Editorial
Field Reports: Can They Add to the Prehospital and Disaster Knowledge Base?
- Samuel J. Stratton
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- Published online by Cambridge University Press:
- 09 October 2015, p. 437
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Original Research
Comparison of Computerized Patients versus Live Moulaged Actors for a Mass-casualty Drill
- Ilene Claudius, Amy Kaji, Genevieve Santillanes, Mark Cicero, J. Joelle Donofrio, Marianne Gausche-Hill, Saranya Srinivasan, Todd P. Chang
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- Published online by Cambridge University Press:
- 12 August 2015, pp. 438-442
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Introduction
Multiple modalities for simulating mass-casualty scenarios exist; however, the ideal modality for education and drilling of mass-casualty incident (MCI) triage is not established.
Hypothesis/ProblemMedical student triage accuracy and time to triage for computer-based simulated victims and live moulaged actors using the pediatric version of the Simple Triage and Rapid Treatment (JumpSTART) mass-casualty triage tool were compared, anticipating that student performance and experience would be equivalent.
MethodsThe victim scenarios were created from actual trauma records from pediatric high-mechanism trauma presenting to a participating Level 1 trauma center. The student-reported fidelity of the two modalities was also measured. Comparisons were done using nonparametric statistics and regression analysis using generalized estimating equations.
ResultsThirty-three students triaged four live patients and seven computerized patients representing a spectrum of minor, immediate, delayed, and expectant victims. Of the live simulated patients, 92.4% were given accurate triage designations versus 81.8% for the computerized scenarios (P=.005). The median time to triage of live actors was 57 seconds (IQR=45-66) versus 80 seconds (IQR=58-106) for the computerized patients (P<.0001). The moulaged actors were felt to offer a more realistic encounter by 88% of the participants, with a higher associated stress level.
ConclusionWhile potentially easier and more convenient to accomplish, computerized scenarios offered less fidelity than live moulaged actors for the purposes of MCI drilling. Medical students triaged live actors more accurately and more quickly than victims shown in a computerized simulation.
,Claudius I ,Kaji A ,Santillanes G ,Cicero M ,Donofrio JJ ,Gausche-Hill M ,Srinivasan S .Chang TP Comparison of Computerized Patients versus Live Moulaged Actors for a Mass-casualty Drill . Prehosp Disaster Med.2015 ;30 (5 ):438 –442 .
Geriatric Disaster Preparedness
- Mary Colleen Bhalla, Amos Burgess, Jennifer Frey, William Hardy
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- Published online by Cambridge University Press:
- 15 September 2015, pp. 443-446
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Introduction
The elderly population has proven to be vulnerable in times of a disaster. Many have chronic medical problems for which they depend on medications or medical equipment. Some older adults are dependent on caregivers for managing their activities of daily living (ADLs), such as dressing, and their instrumental activities of daily living (IADLs), such as transportation.
ProblemA coordinated effort for disaster preparation in the elderly population is paramount. This study assessed the potential needs and plans of older adults in the face of a local disaster.
MethodsThe setting was a community-based, university-affiliated, urban emergency department (ED) that sees more than 77,000 adult patients per year. A survey on disaster plans and resources needed if evacuated was distributed to 100 community-residing ED patients and visitors aged 65 years and older from January through July 2013. Means and proportions are reported with 95% confidence intervals (CIs).
ResultsData were collected from 13 visitors and 87 patients. The mean age was 76 years, and 54% were female. Thirty-one responded that they had a disaster plan in place (31/100; CI, 22.4-41.4%). Of those 31, 94% (29/31; CI, 78.6-99.2%) had food and water as part of their plan, 62% (19/29; CI, 42.2-78.2%) had a supply of medication, and 35% (12/31; CI, 21.8-57.8%) had an evacuation plan. When asked what supplies the 100 subjects might need if evacuated, 33% (CI, 23.9-43.1%) needed a walker, 15% (CI, 8.6-23.5%) needed a wheelchair, 78% (CI, 68.6-85.7%) needed glasses, 17% (CI, 10.2-25.8%) needed a hearing aid, 16% (CI, 9.4-24.7%) needed a glucometer, 93% (CI, 86.1-97.1%) needed medication, 14% (CI, 7.8-22.4%) needed oxygen, 23% (CI, 15.2-32.5%) needed adult diapers, and 21% (CI, 13.2-30.3%) had medical equipment that required electricity. Many of the subjects also required help with one or more of their ADLS, the most common being dressing (17%; CI, 10.3-26.1%), or their IADLS, the most common being transportation (39%; CI, 29.7-49.7%). Only 42% (CI, 32.3-52.7%) were interested in learning more about disaster preparation.
ConclusionOnly a minority of the older adults in the study population had a disaster plan in place. Most of the respondents would require medications, and many would require medical supplies if evacuated.
,Bhalla MC ,Burgess A ,Frey J .Hardy W Geriatric Disaster Preparedness . Prehosp Disaster Med.2015 ;30 (5 ):443 –446.
First Responder Accuracy Using SALT after Brief Initial Training
- Christopher W.C. Lee, Shelley L. McLeod, Michael B. Peddle
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- 01 September 2015, pp. 447-451
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Background
Mass-casualty incidents (MCIs) present a unique challenge with regards to triage as patient volume often outweighs the number of available Emergency Medical Services (EMS) providers. A possible strategy to optimize existing triage systems includes the use of other first responder groups, namely fire and police, to decrease the triage time during MCIs, allowing for more rapid initiation of life-saving treatment and prioritization of patient transport.
HypothesisFirst-year primary care paramedic (PCP), fire, and police trainees can apply with similar accuracy an internationally recognized MCI triage tool, Sort, Assess, Life-saving interventions, Treatment/transport (SALT), immediately following a brief training session, and again three months later.
MethodsAll students enrolled in the PCP, fire, and police foundation programs at two community colleges were invited to participate in a 30-minute didactic session on SALT. Immediately following this session, a 17-item, paper-based test was administered to assess the students’ ability to understand and apply SALT. Three months later, the same test was given to assess knowledge retention.
ResultsOf the 464 trainees who completed the initial test, 364 (78.4%) completed the three month follow-up test. Initial test scores were higher (P<.05) for PCPs (87.0%) compared to fire (80.2%) and police (68.0%) trainees. The mean test score for all respondents was higher following the initial didactic session compared to the three month follow-up test (75% vs 64.7%; Δ 10.3%; 95% CI, 8.0%-12.6%). Three month test scores for PCPs (75.4%) were similar to fire (71.4%) students (Δ 4.0%; 95% CI, −2.1% to 10.1%). Both PCP and fire trainees significantly outperformed police (57.8%) trainees. Over-triage errors were the most common, followed by under-triage and then critical errors, for both the initial and follow-up tests.
ConclusionsAmongst first responder trainees, PCPs were able to apply the SALT triage tool with the most accuracy, followed by fire, then police. Over-triage was the most frequent error, while critical errors were rare.
,Lee CWC ,McLeod SL .Peddle MB First Responder Accuracy Using SALT after Brief Initial Training . Prehosp Disaster Med.2015 ;30 (5 ):447 –451 .
Clinical Outcomes in Cardiac Arrest Patients Following Prehospital Treatment with Therapeutic Hypothermia
- Eric Cortez, Ashish R. Panchal, James Davis, Paul Zeeb, David P. Keseg
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- Published online by Cambridge University Press:
- 12 August 2015, pp. 452-456
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Introduction
Recent studies have brought to question the efficacy of the use of prehospital therapeutic hypothermia for victims of out-of-hospital cardiac arrest (OHCA). Though guidelines recommend therapeutic hypothermia as a critical link in the chain of survival, the safety of this intervention, with the possibility of minimal treatment benefit, becomes important.
Hypothesis/ProblemThis study examined prehospital therapeutic hypothermia for OHCA, its association with survival, and its complication profile in a large, metropolitan, fire-based Emergency Medical Services (EMS) system, where bystander cardiopulmonary resuscitation (CPR) and post-arrest care are in the process of being optimized.
MethodsThis evaluation was a retrospective chart review of all OHCA patients with return of spontaneous circulation (ROSC) treated with therapeutic hypothermia, from January 1, 2013 through November 30, 2013. The primary outcomes were the proportion of patients with initiation of prehospital therapeutic hypothermia with survival to hospital admission, the proportion of patients with initiation of prehospital therapeutic hypothermia with survival to hospital discharge, and the complication profile of therapeutic hypothermia in this population. The complication profile included several clinical, radiographic, and laboratory parameters. Exclusion criteria included: no prehospital therapeutic hypothermia initiation; no ROSC; and age of 17 year old or younger.
ResultsFifty-one post-cardiac arrest patients were identified that met inclusion criteria. The mean age was 61 years (SD=14.7 years), and 33 (72%) were male. The initial rhythm was ventricular fibrillation or pulseless ventricular tachycardia in 17 (37%) patients, and bystander CPR was performed in 28 (61%) patients with ROSC. Thirty-nine (85%) patients survived to hospital admission. Twenty-one patients (48%; 95% CI, 33-64) were administered vasopressors, 10 patients (24%; 95% CI, 10-37) were administered diuretics, and 19 patients (44%; 95% CI, 29-60) were administered antibiotics. Initial chest radiograph (CXR) findings were normal in 12 (29%) patients. Overall, 13 (28%; 95% CI, 15-42) study patients survived to hospital discharge.
ConclusionRecent reports have questioned the efficacy and safety of prehospital therapeutic hypothermia. In this evaluation, in the setting of unstandardized post-arrest care, 85% of the patients survived to hospital admission and 28% survived to hospital discharge, with a complication profile which was similar to that noted in other studies. This suggests that further evidence may be needed before EMS systems stop administering therapeutic hypothermia to appropriately selected patients. In less-optimized systems, therapeutic hypothermia may still be an essential link in the chain of survival.
,Cortez E ,Panchal AR ,Davis J ,Zeeb P .Keseg DP Clinical Outcomes in Cardiac Arrest Patients Following Prehospital Treatment with Therapeutic Hypothermia . Prehosp Disaster Med2015 ;30 (5 ):452 –456 .
Accuracy, Efficiency, and Inappropriate Actions Using JumpSTART Triage in MCI Simulations
- Ilene Claudius, Amy H. Kaji, Genevieve Santillanes, Mark X. Cicero, J. Joelle Donofrio, Marianne Gausche-Hill, Saranya Srinivasan, Todd P. Chang
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- Published online by Cambridge University Press:
- 01 September 2015, pp. 457-460
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Introduction
Using the pediatric version of the Simple Triage and Rapid Treatment (JumpSTART) algorithm for the triage of pediatric patients in a mass-casualty incident (MCI) requires assessing the results of each step and determining whether to move to the next appropriate action. Inappropriate application can lead to performance of unnecessary actions or failure to perform necessary actions.
Hypothesis/ProblemTo report overall accuracy and time required for triage, and to assess if the performance of unnecessary steps, or failure to perform required steps, in the triage algorithm was associated with inaccuracy of triage designation or increased time to reach a triage decision.
MethodsMedical students participated in an MCI drill in which they triaged both live actors portraying patients and computer-based simulated patients to the four triage levels: minor, delayed, immediate, and expectant. Their performance was timed and compared to intended triage designations and a priori determined critical actions.
ResultsThirty-three students completed 363 scenarios. The overall accuracy was 85.7% and overall mean time to assign a triage designation was 70.4 seconds, with decreasing times as triage acuity level decreased. In over one-half of cases, the student omitted at least one action and/or performed at least one action that was not required. Each unnecessary action increased time to triage by a mean of 8.4 seconds and each omitted action increased time to triage by a mean of 5.5 seconds.
DiscussionIncreasing triage level, performance of inappropriate actions, and omission of recommended actions were all associated with increasing time to perform triage.
,Claudius I ,Kaji AH ,Santillanes G ,Cicero MX ,Donofrio JJ ,Gausche-Hill M ,Srinivasan S .Chang TP Accuracy, Efficiency, and Inappropriate Actions Using JumpSTART Triage in MCI Simulations . Prehosp Disaster Med.2015 ;30 (5 ):457 –460 .
Accuracy of Tympanic Temperature Measurement in Firefighters Completing a Simulated Structural Firefighting Task
- Toby Keene, Matt Brearley, Beth Bowen, Anthony Walker
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- Published online by Cambridge University Press:
- 01 September 2015, pp. 461-465
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Introduction
In the course of their duties, firefighters risk heat stroke and other medical conditions due to exertion in high-temperature environments. Infrared tympanic temperature measurement (TTym) is often used by Emergency Medical Services (EMS) to assess the core body temperature of firefighters. The accuracy of TTym in this setting has been called into question.
Hypothesis/ProblemThis study aimed to examine the accuracy of TTym for core body temperature assessment at emergency firefighting events compared with gastrointestinal temperature measurement (TGI) as measured by ingestible thermometers.
MethodsForty-five (42 male, three female) professional urban firefighters from an Australian fire service completed two 20-minute work periods in a 100°C (± 5°C) heat chamber while wearing personal protective clothing (PPC) and breathing apparatus (weighing approximately 22 kg). Measurements were taken immediately before entering, and on exiting, the heat chamber. Tympanic temperature was assessed by an infrared tympanic thermometer and TGI was measured by ingestible sensor and radio receiver.
ResultsComplete data were available for 37 participants. Participant temperatures were higher on exiting the heat chamber than at baseline (TTym: 35.9°C (SD=0.7) vs 37.5°C (SD=0.8); TGI: 37.2°C (SD=0.4) vs 38.6°C (SD=0.5)). Tympanic temperature underestimated TGI on average by 1.3°C (SD=0.5) before entering the chamber and by 1.0°C (SD=0.8) following the exercise. Using pooled data, the average underestimation was 1.2°C (SD=0.7).
ConclusionTympanic thermometers cause an unreliable measure of core body temperature for firefighters engaged in fire suppression activities. Accurate and practical measures of core body temperature are required urgently.
,Keene T ,Brearley M ,Bowen B .Walker A Accuracy of Tympanic Temperature Measurement in Firefighters Completing a Simulated Structural Firefighting Task . Prehosp Disaster Med.2015 ;30 (5 ):461 –465 .
A Descriptive Analysis of Prehospital Response to Hazardous Materials Events
- Ashley J. Martin, Christine M. Lohse, Matthew D. Sztajnkrycer
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- Published online by Cambridge University Press:
- 01 September 2015, pp. 466-471
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Objective
Little is known about the overall frequency of hazardous materials (HazMat) events in the United States and the nature of prehospital care for those exposed. The purpose of the current study was to perform a descriptive analysis of Emergency Medical Services (EMS) activations reported to a national EMS database.
MethodsAnalysis of the 2012 National EMS Information System (NEMSIS) Public Release Research Data Set v.2.2.1, containing EMS emergency response data submitted by 41 states, was conducted. Mandatory data elements E0207 (Type of Response Delay), E0208 (Type of Scene Delay), and E0209 (Type of Transport Delay) contained specific codes for HazMat events and were used to identify specific EMS activation records for subsequent analysis. Overlapping data elements were identified and combined in order to prevent duplicate entries. Descriptive analyses were generated from the NEMSIS Research Data Set.
ResultsA total of 17,479,328 EMS activations were reported, of which 2,527 unique activations involved HazMat response. Mass-casualty incident was coded for 5.6% of activations. The most common level of prehospital care present on scene was Basic Life Support (BLS; 51.1%); 2.1% required aggressive Advanced Life Support (ALS) response. The most common locations for HazMat activations were homes (36.2%), streets or highways (26.3%), and health care facilities (11.6%). The primary symptoms observed by EMS personnel were pain (29.6%), breathing problems (12.2%), and change in responsiveness (9.6%). Two percent of HazMat activations involved cardiac arrest, with 21.7% occurring after EMS arrival. Delays in patient care included response delay, scene delay, and transport delay.
ConclusionHazardous materials events are rare causes of EMS activation in the United States. The majority occur in non-industrial venues and involve two or fewer patients. Scene time frequently is delayed due to multiple barriers. Cardiac arrest is rare but occurred after EMS arrival in one-fifth of patients.
,Martin AJ ,Lohse CM .Sztajnkrycer MD A Descriptive Analysis of Prehospital Response to Hazardous Materials Events . Prehosp Disaster Med.2015 ;30 (5 ):466 –471 .
Epidemiological Study of Child Casualties of Landmines and Unexploded Ordnances: A National Study from Iran
- Batool Mousavi, Mohammad Reza Soroush, Mehdi Masoumi, Shahriar Khateri, Ehsan Modirian, Hamid Shokoohi, Mohammad Javad Fatemi, Mohammad Ali Hematti, Mansour Soroush, Mohammad Ghassemi-Broumand, Mehdi Rassafiani, Mostafa Allami, Farshad Nouri, Amir Yavari, Zohreh Ganjparvar, Mojtaba Kamyab, Seyed Abbas Mirsadeghi
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- Published online by Cambridge University Press:
- 16 September 2015, pp. 472-477
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Background
Despite landmine-risk education programs and extensive demining activities on the Western border of Iran, landmines and unexploded ordnance (UXOs) still cause civilian and child casualties three decades after the Iraq-Iran war (1980-1988). The objective of this study was to understand the epidemiological patterns and risk factors of injury in child casualties of landmines and UXOs in Western and Southwestern Iran.
MethodsChildren who were 18 years old or younger at the time of study and who sustained injuries from landmines and UXOs were identified through a search at the Iranian National Veterans Registry. These children participated in a 5-day gathering. The information on socioeconomic status, health-related issues, quality of life, health care utilization, and clinical profiles concerning the landmine and UXO injuries were collected. The method of data collection consisted of three component surveys: health interview, social survey, and medical examinations. Social surveys and health interviews were conducted in a face-to-face method by utilizing a questionnaire consisting of 39 questions addressing household and individual components, including information on time and type of injuries, physical activity, mental health, and quality of life. A comprehensive team of physicians in different subspecialties evaluated and examined children to assess the current medical and psychiatric conditions and physical activity, and recommended and arranged further medical, rehabilitation, or surgical planning.
ResultsSeventy-eight child casualties were identified and participated in the study. The mean age of the participants at the time of study was 16.11 years old (SD=2 years). The mean age of victims at the time of injury was 8.2 years (SD=3.12 years; ranged from 2 to 15 years old). Sixty-seven (85.9%) of the children were male. Provinces of Kurdistan and Kermanshah had the highest number of casualties, with a total number of 54 children (68.3%). Eighty percent of the injuries were caused by landmines, and UXO explosions were reported in 20% of the cases. Overall, 24 children (30%) had received some landmine-risk education before or after the events. Sixty percent of the explosions had happened in the morning between 9:00 am and 12:00 pm. Playing and grazing livestock were the most prevalent activities/reasons at the time of injury, which were reported in 77% of the subjects. Sixty-three percent of incidents had multiple casualties and in only 13 explosions were the children the only victims of the explosion. The most prevalent injuries were amputations in 41 subjects (52.56%), followed by hearing loss in 23 subjects (29.5%). Amputations were more common in upper extremities (62%) than in lower extremities (38%).
ConclusionLandmines and UXOs comprise a significant safety hazard to the children living in the Western border of Iran decades after the Iraq-Iran War. The large number of injuries and lack of risk training among victims suggest that landmine cleanings and landmine-risk education should be age-specifically targeted and expanded substantially.
,Mousavi B ,Soroush MR ,Masoumi M ,Khateri S ,Modirian E ,Shokoohi H ,Fatemi MJ ,Hematti MA ,Soroush M ,Ghassemi-Broumand M ,Rassafiani M ,Allami M ,Nouri F ,Yavari A ,Ganjparvar Z ,Kamyab M ,Mirsadeghi SA Epidemiological Study of Child Casualties of Landmines and Unexploded Ordnances: A National Study from Iran . Prehosp Disaster Med.2015 ;30 (5 ):472 –477 .
Comprehensive Reviews
Orthopedic Injuries and Their Treatment in Children During Earthquakes: A Systematic Review
- Ilaria Morelli, Maria Grazia Sabbadini, Michelangelo Bortolin
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- Published online by Cambridge University Press:
- 19 August 2015, pp. 478-485
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Orthopedic injuries commonly affect children during earthquakes, but reports about them are rare. This setting may lead to different standards of care, but guidelines are still missing in this field. A systematic review was performed to: (1) assess type and body distribution of pediatric earthquake-related injuries, treatment performed, length of stay, and complications; and (2) identify starting points to define standards of care.
PubMed database was researched for papers (1999-2014 period) in agreement with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Statement. Inclusion criteria were: English, French, Spanish, or Italian language and data reported about orthopedic lesions in children (≤18 years old). Reviews, letters, commentaries, editorials, and single case reports were excluded. Two independent reviewers selected articles after abstract and full-text reading.
Traumatic injuries caused child hospital admissions ranging from 46.9% to 100.0%; 16% to 53% suffered fractures. Lower limbs mostly were involved. Soft-tissue injuries affected 55% of patients. Debridement and external fixation (EF) were the most frequent surgical treatments. Amputation rates varied from 5% to 11%.
This study revealed that field hospitals should be prepared to: (1) treat mainly lower extremities fractures in children; and (2) use especially EF techniques. The presence of orthopedic surgeons familiar with pediatric traumatology should be considered.
,Morelli I ,Sabbadini MG .Bortolin M Orthopedic Injuries and Their Treatment in Children During Earthquakes: A Systematic Review . Prehosp Disaster Med.2015 ;30(5 ):478 –485 .
Emergency Preparedness and Disaster Response: There’s An App for That
- Daniel J. Bachmann, Nathan K. Jamison, Andrew Martin, Jose Delgado, Nicholas E. Kman
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- Published online by Cambridge University Press:
- 15 September 2015, pp. 486-490
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Introduction
Smartphone applications (or apps) are becoming increasingly popular with emergency responders and health care providers, as well as the public as a whole. There are thousands of medical apps available for Smartphones and tablet computers, with more added each day. These include apps to view textbooks, guidelines, medication databases, medical calculators, and radiology images.
Hypothesis/ProblemWith an ever expanding catalog of apps that relate to disaster medicine, it is hard for both the lay public and responders to know where to turn for effective Smartphone apps. A systematic review of these apps was conducted.
MethodsA search of the Apple iTunes store (Version 12; Apple Inc.; Cupertino, California USA) was performed using the following terms obtained from the PubMed Medical Subject Headings Database: Emergency Preparedness, Emergency Responders, Disaster, Disaster Planning, Disaster Medicine, Bioterrorism, Chemical Terrorism, Hazardous Materials (HazMat), and the Federal Emergency Management Agency (FEMA). After excluding any unrelated apps, a working list of apps was formed and categorized based on topics. Apps were grouped based on applicability to responders, the lay public, or regional preparedness, and were then ranked based on iTunes user reviews, value, relevance to audience, and user interface.
ResultsThis search revealed 683 applications and was narrowed to 219 based on relevance to the field. After grouping the apps as described above, and subsequently ranking them, the highest quality apps were determined from each group. The Community Emergency Response Teams and FEMA had the best apps for National Disaster Medical System responders. The Centers for Disease Control and Prevention (CDC) had high-quality apps for emergency responders in a variety of fields. The National Library of Medicine’s Wireless Information System for Emergency Responders (WISER) app was an excellent app for HazMat responders. The American Red Cross had the most useful apps for natural disasters. Numerous valuable apps for public use, including alert apps, educational apps, and a well-made regional app, were also identified.
ConclusionSmartphone applications are fast becoming essential to emergency responders and the lay public. Many high-quality apps existing in various price ranges and serving different populations were identified. This field is changing rapidly and it deserves continued analysis as more apps are developed.
,Bachmann DJ ,Jamison NK ,Martin A ,Delgado J .Kman NE Emergency Preparedness and Disaster Response: There’s An App for That . Prehosp Disaster Med.2015 ;30 (5 ):1 –5 .
Brief Reports
Prehospital Agitation and Sedation Trial (PhAST): A Randomized Control Trial of Intramuscular Haloperidol versus Intramuscular Midazolam for the Sedation of the Agitated or Violent Patient in the Prehospital Environment
- Derek L. Isenberg, Dorian Jacobs
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- Published online by Cambridge University Press:
- 01 September 2015, pp. 491-495
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Introduction
Violent patients in the prehospital environment pose a threat to health care workers tasked with managing their medical conditions. While research has focused on methods to control the agitated patient in the emergency department (ED), there is a paucity of data looking at the optimal approach to subdue these patients safely in the prehospital setting.
HypothesisThis study evaluated the efficacy of two different intramuscular medications, midazolam and haloperidol, to determine their efficacy in sedating agitated patients in the prehospital setting.
MethodsThis was a prospective, randomized, observational trial wherein agitated patients were administered intramuscular haloperidol or intramuscular midazolam to control agitation. Agitation was quantified by the Richmond Agitation and Sedation Scale (RASS). Paramedics recorded the RASS and vital signs every five minutes during transport and again upon arrival to the ED. The primary outcome was mean time to achieve a RASS less than +1. Secondary outcomes included mean time for patients to return to baseline mental status and adverse events.
ResultsFive patients were enrolled in each study group. In the haloperidol group, the mean time to achieve a RASS score of less than +1 was 24.8 minutes (95% CI, 8-49 minutes), and the mean time for the return of a normal mental status was 84 minutes (95% CI, 0-202 minutes). Two patients required additional prehospital doses for adequate sedation. There were no adverse events recorded in the patients administered haloperidol.
In the midazolam group, the mean time to achieve a RASS score of less than +1 was 13.5 minutes (95% CI, 8-19 minutes) and the mean time for the return of normal mental status was 105 minutes (95% CI, 0-178 minutes). One patient required additional sedation in the ED. There were no adverse events recorded among the patients administered midazolam.
ConclusionsMidazolam and haloperidol administered intramuscularly appear equally effective for sedating an agitated patient in the prehospital setting. Midazolam appears to have a faster onset of action, as evidenced by the shorter time required to achieve a RASS score of less than +1 in the patients who received midazolam. Haloperidol offers an alternative option for the sedation of an agitated patient. Further studies should focus on continued investigation into appropriate sedation of agitated patients in the prehospital setting.
,Isenberg DL .Jacobs D Prehospital Agitation and Sedation Trial (PhAST): A Randomized Control Trial of Intramuscular Haloperidol versus Intramuscular Midazolam for the Sedation of the Agitated or Violent Patient in the Prehospital Environment . Prehosp Disaster Med.2015 ;30 (5 ):491 –495 .
Hurricane Sandy: Impact on Emergency Department and Hospital Utilization by Older Adults in Lower Manhattan, New York (USA)
- Hiroshi Gotanda, Joyce Fogel, Gregg Husk, Jeffrey M. Levine, Monte Peterson, Kevin Baumlin, Joseph Habboushe
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- Published online by Cambridge University Press:
- 15 September 2015, pp. 496-502
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Background
On October 29th, 2012, Hurricane Sandy caused a storm surge interrupting electricity with disruption to Manhattan’s (New York, USA) health care infrastructure. Beth Israel Medical Center (BIMC) was the only fully functioning major hospital in lower Manhattan during and after Hurricane Sandy. The impact on emergency department (ED) and hospital use by geriatric patients in lower Manhattan was studied.
MethodsThe trends of ED visits and hospitalizations in the immediate post-Sandy phase (IPS) during the actual blackout (October 29 through November 4, 2012), and the extended post-Sandy phase (EPS), when neighboring hospitals were still incapacitated (November 5, 2012 through February 10, 2013), were analyzed with baseline. The analysis was broken down by age groups (18-64, 65-79, and 80+ years old) and included the reasons for ED visits and admissions.
ResultsDuring the IPS, there was a significant increase in geriatric visits (from 11% to 16.5% in the 65-79 age group, and from 6.5% to 13% in the 80+ age group) as well as in hospitalizations (from 22.7% to 25.2% in the 65-79 age group, and from 17.6% to 33.8% in the 80+ age group). However, these proportions returned to baseline during the EPS. The proportions of the categories “dialysis,” “respiratory device,” “social,” and “syncope” in geriatric patients in ED visits were significantly higher than younger patients. The increases of the categories “medication,” “dialysis,” “respiratory device,” and “social” represented two-thirds of absolute increase in both ED visits and admissions for the 65-79 age group, and half of the absolute increase in ED visits for the 80+ age group. The categories “social” and “respiratory device” peaked one day after the disaster, “dialysis” peaked two days after, and “medication” peaked three days after in ED visit analysis.
ConclusionsThere was a disproportionate increase in ED visits and hospitalizations in the geriatric population compared with the younger population during the IPS. The primary factor of the disproportionate impact on the geriatric population appears to be from indirect effects of the hurricane, mainly due to the subsequent power outages, such as “dialysis,” “respiratory device,” and “social.” Further investigation by chart review may provide more insights to better aid with future disaster preparedness.
,Gotanda H ,Fogel J ,Husk G ,Levine JM ,Peterson M ,Baumlin K .Habboushe J Hurricane Sandy: Impact on Emergency Department and Hospital Utilization by Older Adults in Lower Manhattan, New York (USA) . Prehosp Disaster Med.2015 ;30 (5 ):496 –502.
Development of an Online Toolkit for Measuring Performance in Health Emergency Response Exercises
- Foluso Agboola, Dorothy Bernard, Elena Savoia, Paul D. Biddinger
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- Published online by Cambridge University Press:
- 15 September 2015, pp. 503-508
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Introduction
Exercises that simulate emergency scenarios are accepted widely as an essential component of a robust Emergency Preparedness program. Unfortunately, the variability in the quality of the exercises conducted, and the lack of standardized processes to measure performance, has limited the value of exercises in measuring preparedness.
MethodsIn order to help health organizations improve the quality and standardization of the performance data they collect during simulated emergencies, a model online exercise evaluation toolkit was developed using performance measures tested in over 60 Emergency Preparedness exercises. The exercise evaluation toolkit contains three major components: (1) a database of measures that can be used to assess performance during an emergency response exercise; (2) a standardized data collection tool (form); and (3) a program that populates the data collection tool with the measures that have been selected by the user from the database. The evaluation toolkit was pilot tested from January through September 2014 in collaboration with 14 partnering organizations representing 10 public health agencies and four health care agencies from eight states across the US. Exercise planners from the partnering organizations were asked to use the toolkit for their exercise evaluation process and were interviewed to provide feedback on the use of the toolkit, the generated evaluation tool, and the usefulness of the data being gathered for the development of the exercise after-action report.
ResultsNinety-three percent (93%) of exercise planners reported that they found the online database of performance measures appropriate for the creation of exercise evaluation forms, and they stated that they would use it again for future exercises. Seventy-two percent (72%) liked the exercise evaluation form that was generated from the toolkit, and 93% reported that the data collected by the use of the evaluation form were useful in gauging their organization’s performance during the exercise. Seventy-nine percent (79%) of exercise planners preferred the evaluation form generated by the toolkit to other forms of evaluations.
ConclusionResults of this project show that users found the newly developed toolkit to be user friendly and more relevant to measurement of specific public health and health care capabilities than other tools currently available. The developed toolkit may contribute to the further advancement of developing a valid approach to exercise performance measurement.
,Agboola F ,Bernard D ,Savoia E .Biddinger PD Development of an Online Toolkit for Measuring Performance in Health Emergency Response Exercises . Prehosp Disaster Med.2015 ;30 (5 ):503 –508 .
Case Report
Helicopter In-flight Resuscitation with Freeze-dried Plasma of a Patient with a High-velocity Gunshot Wound to the Neck in Afghanistan – A Case Report
- Mikael Gellerfors, Joacim Linde, Dan Gryth
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- Published online by Cambridge University Press:
- 01 September 2015, pp. 509-511
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Massive hemorrhage with coagulopathy is one of the leading causes of preventable death in the battlefield. The development of freeze-dried plasma (FDP) allows for early treatment with coagulation-optimizing resuscitation fluid in the prehospital setting. This report describes the first prehospital use of FDP in a patient with carotid artery injury due to a high-velocity gunshot wound (HVGSW) to the neck. It also describes in-flight constitution and administration of FDP in a Medevac Helicopter. Early administration of FDP may contribute to hemodynamic stabilization and reduction in trauma-induced coagulopathy and acidosis. However, large-scale studies are needed to define the prehospital use of FDP and other blood products.
,Gellerfors M ,Linde J .Gryth D Helicopter In-flight Resuscitation with Freeze-dried Plasma of a Patient with a High-velocity Gunshot Wound to the Neck in Afghanistan – A Case Report . Prehosp Disaster Med.2015 ;30 (5 ):509 –511 .
Special Reports
Research and Evaluations of the Health Aspects of Disasters, Part I: An Overview
- Marvin L. Birnbaum, Elaine K. Daily, Ann P. O’Rourke, Alessandro Loretti
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- Published online by Cambridge University Press:
- 09 October 2015, pp. 512-522
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The ultimate goals of conducting disaster research are to obtain information to: (1) decrease risks that a hazard will produce a disaster; (2) decrease the mortality associated with disasters; (3) decrease the morbidity associated with disasters; and (4) enhance recovery of the affected community. And decrease the risks that a hazard will produce a disaster. Two principal, but inter-related, branches of disaster research are: (1) Epidemiological; and (2) Interventional. Epidemiological research explores the relationships and occurrences that comprise a disaster from a particular event. Interventional research involves evaluations of interventions, whether they are directed at relief, recovery, hazard mitigation, capacity building, or performance. In response to the need for the discipline of Disaster Health to build its science on data that are generalizeable and comparable, a Disaster Logic Model (DLM) and a set of five Frameworks have been developed to structure the information and research of the health aspects of disasters. These Frameworks consist of the: (1) Conceptual; (2) Temporal; (3) Societal; (4) Relief/Recovery; and (5) Risk-Reduction Frameworks. The Frameworks provide a standardized format for studying and comparing the epidemiology of disasters, and with the addition of the DLM, for evaluating the interventions (responses) provided prior to, during, and following a disaster, especially as they relate to the health status of the people affected by, or at-risk for, a disaster. Critical to all five Frameworks is the inclusion of standardized definitions of the terms. The Conceptual Framework describes the progression of a hazard that becomes an event, which causes structural damage, which, in turn, results in compromised, decreased, or losses of function(s) (functional damage) that, in turn, produce needs that lead to an emergency or a disaster. The Framework incorporates a cascade of risks that lead from the presence of a hazard to the development of a disaster. Risk is the likelihood that each of the steps leading from a hazard to a disaster will take place, as well as the probabilities of consequences of each of the elements in the Conceptual Framework. The Temporal Framework describes this chronological progression as phases in order of their appearance in time; some may occur concurrently. In order to study and compare the effects of an event on the complex amalgam that constitutes a community, the essential functions of a community have been deconstructed into 13 Societal Systems that comprise the Societal Framework. These diverse, but inter-related, Societal Systems interface with each other through a 14th System, Coordination and Control. The DLM can be used to identify the effects, costs, outcomes, and impacts of any intervention. Both the Relief/Recovery and Risk-Reduction Frameworks are based on the DLM. The Relief/Recovery Framework provides the structure necessary to systematically evaluate the processes involved in interventions provided during the Relief or Recovery phases of a disaster. The Risk-Reduction Framework details the processes involved in interventions aimed at mitigating the risk that a hazard will produce a destructive event, and/or in capacity building to augment the resilience of a community to the consequences of such an event.
,Birnbaum ML ,Daily EK ,O’Rourke AP .Loretti A Research and Evaluations of the Health Aspects of Disasters, Part I: An Overview . Prehosp Disaster Med.2015 ;30 (5 ):512 –522 .
Research and Evaluations of the Health Aspects of Disasters, Part II: The Disaster Health Conceptual Framework Revisited
- Marvin L. Birnbaum, Elaine K. Daily, Ann P. O’Rourke, Alessandro Loretti
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- Published online by Cambridge University Press:
- 09 October 2015, pp. 523-538
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A Conceptual Framework upon which the study of disasters can be organized is essential for understanding the epidemiology of disasters, as well as the interventions/responses undertaken. Application of the structure provided by the Conceptual Framework should facilitate the development of the science of Disaster Health. This Framework is based on deconstructions of the commonly used Disaster Management Cycle. The Conceptual Framework incorporates the steps that occur as a hazard progresses to a disaster. It describes an event that results from the changes in the release of energy from a hazard that may cause Structural Damages that in turn, may result in Functional Damages (decreases in levels of function) that produce needs (goods and services required). These needs can be met by the goods and services that are available during normal, day-to-day operations of the community, or the resources that are contained within the community’s Response Capacity (ie, an Emergency), or by goods and services provided from outside of the affected area (outside response capacities). Whenever the Local Response Capacity is unable to meet the needs, and the Response Capacities from areas outside of the affected community are required, a disaster occurs. All responses, whether in the Relief or Recovery phases of a disaster, are interventions that use the goods, services, and resources contained in the Response Capacity (local or outside). Responses may be directed at preventing/mitigating further deterioration in levels of functions (damage control, deaths, injuries, diseases, morbidity, and secondary events) in the affected population and filling the gaps in available services created by Structural Damages (compromise in available goods, services, and/or resources; ie, Relief Responses), or may be directed toward returning the affected community and its components to the pre-event functional state (ie, Recovery Responses). Hazard Mitigation includes interventions designed to decrease the likelihood that a hazard will cause an event, and should an event occur, that the amount of energy released will be reduced. Capacity Building consists of all interventions undertaken before an event occurs in order to increase the resilience of the community to an event related to a hazard that exists in an area-at-risk. Resilience is the combination of the Absorbing, Buffering, and Response Capacities of a community-at-risk, and is enhanced through Capacity-Building efforts. A disaster constitutes a failure of resilience.
,Birnbaum ML ,Daily EK ,O’Rourke AP .Loretti A Research and Evaluations of the Health Aspects of Disasters, Part II: The Disaster Health Conceptual Framework Revisited . Prehosp Disaster Med.2015 ;30 (5 ):523 –538 .
Operation Protective Edge – A Unique Challenge for a Civilian EMS Agency
- Eli Jaffe, Refael Strugo, Oren Wacht
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- Published online by Cambridge University Press:
- 01 September 2015, pp. 539-542
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During July through August 2014, Operation Protective Edge, a military conflict between Israel and the Hamas regime in Gaza, dramatically affected both populations. Magen David Adom (MDA), the Israeli national Emergency Medical Service (EMS) and a member of the Red Cross, faced a unique challenge during the conflict: to continue providing crucial service to the entire civilian population of Israel, which was under constant missile threat. This challenge included not only providing immediate care for routine EMS calls under missile threat, but also preparing and delivering immediate care to civilians injured in attacks on major cities, as well as small communities, in Israel. This task is a challenge for a civilian EMS agency that normally operates in a non-military environment, yet, in an instant, must enhance its capability to respond to a considerable threat to its population. During Operation Protective Edge, MDA provided care for 842 wounded civilians and utilized a significant amount of its resources. Providing EMS services for a civilian population in a mixed civilian/military scenario is a challenging task on a national level for an EMS system, especially when the threat lasts for weeks. This report describes MDA’s preparedness and operations during Operation Protective Edge, and the unique EMS challenges and dilemmas the agency faced.
,Jaffe E ,Wacht O .Strugo R Operation Protective Edge – A Unique Challenge for a Civilian EMS Agency . Prehosp Disaster Med.2015 ;30 (5 ):539 –542 .
Field Report: Medical Response to Super Typhoon Haiyan
- Michael Noone
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- 09 October 2015, pp. 543-544
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Event: Typhoon (high-velocity winds and flooding from storm surge/rains)
Event Onset Date: November 8, 2013
Location of Report: Tacloban, Leyte Island, Philippines
Geographic Coordinates: latitude 11°13m N, longitude 125°1m E; elevation: 3 meters
Response Dates: November 18-28, 2013
Response Type: Medical Relief (Humanitarian)
Front Cover (OFC, IFC) and matter
PDM volume 30 issue 5 Cover and Front matter
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- Published online by Cambridge University Press:
- 09 October 2015, pp. f1-f8
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