Editor’s Corner
2019: The Year in Disaster Health and Medicine Research
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- Samuel J. Stratton
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- Published online by Cambridge University Press:
- 03 February 2020, pp. 1-2
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Original Research
The Risk of Cancer from CT Scans and Other Sources of Low-Dose Radiation: A Critical Appraisal of Methodologic Quality
- Carl H. Schultz, Romeo Fairley, Linda Suk-Ling Murphy, Mohan Doss
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- Published online by Cambridge University Press:
- 03 February 2020, pp. 3-16
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Introduction:
Concern exists that radiation exposure from computerized tomography (CT) will cause thousands of malignancies. Other experts share the same perspective regarding the risk from additional sources of low-dose ionizing radiation, such as the releases from Three Mile Island (1979; Pennsylvania USA) and Fukushima (2011; Okuma, Fukushima Prefecture, Japan) nuclear power plant disasters. If this premise is false, the fear of cancer leading patients and physicians to avoid CT scans and disaster responders to initiate forced evacuations is unfounded.
Study Objective:This investigation provides a quantitative evaluation of the methodologic quality of studies to determine the evidentiary strength supporting or refuting a causal relationship between low-dose radiation and cancer. It will assess the number of higher quality studies that support or question the role of low-dose radiation in oncogenesis.
Methods:This investigation is a systematic, methodologic review of articles published from 1975–2017 examining cancer risk from external low-dose x-ray and gamma radiation, defined as less than 200 millisievert (mSv). Following the PRISMA guidelines, the authors performed a search of the PubMed, Cochrane, Scopus, and Web of Science databases. Methodologies of selected articles were scored using the Newcastle Ottawa Scale (NOS) and a tool identifying 11 lower quality indicators. Manuscript methodologies were ranked as higher quality if they scored no lower than seven out of nine on the NOS and contained no more than two lower quality indicators. Investigators then characterized articles as supporting or not supporting a causal relationship between low-dose radiation and cancer.
Results:Investigators identified 4,382 articles for initial review. A total of 62 articles met all inclusion/exclusion criteria and were evaluated in this study. Quantitative evaluation of the manuscripts’ methodologic strengths found 25 studies met higher quality criteria while 37 studies met lower quality criteria. Of the 25 studies with higher quality methods, 21 out of 25 did not support cancer induction by low-dose radiation (P = .0003).
Conclusions:A clear preponderance of articles with higher quality methods found no increased risk of cancer from low-dose radiation. The evidence suggests that exposure to multiple CT scans and other sources of low-dose radiation with a cumulative dose up to 100 mSv (approximately 10 scans), and possibly as high as 200 mSv (approximately 20 scans), does not increase cancer risk.
Dispatcher Identification of Out-of-Hospital Cardiac Arrest and Neurologically Intact Survival: A Retrospective Cohort Study
- Julian G. Mapp, Anthony M. Darrington, Stephen A. Harper, Chetan U. Kharod, David A. Miramontes, David A. Wampler, Prehospital Research and Innovation in Military and Expeditionary Environments (PRIME) Research Group
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- 29 November 2019, pp. 17-23
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Introduction:
To date, there are no published data on the association of patient-centered outcomes and accurate public-safety answering point (PSAP) dispatch in an American population. The goal of this study is to determine if PSAP dispatcher recognition of out-of-hospital cardiac arrest (OHCA) is associated with neurologically intact survival to hospital discharge.
Methods:This retrospective cohort study is an analysis of prospectively collected Quality Assurance/Quality Improvement (QA/QI) data from the San Antonio Fire Department (SAFD; San Antonio, Texas USA) OHCA registry from January 2013 through December 2015. Exclusion criteria were: Emergency Medical Services (EMS)-witnessed arrest, traumatic arrest, age <18 years old, no dispatch type recorded, and missing outcome data. The primary exposure was dispatcher recognition of cardiac arrest. The primary outcome was neurologically intact survival (defined as Cerebral Performance Category [CPC] 1 or 2) to hospital discharge. The secondary outcomes were: bystander cardiopulmonary resuscitation (CPR), automated external defibrillator (AED) use, and prehospital return of spontaneous return of circulation (ROSC).
Results:Of 3,469 consecutive OHCA cases, 2,569 cases were included in this analysis. The PSAP dispatched 1,964/2,569 (76.4%) of confirmed OHCA cases correctly. The PSAP dispatched 605/2,569 (23.6%) of confirmed OHCA cases as another chief complaint. Neurologically intact survival to hospital discharge occurred in 99/1,964 (5.0%) of the recognized cardiac arrest group and 28/605 (4.6%) of the unrecognized cardiac arrest group (OR = 1.09; 95% CI, 0.71–1.70). Bystander CPR occurred in 975/1,964 (49.6%) of the recognized cardiac arrest group versus 138/605 (22.8%) of the unrecognized cardiac arrest group (OR = 3.34; 95% CI, 2.70–4.11).
Conclusion:This study found no association between PSAP dispatcher identification of OHCA and neurologically intact survival to hospital discharge. Dispatcher identification of OHCA remains an important, but not singularly decisive link in the OHCA chain of survival.
Preparedness of Pharmaceutical Services in Military Organizations: Learning from an Assessment in Brazil
- Tatiana Holanda Pereira de Souza, Elaine Silva Miranda
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- 06 December 2019, pp. 24-31
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Introduction:
The participation of armed forces in humanitarian operations and in disaster response is common in many countries. In Brazil, the armed forces have had history in providing health support to victims in emergencies, which also includes the provision of pharmaceutical services (PS).
Problem:Even though being essential for the provision of health care in disaster response, the preparedness of PS is not well-addressed in the literature. The use of a comprehensive approach to evaluate preparedness of PS in military institutions may subsidize preparedness measures. The goals of this work were to analyze the preparedness of PS for disaster response and humanitarian aid in military units of a Brazilian armed force institution, and to propose a framework to improve the preparedness of PS in operational medicine.
Methods:An investigation of a cross-sectional design was performed. A logic model and indicators to evaluate preparedness of PS were applied. Data were obtained from official documents, interviews with key stakeholders, and observation of good storage practices (GSP).
Results:Identified were: lack of specific budget for medicine procurement in case of disaster, absence of emergency stockpile, proper means for medicine transportation, and records of trained health professionals. An emergency plan, a list of selected medicines, adaptable mobile health care units, and a system for mobilization of health professionals were some of the positive aspects recognized. Different aspects for improvement were acknowledged and recommendations to favor the efficiency and the quality of PS in emergencies were proposed.
Conclusions:The investigation provided valuable results for the planning and execution of responses to disasters and humanitarian aid. The findings and proposed recommendations may be useful for other military organizations similar to those in Brazil.
Temporal Trends and Future Predictions of Regional EMS System Utilization Using Statistical Modeling
- Michael J. Carr, Robert Bauter, Philip Shepherd, Vincent Robbins, A.J. McKechnie, Beatrice Cappuccia, Mark A. Merlin
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- 06 December 2019, pp. 32-40
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Introduction:
Trends in utilization of Emergency Medical Services (EMS) systems can be used to extrapolate future use of an EMS system, which will be valuable for the budgeting and planning of finances and resources. The best model for incorporation of seasonal and regional fluctuations in utilization to predict future utilization is unknown.
Problem:Authors aimed to trend patterns of utilization in a regional EMS system to identify the needs of a growing population and to allow for a better understanding of how the EMS system is used on a basis of call volume and frequency of EMS transportation. The authors then used a best-fitting prediction model approach to show how the studied EMS system will be used in future years.
Methods:Systems data were retrospectively extracted by using the electronic medical records of the studied EMS system and its computer-assisted dispatch (CAD) database from 2010 through 2017. All EMS dispatches entering the system’s 9-1-1 public service access point were captured. Annual utilization data were available from 2010 through 2017, while quarterly data were available only from 2013 through 2017. The 9-1-1 utilization per capita, Advanced Life Support (ALS) utilization per capita, and ALS cancel rates were calculated and trended over the study period. The methods of prediction were assessed through a best-fitting model approach, which statistically suggested that Additive Winter’s approach (SAS) was the best fit to determine future utilization and ALS cancel rates.
Results:Total 9-1-1 call volume per capita increased by 32.46% between 2010 and 2017, with an average quarterly increase of 0.78% between 2013 and 2017. Total ALS call volume per capita increased by 1.93% between 2010 and 2017. Percent ALS cancellations (cancelled en route to scene) increased by eight percent between 2010 and 2017, with an average quarterly increase of 0.42% (2013–2017). Predictions to end of 2019 using Additive Winter’s approach demonstrated increasing trends in 9-1-1 call volume per capita (R2 = 0.47), increasing trends of ALS utilization per capita (R2 = 0.71), and increasing percent ALS cancellation (R2 = 0.93). Each prediction showed increasing future trends with a 95% confidence interval.
Conclusions:The authors demonstrate paramount per capita increases of 9-1-1 call volume in the studied ALS system. There are concomitant increases of ALS cancellations prior to arrival, which suggests a potential burden on this regional ALS response system.
Safety and Efficacy of an On-Site Intensive Treatment Protocol for Mild and Moderate Sympathomimetic Toxicity at Australian Music Festivals
- Ned Douglas, James Carew, Damian Johnson, Madeline Green, Nicholas Wilson, Jake Donovan, Tim Mulherin, Lachlan Holbery-Morgan, Elyssia Bourke, Erin Smith
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- 06 December 2019, pp. 41-45
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Introduction:
Serotonin and sympathomimetic toxicity (SST) after ingestion of amphetamine-based drugs can lead to severe morbidity and death. There have been evaluations of the safety and efficacy of on-site treatment protocols for SST at music festivals.
Problem:The study aimed to examine the safety and efficacy of treating patients with SST on-site at a music festival using a protocol adapted from hospital-based treatment of SST.
Methods:The study is an audit of presentations with SST over a one-year period. The primary outcome was need for ambulance transport to hospital. The threshold for safety was prospectively defined as less than 10% of patients requiring ambulance transport to hospital.
The protocol suggested patients be treated with a combination of benzodiazepines; cold intravenous (IV) fluid; specific therapies (cyproheptadine, chlorpromazine, and clonidine); rapid sequence intubation; and cooling with ice, misted water, and convection techniques.
Results:One patient of 13 (7.7%) patients with mild or moderate SST required ambulance transport to hospital. Two of seven further patients with severe SST required transport to hospital.
Conclusions:On-site treatment may be a safe, efficacious, and efficient alternative to urgent transport to hospital for patients with mild and moderate SST. The keys to success of the protocol tested included inclusive and clear education of staff at all levels of the organization, robust referral pathways to senior clinical staff, and the rapid delivery of therapies aimed at rapidly lowering body temperature. Further collaborative research is required to define the optimal approach to patients with SST at music festivals.
Application of the “Plan-Do-Study-Act” Model to Improve Survival after Cardiac Arrest in Korea: A Case Study
- Joo Yeong Kim, Hanjin Cho, Jong-Hak Park, Joo-Hyun Song, Sungwoo Moon, Hongjae Lee, Hyun Ju Yang, Juliana Tolles, Nichole Bosson, Roger J. Lewis
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- 06 December 2019, pp. 46-54
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Objective:
Low rates of bystander cardiopulmonary resuscitation (CPR) were identified as a shortcoming in the “chain of survival” for out-of-hospital cardiac arrest (OHCA) care in the Korean city of Ansan. This study sought to evaluate the effect of an initiative to increase bystander CPR and quality of out-of-hospital resuscitation on outcome from OHCA. The post-intervention data were used to determine the next quality improvement (QI) target as part of the “Plan-Do-Study-Act” (PDSA) model for QI.
Hypothesis:The study hypothesis was that bystander CPR, return of spontaneous circulation (ROSC), and survival to discharge after OHCA would increase in the post-intervention period.
Methods:This was a retrospective pre/post study. The data from the pre-intervention period were abstracted from 2008–2011 and the post-intervention period from 2012–2013. The effect of the intervention on the odds of ROSC and survival to hospital discharge was determined using a generalized estimating equation to account for confounders and the effect of clustering within medical centers. The analysis was then used to identify other factors associated with outcomes to determine the next targets for intervention in the chain of survival for cardiac arrest in this community.
Results:Rates of documented bystander CPR increased from 13% in the pre-intervention period to 37% in the post-intervention period. The overall rate of ROSC decreased from 18.4% to 14.3% (risk difference −4.1%; 95% CI, −7.1%–1.0%), whereas survival to hospital discharge increased from 3.9% to 5.0% (risk difference 1.1%; 95% CI, −1.8%–3.8%), and survival with good neurologic outcome increased from 0.8% to 1.6% (risk difference 0.8%; 95% CI, −0.8%–2.4%). In multivariable analyses, there was no association between the intervention and the rate of ROSC or survival to hospital discharge. The designated level of the treating hospital was a significant predictor of both survival and ROSC.
Conclusion:In this case study, there were no observed improvements in outcomes from OHCA after the targeted intervention to improve out-of-hospital CPR. However, utilizing the PDSA model for QI, the designated level of the treating hospital was found to be a significant predictor of survival in the post-period, identifying the next target for intervention.
The Effect of Operator Position on the Quality of Chest Compressions Delivered in a Simulated Ambulance
- Scott Mullin, Sinéad Lydon, Paul O’Connor
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- 09 December 2019, pp. 55-60
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Background:
Ambulances are where patient care is often initiated or maintained, but this setting poses safety risks for paramedics. Paramedics have found that in order to optimize patient care, they must compromise their own safety by standing unsecured in a moving ambulance.
Hypothesis/Problem:This study sought to compare the quality of chest compressions in the two positions they can be delivered within an ambulance.
Methods:A randomized, counterbalanced study was carried out with 24 paramedic students. Simulated chest compressions were performed in a stationary ambulance on a cardiopulmonary resuscitation (CPR) manikin for two minutes from either: (A) an unsecured standing position, or (B) a seated secured position. Participants’ attitudes toward the effectiveness of the two positions were evaluated.
Results:The mean total number of chest compressions was not significantly different standing unsecured (220; SD = 12) as compared to seated and secured (224; SD = 21). There was no significant difference in mean compression rate standing unsecured (110 compressions per minute; SD = 6) as compared to seated and secured (113 compressions per minute; SD = 10). Chest compressions performed in the unsecured standing position yielded a significantly greater mean depth (52 mm; SD = 6) than did seated secured (26 mm; SD = 7; P < .001). Additionally, the standing unsecured position produced a significantly higher percentage (83%; SD = 21) for the number of correct compressions, as compared to the seated secured position (8%; SD = 17; P < .001). Participants also believed that chest compressions delivered when standing were more effective than those delivered when seated.
Conclusions:The quality of chest compressions delivered from a seated and secured position is inferior to those delivered from an unsecured standing position. There is a need to consider how training, technologies, and ambulance design can impact the quality of chest compressions.
Systematic Review
Defining and Operationalizing Disaster Preparedness in Hospitals: A Systematic Literature Review
- Marlous LMI Verheul, Michel LA Dückers
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- 12 December 2019, pp. 61-68
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Introduction:
Societies invest substantial amounts of resources on disaster preparedness of hospitals. However, the concept is not clearly defined nor operationalized in the international literature.
Aim:This review aims to systematically assess definitions and operationalizations of disaster preparedness in hospitals, and to develop an all-encompassing model, incorporating different perspectives on the subject.
Methods:A systematic search was conducted in five databases: Scopus, PubMed, Web of Science, Disaster Information Management Research Centre, and SafetyLit. Peer-reviewed articles containing definitions and operationalizations of disaster preparedness in hospitals were included. Articles published in languages other than English, or without available full-text, were excluded, as were articles on prehospital care. The findings from literature were used to build a model for hospital disaster preparedness.
Results:In the included publications, 13 unique definitions of disaster preparedness in hospitals and 22 different operationalizations of the concept were found. Although the definitions differed in emphasis and width, they also reflected similar elements. Based on an analysis of the operationalizations, nine different components could be identified that generally were not studied in relation to each other. Moreover, publications primarily focused on structure and process aspects of disaster preparedness. The aim of preparedness was described in seven articles.
Discussion/Conclusion:This review points at an absence of consensus on the definition and operationalization of disaster preparedness in hospitals. By combining elements of definitions and components operationalized, disaster preparedness could be conceptualized in a more comprehensive and complete way than before. The model presented can guide future disaster preparedness activities and research.
Special Report
CDC’s Multiple Approaches to Safeguard the Health, Safety, and Resilience of Ebola Responders
- Richard W. Klomp, Laurie Jones, Emi Watanabe, William W. Thompson
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- 10 December 2019, pp. 69-75
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Over 27,000 people were sickened by Ebola and over 11,000 people died between March of 2014 and June of 2016. The US Centers for Disease Control and Prevention (CDC; Atlanta, Georgia USA) was one of many public health organizations that sought to stop this outbreak. This agency deployed almost 2,000 individuals to West Africa during that timeframe. Deployment to these countries exposed these individuals to a wide variety of dangers, stressors, and risks.
Being concerned about the at-risk populations in Africa, and also the well-being of its professionals who willingly deployed, the CDC did several things to help safeguard the health, safety, and resilience of these team members before, during, and after deployment.
The accompanying special report highlights innovative pre-deployment training initiatives, customized screening processes, and post-deployment outreach efforts intended to protect and support the public health professionals fighting Ebola. Before deploying, the CDC team members were expected to participate in both internally-created and externally-provided trainings. These ranged from pre-deployment briefings, to Preparing for Work Overseas (PFWO) and Public Health Readiness Certificate Program (PHRCP) courses, to Incident Command System (ICS) 100, 200, and 400 courses.
A small subset of non-clinical deployers also participated in a three-day training designed in collaboration with the Center for the Study of Traumatic Stress (CSTS; Bethesda, Maryland USA) to train individuals to assess and address the well-being and resilience of themselves and their teammates in the field during a deployment. Participants in this unique training were immersed in a Virtual Reality Environment (VRE) that simulated deployment to one of seven different types of emergencies.
The CDC leadership also requested a pre-deployment screening process that helped professionals in the CDC’s Occupational Health Clinic (OHC) determine whether or not individuals were at an increased risk of negative outcomes by participating in a rigorous deployment at that time.
When deployers returned from the field, they received personalized invitations to participate in a voluntary, confidential, post-deployment operational debriefing one-on-one or in a group.
Implementing these approaches provided more information to clinical decision makers about the readiness of deployers. It provided deployers with a greater awareness of the kinds of challenges they were likely to face in the field. The post-deployment outreach efforts reminded staff that their contributions were appreciated and there were resources available if they needed help processing any of the potentially-traumatizing things they may have experienced.
Real-Time Impact Analysis and Response using a New Disaster Metrics: 2018 Sulawesi (Indonesia) Earthquake and Tsunami
- YingYing Yew, Pedro Arcos González, Rafael Castro Delgado
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- 13 January 2020, pp. 76-82
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Introduction:
The Richter Scale measures the magnitude of the seismic activity for an earthquake; however, it does not quantify the humanitarian need at the point of impact. This poses a challenge for humanitarian stakeholders in decision and policy making, especially in risk reduction, response, recovery, and reconstruction. The new disaster metrics tool titled “The YEW Disaster Severity Index” (DSI) was developed and presented at the 2017 World Congress of Disaster and Emergency Medicine, May 2017, Toronto, Canada. It uses a median score of three for vulnerability and exposure indicators, a median score percentage of 100%, and medium YEW DSI scoring of four to five as baseline, indicating the ability to cope within local capacity. Therefore, scoring more than baseline coping capacity indicates that external assistance is needed. This special real-time report was presented at the 2nd National Pre-Hospital Care Conference and Championship, October 2018, Malaysia.
Report:The aim of this analysis is to present the real-time humanitarian impact and response to the 2018 earthquake and tsunami at Donggala and Palu, Sulawesi in Indonesia using the new disaster metrics YEW DSI. Based on the earthquake (measuring 7.7 on the Richter Scale) and tsunami at Donggala, the humanitarian impact calculated on September 29, 2018 scored 7.4 High in the YEW DSI with 11 of the total 17 indicators scoring more than the baseline coping capacity. The same YEW DSI score of 7.4 was scored on the earthquake and tsunami at Palu, with 13 of the total 17 indicators scoring more than baseline ability to cope within local capacity. Impact analysis reports were sent to relevant authorities on September 30, 2018.
Discussion & Conclusion:A State of Emergency was declared for a national response, which indicated an inability to cope within the local capacity, shown by the YEW DSI. The strong correlation between the earthquake magnitude, intensities, and the humanitarian impact at Donggala and Palu reported could be added into the science of knowledge in prehospital care and disaster medicine research and practice. As a conclusion, the real-time disaster response was found to be almost an exact fit with the YEW DSI indicators, demonstrating the inability to cope within the local capacity.
Brief Report
Comparing Resource Management Skills in a High- versus Low-Resource Simulation Scenario: A Pilot Study
- Alba Ripoll Gallardo, Grazia Meneghetti, Jeffrey M. Franc, Alessandro Costa, Luca Ragazzoni, Moran Bodas, Vaclav Jordan, Francesco Della Corte
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- 06 December 2019, pp. 83-87
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Background:
Low-resource environments, such as those found in humanitarian crises, pose significant challenges to the provision of proper medical treatment. While the lack of training of health providers to such settings has been well-acknowledged in literature, there has yet to be any scientific evidence for this phenomenon.
Methods:This pilot study utilized a randomized crossover experimental design to examine the effects of high- versus low-resource simulated scenarios of a resuscitation of a critically ill obstetric patient on a medical doctors’ performance and inter-personal skills. Ten senior residents (fifth-year post-graduate) of the Maggiore Hospital School of Medicine (Novara, NO, Italy) were included in the study.
Results:Overall performance score for the high-resource setting was 5.2, as opposed to only 2.3 for the low-resource setting. The mean effect size for the overall score was 2.9 (95% CI, 1.7–4.0; P <.001). The results suggest a significant decrease in both technical (medical) and non-technical skills, such as leadership, problem solving, situation awareness, resource utilization, and communication in the low-resource environment setting. The latter finding is of special important since it was yet to be reported.
Conclusions:This pilot study suggests that untrained physicians in low-resource environments may experience a considerable setback not only to their professional performance, but also to their interpersonal skills, when deployed ill-prepared to humanitarian missions. Consequently, this may endanger the health of local populations.
Proposal for Reforming Prehospital Response to Chemical Terrorism Disasters in Japan: Going Back to the Basics of Saving the Lives of the Injured by Securing the Safety of the Rescue Team
- Hideaki Anan, Yasuhiro Otomo, Masato Homma, Kenichi Oshiro, Hisayoshi Kondo, Fumihiko Shimamura, Ayako Takahashi, Masahiko Hamada, Atushi Hirabayashi, Yuichi Koido
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- 06 December 2019, pp. 88-91
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Introduction:
Having experienced the Tokyo subway sarin attack in 1995, Japan has established extremely strict rules on handling injured victims before they are sent to a hospital. As a result, it takes a long time before rescue actions are taken. This report aims to propose a reform to change the system that focuses on saving lives.
Methods:First, the issues in firefighting on sites that currently present problems in Japan were identified. Then, Japanese guidelines were compared with those that were considered in other countries. Based on this, an ideal way of running rescue operations was examined, and a proposal to save many lives was made. This research was conducted with funding from the Ministry of Health, Labour, and Welfare of Japan (MHLW; Chiyoda, Tokyo, Japan).
Results:In addition to preventing secondary injuries, the temporal aspect of rescuing people early with the clear goal of saving many lives was emphasized. Priority was given to measures against nerve agents to prevent secondary injuries, which put the rescuers’ lives at risk. Possible decontamination methods were pursued before choosing the one that was most appropriate. A linear algorithm was used to determine which decontamination method could be started immediately, and then the gradual use of equipment was recommended. Even if Level A personal protective equipment (PPE) and other dedicated equipment and materials cannot be procured, the possibility of starting rescue activities under certain condition using regular equipment was pointed out. The need for a system for possible victims who would require support, such as foreigners, the handicapped, and elderly people, was also identified. Japan limits the scope of activities that can be undertaken by emergency medical technicians (EMTs) on-site. The way in which on-site medical care can be provided with future legal revisions in mind was also discussed.
Conclusion:There is an urgent need to build a framework in which rescue activities can take place so that the number of deaths would not rise, even if sarin and other poisons are scattered.
Rationale for Military Involvement in Humanitarian Assistance and Disaster Relief
- Deon V. Canyon, Benjamin J. Ryan, Frederick M. Burkle, Jr
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- 06 December 2019, pp. 92-97
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Good relations and trust are the foundation of soft power diplomacy and are essential for the accomplishment of domestic interventions and any bilateral or multilateral endeavor. Military use for assistance and relief is not a novel concept, but it has increased since the early 1990s with many governments choosing to provide greater numbers of forces and assets to assist domestically and internationally. The increase is due to the growing lack of capacity in global humanitarian networks and increasingly inadequate resources available to undertake United Nations humanitarian assistance and disaster relief (HADR) missions. In response, the military has been more proactive in pursuing the improvement of military-to-military and military-to-civilian integration. This trend reflects a move towards more advanced and comprehensive approaches to security cooperation and requires increased support from the civilian humanitarian sector to help meet the needs of the most vulnerable. Military assistance is progressing beyond traditional methods to place a higher value on issues relating to civil cooperation, restoring public health infrastructure, protection, and human rights, all of which are ensuring a permanent diplomatic role for this soft power approach.
Epidemiological and Accounting Analysis of Ground Ambulance Whole Blood Transfusion
- Julian G. Mapp, Eric A. Bank, Lesley A. Osborn, Michael L. Stringfellow, David W. Reininger, Christopher J. Winckler, Prehospital Research and Innovation in Military and Expeditionary Environments (PRIME2) Group
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- 18 December 2019, pp. 98-103
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Introduction:
In October 2017, the American Association of Blood Bankers (AABB; Bethesda, Maryland USA) approved a petition to allow low-titer group O whole blood as a standard product without the need for a waiver. Around that time, a few Texas, USA-based Emergency Medical Services (EMS) systems incorporated whole blood into their ground ambulances. The purpose of this project was to describe the epidemiology of ground ambulance patients that received a prehospital whole blood transfusion. The secondary aim of this project was to report an accounting analysis of these ground ambulance prehospital whole blood programs.
Methods:The dataset came from the Harris County Emergency Service District 48 Fire Department (HCESD 48; Harris County, Texas USA) and San Antonio Fire Department (SAFD; San Antonio, Texas USA) whole blood Quality Assurance/Quality Improvement (QA/QI) databases from September 2017 through December 2018. The primary outcome of this study was the prehospital transfusion indication. The secondary outcome was the projected cost per life saved during the first 10 years of the prehospital whole blood initiative.
Results:Of 58 consecutive prehospital whole blood administrations, the team included all 58 cases. Hemorrhagic shock from a non-traumatic etiology accounted for 46.5% (95% CI, 34.3%-59.2%) of prehospital whole blood recipients. In the non-traumatic hemorrhagic shock cohort, gastrointestinal hemorrhage was the underlying etiology of hemorrhagic shock in 66.7% (95% CI, 47.8%-81.4%) of prehospital whole blood transfusion recipients. The projected average cost to save a life in Year 10 was US$5,136.51 for the combined cohort, US$4,512.69 for HCESD 48, and US$5,243.72 for SAFD EMS.
Conclusion:This retrospective analysis of ground ambulance patients that receive prehospital whole blood transfusion found that non-traumatic etiology accounted for 46.5% (95% CI, 34.3%-59.2%) of prehospital whole blood recipients. Additionally, the accounting analysis suggests that by Year 10 of a ground ambulance whole blood transfusion program, the average cost to save a life will be approximately US$5,136.51.
Advantage and Limitation of Using a Visual Feedback Device during Cardiopulmonary Resuscitation Training
- Chan Woong Kim, Je Hyeok Oh
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- 08 January 2020, pp. 104-108
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Introduction:
Recent cardiopulmonary resuscitation (CPR) guidelines recommend the use of CPR prompt/feedback devices during CPR training because it can improve the quality of CPR.
Problem:Chest compression depth and full chest recoil show a trade-off relationship. Therefore, achievement of both targets (adequate chest compression depth and full chest recoil) simultaneously is a difficult task for CPR instructors. This study hypothesized that introducing a visual feedback device to the CPR training could improve the chest compression depth and ratio of full chest recoil simultaneously.
Methods:The study investigated the effects of introducing a visual feedback device during CPR training by comparing the results of skill tests before and after introducing a visual feedback device. The results of skill tests from 2016 through 2018 were retrospectively reviewed. The strategy of emphasizing chest compression depth was implemented during the CPR training in 2017, and a visual feedback device was introduced in 2018. The interval between the CPR training and skill tests was seven days. Feedback was not provided during the skill tests.
Results:In total, 159 students completed skill tests. Although the chest compression depth increased significantly from 50 mm (42–54) to 60 mm (59–61) after emphasizing chest compression depth (P < .001), the ratio of full chest recoil decreased simultaneously from 100% (100–100) to 81% (39–98; P < .001). The ratio of full chest recoil increased significantly from 81% (39–98) to 95% (77–100) after introducing a visual feedback device (P = .018). However, the students who did not achieve 80% of the ratio of full chest recoil remained significantly higher than in 2016 (1% in 2016, 49% in 2017, and 27% in 2018; P < .001).
Conclusions:Although introducing a visual feedback device during CPR training resulted in increasing the ratio of full chest recoil while maintaining the adequacy of chest compression depth, 27% of the students still did not achieve 80% of the ratio of full chest recoil. Another educational strategy should be considered to increase the qualities of CPR more completely.
Case Report
Inhaled Epoprostenol to Facilitate Safe Transport in Legionnaires’ Disease
- Corrine Foster, Michael A. Frakes, Erica Puopolo, Francis McNulty, Mark S. Saia, Mike Hourihan, Margaret Flynn, Susan R. Wilcox
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- Published online by Cambridge University Press:
- 09 January 2020, pp. 109-114
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Hypoxemic patients often desaturate further with movement and transport. While inhaled epoprostenol does not improve mortality, improving oxygenation allows for transport of severely hypoxemic patients to tertiary care centers with a related improvement in mortality rates. Extracorporeal membrane oxygenation (ECMO) use is increasing in frequency for patients with refractory hypoxemia, and with increasing regionalization of care, safe transport of hypoxemic patients only becomes more important. In this series, four cases are presented of young patients with severe hypoxemic respiratory failure from Legionnaires’ disease transported on inhaled epoprostenol to ECMO centers for consideration of cannulation. With continued climate changes, Legionella and other pathogens are likely to be a continued threat. As such, optimizing oxygenation to allow for transport should continue to be a priority for critical care transport (CCT) services.
Prehospital External Aortic Compression for Temporizing Exsanguinating Sub-Diaphragmatic Hemorrhage – A Promising Technique, but with Challenges: Four Illustrative Cases, Including Two Survivors
- Bruce Richard Paix, David John Tingey, Grant Copley, Matthew Casson, Damien Shoolbread, Hari Davuluru, James Doube, Wade Emmerton, Ryan Kennedy
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- 13 January 2020, pp. 115-118
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External aortic compression (EAC) has long been used to control exsanguinating post-partum hemorrhage, but it has only recently been described in the prehospital trauma setting. This paper reports four cases where manual EAC was used during transport to manage life-threatening bleeding, twice from stab wounds, once from ruptured ectopic pregnancy, and once from severe lower-limb trauma. It showed that EAC has life-saving potential in the prehospital setting, but that safety and efficacy during transport requires the use of a hands-free compression device, such as an aortic tourniquet.
Front Cover (OFC, IFC) and matter
PDM volume 35 issue 1 Cover and Front matter
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- Published online by Cambridge University Press:
- 03 February 2020, pp. f1-f6
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Back Cover (IBC, OBC) and matter
PDM volume 35 issue 1 Cover and Back matter
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- Published online by Cambridge University Press:
- 03 February 2020, pp. b1-b2
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