Guest Editorials
911 Patient Redirection
- Karl A. Sporer
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- Published online by Cambridge University Press:
- 01 December 2017, pp. 589-592
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.Sporer KA 911 Patient Redirection . Prehosp Disaster Med.2017 ;32 (6 ):589 –592 .
Where There is No EMS: Lay Providers in Emergency Medical Services Care - EMS as a Public Health Priority
- Sierra Debenham, Matthew Fuller, Matthew Stewart, Raymond R. Price
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- Published online by Cambridge University Press:
- 11 August 2017, pp. 593-595
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By 2030, road traffic accidents are projected to be the fifth leading cause of death worldwide, with 90% of these deaths occurring in low- and middle-income countries (LMICs). While high-quality, prehospital trauma care is crucial to reduce the number of trauma-related deaths, effective Emergency Medical Systems (EMS) are limited or absent in many LMICs. Although lay providers have long been recognized as the front lines of informal trauma care in countries without formal EMS, few efforts have been made to capitalize on these networks. We suggest that lay providers can become a strong foundation for nascent EMS through a four-fold approach: strengthening and expanding existing lay provider training programs; incentivizing lay providers; strengthening locally available first aid supply chains; and using technology to link lay provider networks.
,Debenham S ,Fuller M ,Stewart M .Price RR Where There is No EMS: Lay Providers in Emergency Medical Services Care - EMS as a Public Health Priority . Prehosp Disaster Med.2017 ;32 (6 ):593 –595 .
Original Research
Mass-Fatality Incident Preparedness Among Faith-Based Organizations
- Qi Zhi, Jacqueline A. Merrill, Robyn R. Gershon
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- Published online by Cambridge University Press:
- 04 July 2017, pp. 596-603
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Introduction
Members of faith-based organizations (FBOs) are in a unique position to provide support and services to their local communities during disasters. Because of their close community ties and well-established trust, they can play an especially critical role in helping communities heal in the aftermath of a mass-fatality incident (MFI). Faith-based organizations are considered an important disaster resource and partner under the National Response Plan (NRP) and National Response Framework; however, their level of preparedness and response capabilities with respect to MFIs has never been evaluated. The purpose of this study was threefold: (1) to develop appropriate measures of preparedness for this sector; (2) to assess MFI preparedness among United States FBOs; and (3) to identify key factors associated with MFI preparedness.
ProblemNew metrics for MFI preparedness, comprised of three domains (organizational capabilities, operational capabilities, and resource sharing partnerships), were developed and tested in a national convenience sample of FBO members.
MethodsData were collected using an online anonymous survey that was distributed through two major, national faith-based associations and social media during a 6-week period in 2014. Descriptive, bivariate, and correlational analyses were conducted.
ResultsOne hundred twenty-four respondents completed the online survey. More than one-half of the FBOs had responded to MFIs in the previous five years. Only 20% of respondents thought that roughly three-quarters of FBO clergy would be able to respond to MFIs, with or without hazardous contamination. A higher proportion (45%) thought that most FBO clergy would be willing to respond, but only 37% thought they would be willing if hazardous contamination was involved. Almost all respondents reported that their FBO was capable of providing emotional care and grief counseling in response to MFIs. Resource sharing partnerships were typically in place with other voluntary organizations (73%) and less likely with local death care sector organizations (27%) or Departments of Health (DOHs; 32%).
ConclusionsThe study suggests improvements are needed in terms of staff training in general, and specifically, drills with planning partners are needed. Greater cooperation and inclusion of FBOs in national planning and training will likely benefit overall MFI preparedness in the US.
,Zhi Q ,Merrill JA .Gershon RR Mass-Fatality Incident Preparedness Among Faith-Based Organizations . Prehosp Disaster Med.2017 ;32 (6 ):596 –603 .
Community Health Workers and Disasters: Lessons Learned from the 2015 Earthquake in Nepal
- Karla Fredricks, Hao Dinh, Manita Kusi, Chandra Yogal, Biraj M. Karmacharya, Thomas F. Burke, Brett D. Nelson
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- Published online by Cambridge University Press:
- 08 August 2017, pp. 604-609
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Introduction
The Nepal earthquake of 2015 was a major disaster that exacted an enormous toll on human lives and caused extensive damage to the infrastructure of the region. Similar to other developing countries, Nepal has a network of community health workers (CHWs; known as female community health volunteers [FCHVs]) that was in place prior to the earthquake and continues to function to improve maternal and child health. These FCHVs and other community members were responsible, by default, for providing the first wave of assistance after the earthquake.
Hypothesis/ProblemCommunity health workers such as FCHVs could be used to provide formal relief services in the event of an emergency, but there is a paucity of evidence-based literature on how to best utilize them in disaster risk reduction, preparedness, and response. Data are needed to further characterize the roles that this cadre has played in past disasters and what strategies can be implemented to better incorporate them into future emergency management.
MethodsIn March 2016, key-informant interviews, FCHV interviews, and focus group discussions (FGDs) were conducted in Nepali health facilities using semi-structured guides. The audio-recorded data were obtained with the assistance of a translator (Nepali-English), transcribed verbatim in English, and coded by two independent researchers (manually and with NVivo 11 Pro software [QSR International; Melbourne, Australia]).
ResultsAcross seven different regions, 14 interviews with FCHVs, two FGDs with community women, and three key-informant interviews were conducted. Four major themes emerged around the topic of FCHVs and the 2015 earthquake: (1) community care and rapport between FCHVs and local residents; (2) emergency response of FCHVs in the immediate aftermath of the earthquake; (3) training requested to improve the FCHVs’ ability to manage disasters; and (4) interaction with relief organizations and how to create collaborations that provide aid relief more effectively.
ConclusionsThe FCHVs in Nepal provided multiple services to their communities in the aftermath of the earthquake, largely without any specific training or instruction. Proper preparation, in addition to improved collaboration with aid agencies, could increase the capacity of FCHVs to respond in the event of a future disaster. The information gained from this study of the FCHV experience in the Nepal earthquake could be used to inform risk reduction and emergency management policies for CHWs in various settings worldwide.
Fredricks K Dinh H Kusi M Yogal C Karmacharya BM Burke TF Nelson BD Community Health Workers and Disasters: Lessons Learned from the 2015 Earthquake in Nepal . Prehosp Disaster Med.2017 ;32 (6 ):604 –609 .
Observational Study on Safety of Prehospital BLS CPAP in Dyspnea
- Novneet Sahu, Patrick Matthews, Kathryn Groner, Mia A. Papas, Ross Megargel
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- Published online by Cambridge University Press:
- 03 July 2017, pp. 610-614
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Introduction
Continuous positive airway pressure (CPAP) improves outcomes in patients with respiratory distress. Additional benefits are seen with CPAP application in the prehospital setting. Theoretical safety concerns regarding Basic Life Support (BLS) providers using CPAP exist. In Delaware’s (USA) two-tiered Emergency Medical Service (EMS) system, BLS often arrives before Advanced Life Support (ALS).
HypothesisThis study fills a gap in literature by evaluating the safety of CPAP applied by BLS prior to ALS arrival.
MethodsThis was a retrospective, observational study using Quality Assurance (QA) data collected from October 2009 through December 2012 throughout a state BLS CPAP pilot program; CPAP training was provided to BLS providers prior to participation. Collected data include pulse-oximetry (spO2), respiratory rate (RR), heart rate (HR), skin color, and Glasgow Coma Score (GCS) before and after CPAP application. Pre-CPAP and post-CPAP values were compared using McNemar’s and t-tests. Advanced practitioners evaluated whether CPAP was correctly applied and monitored and whether the patient condition was “improved,” “unchanged,” or “worsened.”
ResultsSeventy-four patients received CPAP by BLS; CPAP was correctly indicated and applied for all 74 patients. Respiratory status and CPAP were appropriately monitored and documented in the majority of cases (98.6%). A total of 89.2% of patients improved and 4.1% worsened; CPAP significantly reduced the proportion of patients with SpO2<92%, RR>24, and cyanosis (P<.01). The GCS improved from mean (standard deviation [SD]) 13.9 (SD=1.9) to 14.1 (SD=1.9) after CPAP (mean difference [MD]=0.17; 95% CI, -0.49 to 0.83; P=.59). The HR decreased from 115.7 (SD=53) to 105.1 (SD=37) after CPAP (MD=-10.9; 95% CI, -3.2 to -18.6; P<.01). The SpO2 increased from 80.8% (SD=11.4) to 96.9% (SD=4.2) after CPAP (MD=17.8; 95% CI, 14.2-21.5; P<.01).
ConclusionThe BLS providers were able to determine patients for whom CPAP was indicated, to apply it correctly, and to appropriately monitor the status of these patients. The majority of patients who received CPAP by BLS providers had improvement in their clinical status and vital signs. The findings suggest that CPAP can be safely used by BLS providers with appropriate training.
,Sahu N ,Matthews P ,Groner K ,Papas MA .Megargel R Observational Study on Safety of Prehospital BLS CPAP in Dyspnea . Prehosp Disaster Med.2017 ;32 (6 ):610 –614 .
Benefits of Manometer in Non-Invasive Ventilatory Support
- Rodrigo Silva Lacerda, Fernando Cesar Anastácio de Lima, Leonardo Pereira Bastos, Anderson Fardin Vinco, Felipe Britto Azevedo Schneider, Yves Luduvico Coelho, Heitor Gomes Costa Fernandes, João Marcus Ramos Bacalhau, Igor Matheus Simonelli Bermudes, Claudinei Ferreira da Silva, Luiza Paterlini da Silva, Rogério Pezato
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- Published online by Cambridge University Press:
- 26 July 2017, pp. 615-620
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Introduction
Effective ventilation during cardiopulmonary resuscitation (CPR) is essential to reduce morbidity and mortality rates in cardiac arrest. Hyperventilation during CPR reduces the efficiency of compressions and coronary perfusion.
ProblemHow could ventilation in CPR be optimized? The objective of this study was to evaluate non-invasive ventilator support using different devices.
MethodsThe study compares the regularity and intensity of non-invasive ventilation during simulated, conventional CPR and ventilatory support using three distinct ventilation devices: a standard manual resuscitator, with and without airway pressure manometer, and an automatic transport ventilator. Student’s t-test was used to evaluate statistical differences between groups. P values <.05 were regarded as significant.
ResultsPeak inspiratory pressure during ventilatory support and CPR was significantly increased in the group with manual resuscitator without manometer when compared with the manual resuscitator with manometer support (MS) group or automatic ventilator (AV) group.
ConclusionThe study recommends for ventilatory support the use of a manual resuscitator equipped with MS or AVs, due to the risk of reduction in coronary perfusion pressure and iatrogenic thoracic injury during hyperventilation found using manual resuscitator without manometer.
,Lacerda RS ,de Lima FCA ,Bastos LP ,Vinco AF ,Schneider FBA ,Coelho YL ,Fernandes HGC ,Bacalhau JMR ,Bermudes IMS ,da Silva CF ,da Silva LP .Pezato R Benefits of Manometer in Non-Invasive Ventilatory Support . Prehosp Disaster Med.2017 ;32 (6 ):615 –620 .
A Comparison of Paramedic First Pass Endotracheal Intubation Success Rate of the VividTrac VT-A 100, GlideScope Ranger, and Direct Laryngoscopy Under Simulated Prehospital Cervical Spinal Immobilization Conditions in a Cadaveric Model
- Ryan Hodnick, Tony Zitek, Kellen Galster, Stephen Johnson, Bryan Bledsoe, Daniel Ebbs
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- Published online by Cambridge University Press:
- 15 August 2017, pp. 621-624
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Objective
The primary goal of this study was to compare paramedic first pass success rate between two different video laryngoscopes and direct laryngoscopy (DL) under simulated prehospital conditions in a cadaveric model.
MethodsThis was a non-randomized, group-controlled trial in which five non-embalmed, non-frozen cadavers were intubated under prehospital spinal immobilization conditions using DL and with both the GlideScope Ranger (GL; Verathon Inc, Bothell, Washington USA) and the VividTrac VT-A100 (VT; Vivid Medical, Palo Alto, California USA). Participants had to intubate each cadaver with each of the three devices (DL, GL, or VT) in a randomly assigned order. Paramedics were given 31 seconds for an intubation attempt and a maximum of three attempts per device to successfully intubate each cadaver. Confirmation of successful endotracheal intubation (ETI) was confirmed by one of the six on-site physicians.
ResultsSuccessful ETI within three attempts across all devices occurred 99.5% of the time overall and individually 98.5% of the time for VT, 100.0% of the time for GL, and 100.0% of the time for DL. First pass success overall was 64.4%. Individually, first pass success was 60.0% for VT, 68.8% for GL, and 64.5% for DL. A chi-square test revealed no statistically significant difference amongst the three devices for first pass success rates (P=.583). Average time to successful intubation was 42.2 seconds for VT, 38.0 seconds for GL, and 33.7 for seconds for DL. The average number of intubation attempts for each device were as follows: 1.48 for VT, 1.40 for GL, and 1.42 for DL.
ConclusionThe was no statistically significant difference in first pass or overall successful ETI rates between DL and video laryngoscopy (VL) with either the GL or VT (adult).
,Hodnick R ,Zitek T ,Galster K ,Johnson S ,Bledsoe B .Ebbs D A Comparison of Paramedic First Pass Endotracheal Intubation Success Rate of the VividTrac VT-A 100, GlideScope Ranger, and Direct Laryngoscopy Under Simulated Prehospital Cervical Spinal Immobilization Conditions in a Cadaveric Model . Prehosp Disaster Med.2017 ;32 (6 ):621 –624 .
Single Rescuer Ventilation Using a Bag Valve Mask with Removable External Handle: A Randomized Crossover Trial
- Paul Reed, Baruch Zobrist, Monica Casmaer, Steven G. Schauer, Nurani Kester, Michael D. April
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- Published online by Cambridge University Press:
- 15 August 2017, pp. 625-630
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Introduction
Ventilation with a bag valve mask (BVM) is a challenging but critical skill for airway management in the prehospital setting.
HypothesisTidal volumes received during single rescuer ventilation with a modified BVM with supplemental external handle will be higher than those delivered using a standard BVM among health care volunteers in a manikin model.
MethodsThis study was a randomized crossover trial of adult health care providers performing ventilation on a manikin. Investigators randomized participants to perform single rescuer ventilation, first using either a BVM modified by addition of a supplemental external handle or a standard unmodified BVM (Spur II BVM device; Ambu; Ballerup, Denmark). Participants performed mask placement and delivery of 10 breaths per minute for three minutes, as guided by a metronome. After a three-minute rest period, they performed ventilation using the alternative device. The primary outcome measure was mean received tidal volume as measured by the manikin (IngMar RespiTrainer model; IngMar Medical; Pittsburgh, Pennsylvania USA). Secondary outcomes included subject device preference.
ResultsOf 70 recruited participants, all completed the study. The difference in mean received tidal volume between ventilations performed using the modified BVM with external handle versus standard BVM was 20 ml (95% CI, -16 to 56 ml; P=.28). There were no significant differences in mean received tidal volume based on the order of study arm allocation. The proportion of participants preferring the modified BVM over the standard BVM was 47.1% (95% CI, 35.7 to 58.6%).
ConclusionsThe modified BVM with added external handle did not result in greater mean received tidal volume compared to standard BVM during single rescuer ventilation in a manikin model.
,Reed P ,Zobrist B ,Casmaer M ,Schauer SG ,Kester N .April MD Single Rescuer Ventilation Using a Bag Valve Mask with Removable External Handle: A Randomized Crossover Trial . Prehosp Disaster Med.2017 ;32 (6 ):625 –630 .
A Descriptive Analysis of Traction Splint Utilization and IV Analgesia by Emergency Medical Services
- Joshua Nackenson, Amado A. Baez, Jonathan P. Meizoso
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- 15 August 2017, pp. 631-635
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Study Objectives
Traction splinting has been the prehospital treatment of midshaft femur fracture as early as the battlefield of the First World War (1914-1918). This study is the assessment of these injuries and the utilization of a traction splint (TS) in blunt and penetrating trauma, as well as intravenous (IV) analgesia utilization by Emergency Medical Services (EMS) in Miami, Florida (USA).
MethodsThis is a retrospective study of patients who sustained a midshaft femur fracture in the absence of multiple other severe injuries or severe physiologic derangement, as defined by an injury severity score (ISS) <20 and a triage revised trauma score (T-RTS)≥10, who presented to an urban, Level 1 trauma center between September 2008 and September 2013. The EMS patient care reports were assessed for physical exam findings and treatment modality. Data were analyzed descriptively and statistical differences were assessed using odds ratios and Z-score with significance set at P≤.05.
ResultsThere were 170 patients studied in the cohort. The most common physical exam finding was a deformity +/- shortening and rotation in 136 patients (80.0%), followed by gunshot wound (GSW) in 22 patients (13.0%), pain or tenderness in four patients (2.4%), and no findings consistent with femur fracture in three patients (1.7%). The population was dichotomized between trauma type: blunt versus penetrating. Of 134 blunt trauma patients, 50 (37.0%) were immobilized in traction, and of the 36 penetrating trauma victims, one (2.7%) was immobilized in traction. Statistically significant differences were found in the application of a TS in blunt trauma when compared to penetrating trauma (OR=20.83; 95% CI, 2.77-156.8; P <.001). Intravenous analgesia was administered to treat pain in only 35 (22.0%) of the patients who had obtainable IV access. Of these patients, victims of blunt trauma were more likely to receive IV analgesia (OR=6.23; 95% CI, 1.42-27.41; P=.0067).
ConclusionAlthough signs of femur fracture are recognized in the majority of cases of midshaft femur fracture, only 30% of patients were immobilized using a TS. Statistically significant differences were found in the utilization of a TS and IV analgesia administration in the setting of blunt trauma when compared to penetrating trauma.
,Nackenson J ,Baez AA .Meizoso JP A Descriptive Analysis of Traction Splint Utilization and IV Analgesia by Emergency Medical Services .Prehosp Disaster Med.2017 ;32 (6 ):631 –635 .
Retrospective Analysis of Mosh-Pit-Related Injuries
- Andrew M. Milsten, Joseph Tennyson, Stacy Weisberg
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- Published online by Cambridge University Press:
- 03 July 2017, pp. 636-641
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Objectives
Moshing is a violent form of dancing found world-wide at rock concerts, festivals, and electronic dance music events. It involves crowd surfing, shoving, and moving in a circular rotation. Moshing is a source of increased morbidity and mortality. The goal of this study was to report epidemiologic information on patient presentation rate (PPR), transport to hospital rate (TTHR), and injury patterns from patients who participated in mosh-pits.
Materials and MethodsSubjects were patrons from mosh-pits seeking medical care at a single venue. The events reviewed were two national concert tours which visited this venue during their tour. The eight distinct events studied occurred between 2011 and 2014. Data were collected retrospectively from prehospital patient care reports (PCRs). A single Emergency Medical Service (EMS) provided medical care at this venue. The following information was gathered from each PCR: type of injury, location of injury, treatment received, alcohol or drug use, Advanced Life Support/ALS interventions required, age and gender, disposition, minor or parent issues, as well as type of activity engaged in when injured.
ResultsAttendance for the eight events ranged from 5,100 to 16,000. Total patient presentations ranged from 50 to 206 per event. Patient presentations per ten thousand (PPTT) ranged from 56 to 130. The TTHR per 10,000 ranged from seven to 20. The mean PPTT was 99 (95% CI, 77-122) and the median was 98. The mean TTHR was 16 (95% CI, 12-29) and the median TTHR was 17. Patients presenting from mosh-pits were more frequently male (57.6%; P<.004). The mean age was 20 (95% CI, 19-20). Treatment received was overwhelmingly at the Basic Life Support (BLS) level (96.8%; P<.000001). General moshing was the most common activity leading to injury. Crowd surfing was the next most significant, accounting for 20% of presentations. The most common body part injured was the head (64% of injuries).
ConclusionsThis retrospective review of mosh-pit-associated injury patterns demonstrates a high rate of injuries and presentations for medical aid at the evaluated events. General moshing was the most commonly associated activity and the head was the most common body part injured.
,Milsten AM ,Tennyson J ,Weisberg S Retrospective Analysis of Mosh-Pit-Related Injuries . Prehosp Disaster Med.2017 ;32 (6 ):636 –641 .
Acute Care Referral Systems in Liberia: Transfer and Referral Capabilities in a Low-Income Country
- Jimin Kim, Maria Barreix, Christine Babcock, Corey B. Bills
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- Published online by Cambridge University Press:
- 27 July 2017, pp. 642-650
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Introduction
Following two decades of armed conflict in Liberia, over 95% of health care facilities were partially or completely destroyed. Although the Liberian health system has undergone significant rehabilitation, one particular weakness is the lack of organized systems for referral and prehospital care. Acute care referral systems are a critical component of effective health care delivery and have led to improved quality of care and patient outcomes.
ProblemThis study aimed to characterize the referral and transfer systems in the largest county of Liberia.
MethodsA cross-sectional, health referral survey of a representative sample of health facilities in Montserrado County, Liberia was performed. A systematic random sample of all primary health care (PHC) clinics, fraction proportional to district population size, and all secondary and tertiary health facilities were included in the study sample. Collected data included baseline information about the health facility, patient flow, and qualitative and quantitative data regarding referral practices.
ResultsA total of 62 health facilities—41 PHC clinics, 11 health centers (HCs), and 10 referral hospitals (RHs)—were surveyed during the 6-week study period. In sum, three percent of patients were referred to a higher-level of care. Communication between health facilities was largely unsystematic, with lack of specific protocols (n=3; 5.0%) and standardized documentation (n=26; 44.0%) for referral. While most health facilities reported walking as the primary means by which patients presented to initial health facilities (n=50; 81.0%), private vehicles, including commercial taxis (n=37; 60.0%), were the primary transport mechanism for referral of patients between health facilities.
ConclusionThis study identified several weaknesses in acute care referral systems in Liberia, including lack of systematic care protocols for transfer, documentation, communication, and transport. However, several informal, well-functioning mechanisms for referral exist and could serve as the basis for a more robust system. Well-integrated acute care referral systems in low-income countries, like Liberia, may help to mitigate future public health crises by augmenting a country’s capacity for emergency preparedness.
Kim J Barreix M Babcock C Bills CB Acute Care Referral Systems in Liberia: Transfer and Referral Capabilities in a Low-Income Country . Prehosp Disaster Med.2017 ;32 (6 ):642 –650 .
Evaluation of Skin Damage from Accidental Removal of a Hemostatic Wound Clamp (The iTClamp)
- Jessica L. Mckee, Prasanna Lakshminarasimhan, Ian Atkinson, Anthony J. LaPorta, Andrew W. Kirkpatrick
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- Published online by Cambridge University Press:
- 24 August 2017, pp. 651-656
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Background
Controlling bleeding early in the prehospital and military setting is an extremely important and life-saving skill. Wound clamping is a newly introduced technique that may augment both the effectiveness and logistics of wound packing with any gauze product. As these devices may be inadvertently removed, the potential consequences of such were examined in a simulated, extreme, inadvertent disengagement.
MethodsThe wound clamp used was an iTClamp (Innovative Trauma Care; Edmonton, Alberta, Canada) that was applied and forcefully removed (skin-pull) from the skin of both a human cadaver and swine. Sixty skin-pull tests were sequentially performed to measure the pull weight required to remove the device, any potential skin and device damage, how the device failed, and if the device could be re-applied.
ResultsObservations of the skin revealed that other than the expected eight small needle holes from device application, no other damage to the skin was sustained in 98.3% of cases. Conversely, of the 60 devices pulled, 93.3% of the devices sustained no damage and all could be re-applied. Four (6.7%) of the devices remained in place despite a maximum pull weight >22lbF (pound-force). The mean pull weights for pin bar pull were (lbF): vertical 9.2 (SD=5.0); perpendicular 2.5 (SD=1.7); and parallel 5.3 (SD=3.1). For the encompassed pull position group, mean pull weights were (lbF): vertical 5.7 (SD=2.3); perpendicular 3.0 (SD=2.5); and parallel 14.5 (SD=3.5). The overall mean for all groups was 6.7 (SD=5.2). The two main reasons that the iTClamp was pulled off were because the friction lock let go or the needles slipped out of one side of the skin due to the angle of the pull.
ConclusionInadvertent, forcible removal of the iTClamp created essentially no skin damage seen when the wound clamp was forcibly removed from either cadaver or swine models in a variety of positions and directions. Thus, the risks of deployment in operational environments do not seem to be increased.
,Mckee JL ,Lakshminarasimhan P ,Atkinson I ,LaPorta AJ .Kirkpatrick AW Evaluation of Skin Damage from Accidental Removal of a Hemostatic Wound Clamp (The iTClamp) . Prehosp Disaster Med.2017 ;32 (6 ):651 –656 .
Special Reports
Management of Diabetic Surgical Patients in a Deployed Field Hospital: A Model for Acute Non-Communicable Disease Care in Disaster
- Kathleen M. McDermott, Ruth M. Hardstaff, Sophie Alpen, David J. Read, Nicholas R. Coatsworth
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- Published online by Cambridge University Press:
- 27 July 2017, pp. 657-661
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Sudden onset disasters (SODs) have affected over 1.5 billion of the world’s population in the past decade. During the same time, developing nations have faced a sustained increase in the burden of non-communicable disease (NCD) with extra pressure placed on health systems. The combined increase in SODs and the NCD epidemic facing the world’s most disaster-prone nations will present new challenges to emergency medical teams (EMTs) during disaster response. This report details the experience as an EMT during the Typhoon Haiyan disaster of 2013, with particular reference to the challenges of diabetic management in a surgical field hospital. The incidence of diabetes in this surgical cohort exceeded that of the population by a factor of four. The steps to prepare for and treat diabetes in the field provide a useful model for the management of NCD in the deployed field hospital environment after a disaster.
,McDermott KM ,Hardstaff RM ,Alpen S ,Read DJ .Coatsworth NR Management of Diabetic Surgical Patients in a Deployed Field Hospital: A Model for Acute Non-Communicable Disease Care in Disaster . Prehosp Disaster Med.2017 ;32 (6 ):657 –661 .
Assessing and Improving Hospital Mass-Casualty Preparedness: A No-Notice Exercise
- Daniel A. Waxman, Edward W. Chan, Francesca Pillemer, Timothy WJ Smith, Mahshid Abir, Christopher Nelson
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- Published online by Cambridge University Press:
- 07 August 2017, pp. 662-666
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In recent years, mass-casualty incidents (MCIs) have become more frequent and deadly, while emergency department (ED) crowding has grown steadily worse and widespread. The ability of hospitals to implement an effective mass-casualty surge plan, immediately and expertly, has therefore never been more important. Yet, mass-casualty exercises tend to be highly choreographed, pre-scheduled events that provide limited insight into hospitals’ true capacity to respond to a no-notice event under real-world conditions. To address this gap, the US Department of Health and Human Services (Washington, DC USA), Office of the Assistant Secretary for Preparedness and Response (ASPR), sponsored development of a set of tools meant to allow any hospital to run a real-time, no-notice exercise, focusing on the first hour and 15 minutes of a hospital’s response to a sudden MCI, with the goals of minimizing burden, maximizing realism, and providing meaningful, outcome-oriented metrics to facilitate self-assessment. The resulting exercise, which was iteratively developed, piloted at nine hospitals nationwide, and completed in 2015, is now freely available for anyone to use or adapt. This report demonstrates the feasibility of implementing a no-notice exercise in the hospital setting and describes insights gained during the development process that might be helpful to future exercise developers. It also introduces the use of ED “immediate bed availability (IBA)” as an objective, dynamic measure of an ED’s physical capacity for new arrivals.
,Waxman DA ,Chan EW ,Pillemer F ,Smith TWJ ,Abir M .Nelson C Assessing and Improving Hospital Mass-Casualty Preparedness: A No-Notice Exercise . Prehosp Disaster Med.2017 ;32 (6 ):662 –666 .
Brief Reports
Utility of Ambulance Data for Real-Time Syndromic Surveillance: A Pilot in the West Midlands Region, United Kingdom
- Dan Todkill, Paul Loveridge, Alex J. Elliot, Roger A. Morbey, Obaghe Edeghere, Tracy Rayment-Bishop, Chris Rayment-Bishop, John E. Thornes, Gillian Smith
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- Published online by Cambridge University Press:
- 01 August 2017, pp. 667-672
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Introduction
The Public Health England (PHE; United Kingdom) Real-Time Syndromic Surveillance Team (ReSST) currently operates four national syndromic surveillance systems, including an emergency department system. A system based on ambulance data might provide an additional measure of the “severe” end of the clinical disease spectrum. This report describes the findings and lessons learned from the development and preliminary assessment of a pilot syndromic surveillance system using ambulance data from the West Midlands (WM) region in England.
Hypothesis/ProblemIs an Ambulance Data Syndromic Surveillance System (ADSSS) feasible and of utility in enhancing the existing suite of PHE syndromic surveillance systems?
MethodsAn ADSSS was designed, implemented, and a pilot conducted from September 1, 2015 through March 1, 2016. Surveillance cases were defined as calls to the West Midlands Ambulance Service (WMAS) regarding patients who were assigned any of 11 specified chief presenting complaints (CPCs) during the pilot period. The WMAS collected anonymized data on cases and transferred the dataset daily to ReSST, which contained anonymized information on patients’ demographics, partial postcode of patients’ location, and CPC. The 11 CPCs covered a broad range of syndromes. The dataset was analyzed descriptively each week to determine trends and key epidemiological characteristics of patients, and an automated statistical algorithm was employed daily to detect higher than expected number of calls. A preliminary assessment was undertaken to assess the feasibility, utility (including quality of key indicators), and timeliness of the system for syndromic surveillance purposes. Lessons learned and challenges were identified and recorded during the design and implementation of the system.
ResultsThe pilot ADSSS collected 207,331 records of individual ambulance calls (daily mean=1,133; range=923-1,350). The ADSSS was found to be timely in detecting seasonal changes in patterns of respiratory infections and increases in case numbers during seasonal events.
ConclusionsFurther validation is necessary; however, the findings from the assessment of the pilot ADSSS suggest that selected, but not all, ambulance indicators appear to have some utility for syndromic surveillance purposes in England. There are certain challenges that need to be addressed when designing and implementing similar systems.
,Todkill D ,Loveridge P ,Elliot AJ ,Morbey RA ,Edeghere O ,Rayment-Bishop T ,Rayment-Bishop C ,Thornes JE .Smith G Utility of Ambulance Data for Real-Time Syndromic Surveillance: A Pilot in the West Midlands Region, United Kingdom . Prehosp Disaster Med.2017 ;32 (6 ):667 –672 .
Knowledge, Attitudes, and Practices among Members of Households Actively Monitored or Quarantined to Prevent Transmission of Ebola Virus Disease — Margibi County, Liberia: February-March 2015
- Jason A. Wilken, Paran Pordell, Brant Goode, Rachel Jarteh, Zayzay Miller, Benjamin G. Saygar, Sr., Leroy Maximore, Watta M. Borbor, Moses Carmue, Gregory W. Walker, Adolphus Yeiah
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- Published online by Cambridge University Press:
- 27 July 2017, pp. 673-678
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Background
In early 2015, a patient from a cluster of cases of Ebola Virus Disease (EVD) in Monrovia, Liberia traveled to a rural village in Margibi County, potentially exposing numerous persons. The patient died in the village and post-mortem testing confirmed Ebola Virus infection.
ProblemThe Margibi County Health Team (CHT; Kakata, Margibi, Liberia) needed to prevent further transmission of EVD within and outside of the affected villages, and they needed to better understand the factors that support or impede compliance with measures to stop the spread of EVD.
MethodsIn February-March 2015, the Margibi CHT instituted a 21-day quarantine and active monitoring for two villages where the patient had contact with numerous residents, and a 21-day active monitoring for five other villages where the patient had possible contact with an unknown number of persons. One contact developed EVD and quarantine was extended an additional 12 days in one village. In April 2015, the Margibi CHT conducted a household-based EVD knowledge, attitudes, and practices (KAP) survey of the seven villages. From April 24-29, 2015, interview teams approached every household in the seven villages and collected information on demographics, knowledge of EVD, attitudes about quarantine to prevent the spread of EVD, and their quarantine experiences and practices. Descriptive statistics were calculated.
ResultsOne hundred fifteen interviews were conducted, representing the majority of the households in the seven villages. Most (99%) correctly identified touching an infected person’s body fluids and contact with the body of someone who has died from EVD as transmission routes. However, interviewees sometimes incorrectly identified mosquito bites (58%) and airborne spread (32%) as routes of EVD transmission, and 72% incorrectly identified the longest EVD incubation period as ≤seven days. Eight of 16 households in the two quarantined villages (50%) reported times when there was not enough water or food during quarantine. Nine of 16 (56%) reported that a household member had illnesses or injuries during quarantine; of these, all (100%) obtained care from a clinic, hospital, or Ebola treatment unit (ETU).
ConclusionResidents’ knowledge of EVD transmission routes and incubation period were suboptimal. Public health authorities should consider assessing residents’ understanding of Ebola transmission routes and effectively educate them to ensure correct understanding. Quarantined residents should be provided with sufficient food, water, and access to medical care.
,Wilken JA ,Pordell P ,Goode B ,Jarteh R ,Miller Z ,Saygar BG Sr. ,Maximore L ,Borbor WM ,Carmue M ,Walker GW .Yeiah A Knowledge, Attitudes, and Practices among Members of Households Actively Monitored or Quarantined to Prevent Transmission of Ebola Virus Disease — Margibi County, Liberia: February-March 2015 . Prehosp Disaster Med.2017 ;32 (6 ):673 –678 .
A Pilot Project Demonstrating that Combat Medics Can Safely Administer Parenteral Medications in the Emergency Department
- Steven G. Schauer, Cord W. Cunningham, Andrew D. Fisher, Robert A. DeLorenzo
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- Published online by Cambridge University Press:
- 15 August 2017, pp. 679-681
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Introduction
Select units in the military have improved combat medic training by integrating their functions into routine clinical care activities with measurable improvements in battlefield care. This level of integration is currently limited to special operations units. It is unknown if regular Army units and combat medics can emulate these successes. The goal of this project was to determine whether US Army combat medics can be integrated into routine emergency department (ED) clinical care, specifically medication administration.
Project DesignThis was a quality assurance project that monitored training of combat medics to administer parenteral medications and to ensure patient safety. Combat medics were provided training that included direct supervision during medication administration. Once proficiency was demonstrated, combat medics would prepare the medications under direct supervision, followed by indirect supervision during administration. As part of the quality assurance and safety processes, combat medics were required to document all medication administrations, supervising provider, and unexpected adverse events. Additional quality assurance follow-up occurred via complete chart review by the project lead.
DataDuring the project period, the combat medics administered the following medications: ketamine (n=13), morphine (n=8), ketorolac (n=7), fentanyl (n=5), ondansetron (n=4), and other (n=6). No adverse events or patient safety events were reported by the combat medics or discovered during the quality assurance process.
ConclusionsIn this limited case series, combat medics safely administered parenteral medications under indirect provider supervision. Future research is needed to further develop this training model for both the military and civilian setting.
,Schauer SG W,Cunningham C ,Fisher AD .DeLorenzo RA A Pilot Project Demonstrating that Combat Medics Can Safely Administer Parenteral Medications in the Emergency Department . Prehosp Disaster Med.2017 ;32 (6 ):679 –681 .
Case Reports
On-Scene Rescue Breathing Resulting in Gastric Perforation and Massive Pneumoperitoneum
- Mike Butterfield, Tamas Peredy
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- Published online by Cambridge University Press:
- 03 July 2017, pp. 682-683
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Rescue breathing performed too vigorously or by untrained individuals may cause gastric distension and perforation. A 26-year-old woman is presented who developed acute abdominal pain and distension after receiving rescue breathing following a heroin overdose. Massive pneumoperitoneum was seen on chest x-ray, and on subsequent laparotomy, a 4cm laceration was found in the lesser curvature of the stomach. Review of the literature suggests that the lesser curvature is particularly susceptible to perforation following over-distension. Emergency personnel should be aware of this rare, but serious, complication. Expansion of community and first responder naloxone use in the proper clinical setting may further diminish utilization of rescue breathing.
,Butterfield M .Peredy T On-Scene Rescue Breathing Resulting in Gastric Perforation and Massive Pneumoperitoneum . Prehosp Disaster Med.2017 ;32 (6 ):682 –683 .
The Use of Interpreters in Medical Triage during a Refugee Mass-Gathering Incident in Europe
- Lykourgos Christos Alexakis, Anastasia Papachristou, Chiara Baruzzi, Angeliki Konstantinou
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- Published online by Cambridge University Press:
- 31 July 2017, pp. 684-687
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Introduction
During a refugees’ mass-gathering incident in Kos Island, Greece, Médecins Sans Frontières (MSF; Brussels, Belgium) teams provided emergency medical care. A case report of the event focusing on difficulties encountered by the interpreters during triage and emergency response was prepared.
MethodsData collected during the event were reviewed from the patient’s register and qualitative interviews were obtained from the MSF interpreters involved in the response. In addition, a description of the event and a literature review were included.
ResultsTotal consultations were 49 patients, mainly from Syria, with an average age of 25 years. During triage, 20 patients were tagged green with only minor injuries; 11 patients were tagged yellow, mostly due to heat exhaustion, but also a hypertensive crisis, a diabetic, a pregnant woman with abdominal pain, and a peptic ulcer exacerbation. The remaining 18 patients were tagged red and diagnosed with heat syncope, except from a case of epileptic seizures and an acute chest pain patient. Interpreters were insufficient in number to accompany each doctor and every nurse providing care during the event. In addition, they were constantly disturbed by both refugees and fellow medical team members demanding their service. Interpreters had to triage and prioritize where to go and for whom to interpret.
ConclusionInterpreters are an integral part of a proper refugee reception system. They should be included in authorities planning where mass gatherings of refugees are expected. Appropriate training may be needed for interpreters to develop skills useful in mass gatherings and similar prehospital settings in order to better coordinate with the medical team.
Alexakis LC Papachristou A Baruzzi C .Konstantinou A The Use of Interpreters in Medical Triage during a Refugee Mass-Gathering Incident in Europe . Prehosp Disaster Med.2017 ;32 (6 ):684 –687 .
Allergic Bronchopulmonary Mycosis due to Exposure to Eurotium herbariorum after the Great East Japan Earthquake
- Chiyako Oshikata, Maiko Watanabe, Akemi Saito, Masatsugu Ishida, Seiichi Kobayashi, Rumi Konuma, Yoichi Kamata, Jun Terajima, Junichi Cho, Masaru Yanai, Naomi Tsurikisawa
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- Published online by Cambridge University Press:
- 15 August 2017, pp. 688-690
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Background
Indoor mold levels typically increase after natural disasters, flooding, and water damage. Eurotium herbariorum is the sexual stage of Aspergillus glaucus.
Case PresentationA 66-year-old, Japanese male, ex-smoker had been diagnosed with bronchial asthma when he was five years old; he achieved remission at the age of 13 years. He was displaced from his home during the Great East Japan Earthquake on March 11, 2011 and moved to temporary housing in Miyagi Prefecture in June 2011. He experienced the first episode of chest tightness, coughing, and wheezing in February 2012, when he again was diagnosed as having bronchial asthma. Mycofloral surveillance detected high counts of Eurotium in the air of his bedroom, kitchen, and living room, with a maximal fungal count of 163,200 colony-forming units per cubic meter (CFU/m3). Although Cladosporium and Penicillium typically predominate in the indoor air of residential dwellings, only low levels of these organisms were present in the patient’s home. Morphologic identification confirmed the isolates as E. herbariorum. The patient had positive reactions to E. herbariorum in skin prick testing and the presence of antigen-specific precipitating antibodies to E. herbariorum. Computed tomography of the chest in August 2013 revealed central bronchiectasis and bronchial wall thickening. The patient experienced late reactions after provocation testing with E. herbariorum.
ConclusionThis report presents the rare case of a patient who developed allergic bronchopulmonary mycosis (ABPM) due to exposure to E. herbariorum during temporary housing after the Great East Japan Earthquake.
,Oshikata C ,Watanabe M ,Saito A ,Ishida M ,Kobayashi S ,Konuma R ,Kamata Y ,Terajima J ,Cho J ,Yanai M .Tsurikisawa N Allergic Bronchopulmonary Mycosis due to Exposure to Eurotium herbariorum after the Great East Japan Earthquake . Prehosp Disaster Med.2017 ;32 (6 ):688 –690 .