bluuebunny/crossref_metadata_2025 huggingface dataset:
Emergency Medical Services During the Siege of Sarajevo, Bosnia and Herzegovina: A Preliminary Report
Authors: Pretto Ernesto A. , Begovic Mirsada , Begovic Mirza
Published: July 2016

Background:

The siege of Sarajevo is a longterm, human-made, medical disaster of international significance. The delivery of emergency health care provided to the large civilian population held captive in that war zone for an extended time was studied.

Methods:

In May 1993, a humanitarian and fact-finding visit to Sarajevo was conducted. Physicians, administrators, and public health officials were interviewed; epidemiological data were acquired—the resuscitation of war casualties at the two largest hospitals were observed; and local published reports and videotaped footage on the organization and delivery of prehospital and hospital care were reviewed. The videotapes also served to document war crimes.

Results:

Daily bombardment and sniper fire directed at civilians have caused a steady stream of casualties (64,130, or an average of 119 killed or injured per day in 18 months). Eighty percent of the victims were civilian. Despite hazardous conditions from direct shelling, disruption of vital lifelines, and shortage of supplies, medicines, oxygen, and anesthetics, the physicians continue to provide at least a minimum standard of resuscitative care. Seventy percent of all war victims were transported to hospitals in private vehicles. Most casualties (93%) received some form of prehospital, basic first-aid from lay bystanders or first responders. From November 1992 to February 1993, 27,733 patients were treated in hospitals, resulting in 2,139 major surgical procedures. The primary cause of death in 71 of 273 victims was prolonged hemorrhagic, hypovolemic shock. Sixty-one percent of these victims died within 24 hours of injury.

Conclusions:

Continuous needs assessment be accompanied by rapid delivery of outside aid. International “peacekeeping” forces should protect hospitals and their staffs, and ensure the entry of supplies and evacuation of some patients. A public trained in life-supporting first-aid, and physicians and paramedics with experience in advanced life support may have enhanced lifesaving efforts in Sarajevo.
Effects of EMS Transportation on Time to Diagnosis and Treatment of Acute Myocardial Infarction in the Emergency Department
Authors: Swor Robert , Anderson William , Jackson Raymond , Wilson Andrew
Published: July 2016

Introduction:

Recent studies have documented decreased time to emergency department (ED) thrombolytic therapy with the use of prehospital electrocardiography.

Purpose:

Is the time to ED diagnosis and treatment of acute myocardial infarction (AMI) patients with thrombolytic agents decreased by emergency medical services (EMS) transport when compared with those transported by other means (non-EMS)?

Design:

Retrospective, case-control study

Population:

The AMI patients treated with thrombolytic agents at a 34,000-visit, community hospital ED during 1992.

Methods:

Review of records of patients who received thrombolytic therapy for AMI. Statistical analysis was performed using “Student's” t-test and Yates corrected Chi-square (X2).

Results:

Eighty-seven patients received thrombolytic agents for AMI during 1992; 33 arrived by ambulance, 54 arrived by other methods. There were no differences in age, gender, or time of ED arrival among these groups. Ambulance patients received standard advanced life support (ALS) care, but not a 12-lead electrocardiogram (ECG) or thrombolytic agents. Ambulance patients experienced a significantly shorter time to first ECG (12.9 ±9.1 min. versus 20.8 ±25.3 win.; p = .028) and received thrombolytic therapy sooner than did controls (56.0 ±31.5 min. versus 78.0 ±63.4 min.; p = .018). There was no difference in time from diagnosis to treatment between these groups.

Conclusion:

Emergency medical services transport of AMI patients in this study decreased time to diagnosis and treatment and may be a confounder in studies that assess the value of field EMS interventions. Non-EMS AMI patients did not receive as rapid diagnosis and treatment, and emergency physicians should evaluate and address this issue in their departments.
Determinants of On-Scene Time in Injured Patients Treated by Physicians at the Site
Authors: Sampalis John S. , Lavoie André , Salas Maribel , Nikolis Andreas , Williams Jack I.
Published: July 2016

Introduction:

The controversy surrounding the use of advanced life support (ALS) for the prehospital management of trauma pivots on the fact that these procedures could cause significant and life-threatening delays to definitive in-hospital care.

In Montreal, Québec, on-site ALS to injured patients is provided by physicians only. The purpose of this study was to identify parameters associated with the duration of scene time for patients with moderate to severe injuries treated by physicians at the scene.

Hypothesis:

The use of on-site ALS by physicians is associated with a significant increase in scene time.

Methods:

A total of 576 patients with moderate to severe injuries are included in the analysis. This group was part of a larger cohort used in the prospective evaluation of trauma care in Montreal. Descriptive statistics, analysis of variance, multiple linear regression, and multiple logistic regression techniques were use to analyze the data.

Results:

Use of ALS in general was associated with a statistically significant increase in the mean scene time of 6.5 min. (p = .0001). Significant increases in mean scene time were observed for initiation of an intravenous route (mean = 6.6 min., p = .0001), medication administration (mean =5.7 min., p = .0001), and pneumatic antishock garment (PASG) application (mean = 9.3 min., p = .03). Similar differences were observed for total prehospital time. A significant increase in the relative odds for having long scene times (>20 min.) also was associated with the use of ALS. This level of scene time was associated with a significant increase in the odds of dying (OR = 2.6, p = .009).

Conclusion:

This study shows that physician-provided, on-site ALS causes significant increase in scene time and total prehospital time. These delays are associated with an increase in the risk for death in patients with an severe injuries.
Saline Locks in Prehospital Care
Authors: Boyle Michael F. , Kuntz Brian
Published: July 2016

Objectives:

1) To determine if paramedics could select appropriate patients for use of the saline lock; 2) to evaluate saline-lock patency upon arrival at the emergency department (ED); and 3) to define any cost-savings associated with the use of the saline lock.

Population:

Patients in the prehospital setting who required intravenous (IV) access, but did not require fluid resuscitation. Patients with hypotension or multiple traumatic injuries were excluded.

Methods:

Paramedics were given the option for the use of either the saline lock or a routine IV set-up. Initially, the reservoir was flushed with 1 ml 0.9 N saline solution and the flush was repeated only if medications subsequently were completed for each patient. Information collected included: 1) demographics; 2) reason for selection; 3) need for fluid infusion; 4) conversion of the lock to a routine IV set-up; and 5) administration of medications through the lock. Failures included inability to flush after arrival to the ED, or local infiltration detected on flush while in the ED. Costs associated with the use of the saline locks were compared with those associated with the use of traditional IV set-ups. Cost-savings were calculated as the cost of a traditional IV set-up minus costs of the lock set-up.

Results:

A total of 58 male and 42 female patients was enrolled. All patients were assigned appropriately. The most commonly used indications included chest pain, possible stroke, and shortness of breath. Two locks were occluded, and two had infiltrated when flushed following arrival of the patient to the ED. Five patients had IV fluid bads initiated through the locks. Cumulative cost-saving were [U.S.]$130 to the hospitals and $1,710 to the patients or their carriers. Most paramedics were pleased with the performance and utility of the locks.

Conclusions:

The use of saline locks is an alternative to the use of traditional IVs in certain patients in the prehospital setting.
Teaching Basic EMTs Endotracheal Intubation: Can Basic EMTs Discriminate between Endotracheal and Esophageal Intubation?
Authors: Sayre Michael R. , Sakles John , Mistler Alan , Evans Janice , Kramer Anthony , Pancioli Arthur M.
Published: July 2016

Hypothesis:

Advanced airway intervention techniques are being considered for use by basic emergency medical technicians (EMTs). It was hypothesized that basic EMTs would be able to discriminate reliably between intratracheal and esophageal endotracheal tube, placement in a mannequin model.

Design:

An airway mannequin with a closed chest cavity was intubated randomly either esophageally or tracheally, and the cuff was inflated. A stethoscope, bag ventilator, and laryngoscope were available next to the mannequin. Placement was assessed by auscultation or direct visualization at the discretion of the EMT. A blinded investigator graded the student.

Setting:

A classroom in a large, urban medical center.

Participants:

Subjects were basic EMTs who volunteered to take part after the conclusion of a six-hour endotracheal intubation training course.

Results:

Thirty-three subjects were tested. Seventeen of 18 (94%) tracheal intubations and 11 of 15 (73%) esophageal intubations were identified correctly. Only 72% of the students listened to the epigastrium, 81% listened to the lungs, and 85% attempted ventilation. The 10 students who visualized the cords discovered all five esophageal intubations. The 23 students who did not visualize the cords missed four and found six esophageal intubations.

Conclusion:

Basic EMTs had difficulty assessing endotracheal tube placement in a mannequin model. The 27% miss rate for identifying esophageal intubations suggests that basic EMTs will require additional training for safe field use of any airway that requires assessment of tube placement.
Complex, Humanitarian Emergencies: III. Measures of Effectiveness
Authors: Burkle Frederick M. , McGrady Katherine A.W. , Newett Sandra L. , Nelson John J. , Dworken Jonathan T. , Lyerly William H. , Natsios Andrew S. , Lillibridge Scott R.
Published: July 2016

Complex humanitarian emergencies lack a mechanism to coordinate, communicate, assess, and evaluate response and outcome for the major participants (United Nations, Intenational Committee of the Red Cross, non-governmental organizations and military forces). Success in these emergencies will depend on the ability to accomplish agreed upon measures of effectiveness (MOEs). A recent civil-military humanitarian exercise demonstrated the ability of participants to develop consensus-driven MOEs. These MOEs combined security measures utilized by the military with humanitarian indicators recognized by relief organizations. Measures of effectiveness have the potential to be a unifying disaster management tool and a partial solution to the communication and coordination problems inherent in these complex emergencies.
The Use of Intraperitoneal Infusion for the Outpatient Treatment of Hypovolemia in Somalia
Authors: VanRooyen Michael J. , VanRooyen Julia B. , Sloan Edward P.
Published: July 2016

Introduction:

The civil war in Somalia has destroyed the medical system and left hundreds of thousands of people without access to medical care. Samaritan's Purse and World Medical Missions, two relief organizations, developed mobile medical teams to provide health care to urban and rural Somalia. Gastroenteritis with severe dehydration was encountered frequently, and difficult intravenous (TV) access presented a challenging dilemma for patients who were unable to tolerate oral or nasogastric fluid administration.

Hypothesis:

Intraperitoneal (IV) fluid infusion may be used to treat dehydration in patients with poor venous access and ongoing fluid losses.

Methods:

Two mobile medical teams treated patients from 1 January to 1 April 1993. Intraperitoneal fluid infusions were given to 16 patients with severe dehydration in whom IV access was unobtainable. Children received approximately 80 ml/kg of 0.45% normal saline, and adults received 40 ml/kg of 0.9% normal saline. Patients were reexamined at one and seven days.

Results:

A total of 25,659 patients were seen in the mobile medical clinics during a 3-month period. Dehydration was diagnosed in 1,833 (7.1%) patients, and 1,203 (4.7%) patients were found to be malnourished. Sixteen patients were treated with IP fluid infusions, 14 patients (87.5%) survived, and two patients (12.5%) died, both within 24 hours. In one patient (6.3%), subcutaneous infiltration occurred without subsequent adverse effects.

Conclusion:

This case series found that in the mobile clinic setting in Somalia, IP fluid administration improved the hydration status in patients with significant dehydration. Although IV infusion remains the treatment of choice when oral or nasogastric fluid administration is not possible, IP infusion is easily performed and may be an important alternative in disaster setting.
Successful Resuscitation of a Child with Severe Hypothermia after Cardiac Arrest of 88 Minutes
Authors: Schmidt Ulf , Fritz Karl-Wilhelm , Kasperczyk Wolfgang , Tscherne Harald
Published: July 2016

A 4-year-old boy broke through the ice of a frozen lake and drowned. The boy was extricated from the icy water by a rescue helicopter that was dispatched shortly after the incident. Although the boy was severely hypothermic, no cardiac response could be induced with field resuscitation measures, including intubation, ventilation, suction, and cardiopulmonary resuscitation.

On admission, the primary findings included fixed, nonreacting pupils and asystole. The first core temperature measured was 19.8° C (67.6° F). During active, external warming, the first ventricular beats were observed 20 minutes after admission, and changed 10 minutes later to a sinus rhythm. Continuous monitoring included repeated arterial blood gas and electrolyte tests; prophylaxis for cerebral edema was performed with hyperventilation and administration of sodium Brevimytal and dexamethasone. Seventy minutes after admission, hemodynamics stabilized and the boy was transferred to the pediatric intensive care unit (PICU), where active external warming was continued to raise the core temperature at a rate of 1° C/hour.

Adult respiratory distress syndrome developed, and the boy had to be ventilated in the PICU for 10 days. He was discharged home after another two weeks. He recovered fully. The rapid heat loss with the induction of severe hypothermia (<20° C; 68° F) was the main reason for survival in this rare event of a patient with cardiac arrest lasting 88 minutes after accidental hypotherma.
Case Law Involving Base-Station Contact
Authors: Shanaberger Carol J.
Published: July 2016

Introduction:

Although general discussions of legal claims against emergency medical services (EMS) have been published, there is no literature that examines legal claims that specifically have involved base-station contact for direct medical control.

Methods:

A review of case law through July 1994 was conducted to identify cases that involved radio communications between a prehospital provider and a physician or nurse under the direction of a physician.

Results:

Only eight cases could be identified. Each case is described in terms of the event, selected pertinent legal issues, and the opinions rendered by the court.

Conclusions:

These few cases illustrate some important observations that indicate that there will occur an increase in the detail, role delineation, and clarification of the prehospital providers, medical directors, base-station physicians, and others who provide direct medical control to prehospital EMS providers. These findings have important implications for EMS medical directors.
Assessment of Pulmonary Mechanics and Gastric Inflation Pressure During Mask Ventilation
Authors: Weiler Norbert , Heinrichs Wolfgang , Dick Wolfgang
Published: July 2016

Introduction:

Mask ventilation is a procedure routinely used in emergency medicine. Potential hazards are inadequate alveolar ventilation and inflation of the stomach with air, leading to subsequent regurgitation and aspiration. The aim of this study was to measure lung function and gastric inflation pressures during mask ventilation.

Methods:

For this purpose, 31 patients scheduled for routine urological procedures were studied during induction of anesthesia. Lung function was assessed by recording respiratory flow and pressure directly at the face mask. Gastric inflation was observed with a microphone taped to the epigastric area.

Results:

Gastric inflation occurred in 22 of the 31 patients. Mean gastric inflation pressure was 27.5 ±6.55 cm H2O, mean compliance was 67 ±24.1 ml/cm H2O, mean resistance was 17.4 ±6.41 cm H2O/L/sec, and the mean respiratory time constant was 1.1 ±0.26 seconds.

Conclusions:

These data suggest that inspiratory pressure be limited to 20 cm H2O, and that an inspiratory time of at least four times the respiratory time constant be allowed. Monitoring airway pressure and gastric inflation is a simple technique that may improve the safe-ty of patients during mask ventilation.
Mistaken Identity: The Effect of Badges on EMT Recognition
Authors: Brown Lawrence H. , Waldman Jeff , Copeland Terry W. , Smithson William E. , Prasad N. Heramba
Published: July 2016

Introduction:

Many emergency medical services (EMS) providers wear badges with their uniforms. This study was undertaken to determine whether emergency medical technicians (EMTs) who wear badges with their uniforms are more likely to be mistaken for law enforcement personnel than are those who do not wear badges.

Hypothesis:

Emergency medical services providers who wear badges are more likely to be mistaken for law enforcement personnel than are those who do not wear badges.

Methods:

High school students, college students, civic organizations, and church groups were shown slides of different uniforms and badges/insignia and asked to identify the person portrayed. Responses were categorized as “EMS,” “law enforcement,” or “other.” Frequency of responses for each uniform and insignia were compared with chi-square analysis.

Results:

Fifty-nine percent of the uniforms with badges were identified as law enforcement personnel. Only 5.5% of the uniforms with badges were identified as “EMS,” compared with 74% of the uniforms with a Star of Life (p<0.001).

Conclusion:

Individuals wearing uniforms with badges are more likely to be identified as law enforcement personnel than are EMS personnel. Emergency medical services providers who do not wish to be mistaken for law enforcement personnel should wear the Star of Life, not a badge, with their uniform.
Paramedic Diagnostic Accuracy for Patients Complaining of Chest Pain or Shortness of Breath
Authors: Schaider Jeffrey J. , Riccio John C. , Rydman Robert J. , Pons Peter T.
Published: July 2016

Introduction:

A multitude of life-threatening and nonlife-threatening processes cause chest pain and shortness of breath. Prehospital therapy for these patients may be lifesaving and includes pharmacologic interventions, as well as invasive procedures. Appropriate therapy depends on the diagnostic skills of the paramedic.

Objective:

This study was undertaken to determine the accuracy of the paramedic diagnosis in patients transported with a chief complaint of pain or shortness of breath.

Setting:

Multihospital, one large municipal hospital, one community hospital.

Design:

Prospective, cross-sectional study. Paramedics evaluated the patient and then completed a standard form indicating the diagnosis. The paramedic's and final emergency physician's diagnoses were compared to assess the accuracy of the paramedic diagnosis.

Population:

All patients who complained of chest pain or shortness of breath, transported to the study centers by the city of Denver paramedia, were eligible for the study. Ninety-nine of the 102 patients enrolled had complete records for analysis and were entered into the study.

Results:

Diagnostic concordance data were analyzed by organ system (e.g., cardiac, pulmonary, etc.) and for specific diagnoses using the kappa statistic and McNemar's chi-square analysis for discordant pairs. Using the kappa statistic, there was statistically significant concordance between the paramedic and emergency-physician diagnosis for cardiac (p = 0.0001; kappa value = 0.54) and pulmonary organ systems (p = 0.0001; kappa value = 0.61). Overall, for organ system diagnosis, the paramedics had an 82% accuracy (p = 0.05) rating. For specific cardiac and pulmonary diagnosis, paramedics had good concordance with emergency physicians.

Conclusions:

Overall, paramedia have excellent diagnosis by organ system. They retained good agreement on specific cardiac diagnoses and pulmonary diagnosis.
Use of On-Line Medical Command to Randomize Patients in a Prehospital Research Study
Authors: Tortella Bartholomew J. , Lavery Robert F. , Quadrel Mark , Cody Ronald P. , Heyt Greg
Published: July 2016

Objective:

To describe the efficiency of using on-line medical command (OLMC) to conduct a prospective, randomized clinical trial addressing safety and patient enrollment.

Design, Setting, and Participants:

Prospective design using OLMC to randomize adult asthmatics into one of three treatment groups. After verifying inclusion and exclusion criteria, OLMC physicians removed a covering label on study sheets and ordered the treatment specified underneath the label that had been assigned in a random sequence.

Results:

A total of 204 patients were seen with dyspnea and wheezing during the three-month study. Of these, 68 (33%) were excluded from the study. Of the 136 (67%) patients who were eligible for study, 87 were enrolled (enrollment efficiency 64%), with 79 fully evaluable (evaluable efficiency 91%). The study safety was 100% because no enrolled patients met any exclusion criteria.

Conclusions:

The design was random and prospective, with patient entry blinded, using paramedics to enroll patients and OLMC physicians as gatekeepers, thus ensuring appropriate patient eligibility and study-arm assignment. Use of OLMC physicians to perform prospective randomized studies is safe and efficient, and results in a high yield of evaluable patients.
The Esophageal Detector Device: Accuracy and Reliability in Difficult Airway Settings
Authors: Kapsner Christopher E. , Seaberg David C. , Stengel Charles , Ilkhanipour Kaveh , Menegazzi James
Published: July 2016

Introduction:

The esophageal detector device (EDD) recently has been found to assess endotracheal (ET) tube placement accurately. This study describes the reliability of the EDD in determining the position of the ET tube in clinical airway situations that are difficult.

Methods:

This was a prospective, randomized, single-blinded, controlled laboratory investigation. Two airway managers (an emergency-medicine attending physician and a resident) determined ET-tube placement using the EDD in five swine in respiratory arrest. The ET tube was placed in the following clinical airway situations: 1) esophagus; 2) esophagus with 1 liter of air instilled; 3) trachea; 4) trachea with 5 ml/kg water instilled; and 5) right mainstem bronchus. Anatomic location of the tube was verified by thoracotomy of the left side of the chest.

Results:

There was 100% correlation between the resident and attending physician's use of the EDD. The EDD was 100% accurate in determining tube placement in the esophagus, in the esophagus with 1 liter of air instilled, in the trachea, and in the right mainstem bronchus. The airway managers were only 80% accurate in detecting tracheal intubations when fluid was present.

Conclusions:

The EDD is an accurate and reliable device for detecting ET-tube placement in most clinical situations. Tube placement in fluid-filled trachea, lungs, or both, which occurs in pulmonary edema and drowning, may not be detected using this device.
AIDS and Prehospital Personnel: Knowledge and Prevention of Occupational Exposure
Authors: Gellert George A. , Maxwell Roberta M. , Higgins Kathleen V. , Barnard Rebecca , Page Brandon
Published: July 2016

Objectives:

Prehospital personnel, including law enforcement officers, paramedics, and fire-fighters, may be exposed to the human immunodeficiency virus (HIV) while working. This study of prehospital personnel sought to determine: 1) their knowledge of the acquired immune syndrome (AIDS) and HIV transmission; 2) the extent of AIDS training received; 3) self-assessment of risk for HIV infection; and 4) precautions adopted to reduce occupational risk of exposure to HIV.

Methods:

A survey was administered to prehospital personnel in a large Southern California jurisdiction. The response rate was 41% (n = 1,756) in 10 city and county departments where respondents were employed. Law enforcement officers (44%), firefighters (44%), and paramedics (12%) comprised the sample.

Results:

Respondents had accurate knowledge about AIDS, but incorrect perceptions about HIV transmission. A minority believed that HIV could be contracted from casual contact. Training relating to AIDS was not frequent. Preventive practices were infrequent in the work setting, with precautions used less than 50% of the time on eight of 10 measures. One-third of these prehospital personnel assessed their risk for HIV infection as medium to high, largely attributable to fear of occupational exposure.

Conclusions:

Improved educational programs regarding HIV/AIDS are needed for prehospital personnel to increase the use of preventive occupational practices in the field.
Disaster Triage: START, then SAVE—A New Method of Dynamic Triage for Victims of a Catastrophic Earthquake
Authors: Benson Mark , Koenig Kristi L. , Schultz Carl H.
Published: July 2016

Triage of mass casualties in situations in which patients must remain on-scene for prolonged periods of lime, such as after a catastrophic earthquake, differs from traditional triage. Often there are multiple scenes (sectors), and the infrastructure is damaged. Available medical resources are limited, and the time to definitive care is uncertain. Early evacuation is not possible, and local initial responders cannot expect significant outside assistance for at least 49–72 hours. Current triage systems are based either on a shorter time to definitive care or on a longer time to initial triage.

The Medical Disaster Response (MDR) project deals with the scenario in which specially trained, local health-care providers evaluate patients immediately after the event, but cannot evacuate patients to definitive care. For this type of scenario, a dynamic triage methodology was developed that permits the triage process to evolve over hours or even days, thereby maximizing patient survival and resulting in a more efficient use of resources. This MDR system incorporates a modified version of “Simple Triage and Rapid Treatment” (START) that substitutes radial pulse for capillary refill, coupled with a system of secondary triage termed, “Secondary Assessment of Victim Endpoint” (SAVE).

The SAVE triage was developed to direct limited resources to the subgroup of patients expected to benefit most from their use. The SAVE assesses survivability of patients with various injuries and, on the basis of trauma statistics, uses this information to describe the relationship between expected benefits and resources consumed. Because early transport to an intact medical system is unavailable, this information guides treatment priorities in the field to a level beyond the scope of the START methodology.

Pre-existing disease and age are factored into the triage decisions. An elderly patient with burns to 70% of body surface area is unsalvageable under austere field conditions and would require the use of significant medical resources—both personnel and equipment—and would be triaged to an “expectant area.” Conversely, a young adult with a Glasgow Coma Scale score of 12 who requires only airway maintenance would use few resources and would have a reasonable chance for survival with the interventions available in the field, and would be triaged to a “treatment” area.

The START and SAVE triage techniques are used in situations in which triage is dynamic, occurs over many hours to days, and only limited, austere, field, advanced life support equipment is readily available. The MDR-SAVE methodology is the first systematic attempt to use triage as a tool to maximize patient benefit in the immediate aftermath of a catastrophic disaster.
An Attempt at More Accurate Estimation of the Number of Ambulances Needed at Disasters in The Netherlands
Authors: de Boer Jan
Published: July 2016

A more accurate estimate of the number of ambulances needed at disasters prevents vehicles from being withdrawn unnecessarily from their “normal” duties, thereby curtailing needless expense and helping to ensure that disaster sites are not overcrowded with emergency workers impeding each other's effectiveness. This article discusses a formula for determining the number of ambulances needed at a disaster.
A Decentralized Trauma System Design for a Rural Area
Authors: Narad Richard A. , Becker Jack L. , Frecceri Christy
Published: July 2016

Most trauma-care systems are based on an urban model in which patients are found in sufficient proximity to the trauma center to allow preferential triage. The roles of other hospitals in the community are limited. In rural areas, patients may be remote from the trauma center and may require initial stabilization at a closer, nontrauma “center” designated hospital. An inclusive trauma system design is more appropriate in such situations.

The Emergency Department Approved for Trauma (EDAT) is a program implemented in a rural area of northeastern California that establishes minimum standards for non-trauma center designated hospitals in remote areas. It integrates these hospitals into the trauma system through transfer guidelines and agreements and participation in systemwide quality assurance/improvement programs. The EDAT program promotes both improved initial treatment of rural trauma patients and appropriate transfer of patients to designated trauma centers.
Relevant in Times of Turmoil: WHO and Public Health in Unstable Situations
Authors: Loretti Alessandro , Leus Xavier , Van Holsteijn Bart
Published: July 2016

For millions of people world-wide, surviving the pressure of extreme events is the predominant objective in daily existence. The distinction between natural and human-induced disasters is becoming more and more blurred. Some countries have known only armed conflict for the last 25 years, and their number is increasing. Recently, humanitarian sources reported 24 ongoing emergencies, each of them involving at least 300,000 people “requiring international assistance to avoid malnutrition or death”. All together, including the countries still only at risk and those emerging from armed conflicts, 73 countries, i.e., almost 1.8 trillion people, were undergoing differing degrees of instability.

Instability must be envisioned as a spectrum extending between “Utopia” and “Chaos”. As emergencies bring forward extreme challenges to human life, medical and public health ethics make it imperative for the World Health Organisation (WHO) to be involved. As such, WHO must enhance its presence and effectiveness in its capacity as a universally accepted advocate for public health. Furthermore, as crises become more enmeshed with the legitimacy of the State, and armed conflicts become more directed against countries' social capital, they impinge more on WHO's work, and WHO must reconcile its unique responsibility in the health sector, the humanitarian imperative and the mandate to assist its primary constituents.

Health can be viewed as a bridge to peace. The Organization specifically has recognised that disasters can and do affect the achievement of health and health system objectives. Within WHO, the Department of Emergency and Humanitarian Action (EHA) is the instrument for intervention in such situations. The scope of EHA is defined in terms of humanitarian action, emergency preparedness, national capacity building, and advocacy for humanitarian ^principles. The WHO's role is changing from ensuring a two-way flow of information on new scientific developments in public health in the ideal all-stable, all-equitable, well-resourced state, to dealing with sheer survival when the state is shattered or is part of the problem. The WHO poses itself the explicit goals to reduce avoidable loss of life, burden of disease and disability in emergencies and post-crisis transitions, and to ensure that the Humanitarian Health Assistance is in-line with international standards and local priorities and does not compromise future health development. A planning tree is presented.

The World Health Organization must improve its own performance. This requires three key pre-conditions: 1) presence, 2) surge capacity, and 3) institutional support, knowledge, and competencies. Thus, in order to be effective, WHO's presence and surge capacity in emergencies must integrate the institutional knowledge, the competencies, and the managerial set-up of the Organization.
Post-War Kosovo: Part 3. Development and Rehabilitation of Emergency Services
Authors: Lis Julian , Eliades M. James , Benishi Dukagjin , Koci Bajram , Gettle David , VanRooyen Michael J.
Published: July 2016

The recent crisis in Kosovo led to nearly complete destruction of a healthcare system serving the needs of approximately 2 million people. Even prior to the crisis, the pre-existing healthcare system had inadequate provisions for the delivery of Emergency Medical Services. More than 440 diverse governmental and non-governmental organizations (NGOs) arrived to assist (and often compete) in the rehabilitation of Kosovo's healthcare needs. Each brought with them individual biases and strategies for how this rehabilitation should occur, and each faced numerous unforeseen barriers to the implementation of its programs.

The authors used a four-step, multi-modal, needs assessment to gather information on the needs and potential barriers to the implementation of a program to rehabilitate emergency services as discussed in Part II. This paper chronicles the phases of the Emergency Medicine program development and the process of responding to barriers and changing needs. The program's successes and failures are noted, and the actual barriers encountered are reviewed. Overall, the needs assessment tool employed in this program was useful in the implementation of a program to restore and rehabilitate Emergency Services in Kosovo. The authors recommend the use of combined quantitative and qualitative methods for developing priorities for interventions in post-conflict settings following complex emergencies.
Complex Emergencies in Indonesia
Authors: Bradt David A. , Drummond Christina M. , Richman Mark
Published: July 2016

Recently, Indonesia has experienced six major provincial, civil, armed conflicts. Underlying causes include the transmigration policy, sectarian disputes, the Asian economic crisis, fall of authoritarian rule, and a backlash against civil and military abuses. The public health impact involves the displacement nationwide of >1.2 million persons. Violence in the Malukus, Timor, and Kalimantan has sparked the greatest population movements such that five provinces in Indonesia each now harbor > 100,000 internally displaced persons. With a background of government instability, hyperinflation, macroeconomic collapse, and elusive political solutions, these civil armed conflicts are ripe for persistence as complex emergencies.

Indonesia has made substantial progress in domestic disaster management with the establishment of central administrative authority, strategic planning, and training programs. Nevertheless, the Indonesian experience reveals recurrent issues in international humanitarian health assistance. Clinical care remains complicated by absences of treatment protocols, inappropriate drug use, high procedural complication rates, and variable referral practices. Epidemiological surveillance remains complicated by unsettled clinical case definitions, non-standardized case management of diseases with epidemic potential, variable outbreak management protocols, and inadequate epidemiological analytic capacity. International donor support has been semi-selective, insufficient, and late.

The militia murders of three UN staff in West Timor prompted the withdrawal of UN international staff from West Timor for nearly a year to date. Re-establishing rules of engagement for humanitarian health workers must address security, public health, and clinical threats.
Principles of Disaster Management Lesson 14. Criteria for Assessing a Program
Authors: Cuny Fred C.
Published: July 2016

This lesson examines mechanisms that can be used for the evaluation of a program or project. The principal concern raised is whether the project has met its stated goals and objectives and whether the project has resulted in producing benefits to the affected society. Short-term (immediate) and long-term (developmental) contributions are discussed. The importance of projects contributing to increasing the absorbing capacity of the affected community for the next event is stressed. Twelve problems commonly encountered in program execution are defined. Optimal management attempts to identify potential pitfalls in advance, designing and implementing mechanisms to avoid them, and to deal with them if they should become manifest. Simply meeting the goals and objectives of the sponsoring organization is inadequate, as all responses must be coordinated and approved by the national coordinating agency. Thus, not only is the effectiveness of the project in meeting the defined goals and objectives important, but the project must be assessed in terms of the overall impact of the project on the society. Reference is made to using the structure provided by the Health Disaster Management: Guidelines for Evaluation and Research in the Utstein Style as promulgated by the Task Force on Quality Control of the World Association for Disaster and Emergency Medicine and the Nordic Society of Disaster Medicine.
The League of Red Cross and Red Crescent Societies (1983)
Authors: Kisselev Andrei K.
Published: July 2016

The League of Red Cross Societies is the international federation of the 130 National Red Cross and Red Crescent Societies, which together have a membership of more than 230,000,000. The League is one of the three components of the International Red Cross, the others being the International Committee of the Red Cross (ICRC) and the National Red Cross/Red Crescent Societies.

The ICRC acts as a neutral intermediary in humanitarian matters during international conflicts, civil wars and internal disturbances, providing protection and assistance to victims, prisoners of war and civilian detainees. The League objective is to facilitate, encourage and promote the humanitarian activities of its member societies and thus contribute to the promotion of peace in the world.
In Memoriam, Rudolf Frey
Authors: Safar Peter , Kirimli Nancy
Published: July 2016

Rudolf Frey, known as “Rolf“ in Europe and “Rudi” in America — a leading star of anesthesiology, emergency medicine and disaster medicine — has ended his life's struggles. He influenced many lives positively. His years were rich with experiences and contributions.

Surgery and anesthesiology were his base specialties. Alone, these fields would have been too narrow for him. He initiated the first professorship of anesthesiology in Germany at the University of Heidelberg in the 1950's; the first autonomous university department of anesthesiology in Germany at the Gutenberg University of Mainz in 1960; the journalDer Anaesthesist, the first textbook of anesthesiology in German; one of the first physician-staffed advanced life support ambulance and ambulance helicopter services in Europe; numerous training programs, symposia and congresses; and theClub of Mainzand its associated monograph seriesDisaster Medicine, originally published by Springer-Verlag.
Resuscitation Research Programs in Three Spheres
Authors: Safar Peter
Published: July 2016

Research on acute dying processes, emergency resuscitation (cardiopulmonary-cerebral resuscitation, CPCR) and long-term resuscitation (intensive therapy) have the potential of leading to so far unimagined restoration of total body function, including human mentation, after sudden cardiac death from ventricular fibrillation, asphyxia or exsanguination; and also after prolonged terminal states from trauma or other insults—conditions which have so far been considered irreversible. Since the 1950's, an increasing number of investigators have embarked on resuscitation-related research.
Education in Cardiopulmonary-Cerebral Resuscitation (CPCR) Using Self-Training Methods
Authors: Berkebile Paul
Published: July 2016

Although there may be international differences in some aspects of CPCR course content, we hope material presented will catalyze research in education with CPCR self-training systems. Historically, self-training in CPCR was first introduced to the University of Pittsburgh medical students in 1971 through a pilot program in a CPR learning laboratory. This training was enhanced by the development of a mobile prototype recording manikin (by Laerdall with immediate feedback via lights indicating correct and incorrect actions in breathing and external chest compressions.
Life Supporting First Aid (LSFA) Self Training for the Public
Authors: Esposito G. , Safar P. , Medsger A. , Nesbitt J.
Published: July 2016

Lay persons can learn cardiopulmonary resuscitation (CPR) with the instructors' method, and by self-training with the use of manikins. LSFA includes airway control (head-tilt, jaw thrust), mouth-to-mouth ventilation, control of external bleeding by direct compression and elevation, positioning for coma (stable side position) and shock (horizontal, legs up), and extrication from a wreck (rescue pull). LSFA so far has not included chest compressions for cardiac arrest. LSFA capability by bystanders who would treat injured victims in mass disasters might be the most important component to consider for disaster response. A LSFA self-training system, including a manual which coaches skill practice on one another, and an attractive first aid kit (A. Laerdal) was found effective in a study carried out in Norway. The present controlled study was to compare two self-training systems (designed by A. Laerdal et al), one with and one without the use of manikins, with the presently prevalent instructors' method and an untrained control group. The trainees were high school students in a typical community in Indiana PA, USA. The study was carried out in 1978–1979.
Introduction to Emergency Medical Services (EMS) Organization
Authors: Stewart Ronald D.
Published: July 2016

Experience and history have taught us that much can be done for the sick and injured before such patients reach the hospital. From the legacy of the Good Samaritan to the modern day organization of emergency medical services, the immediate care of those stricken has undergone significant change in both philosophy and practice. While many prehospital care organizations with roots established deeply in the past still flourish, modern emergency care, in the new world at least, has developed rapidly only over the past ten years.

In the United States, a concerted effort to improve the care of the wounded during the Civil War led to the introduction of the “flying ambulances” used earlier by Napoleon's Chief Surgeon, Larrey. Americans made significant contributions to acute care with the work of such noted men as Crile, with his form of external pneumatic counterpressure; Kouwenhoven, Knickerbocker and Jude at lohns Hopkins; Beck and the first reported defibrillation in a patient; Safar and his co-workers with the rediscovery of mouth-to-mouth; and many others.
Simplified Triage and Registration in Disasters
Authors: Schinke Lutz
Published: July 2016

The triage (i.e., sorting) of casualties is the most important task of a physician in a disaster. This function is so extensive that only an experienced doctor can fulfill it satisfactorily. To do so, he needs comprehensive information. This article will demonstrate a time-saving method of receiving and giving information for triage in connection with the registration of casualties.

The immediate situation determines classification. A rigid pattern cannot be applied. The doctor must know the number of casualties and helpers, transportation facilities, hospital capacities, and medical supplies. To help him assemble these data, the doctor has at his disposal an assistant registrar. This assistant is equipped with a walkietalkie to communicate with ambulance control. He also has a registration list and can enter important data concerning the patients clearly thereon (Figures 1 A, B).
Critical Care Medicine (CCM) in Czechoslovakia (CSSR): Present State and Its Development
Authors: Pokorny Jiri
Published: July 2016

Due to the development of modern resuscitation during anesthesia and surgical operations, methods of intensive therapy have been introduced in clinical medicine. Efforts, through cardiopulmonary resuscitation (CPR), to give any patient in need the chance to survive resulted in systems of emergency medical services (EMS). A short account of the present state of CCM in the CSSR is given here. The principle of “differentiated patient care” is outlined, with accepted definitions of resuscitative and intensive care. The terminology of different steps in CCM is offered for discussion.

In Czechoslovakia, the Constitution of 1960 proclaims the right to health care for every citizen. Medical care is provided to all citizens free of charge by the State. The State took over the responsibility for planning, organizing and providing medical care on the highest attainable contemporary level. In the last ten years, special programs have been launched in order to cover most actual health areas such as neonatal and maternal health care, cardiovascular disease programs, oncology, geriatric care, and, last but not least, the care of patients with acute organ systems' failure.
Role of Anesthesiology in Emergency Medical Services (EMS) in Poland
Authors: Rondio Zdzislaw , Jurczyk Witold
Published: July 2016

Improvements of results in emergency care of critically ill patients can be realized if EMS organizations are properly based on local conditions. The Emergency Medical Unit is the first of three parts of the Integrated Health Service in Poland. The second part is in-hospital treatment. The third part is outpatient care. In most hospitals, the head of the department of anesthesiology and intensive therapy coordinates each emergency medical unit. Each unit consists of ambulances (mobile intensive care units), admission (emergency) rooms, and an intensive medical care unit (ICU). A specialization program was created and physicians who complete this type of training obtain the title “specialist in anesthesiology and intensive therapy.”

This four year specialization program contains the educational elements necessary to administer all types of modern anesthesia, and provides full preparation for work in mobile and stationary intensive medical care units as well. Such training has also given these specialists the chance to initiate treatment methods for chronic pain. An examination consisting of practical tests, multiple choice written knowledge tests, and oral tests completes the program. The latter is a conversation with a commission, consisting of full professors and associate professors in anesthesiology and intensive therapy.