bluuebunny/crossref_metadata_2025 huggingface dataset:
Physician In-field Observation of Prehospital Advanced Life Support Personnel: A Statewide Evaluation
Authors: Spaite Daniel W. , Valenzuela Terence D. , Meislin Harvey W.
Published: July 2016

Study Hypothesis:

Direct physician observation of advanced life support (ALS) personnel is rare in a demographically diverse state.

Study Population:

Twenty ALS agencies from throughout Arizona.

Methods:

A board-certified emergency physician performed on-site interviews with the emergency medical services (EMS) supervisor of each agency to approximate the number of days per year that physicians observe ALS personnel in the field.

Results:

Only 11 agencies (55%) reported that physicians ever observed ALS personnel. Among all agencies, an estimated total of 84 observer-days occurred per year. The agencies staffed a total of 86 ALS units, resulting in an estimated 0.98 observer-days/unit/year (84/86). On the average, it took 3.4 ALS personnel to staff a given unit over time and the probability that an ALS provider would be on a unit on any given day was 0.29 (1/3.4). The probability of a given provider being observed during one year was approximately 0.29 (0.98 x 0.29). Thus, on the average, an ALS provider would be observed by a physician approximately once every 3.5 years (1/0.29). Among urban agencies, the “average” ALS provider would be observed once every 2.9 years. This compared to a likelihood of in-field observation of only once every 6.7 years for non-urban providers (p = .036).

Conclusions:

The skills of ALS providers in Arizona are observed by a physician in the field very infrequently. Although an uncommon occurrence in urban agencies, observation of non-urban ALS personnel occurs even less frequently. In addition, nearly one-half of the agencies surveyed never had a physician-observer. Although a variety of skills evaluation methods exist, it remains unclear whether any method is as useful as direct observation. Future investigations are needed to evaluate whether in-field physician observation impacts skills, patient care, or outcome in EMS systems.
Prehospital Do-Not-Resuscitate Orders: A Survey of State Policies in the United States
Authors: Adams James G.
Published: July 2016

Introduction:

Many states in the United States ‘have developed policies that enable prehospital emergency medical services (EMS) providers to withhold cardiopulmonary resuscitation (CPR) in the terminally ill. Several states also have policies that enable the implementation of do-not-resuscitate (DNR) orders.

Objectives:

1) assess which states have statutes governing DNR orders for the prehospital setting; 2) determine which states authorize DNR orders in ways other than by specific state statue; and 3) define those states that had regional protocols which address prehospital DNR orders.

Methods:

Survey of the state EMS directors in each of the 50 U.S. states, the District of Columbia, and Puerto Rico.

Results:

As of 1992, specific legislation authorizing the implementation of DNR orders was in place in 11 states. In addition, six others have a legal opinion or policy allowing the implementation of DNR orders. Fourteen additional states have either working groups or legislation pending that address prehospital DNR orders. In only five were there no existing regional protocols for implementation of DNR orders in the prehospital setting.

Conclusions:

There exists great variation in legal authorization by states for implementation of DNR orders in the prehospital setting. Despite the existence of enabling legislation, many state, regional, or local EMS systems have implemented policies dealing with DNR orders.
Mouth-to-Mouth Ventilation of Cardiac Arrested Humans Using a Barrier Mask
Authors: Lufkin Kirk C. , Ruiz Ernest
Published: July 2016

Introduction:

Concern for possible disease transmission during mouth-to-mouth resuscitation has decreased the incidence of bystander cardiopulmonary resuscitation (CPR). Barrier masks have become available that may be effective in CPR as well as protective against cross-contamination.

Hypothesis:

A silicone rubber barrier mask incorporating a one-way-valved airway (Kiss of Life [KOL]) designed to prevent contamination of the rescuer, permits satisfactory mouth-to-mouth ventilation of victims of cardiopulmonary arrest.

Methods:

Ten adult patients who did not survive non-traumatic cardiac arrest were ventilated with exhaled room air using a KOL barrier mask while external cardiac massage continued. Arterial blood gases were obtained every two minutes for a maximum of 10 minutes. The operator was blinded to the results of these blood tests.

Results:

Eight men and two women with ages from 55 to 99 years were studied. Four patients were edentulous and two of these had marked mandibular atrophy. The two patients with mandibular atrophy were poorly ventilated with the barrier mask. One other patient was not ventilated successfully. This patient had undergone multiple attempts at endotracheal intubation and had transtracheal needle ventilation performed prior to use of the barrier mask. One patient had elevated PaCO2 despite being well-ventilated clinically. Six patients were ventilated well clinically and had satisfactory PaCO2 and PaO2 values.

Conclusion:

The barrier mask studied appears to be an effective aid to ventilation in CPR Patients without facial support, as in edentulous patients with mandibular atrophy, are not ventilated well with this device.
Emergency Medical Training in the 82d Airborne Division: The Gulf War Experience
Authors: Cancio Leopoldo C. , Goforth Gary A.
Published: July 2016

The 82d Airborne Division, as the Army's worldwide contingency division, places unique demands on its medical personnel. This was true particularly during Operations Desert Shield and Desert Storm in 1990–1991. An unprecedented emergency medical training program was carried out in preparation for the Gulf War.

All levels of expertise were involved: non medical Combat Lifesavers, medics, physician assistants, and physicians. Courses provided included Combat Lifesaver provider and refresher training, Basic Trauma Life Support (BTLS) provider and instructor training, Chemical Casualty courses, and a Combat Surgical Skills course. Approximately 736 personnel, including 80 Saudi and allied physicians and medics, participated in these courses. Confidence and competence in handling war casualties at all levels was enhanced greatly. Prepackaged courses such as BTLS enabled the rapid training of large numbers of medical personnel under challenging conditions.
In the Shadow of El Chichon: An Overview of the Medical Impact of the 28 March to 4 April 1982 Eruptions of the Mexican Volcano
Authors: Nania James M. , Garcia Manuel Rodriguez , Fruchter John S. , Olsen K.B. , Hooper Peter R.
Published: July 2016

On 28 March 1982, El Chichon, a volcanic peak located in southern Mexico, began an eruptive phase of activity. Four major eruptions occurred within the next eight days, culminating in a cataclysmic eruption on 4 April. When the dust had settled, an estimated 200 million tons of ash blanketed more than 200 square kilometers of southern Mexico and neighboring Central American countries. Forty thousand villagers were left homeless and several thousand people may have lost their lives. Fifty thousand head of cattle were destroyed outright with many more succumbing to lack of water and pasture. Millions of hectares of crops were destroyed (Figure 1).
Natural Hazards: Causes and Effects: Lesson 1—Introduction to Natural Disasters
Authors: Perez Eddie , Thompson Paul
Published: July 2016

This course is an introduction to the topic of natural hazards, their causes and their consequences. The subject is so vast that this course cannot begin to provide a definitive treatment of all aspects of these hazards. Instead, it seeks to present an overview of the general subject.

The course begins with a definition of each major natural hazard that disaster managers may encounter in developing countries. Historical examples are presented to give perspective to the potential scope of these natural events and their actual effects within a community or country. The geographical distribution of the hazard type, indicating the possibility of its occurrence in all parts of the world, is shown. The natural pre-conditions that must exist for the phenomenon to occur are described. The actual event is described in its physical/natural manifestation, with a detailed account of what happens and why, before, during, and after the event. The impact on the natural and human-produced environment—the reason it becomes a “disaster” rather than simply a natural phenomenon—is reviewed. Each lesson then discusses what disaster managers, in particular, and the public, in general, can do to respond.
An Analysis of Prehospital Mortality in an Earthquake
Authors: Pretto Ernesto A. , Angus Derek C. , Abrams Joel I. , Shen Bern , Bissell Richard , Castro Victor M. Ruiz , Sawyers Roberto , Watoh Yukihiro , Ceciliano Norma , Ricci Edmund ,   other members of the Disaster Reanimatology Study Group
Published: July 2016

Introduction:

Anecdotal observations about prehospital emergency medical care in major natural and human-made disasters, such as earthquakes, have suggested that some injured victims survive the initial impact, but eventually die because of a delay in the application of life-saving medical therapy.

Methods:

A multidisciplinary, retrospective structured interview methodology to investigate injury risk factors, and causes and circumstances of prehospital death after major disasters was developed. In this study, a team of United States researchers and Costa Rican health officials conducted a survey of lay survivors and health care professionals who participated in the emergency medical response to the earthquake in Costa Rica on 22 April 1991.

Results:

Fifty-four deaths occurred prior to hospitatization (crude death rate = 0.4/1,000 population). Seventeen percent of these deaths (9/54) were of casualties who survived the initial impact but died at the scene or during transport. Twenty-two percent (2/9) were judged preventable if earlier emergency medical care had been available. Most injuries and deaths occurred in victims who were inside wooden buildings (p <.O1) as opposed to other building types or were pinned by rubble from building collapse. Autopsies performed on a sample of victims showed crush injury to be the predominant cause of death.

Conclusions:

A substantial proportion of earthquake mortality in Costa Rica was protracted. Crush injury was the principal mechanism of injury and cause of death. The rapid institution of enhanced prehospital emergency medical services may be associated with a significant life- saving potential in these events.
Mission to Sarajevo
Authors: Pretto Ernesto A. , Begovic Mirsada
Published: July 2016

Each of us has witnessed news reports and graphic television scenes of the willful targeting of innocent noncombatants by military forces; the displacement of tens of thousands of men, women, and children; and the diabolical genocidal tactics of “ethnic cleansing” of the war in Bosnia and Herzegovina. An international effort to establish a United Nations war crimes tribunal is being developed, but even this plan is running out of steam for lack of funding. These events are unfolding in “civilized” and “enlightened” Europe. We all know what is happening, yet world leaders have been reluctant to intervene.
A Short Look at the History of the State Hospital of Sarajevo
Authors: Nakas Bakir
Published: July 2016

The State Hospital of Sarajevo has a tradition that is 127 years old. It is located on the spot where the first Turkish Army hospital—the first hospital on the territory of Bosnia and Herzegovina—was established in 1865. Through the ages, military health institutions in the city of Sarajevo always have been located on this spot. In its time, that first hospital was a modern health facility with its own running water and sewage system. It was used for the treatment of Turkish soldiers. Civilians had their facility built in 1866— the so-called Vakuf Hospital, the operation of which was aided occasionally by two military physicians.
Transfusion Therapy During War and Peace in Sarajevo
Authors: Begovic Mirza , Kozlicic Abdulah
Published: July 2016

Objective:

To investigate surgical blood usage during the siege of Sarajevo.

Methods:

Data on blood usage and pre-transfusion hematocrit (Hct) values from blood transfusion request forms in 250 wartime emergency surgical procedures during August through October 1992 (experimental group), and in 146 peacetime elective surgical procedures (control group) during April through June 1991 at the State Hospital of Sarajevo, were reviewed.

Results:

The mean number of blood units transfused per patient (blood usage rate) was 1.13 in the experimental group versus 2.56 in the control group (p <0.001). During the war, for blood conservation, normovolemic hemodilution was practiced widely. A significantly lower mean pre-transfusion Hct value of 0.21 was observed in the experimental group versus 0.27 in the control group (p <0.001).

Conclusion:

Blood-usage rate was lower during emergency surgical procedures in war than during elective surgical procedures in peacetime without apparent adverse patient outcome. This decrease in blood-usage rate in the face of increased numbers of trauma victims was the result of a planned blood-conservation program which included: stringent blood-usage criteria, and widespread implementation of casualty resuscitation using normovolemic hemodilution with colloid and crystalloid plasma substitutes.
The Effect of Hospital Resource Unavailability and Ambulance Diversions on the EMS System
Authors: Neely Keith W. , Norton Robert L. , Young Gary P.
Published: July 2016

Hypotheses:

1) There is no increase in transport or scene time of diverted patients and no increase in distances traveled; 2) hospital resource shortages bear no relationship to the number of patients diverted; and 3) paramedics are able to match their patient correctly with the resources available at a given hospital.

Methods:

This was a five-month, prospective, observational study in an urban area with a population of 600,000 comparing all 9-1-1 ambulance diversions against a randomly selected sample of 5% of all other 9-1-1 originated patients. All patient diversions that originated from the 9-1-1 center are included in the study.

Results:

Hospitals identify their diversion status on a community-wide computer system monitored at the 9-1-1 center and base station. Accepted categories include: 1) diversion of all patients through the 9-1-1 center from the emergency department (ED); 2) trauma system patients (T); 3) psychiatric secure beds (PSB); 4) general acute ward beds (AW); 5) critical care (CC); 6) computed tomography scan (CT); 7) labor and delivery (LD); and 8) pediatric beds (PEDS). Data were abstracted from 481 patients' records. A total of 111 were diverted from their intended destination. Transport times were longer and diverted patients traveled further (p <.002). Hospitals showing ED and LD diversion categories were more likely to have patients diverted away (r2 = .895, multilinear regression, p <.001). Of the 111 patients, 21 (19%) were diverted because of CC unavailability. Six of these (28%) were inappropriate because they did not fit the CC definition.

Conclusions:

In this system, hospital diversions increase transport times and distances traveled. Diversion of patients correlated strongly to unavailability of specific categories. Paramedics make errors in determining appropriate CC diversions. Systems reviewing their diversion problems need to assess the impact of longer out-of-hospital times and of certain diversion categories, and to clarify definitions.
Patient Outcome Using Medical Protocol to Limit “Lights and Siren” Transport
Authors: Kupas Douglas F. , Dula David J. , Pino Bruno J.
Published: July 2016

Introduction:

Emergency medical services vehicle collisions (EMVCs) associated with the use of warning “lights and siren” (L&S) are responsible for injuries and death to emergency medical services (EMS) personnel and patients. This study examines patient outcome when medical protocol directs L&S transport.

Design:

During four months, all EMS calls initiated as an emergency request for service and culminating in transport to an emergency department (ED) were included. Medical criteria determined emergent (L&S) versus non-emergent transport. Patients with worsened conditions, as reported by EMS providers, were reviewed.

Setting:

Countywide suburban/rural EMS system.

Results:

Ninety-two percent (1,495 of 1,625) of patients were transported non-emergently. Thirteen (1%) of these were reported to have worsened during transport, and none of them suffered any worsened outcome related to the non-L&S transport.

Conclusion:

This medical protocol directing the use of warning L&S during patient transport results in infrequent L&S transport. In this study, no adverse outcomes were found related to non-L&S transports.
The Impact of Variation in Trauma Care Times: Urban versus Rural
Authors: Esposito Thomas J. , Maier Ronald V. , Rivara Frederick P. , Pilcher Susan , Griffith Janet , Lazear Susan , Hogan Scott
Published: July 2016

Study Objectives:

To document the existence and nature of variation in times to trauma care between urban and rural locations; to assess the impact of identified variations on outcome.

Design:

Retrospective case review

Setting:

Washington state, 1986

Participants:

Motor-vehicle-collision fatalities

Methods:

Previously unreported definitions of urban and rural location and possibly preventable death were used to conduct a comparative analysis of urban and rural fatalities. Trauma care times in the prehospital and the emergency department (ED) phases of care were abstracted. Their relationships to corresponding crude death rates and possibly preventable death rates also were examined.

Results:

Prehospital times averaged two times longer in rural locations than in urban areas. First-physician contact in the ED averaged six times longer in rural locations than in urban settings. Concomitantly, the crude death rate in rural settings was three times that of the urban areas. The overall possibly preventable death rate was double the urban rates in rural incidents. When stratified by phase of care, rate of possibly preventable death showed no urban/rural variation for the prehospital phase, but was three times greater for the ED phase in rural areas than in urban ones.

Conclusions:

Trauma care times and adverse outcome appear to be associated. Allocation of resources to decrease length of and geographic variation in time to definitive care, particularly in the ED phase, seems appropriate.
Isolated Intrathoracic Injury with Air Bag Use
Authors: Sama Andrew E. , Barnaby Douglas P. , Wallis Kevin J. , Gadaleta Dominick , Hall Michael H. , Nelson Roy L. , Naidich James , Ward Robert J.
Published: July 2016

The restrained (air bag and seatbelt) driver of a vehicle involved in a high-speed motor-vehicle accident sustained a tear of the thoracic aorta with no signs of external injury. Air bag deployment may mask significant internal injury, and a high index of suspicion is warranted in such situations.
How Should an Unconscious Person with a Suspected Neck Injury be Positioned?
Authors: Gunn Barry D. , Eizenberg Norman , Silberstein Morry , McMeeken Joan M. , Tully Elizabeth A. , Stillman Barry C. , Brown Douglas J. , Gutteridge Geoffrey A.
Published: July 2016

Introduction:

Awareness of the risk of spinal-cord damage in moving an unconscious person with a suspected neck injury into the “lateral recovery position,” coupled with the even greater risk of inadequate airway management if the person is not moved, has resulted in a suggested modification to the lateral recovery position for use in this circumstance.

Hypothesis:

It is proposed that the modification to the lateral recovery position reduces movement of the neck. In this modification, one of the patient's arms is raised above the head (in full abduction) to support the head and neck. The position is called the “HAINES modified recovery position.” HAINES is an acronym for High Arm IN Endangered Spine.

Methods:

Neck movements in two healthy volunteers were measured by the use of video-image analysis and radiographic studies when the volunteers were rolled from the supine position to both the lateral recovery position and the HAINES modified recovery position.

Results:

For both subjects, the total degree of lateral flexion of the cervical spine in the HAINES modified recovery position was less than half of that measured during use of the lateral recovery position (while an open airway was maintained in each).

Conclusion:

An unconscious person with a suspected neck injury should be positioned in the HAINES modified recovery position. There is less neck movement (and less degree of lateral angulation) than when the lateral recovery position is used, and, therefore, HAINES use carries less risk of spinal-cord damage.
In-Field Extremity Amputation: Prevalence and Protocols in Emergency Medical Services
Authors: Kampen Kathryn E. , Krohmer Jon R. , Jones Jeffrey S. , Dougherty J.M. , Bonness Robert K.
Published: July 2016

Objective:

To determine current experience, attitudes, and training concerning the performance of in-field extremity amputations in North America.

Design:

Cross-sectional, epidemiological survey.

Participants:

Emergency medical services (EMS) directors from the 200 largest metropolitan areas in North America and attendees at the 1992 Mid-Year National Association of EMS Physicians Meeting.

Interventions:

The survey consisted of five questions focusing on demographic and operational data, the frequency of occurrence of the performance of in-field amputations, personnel responsible for performing the procedure, existing written protocols for the procedure, and the scope of training provided.

Results:

A total of 143 surveys was completed. Eighteen respondents (13%) reported a total of 26 in-field extremity amputations in the past five years. The most common cause for the injuries requiring amputations was motor-vehicle accidents. In the majority of cases (53.2%), trauma surgeons were responsible for performing the amputation, followed by emergency physicians (36.4%). Of respondents, 96% stated that there was no training available through their EMS agencies related to the performance of in-field extremity amputations. Only two EMS systems had an existing protocol regarding in-field amputations.

Conclusions:

The results suggest a need for established protocols to make the procedure easily accessible when needed, especially in large metropolitan EMS systems. This information should be emphasized during EMS training and reinforced through continuing education.
Prehospital Use of a Prototype Esophageal Detection Device: A Word of Caution!
Authors: Marley Charles D. , Eitel David R. , Koch Mark F. , Hess Dean R. , Taigman Michael A.
Published: July 2016

Objective:

To determine the effectiveness of a prototype esophageal detection device (EDD) during use in the prehospital setting.

Design/Setting:

Prospective convenience sample in a prehospital setting.

Population:

Intubated adult patients.

Interventions:

The study device was used to determine esophageal or endotracheal placement of endotracheal tubes in intubated patients. Clinical means were used to confirm tube location. A data sheet was completed for each patient.

Results:

Of 105 uses of the device, 17 of 17 esophageal tubes were identified correctly (100% sensitivity). Sixty-five of 88 tracheal tubes were correctly identified (78% specificity). There was intermediate reinflation of the device on 13 of the 65 tracheal tubes. Five tests were indeterminate. There were no false negatives (negative predictive value 100%), but 18 false positives (positive predictive value 48%).

Conclusion:

This prototype EDD adequately identifies esophageally placed endotracheal tubes. Correct identification of endotracheally placed tubes was less sensitive. Much work needs to be done regarding the use of negative aspiration devices to identify placement of endotracheal tubes.
Evaluation of Agricultural Rescue Course by Providers
Authors: Stueland Dean T. , McCarty John E. , Stamas Peter , Gunderson Paul D.
Published: July 2016

Study objective:

To assess the characteristics of rural emergency medical services providers involved in the prehospital care of victims of agricultural injuries and determine which aspects of an agricultural rescue course were perceived as most useful.

Design:

A questionnaire was sent to participants of a course designed for agricultural prehospital providers who had attended a farm accident rescue course between 1986 and 1993.

Setting:

A rural referral center in central Wisconsin.

Participants:

The questionnaire was sent to all persons who had participated in the course. Respondents to the questionnaire characterized their service experience and rated the topic areas in usefulness and whether the subject should be included in future courses.

Results:

A total of 459 surveys (44% of potential respondents) was returned. Of the respondents, 316 (74.4%) were men, and the mean age was 39.4 years. There were 247 (60.8%) who were volunteers, and an additional 126 (31%) were paid, on-call workers. There were 232 (56.4%) basic providers, and 365 (87.5%) were from a rural area. Many (n = 149; 36.9%) had not responded to farm accidents during the past year. Training course topics rated most useful were machinery extrication, tractor overturn, and enclosed-space rescue.

Conclusions:

Respondents to an evaluation of an agricultural rescue course primarily were rural, basic providers. Future development of courses for emergency medical technicians involved in agriculture rescue must account for this level of training. Such courses should be short and modular with an emphasis on continuing education, practice, and focus on the identified needs of the participants.
Does Basic life Support in a Rural EMS System Influence the Outcome of Patients with Respiratory Distress?
Authors: Brown Lawrence H. , Prasad N. Heramba , Whitley Theodore W. , Benson Nicholas H. , Corlette Adrian
Published: July 2016

Purpose:

The purpose of this study was to determine whether basic life support, prehospital emergency medical care in a rural area affects the hospital course of patients with respiratory distress.

Methods:

Medical records for patients admitted from the emergency department with a discharge diagnosis related to respiratory disease were reviewed. Data collected included: 1) mode of arrival; 2) initial symptom; 3) vital signs; 4) prehospital interventions applied; 5) hospital days; 6) discharge status; and 7) principal diagnosis. Multiple logistic regression analysis was used to predict length of hospital stay.

Results:

Charts for 603 patients were reviewed. Complete data for all variables included in the logistic regression analysis were available for 471 patients (78.1%). Because 55 patients died, only 416 (69.0%) were included in the multiple regression analysis conducted to predict length of hospital stay. Logistic regression analysis demonstrated that patients who arrived by ambulance and older patients were more likely to die; patients with higher systolic blood pressures were more likely to survive. Only patient age predicted length of hospital stay, with older patients having longer stays.

Conclusions:

Basic life support prehospital care in this rural emergency medical services system does not result in a lower mortality rate or a shorter hospital stay for a broad group of patients with respiratory distress who require hospital admission. Although this study is limited to a single population and a single emergency medical services system, it is one of only a few studies of outcome in basic life support systems.
Introduction to “Disaster Resuscitology”
Authors: Safar Peter
Published: July 2016

History of “Disaster Resuscitology.” The late Rudolf Frey, Professor of Anesthesiology at the Johannes Gutenberg University of Mainz, West Germany (see pages VIII-X), founded the “Club of Mainz” in September 1976, following initiating discussions with Peter Safar at the “International Symposium on Mobile Intensive Care and Advanced Emergency Medical Services (EMS) Delivery Systems” in September 1973 in Mainz (1), and the drafting of objectives and plans with the founding members in 1976 in Geneva and Mainz. Throughout the initiating discussions, Safar stressed the following: Presently active national and international disaster relief organizations are public health oriented. In mass disasters, such as major earthquakes, these organizations have been rendering effective aid to uninjured survivors, usually starting one day or later after the disaster event.
A Head Injury Animal Model: Physiological Studies of Mechanical Brain Injury in the Cat
Authors: Hayes R. L. , Pechura C. M. , Becker D. P.
Published: July 2016

Functional and structural disturbances of the brain produced by sudden impact to the skull represent a fundamental problem in neurosurgical treatment of head trauma. A proper experimental approach to brain trauma requires the development of an adequate animal model useful in defining both the biomechanical and physiological variables relevant to mechanical injury to the human central nervous system (CNS). The development of appropriate animal models has proved essential to progress in other clinically related research and is a prerequisite for the development of rational modes of diagnosis and treatment of head injury.
A Model for Evaluation of Disaster Management
Authors: Ricci Edmund M.
Published: July 2016

Our ability to manage disaster relief activities at regional, national or international levels of socio-political organization has, according to many analysts, not kept pace with the knowledge and technical capability presently available to contend with disasters. In a report released in 1977 a panel of experts assembled by the United Nations Association characterized disaster relief efforts as being routinely mismanaged. For example, the panel described what has been considered one of the better organized disaster relief efforts (the 1976 earthquake in Guatamala) in the following way.
Design of Clinical Trials
Authors: Detre Katherine M.
Published: July 2016

A Controlled Clinical Trial is the formal experimental approach to treatment evaluation. In such a trial, the investigator controls the assignment of treatments—ideally by randomization— to experimental groups. When well executed, such a trial provides the strongest evidence for the relative effectiveness of the different therapeutic interventions. Some people, myself among them, believe that the clinical trial approach should be used early when a new therapeutic modality is first introduced.

The purpose of a controlled clinical trial is to answer the question of whether the new therapy is preferable to standard therapies. If no standard therapy exists, then new therapy has to compete either with no treatment or placebo.
International Use of a Classification System for Evaluation of Outcome of Acutely Ill Patients
Authors: Knaus William A. , Le Gall Jean R. , Campos R. Abizanda , Nicolas Francoise , Granthil C. , Loirat Phillippe , Glaser Paul , Wattel Francis , Mercier Phillippe , Shin Baekhyo , Snyder James V. , Cullen David J. , Kohles Mary K. , Birnbaum Marvin L. , Draper Elizabeth A. , Wagner Douglas P.
Published: July 2016

Investigations describing the utilization pattern and comparing the outcome from emergency and mass casualty situations are limited by the lack of a reliable and valid patient classification system. In this study we briefly describe the use of APACHE (Acute Physiology and Chronic Health Evaluation), a physiologically based classification system for measuring severity of illness in groups of critically ill patients, as a tool in comparing outcomes of 1437 ICU admissions from eight European and five American hospitals. Because of the successful results from this pilot effort, we believe that APACHE could be used to compare the performance of hospitals in an emergency or mass casualty situation.
Measuring the Impact of Various Dispatching Procedures on Response Time, Backlog, Availability and Patient Care in an Urban Setting
Authors: DeLucia David , Pascarelli Emil
Published: July 2016

A study conducted by the Massachusetts Institute of Technology concluded that in a large city, a minimum of eight ambulances per 500,000 population was desirable to assure a reasonable response time.

How does a large city with less than this suggested minimum make best use of its available ambulance units ?

A three week study was conducted in New York City to examine the impact of various dispatching procedures on response time, “backlog”, availability of “back-up” units and patient care.
The Potential Impact of Cardiopulmonary Cerebral Resuscitation (CPCR) Education
Authors: Safar Peter
Published: July 2016

This is an introduction for a one-day CPCR course for intended instructors-coordinators. The course is a pilot project using a new manual. Its goal is to explore the feasibility of instructors using semi-self-training modes to acquire the necessary knowledge and skills for the organization of basic and advanced life support courses in CPR for all types of personnel, ranging from the lay public via ambulance personnel and nurses to physician generalists and physician specialists. The American Heart Association (AHA) CPR courses for instructors-to-be were originated in Pittsburgh in the early 1960s; this present course, sponsored by the World Federation of Societies of Anesthesiologists (WFSA) CPR Committee was given in 1981. The traditional 2 to 3 days CPR instructors' courses for physicians have spread knowledge and skills slowly. We believe that the dissemination and uniformity of resuscitation training could be enhanced by wider use of self-training systems, not only for doers but also instructors-to-be.
Decentralized Teaching in Emergency Medicine in a Thinly Populated Area in Norway
Authors: Hotvedt Ragnar , Gilbert Mads
Published: July 2016

Norway has fairly well developed primary health care. It is developed around general practitioners who, in their local regions, are responsible for total health care, including emergency medical care. During the last few years, there has been an increasing buildup of resources in the hospitals in the area. Modern technical equipment, increasing knowledge and practical training among the house physicians have greatly improved standards of CPR and emergency health service inside hospitals. Unfortunately, there has not been a proportional build up of resources, knowledge and practical skills in the districts and rural areas. An increasing gap between the treatment offeredinsideandoutsidehospitals has developed.
Operational Medicine: Specialized Emergency Medicine Training
Authors: Vaughn Prentis B.
Published: July 2016

The discipline of emergency medicine includes the field of disaster medicine. Unfortunately, little actual emphasis is placed upon this vital area of training in emergency medical residency programs aside from nominal involvement in mock hospital-community disaster drills and triage exercises. In addition to these important areas of disaster medicine, physicians must be knowledgeable in field medical sanitation, environmental illnesses, ground and aero-medical evacuation, epidemiology and logistics in addition to hands on emergency medical casualty care. To better serve this important neglected area of the emergency medicine residency curriculum, we developed a one-month block of instruction.

The operational medicine course is composed of separate instructional modules. The emphasis of the field medical training is obviously a military one; however, that emphasis is easily translated into a field medical environment, one that is commonly employed in military disaster relief operations. The American armed forces, particularly the US Army, frequently come to the aid of victims of both civil and natural disasters. This humanitarian assistance also serves the readiness training goals of the Army Medical Department during peacetime.
Physician Leadership of Emergency Medical Services (EMS)
Authors: Nagel Eugene
Published: July 2016

I would hope that there is no question regarding the need for physician leadership in an EMS system; and that the question, if there is any, concerns the amount required, where it is to be applied, and its quality. EMS, I would remind you, stands for emergencymedicalservices. Medical delivery systems, in my opinion, require physicians for their design and implementation. That does not mean that all the services have to be delivered by physicians, but they need physician leadership.

If this outlines the area of physician authority, then there is by definition a concomitant responsibility—authority without responsibility would be tyranny. The responsibility should provide an appropriate level of medical care that is current in concept, appropriate to the needs, considerate of the resources available, and coherent with the overall health care system. It must not be just an isolated EMS system.
Burn Mass Casualty Management: Lessons Learned
Authors: McManus William F.
Published: July 2016

Successful management of a mass casualty situation involving 45 injured marines following a fire in Japan demonstrates the important principles of triage, patient movement, quality patient care, logistics, communication and medical direction.

Following the accident, the US Army Institute of Surgical Research assembled a burn team consisting of three surgeons, three nurses, one microbiologist and eleven clinical specialists (three of whom were inhalation therapy technicians) and the equipment and supplies necessary to treat and transport these patients. The US Air Force Military Airlift Command transported the team and equipment to Japan in a C–141 Starlifter Medevac plane and pre-positioned a second C–141 in Japan for the return flight. Additional ventilators and supplies were mobilized from Japan, Okinawa, the Philippines and Alaska.
Chilean-Pan American Project of Emergency and Critical Care for Infants (Progressive Care)
Authors: Caballero Rodrigo Miranda
Published: July 2016

The following papers, submitted in Spanish, may be obtained directly from the author (Telephone: 258458):

1. Manejo de Emergencias y Accidentes en el nino. Reanimacion Cardiopulmonar Cerebral en un Sistema de Cuidado Progressivo.

2. Programma Asistencial Docente de Medicina Urgencia-Primeros Auxilios y Cuidado Intensivo.

3. Proyecio Chileno-Panamericano Sobre Prevencion y Manejo de Emergencias y Accidentes en la Infancia. Sistema de Atencion Progresiva.
Irreversible Hemorrhagic Shock Model in the Monkey
Authors: Bar-Joseph Gad , Safar Peter , Stezoski William S.
Published: July 2016

In spite of extensive research, the question of fluid therapy for hemorrhagic shock is still controversial. Certain drawbacks in the experimental models are among the reasons for this controversy. These drawbacks are mainly related to the animal species used, to the way the shock insult is initiated and to the effects of deep anesthesia on the response to shock.

Dogs were used in more than 90% of shock studies—although their response to bleeding is different from the human response. The dog has a large, contractile spleen, which can modify its cardiovascular response to bleeding.
Blood Volume Substitutes in Emergency Care
Authors: Müller-Suur Niels , Kleeman Peter P. , Brost Frank , Halmagyi Miklos P.B.
Published: July 2016

Volume substitutes for restoring circulating blood volume are eminently important for emergency care. In addition to side effects, the intravascular volume effect immediately after infusion and the duration of this volume effect are determining factors for the selection of volume replacement solutions available on the market today. Therefore, we controlled the intravascular volume effect of 16 test solutions, immediately as well as 90 and 240 min after the end of infusion.
Advantages of Resuscitation with Balanced Hypertonic Sodium Solution in Disasters
Authors: Civetta Joseph M. , Fox Charles L.
Published: July 2016

Resuscitation in disasters must be effective, prompt, safe and uncomplicated. Clinical experience in severe, extensive thermal burns in numerous clinics has shown that balanced hypertonic sodium solution (BHSS) can achieve effective resuscitation with: administration of less volume of fluid; early onset of excretion of sodium-containing urine; less generalized edema and without pulmonary edema. This experience is now being transferred to patients after trauma and major surgical procedures often complicated by peritonitis. In an ongoing study of randomly selected adults following surgical trauma, either Ringer's lactate (RL) or the BHSS (0.9% NaCl plus 100ml of one molar sodium acetate, total 1100ml yielding Na230, Cl 140, acetate 90mEq/l) was administered. All patients received daily (or more frequent) electrolyte and osmotic analyses of plasma and urine, continuous ICU monitoring of pulmonary and cardiac function, and similar wound care.
Total Parenteral Nutrition in Critical Polytrauma Patients. Effects of Essential Aminoacid Distribution.
Authors: Magalini Sergio I. , Proietti Rodolfo , Pelosi Giuliano
Published: July 2016

Previous work of our group and data from the literature show that in the polytraumatic patient the metabolic status is characterized by a severe and persistent catabolic situation involving carbohydrate, protein, lipid, mineral metabolism and hormonal and chemical mediators. This situation is clinically expressed by the so-called “post stress syndrome.”

Total parenteral nutrition has assumed a major role in the treatment of polytrauma patients and its application has produced a significant modification of the physiopathological evolution and improvement of the clinical outcome.
Heimlich's Maneuver — Pros and Cons
Authors: Wedel Karl-Wilhelm
Published: July 2016

In early 1975, H.J. Heimlich demonstrated external compression of the diaphragm as a first-aid measure in the event of threatening death by suffocation.

A controversial debate developed in the ensuing years. What speaks infavorof the so-called “Heimlich Maneuver,” which should be applied only when:

• the foreign substance sits too deep or too tight to be removed by other means; and

• the trachea is completely closed by the foreign substance and breathing has ceased entirely,

is the dramatic situation which leaves a helper only a few minutes to save life in view of imminent unconsciousness and threatening hypoxic cardiac arrest.

What speaksagainstapplying the maneuver are possible lesions of the intrathoracic organs (including fractures of the osseous thorax) and ruptures of internal organs, also the application without an existing indication or inadequate mastery of the manipulation.
High Frequency Jet Ventilation Versus IPPV for CPR in Dogs
Authors: Brader Eric , Klain Miroslav , Safar Peter , Bircher Nicholas
Published: July 2016

Investigation of High Frequency Jet Ventilation (HFJV) for cardiopulmonary resuscitation (CPR) was initiated to determine whether HFJV may be used as an alternative to conventional intermittent positive pressure ventilation (IPPV) and also to determine whether HFJV may be employed in CPR if cardiac arrest should occur during use of HFJV.

The novel method of HFJV has several advantages over conventional ventilation, namely low airway pressure, no hemodynamic impairment and no need for muscle paralysis. Transtracheal HFJV offers in addition cricothyroid membrane puncture as a fast alternative to tracheal intubation in cases of difficult airway control. It is able to prevent aspiration, and allows direct intrapulmonary drug administration.
Intrapulmonary Drug Administration during High Frequency Jet Ventilation
Authors: Klain M. , Keszler H. , Nordin U. , Kalla R.
Published: July 2016

It has previously been demonstrated that high frequency jet ventilation, via transtracheal cricothyroid membrane puncture, can maintain good gas exchange even during cardiopulmonary resuscitation. When the upper airways were filled with fluid, aspiration could be prevented without a cuffed endotracheal tube when respiratory rates of 100/min or higher and an inspiratory time of at least 50% were used. We have also shown that cricothyroid membrane puncture is relatively easy to perform and produces less tracheal damage than a cuffed endotracheal tube.

In one of our studies, cardio-green dye was mixed into the jet using a Y-connector on the proximal end of the angiocath cannula (Figure 1). In two dogs, the distribution of the dye in the lungs was investigated. It was found that nebulized dye was transported by the jet stream to the most distant bronchi which could be observed. On subsequent autopsy, the dye was found in the most peripheral airways.
A Comparison of Standard and “New” Cardiopulmonary Resuscitation (CPR) in Dogs
Authors: Bircher Nicholas G. , Safar Peter
Published: July 2016

Standard CPR, consisting of 60 chest compressions per min with a ventilation interposed after every fifth compression, often allows restoration of spontaneous circulation but cannot be relied upon to preserve the brain during resuscitation attempts. In experimental models, it produces only one-third to one-half of normal cerebral blood flow and cannot sustain EEG activity. Many attempts have been made to augment overall cardiac output during CPR and presumably thereby increase cerebral blood flow. Crile used a pneumatic pressure suit to bind the abdomen and legs, but subsequent investigations found a high risk of hepatic trauma with abdominal binding. Both Wilder and Harris showed in dogs that simultaneous ventilation and compression augment carotid flow. Birch showed in an animal model that prolonged compression increased mean arterial pressure during CPR. Weisfeldt and colleagues of Baltimore have recently extended these findings to man, and combined them into a so-called “New” CPR, which consists of:

a) high pressure ventilation simultaneous with sternal compression;

b) 40 compressions per min;

c) 60% compression duration; and

d) abdominal binding.
A New Automatic Resuscitator for Hospital and Emergency
Authors: Tonczar Laszlo
Published: July 2016

We could obtain good results similar to other groups with a device for cardiac compression and automatic ventilation during CPR. The following paper will not discuss the experience with such a device, but the further development and improvement of a device already used and found to be useful.

The further development seemed to be necessary since we tried to utilize new hemodynamic results important for external cardiac compression and ventilation. Other reasons were problems occurring with its practical use.
Automatic Implanted Defibrillator — Initial Clinical Experience
Authors: Mirowski M. , Reid Philip R. , Mower Morton M. , Langer Alois , Heilman M. S. , Kolenik Steve A.
Published: July 2016

The automatic implantable defibrillator is an electronic device designed to continuously monitor cardiac rhythm, identify ventricular fibrillation and deliver corrective defibrillatory discharges, when indicated. Physically similar to early pacemakers, it weights 250 grams and has a volume of 145 cc (Figure 1). All materials in contact with body tissue are biocompatible. The defibrillating electrodes are made from titanium and silicone rubber. One electrode, designed for placement in the superior vena cava near the right atrial junction, is located on the distal end of an intravascular catheter. The second electrode, in the form of a flexible rectangular patch, is placed extrapericardially over the apex of the heart. The outside surface of the apical electrode is insulated to achieve optimal current distribution.

The device is powered by lithium batteries having a projected monitoring life of approximately 3 years or a discharge capability of approximately 100 shocks. The sensing system detects ventricular fibrillation by monitoring a sampled probability density function of ventricular electrical activity.