-up, traffic procedures, staging areas, vehicles, person and equipment inventory, nominate a medical operation manager who will manage the CCP and FMP.
Casualties reduction is the next step and is summarized by the acronym OSDOR (Objective, Situation, Design, Operational, Reevaluation). Objective identification means team work around rational choice, organizational choice, political choice or team negotiation in the way Allison defines it. Situation denotes looking for the facts, but also survey for crisis potential and probable evolution (What in 30, 60, 90 minutes?). Design a suitable course of actions of at least two different courses of actions (most likely this is between the creation of a "field hospital" and "scoop and run"), evaluate those designs and choose among those actions. Operational implementation means power delegation and mission orders; and finally conduct regular reevaluations (How is the situation evolving? What are the consequences of this evolution on the first 4 points (OSDO) and, if necessary, go again through the entire OSDOR process. Accurate information and managing manpower are the key success factors in crisis management.
Standard procedures are used by the FMP and every victim following the same track. Triage is the first step and victims are assigned to one of two categories: immediate emergencies (IE) or relative emergencies (RE). Registration occurs with the entry secretary. The victim is identified using a simplified medical file. Part of this file is sent to the Regulation Secretary to allow the dispatching of the victims to hospitals with adapted capabilities. Treatment or simple life support is performed in two different areas (IE and RE zones). Evacuation occurs when the dispatching is done and a team and vehicle are available (priorities are IE followed by RE). We propose to manage a third category of victims (Extreme Emergency or EE) with a specific procedure. For EE victims the simplified file is a specific red file. A member of the collecting rescue team managing the EE victim takes this file directly to the entry secretary and, after registration, to the Regulation Secretary where the dispatching is done without delay. While the team member waits to take this file back, the EE victims and the collecting team simply go through the FMP directly to the evacuation zone. The evacuation occurs as soon as possible, using the collecting team as the evacuation team. Those procedures can be followed only because logistic follow-ups and information treatment (files transit and workout) are strictly managed. Logistic follow-up is the logistic officer's job. Information gathering and transmission are the roles of the FMP Chief. Frequently encountered errors are the arrival of victims in a FMP with the entry secretary not already in function, shunt of the entry secretary, and changes of categorization without transmission of the information at the regulation.
Key words: crisis; field; forward medical post (FMP); information; operations; organization; triage
Prehosp Disast Med 2001;16(2):s55.
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Emergency Medicine in the Czech Republic
During the last decade, the disaster readiness of the Czech Republic has gone through a fundamental systemic transformation determined by two things: (1) the preparation and its later admission into the North Atlantic Alliance (NATO) and, (2) by the preparation of joining into the European Union. To achieve this, the legal environment was transformed to maintain the basic function of the State, even in case of possible crisis situations—whether it is of military or nonmilitary character. A direct result of this change to the security policy of the State became Constitutional Law Nr.110/1998: The Security of the Czech Republic. This law is the foundation for the comprehensive architecture of Crisis Legislation. The central mission of the legal norms that came into operation was the completion of the fundamental obligation of the State to the protection of lives, health, and property.
For this goal, a National System of Crisis Management was developed. The system is based on two organizational structures: (1) a network of crisis management authorities formed by the central and other administrative offices, and (2) on an effective instrument that combines the appropriate aggregation of capacities and means into a system called the Integrated Rescue System (IRS-according to the law). Such a systematic solution ensures cooperation between such bodies as the armed forces, the armed security forces, the rescue corps (firemen, health, air rescue), and other crews that will respond in any crisis situation.
One of the organizations participating in crisis preparedness is the Health Services, an authoritative power. Therefore, from 1990 to 1994, within the framework of the transformation of the Czech Health System, Emergency and Disaster Medicine began. Its inception coincided with such activities as the proclamation of the International Decade for Natural Disaster Reduction 1990-2000 and followed by the Strategy for a Safer World in 21st Century: Disaster and Risk Reduction (IDNDR Program Forum, Geneva, July 1999), including the reference of the WHO-Secretary General after the Chernobyl disaster in April 1986.
A direct consequence from this has been the creation of Emergency Medicine as an independent medical specialization in 01 January 1999. The specialization includes problems of disaster medicine, creating a medical foundation for the thorough and systematic preparation of the professional health staff to participate in finding solutions for the human health consequences that result from disasters. Currently, 180 physicians in the Czech Republic have passed successfully the examination and have achieved the specialization. Advanced professional education is now a reality in one of the main bodies of the Integrated Rescue System@the Emergency Medical Service. The Integrated Rescue System aids the police and the Firemen Rescue Corps of the Czech Republic. The disaster health consequences are cover by law: all medical organizations are included within the "other bodies" of the IRS with a legal obligation to assist in and control the medical situation.
Contemporarily, intensive efforts on the definitive formulation of Emergency and Disaster Medicine are in progress, in order to prepare for possible risks and to enhance the health service response to meet the severity of the risk. The priorities are specified primarily in the basic document of the Czech Republic-in the Security Strategy-that recognizes the necessity of preparedness for natural and industrial disasters.
The Czech Republic received immediate experience from rescue and restoration efforts during and after the floods that occurred from 1997 through 1999. These floods occurred along the Morava River that runs from north to south through the Czech Republic. It affected persons along the whole riverside, took 50 human lives and created damage in the amount of 62 billion Czech crowns.
Key words: costs; Czech Republic; disasters; emergency medical services; floods; health; Integrated Rescue System; legislation; Morava River; preparedness; priorities; rescue; restoration; risks; strategies; systems
Prehosp Disast Med 2001;16(2):s56.
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Flood Disaster in Northern Italy: The Experience of the Azienda Sanita Locale (ASL) 10 in Pinerolo (Torino).
The northwestern part of Piedmont was affected by a four-day period (13-16 October 2000) of torrential rain followed by a widespread flooding. Greater concentration of the adverse meteorological phenomena involved the Valleys of the Pinerolese between the 14th and 15th of October. Roads, railways, and bridges were closed by landslides and mudslides with consequent isolation of inhabited centres and hospitals. Severe damage occurred to the electrical network and caused the interruption of the supplies of drinkable water.
The health professionals and hospitals of the ASL-10 had to confront this emergency in order to ensure continuing medical assistance. This communication focuses on the ASL 10 reaction plan.
Key words: electricity; floods; health; hospitals; isolation; landslides; mudslides; plan; rain; water
E-mail: lazzero@dag.it or medipine@libero.it
Prehosp Disast Med 2001;16(2):s56.
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System of Rendering Psychological-Psychiatric Assistance to Population of the Chechen Republic in an Antiterrorism Operation
The problems of rendering psycho-psychiatric assistance to the population of the Chechen Republic had some peculiarities: (1) the location of the great number of temporarily displaced people in camps (40,000); (2) accommodation of population in private sector, destroyed settlements and cities; and (3) absence of specialized medical institutions for rendering psychological-psychiatric assistance. From October 1999 to May 2000 on the territory of the Chechen Republic and Ingushetia, teams of psychological-psychiatric assistance were working. They included specialists from the ARCDM "Zaschita", Moscow Research Institute of Psychiatry and State Research Scientific Centre of Social and Forensic Psychiatry of Ministry of Health of Russia. The main tasks of these teams were: (1) rendering specialized psychological-psychiatric assistance to the temporarily displaced population and population of the Chechen Republic; (2) organization of evacuation of psychologically impaired patients for the provision of specialized medical assistance in nearby territories; and (3) determination of the needs for specialization and for an increase in the qualifications of specialists in the psychiatric field. These teams included a psychiatrist, psychotherapist, or psychologist. For examination, special diagnostic questionnaires and tests were used; changes of personal psychological status were determined with the help of special programs. More than 4,500 of the temporarily displaced population of the Chechen Republic, including 480 children, were examined. In 11.3% cases some psychological diseases were revealed among the adult population: manic-depressive syndrome, schizophrenia, epilepsy, and psychoorganic syndrome. In 81.5% of cases, non-psychotic disorders were diagnosed, which were demonstrated by neurotic character and behavioral disorders.
Considerable place in the structure of nonpsychotic forms of psychic disorders was taken by lasting hypothymic situational reactions@anxiety and dysphoria-caused by situations. Specialists of psychological-psychic teams used the correction program for nonpsychotic forms of disorders (developed by the authors) among persons, being examined. This program included program of pharmacological support (three-cycle antidepressants, MAO inhibitors, etc), transpersonal psychotherapy, information-wave technologies (microwave resonance therapy, mesodyencephaly modulation, etc) that allowed them to obtain corrective effects in 87%. Patients with psychic diseases were sent for treatment into specialized medical institutions in cities of the Russian Federation (Krasnodar, Rostov, Vladicavkaz, etc.).
The system presented for rendering psychological-psychiatric assistance to the population was very effective, since it revealed the main forms of psychic disorders in the early stages. Special programs of treatment allowed correction in 87% of the cases. This system may be proposed for use in other countries in local conflicts and humanitarian disasters.
Key words: complex human emergencies; displaced populations; pharmacological support; psychological disorders; psychotherapy; recognition
E-mail: rcdm.org@g23.relcom.ru
Prehosp Disast Med 2001;16(2):57.
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Deployment of French Military Field Hospital Following the 1999 Earthquake in Turkey
On 22 August 1999, France sent a military field hospital to relieve the rescue clearing team of the Security Service and to complete the first aid organization to the victims of the earthquake that occurred in Turkey. This hospital was deployed under tents near the disaster-stricken local hospital in AKYAZI (200 km from Istanbul). It is important to restore the confidence of a disaster-stricken population that suffered from a recurrence of an earthquake. The rules of the action are: (1) reinforcement of the local medical organization that sorts the patients in order to send them to our hospital, (2) total autonomy of the hospital, and (3) close collaboration with the Turkish authorities to adapt the medical activity to the needs of the population.
During 24 days, the activities included 143 surgeries (46% of pediatric surgeries), 1,491 med surgeries, 1,262 radiology procedures, and 151 patients hospitalized.
Key words: deployment; earthquake; field hospital; rules; triage
Prehosp Disast Med 2001;16(2):s57.
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Pediatric Anesthesia by Military Field Hospital in Disaster Situation
Military surgical teams also are employed in disaster situations. During 1999, they were deployed in a humanitarian mission in Turkey for earthquake victims, in East Timor for refugees, and in Chad for helping poor people beside the military mission. In these countries, the population is very young and surgical teams have performed many pediatric surgeries, mainly in emergencies: 158 children, 22% of all surgeries in the three missions and 46% in Turkey.
Many types of surgery were performed, and in these emergency and disaster situations, the anesthetic procedure must be very simple. Loco-regional anesthesia is a good way to easily manage pediatric analgesia.
Key words: anesthesia; children; earthquake; military; refugees; surgery; teams
Prehosp Disast Med 2001;16(2):s57.
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Medical Radio Network Contribution for Medevac during Military Operations
Due to the impossibility of medical coordination, medical assistance in military operations is based upon a convoy of ambulances for medical evacuation, and upon mandatory stages of treatment or dispatching. Medical reports are written on field medical cards (NATO format), and reviewed or transcribed at each and every stage of medical care. Emergency categorization is made at the surgical clearing center, after first level of evacuation and the injured having been through the battalion first aid post. During the Gulf War, casualties were taken directly into the charge of medical teams on the battlefield. In Sarajevo, during peacekeeping operations, in order to reduce the waiting period before surgical treatment, simplified procedures were developed thanks to the use of operational radio networks and special medical messages. With the use of medical radio networks, regiment or battalion medical doctors can sort casualties, which could be dispatched directly to the specified field hospitals that are able to treat their respective injuries. Medical examination data also could be collected through a computer software application. These procedures could be extended to disaster situations.
Key words: coordination; doctors; evacuation; Gulf War; military; networks; radio; Sarajevo; treatment; triage
Prehosp Disast Med 2001;16(2):s58.
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Feasibility of Transplantation Treatment of Spinal Cord Injures
Objective: To investigate the effects of transplation of fetal nervous and hemopoetic cells into patients with spinal cord injuries.
Methods: The cells from fetal nervous and hemopoietic tissues (gestational age 16-22 weeks) were implanted subarachnoidally into eight patients (21-to-49 year old) with severe, traumatic, spinal cord injures at various cervico-thoracic spine levels. The trauma was incurred from automobile accidents. The remoteness of the occurrence of the trauma was from 1 month to 6 years before the transplantation was performed. Before transplantation treatment, the neurological state of each of the patients was consistently a grade =93A=94 of spinal injury according to Francel classification. In seven cases, cell transplantation was preceded by resection of a connective tissue cyst that has formed within the site of traumatic injury.
Results: A noticeable clinical improvement was observed in 6 of 8 cell-grafted patients. The neurological state of 4 and 2 patients became to be clinically consistent with =93C=94 and =93B=94 grade of spinal injury, respectively. No clinical effect was noted in two patients both of whom had the longest time elapsed from the trauma (3 and 6 years). No serious complications of transplantation treatment was noted.
Conclusion: The results presented point out a clinical relevance of transplantation approach to treating consequences of spinal cord injury.
Key words: fetal tissue; injuries; spinal cord; transplantation; trauma
E-mail: gaf@online.nsk.su
Prehosp Disast Med 2001;16(2):58.
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Early Non-Operative Treatment of Severe Acute Pancreatitis
Introduction: The effects of different treatments in severe acute pancreatitis (SAP) have not been established.
Methods: From January 1992 to May 1997, 86 cases of SAP were studied retrospectively. They were separated into two groups: (1) operated, and (2) non-operated patients. The operated group consisted of 43 cases operated upon during the first two weeks after they were admitted in the hospital. The patients in the other group were not operated upon during the same period. The morbidity of complications and the curative rates were compared.
Results: The morbidity rate associated with complication in non-operative group (36.8%) was lower than for the operated group (91.7%). The curative rate for the non-operated group was increased significantly over the rate for the operated group, especially in SAPII cases.
Conclusion: The treatment of nonoperated patients in the early stages can bring a satisfactory therapeutic result. This treatment included: (1) the continuous monitoring in ICU, (2) alimentary support, (3) using the pancreatin inhibitor, (4) rest for the pancreas, and (5) the early administration of antibiotics.
Key words: care; intensive care; morbidity; pancreatitis; surgery
E-mail: zhoumingqing@163.net
Prehosp Disast Med 2001;16(2):58.
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Advantages of a Common Patient File System for SAMU Emergency Services and Hospitals
Introduction: The quality of prehospital emergency service medical practice still has not been assessed completely. The main studies available in France are quantitative, describing the level of equipment and the activity of the SAMU emergency service organisations. Medical evaluation of prehospital Emergency Medicine is rendered difficult in France by a number of obstacles. Reluctance to change is only one of these. The means to collect and interpret the medical data often is lacking. Prehospital Emergency Medicine can be compared to the exposure of a negative that will be revealed by the hospital. It is made up of a range of actions for which the only way to assess, if they are appropriate, is the subsequent history of the patient in the hospital. If this part of the picture is lacking, it is difficult to study the quality of prehospital care, the impact of various treatments given prior to transport, the indications according to the pathology, while considering the cost-effectiveness ratio. Consequently it appears difficult to make recommendations that are backed up by solid arguments, whether in terms of clinical practice, means of management, the strategies for allocation of prehospital health care equipment and health policies. The exploitation of data for research purposes is equally difficult, if not impossible.
Methods: The idea is to pool the SAMU emergency service medical files and those of the hospitals. The expected advantage is the possibility of following the patient's history systematically from the beginning-the first patient contact-and through to his discharge from hospital. Identification of the patient respecting all the requirements of law, the succession of diagnoses made from the point when first taken charge of up to the final diagnosis, the succession of treatments, the time required to carry out the main investigations/treatments, steering and any change in destination, the time spent in each department, and the patient's condition on discharge.
Ample use of computer technology together with a vocabulary for diagnoses and treatments that is as standardised as possible would be invaluable for effective sharing of this information. If the data listed above were available, it would be easy to assess the impact and any shortcomings of prehospital emergency treatments. Any consequences arising from a lack of available resources would become clear also.
In France, it is legally possible to pool the patient file of a SMUR (emergency medical service) with those of the hospital it belongs to. However, there are administrative and possibly legal problems involved when trying to share files between different hospitals, or with the administrative file system for the emergency telephone centres, or again with services that answer to different administrations.
Conclusion: Although there still would be problems, medical assessment of prehospital emergency services medical practice in France requires the patient files with the SAMU emergency services to be held in common with those of the hospital. The design of modem software programs should allow for this, while complying with the operational computer organisation of the SAMU services, for the sole benefit of public health needs.
Key words: computers; data; emergency medical services; hospitals; patient files; prehospital; quality; records; research
Prehosp Disast Med 2001;16(2):s59.
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The Role of Selective Management of Penetrating Abdominal Wounds
With the rising incidence of urban violence and related events, we observed a proportional rise in the number of patients with penetrating abdominal wounds. It is necessary, in these patients, to validate clinical and radiological criteria to justify the use of diagnostic laparotomy, since this procedure is associated with significant pre- and postoperation morbidity.
In a retrospective study of the patients submitted to diagnostic laparotomy at Municipal Hospital Miguel Couto (Rio de Janeiro, Brazil) between April 1995 and April 2000, it was observed that, of 562 laparotomies in patients with penetrating abdominal trauma, 82 (14.6%) were considered negative, without intra-abdominal lesions. Of these, 31 were gunshot wounds (9.6% of the gunshot-related laparotomies) and 51 were stab wounds (21.2 per cent of the stab wound related laparotomies).
We conclude that the high rate of unnecessary abdominal exploration in patients with stab wounds make this group suitable for selective management based on clinical grounds. Conversely, gunshot wounds patients, once confirmed abdominal penetration, are candidates for surgical intervention.
Key words: abdomen; gunshot; management; penetrating; stab wounds
E-mail: lucanunes@dr.com
Prehosp Disast Med 2001;16(2):s59.
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Airline Accident at the Chang Kai-Chek Airport, 31 October, 2000
Tuesday, 31 October at 23:00 hours, the Singapore Airlines, Flight SQ006 from Taipei to Los Angeles, a Boeing747-400 with 179 persons on board was taxiing on the runway at the Chang Kai-Chek Airport. The weather conditions were poor with strong winds@some reaching 50 knots@pouring rain, and visibility was limited to 400 meters. A part of the airport was under repair, and a former runway was closed and only partly used as a taxiway. These circumstances that still are under investigation may have contributed to the fact that the aircraft, on its way out to the runway, turned around for takeoff on the closed taxiway. At 23:10 hours, the aircraft started its acceleration to a speed of more than 150 miles/hour when the pilot suddenly saw a construction machine in front of him. The collision was inevitable and surviving passengers experienced an enormous bang just as the nose of the aircraft was lifted in the air, throwing it back on the ground, and breaking the aircraft into three parts. The front was separated from the rest of the aircraft, the middle part with the wings was immediately set on fire, and the rear part was separated, but remained in close connection with the middle part. 82 passengers died instantly or shortly after the crash, 2 patients died later in hospital. The airport alert was almost immediate, and the 32 men at the airport's fire brigade, who 4 months earlier had trained on a similar scenario, were prepared. They responded instantly by being at the scene of the accident in 1 minute, 38 seconds. The disaster alert also was sent to the dispatch centre in the county of Tao-Yuan, which further alerted the 17 emergency hospitals in the area. Emergency medical teams from each hospital were gathered rapidly and sent to the airport. The extreme weather conditions made the fire fighting as well as the evacuation of the passengers difficult. A gathering area for injured could be established at 300 meters distance, but adequate means of transport were mobilised early, and 10 patients were sent directly from the site of accident to hospital. No advanced medical management was performed at the site of accident or at the gathering area. The early arrival of more than 100 ambulances at the airport facilitated expeditious transport to hospital. However, the distribution of the injured to different hospitals was without any co-ordination, and the prehospital medical records on each injured were poor or lacking. A smaller hospital near the airport, received within a short time, 20 patients, 7 with severe burn injuries. Sixteen of them within 2 hours were transported further to the trauma centre at Chang Gung Memorial Hospital, where the disaster alert 333 had mobilised sufficient medical resources ready to receive more than 100 injured. Altogether, 36 injured arrived to the trauma centre, 18 with burn injuries, several with severe burns. Only 5 patients were in need of emergency surgery. A certain number of minor injuries, although not recorded, could have been treated at the airport or in other hospitals.
Summary: Due to recent training, the Chang Kai-Chek Airport Rescue Services were well-prepared to manage the severe airline accident When conditions are in favour of rapid transport to hospital, triage and more advanced medical management could be more adequately performed in a hospital, but the co-ordination of ambulance transports remains important. Communication with the dispatch centre is in similar situations important. The hospital system in Taipei, including the large trauma and burn centre, seems well-prepared to handle a mass casualty situation.
Key words: airline; airport; burns; casualties; co-ordination; crash; deaths; hospitals; injuries; rescue; response; transport
Prehosp Disast Med 2001;16(2):s60.
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Training Course in Human Resources: Descriptive Analysis of Traffic Accidents During Year 2000
Introduction: Of the demands required of the Centro Informacion y Coordinacion de Urgencias de Castellon (CICU), the cases related to the traffic accidents make up 17% of the total of emergencies. In addition, they are emergencies that usually take place in another type of nonhealth sector. Therefore, it is interesting to know the profile and data that are responsible for this health care demand.
Objective: To conduct a descriptive analysis of the traffic accidents in the province of Castellon during year 2000, classified according to Galeno as emergencies.
Methods: A cross-sectional, descriptive study with a sample of 936 accidents gathered from 01 January through 31 December 2000 was used. A worksheet was created (in the Excel, Microsoft, Inc., Redmond, Washington USA) that contains the following variables: (1) with respect to the wreck, the location of the accident, date, day of the week, and hour of the alert; and (2) with respect to the wounded, the number of injured in each wreck, age, gender, evaluation, diagnoses, and resources used in providing the medical assistance.
Results: Traffic accidents caused 17% of the total number of emergencies taken care of during this period. The months with greater frequency were April, July, and August. Of 461 accidents studied, they occurred on the weekend, including Friday, Saturday, and Sunday. The hourly distribution between morning, evening, night, and dawn indicates that greater percentage happen in the afternoon, with a clear peak in frequency between the 18:00 h and 20:00 h with 58 accidents; 40.8% of the accidents take place in an urban zone and environs; and 59.2% on the roads (highways) of the urban zones: highway (freeway) 133 accidents; state roads (highways), 231; and roads (highways) of local or regional importance, 159.
Key words: accidents; analysis; frequency; profile; traffic
Prehosp Disast Med 2001;16(2):s60.
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Assessment of Hospital Disaster Plan Conferences in Turkey: A Report of the Emergency Medicine Association of Turkey (EMAT)
Objective: To determine hospitals' general adequacy and preparedness in response to disasters a year after the 17 August, 1999 earthquake, and to evaluate the need for comprehensive hospital disaster plans in Turkey during the Hospital Disaster Plan Conference Series.
Methods: From 25 September 2000 to 09 October 2000, nine prepared standard conferences were organized by EMAT and Emergency Medicine Research International (EMRI) in seven different cities. Organisations of the conferences was done by EMAT Secretery and the local Turkish Physicians' Association offices. Professionals who work in their hospital's disaster teams, administrative offices, clinical services (doctors, nurses, etc.), and ambulance services were invited to the conference. The conferences were organised for participants from university, state, and insurance hospitals. Postconference questionnaires containing 20 questions were given to all participants.
Results: The conferences were attended by 373 professionals. The participants were group into the following categories: (1) doctors, 114 (31%); (2) nurses, 96 (25%); (3) paramedics, 49 (13%); and (4) others 114 (31%). Of these, 25% said "no" to "Does your hospital or facility have any disaster plan?", Thirty-four percent of participants chose "not sure" for the same question. Ninety-six percent of participants said "yes" to, "Would you like to have a role in your hospital's or facility's disaster plan?" Ninety-three percent of participants said "yes" to "Can the Hospital Disaster Plan Program be effective on your hospital or facility?" Forty-nine percent of participants said that their hospitals were "not ready" for a disaster.
Conclusion: Health care professionals are the cornerstones of any disaster plan. Most of the hospitals visited during the conference series don't have organized hospital disaster plan one year after the Marmara earthquake. However, professionals want to have a role in any new disaster plan. We concluded that while some hospitals are not prepared to deal with any new disaster, this Hospital Disaster Plan (HEICS) can form a solid basis for new guidelines that are easily applicable to every hospital in the country.
Key words: disaster; disaster plan; hospitals; planning; preparedness
E-mail: ulkumenrodoplu@ttnet.net.tr
Prehosp Disast Med 2001;16(2):s60.
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Assessment of the Staff of an Emergency Department Training in the Hospital Emergency Incident Command System
Objective: Dokuz Eylul University Hospital and its Emergency Department is one of the best equipped, staffed, and designed centers throughout Turkey. Despite this, until the two recent devastating earthquakes took place in Turkey, we were not sufficiently ready for a disaster. This lack of preparedness was, and, to a certain extent, still is so countrywide. To rectify this condition, the medical director of our hospital invited a group from the United States to train a group of physicians and nurses about the "Hospital Emergency Incident Command System" (HEICS). Beginning with the Emergency Department, all of the staff working in the hospital began to be trained. At the end of the course, the audience was asked to complete the standard questionnaire consisting of nine questions. Our main goal was to evaluate the staff about their perception of the disaster management system, a system that is very new to Turkey.
Methods: All of the staff of our Emergency Department (doctors, nurses, paramedics, secretaries, etc.) received a standard four-hour course about HEICS. A standard questionnaire was completed immediately at the end of the course. Their answers were later evaluated by one of the trainers.
Results: Thirty-three people attended the course. The results were as follows:
1. Distribution of the jobs of the audience: Three physicians (9%); 17 resident physicians (51%); five nurses (15%); three paramedics (9%); five clerk, secretary, etc. (15%)
2. Does your hospital already have a written disaster plan? Yes, 27 (82%); No, 3 (9%); and "I don't know", 3 (9%)
3. Would you like to participate in the disaster plan of your hospital?: Yes, 33 (100%); No, 0 (0%);
4. The disaster plan of your hospital is similar or the same as HEICS? Yes, 24 (74%); No, 8 (24%); No comment, 1 (2%)
5. Do you believe that HEICS can be successful and effective for your hospital? Yes, 30 (90%); No, 0 (0%); No comment, 3 (10%)
At the end of this course, do you believe that you could be able to be (Certainly agree, Agree, Agree a little, Don't exactly agree, don't agree):
6. Informed about a new disaster management system: 13 (40%); 19 (57%); 0 (0%); 0 (0%); 1 (%3)
7. Informed sufficiently about HEICS: 4 (12%); 19 (57%); 9 (28%); 0 (0%); 1 (3%)
8. Use HEICS plan for a possible disaster: 16 (49%); 11 (35%); 4 (13%); 0 (0%); 1 (3%)
9. Say that you are ready for a disaster: 2 (6%); 5 (15%); 13 (38%); 13 (39%); 2 (6%)
Conclusion: The rate of participation in the course was 100%, though it was not mandatory. This may indicate that the staff is interested in the subject, perhaps due to the fact that they are working in an Emergency Department and/or because of the earthquakes we recently experienced. Interestingly, a large percentage of the staff believed that our hospital already has a written disaster plan. While this is not completely true at the moment, work is being done to establish a thorough plan. This is unlike most of the country's other hospitals. One hundred percent of the staff wants to participate and be involved in this plan.
A very large percentage of the staff believes that this new disaster management system (HEICS) seems to work efficiently during a possible disaster. Again, a very large percentage of the staff was very happy to listen and be informed about such a new subject. Perhaps one of the most striking results was that a high percentage of staff thought that they still were not ready for a new disaster, despite having taken the course and experienced several large earthquakes. Though we have a fairly limited number of results, we can claim that our hospital will be more successful using the HEICS plan during a disaster. Dokuz Eylul University Hospital is now one step ahead, having been trained about HEICS. We now are more prepared to both spread this knowledge and to minimize casualties at any disasters that may occur.
Key words: disaster; education; emergency department; hospital; incident command system; planning; preparedness; training
E-mail: gurkan.ersoy@deu.edu.tr
Prehosp Disast Med 2001;16(2):s61.
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Volunteer Disaster EAM and Field Triage Drill
"
Objective: Emergency Medicine Association of Turkey (EMAT) has a disaster team that includes emergency physicians, nurses, paramedics, and volunteers. This group was first established after the two devastating earthquakes experienced in 1999 in Turkey. The team is trained to work at triage sites. As a new and unique disaster and emergency medicine association, our objectives with this drill are: (1) to make the team knowledgeable on field triage, (2) to develop a standard approach to the disaster victims and injured people, (3) to evaluate the patients and find out which of them need immediate intervention, and (4) to teach the team members the importance of use of the triage tags.
Methods: The drill was planned to be at the Izmir City Municipal grounds on 17 August 2000, the first anniversary of the Kocaeli earthquake. There were 100 EMAT members that participated during the drill acting as wounded people. They all had make-up and knew what their problem was. Their disease or injury was written on a paper pinned over their chest. Sixty of the injured were sorted as green, 20 were yellow, 5 were red, and 15 were black. The volunteers that joined the drill to act as wounded were given their coloured badges. On the paper badge, each person had information about their problem. They were asked to act as if they had that problem. Each person with black or red tags was asked to lie down on the ground. Those with yellow tags would sit down and wait for the paramedics. Patients with green tags would start walking to either the triage area or the emergency room. The volunteers would know what coloured tag they were carrying, but the disaster professional team would not see the tags until the patient was at the triage site. The triage officer was to pull out the coloured tag when the patient arrived to the triage area.
Drill Sites were as: I. Disaster area; II. Triage area; III. Green area; IV. Black area; and V. Emergency room
The whistle indicating the beginning of a significant earthquake was blown at 6.00 PM. Right after the announced earthquake, the injured people went to their sites. Thirty-seven EMAT Disaster Team Members worked at this drill. The first group consisted of two paramedics that started sorting out the 100 injured people. After sorting the patients, they transported them to the triage area using backboards, if needed. The patient's identification information was written on the triage tags. The red and black labeled patients' photos were taken. Right behind the triage area, the red, green, yellow and black areas were constructed. The ambulances were located close to the triage area, and were ready to transport patients. The ambulances were used to transport the red labeled patients first and the yellow patients after the red ones had all been transported.
Results: The disaster team of 37 volunteers practiced their knowledge and skills of triage organisation. The disaster area with 100 patients was cleared and it took the paramedics and the first-aid volunteers 9.4 minutes to transport all patients to the triage area. The triage area was clear after 24.3 minutes. The ambulances transported all the red and yellow tagged patients to the emergency room, starting with the red tagged ones. There were no missed diagnoses. The team used their knowledge about triage tag colors. All were very eager to sort and find the red labeled patients. By the way they performed, we perceived that our volunteer disaster team was ready to perform true triage in a real disaster.
Key words: ambulances; casualties; disaster; drill; exercise; simulation; tags, triage; team; triage
E-mail: ulkumenrodoplu@ttnet.net.tr
Prehosp Disast Med 2001;16(2):s62.
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Social Problems at the Emergency Department: Emergency and Family Physician's Role
Introduction: Emergency doctors must deal with many different problems. With this work we try to assess the role that emergency doctors and family physicians can develop regarding to the emerging social problems affecting their patients.
Methods: From 1994 through 1996, 266 patients admitted to our hospital emergency department asked for assistance from the hospital social work unit (SWU). We made a transversal descriptive study considering patient's age, sex, profession, marital status, social status, clinical diagnosis, method of accession to the SWU, and implemented social work.
Results: Mean age was 62.7 years; 58.6% were male, and most of them were single (46.6%) and retired (67.7%). Patients themselves requested social help in 18.4%, the rest were requested by emergency department personal. The most common clinical diagnoses among these patients were: stroke (11.5%), malnutrition/dehydration (7.6%), and alcohol/drug abuse (6.8%). Half of the patients had adequate economic income. Social problems were mainly related to lack of family support (92.5%) or decreased functional outcome (78.2%). Social work was focused on advice to families (246 patients), health care (208) and community assistance (164). Social services from the community (185), specific associations for geriatric (95) and disabled (3) people, health care associations (21) and foreign embassies (3) cooperated in the resolution of the different problems.
Conclusions: Low income and family support, but not clinical diagnosis, were factors that usually gave rise to social problems in elderly patients admitted to our emergency department. The work developed by our SWU was mainly directed tofamilies and to a wider use of community social resources. According to these findings, family doctors and emergency doctors play an essential role in this area.
Key words: elderly; family support; social problems
E-mail: montilla@arrakis.es
Prehosp Disast Med 2001;16(2):s62.
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Medical Aid to Children Who Survived the Earthquake in Turkey (1999)
Medical aid to children who survived the earthquake in Turkey was provided by Turkish physicians and by a specialised pediatric team from Russia that included specialists of intensive care, traumatology, neurotraumatology, and general surgery. All together, 150 children were admitted to different hospitals in Turkey. The major numbers of them were placed in Istambul, in Kartal, and in Marmara Hospitals.
Almost half the total number of these children had sustained various forms of crush syndrome (52%); every third child had fractures of the long tubular bones; and 14% of children had head traumas. Less frequently, they sustained different types of traumas including burns, closed traumas of intraabdominal organs, and/or eye traumas. Isolated and combined traumas were in similar proportions.
The children with the crush syndrome were the most severely compromised patients. Most often, the crush injury was localised to the ankle (30%), thigh (28.6%), head (23.8%), or forearm (7%). Of all children with crush syndrome, 12.6% required amputations. Positive results were seen in children who had fasciotomy with early plastic surgery procedures to the skin. Acute renal insufficiency has been reported in 27% of children with crush syndrome.
Despite generally positive results of treating child victims, we could have had even better results if all children had been concentrated in one hospital, and had had, from the beginning, qualified pediatric help.
Key words: amputations; children; crush syndrome; earthquake; injuries; pediatricians
Prehosp Disast Med 2001;16(2):s63.
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Principles of Rendering Medical Aid to Children in Disasters
Our experience in rendering medical aid to children in emergency situations in many countries of the world (Afghanistan, Armenia, Egypt, Georgia, India, Iran, Japan, Russia, Turkey) has enabled us to formulate some principles that should help to decrease mortality and morbidity rates among injured children:
1. Medical aid should be rendered by pediatric specialists
2. Specialized medical aid in case of disaster should be as close to the site of disaster as possible
3. Pediatric intensive care specialists and pediatrician-traumatologists, as well as physicians who have had special training courses on rendering medical assistance to children in extreme situations and having a proper license should work in the disaster areas
4. Transportation of an injured child to a hospital should be done only if the child is transportable, and only after all preliminary intensive care measures are performed at the site
5. Children from a disaster area must be concentrated in one, or at most, two hospitals. The time of transportation, if all necessary curative measures are performed simultaneously, is of no importance. It is important for the child to be hospitalized at a specialized pediatric hospital that has many types of pediatric specialists on emergency therapy, traumatology, plastic surgery, pediatric surgery, and nephrology. This hospital should be equipped with a modern laboratory and other equipment like a computerized tomographic scanner, renal dialyzer, etc.
Key words: children; credentials; disasters; intensive care; pediatricians; principles; specialization; transportation; treatment
Prehosp Disast Med 2001;16(2):s63.
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SWEDE: A Management System with Internet Technology Support for the Health Care System in Emergency and Disaster Situations
The Swedish National Board of Health and Welfare has introduced SWEDE, a new management system to ensure a high level of preparedness for major emergencies and disaster situations. The SWEDE system is based on a general protocol and a computerised information system-IS Swede. The protocol standardises terminology, enabling emergency personnel to cooperate and coordinate activities during major emergencies and disasters in a more efficient way. The protocol is understood and accepted by the health care system, and is similar to those used by police and rescue services. The information system includes patient information as well as information on available resources.
New equipment has been introduced in ambulances. Information is sent on-line to receiving hospitals using the Mobitex® system and Internet technology. In situations of disaster or during a state of alert, this system provides continuous access to relevant information.
One important part of the SWEDE concept is that it is used daily and, when situations escalate, it is already in place and can be mobilized rapidly. Where introduced, the IS Swede today is used routinely in all situations involving an ambulance. The information is sent to a central database then directed to the receiving hospital by encrypted Internet. The hospital receives advance information about the accident, the patient(s), and the treatment being given at scene and during transport. In disaster situations, the management group can also use the IS Swede to direct the ambulances to those hospitals having the necessary resources.
Currently, the system has been introduced in four county councils in Sweden. Other county councils, as well as the Swedish National Defence, are considering the system and it is proposed that 75% of all county councils in Sweden should have the SWEDE system in use at the end of 2005.
Key words: ambulances; disaster; emergencies; information systems; Internet; management systems; structure; Sweden; terminology
E-mail: anders.ruter@lio.se
Prehosp Disast Med 2001;16(2):s63.
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Amendment in the Regulations of the Emergency Plan ("Red Plan") in Case of Major Accidents with Limited Consequences in a City
The "Red Plan" is a one of several emergency plans destined to help numerous victims. A decree details the circumstances in which the plan can be launched and just how it should develop at a regional or "department" level (France is divided into "departments"). The various texts that have successively established the rules concerning the organization of the Red Plan on a local level and national level have been analyzed, and the differences they reveal have been stressed in the light of the events that have lead to its evolution.
The first emergency plan for numerous victims elaborated in the Paris area dates back to 1975. The first Director of Medical Assistance had been named one year earlier. At the time, the regulations were those of the Paris fire brigade, and anticipated three situations: Blue Plan, 10 victims; White Plan, 20 victims; and Red Plan, 50 victims. Later, these three were grouped into a single category: the Red Plan, with three "functional chains" for collecting, selecting/treating and evacuating.
The first actual application of this system occurred in 1978 after a gas explosion in rue Raynouard, and it was obvious that there were many flaws in the functioning of the Plan. These flaws were further exposed after responding to two additional explosions involving the emergency teams, and to spontaneous evacuations done by passersby and policemen. One year later, another gas explosion in rue Saint-Ferdinand provided the opportunity to implement the Red Plan. Since then, the lessons learnt during the major interventions and from the regular training have prompted regular updates in the regulations. The 1986 terrorist attacks in Paris made it clear that it was necessary to integrate the SAMU (urgent medical aid service) into the Red Plan, a decision that proved satisfactory later with the 1987 and 1988 train accidents, primarily that of Gare de Lyon. The new series of terrorist attacks in 1995 was the occasion to improve the way victims are cared for, thanks to the creation of a center for those implicated in the accident, and a specification in the role of the emergency medical-psychological department. In 1999, a new step was made due to the special geographical context of the Paris region, when an "interdepartmental" (interregion) Red Plan was adopted along with a new medical file.
Conclusion: Emergency aid was born from the war experience. The application of the regulations to actual and major accidents with limited effects has generated the conception of a more effective emergency plan, whose regulations should remain flexible in order to encourage regular evolutions.
Key words: casualty collection; chains, emergency aid; evacuation; functional; multiple casualties; plan; planning; preparedness; regulations; SAMU
Prehosp Disast Med 2001;16(2):s64.
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Sydney 2000: Olympic Stadium Medical Programme
The Sydney 2000 Olympic Stadium is the world's largest ever purpose built Olympic facility, with a capacity of 118,000 people. Over the course of the Olympic programme, (8 days of athletics competition as well as the Opening and Closing Ceremonies), more than 1.9 million people passed through the turnstiles of the Olympic Stadium. Meeting the challenge to provide timely, effective, and efficient emergency care to all people in the stadium is discussed. It begins by looking at the challenges that needed to be overcome; it details the operating plan that ultimately was put in place; it outlines the disaster preparedness programme, the resources committed to implementing the programme, and the results achieved.
Ultimately, the plan involved over 100 medical staff providing medical care for over 100,000 people for each session of competition. How this was carried out is detailed and the activity of the programme is presented: 100-120 people treated per session: 50-60 of these needed basic first aid, and 50-60 needed more formal medical intervention (detailed medical assessment and invasive interventions). Ultimately, 5-7 people per session were transferred by ambulance to a hospital. No one died.
Key words: first aid; interventions; mass gatherings; medical care; Olympics; plan; preparedness; stadium; staffing
E-mail: john.sammut@unsw.edu.au
Prehosp Disast Med 2001;16(2):s64.
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Fifty-month CEP-Experience in an Area of a Half-million People
Introduction: Following the education as Coordinating Emergency Physicians (CEPs) according the Bavarian Rescue Laws (BRLs), we formed a voluntarily acting CEP group in our rescue region in Western Bavaria in January 1996. The group was accredited by the authorities in May 2000. To improve the performance of our missions, we analyzed the system capacities according J. de Boer1 and tried to implement M. Villareal's QC tools.2
Methods: From January 1996 to February 2001, we handled 50 missions that were prospectively registered and analyzed since June 1997. According to de Boer's Criteria for Disaster Preparedness, we calculated the capacities of our rescue chain using the elements: (1) medical rescue capacity, (2) medical transport capacity, and (3) the local hospital treatment capacity according to the number of available hospital beds. We did these calculations to be prepared for the EMS management of the World Exhibition of Fire Brigades, which took place in our city in June 2000. M. Villareal's tools for QC were tested on scene and in postevent meetings to gain best information and feedback for our learning curve as CEPs.
Results: In total, we served 23 missions during daytime (4 in the morning, 19 in the afternoon), and 27 missions were necessary during the night. Regarding the reasons for the calls, there were 24 fire alarms, 14 accidents (cars, railroad, aircraft), 4 poisonings, 5 explosions or bomb alarms, and 3 during mass gatherings. Of these missions, 41 were graded as events of first degree (according to Villareal's staging system) and 9 required additional manpower like SEGs (special acting groups) so that these events were graded as 2nd degree casualities according to Villareal.
From the total number of 3,724 hospital beds, a theoretical hospital treatment capacity of 112 patients/hour was calculated for a performance score of level 5. This is served by a transport capacity of 49 ambulances directed by 8 emergency physician cars. For increasing the rescue capacities, the rescue teams could be supported by 7 local SEGs (pecial acting groups) and 5 helicopters from the vicinity.
In total, up to 05/2000 voluntary CEP system took responsibility for about 550 victims of minor injuries. According de Boer's criteria for disaster scoring, we had to deal with events of a disaster severity score from 1 to 6. The severity index was calculated between 0.3 and 3.
Conclusions: To be able to distinguish between the three degrees of Villareal's differentiation of MCs: I=B0, II=B0, III=B0, it is necessary to know exactly the capacities of your local rescue chain elements. It is essential to be able to distinguish between MCs II=B0 and III=B0 because you have to call for help in the vicinity in time in case of MC III=B0. So you should be able to prevent that your local MC might end as a disaster because of bottleneck problems within your local system capacities.
References
1. de Boer J: Criteria for the assessment of disaster preparedness @ II. Prehosp Disast Med 1997;12:13@16.
2. Villareal M: Quality control module for mass casualities. Prehosp Disast Med 1997;12:200@209.
3. de Boer J: Definition, classification and scoring of disaster. In: Handbook of Disaster Medicine. De Boer J,. Dubouloz M (ed), VDW publisher 1999, pp 227-228.
Key words: capacities; classification; coordinating emergency physicians; disaster; performance; quality assurance
E-mail: bm.schneider@medizin.uni-ulm.de
Prehosp Disast Med 2001;16(2)s65.
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The Complications in Excimer Laser In-Situ Keratomileusis for Severe Myopia
Objective: To evaluate the safety and efficacy of excimer laser in-situ keratomileusis for severe myopia.
Method: 463 eyes of 237 cases which ranged from -6.00D to -22.00D were operated upon using Lasik using SCMD Microkeratome and NIDEK EC-500 excimer laser system. The complications and prognosis were analyzed retrospectively.
Results: Postoperative, uncorrected visual acuity increased significantly, and 75.3% of the patients achieved preoperative best corrected visual acuity or better. The perioperative complications included: incomplete corneal flap (0.86%); free cap (0.43%); decentred flap (0.22%); and limbus hemaorrhage (7.3%). The postoperative complications included: particulate debris undcr the repositioned flap (2.8%); over or undercorrection (9.8%); and epithelial interface ingrowth (0.65%).
Conclusion: Lasik for severe myopia proved to be safe and effective, although it needed to be improved microkeratome and experience.
Key words: acuity; complications; efficacy; excimer laser; keratomileusis; myopia; safety
Prehosp Disast Med 2001;16(2):s65.
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Reducing Community Vulnerability of Lalitpur Submetropolitan City
The high rate of urbanization and haphazard urban growth coupled with change in the economic base has transformed the tiny town of Lalitpur into a submetropolitan city. Founded in 299 AD along Tibetan and Indian trade routes, the town developed based on Hindu and Buddhists planning principles into the present form. Lalitpur, within its 22 municipal wards over an area of 459 hectares, is comprised of both planned and unplanned, as well as old and new urban fabrics, exhibiting the socioeconomic reality and development process that prevailed in those earlier periods.
The consequences of this transformation not only are limiting physically, such as destruction of traditional homogeneous building stocks into inferior parts, severe deficiencies in basic urban services, conversion of courtyards and pedestrian lanes into "death traps" and so on, but also on reduction of an individual's or society's ability to cope with hazards, thus making the old neighborhood more vulnerable. The government's response to deal with various problems associated with this process through enforcing building legislation and rescue operation on an ad hoc basis is insufficient and discouraging.
This paper examines the community vulnerability from an integrated approach of Lalitpur, just next to the capital city of Kathmandu. It has four objectives. First, it demonstrates the natural hazards in the city, considers seismic risk and socioeconomic structure including variables in infrastructure, building materials, and population vulnerabilities. Second, it analyzes the preparedness level and response capacity of the city (and society) for vulnerability analysis. Also, a case study of a typical neighbourhood in the historical core area is examined in order to demonstrate the process of urban transformation and its consequences on neighbourhood vulnerability. Third, it identifies various reasons of vulnerability increases, and then, assesses the risk analysis (future probable damage). Finally, it proposes some recommendations for public authorities, communities, and policy makers in the fields of planning and development, vulnerability analysis, and capacity of local government (and ward office) and local resource mobilisation and community awareness.
Key words: community vulnerability; Lalitpur; seismic risk; socioeconomy; urban transformation
E-mail: shrestha@hyogo.uncrd.or.jp
Prehosp Disast Med 2001;16(2):s65.
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Management of Calcium Oxide Intoxication
1. Rinsis, Mons, BELGIUM
2. Chr Warquignies, BELGIUM
3. Chu Ambroise Pare, Mons, BELGIUM
Introduction: On an industrial site, an intoxication of a large number of workers by calcium oxide has necessitated strict triage so as to avoid a massive evacuation toward the hospitals.
Method: Work on a construction building site settled within an industrial area required spreading of quick lime near the factory. A change of wind direction exposed a large numbers of labourers to calcium oxide emanations. The first dispatch of assistance consisted of two ambulances and one medical team. The director of medical assistance (DMA) also was notified and went to the scene. The intoxication was moderate and consisted of airway and eye irritation.
Initially, around 40 labourers showed up with these symptoms, but soon more than 100 labourers complained of cough and ocular irritation. An accurate triage was indispensable on the scene as to avoid a massive evacuation of the victims toward the hospitals, and in this way, impeding emergency medical services. The arrival on the site of an extra ambulance and a second medical team permitted the realization of the DMA directives, triage in an hour, and the evacuation started 1.08 hrs after the alert. Transportation of casualties was done by ambulances for four victims and 16 other victims were tranported with the help of the minivan of the civil security. The major problem confronted during this incident was a hysterical panicking among the workers and only a few casualties really had the symptoms.
Results: Of the hundred or so labourers who arrived in the triage area, only 20 had to be evacuated. The last casualties left the scene 1.45 hrs after the alert and the DMA left 2.23 hrs after the start of the event.
Conclusions: An important number of casualties did not need evacuation, and an appropriate triage allows nontransport of people involved who otherwise would overwhelm the emergency services.
References
Koch P: Skin burns, necrosis and ulcers caused by wet cement, ready-mixed concrete and lime. 8 cases.Ann Dermatol Venereol. 1996;123(12):832-836.
Key words: calcium oxide; director; evacuation; lime; symptoms; triage
Prehosp Disast Med 2001;16(2):s66.
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Study of Stress among Rinsis Workers
Introduction: Rinsis (call centre for emergency needs, ambulance, firepersons, emergency medical team, etc.) services a population of about 1,350,000. The calls (about 1,400 each day) cause stress among workers. We evaluated the stress levels using several studies.
Methodology: First test of Derogatis is a list of 90 proposals. Participants must choose between 5 possible answers ("not at all", "a little", "sometimes", "often", "very often"). The score is compared with the score of witness population. The second test is the Maslach and Jackson test: 22 proposals permit choice between 6 frequency and 7 intensity. We established an emotional exhaustion coefficient, a depersonalisation coefficient, and a personal accomplishment coefficient.
Results: Score of was is 32.1 for the Rinsis and 62 for witness population. Test of Maslach and Jackson showed the following results:
Conclusions: The score of Derogatis indicates a better adaptation to the stress for Rinsis than for the witness population. The tests of Maslach and Jackson indicates a low score of emotional exhaustion with very few people who depersonalise relationships with callers. Their work represents a satisfying personal accomplishment for 55% of the Rinsis workers.
Key words: call center; dispatchers; emotions; relationships; Rinsis call center; stress
Prehosp Disast Med 2001;16(2):s66.
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The Sleipner Catamaran Incident@Norway, November 1999
During the evening of 26 November 1999, the passenger catamaran vessel SLEIPNER, with 85 persons on board, ran aground in open sea near the west coast of Haugesund, Norway. It was dark and cold with strong winds and rough seas. The sea temperature was 9 deg; C. The Search and Rescue (SAR) services were alarmed by a coastal radio station a few minutes after the event. At about 19:45 hours , the ship sunk, approximately 40 minutes after the grounding, and all persons on board were in the water. By means of helicopter and nearby boats, 69 were saved alive, 11 were found dead during the SAR operation the same evening, and five were found dead by underwater search.
The Coastal Radio Station alarmed the Joint Rescue Coordination Centre Southern Norway(RCC) and nearby vessels according to IMO procedures. The RCC also alarmed the Emergency Dispatch Centre at Haugesund Public Hospital. Health personnel from this hospital went out to a small harbour nearby the site of incident. A SAR-helicopter was dispatched from Sola Air Base at Stavanger, some 40 nm south of the scene of incident. Due to response time, the helicopter left base at 19:45 hours, arriving on scene at about 20:10 hours. Nearby vessels had just arrived. Both the helicopter and the surface vessels were met by a lot of small sparkling lights in the water, that turned out to be the lights on the life jackets on the persons in the water. The helicopter doctor decided to give priority to the persons lying alone with their heads above the water. The helicopter dropped fuel to gain capacity. When full, the helicopter went to the shore to land the persons at the arrival point established by the health personnel from the hospital.
The incident and rescue operation is documented and evaluated through a report from a governmental assessment group. The lessons learnt are:
1. A decentralised health care system integrated with the public SAR-services guarantees a rapid response and makes use of local general and specialised health care. However, this same integration may complicate the alerting process a bit. Therefore, this must be described clearly through written procedures and incorporated into the training;
2. There is a need to make medical prioritising on scene, and demonstrates the need for the transport of competent medical personnel to the point of the accident as soon as possible after the incident. A highly qualified medical practitioner should be available on scene as soon as possible, with first helicopter;
3. There also is a need for a superior organisation of local and regional medical emergency dispatch centres to ensure prioritising and quality assurance of the medico-professional sides of an operation of this kind. This is a professional medical task, not a task for the joint rescue coordination centre that focuses upon the coordination of resources of all kinds on scene;
4. Even though personnel with much experience provide good professional performance under difficult and uncommon conditions, the need for thorough debriefing is obvious.
After the incident, many of the rescue personnel were invited to and engaged in events arranged by the survivors and their relatives. This is a new and increasing phenomenon in Norway. There is not a tradition for emergency personnel to take part in psychosocial follow-up after large accidents. The role of and effects on emergency personnel taking part in post-incident follow-up of survivors and relatives is new, and should be assessed thoroughly before it is developed any further.
Key words: boat; debriefing; doctor; experience; helicopter; rescue; sea; search and rescue; triage
Prehosp Disast Med 2001;16(2):s67.
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Alcoholic Ketoacidosis: Prospective Study of ACTH, Cortisol, Insulin, and Glucagon Seric Levels
Introduction: Alcoholic ketoacidosis is an unrecognised syndrome in Europe, whereas in USA, it is involved in 20% of the cases with ketoacidosis. The physiopathology of alcoholic ketoacidosis still is obscure. A relative deficiency in insulin and an increase of glucagon have been suggested. However, the levels of these hormones never has been studied together. The aim of this study was to clarify the hormonal profile of alcoholic ketoacidosis before treatment.
Methods: The levels of cortisolaemia, ACTH, insulineamia, and glucagoneamia were assessed by radioimmunoassays; glycemia was measured at the same time. Blood sampling was done at admission into the Emergency Department. The inclusion criteria were: (1) a past history of alcoholism, (2) absence of known diabetes, (3) metabolic acidosis with an increased anion gap and ketosis detected in the urine, (4) ketoacidosis correction without insulin, and (5) hospital discharge without antidiabetic medicine. The results are expressed as mean ±DS. Seven women and two men, average age 48.5 ±12.5 years, were included during 10 episodes of alcoholic ketoacidosis.
Results: All patients recovered after hydration, with correction in arterial pH within 10 ±2 hours, and correction plasma bicarbonate concentration within 24 to 48 hours. Insulin infusion never was necessary. The average levels of insulineamia (normal range 5 to 15 mU.l-1) and glucagoneamia (normal range 60 to 200 pg.ml-1) were respectively to 7.25 ±4.7 mU.l-1 and 369.4 ±161 pg.ml-1; the glycemiea was 7.3 ±4.3 mmol.l-1 (range: 2.2 and 15.9 mmol.l-1). The cortisolaemia (normal range 220 to 610 nmol.l-1) were increased to 1,240.4 ±778.6 nmol.l-1 and the plasma ACTH levels (normal range 9 to 52 pg.ml-1) were very low to 5.3 ±7.6 pg.ml-1 (non-detectable levels in four cases).
Discussion: These results confirm an increase of glucagoneamia and a non-adapted insulin concentration. Other ketogenetic factors were present in these patients: recent weaning from alcohol, starvation, and hypovolemia. The extracellular fluid volume contraction related to the conjugated action of vomiting and decrease of oral intake could stimulate the sympathetic system and the "stress" hormones secretion (cortisol, glucagon, GH). The cortisolaemia was always high. These hormones activate the adipocyte lipase inducing an excessive release of free fatty acids and glycerol into the circulation. The increase of glucagon/ insulin ratio in the portal circulation together with an excessive flow of free fatty acids to liver are important factors for ketone bodies production in man. The ACTH levels were variable, but it was very low in four cases. Although, there was no cirrhosis, the alteration of liver functions in these heavy drinkers could alter the normal course of different metabolic pathways and favour ketogenesis in the liver.
Conclusion: Hormonal profile of alcoholic ketoacidosis is unremarkable. Nevertheless, it is possible that starvation, diminution of alcoholic intoxication and alcoholic hepatitis induce a deviation of liver metabolism in favour of ketogenesis.
Key words: ACTH; alcohol; cirrhosis; glucagonemia; hormonal profile; insulinemia; intoxication; ketoacidosis
Prehosp Disast Med 2001;16(2):s67.
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Alcoholic and Diabetic Ketoacidosis: Is It Possible, with Biological Parameters, to Differentiate These Two Pathologies
Introduction: Alcoholic ketoacidosis is an unrecognised syndrome in Europe. It often is unrecognised and could be very misleading. Clinicians must be aware that besides diabetic ketoacidosis, alcoholic ketoacidosis is another cause of ketoacidosis with some peculiar signs The alcoholic ketoacidosis possesses clinical and biological characteristics close to those of diabetic ketoacidosis; the processing differs and risks of an inappropriate treatment with insulin are not negligible. The purpose of this work is to extract biological serum elements on admission to an emergency room sufficiently significant to differentiate between these two pathologic states.
Methods: 26 biological blood parameters and 2 calculated values (anion gap and osmolarity) were compared in patients with alcoholic ketoacidosis and in consecutive patients with diabetic ketoacidosis admitted in an emergency room.
Results: 16 patients with alcoholic ketoacidosis (11 women and 5 men, mean age 46 ±12.5 years) were compared to 29 patients with diabetic ketoacidosis (19 women and 10 men, mean age 44.7 ±22 years). The serum rates of sodium, potassium, chloride, carbon dioxide, urea nitrogen, creatinine, total proteins, amylase, lactate dehydrogenase, creatine kinase, lactates, anion gap, and the arterial blood gases did not differ between the groups. In patients with alcoholic ketoacidosis: (1) the glucose levels and the serum osmolarity were significantly lower (glucose 8.6 ±5 vs. 41 ±22 mmol.l-1 ; p <0.001); (2) the serum levels of aspartate aminotransferase, bilirubin and gamma glutamyltransferase were significant higher (aspartate aminotransferase 121.7 ±92.3 vs. 30.4 ±22.5 UI.l-1; bilirubin 17.2 ±8.4 vs. 7.86 ±4.51 mmol.l-1; gamma glutamyltransferase 537 ±460.5 vs. 48 ±55.6 UI.l-1 ; p <0.001); (3) the mean counts of leukocytes, red blood cells, and platelets were significantly lower (leukocytes 11,387 ±4,580 vs. 17,982 ±7,070 /mm3; red blood cells 3.97 ±0.45 vs. 4.81 ±0.72,106 /mm3; platelets 199,375 ±83,178 vs. 308,607 ±103,507/mm3; p <0.001), and the mean corpuscular volume was greater (103.2 ±8 vs. 88.3 ±7.7 µ3; p <0.001). The most significant abnormal serum values in favour of alcoholic ketoacidosis were glucose <20 mmol.l-1 (sensitivity and specificity 100%), an increase of aspartate aminotransferase (sensitivity 93.7%, specificity 93.1%), and gamma glutamyltransferase (sensitivity 92.8%, specificity 61%), and a mean corpuscular volume 98 µ3 (sensitivity 75%, specificity 96.4%). An increase of the bilirubin and a platelets counts <150,000 /mm3 were specific (respectively 100 and 92.8%), but not sensitive (23 and 25%).
Discussion: The diagnosis of alcoholic ketoacidosis is evoked in patients with history of alcohol abuse and without past of diabetes, with a normal, slightly elevated or sometimes decreased serum glucose. However, there are some clinical forms in which the serum glucose is increased; in these cases, the existence of others biological signs, such that an increase of aspartate aminotransferase, gamma glutamyltransferase, or mean corpuscular volume are very important in the differential diagnosis with the diabetic ketoacidosis.
Key words: alcoholic ketoacidosis; chemistries; clinical signs; diabetic ketoacidosis; differentiation
Prehosp Disast Med 2001;16(2):s68.
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Effect of Sodium Bicarbonate on Ventricular Conduction Velocities in Experimental Intoxication by Clomipramine in Dogs
Introduction: The myocardial electrical impulse does not displace to the same velocity (V) in all directions (anisotropic conduction). The purpose of this work were to study, with epicardial mapping, the influence of a tricyclic antidepressant, clomipramine, on the conduction velocity longitudinal (VL) and transverse (VT) to myocardial fiber orientation and on anisotropy (A = VL/VT), and their modifications by the administration of sodium bicarbonate (B).
Methods: A plaque with 64 electrodes, positioned on the left anterior ventricular wall of nine anesthetized dogs, allowed the delivery through central electrodes, of programmed electrical stimulations that induced ventricular complexes and their collection. Each entailed unipolar electrogram was processed by a computer system that drew the isochrones and a map of activation that allowed the calculation of the V. The clomipramine was infused (0.5 mg/kg/min. as a continuous intravenous infusion) for 75 min. At T60 (60 min.), the dogs received the sodium bicarbonate infusion until the duration of QRS complexes returned to its T0 value. A lengthening of the duration of the QRS complexes of at least 30% of their T0 value was necessary before the administration of sodium bicarbonate.
Results : All values (mean arterial pressure, heart rate, QRS and QT intervals, and V) differed significantly (p <0.05) compared to T0 values except QRS at T65.
T0 T15 T30 T45
MAP (mmHg 115.8 ±13.6 99.5 ±19.4 98.8 ±16.4 92.6 ±7.5
HR (cyc/min) 389 ±59.4 497.5 ±95 546 ±80 575 ±77.6
QRS (ms) 49 ±6.4 59 ±9.5 65 ±10.3 67.5 ±10
QT (ms) 188 ±32 217 ±39 247 ±34 257 ±36
VL (cm/sec) 57.4 ±19 47.6 ±14 38.6 ±11 38.3 ±11
VT (cm/sec) 28.2 ±8 22.4 +7 18.8 ±4 19.1 ±6
A 2.1 ±0.6 2.1 ±0.5 2.1 ±0.4 2.1 ±0.4
T60 T65 T75
MAP (mmHg) 92.5 ±13.3 82.7 ±18.5 88.2 ±25.6
HR (cyc/min) 611.2 ±80.6 587.5 ±88.7 595 ±87.4
QRS (ms) 70 ±10.3 51 ±6.5 64.4 ±9
QT (ms) 261 ±22 265 ±36 272 ±36
VL (cm/sec) 33.4 ±11 32.8 ±15 34.9 ±11
VT (cm/sec) 15.8 ±4 15.6 ±4 17.5 ±5
A 2.1 ±0.7 2.1 ±0.7 2.1 ±0.5
Conclusion: The administration of clomipramine slowed VL and VT without modifying the A. The sodium bicarbonate did not modify the conduction V while the QRS prolongation was corrected. The clomipramine acts as a class I antiarythmic drug on the inward sodium current during the Phase 0 of the action potential, but a modulation of the junctional resistivity can not be ruled out.
Key words: anti-depressants; tricyclic; bicarbonate; clomipramine; intoxication, QRS; velocities, conduction; ventricles
Prehosp Disast Med 2001;16(2):s69.
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National Prospective Survey on Emergency Endotracheal Intubations in French Emergency Departments: Preliminary Results
In United States, data on emergency endotracheal intubations in emergency departments are listed in a national register (National Emergency Airway Registry Study or NEAR). These data are unknown in French emergency departments.
Objective: To characterize emergency department airway management in France, including frequency, practice, and success and complication rates.
Methods: We conducted a prospective, observational one-month study in emergency departments to assess the endotracheal intubations consecutively attempted in emergency rooms.
Results: A total of 51 French emergency departments (17 teaching hospitals, 29 non-teaching hospitals, and 5 private hospitals) recorded their data during this preliminary study. A total of 274 intubations were registered over this period: average of 4.8 ±5.1 intubations/month/emergency department (range: 0-24). In seven emergency departments, no patients were intubated during an eight-month periods. The demography of the patients and the main problems for which intubations were attempted included: men, 62.6%; 55 ±21 years, range 2-94 years who were: (1) toxic, 21%; (2) had acute cerebrovascular diseases such as stroke and epilepsy, 17%; (3) trauma, 15%; (4) cardio-vascular, 11%; and/or (5) respiratory failure, 11%. The airway management indications were dominated by: (1) decreased mental status or unconsciousness, 56%; (2) respiratory failure, 34%; (3) hemodynamic distress, 14%; and/or (4) cardiac arrest, 10%. Oral endotracheal intubations and nasal endotracheal intubations were the first method attempted in 81% and 19% of intubations respectively. Intubations of adults and children were managed by emergency practitioners in 66.4% of cases, anesthesia or intensive care physicians in 31.1%, and anesthesia nurses in 1%. The average number of attempts was 1.2 ±0.9/operator (range: 1-10), most being realized from first glottic exposure (82%). It was necessary to call in a second operator 25 times and this second operator was a member of the emergency team 11 of these times. The endotracheal intubation was undertaken with the administration of an intravenous anesthesic drug 198 times (72.3%); Rapid sequence intubation and intubation with sedation only, were performed respectively in 24% and 35% of intubations. The immediate complications directly attributable to the intubation were detected in 17%, the most frequent being: (1) low blood pressure, 44%; (2) arterial desaturation, 19.5%; (3) vomiting, 14.6%; (4) selective intubation, 146%; (5) esophageal intubation, 12.2%; (6) epistaxis, 73%; and (7) laryngospasm, 5%. The intubations were impossible one time (a tracheotomy was necessary).
Conclusion: This study is the first survey on intubation in the French emergency departments. Most intubations were not done using rapid sequence intubation. However, the emergency physicians- success rate was high. The endotracheal intubations in Emergency Department are managed mainly by emergency practitioners who have preliminary training in their courses of study.
Key words: anaesthetics; emergency; emergency departments; endotracheal; France; indications; intubation; rapid sequence; sedation
Prehosp Disast Med 2001;16(2):s69.
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Emergency Endotracheal Intubations: Procedures, Medications, and "Difficult Airway Cart" Available in Emergency Departments in France
Introduction: Efficient and rapid airway management must to be learned and mastered by emergency physicians. Airway management is a key component of the care of the critically ill or injured patients. This work purposes to identify the dispositions for emergency endotracheal intubation in French emergency departments.
Method: A questionnaire was sent to the heads of emergency departments in France. The data collected ascertained the emergency department typology, the intubation procedures, the medicaments used to intubate, and options used for difficult airway management.
Results: 92 French emergency departments (20 teaching hospitals, 67 non-teaching hospitals, and 5 private hospitals), receiving more than 2.5 millions of patients per year, recorded their data. An anaesthesiologist or intensive-care practitioners were present 24 hours in 85.9% of hospitals. The average number of endotracheal intubations was estimated at 169.4 ±79.4/emergency department/year (28 emergency departments have not provided data for this study). A systematic collection of the number of endotracheal intubations performed and the conditions under which the attempts were made was done in only 9.9% of the emergency departments. A written procedure on airway management existed in 18.7% of the emergency departments (n = 17). Most often, a nurse undertook daily (71%) or weekly (14%) systematic verification of endotracheal intubation equipments in 87 emergency departments (94.6%). The necessary drugs for the performance of endotracheal intubation and that were present in emergency rooms were: (1) midazolam, 100%; (2) diazepam, 98.9%; (3) thiopental, 83.3; (4) propofol, 83.3%; (5) fentanyl, 81.1%; (6) succinylcholine, 77.8%; (7) etomidate, 77.8%; (8) ketamine, 57.8%; vecuronium, 55.6%; (9) rocuronium, 31.1%; and (10) other non-depolarizing agents, 26.7%. In case of difficult airway management, the emergency practitioners found these other supplies available in emergency rooms: (1) kit for cricothyroidotomy, 69.7%; (2) catheter for percutaneous transtracheal ventilation__; (3) kit for retrograde intubation, 21.3%; (4) intubating laryngeal mask airway, 21.3%; (5) combitube, 14.6%; (6) fibroscope, 14.6%; and (7) fast-track, 12.4%.
Conclusion: Anaesthetic agents are present in most of emergency departments. These emergency departments are less equipped with equipment and supplies for difficult airway techniques. The presence of airway management protocols or guidelines are rare. However, in France, it is necessary to improve the endotracheal intubation training of emergency physicians. In this training, the practitioners also must learn rapid sequence intubation (RSI), which is a standard emergency department procedure, and new airway devices such as the intubating laryngeal mask airway and a Bullard laryngoscope bade.
Key words: airway management; anesthetic agents; cricothyrotomy; drugs; endotracheal intubation; equipment; emergency departments; rapid sequence intubation; supplies; ventilation
Prehosp Disast Med 2001;16(2):s70.
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Consumption and Cost of Prescribed Medicines in Eight Emergency Departments in France and in Switzerland
Introduction: Monitoring of consumption and costs of prescribed medicines in emergency department (budgetary monitoring) are often unknown by the emergency teams. This work analyzes these data in different emergency departments.
Methods: For each emergency department, the annual (1999) medicine expenses have been classified according to two modes: (1) quantitative by decreasing order the 20 first per os administered products on the one hand, and the first 20 intravenously or intramuscularly administered products; (2) by cost by decreasing the orders for the 20 most expensive products. For the global quantitative analysis, the products have been classified according to their frequency of quotation in each 20 first administered products list.
Results: Eight emergency departments were enrolled in the study (seven in France and one in Switzerland). Characteristics of these emergency departments were: five teaching departments, two medical and six trauma-medical emergency centers, with a short-term hospitalisation unit in five emergency departments. For this study, the average number of annual admissions was 43,150 ±19,360 / year (400,000 annual admissions entirely). Among the 20 first per os administered products, in all emergency departments, paracetamol (acetaminophen) was the most frequently delivered product (more than 190,000 units distributed /year), and associated paracetamol and propoxyphene constituted 37% of the shares. The other 20 first per os administered products were, in descending order: phloroglucinol, aspirin, alprazolam, amoxicillin, amoxicillin-clavulanate, prednisone, omeprazole, and activated charcoal. Among the 20 first intravenously or intramuscularly administered products, the proparacetamol was the most prescribed (36,000 units of 1 and 2 g by year); the other most current parenteral injectable molecules in descending order were: lidocaïne, amoxicillin-clavulanate, phloroglucinol, ketoprofene, methylprednisolone, morphine, furosemide, omeprazole, metoclopramide, epinephrine, trinitrine, unfractionated heparin, and low molecular weight heparin. Among the most expensive molecules, some did not belong to quantitatively prescribed products: antiretroviral drugs, sandostatine, some antidotes (flumazenil, N-acetyl cysteine), dobutamine, rt-PA; others already had been noted and included: amoxicillin-clavulanate, proparacetamol, omeprazole, activated charcoal, phloroglucinol, lidocaïne, and ketoprofene.
Conclusion: This multicenter evaluation is an interesting economic approach among French-speaking emergency departments. In each emergency department, this approach provides the data to create a budget monitoring of the consumption and costs of prescribed medications.
Key words: consumption; costs; drugs; emergency departments, France
Prehosp Disast Med 2001;16(2):s70.
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Abuse of Poppers: Four Cases of Methemoglobinemia Observed in an Emergency Room
Introduction: Methemoglobinemia is an exceptional complaint in emergency rooms. Its origin is especially toxic. Butyl and propyl nitrites "poppers" are being used increasingly as aphrodisiacs. We describe four cases of methemoglobinemia following ingestion or inhalation of nitrite poppers.
Case 1: A 36 year-old-man was admitted for cyanosis, confusion, agitation, and loss of consciousness following the ingestion of poppers. The blood pressure was 130/79 mmHg, the pulse rate was 103 beats/min., and pulse oximeter (SpO2) read 90% (oxygen administreation at 6 l/min). The patient presented with coma, agitation, dark colour of the skin, and chocolate colour of the blood. The lungs were clear. Methemoglobinemia saturation of the blood was 67%. The laboratory tests included lactic acidosis (pH = 7.32, HCO3- = 18.5 mmol.l-1, PaCO2 = 37 mmHg, lactate = 5.39 mmol.l-1) and PaO2 = 340 mmHg (oxygen 6 l/ min). After 100 mg of intravenous methylene blue, the cyanosis disappeared and the level of consciousness became normal.
Case 2: A 31 year-old-man was admitted for dizziness and loss of consciousness following sniffs of poppers and space. The anomalies were a grey complexion, low blood pressure (90/60 mmHg), pulse rate = 95 beats/min., and SpO2 = 92%. Otherwise, clinical findings were unremarkable. The arterial blood gases were: PaO2 = 70.5 mmHg, SaO2 92%, and the methemoglobinemia saturation = 27%. After 65 mg of intravenous methylene blue, the evolution was rapidly favorable.
Case 3: A 49 year-old-man was admitted for loss of consciousness after 10-12 inhalations of poppers during 30 min. There was diffuse cyanosis without cardiac and lung anomalies, and SpO2 = 89%. The laboratory tests showed a PaO2 = 77 mmHg, SaO2 = 73%, methemoglobinemia = 22% with a normal electrocardiogram and chest X-ray. At the end of methylene blue injection (100 mg intravenous), the cyanosis had disappeared and SaO2 was 96%.
Case 4: A 39 year-old-man was admitted for headache, fatigue, pallor, cyanosis of lips and extremities, and low blood pressure. The examination noted a pallor, grey complexion, blood pressure = 98/49 mmHg, pulse rate = 85 beats/min., SpO2 = 92% without cardiac or lung anomalies. The electrocardiogram showed a raised ST segments in V2-V4. Arterial blood gases showed PaO2 = 68 mmHg and SaO2 = 92% with normal chest X-ray. Methemoglobinemia was not administered because the diagnosis was not evoked. Later, the patient confessed the inhalation of poppers that provoked palpitations and a loss of consciousness before his arrival to emergency rooms.
Discussion: The poppers contain nitrate of propyl or butyl, causing vasodilation. Ingestion or inhalation of these products can produce a methemoglobinemia that may be fatal. Methemoglobinemia occurs when the concentration of methemoglobin in the erythrocytes is greater than 1%. Because of the potential toxicity of the methylene blue, the patients, symptomatic or not, having a methemoglobinemia saturation of 30% and symptomatic patients (other that cyanosis) with a rate <30% should be treated with methylene blue.
Key words: aphrodisiacs; clinical manifestations; methemoglobinemia; methylene blue; nitrites; poppers
Prehosp Disast Med 2001;16(2):s71.
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Examining Networks of Care Proposed by Emergency Departments in France to Patients that have Attempted Suicide
Introduction: Suicide prevention is a public health priority in France with approximately 12,000 deaths by suicide (prevalence 24 cases for 100,000 inhabitants) and 150,000 suicide attempts per year. Patients having made a suicide attempt commonly have recourse to emergency departments. The purpose of this work is to analyse the networks of care that are proposed to them by the staffs of the emergency departments.
Method: A questionnaire was administered that sought data concerning the patient, the suicidal gesture, the patient's evolution, and the proposed networks of care recommended. The emergency departments that participated in this prospective study had to ensure the inclusion of 50 consecutive patients admitted for suicide attempt.
Results: A total of 3,687 files from 77 emergency departments were abstracted. Characteristics of the suicidants were: female predominance (66%), average age 36 ±14 years, antecedent of suicide attempts (49%), followed by a medical practitioner (77%) or a psychiatrist (43.5%), and voluntary drug ingestion (90%). Non-hospitalised patients (18%) left the emergency departments after receiving a psychiatric notice (68%), against medical advice (14%), or by escape (9.5%). Twenty-nine percent of them left the emergency department without a directive, and 70% were referred to a psychiatrist (45%) and/or to the family doctor (28%) with an appointment in 27% of the cases. A prescription was delivered to 6.2% of non-hospitalised patients with, in half of cases, an antidepressant and/or an anxiolytic drugs. Hospitalizations (82% of patients) were provided in a short-term hospitalisation unit (69%), in medical departments (11%), in intensive care units (9%), or in psychiatry (9%); this varied according to the centers. The majority of patients left the hospital (67%) after the initial hospitalization; except for psychiatry, the duration of hospitalization were 1 day and 2 days for respectively 69.5 and 84% of the patients with suicide attempts. During the hospitalization, 63% of patients met with a psychiatrist one time; services of a social worker were rarely requested (5%)., No follow-up medical care has been proposed for 13.4% of the patients when they left hospital, and in 40% of cases, they were directed to a family doctor and/or a psychiatrist; the assistance of associations for suicidal patients only were requested as an exception. A prescription was given to 16.3% of patients with an antidepressant and/or an anxiolytic in 62% of cases. The main diagnoses obtained by psychiatrists have been "circumstantial crisis" (46.6%), depression (37.6%) with melancholy in 1.3% of depression cases, and psychosis (6.5%).
Conclusion: The hospital management of suicide attempts is short and multidisciplinary. Nevertheless, psychological awakening beds have been created for the best networks of medical care.
Key words: attempts; care; causes; demography; disposition; emergency departments; gestures; hospitalizations; suicide; treatment
Prehosp Disast Med 2001;16(2):s71.
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Incidence, Profile, and Evolution of Suicide Attempts Seen in Emergency Wards in France: Results of a Multicenter Study
Introduction: The suicide prevention is a public health priority in France; there are approximately 12,000 deaths by suicide (prevalence 24 cases for 100,000 inhabitants) and 150,000 suicide attempts per year; these data probably are an underestimate. The purpose of this work is to identify the incidence and profile of patients following a suicide attempt examined in Emergency Departments (ED), and to develop a different epidemiological aspect.
Methods: This was a one-week prospective study conducted in ED of various sizes, situated all over the French territory. This inquiry has been realised with the help of a questionnaire filled in at the patient's bedside. Data concerned the patient, the suicidal gesture, and the patient's evolution.
Results: Data for a total of 640 patients following suicide attempts were collected from 57 EDs; the mean suicide attempts rate per ED was 11.2 ±9 (range 0-51) and the number of patients in one week was 7 in 75.4% of the EDs. Except for _15-year old patients, the number of females predominated (64.5%). The mean age was 34.8 ±13.6 years (range 12-95 years) ; only 21 (3.3%) of the patients were -65 years old, and the majority (77%) were 15 to 44 years old. The social status indicated that 35.5% of the patients were unmarried, 36.7% were married and almost quarter of them were separated from their spouse, 8.3% were divorced, 3.1% were widowers, and 13.6% were in cohabitation. Nearly 45.3% of the women were unemployed vs. 41.4% of the men. Except for those patients 65-years old, the age brackets, which were mostly concerned by professional inactivity, were 35-44 years for women, 25-34 years for men, and 55-64 years in both. Employees, students or schoolkids, and civil servants gathered almost 78% of all occupations. A psychiatric past history including suicide attempt, psychiatric hospitalization, or consultation was found in 68.8% of women and 62.1% of men. Drug addiction, HIV seropositivity, or chronic alcoholism concerned respectively 6.7, 1.1, and 12.8% of patients, and were significantly more frequent among men. A medical physician or a psychiatrist had been consulted by 40.5% of patients during the month preceding the suicidal act. The mean time interval between the suicide attempt and ED consultation was 332 ±550 min (range: 15 min@4 days). The suicidal procedure most often (73.3%) was unique (one procedure); when two different procedures were used in 24.7%, it was mostly in association with alcohol ingestion. Voluntary drug intoxications by ingestion were employed 580 times (90.6%), associated 143 times to alcohol ingestion and/or 27 times to others suicidal gestures. Alcohol ingestion was sometimes the only suicidal gesture (1.4%). The other suicidal procedures were self-mutilation by phlebotomy (5%) or with knife (0.8%), illicit drugs abuse (1.9%), hanging (1.7%), household products or glass ingestion (1.1%), gas inhalation (0.6%), drowning (0.6%), road accident (0.5%), firearm (0.3%), jump (0.16%), electrocution (0.16%), or immolation (0.16%). The majority of patients had been hospitalized either in short duration hospitalization units (28.3%) and medical wards (19.8%), or in intensive care units (14.7%), in psychiatric (11.2%) or surgical (3.3%) wards. Three patients died in the ED (0.005%). Of the total number of patients, 3.3 and 1.1% left the hospital either against medical and/or psychiatric advice or left without notice in respectively; 100 patients were not hospitalized after psychiatric and medical decision (15.7%).
Conclusion: This study emphasizes the important role of ED and short duration hospitalization units in the management of suicide attempts.
Key words: attempts; demography; disposition; emergency departments; epidemiology; gestures; hospitalization; outcome; suicide
Prehosp Disast Med 2001;16(2):s72.
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Two Cases of D-Propoxyphene Acute Poisoning with Atrial and Ventricular Conduction Abnormalities
Propoxyphene is a compound chemically similar to methadone. Acute overdosage produces a pattern of clinical signs very similar to those of morphine poisoning with coma, respiratory failure, myosis, convulsions, and cardiogenic shock. Prolongation of atrio-venticular conduction has been described less frequently, noted in only 20% of cases.
Case 1: A 29 year-old-man was admitted into an emergency department for ingestion of flunitrazepam, bromazepam, paracetamol and 1.3 g of propoxyphene. He took daily propoxyphene to substitute for heroin. He was restless. Suddenly, he presented with generalised tonic-clonic seizures. After resolution of the seizures, we noted: unconsciousness, low blood pressure (70/40 mmHg), pulse rate = 55 beats/min., cyanosis, bradypnea (6 breaths/min.), myosis, acidosis (pH = 7.1, HCO3- = 20 mmol.l-1, PaCO2 = 9.8 kPa, PaO2 = 6 kPa), and lactate concentration = 12 mmol.l-1. After injection of diazepam and valproate, the seizures stopped; after intubation, the PaO2, arterial blood pressure and cardiac pulse rate normalised. A gastric lavage evacuated pills. The toxic screening for antidepressant and cocaine was negative, and for benzodiazepines and paracetamol rates were weak. Electrocardiogram before intubation showed a junctional rhythm at 55 /min, QRS complexes widened to 0.16 mm with a right bundle branch block. 15 min after the PaO2 and blood pressure correction, the electrocardiogram showed a sinus rhythm at a rate of 90 /min, and persistence of a widened QRS complex and right bundle branch block. Electrocardiogram became normal by 4 hours.
Case 2: A 21 year-old-woman drug addict was admitted to the emergency department for ingestion of flunitrazepam. We noted regular respiration to 12 breaths/min., arterial blood pressure of 120/90 mmHg, cardiac pulse rate of 84, normal level of consciousness and myosis; 30 minutes later she became sleepy and then 20 minutes later she became unconscious with bradypnea to 6 breaths/min. An awakening of short duration was obtained after intravenous flumazenil. Toxic screening showed the presence of benzodiazepine; 8 hours later she was sleepy, but responded to stimuli without bradypnea, but with myosis. Administration of intravenous naloxone resulted in complete awakening and disappearance of the myosis. The patient confessed the ingestion of propoxyphene and sniffing of heroin. In the urine, the concentration of opiates and propoxyphene were high. The initial electrocardiogram showed PR interval to 0.24 mm persisting after naloxone ; 16 and 20 hours later, it was respectively to 0.18 mm, then 0.16 mm. The patient left the hospital without anomalies.
Conclusion: Studies in laboratory animals suggest that the propoxyphene can cause cardiac failure and prolong atrio-venticular conduction; propoxyphene is a strong negative inotropic and chronotropic agent that also dilates the systemic and coronary vascular beds. A decrease in the rate of rise and a shortening of the duration of the Purkinje fiber potential are observed experimentally. These cardiac side-effects are due to a local anaesthetic effect. The effectiveness of naloxone in propoxyphene poisoning is well-es-tablished and it has been shown to reverse all the opiate features. However, experimentally and most often in man, naloxone failed to reverse propoxyphene cardiotoxicity. Adrenergic and dopaminergic agonists usually are used against cardiac failure. Propoxyphene intoxication must be known because of the associated high mortality rate.
Key words: clinical signs; conduction defects; intoxication; poisoning; propoxyphene; treatment
Prehosp Disast Med 2001;16(2):s73.
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The Rallye Rejiz Project
The Rallye Rejvíz (RR) Project is a professional exercise and competition for EMS teams. Following the inaugural Rally Rejviz in 1997, the concept of testing emergency medical, driving, and management skills in a playful, yet competitive, but foremost a real-life setting, has met with increasing enthusiasm, both nationally as well as internationally. Building on existing experience, this project aims to bring international emergency teams together in a non-threatening environment to compare performances and exchange information about techniques and approaches, whilst building friendships and opportunities for cross-border cooperation.
Key words: competition; driving; emergency medical services; information, exchange of; management; performance; testing
E-mail: stana@rallye-rejviz.cz
Prehosp Disast Med 2001;16(2):s73.
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International Cooperation in Disasters
International cooperation in disasters has been discussed for a long time. However, is it realistic to expect effective and timely help from abroad? Past experience is discussed with particular regard to the possible international medical help in the case of an earthquake in Ljubljana, the capital of Slovenia. Ljubljana is the economic and governmental centre of Slovenia and, with a population of 300,000, it also is the largest city in Slovenia. The major teaching hospital (Medical Center Ljubljana) and other hospitals comprise almost one third of the hospital beds in Slovenia, and some important specialist treatments only can be provided in Medical Center Ljubljana.
In the case of a major earthquake, we would face several problems and, among them would be the provision of adequate medical treatment for casualties. This article analyses what we can expect, and the possible solutions for future work.
Key words: urban; cooperation international; earthquake; hospitals; preparedness
E-mail: edita.stok@gov.si
Prehosp Disast Med 2001;16(2):s73.
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Local Microcirculatory Changes of Primary Bone Lengthening Using External Fixator for Bone Defects from Gunshots
Objective: To observe the changes in the local microcirculation associated with primary bone lengthening for bone defects from gunshots using an external fixator.
Methods: The experimental study was carried out using a canine model of bone defect produced by a gunshot to the extremities. Sixteen mongrel dogs were randomly assigned into 2 groups: Group I, we executed early callus distraction by external fixator; and in Group II, plaster immobilization was used. The local microcirculation of two groups was measured.
Results: In relation to normal fractures, the local blood flow of gunshot fractures was reduced during the first 3 days, and then increased. At the 6th week, it was restored to the normal level. There was no significant difference in the restoration of blood flow between the groups of external fixation and plaster immobilization.
Conclusion: Primary bone lengthening for gunshot bone defect by external fixator exhibited no detrimental effects on the restoration of the local blood flow.
Key words: bone defect; external fixator; gunshot; microcirculation; plaster; primary bone lengthening
Prehosp Disast Med 2001;16(2):s73.
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Effect of Emulsion Open Therapy of Burns
Objective: To evaluate the effects of using the Emulsion Open Therapy of Burns (EOTB).
Methods: From 01 January 1984 to 30 December 1996, our ward has had 71 cases of people who were hospitalized due to sustaining burns, were treated by EOTB. Twenty-three cases in whom the size of the burn wounds were the same, were treated by routine therapy. The ETOB was composed of 60 ml of isotonic saline or distilled water, 20 ml of 70# petrol, 20 ml of colza oil, 0.5 g of injectable chloramphenicol, and medicative soap. In a universal sterile container, these materials were mixed until it looked emulsified . After the burn wound was cleaned, the emulsion was put onto the wound, which was left open. This was used for superficial burns (1-2 degree small area) 3-4 times a day, and for deep thickness burns, 4-6 times a day. Most of them did not need skin grafting, as they can heal by themselves. The two groups of patients were compared for the restoration of health, improvement, effectiveness, and mortality.
Results: Sixty-six cases restored health by the use of EOTB, 4 cases were improving, 1 died, and the effectiveness rate was 98.6%. Fifteen cases were restored to health using routine therapy, 3 cases improved, 5 died, and the effectiveness rate was 78.3%. These differences were statistically significant (p <0.05).
Conclusion: We believe that EOTB's curative effect is better than routine therapy. The material was easy to obtain, proved economical, and was easy to administer .We did not identify any toxic actions or side effects. Its use will be applicable in peace or wartime and in cities or villages.
Key words: burns; effectiveness; emulsion; emulsion open therapy; treatment; wounds
Prehosp Disast Med 2001;16(2):s74.
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Photo Documentation on the Scene of an Accident: A Complement to the Ordinary Documentation
Introduction: In Sweden, 150 people are injured in traffic every day: seven of them become invalids, and two of them die. Each year, approximately 60,000 people are injured in traffic accidents, and 14,000 of them are so seriously injured that they must be hospitalised.
A traffic accident generates a great deal of energy, which reflects in the types of injuries sustained. Therefore, it is possible to identify characteristic injuries for different kinds of accidents, and with the help of a thorough injury-anamnesis, the physician can be led to the correct diagnosis. To make the assessment of the injuries easier at the accident site, several systems for classification of injuries have been developed to predict the outcome from different injuries.
Personnel in an ambulance service should be able to assess a patient, both primarily and secondarily, when the patient receives prehospital care. This primary assessment on the scene of accident provides the basis for the examination that the physician performs later in the emergency ward.
The type of vehicle involved, impact force, and type of injury are important parameters for a correct evaluation of the patients' condition. The ambulance crew is responsible for the medical information, but they also should inform the physician about the impact force caused by the collision. Visualization with photographs taken at the site could provide additional information that may be helpful for the physician's assessment of the injured patient. The aim of the study was to investigate the advantage of photo documentation at the accident site as a complement to ordinary patient records.
Method: When they arrive on the scene of accident, the ambulance crew from three different ambulance stations, take photographs using a digital camera in a sequence of 3 to 5 pictures according to given instructions. On arrival at the hospital, the pictures are transferred from the camera into a stationary computer for visualisation on a screen and printouts of high quality colour pictures. Thereafter, the pictures are stored with the ordinary patient records. The receiving physician can immediately get information about what the scene of the accident looked like. A first evaluation was made when the physician has answered a questionnaire (n = 25) that included both open and closed questions.
Result: An analysis of the first 25 traffic accident cases indicated that 16 (64%) of the receiving physicians thought that the pictures from the scene of the accident were an important aid for them in making a better assessment of the patient@s condition. Some of the physicians reported that the pictures in several cases have led to complementary examinations that they did not think would have been done without this documentation from the accident site.
Nine physicians reported that the pictures didn't add anything. In five of the cases, this perception was related to poor quality of the photographs, in two cases the pictures came too late, and in two cases, the patient had died.
Conclusion: Photographs taken at the scene of an accident may be a helpful addition to the routine assessments of victims of traffic accidents.
Key words: ambulances; assessments; crashes; digital cameras; photographs; scene; traffic
E-mail: bjornove.suserud@hb.se
Prehosp Disast Med 2001;16(2):s74.
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Kegworth: To Know History Is To Predict Future
Problem: What anatomic injuries will occur within human organ system due to air accident?
Method: Kegworth air accident investigators present an AIS-scored material for all 126 persons involved. By computer-aided analysis, one can record the severity of injuries and the number of organ systems involved for all casualties. Then by choosing an optional number of casualties that corresponds to the capacity of local air traffic, and the computer program will randomly compose a new list of casualties similar to that of the consultative group.
Result: It can provide a model for predicting the problems for which the hospital's disaster organization should prepare e.g., resource allocation and need of equipment and examples of probable anatomic injuries. Additionally, it is a valuable teaching tool for triage training, prediction of mortality, survival time, hospital length of stay, and disability.
References
The use of injury scoring in the evaluation of the Kegworth M1 aircrash. J Trauma, Vol.32, No 4:211-215.
Key words: AIS-score; anatomic injury pattern; computing; prediction; teaching tool
E-mail: sm1dyr@hotmail.com
Prehosp Disast Med 2001;16(2):s75.
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Preparation of Chartered Helicopters for a Disaster in Japan
One of the major problems following the Hanshin-Awaji Great Earthquake of 17 January 1995 in the Hanshin area was that helicopters were not used effectively for the medical evacuation and transportation of the victims, even though there were many helicopters prepared for that use. This was related to the lack of knowledge by doctors that the helicopters could be used for the transportation of severely injured or ill patients from Kobe to undamaged facilities. The doctors never had used helicopters for the transport of patients.
Following the Great Hanshin-Awaji Earthquake, the Fire and Rescue Department of Government have intended to regularly use helicopters for the rescue and transport of emergency patients, but they still have not been used effectively. Hence, the Department of Health and Welfare and Labor of the Japanese Government organized a system to hire and use the chartered helicopters that are in possession of civil aviation companies for immediate use at the time of a disaster. This system is now being developed and soon will be contracted with the Tokyo Metropolitan Government, to prepare for the next big earthquake in the south Kantoh areas.
Key words: civil aviation; earthquake; evacuation; helicopters; private; transportation
E-mail: takihem@cc.hirosaki-u.ac.jp
Prehosp Disast Med 2001;16(2):s75.
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Using Catecholamines in Prehospital Settings by French Mobile Intensive Care Unit
Introduction: Very few studies have been undertaken concerning the use of catecholamines in prehospital reanimation efforts. The aim of the present study conducted among mobile intensive care unit physicians is to estimate the indications for the use of different catecholamines in the prehospital stage of emergency care.
Methods: This study took place from March to November 2000, and involves 182 mobile intensive care units (MICU). Eleven regions were chosen at random among the 22 French regions. A telephone conversation took place with the physician on duty, chosen at random, in each of the 182 MICUs. During the conversations, each physician answered a preselected questionnaire concerning the use of different catecholamines according to the etiology of the state of shock.
Results: Of the 182 physicians questioned, 175 (96%) agreed to participate. Dobutamine and adrenaline are available in most of the MICUs. Four units did not have dopamine, and 42 declared having noradrenaline on board. During a hemorrhagic state of shock, all physicians said they used catecholamines if the systolic blood pressure remained <90 mmHg despite intravenous fluid therapy (IFT); 76 (43%) said they used adrenaline first, 72 (41%) said they used dopamine, 5 (3%) used noradrenaline, and 19 (11 %) used dobutamine. In septic shock, 101 (58%) of the physicians used dopamine first, 34 (19%) used dobutamine, 27 (15%) used adrenaline, and 13 (7%) used noradrenaline. In the case of carbamate medication poisoning with blood pressure <90 mmHg despite IFT, 94 (62%) of the physicians used dobutamine first, 25 (16%) used dopamine, 22 (12%) used adrenaline, and 9 physicians said they didn't know. 158 (90%) MICUs are able to apply noninvasive blood pressure monitoring, 7 MICUs have the facilities for invasive monitoring of blood pressure in a prehospital scene.
Conclusion: Catecholamines are used often in reanimation for a state of shock in the prehospital stage. However, it seems necessary to rationalize their use with the help of protocols according to the etiology of shock.
Key words: blood pressure; catecholamines; criteria; hypotension; intravenous fluids; mobile intensive care units (MICU); prehospital; reanimation; shock states
Prehosp Disast Med 2001;16(2):s75.
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Videotape Recordings for Evaluation of Quality of Prehospital Trauma Care: First Experiences with a New Technique
Introduction: Schneider et al1 assessed the structural and procedural quality of the Mainz emergency medical services (EMS) system providing prehospital basic and advanced cardiac life support using on-line tape recordings of prehospital cardiopulmonary resuscitation (CPR) efforts. In the evaluation of advanced trauma life support, voice recordings pose problems because of surrounding noise, the much more complex setting and the more differentiated treatment compared to advanced cardiac life support. Michaelson et al2 described the usefulness of videotaping in trauma admitting areas when used to improve quality.
Methods: Prehospital trauma management performance of a helicopter crew (anaesthesiologist, paramedic, local EMS personnel) was recorded and evaluated using video recordings by a small, flexible, microcamera and a portable video tape recorder carried in a backpack.
Results: The described recording technique-even in remote surroundings@is easy to perform and very reliable. So far, 15 calls involving 32 patients have been evaluated during a two-month period. Mean values for time intervals between landing and take-off were 26 min. Three major time-consuming factors found were: (1) entrapped patients that took additional time of 18 minutes (min) on average; (2) difficult patient conditions (e.g., for the establishment of intravenous lines, endotracheal intubation) that required an average additional time of 18 min.; and (3) the lack of EMS team coordination during invasive measures (e.g., anaesthesia induction, chest tube insertion, etc.) that required an average of 6 min. of additional time.
Conclusions: Videotape recording using a microcamera is a reliable and feasible technique to evaluate the prehospital management of trauma patients and to define areas of quality improvement.
References
1. Schneider, et al: Resuscitation 1994;27:197-206.
2. Michaelson, et al: Eur J Emerg Med 1997; 4:94-96.
This study was sponsored by the Laerdal Foundation, Stavanger, Norway.
Key words: advance cardiac life support (ACLS); advanced trauma life support (ATLS); anaesthesia; extrication; intervals; intravenous lines; intubation, endotracheal; quality assurance; trauma; videotape recording
Prehosp Disast Med 2001;16(2):s76.
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Medical Support for Children During Mass Gatherings
Introduction: Mass gatherings are special situations for which mass medical care must be preplanned. Fairs, concerts, parades, and rallies are some events that cause large numbers of people to gather in one place. The extent and quality of medical care was measured at a mass gathering of approximately 100,000 children, meeting at a television-sponsored fun fair.
Methods: Every patient contact was recorded on printed forms, including data such as the number of patients treated, patient gender, parent's escort, time distribution of patient contacts, duration of treatment, diagnosis, therapy, and patient disposition.
Results: Eighty-one male and 111 female patients were included. Only 0.19% of the estimated number of participants) were treated during the 9-hour period. Twenty percent of all of the children up to the age of 10 years, who needed medical help were not accompanied by an adult; 75% of all patient contacts were made during the afternoon; 164 (85.4%) suffered only from minor medical problems or injuries and were treated for less than 10 minutes. The most common complaint was minor trauma, 103 patients (53.6%), followed by minor medical problems, 21 patients (10.9%); insect bites, 20 patients (10.4%); and serious medical problems, 19 patients (9.9%). Treatment provided included dressings, 100 patients (52.1%); local therapy, 68 patients (35.4%); analgesic therapy, 10 patients (5.2%); and others. Only 4 patients (2%) had to be admitted to local hospitals, mainly for diagnostic measures, and 10 (5.2%) were transported to a family practitioner.
Conclusion: Most of the medical needs in this young population were minor. However, medical teams must be prepared for serious, life-threatening medical problems, including trauma, as well. The determining factor for overall quality of care is the rate of hospital admittance, which must be kept as low as possible.
Key words: children; demography; mass gatherings; medical care; preparedness
Prehosp Disast Med 2001;16(2):s76.
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Clinical Practice of Cultivating Therapy in Treatment of Burns
Objective: To probe into the curative effect of cultivating therapy in deep second- to light third-degree burns.
Methods: We selected the same term in-patients (40 cases) and cultivated their deep second- to light third- degree burns (light second and deep third excluded) with MEBO for external use.
Results: Deep second and light third degree burns in different locations were treated with the same therapy. The duration of both the liquefaction and the healing of the burns was different.
Conclusion: Cultivation therapy can improve the microcirculation and the liquefaction of the wound, and shorten the period of healing.
Key words: burns; cultivation, early; healing; liquifaction; MEBO; treatment; topical
Prehosp Disast Med 2001;16(2):s76.
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Collaboration between Firemen, Civil Protection, and Medical Team During Extrication
Introduction: During an accident with a truck, the driver is pinned below the truck. No possible access exists, and only an ankle can be reached.
Method: Collaboration between firemen, paramedics, medical team, and civil protection must permit extrication of the driver as soon as possible with maximum of security for the driver. This patient was conscious, can answer the questions, and has problems breathing because of compression.
Results: Following consciousness, the paramedics gave oxygen to the victim with a mask introduced below the truck as close as possible of the supposed localization of the face.
The fire personnel attempted to move the truck with several extrication apparatus, but with no results because of the weight if the truck. Civil protection then was called.
The medical team then set a trans-tibial infusion line and sedation using ketamine.
Civil protection then lifted the truck with a wrecking crane.
After the truck was lifted, the paramedics could then place a cervical collar and a backboard and begin monitoring vital signs. The medical team could then set a peripheral intravenous line.
Conclusions: Collaboration between different services (firepersons, paramedics, doctors, nurses, and civil protection) permitted extrication in one and a half hours with maximum efficiency.
Key words: compression; doctors; efficiency; entrapment; extrication; firemen; nurses; paramedics; civil protection; team
Prehosp Disast Med 2001;16(2):s77.
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Management of the PMA (Advanced Medical Post): Contributions of New Tools
Introduction: Any catastrophic event implies problems in the management of the victims at the scene of the accident, as well as identifying the appropriate area to which they should be admitted. The implementation of the "red plan" in our industrial nations is mainly in response to "catastrophic accidents with limited effects" (ACEL). The administrative management of the disaster is at the charge of nonmedical authorities, and must face on one hand, the difficulty of management appropriate to the ACEL, but also on the other hand, the pressing demand of information on behalf of the media. This implies a constant and effective flow of information to the administrative authorities through the medical staff, mainly at the level of the "advanced medical post" (PMA). It also demands a successful secretariat with fast and reliable communications that facilitates permanent control of victims@ movements within the PMA. In this paper, we explain innovative measures to meet this target.
Method: The first point is about the initial and definitive identification of the patient. Ideally, the victim is identified, conscious or not, at the site of the event, by means of recognition that is appropriate for him or her. We use bracelets that bear a bar code in order to use the advantages of the computerization of the PMA. These bracelets are of various colors according to the severity of the victim's injuries (absolute emergency [UA], relative emergency [UR], injured, dead). A bar code identifying the number of the bracelet is written on it transversely and longitudinally, so that it can be read quickly no matter the position of the patient. In addition, it has detachable labels that carry the bar code, and the numbers also are available. They can be used at each level of management of the disaster.
The second point is computerization of the PMA, which consists of a network system of laptops and printers that equip a secretariat at the entrance of the PMA, another secretariat at the exit, and one at the headquarters. The initial conditions of the software elements are: (1) simplicity and speed of application, (2) simplicity and speed of use with the assistance in crises by means of pop-up menus, (3) automatic publishing of list and statistics during the course of the mission, (4) respect for the input-output chain, with control of double or missing elements, and (5) modular use (no position or server dedicated) and total security of data autonomy for 3 hours.
To test this equipment in actual conditions, we took advantage of the annual exercise of the SAMU 67 to perform a "double blind" test using a classical secretariat and a computerized secretariat. The exercise consisted of an accident of a tramway in a tunnel using actors simulating as close as possible to reality, including desperate and impulsive acts that may occur with patients under stress.
Results: The superiority of the computerized secretariat could be seen within the first quarter of an hour, because only the computerized "version" was able to provide regular information regarding the situation in real time with only two members of the staff engaged in the process. Acquisition was facilitated largely with the bar code bracelets, because one person was able to register 41 patients at the entrance within the first 20 minutes. In addition, use of the computer version avoided double registrations, and provided a precise picture of the flow of the victims. On the other hand, the secretariat done manually registered doubles and lost one victim. The exercise was concluded after 1.55 hours during which time 78 victims were treated (8 UA, 14 UR, 56 injured, 0 dead).
Conclusion: This experiment of "double blind" type demonstrated the feasibility of computer-assisted management of the PMA. Furthermore, we were able to define a number of advantages: (1) reliability and speed of balance listing supplied in the operational headquarters (PCO), (2) constant check of patients flows within the PMA, with fast detection of possible errors, and (3) savings in terms of the numbers of staff engaged in the process. Additionally, this type of management remains flexible with regard to the type of catastrophic accident, constant connection with the SAMU, management of destinations, management of several PMA, and an "evacuation grouping point".
Key words: advanced medical post; communications; computers; disaster; information; records; registration; triage
Prehosp Disast Med 2001;16(2):s77.
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M-technologies in Management of Disasters and Mass Casualties
Nowadays, a great number of applications are used to compile and transmit information relative to casualties and disasters, but there are many problems associated with the technology including reliability, and the size and weight of the devices that a medical staff must carry. Telecommunication infrastructures support information movement among geographically dispersed locations. Recently, many small devices have appeared in the buyer's market. They are called Personal Digital Assistants, and because of their physical and technical features, they can be very useful in the emergency field. With regard to communications reliability, many technologies have been developed in the last few years. However, it is necessary to find a solution that can be used in every situation independent of the emergency circumstances.
In cases of disaster, the responsible Health Emergency Coordination Centre must receive accurate and current information about the number, type of injuries, and location of the victims. This information, as well as the location and status of all the available resources, must be communicated immediately to the related emergency services and to the authorities in charge of the situation. Acknowledging this need, the Spanish government funded REMAF, an ATYCA (Initiative of Support for the Technology, Security and Quality in the Industry) project. The REMAF joined research groups (UPM), telephone operators (Fundación Airtel Móvil), and the end users (SAMUR) to build a disaster data management system. The system was designed to use modern telemedicine systems-including the aforementioned mobile communication tools and networks in order to optimise management of these situations.
Key words: communications; computers; disasters; management; system; telecommunications; telemedicine
E-mail: chiqui@gbt.tfo.upm.es
Prehosp Disast Med 2001;16(2):s78.
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Four Workers Poisoned with Crezol
Introduction: Four patients who were in contact with Creozote (crezol) came to the emergencies with a cutaneous and respiratory symptomatology.
Method: Four workers handled beams which were soaked in creozote oil a few days prior to the exposure. Creozote is a mixture of phenols and polyphenols. These beams are exposed to the sun and diffuse emanations of chlorinated polyphenols. The workers suffered from a face rash and irritated eyes and were also hyperthermic. The poisoning with crezol ingestion usually results in the development of a hepatocellular syndrome,1 and/or neurotoxicity.2 The local symptoms often consist of cutaneous irritation or even a cutaneous burning.3
Results:
Patient (age) Symptoms Chest X-ray
1 (26 years old) Face irritation Normal
breathing problem,
wheezing, T: 37.7ºC.
2 (38 years old) Face irritation, Normal
normal pulmonary auscultation, T: 38.5ºC._
3 (46 years old) Face irritation, Normal
normal pulmonary auscultation. T: 37.7ºC._
4 (29 years old)_Important face irritation, Normal
_breathing problem, _normal pulmonary _auscultation. T: 38.7ºC._
Patient (age) Biology
Gasometry pH pO2 pCO2 SaO2 %
1 (26 years old) 7.41 99 41 98% Normal
2 (38 years old) 7.40 93 36 97% Normal
3 (46 years old) 7.38 78 46 95% Normal
4 (29 years old) 7.45 60 38 93% Normal
Conclusions: The handling of soaked creozote oil beams caused face irritation, breathing problems, and an unexplained hyperthermia.
References
1. Hashimoto T, Lida H, Dohi S: Marked increases of aminotransferase levels after cresol ingestion. Am J Emerg Med 1998;16(7):667-668.
2. Craig PK, Barth ML: Evaluation of the hazards of industrial exposure to tricesyl phosphate: A review and interpretation of the literature. J Toxicol Environ Health B Crit Rev 1999;2(4):281-300.
3. Lin Ch, Yang Jy: Chemical burn with cresol intoxication and multiple organ failure. Burns 1992;18(2):162-166.
Key words: creazote; hyperthermia; hypoxemia; manifestations; phenols; polyphenols; rash
Prehosp Disast Med 2001;16(2):s78.
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Efficiency of Cardiopulmonary Resuscitation: Comparison Between Evolutions
Introduction: Criteria used for teaching of cardiopulmonary resuscitation (CPR) change with time. We studied the results of evaluations of nurses tested following several standards used at several times of CPR teaching.
Method: Nurses were evaluated on the Resusci-Anne Skillmeter (Laerdal, Stavanger, Norway). Results from ventilation were analysed using the old American criteria for resuscitation (800 to 120 ml for each ventilation), old European criteria for resuscitation (400 to 600 ml for each ventilation), and the new recommendations from the European Resuscitation Council (10 ml/kg). The results were compared with results of similar evaluation realised in 1989 with nurses at the end of their formation and eight months after CPR formation with American criteria from 1989 (800 to 1,200 ml). Each group contained 18 people. Percentage of correct compressions in 2001 were also compared with 1989.
Results:
Conclusions: The percentage of correct compressions can be considered as similar between 1989 and 2001 for nurses trained for CPR for more than eight months. Percentage of correct ventilations also is similar if we considered old European standards or actual standards. We can explain this by the fact than nurses tested are young and CPR was learned with standards of 2001 or more recent European standards and not 1989 standards. The same conclusion than in 1989 can be made: the efficiency of CPR performance quickly decreases when they don@t train frequently.
References
Verbeiren A: Etude du besoin de formation en réanimation cardio-pulmonaire des infirmières d'un hôpital général. ULB, Ecole de Santé Publique.1989.
Key words: cardiopulmonary resuscitation; criteria; deterioration; nurses; skill; standards
Prehosp Disast Med 2001;16(2):s79.
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Comparative Study of Cardiopulmonary Resuscitation Efficiency
Introduction: During cardiopulmonary resuscitation (CPR), different people (nurse, paramedics, doctors) perform CPR. We compared their efficiency.
Method: We used Resusci-Anne Skill reporter mannequin (Laerdal, Stavanger, Norway). We recorded tidal volume, ventilation rate, minute volume, percentage of correct ventilation, deepness of compression, and percentage of external cardiac compressions that were correct during CPR performed by paramedics, emergency service@s nurses and doctors, nurses following special course for acute medicine (SIAMU), and finally people with no CPR training. Each group contained 18 people. Data were analysed following the last European Resuscitation Council recommendations.
Results:
Conclusions: Paramedics, by daily experience, have better results. SIAMU nurses have more of a habit of training on mannequins during their year of training. Nurses have the worst score for compression due to of insufficient compression. Doctors generally perform less CPR, and so, have relatively bad results.
Key words: Cardiopulmonary resuscitation (CPR); doctors; experience; nurses; paramedics; performance
Prehosp Disast Med 2001;16(2):s79.
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Evaluation of Analgesia for Outpatients
Objectives: Minor traumatic injuries handled by the casualty department usually are treated on an outpatient basis, often without being reexamined in the hospital. Analgesics are prescribed often without receiving feedback on their effectiveness. The purpose of this small exercise was to see whether the analgesic prescribed was sufficient, and if the method for collecting the information is practical.
Method: We evaluated inpatients with minor injuries (ATLS classification, I), using a visual analog scale (VAS). Consequently, we have a baseline without any analgesic intake. Three groups were formed: Group I received 6 tablets of piroxicam, 20 mg in the form of lyophilised pills (2 pills taken the day of the consultation at the casualty department, 2 pills the next day and 1 pill for each of the next 2 days). Group 2 received 12 paracetamol tablets (4 each day);. And Group 3 received both drugs. We asked the patients for consent to our contacting them by telephone once each day during the 3 days following the day of consultation at the casualty department. During the phone call, we ask the patient to refer to the VAS provided at the casualty department and to tell us the actual corresponding degree of discomfort. We also l enquired about any secondary effects that may have occurred.
Results: 150 patients were evaluated (50 in each group): 13 Patients (8.67%) did not answer any of the telephone calls and 34 patients (22.67%) did not reply to either 1 or 2 of the 3 calls.
The average VAS evolution is shown in the following table:
Day Group 1 Group 2 Group 3
n VAS n VAS n VAS
(mean) (mean) (mean)
D 0 50 4.9 50 5.1 50 5.2
D 1 46 3.0 45 3.5 48 2.6
D 2 43 1.8 44 2.8 45 1.7
D 3 42 1.6 41 2.3 42 1.5
Conclusions: The analgesic levels in the 3 groups appear satisfactory (the group piroxicam + paracetamol is logically slightly better). The method for collecting the information figures seems practical despite the loss of 31.3% of the patients.
References
Berthier F, Le Conte P, Garrei P, Potel G, Baron D: Analyse de la prise en charge de la douleur aiguë dans un service d'accueil et d'urgence. Réan Urg 1998:7; 281-285.
Conférence de consensus sur la prise en charge de la douleur aux urgences - Paris 1993.
Key words: analgesics; paracetamol; piroxicam; visual analog scale
Prehosp Disast Med 2001;16(2):s80.
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Experimental Model allowing Comparison between Different Ways of Oxygen Administration
Objectives: We compared the FiO2 available in a normal mask, a partial non-rebreathing mask (PNRM), a total non-rebreathing mask (TNRM), and a new way of administering oxygen, the Tusk Mask II (TM II).
Method: The Tusk Mask II is made up of a normal mask in which a lateral 22 mm hole is made on each side. A fixed a ringed tube 18 cm long and 22 mm in diameter is attached to each side. The experimental model consists of tightly sealing the four types of masks successively onto a board. A hole made in the board allows an oxygen monitor, the OM-100, to be fixed tightly into a T form.
Ten healthy volunteers breathed normally into the apparatus. The FiO2 are measured at the end of the breathing-out phase and at the end of the breathing-in phase for an intake of oxygen increasing successively from 0 to 15 litres per minute. A 20-minute stabilisation period between each measure was necessary at each change in the number of litres of oxygen administered.
Results: The results for administration of oxygen for the four types of masks were:
Conclusion: The FiO2 always is higher when oxygen is given by the Tusk Mask II. In this example, there are no significant differences of FiO2 between the normal mask and the non-rebreathing mask.
References
Hnatiuk OW, Moores LK, Thompson JC, Jones MD: Delivery of high concentrations of inspired oxygen via tusk mask. Crit Care Med 1998;1032-1035.
Key words: administration; masks; oxygen; Tusk Mask II
Prehosp Disast Med 2001;16(2):s80.
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Theoretical Saving of Oxygen in Disaster Situations Using a New Oxygen Administration Mode: The Tusk Mask II
Objectives: The aim is to calculate possible savings in using a new oxygen administration mode in a disaster situation-the Tusk Mask II (TM II).
Method: We start with a concrete example, a carbon-monoxide intoxication of 20 patients. All of them received 6 litres of oxygen per minute during 45 minutes, the time required for their evaluation, triage, and evacuation to hospitals for their admission. We calculated the quantity of carboys of 2.8 litres necessary to provide such oxygenation. The administration of 6 litres per minute generates a certain FiO2 within the mask (measured in a reproducible experimental model). To obtain the same value of FiO2, we identified which oxygen output should be administered by the TM II. The latter is constituted by a normal mask in which one would pierce a lateral hole of 22 mm of diameter on each side joined by an annulated pipe of 18 cm long and 22 mm diameter.
Result: 6 litres per minute x 45 minutes x 20 patients = 5,400 litres and a carboy of 2.8 litres contains 2.8 x 150 bars = 420 litres. Therefore, the need with classic masks will be 5400/420 = 13 carboys. The following table taking the measures done on experimental model allows to compare the FiO2 in a classic mask and in a TM II.
Litres/min 0 1 2 3 4 5 6 7
FiO2 in 19.2 21.1 25.0 28.7 32.3 37.4 41.6 46.6
classic mask
FiO2in TM II 19.6 23.0 29.5 38.6 45.0 49.0 54.6 58.8
Litres/min 8 9 10 11 12 13 14 15
FiO2 in 50.6 54.1 57.4 61.1 63.8 67.2 69.9 73.0
classic mask
FiO2 in TM II 66.1 72.4 75.0 77.7 80.9 84.8 87.8 91.2
This table allows prediction of the same FiO2 administered to the patient, we will need a theoretical flow of 3.5 litres per minute. Using the same computation used above:
3.5 litres per minute X 45 minutes X 20 patients = 3,150 litres of oxygen; A carboy of 2.8 litres contains 2.8 X 150 bars = 420 litres; The need with TM II will be 3,150/420 = 8 carboys.
Conclusions: The use of TM II allows a saving of oxygen sources, not as essential in emergency situation as it could be in a disaster situation.
Key words: administration; carbon-monoxide; computation; disaster; model; oxygen; masks; Tusk Mask II
Prehosp Disast Med 2001;16(2):s81.
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A New Approach for Casting Fingers, Hands, or Arms within Seconds
The authors present a new approach for casting, their experience with it, and compare its practicability with the usual techniques (plaster of Paris and casting with thermoplastics). The new approach is based on a Hungarian-Swiss patent called the "Chrisofix" concept. All of the corresponding splints have a corrugated, thin aluminium core covered with cotton- or polyamide-laminated polyethylene layers. The form of the individually adjustable splints/ortheses depends on the target joint/s of immobilisation. Thus, the limitation of function is reduced to the necessary minimum.
The comparisons of the different casting techniques discussed are based on the authors' experiences with the conventional techniques and with different types of splints based on the new approach in 100 cases partially during SFOR and KFOR missions, respectively. Reports from Hungarian National Institutes of Traumatology and Rheumatology are included in the discussion. Its quick applicability and its ability to ensure functioning of the uninvolved joints are the advantages of this new approach and are the reasons that make it so useful in field medical practice and disaster situations.
Key words: casting; "Chrisofix"; fractures; immobilization; ortheses; splints; techniques
Prehosp Disast Med 2001;16(2):s81.
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Drug Consumption in Traffic Accidents
Introduction: Traffic accidents constitute an important cause of morbidity and mortality in developed countries, mainly in young people. In Spain, around 5,000 people die annually due to these accidents, with 100,000 injured. Drug and alcohol consumption, as well as the nonuse of safety measures, influence the incidence as well as the severity of the injuries of the traffic victims.
Objectives: We set out to evaluate the existing relationships between the consumption of alcohol or other drugs among injured drivers, with respect to the use or nonuse of safety measures and the severity of the injuries produced in the accident.
Methods: We studied 62 drivers involved in and injured from traffic accidents and who were transported to our Hospital Emergency Service. The classic descriptive variables were analyzed: age, gender, means of locomotion, alcohol ingestion, drugs, use of safety measures, determination of type of toxic materials in the urine and blood alcohol levels, main diagnosis, index of gravity (Scale of Crams), and disposition of the patient.
Results: Of the study population, 68% were men (32%, women), with an average age of 30.2 ±12.3 years. Only 45.2% of the persons used a car safety belt or helmet, 38% affirmed to have ingested alcohol, and 1.6% to have consumed another type of drugs before the accident. Moreover, blood alcohol level was 0.5 g/100 ml. in 57.3% and toxic materials were present in the urine in 16.1% (all the patients with positive toxic screens also had alcohol in their blood). Cannabis was the drug most frequently found (65.3% of the positive determination). Of these patients, 37.4% needed to be admitted to hospital, and 29.2% injured were considered to be injured seriously. Among those that had a positive result for alcohol in blood, 85.1% did not use safety measures, and 87.8% were admitted to hospital. Among the victims who had consumed other drugs, 100% did not use safety measures and needed to be admitted; 70.7% of patients intoxicated with some kind of drug were considered serious.
Conclusions: A high proportion of alcohol consumption and other drugs exists among the drivers of motor vehicles that are involved in traffic accidents, and a high disproportion exists between the recognition of such consumption and the analytical determinations. Drug consumption is related clearly to the nonuse of safety measures, having the potential to increase the severity of the injuries and the cost of medical resources.
Key words: accidents; alcohol; consumption; drivers; drugs; injuries; safety measures; traffic
E-mail: fjgvega@nexo.es
Prehosp Disast Med 2001;16(2):s81.
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Model of Disaster Medical Response in Metropolitan Taipei
Introduction: Disasters are tragedies that overwhelm our communities, destroy our property, and harm our population. Since 21 September 1999, we suffered from a major disaster (earthquake) that killed about 2,347 people, and injured approximately 9,400 people. Three days later, there were 320,000 people (12.8%) who were staying in shelters, because their houses (81,000) were totally or partly damaged. The affected area was suburban, and the amount of damage was limited, but the disaster medical response was very important. For further preparation, it was necessary to build a model for disaster medical response in the metropolis.
Objective: This study should explain the importance of building a model of disaster medical response in the metropolis using the Taipei experiences. We provided the establishment of emergency medical services (EMS) system, the organization, and the multidisciplinary team response to a major disaster.
Method: We chose the city of Taipei for the study sample. Taipei has a population of 2,640,000 people, and has 12 local administration areas. The emergency medical services system (EMSS) has 24 system hospitals (6 medical centers, 14 regional, and 4 local hospitals). We divided Taipei into 5 disaster medical response areas (east, south, west, north, and middle), and the demographic data, the use of severity scores, and questionnaires from the respondent persons were collected. A cohort study design was used.
Results: The accuracy and reproducibility of these assessments depended upon the training and skill of the assessors and upon the refinement of the tools used in the conduct of these assessments. The data collected included: medical, public health, sanitation and water supplies, shelter and clothing, food, energy supplies, search and rescue, public works and engineering, environment, logistics and transport, security, communication, economy, and education. After five disaster medical response areas were compared, the best responses were found in the north and middle areas.
Conclusion: To build a model of disaster medical response in the metropolis is necessary. From the project design, we can identify our vulnerabilities. Implementation of change is directed towards mitigation of the damage that may occur from disasters.
Key words: assessment; design disaster medicine; disasters; earthquake; medical responses; model; preparedness
Prehosp Disast Med 2001;16(2):s82.
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Clinical Characteristic and Prevention of AMI in Middle Age and Young Patients
Objective: For improving the diagnosis of younger patients presenting with acute myocardial infarction (AMI).
Methods: The clinical analysis was done in 125 patients with AMI who were <49 years of age with 125 middle and young age cases.
Results: The middle and young age patients were 15.1% of total AMI cases evaluated during the same period with 122 males and 3 females; the ratio was 40.7:1. In the young group, 74.6% smoked, 56.0% had hyperlipidemia, 40.8% drank, 27.2% had hypertension, and 27.2% had a family history of AMI. The mortality was 7.2% in four weeks. The male to female ratio, smoking and family history in the young group were higher than they were in the older group, whereas hypertension and mortality were lower than in older group. These differences were significant statistically.
Conclusion: The middle and young age patients mostly had risk factors, significant predisposing causes, sudden onset, and on premonition. The early sudden death rate was higher, but the late complication rate was lower. Therefore, the course of disease was short and the prognosis was better than for the older cases.
Key words: age; clinical characteristics; diagnosis; mortality; myocardial infarction; prevention; risk factors
Prehosp Disast Med 2001;16(2):s82.
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Relationship Between Mortality and Building Collapsed Patterns
Introduction: This presentation describes the relationship between injuries to persons and the collapsed patterns of buildings in the Cokaeli Earthquake in Turkey, 1999. Collapse of buildings is responsible for many victims during an earthquake, while there are some patterns of collapse that do not kill. On 17 August 1999, an earthquake with a magnitude of 7.4 on Richter scale, struck Cokaeli, Turkey. More than 16,000 people were killed.
Methods: The research team defined the collapsed RC buildings 20 types, and classified them using the 5 MSK damage grade, D0 - D5, in the view point of architect engineering. Moreover, the team subclassified the D5 damage, considered totally destroyed, into 11 precise patterns. The team visited the site-Adapazari, Turkey-and collected the data about individual collapsed buildings and the mortality of the inhabitants, using inspections and interviews.
Results: The results showed that the mortality related strongly to the type of collapse. The deaths only occurred in 5 of the 11 types of MSK-D5, a pancake-like collapse in the lower stories of the structures.
Discussion: The research team proposes discussion about the human damage and building damage under the more precise classification of complete collapse than those of ordinary MSK damage grade.
Conclusions: The survival potential of trapped victims according to the collapsed patterns, may help the decision-making for the optimal triage for search and rescue. The conclusions should be associated with improvements in the strategies used for search and rescue activities, and also the induced building-collapse type to the survival.
Key words: building collapse; earthquakes; patterns; search and rescue; survival
E-mail: allstar@kanazawa-med.ac.jp
Prehosp Disast Med 2001;16(2):s82.
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Evaluation of Training and Quality Management during 8 Years
Early defibrillation is an internationally recognised first aid concept in case of cardiac arrests caused by ventricular fibrillation. Comprehensive studies show a significant increase in the rate of successful resuscitations. However, due to the organisational structure of the rescue service, the immediate availability of a doctor for defibrillation in case of ventricular fibrillation is not always ensured. Therefore, this activity should be delegated to the medical assistant staff. This evaluation shows the application of this concept over a period of eight years.
The District of Dachau covers an area of 579 km2 with approximately 129,000 inhabitants. The rescue service is provided exclusively by the Bavarian Red Cross. They operate four rescue stations and two emergency doctor vehicles around the clock. During daytime, the emergency doctors on call are provided by the hospitals of Dachau and Markt Indersdorf. At night and on weekends, the emergency doctors on call are provided by a group of specialist doctors only. In addition, there always is a "leading emergency doctor" on duty.
The training concept was carried out as follows: In June 1993, the first medical assistant staff was trained in a pilot project. At that time, mostly paramedics could participate in this project. The course included a 16-hour basic training in ECG interpretation and knowledge of medical equipment. Furthermore, the participants were taught the application of the preset algorithm by case simulations. The algorithm was preset by the persons in charge according to the general guidelines of the AHA and the ERC. The doctor-in-charge tested the training success by a written and practical examination. To maintain a high quality standard, the training was repeated every six months with a final refreshing examination. Already in 1994, the suggestion was taken up to train also medical staff whose education did not correspond with that of the paramedics. So, it was ensured that also first responders master early defibrillation. Therefore, the number of medical aids participating in the refresher courses has continued to grow. In 1993, 43 persons were trained, while in 2000 the number of participants rose to 125 whose prevailing role was as first responders.
In accordance with these requirements, requisition of equipment had to be increased. In 1993, only two defibrillation training units were available. Today, we are able to meet our requirements with AEDs on every ambulance, emergency vehicle and first responder.
Thanks to these efforts, the rate of primary successful resuscitations could be raised to 42% in the District of Dachau. The rate of long-term survivors amounts to approximately 12%. For example, in 2000, the AED was used eight times without the presence of a doctor with respect to a total of 90 resuscitations.
Thus, it can be shown that quality management leads to higher quality standards also in the rescue service, significantly improving the medical care to the population.
Key words: automatic external defibrillation; first responders; paramedics; physicians; resuscitation; success; training
Prehosp Disast Med 2001;16(2):s83.
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Trauma Management in the Rescue Service: Circle Training as an Educational Concept and Analysis of a New Training Method
Introduction: Trauma management is a challenge for every doctor on emergency call. An emergency with poly-traumatised patients always represents a special stress situation for the medical staff involved. This situation may be aggravated by the technical rescue teams with unknown equipment and different working methods. If communication and teamwork have not been trained at all levels, a rather simple, but potentially complex situation can quickly turn into a dangerous one for the patient and the rescue team. In order to reduce these uncertainties, a new training concept was tested within the service area of the Rescue Association of Dachau.
The District of Dachau covers an area of 579 km2 with approx. 129,000 inhabitants. There exist two federal highways as well as a great number of winding country roads as potential dangers for creating trauma. The district is crossed by an ICE railway track. Moreover, the district is situated within the closer lane of approach to the Munich Airport Franz-Josef-Strauß, and is included into its primary plan of alert. The rescue service is provided exclusively by the Bavarian Red Cross that operates four rescue stations and two emergency doctor vehicles around the clock. During the daytime, the emergency doctors on call are provided by the hospitals of Dachau, Markt Indersdorf. At night and on weekends, the doctors on emergency doctors on call are provided only by a group of specialist doctors. In addition, there is always a "leading emergency doctor" on duty.
Method: The training concept was carried out as follows: (1) to the effect of a circle training, the participants were assigned into small groups. The training was offered as a lecture and performance simultaneously for assistant staff and emergency doctors; (2) the teams were formed only at the route of practice, but were not separated during the whole training program; (3) the teams consisting of at most 4 emergency doctors and 4 to 6 paramedics passed one after the other through realistic stations of practice, such as road accidents, explosion accidents, construction site accidents; and (4) a forward medical post with approximately 20 injured persons had to be built up@this being the most difficult task to organise from a tactical point of view. The training concept contained the support and guidance of the team by experienced emergency doctors and members of the Fire Brigade of Dachau on the basis of a tutor system. Special attention was paid to the organisation of the place of damage under the restricted conditions of first action. Another aim of practice, was to improve the cooperation and communication with the technical rescue team, such as the fire brigade. The teams were given sufficient opportunities for discussion with the tutors. No model solution was proposed to the teams in order to allow several different ways of solution to be found.
Results: The analysis of the trauma training provided interesting results. Overall, the participants were enthusiastic about the performance. On a range of marks from 1 to 5, the average total mark was 1.2. All participants would recommend it to others. The professional benefit was stated as being very high (mark: 1.1).
To the effect of a quality process, all persons seriously injured now are recorded within the rescue service area. The first results also show an increased application of the subjects taught in the real situation.
Conclusion: Thus, it can be shown that quality management leads to higher quality standards also in the rescue service, significantly improving the medical care provided to the population.
Key words: alert; analysis; doctors; hazards; management; paramedics; plan; quality; rescue; standards; stress; team; training; trauma; tutors
Prehosp Disast Med 2001;16(2):s84.
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Quality Management in the Rescue Service: Resuscitation Analysis in a Rescue Service Area
Introduction: Based on a prospective study, resuscitations in a rescue service area were analysed within a period of 12 months with respect to place, time, primary cardiac rhythm, measures to be taken, and, in particular, the outcome of the patients. The data all were collected in the District of Dachau, Bavaria, where emergency medical services are provided exclusively by the Bavarian Red Cross. A demanding training of the paramedics who have to undergo an annual test in Advanced Cardiac Life Support (ACLS) and early defibrillation has been running for several years. A first-responder system also has been installed. The ambulance and emergency vehicles, as well as the first-responder systems are equipped with AEDs. The patients are resuscitated according to a preset resuscitation algorithm including early defibrillation by rescue service staff and drug treatment on the basis of the American Heart Association (AHA) guidelines.
Methods: The district analysed has approximately 129,000 inhabitants. The medical care of the population is nearly exclusively provided by the district-owned hospitals of Dachau and Markt Indersdorf. The rescue service operates four rescue stations and two emergency doctor vehicles around the clock. Based on a record sheet, all resuscitations within the period of 01 January 2000 through 31 December 2000 were recorded. The outcome of the patients could be followed-up in all cases.
Results: In total, there were 90 resuscitations. The average age was 60 years. A few more men than women were resuscitated. The most outstanding fact was a relatively high rate of resuscitations of children (8%). Approximately 20% of the patients were resuscitated by laymen. The most frequent cause for the resuscitations were internal diseases (81%). Most patients (78%) were treated at home. The outcome was surprising: 42% of the patients were taken to hospital after return of spontaneous circulation. Also, 12% were long term survivors. A most satisfactory outcome is the fact that 6% of the survivors were able to leave the hospital without any neurological deficiencies.
The subgroup analysis of resuscitations indicates that the best outcome occur in cases of observed cardiac arrest and immediate resuscitation by laymen.
Conclusions: First-class technical equipment and superior training of the rescue service staff may significantly improve the rate of resuscitations in a rescue service area. It can be shown that quality management leads to higher quality standards also in the rescue service, significantly improving the emergency medical service for the population.
Key words: bystanders; cardiopulmonary arrests; defibrillation; outcome; quality management; resuscitation; standards; training
Prehosp Disast Med 2001;16(2):s84.
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Quality Management in the Rescue Service: Development of Standards for Treatment of Stroke Patients
Karl Wilhelm; Christian Günzel; Heidi Estner; Hubert Böck; Bernd Rupprecht; Frederic William
Förderverein Rettungsdienst Dachauer Land e.V. GERMANY
Introduction: In view of the number of stroke patients to be treated each year, and the importance of the emergency "stroke" for each patient, the Förderverein and the Bavarian Red Cross of Dachau decided to promote quality standards in the preclinical care by specific training and the development of a stroke record.
Methods: Based on a prospective observation, the treatment of stroke patients was to be surveyed in a rescue service area over a period of 8 months with respect to gender of the patient, age, body temperature, blood sugar, oxygen saturation, and ECG-rhythm.The collective survey comprised the District of Dachau, Bavaria, the rescue service of which being exclusively provided by the Bavarian Red Cross. The District of Dachau covers an area of 579 sqkm with approx. 129,000 inhabitants. The rescue service operates four rescue stations and two emergency doctor vehicles. Several first-responder systems have been installed.
In current training courses, guidelines for stroke treatment were imparted, and a standardised record sheet was introduced; it was to be filled-in by every paramedic in case of the diagnosis of "stroke". Besides age and gender, the risk and prognosis factors for the disease as known today, had to be obtained in accordance with an algorithm.
Results: On the basis of this record sheet, all stroke treatments from 01 June 2000 up to 01 February 2001 inclusive were recorded. The evaluation of these records indicated that: in total, 94 patients were treated under the primary diagnosis "stroke". Almost as many men (n = 46) as women (n = 47) were treated. The average age of the patients was 77 years, while the most strokes were observed in the age group ranging from 80 to 90 years (n = 42). Not only the diastolic, but also the systolic blood pressure was to be measured in at least 10-minute intervals. The average systolic blood pressure was 154 mmHg, while 3 patients had systolic pressures of <100 mmHg and 16 patients 190 mmHg. The diastolic blood pressure was around 85.5 mmHg. The body temperature was to be taken axillary with digital thermometers. 61 patients did not run a fever, 7 patients had a slightly higher temperature, and 2 patients had a temperature exceeding 38.0ºC.
The oxygen saturation amounted to an average of 94.9%. Yet 6 patients had a primary oxygen saturation of less than 90%.
Key words: algorithm; oxygen saturation; prehospital; protocol; risk factors; stroke
Prehosp Disast Med 2001;16(2):s85.
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Remote Area Mass Casualty Incident Response in Australia
Australia has a land mass of 7,682,300 sq. km., approximately the same size as the United States of America excluding Alaska, 32 times the size of the United Kingdom, twice the size of Europe (excluding the Russian Federation), and three to four times the size of the European Union (European Economic Community). Australia's population of 20 million is mostly centred around state capital cities which are situated peripherally on the island continent. Distance is a major consideration for planning a response to mass casualty incidents. Under the Australian Constitution, the Federal Government of The Commonwealth of Australia has the responsibility for the defence of Australia, and for protection of the States against invasion. However, each state and territory is responsible for the protection of citizens and property, including emergency planning and response within its jurisdiction. The Commonwealth centrally, plans and coordinates programs for response to national threats affecting national interests and provides coordination of actions between states if required. Such national programs include the development of a cyclone warning system and the Commonwealth Search and Rescue Organization, which coordinates the initial response to air and maritime incidents.
This paper outlines the measures necessary to provide effective mass casualty management for remote area incidents and for communities, which may be remote from major treatment centres. The medical coordination and organization issues involved in prehospital management and the distribution of casualties to appropriate treatment facilities will be outlined.
Key words: Australia; cyclone; mass casualties; maritime; plan; preparedness; remote; responses; responsibility; search and rescue
Prehosp Disast Med 2001;16(2):s85.
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Distal Tubes for Left Colorectal Trauma and Obstructive Carcinomas
Objective: To prevent and reduce anastomotic leakage after a one-stage operation for left colorectal trauma and obstructive carcinomas, and after Dixon operation for rectal carcinomas.
Methods: Drainage by perianastomotic, proximal and distal tubes was used in 142 patients with left obstructive colonic carcinomas, 86 patients with left colorectal trauma, and 157 patients undergoing a Dixon operation. The incidence of postoperative anastomotic leakage and the healing time of lower anastomotic leakage after operation for rectal carcinomas were observed.
Results: By means of drainage by perianastomotic proximal and distal tubes, the incidence of postoperative anastomotic leakage was 4.2% (6/142) and 1.9% (3/157) respectively in patients with left obstructive colorectal carcinomas and patients undergoing Dixon operation for rectal carcinomas. These indexes were different from those in control groups (p <0.05). The incidence of postoperative anastomotic leakage was 3.5% (3/86) in patients with left colorectal trauma.
Conclusion: Drainage by perianastomotic proximal and distal tubes can effectively prevent and reduce the incidence of anastomotic leakage after one-stage operation for left colorectal trauma, obstructive carcinomas, and after Dixon operation for rectal carcinomas.
Key words: carcinoma; colorectal trauma; leakage; operations; perianastomotic proximal and distal tubes; surgery
Prehosp Disast Med 2001;16(2):s85.
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Prediction of Death in Patients with Acute Hypertensive Cerebral Hemorrhage
Objective: In order to increase the rate of success of emergency treatment for patients with an acute, hypertensive cerebral hemorrhage, the risk factors for predicting death were studied in 101 patients.
Methods: The relationships between age, state of consciousness, blood pressure (BP) at the onset, amount of bleeding; and morality were analyzed retrospectively.
Results: The older the patient; the worse the state of consciousness, the higher the BP at the onset, the higher the amount of bleeding, and the higher the mortality (p <0.01.)
Conclusion: The aforementioned indices are of prognostic significance for patients with an acute, hypertensive cerebral hemorrhage.
Key words: cerebral hemorrhage; consciousness; hypertension; mortality; prediction; stroke
Prehosp Disast Med 2001;16(2):s85.
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Contrastive Analysis of Pre-and Post-functioning of the Yueqing City Tuberculosis Control Project
Introduction: Tuberculosis is a serious and infectious disease harmful to human health. Since 1990, tuberculosis has occurred frequently, and has not been controlled effectively. Tuberculosis is one of important infectious diseases in our state's "nine-five" infectious disease control plan, so fulfilling the task of preventing and curing tuberculosis is our obligation.
Methods: For controlling tuberculosis effectively, we implemented a united management strategy for this disease, enhancing the ratio of exact diagnosis and cure, thus fulfilling the purpose of this project.
Results: Tuberculosis may be controlled effectively by: (1) enhancing the understanding, responsibility, and the importance of preventing this disease, (2) improve the propagation and citizen@s self-protection; and (3) manage uniformly patients with tuberculosis; (4) carry out methods of WTO cure generally, and (5) develop investigation of tuberculosis and enhancing the ratio of exact diagnosis, etc.
Key words: analysis; control; infectious diseases; plan; treatment; tuberculosis
Prehosp Disast Med 2001;16(2):s86.
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Retinal Detachment after Intraocular Foreign Body Removal with Vitrectomy
Objective: To report the incidence of retinal detachment after intraocular foreign body removal with vitrectomy, and to analyze the relative reasons.
Methods: A retrospective analysis of 20 consecutive patients (20 eyes) who underwent pars plana vitrectomy for the removal of intraocular foreign body was conducted .A standardized, three port vitrectomy was used in all injured eyes.
Results: Four (20%) of 20 eyes had retinal detachment. Visual acuity increased in 14 eyes (70%), stabilized in 3 eyes (15%), and deteriorated in 3 eyes (15%).
Conclusion: The possible reasons of retinal detachment after intraocular foreign bodies removal with vitrectomy included: (1) the remnant vitreous traction formation, (2) not proper photocoagulation around the retinal hole, (3) tiny retinal hole not found during the surgery, (4) no preoperative photocoagulation on the surface of retina around the foreign body, and (5) the peripheral retinal tear induced by removal of a large foreign body.
Key words: detachment; foreign bodies; intraocular; removal; retina; vitrectomy
Prehosp Disast Med 2001;16(2):s86.
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Investigation on Lens Condition of 370 Han Nationality Officials Living at an Altitude 4,000 M
Cataract disease is a worldwide ophthalmological disease and is correlated to living conditions, living habits, natural environment, and geographical location, but not to nation, nationality, race, or sex. Patients who suffer from cataract disease almost always live in the highlands. Deliquescence of this disease is very long; it most often occurs in adults and the elderly.
In China, the number of persons who are blind as a result of cataract disease is about 4 million. Control of cataract disease is one of three rehabilitation projects, according to the disease control plan of the Ministry of Health of China. Through our investigation of 337 persons, we conclude that there are three reasons for lens turbidity: (1) strong radiation exposure to infrared and ultraviolet rays., (2) metabolization turbulence and lens nutrition decompensation, and (3) incretion function turbulence and a genetic factor .
Key words: blindness; causes; cataract; lens; turbidity
Prehosp Disast Med 2001;16(2):s86.
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Investigating Injuries among Middle and Primary School Students in Huaiyuan County
Objective: To investigate the level of injuries and the epidemiological features of injuries among middle and primary students, in order to find out the effective intervention measures for preventing injuries. Methods: A questionnaire was used to investigate the injuries sustained by 15,149 middle and primary school students.
Results: There were 12 kinds of injuries, the total rate of injuries was 39.0%. The top three kinds of injuries included: injuries from falls (15.9%), bitten by animals (15.2%), and knife-cutting or sharp weapon wounds (11.5%). The rate of injuries among junior middle school students was the highest (51.7%), that of high school students was lower (45.2%), and that for primary school was the lowest. The rate of injuries was related closely to the kind of school.
Conclusion: Injury has affected the studies and health of middle and primary school students. We must strengthen supervision, safety education, and increase awareness on self-protection among the students.
Key words: bites; children; cuts; epidemiology; falls; injuries; prevention; schools; students; types
Prehosp Disast Med 2001;16(2):s86.
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The Medical Response to Nuclear and Radiological Accidents in China
A nuclear or radiological accident is an unintended or unexpected event occurring with a radiation source or during a practice involving ionizing radiation that may result in significant human exposure and/or material damage. It includes accidents with reactors, industrial sources, and medical facilities. Not only workers, but also members of the public including children, have suffered radiation injuries as a result of nuclear and radiological accidents over the past few years. The accidents involved external irradiation and occasionally included internal and skin contamination. Over the past few years, the International Atomic Energy Agency (IAEA) has issued publications that provide information on general recommendations to physicians for the diagnosis and treatment of radiation injuries resulting from a nuclear or radiological accident. They also may serve as safety guides providing general recommendations for emergency preparedness, including some medical aspects and guidance on radiation protection criteria for health consequences. The medical assistance to be provided may be considered at several different levels depending on the seriousness of the accident. These levels would extend from a local on-site emergency station, medical service facility, and regional hospital to a large central hospital with specialized facilities.
In the People's Republic of China, the Center for Medical Assistance in Nuclear Accidents of the Ministry of Health (CMANA) was established in 1993. The CMANA functions as a national, professional institute for medical assistance in nuclear accidents including drafting of the National Emergency Program for Nuclear and Radiological Accidents, preparing medical responses and assistance for accidents, and developing medical treatment for injured persons in nuclear and radiological accidents.
Key words: assistance; International Atomic Energy Agency (IAEA); China; injuries; medical responses; nuclear accidents; radiological accident
Prehosp Disast Med 2001;16(2):s87.
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Clinical Treatment of Severe Head Injury from Falls
Injuries from falls are one of the leading causes of accidental death, second only to traffic accidents. From January of 1998 to May of 1999, 96 cases with injuries from falls were treated in our hospital, including 13 cases of severe head injury. According to the Glasgow Coma Scale Scoring system (GCS) standard, a severe head injury is one whose GCS score does not attain a scores of "8" after head recover y, or those whose scores have been down to this level. In these cases, emergency treatment after recovery of heart and lung function and timely surgery for patients whose symptoms and signs agree with the surgical standards, must be performed first. Early, effective support of ventilation and circulation is not only a fundamental measure, but also the foundation for brain recovery, and surgery is the key of life. In addition, large doses of hormones, induced sleep, and hypothermia treatment also contribute to recovery.
Key words: falls; head injury; recovery; resuscitation; signs; symptoms; treatment
Prehosp Disast Med 2001;16(2):87.
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Preventable Trauma Deaths and Prehospital Care in Pakistan
Introduction: Preventable trauma deaths have been well-studied in developed countries. Very little is reported on the incidence and factors leading to preventable trauma deaths in developing countries. The objective of this study was to evaluate the trauma deaths in a university hospital in Pakistan, and to identify any deficiencies in care.
Methods: Trauma deaths were identified from a trauma registry: 279 patients presented from 01 January 1998 to 31 December 1999, and there were 17 deaths. The probability of survival using the trauma injury severity score (TRISS) was calculated ,and outcome was compared with western norms. In addition, a multidisciplinary, peer review committee reviewed these cases. They classified deaths into preventable, potentially preventable, and nonpreventable categories, and identified factors responsible for poor outcome. A time line for all phases of care also was generated.
Results: There were 6 (35%) preventable, 7 (41%) potentially preventable, and 4 (24%) nonpreventable deaths. The median injury severity score was 25 (range 9-75), and the mean value for the revised trauma score was 4.4 ±.6. The TRISS predicted 12 deaths. The mean of the time to definitive treatment was 6 hours and 54 minutes. The absence of prehospital care, lack of communication, and interhospital transfer of trauma patients contributed significantly to poor outcome. In addition, nonadherence to the principles of advance trauma life support also was a major determinant of poor outcome.
Conclusion: A large proportion of the trauma deaths in a developing country like Pakistan is potentially or completely preventable. Improved prehospital care and applications of the principles of early trauma care should significantly improve outcome.
Key words: deaths; prehospital; preventable; trauma; TRISS
E-mail: hasnain@akunet.org
Prehosp Disast Med 2001;16(2):s87.
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Management of Traffic Accidents in Shanghai City
China has 2.2% of the number of motor driven in the world, but automobile accidents in China comprise 9% of the automobile accidents in the world. Currently, 86,000 deaths result from traffic accidents annually. Shanghai is one of the largest cities of the world with a population of 13,000,000 inhabitants. The average density of population is 1,000 persons per km2, and that in the central part of the city, it is 10,000 persons per km2. Currently, more than 2,000,000 people move through Shanghai daily. The total number of passengers using buses during 1995 was over 5,500 million.
Statistics of the past five years indicate that the number of traffic accidents exceeded the past records by 60,000 cases with two persons killed daily (in the whole of China, 1 person is killed by accidents every 6 minutes). Tables 1 and 2 present these traffic accident statistics.
Table 1-Statistics of Traffic Accidents in Shanghai from 1994 to 1998
Year Number of Number of Number of
Accidents Injured Deaths
1994 18,475 10,059 1,514
1995 20,074 9,500 1,164
1996 8,736 8,991 947
1997 7,621 4,699 607
1998 7,524 4,450 594
Total 62,430 37,699 4,826
Table 2-Statistics of Traffic Accidents in China from 1994 to 1998
Year Number of Number of Number of
Accidents Injured Deaths
1994 298,147 187,399 53,439
1995 276,071 170,598 54,814
1996 258,030 159,002 50,441
1997 250,297 155,072 49,271
1998 264,817 162,019 53,292
Total 1,347,362 834,090 261,257
From the above traffic accidents, the following characteristics can be identified:
1. Of all the persons killed in traffic accidents, 85% are below the average of 40 years of age;
2. Prehospital mortality rate from traffic accidents was 66%; and
3. 60% of traffic accidents are related to bicyclists
Improvement of prehospital first aid and emergency facilities has decreased the rate of mortality and injuries by traffic accidents in recent years. The Shanghai First Aid Central Station (SFACS) possesses 173 ambulances and is staffed by 517 specialists. The facilities of the new resuscitation ambulances, called a "Movable ICU", consists of a cardiopulmonary monitor, ventilator, emergency drugs, and other resuscitative equipment. The ambulance also has an excellent communication device that can connect with any part of the communication network in Shanghai City. Altogether, 110,889 persons requiring first aid were transported by SFACS in 1996. The number of the wounded by traffic accidents and other disasters (e.g., burn accidents, intoxication, drowning, etc.) was 26,681 with 318 persons found dead before hospitalization.
All severe trauma patients should be transported to the identified hospital in Shanghai. Every central hospital in Shanghai carries out the actions to set up a resuscitative department so as to accept masses of critically wounded casualties in time based on the conditions of the disaster. The functions of a resuscitative department are to sort all of the critically wounded from ordinary ones, resuscitate them, and render all supportive treatments required. Their functions include cardiopulmonary resuscitation, immediate treatment of life threatening respiratory failure, organ injuries, and stopping the loss of blood. Initial management of fractures and injuries from these disasters should be referred to the orthopedic department.
Key words: accidents; ambulances; deaths; hospitals; injuries; re