Following renewed ethnic violence at the end of September 1996, conflict between Tutsi rebels and the Zairian army spread to North Kivu, Zaire where approximately 700,000 Rwandan Hutu refugees resided following the 1994 genocide. After a major rebel offensive against the camps' militia groups on 15 November, a massive movement of refugees towards Rwanda through Goma town, the capital of North Kivu, began. Massive population movements such as this are likely to be associated with substantial mortality and morbidity.

To study patterns of mortality, morbidity, and health care associated with the Rwandan refugee population repatriation during November 1996.

This study observed the functioning of the health-care facilities in the Gisenyi District in Rwanda and the Goma District in Zaire, and surveyed mortality and morbidity among Rwandan refugees returning from Zaire to Rwanda. Patterns of mortality, morbidity, and health care were measured mainly by mortality and health centre consultation rates.

Between 15 and 21 November 1996, 553,000 refugees returned to Rwanda and 4,530 (8.2/1,000 refugees) consultations took place at the border dispensary (watery diarrhea, 63%; bloody diarrhea, 1%). There were 129 (0.2/1,000) surgical admissions (72% soft tissue trauma) to the Gisenyi hospital in the subsequent two weeks. The average number of consultations from the 13 health centres during the same period was 500/day. Overall, the recorded death rate was 0.5/10,000 (all associated with diarrhea). A total of 3,586 bodies were identified in the refugee camps and surrounding areas of Goma, almost all the result of trauma. Many had died in the weeks before the exodus. Health centres were overwhelmed and many of the deficiencies in provision of health care identified in 1994 again were evident.

Non-violent death rates were low, a reflection of the population's health status prior to migration and immunity acquired from the 1994 cholera out-break. Health facilities were over stretched, principally because of depleted numbers of local, health-care workers associated with the 1994 genocide. Health-care facilities running parallel to the existing health-care system functioned most effectively.

The effectiveness of a tiered emergency medical services system often hinges upon the ability of initial care providers with little or no formal training to identify emergent patient needs and determine the best means to meet those needs.

To determine if out-of-hospital emergency care providers consistently make appropriate triage, transportation, and destination decisions; and to determine if experience and training have an effect on these decisions.

A survey consisting of 14 patient-care scenarios was administered to certified and non-certified out-of-hospital emergency-care providers (n = 311) from 20 randomly selected EMS agencies. These agencies were part of EMS systems that utilize one, two, and three tiered responses by ambulance and fire-based commercial, municipal, and volunteer agencies. Participants were asked to select the most appropriate mode of transport and destination facility using the assumption that they had responded to each scenario in a basic life support ambulance. Answers included transporting the patient to various receiving facilities or requesting a more advanced-level unit to respond to the scene. Transport times to receiving facilities and estimated times of arrival for advanced-level units were provided with each choice. Eight emergency physicians unanimously had agreed upon the most appropriate answer for each scenario. A two-tailed t-test was used to compare the scores of the certified and non-certified groups; and Spearman's Correlation Coefficients were used to test the effects of experience and training.

Non-certified providers (n = 108) had a mean score of 32.6% or 4.6 (SD = 1.84) correct answers; certified providers (n = 203) had a mean score of 41.1% or 5.76 (SD = 2.12) correct answers (p < 0.000001). Spearman's Correlation Coefficients were: 1) individual provider level - (0.3978); 2) agency provider level - (0.2741); 3) hours workea per week - (0.2505); 4) years in EMS - (- 0.0821); 5) commercial or volunteer provider - (0.2398); 6) agency call volume - (0.2012); 7) agency location - (0.0685), and 8) transporting versus non-transporting agency - (0.2523).

A need exists for further education of out-of-hospital emergency care providers with respect to triage, transportation, and destination decisions. Provider experience and level of certification do not appear to affect these critical patient-care decisions.

A mass casualty disaster (MCD) never has occurred in the United States, but such an event remains a fearful possibility. The purpose of this study was to establish baseline information concerning the perceptions relative to the capabilities of the United States to respond to a MCD of persons most likely to involved in the responses to such an event when it does occur.

A survey was constructed in 1995 to query the perceptions of persons in authority in federal, state, and local agencies who would participate in the medical responses to a MCD. Participants were asked to select the most likely scenario, a hurricane or earthquake, that could generate 30,000 casualties within their respective region. The survey requested respondent's perceptions as to the timing of the federal responses and the quality and sufficiency of these responses. The survey also sought information about the availability of plans to meet such a catastrophe in the region, and the frequency with which such plans have been exercised.

Responses were grouped by phase of the responses and whether the respondents were employed by federal, state, or local agencies. Descriptive statistics were used to summarize the data. When appropriate, a one-tailed t-test was used to compare the responses of the groups. A p-value = 0.05 was considered statistically significant.

A total of 104 surveys were distributed of which 88 were completed and returned (85%). Both the federal and state respondents had considerable experienced in this area.

Overall, the federal respondents were more optimistic about the availability, utility, and timely arrival of federal resources to assist regions in meeting the medical needs. In each of the three phases of MCD responses evaluated (medical response, patient evacuation, and definitive care), there was concern that there were insufficient resources to meet the requirements. States and local respondents perceived that initially, they will be on their own for field rescue, life-supporting first-aid, and casualty evacuation. Respondents acknowledged that a combination of local, state, federal, and private resources eventually would be needed to meet the huge demand. Only 31% federal and 26% state/local respondents believed that there will be sufficient combined local, state, federal, and private resources to meet the requirements for the evacuation of casualties to definitive care facilities outside of the region, and another 50% acknowledged the resources would only partially meet these requirements. Sixty-eight percent of state/local respondents believed that there would be insufficient local, state, federal, and private definitive care resources to meet the requirements for definitive care.

While three years have elapsed since the survey was conducted and there have been some improvements in preparedness and responses, concerns center around the perceived lack of resource capability or lack of ability to get the resources to the MCD scene in time to meet requirements. Such perceptions by experienced professionals warrant further review by those at all levels of government responsible for planning and responding to mass casualty disasters.

By introducing an intensified insulin treatment regime to patients with insulin-dependant diabetes mellitus (IDDM), the frequency of long-term complications that the patient will experience has been shown to decrease. The price is an increase in the frequency of severe and mild hypoglycaemic events. Therefore, constant monitoring of these patients is necessary.

This study compares the time until full recovery of IDDM patients with severe hypoglycaemia after treatment with either intravenous glucose or intramuscular glucagon.

14 patients with IDDM with severe hypoglycaemia requiring treatment by the medical staff was randomised to treatment either with 50 ml of 50% glucose intravenously or intramuscular 1 mg glucagon. The time to recovery was recorded. Plasma glucose was measured at fixed intervals to achieve a glycaemia profile. Demographic data were acquired through patient interviews following recovery.

Recovery time between the two groups was significantly different statistically. Recovery time ranged for 1 to 3 minutes for those receiving glucose intravenously and 8 to 21 minutes for those receiving intramuscular glucagon. Characteristic glycaemia profiles were identified and differences were present between the two groups with a greater fluctuating pattern for the glucose group compared to the steadily increasing pattern seen after glucagon treatment. Alcohol was believed to be involved in 8 out of the 14 cases, and thereby, is the major confounding factor in this study.

Intramuscularly administered glucagon is a safe and reliable alternative to intravenous glucose infusion. The fluctuating glyceamia pattern seen after glucose treatment indicates a low risk for secondary hypoglycaemia. However, further studies are necessary to support this assertion.

To determine the effect of a return of spontaneous circulation (RO SC) on survival to hospital discharge as compared to other established predictors of survival.

A retrospective case review of all out-of-hospital primary cardiac arrests from 01 January, 1992 to 31 December 1994 was conducted. The relative values of age, race, gender, presenting cardiac rhythm, witnessed event, initiation of CPR by bystanders, response time intervals, and return of spontaneous circulation (ROSC) in an Utstein-template database were tested as predictors of survival of patients who had suffered a cardiac arrest in the out-of-hospital setting. The ROSC was defined as return of spontaneous circulation prior to and present upon arrival at the emergency department. Predictors were evaluated for statistical significance using a logistic regression analysis (p < 0.05). Odds ratios (OR) and 95% confidence intervals (CI) with positive and negative predictive values (PPV, NPV) were calculated.

Of 832 patients with primary cardiac arrest, 153 (18.4%) had ROSC and 67 (8.1%) survived to hospital discharge. Comparing survivors to nonsurvivors, the mean values for age were 64 to 67 years, with 59.7% to 36.1% being witnessed, 35.8% to 23.9% having bystander CPR initiated, 88.1% to 48.4% having ventricular fibrillation (V-fib) and 82.1% to 64.0% having ROSC. An initial electro-cardiographic rhythm of V-fib (p = 0.009; OR = 2.2; CI = 1.2-3.9), and ROSC (p < 0.0001; OR = 5.2; CI = 3.6-7.5) are statistically significant predictors of survival to hospital discharge. The PPV was 13.8% for V-fib and 35.9% for ROSC, and the NPV was 98.0% for V-fib and 98.2% for ROSC.

Presenting V-fib and out-of-hospital ROSC are significant predictors of survival from cardiac arrest. Failure to obtain ROSC in the out-of-hospital setting strongly suggests consideration for terminating resuscitation efforts.

To use the clinical activities of an ambulance service as a tool to assess the residual and unmet medical needs of a city in the aftermath of a major earthquake and to apply that assessment to the development of a training curriculum for the prehospital personnel.

The researchers conducted structured interviews with health care workers at all levels of the emergency health care delivery system in Gyumrii, Armenia, and carried out a retrospective frequency analysis of 29,010 ambulance runs for an 11-month period from February through December 1992. Runs first were assigned into the broad categories of: 1) Adult Medical; 2) Pediatric Medical; or 3) Trauma, and then, according to diagnosis. The runs then were classified further as: 1) Primary Care; 2) Basic Life Support (BLS); or 3) Advanced Life Support (ALS).