Nitroglycerine (NTG) commonly is used in the prehospital emergency care setting for the treatment of chest pain suggestive of myocardial ischemia or infarction or for cardiac unloading in patients with presumed pulmonary edema. The usual form of this drug is as a 400 mcg tablet administered sublingually. Recently, NTG has become available as an aerosolized form (NTGA) in a multiple dose, pressurized canister containing 200 metered doses of 400 meg of NTG each. In this form, the drug is purported to be absorbed rapidly from the surface of the tongue.

In the field, we have noted that the sublingual tablet form of NTG occasionally remains undissolved following administration to patients complaining of chest pain. In each of these cases, clinically, the patients were unchanged on arrival at the receiving hospital and an intact tablet was discovered properly placed under the tongue. In an attempt to evaluate the ease of administration and clinical responses of patients with chest pain to the aerosolized form of the drug, we replaced NTG sublingual tablets on paramedic units in the Burbank system with the NTGA form.

Transcutaneous Pacing (TCP) is a rapidly applied “non-invasive” technique that can be used successfully in the hospital, emergency department or field setting (1–9). Although the technique has been studied for three decades (7), it is only in the last few years that commercial units have been widely available. Improvements in pad design (particularly the development of non-metallic electrodes) and pulse characteristics (a pulse width of greater than 20 msec.) have allowed the development of units which may provide high capture rates with a level of discomfort which is tolerable in the conscious patient. Transcutaneous pacing may obviate the need for emergency transvenous pacing; further, it is easily adaptable to the field setting although early application appears to be needed for success (1,2).

No study has compared the relative effectiveness of different TCP units, and there are no published data on some of the devices. The purpose of this investigation was to compare the functions of five different external pacemaker units on ten volunteers, in order to determine: 1) what percent of subjects could be captured within the limits of tolerability (the capture rate); 2) how much current was required by each unit to capture (the capture threshold); and 3) the degree of discomfort produced by each pacemaker at the capture threshold.

Recovery and reconstruction following major sociocultural upheavals, such as natural disasters and war, result in multiple changes. In addition to loss of life and property, social structures and ways of life are temporarily and sometimes permanently altered. Sources of change are both from within due to loss and damage as well as from the outside through new ideas, relief, and economic aid. Some aspects of change may be viewed positively, as a society measures the benefits, while still other aspects may be worthless or detrimental to the survival of the group.

Because of the magnitude of the 1976 Guatemalan Earthquake, as well as the unprecedented outpouring of disaster relief and reconstruction aid, a longitudinal study funded by National Science Foundation was begun in 1977 (18 months after the event) and extended through 1982 (in selected areas). Chiefly because of financial expense, most research studies of disasters are limited to short-term follow-up studies of several weeks to a year after the traumatic event. However, many scientists have urged the importance of doing longitudinal studies (1–3). This study had as an overall goal, the study of the process of recovery over a five year period post-Earthquake. A quasiexperimental design was used to compare the recovery process in 19 experimental and 7 control sites. The overall guiding research question was: Does a catastrophy or social upheaval stimulate the recovery of the society so that the level of living post-disaster is higher than the pre-disaster state? Level of Living was operationalized to include housing conditions, cost of living, as well as quality of life measures. The results of a specific portion of the 1976 Guatemalan Earthquake Study (as it is popularly called), the urban resettlements, is presented in this paper.

Emergency Medical Services and the care of patients in the field have taken giant steps forward over the past decade. Born of the desire of physicians to influence the mortality rates of sudden cardiac death in the community, systems of advanced life support have taken root in the urban centers in the United Kingdom, Australia, the United States, and other countries (1-3). Although originally largely designed around the concept of “mobile coronary care,” these systems soon were deluged with calls for help from all sectors of the community, and faced a variety of medical problems. As trauma gradually became recognized for the killer and maimer of young lives that it is, regional programs of trauma care were developed in the United States and led gradually to the expansion of prehospital and interhospital transport systems in which critically injured patients were being moved about, often over long distances. The growth of emergency medicine as a specialty in its own right has encouraged the study and improvement of systems of disaster and mass casualty management.

Although the focus of these efforts has been largely the overall reduction of death and disability in critically ill or injured patients, controversy continues around not only the extent of field intervention but also the influence of our efforts on the outcome of these patients (4, 5). The importance of particular interventions such as intravenous line placement, administration of certain medications, the use of the pneumatic anti-shock garment, and other sacred cows of prehospital care, all have been questioned of late (6, 7).

In Jerusalem, the Emergency Medical Service is the sole prehospital provider for a population of 450,000 residents. Ambulances are dispatched from a centrally located first-aid center. Separate basic and advanced life support (MICU) ambulances are provided. Basic life support units are staffed by Emergency Medical Technicians (EMTs) trained to provide first aid and cardiopulmonary resuscitation (CPR). These units are dispatched to service persons in whom advanced life support (ALS) services are not likely to be required. The MICU is staffed by paramedical personnel plus a qualified physician. In order to maximize the efficiency of the service an attempt was made to use the MICU only for patients who may benefit from ALS interventions.

Selection of patients for whom the ALS unit may be required is accomplished by switchboard operators. These personnel routinely dispatch the MICU for definite emergencies such as unconsciousness or absence of breathing. All other cases have been reported first to an on-call physician who ultimately decides whether or not to dispatch the MICU. This method of determining priority for dispatch is called the Consultation-Dispatch System (CDS). This method of determining priority seemed inefficient, so an alternative system was implemented that did not require prior physician consultation. This brief report details the impact of this change on system operation and MICU activity.

The oft-repeated historic development of the pneumatic lower body compression suit (MAST, PASG) for the presumed treatment of hypotension has been well-documented by McSwain(l). While the experimental and anecdotal clinical observations of Crile, Gardner, Wangenstein and Kaplan are interesting, they are not prospective, controlled, randomized clinical trials in humans(2,3,4,5). In the early 1970s, the EMS community was ripe for the bandwagon reflex to grasp at any and all gimmicks and gadgets which became available, regardless of a lack of evidence regarding their safety or danger to patients. Inventions such as the esophageal obturator airway, various darts, MAST, external cardiac bumpers, percutaneous trachea obturators, and many others simultaneously were thrust upon the unsuspecting and unprotected patient community. Some of these innovations may have been beneficial but others were dangerous. Contending that some intervention in a “life threatening, good Samaritan situation” was better than no interventional treatment or “stabilization” at all, the paramedics' blind faith in these modalities persisted. The Medical Device Amendment of 1976 (6), which requires safety and efficacy for devices, similar to that long in effect for new drugs, had not yet been enacted into law to require premarketing clearance of new medical devices. Building on blind faith and premature recommendations regarding in the unproven concept of MAST, the EMS community exercised poor judgment in recommending to state legislators that this unproven device be “required equipment” on board ambulances. Furthermore, this small cadre of “special interest groups” lobbied to have the MAST mandated as essential equipment in trauma centers(7,8). Although the minutes of the trauma planning meetings do not reflect the debate at the American College of Surgeons Committee on Trauma, numerous voices of advised constraint, said “go slow” on including the MAST as part of the ATLS course and the ACS optimal resources document.

The use of the Pneumatic Anti-Shock Garment (PASG) has created much controversy in prehospital care. It is interesting that such an inexpensive device and technique has created so much controversy regarding effectiveness when expensive devices and techniques, such as coronary artery bypass, carotid endarteroectomy, and laser angioplasty have been questioned as to effectiveness, but have not created as much controversy.

Where do we stand on the PASG today? One well-done, randomized, prospective study has been reported as several different papers. In reality, these reports originate from only one study (1-5). This is compared to more than 200 other studies, many of which have been randomized, prospective studies in animals using the same quality as the randomized, prospective study done on humans. Such studies have the advantage of having better isolation of the specific condition being studied. It does not seem appropriate to base the clinical use or non-use on just one study. All studies should be reviewed and placed in context when attempting to identify the role the PASG has in patient care.