Prehospital management and medical intervention after a chemical attack

Chemical warfare agents are toxic weapons and emergency prehospital medical care providers should be well prepared, trained, and equipped to give response. Personnel need to be aware of the following medical issues regarding prehospital management of a chemical attack, event recognition, incident medical command and control, safety and protection, decontamination, isolation of the incident area (hot zone, warm zone, and cold zone), sampling and detection, psychological management, communication, triage, treatment, transportation, recovery activities and fatality management. During prehospital response, healthcare responders should provide self protection by wearing proper protective equipment and ensuring that the casualty is thoroughly decontaminated. Medical first responders are also responsible for performing triage in each zone of the incident area. Victims are triaged into four categories based on the need for medical care; immediate, delayed, minimal, and expectant. Finally, a medical emergency planning should be completed, and exercises conducted to test the system before an event occurs.     

Clinical analogies for the management of toxic trauma

The management of injuries from toxic release (HAZMAT) incidents is unfamiliar to many emergency medical responders owing to the relative rarity of such incidents. However, the risks from toxic release in both industrial and other metropolitan areas are increasing and emergency medical services (EMS) personnel should be trained to be aware of the dangers to both victims and responders alike. Many examples exist of analogies for the management of HAZMAT situations from conventional prehospital and hospital emergency medicine. Application of the lessons learned in more familiar situations will be of benefit for the preparation of an effective EMS response for HAZMAT.     

A primer for nuclear terrorism

Mass exposure to radiologic substances presents a unique challenge to the entire response effort, which includes health care professionals, law enforcement personnel, and other first responders. Recognition of signs and symptoms of exposure, and focus on removal and decontamination are priorities of management. Radiation injuries require specialized equipment and access to experts. Patients can have complex patterns of injury, ranging from trauma and the immediate results of an explosion or exposure, to progressive damage associated with radiation sickness. Both conventional injury and radiation illness may require critical care management. Remembering the essentials of first response, that is, treat the patient, not the poison, by addressing the ABCs of airway, breathing, and circulation, is critical to appropriate treatment of radiation exposure. Understanding the basic science of radiologic agents will aid the provider in managing affected patients and preventing further casualties.     

Nonresponse bias: does it affect measurement of clinician behavior?

BACKGROUND: Previous studies of nonresponders have not assessed the effects of nonresponse on the accuracy of clinician behavior measurements. Knowledge of these effects is critical to both research and quality improvement. OBJECTIVE: To evaluate the hypothesis that nonresponders to a survey would not adversely affect the ability to measure rates of preventive services. RESEARCH DESIGN: Four primary-care medical practices participating in a randomized clinical trial provided an unusual opportunity to compare the medical record-documented care of both responders and nonresponders to a survey of their patients. SUBJECTS: Three hundred forty-five nonresponders and 321 responders to a questionnaire requesting participation in the study. MEASURES: Differences in patient characteristics and diseases and documentation of screening and management of tobacco use, hypertension, and hypercholesterolemia. RESULTS: Although the survey process resulted in a response rate of only 52.5% and some statistically significant differences in responder and nonresponder characteristics, there were no differences in management behavior regarding cardiovascular risk factors. Responders were more likely to have adjusted documentation of tobacco use (OR = 1.4), blood pressure measurement (OR = 9.8), and cholesterol testing (OR = 2.0), but not family history of cardiovascular disease. The most striking difference in subject characteristics was that 22.0% of nonresponders and only 12.1% of responders were tobacco users (P = 0.002). CONCLUSIONS: This study confirms that survey nonresponders may have some different characteristics and risk factor screening rates than responders. However, if confirmed by others, nonresponders who have risk factors identified may not be managed differently than responders.     

临床科室应用计算机管理系统的体会

笔报道医院病房应用住院信息网络管理系统的体会。介绍医院住院信息管理系统的组成及功能，阐述病人管理、医嘱管理、工作单、信息查询、数据维护操作方法，认为该系统在应用过程中操作简便，功能齐全，对医院住院管理实现科学化、规范化、系统化，提高护理人员素质，提高医护质量和工作效率，减少医患矛盾起到重大的作用。     

2015 Pediatric Research Priorities in Prehospital Care

Background: Pediatric prehospital research has been limited, but work in this area is starting to increase particularly with the growth of pediatric-specific research endeavors. Given the increased interest in pediatric prehospital research, there is a need to identify specific research priorities that incorporate the perspective of prehospital providers and other emergency medical services (EMS) stakeholders. Objectives: To develop a list of specific research priorities that is relevant, specific, and important to the practice of pediatric prehospital care. Methods: Three independent committees of EMS providers and researchers were recruited. Each committee developed a list of research topics. These topics were collated and used to initiate a modified Delphi process for developing consensus on a list of research priorities. Participants were the committee members. Topics approved by 80% were retained as research priorities. Topics that were rejected by more than 50% were eliminated. The remaining topics were modified and included on subsequent surveys. Each survey allowed respondents to add additional topics. The surveys were continued until all topics were either successfully retained or rejected and no new topics were suggested. Results: Fifty topics were identified by the three independent committees. These topics were included on the initial electronic survey. There were 5 subsequent surveys. At the completion of the final survey a total of 29 research priorities were identified. These research priorities covered the following study areas: airway management, asthma, cardiac arrest, pain, patient-family interaction, resource utilization, seizure, sepsis, spinal immobilization, toxicology, trauma, training and competency, and vascular access. The research priorities were very specific. For example, under airway the priorities were: “identify the optimal device for effectively managing the airway in the prehospital setting” and “identify the optimal airway management device for specific disease processes.” Conclusion: This project developed a list of relevant, specific, and important research priorities for pediatric prehospital care. Some similarities exist between this project and prior research agendas but this list represents a current, more specific research agenda and reflects the opinions of working EMS providers, researchers, and leaders.     

Pain and combat injuries in soldiers returning from Operations Enduring Freedom and Iraqi Freedom: implications for research and practice

Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF) have resulted in a growing number of seriously injured soldiers who are evacuated to the United States for comprehensive medical care. Trauma-related pain is an almost universal problem among these war-injured soldiers, and several military and Department of Veterans Affairs initiatives have been implemented to enhance pain care across the continuum of medical services. This article describes several innovative approaches for improving the pain care provided to OEF and OIF military personnel during acute stabilization, transport, medical-surgical treatment, and rehabilitation and presents summary data characterizing the soldiers, pain management services provided, and associated outcomes. We also identify some of the pain assessment, classification, and treatment challenges emerging from work with this population and provide recommendations for future research and practice priorities.     

Pain management documentation: analyzing one hospital's computerized clinical records

Pain management documentation, consisting of assessment, interventions, and reassessment, can help provide an important means of communication among practitioners to individualize care. Standard-setting organizations use pain management documentation as a key indicator of quality. Adoption of the electronic medical record alters the presentation of pain management documentation data for clinical and quality evaluation use. The purpose of this study was to describe pain management documentation output from the electronic medical record to gain an understanding of its presentation and evaluate the quantity and quality of the output. After institutional review board approval, data were abstracted from 51 electronic records of postsurgical patients in a 100-bed community hospital. Time-variant pain assessments, interventions, and reassessments were organized into pain management episodes to provide clinically interpretable data for evaluation. Data sources were identified. Data generated 1499 episodes for analysis. Analysis of variance results implied that pain management documentation changes with pain severity. Despite legibility and date and time stamping, inconsistencies and omitted and duplicated documentation were identified. Inconsistent data origination posed difficulty for interpreting clinically relevant associations. Improvements are required to streamline fields and consolidate entries to allow for output in alignment with care.     

Initial Management of Trauma

Treatment of patients with multiple injuries involves the clinician's judgement in establishing treatment priorities, and certain mechanical skills which are outlined in this article. Resuscitation, treatment, management, and transportation priorities are described, with illustrative case histories. This article is written primarily for the physician practicing outside a metropolitan centre.     

Management of patients with factor VIII inhibitors

In summary, while a great deal of information has accumulated concerning the properties and natural history of F VIII inhibitors, management remains frustrating and controversial. While bleeding episodes in those who are low responders can be treated with F VIII concentrates, treatment of bleeding in high responders is often much more difficult. Current therapeutic options include F VIII concentrates of human or porcine origin in high dosage, and PCC or APCC. The choice of treatment depends on the patient's current inhibitor concentration, the type and severity of bleeding, product availability, and the preference of the medical personnel involved. However, none of the available therapeutic modalities work as well as F VIII in a hemophiliac without an inhibitor. Perhaps more promising are the immune tolerance regimens that have been developed and are now being modified and fine tuned by a number of investigators. Such regimens have reportedly eradicated F VIII inhibitors in some hemophiliacs, and have converted others from high responders to low responders, in whom bleeding episodes can be effectively treated with conventional doses of F VIII. In contrast to the F VIII inhibitors developing in hemophiliacs, those developing in nonhemophiliacs can often be eradicated with corticosteroids or immunosuppressive drugs, either alone or in combination with F VIII. Not all respond to such approaches and serious hemorrhage may still occur. Treatment of bleeding episodes has included the use of human or porcine F VIII, APCC and, in two instances, DDAVP.     

An Internet-based exercise as a component of an overall training program addressing medical aspects of radiation emergency management

The use of ionizing radiation and radioactive materials continues to increase worldwide in industry, medicine, agriculture, research, electrical power generation, and nuclear weaponry. The risk of terrorism using weapons of mass destruction or simple radiological devices also has increased, leading to heightened concerns. Radiation accidents occur as a consequence of errors in transportation of radionuclides, use of radiation in medical diagnosis and therapy, industrial monitoring and sterilization procedures, and rarely, nuclear power generation. Compared to other industries, a small number of serious radiation accidents have occurred over the last six decades with recent cases in the Republic of Georgia, Peru, Japan, and Thailand. The medical, psychological, and political consequences of such accidents can be considerable. A number of programs designed to train medical responders in the techniques of radiation accident management have been developed and delivered in many countries. The low frequency of serious radiation accidents requires constant re-training, as skills are lost and medical staff turnover occurs. Not all of the training involves drills or exercises in which responders demonstrate learning or communication over the broad spectrum of medical response capabilities. Medical preparedness within the context of a total emergency response program is lacking in many parts of the world, particularly in Central and Eastern Europe and the Newly Independent States. This paper describes an effort to enhance medical preparedness in the context of a total program of international cooperation and conventions facilitated by the International Atomic Energy Agency. The paper concludes that novel application of telecommunications technology as part of a training activity in radiation accident preparedness can help address gaps in training in this field in which preparedness is essential but experience and practical field exercises are lacking.     

Quality management tool for mass casualty emergency responses and disasters

INTRODUCTION AND BACKGROUND: Quality management (QM) principles generally have not been applied to multi-casualty and disaster situations. Quality management incorporates quality assurance (QA) and quality improvement (QI) supported by a management information system (MIS). Since responders to disasters and multi-casualty incidents generally operate on standing orders and/or protocols, the character of the responses lends itself to quality management methods. Standards and indicators of performance readily can be developed for these situations. OBJECTIVES: 1) to format disaster medical records as data collection instruments; 2) to develop appropriate tools that are easy to use for rapid assessments; 3) to develop a mechanism for determination of causes of injuries; and 4) to develop methods to: a) track patients; b) document response and recovery; and c) document the circumstances associated with the event. METHODS: Model tools using checklists and short, fill-in answers are provided. These tools are designed to be incorporated into the trauma or EMS registries. Emergency medical technicians, nurses, physicians, and medical students scored the same disaster scenario for the functional areas of calling the state of the disaster, triage, and field stabilization. RESULTS: Testing indicated that the checklists are completed in less than one minute, and produce objective data per patient in each functional area evaluated. In one instance, data were compiled for 38 patients from one bus accident in less than 10 minutes. The same data were reproduced, without variation, in the same amount of time, by three different providers of varied professional backgrounds.     

Surgical preparation of the trauma victim

Successful management of the victim of multisystem trauma depends on an orderly scheme of resuscitation and diagnostic evaluation. This management is directed by the general surgeon heading the trauma service. Based on his or her knowledge of the mechanisms of injury and the initial physical examination, the surgeon establishes priorities of treatment for the most life-threatening injuries. He directs the preoperative preparation, including communication with the operating room and anesthesia staffs, assembly of a basic laboratory profile, and placement of lines and tubes. The trauma surgeon identifies need for consultation in the medical or surgical specialties and formulates a strategy for surgical management with the consultants. Finally, based on his or her impression of the injuries and their relative severity, the surgeon selects the diagnostic tests, particularly peritoneal lavage, CT scan of the head and body, and arteriography, all of which will be needed to complete the surgical preparation.     

Mass casualty management of a large-scale bioterrorist event: an epidemiological approach that shapes triage decisions

The threat of a BT event has catalyzed serious reflection on the troublesome issues that come with event management and triage. Such reflection has had the effect of multiplying the efforts to find solutions to what could become a catastrophic public health disaster. Management options are becoming more robust, as are reliable detection devices and rapid access to stockpiled antibiotics and vaccines. There is much to be done, however, especially in the organizing, warehousing, and granting/exercising authority for resource allocations. The introduction of these new options should encourage one to believe that, in time, evolving standards of care will make it possible to rethink the currently unthinkable consequences. Unfortunately the cost of such preparedness is high and out of reach of most governments. Most of the developing world has neither the will nor the means to plan for BT events and remains overwhelmed with basic public health concerns (i.e., water, food, sanitation, shelter) that must take priority. Therefore, developed countries will be expected to respond using international exogenous resources to mitigate the effects of such a disaster. As a result, the state capacity of the effected government will be severely compromised. If triage and management of casualties is further compromised, terrorists will have met their goals. One could argue that health sciences will continue for decades to play catch up with the advanced technology driving potential bioagent weaponry. If one lesson was learned from the review of the former Soviet Union's biological weapons program, it is that the unthinkable remains an option to terrorists who have comparable expertise. It is crucial to develop realistic strategies for a BT event. Triage planning (the process of establishing criteria for health care prioritization) permits society to see cases in the context of diverse moral perspectives, limited resources, and compelling health care demands. This includes a competent and compassionate management and triage system and an in-depth and accurate health information system that appropriately addresses every level of threat or consequence. In a PICE stage I to III BT event resources will be compromised. Triage and management will be one process requiring multiple levels of cooperation, coordination, and decision-making. An immediate challenge to existing emergency medical services systems (EMSS) is the recognition that locally there will be a shift of emphasis and decision-making from prehospital first responders to community public health authorities. The author suggests that a working relationship, in most areas, between EMSS and the public health system is lacking. As priorities shift in a BT event to hospitals and public health care systems, they need to: 1. Improve their capabilities and capacities in surveillance, discovery, and in the consequences of different triage and management decisions and interventions in a BT environment, starting at the local level. 2. Develop triage and management systems (with clear lines of authority) based on public health and epidemiologic requirements, capability, and capacity (triage teams, categories, tags, rapid response, established operational priorities, resource-driven responsible management process), and link local level surveillance systems with those at the national or regional level. 3. Use a triage and management system that reflects the population (cohort) at risk, such as the epidemiologic based SEIRV triage framework. 4. Develop an organizational capacity that uses lateral decision-making skills, pre-hospital outpatient centers for triage-specific treatments, health information systems, and resource-driven hospital level pre-designated protocols appropriate for a surge of unprecedented proportions. Such standards of care, it is recommended, should be set at the local to federal levels and spelled out in existing incident-management system protocols.     

Surviving collapsed structure entrapment after earthquakes: a "time-to-rescue" analysis

INTRODUCTION: Massive earthquakes often cause structures to collapse, trapping victims under dense rubble for long periods of time. Commonly, this spurs resource intensive, dangerous, and frustrating attempts to find and extricate live victims. The search and rescue phase usually is maintained for many days beyond the last "save," potentially diverting critical attention and resources away from the pressing needs of non-trapped survivors and the devastated community. This recurring phenomenon is driven by the often-unanswered question "Can anyone still be alive under there?" The maximum survival time in entrapment is an important issue for responders, yet little formal research has been conducted on this issue. Knowing the maximum survival time in entrapment helps responders: (1) decide whether or not they should continue to assign limited resources to search and rescue activities; (2) assess the safety risks versus the benefits; (3) determine when search and rescue activities no longer are indicated; and (4) time and pace the important transition to community recovery efforts. METHODS: The time period of 1985-2004 was selected for investigation. Medline and Lexis-Nexis databases were searched for earthquake events that occurred within this timeframe. Medical literature articles providing time-torescue data for victims of earthquakes were identified. Lexis-Nexis reports were scanned to select those with time-to-rescue data for victims of earthquakes. Reports from both databases were examined for information that might contribute to prolonged survival of entrapped individuals. RESULTS: A total of 34 different earthquake events met study criteria. Forty-eight medical articles containing time-to-rescue data were identified. Of these, the longest time to rescue was "13-19 days" post-event (secondhand data and the author is not specific). The second longest time to rescue in the medical articles was 8.7 days (209 hours). Twenty-five medical articles report multiple rescues that occurred after two days (48 hours). Media reports describe rescues occurring beyond Day 2 in 18 of 34 earthquakes. Of these, the longest reliably reported survival is 14 days after impact, with the next closest having survived 13 days. The average maximum times reported from these 18 earthquakes was 6.8 days (median = 5.75 days). The event with the most media reports of distinct rescue events was the 1999 Marmara, Turkey earthquake (43 victims). Times range from 0.5 days (12 hours) to 6.2 days (146 hours) for this event. Both databases provide little formal data to develop detailed insight into factors affecting survivability during entrapment. CONCLUSIONS: A thorough search of the English-language medical literature and media accounts provides a provocative picture of numerous survivors beyond 48 hours of entrapment under rubble, with a few successfully enduring entrapment of 13-14 days. These data are not necessarily applicable to non-earthquake collapsed-structure events. For incident managers and their medical advisors, the study findings and discussion may be useful for post-impact decision-making and in establishing and/or revising incident priorities as the response evolves.     

Traumatic brain injury rehabilitation: case management and insurance-related issues

Traumatic brain injury (TBI) cases are medically complex, involving the physical, cognitive, behavioral, social, and emotional aspects of the survivor. Often catastrophic, these cases require substantial financial resources not only for the patient's survival but to achieve the optimal outcome of a functional life with return to family and work responsibilities for the long term. TBI cases involve the injured person, the family, medical professionals such as treating physicians, therapists, attorneys, the employer, community resources, and the funding source, usually an insurance company. Case management is required to facilitate achievement of an optimal result by collaborating with all parties involved, assessing priorities and options, coordinating services, and educating and communicating with all concerned.     

Acute care patient falls: evaluation of a revised fall prevention program following comparative analysis of psychiatric and medical patient falls

Eliminating falls and fall-associated injuries are priorities in health care. This study examined the impact of revised fall prevention interventions on psychiatric and medical patient falls. After policy revisions were well established, psychiatric falls diminished and medical falls increased. A contributing factor to the medical population finding was policy intervention noncompliance.