院外心搏骤停第一反应人空间需求配置研究

目的通过构建最大覆盖选址模型,分析基于院外心搏骤停(out-of-hospital cardiac arrest,OHCA)的第一反应人空间需求配置,以有效缩短OHCA应急反应时间,提高院前急救和现场救护水平。方法收集上海市浦东新区2012年1月至2016年12月OHCA院前急救病历信息,将OHCA位置信息录入Arc地理信息系统(geographic information system,GIS)中,并构建最大覆盖选址模型,输出不同OHCA覆盖率下第一反应人的需求量及对应位置。结果当覆盖半径为100 m时,第一反应人可在指南推荐的救治时间内快步行走至OHCA患者身边,其需求量至少为4626人时才能覆盖95%的OHCA。若第一反应人借助自行车骑行至患者身边,其最大覆盖半径为300 m,此时需至少配置1626名第一反应人才能覆盖95%的OHCA。结论第一反应人空间需求配置方案为建立第一反应人体系和现场救护新模式提供了参考依据,并提示在未来可以培训网格化管理人员作为第一反应人,为其合理配置交通工具,从而提高OHCA患者存活率和社区急救护理水平。     

A Pooled Analysis of Two Randomized,Double‐Blind,Placebo‐Controlled Trials of Milnacipran Monotherapy in the Treatment of Fibromyalgia

Milnacipran has been shown to significantly improve the pain, global well‐being, and physical function of fibromyalgia (FM), and is approved by the U.S. Food and Drug Administration for the management of this disorder. Post hoc analyses of data from two pivotal trials were conducted to further assess the clinical benefits of milnacipran, to determine the impact of baseline pain severity on treatment outcomes, and to confirm the safety and tolerability of this medication in patients with FM. Patients in these trials were randomized to placebo (n = 624), milnacipran 100 mg/day (n = 623), or milnacipran 200 mg/day (n = 837). Two different composite responder analyses were used to evaluate efficacy: a 2‐measure analysis, requiring ≥ 30% improvement from baseline visual analog scale 24‐hour recall pain scores and a Patient Global Impression of Change (PGIC) score of “very much improved” or “much improved”; and a 3‐measure analysis, requiring a ≥ 6‐point improvement from baseline in SF‐36 Physical Component Summary scores in addition to the pain and PGIC criteria. Additionally, a pooled analysis of mean changes from baseline pain scores was conducted in order to evaluate the efficacy of milnacipran over the entire course of treatment. At 3 months, composite responder rates were significantly higher in the milnacipran treatment groups than in the placebo group (2‐ and 3‐measure composite responder analyses: P ≤ 0.001, both doses vs. placebo). These improvements were not dependent on baseline pain severity. Similar composite responder results were observed in patients who continued treatment for up to 6 months. Significant improvements in mean pain scores were seen with both doses of milnacipran vs. placebo as early as 1 week after treatment initiation and were sustained for up to 6 months of milnacipran treatment. The most common adverse events associated with milnacipran were nausea, headache, and constipation.     

Counter-Terrorism for Emergency Responders,Second Edition

Abstract

Acute coronary syndrome and myocardial infarction have been described to present with atypical symptoms in certain subsets of patients. However, these subsets commonly do not include middle-aged males with a paucity of underlying medical conditions. We present a very unique case of acute coronary syndrome in a 53-year-old male, with no previously identified medical conditions other than chronic back pain. The patient was encountered by rural emergency medical service providers presenting with syncope followed by intermittent episodes of lightheadedness. Further, electrocardiographic changes consistent with acute ischemia could only be demonstrated with the patient in a standing position, prior to the development of an occurrence of ventricular tachycardia, which degenerated into ventricular fibrillation. To our knowledge, this is a very rare case of electrocardiographic changes consistent with occult, acute cardiac ischemia with a proven coronary artery lesion seen initially only with the patient in a standing position.     

Can First Responders Be Sent to Selected 9‐1‐1 Emergency Medical Services Calls without an Ambulance?

OBJECTIVES: To evaluate the feasibility and safety of initially dispatching only first responders (FRs) to selected low-risk 9-1-1 requests for emergency medical services. First responders are rapidly-responding fire crews on apparatus without transport capabilities, with firefighters trained to at least a FR level and in most cases to the basic emergency medical technician (EMT) level. Low-risk 9-1-1 requests include automatic medical alerts (ALERTs), motor vehicle incidents (MVIs) for which the caller was unable to answer any medical dispatch questions designed to prioritize the call, and 9-1-1 call disconnects (D/Cs). METHODS: A before-and-after study of patient dispositions was conducted using historical controls for comparison. During the historical control phase of six months, one year prior to the study phase, basic life support ambulances (staffed with two basic EMTs) were dispatched to selected low-risk 9-1-1 incidents. During the six-month study phase, a fire FR crew equipped with automated external defibrillators (AEDs) was sent initially without an ambulance to these incidents. RESULTS: For ALERTs (n = 290 in historical group vs. 330 in study group), there was no statistical difference in the transport rate (7% vs 10%), but there was a statistically significant increase in the follow-up use of advanced life support (ALS) (1% vs 4%, p = 0.009). No patient in the ALERTs historical group required airway management, while one patient in the study group received endotracheal intubation. No patient required defibrillation in either group. Analysis of the MVIs showed a significant decrease (p < 0.0001) in the patient transport rate from 39% of controls to 33% of study patients, but no change in the follow-up use of ALS interventions (2% for each group). For both the ALERTs and MVIs, the FR's mean response time was faster than ambulances (p < 0.0001). Among the 9-1-1 D/Cs with FRs only (n = 1,028), 15% were transported and 43 (4%) received subsequent ALS care. Four of these patients (0.4%) received intubation and two (0.2%) required defibrillation. However, no patient was judged to have had adverse outcomes as a result of the dispatch protocol change. CONCLUSIONS: Fire apparatus crews trained in the use of AEDs can safely be used to initially respond alone (without ambulances) to selected, low-risk 9-1-1 calls. This tactic improves response intervals while reducing ambulance responses to these incidents.     

Development,Implementation andOutcomes of a Training Program for Responders to Acts of Terrorism

Introduction. Responding to acts of terrorism requires the effective use of public-safety andmedical-response resources. The knowledge, skills andattitudes necessary to respond to future threats is unfamiliar to most emergency responders. Objectives. The purpose of this report to describe the development, implementation andevaluation of a multidisciplinary, interactive andsimulation-enhanced course to prepare responders to acts of terrorism. Methods. We used a 5-step systematic process to develop a blended-learning, simulation-enhanced training program. Learners completed a self-confidence questionnaire andwritten examination prior to the course anda self-confidence questionnaire, written examination andcourse evaluation when they finished the course. Results. From July 7, 2003 to March 8, 2005, 497 consenting learners completed the course. After course completion, learners demonstrated significant increases in their knowledge of terrorism response (t = ?64.3, df = 496, p < 0.05) andtheir confidence in responding to terrorist events (t = ?45.5, df = 496, p < 0.05). Learner feedback about the course was highly positive. Conclusions. We successfully implemented a two-day course for professionals likely to respond to terrorist acts that included scenario-based performance training andassessment. Course participants increased their knowledge andwere more confident in their ability to respond to acts of terrorism after participating in this course.     

Three Examples of Rh‐Positive, Good Responders to Blood Group Antigens

Three patients are described who produced a variety of blood group antibodies following exposure to foreign red cells. These findings are considered in relation to the theory that a small group of individuals possess an ability, possibly genetically determined, to readily form antibodies and the theory that the first antibody formed may augment the production of other antibodies.     

Organizational description and emergency preparedness of Nationally Registered First Responders

INTRODUCTION: This study intended to describe the types of organizations and communities in which Nationally Registered First Responders (NRFR) perform their duties. Also, it aimed to estimate the number of NRFR who received disaster preparedness training. It was hypothesized that NRFR participation in disaster preparedness training was related to the types of organizations and communities in which they performed their duties. METHODS: The NRFR re-registering in 2006 were asked to report the organization type and community size in which they work. They also were asked to report the amount and content of preparedness training received during the last 24 months. Multivariable logistic regression modeling was utilized to describe the relationship between NRFR organizational characteristics and the receipt of disaster preparedness training. RESULTS: The analysis included 872 (59%) individuals who completed the survey and reported working for one or more emergency medical services (EMS) organizations. The majority of NRFR performed work in rural areas (75%) and more NRFR reported working for fire departments (61%) than for any other organization type. In all categories of service type, participants who reported working in urban areas had higher odds of receiving disaster preparedness training than those working in rural areas. Additionally, regardless of community size, individuals working in fire departments were more likely to receive disaster preparedness training. CONCLUSIONS: This study indicated that the majority of NRFR perform EMS duties for fire departments and work in rural communities. In this sample of NRFR, more than one-quarter did not receive disaster preparedness training within a 24-month period. Finally, a statistical model was constructed that indicated a relationship between service type, community size, and the participation in disaster preparedness training.     

Explosions and Radioactive Material: A Primer for Responders

A comprehensive primer on the threat posed by radiological dispersion devices, or “dirty bombs,” and the management challenges for first responders is presented. The discussion is scenario-driven, presenting guidance for medical responders as to triage and treatment priorities in the face of radiation risk. Key questions are posed that present the need for operational and tactical planning, equipping, and training around this scenario. Decontamination priorities and potential medical management are discussed for both victims and responders.     

Occupational Health Hazards to First Responders from Clandestine Methamphetamine Labs

Methamphetamine is synthesized in clandestine drug labs from common household products and over-the-counter medications. Production methods involve numerous chemical reactions that can cause fire, explosion, and release of toxic gases and waste, thereby making these labs potential hazardous waste sites. First responders (fire fighters, police officers, and Emergency Medical Services personnel) are at risk for numerous health problems when they come in contact with clandestine methamphetamine labs during the course of their jobs, including eye and respiratory irritation, lung damage, burns, and violence perpetrated by methamphetamine producers and users. The objectives of this article are to review current literature on clandestine methamphetamine labs, describe methamphetamine production processes, describe the risks to first responders from the occupational health hazards generated by these labs, and, finally, discuss prevention strategies.     

三种不同促排卵方案在卵巢低反应患者中的应用

【目的】比较三种不同的控制性超排卵方案（COH）对卵巢低反应患者的体外受精胚胎移植（IVF—ET）临床结局,旨在寻求更为适合的促排卵方案。[A-法】回顾性分析2010年1～12月在本院接受体外受精（IVF）或卵细胞浆单精子注射（ICSI）助孕的卵巢低反应患者133例,超短方案组（A组）36例,改良超长方案组（B组）34例,拮抗剂方案组（C组）63例,比较三组超排卵天数、血清激素水平、获卵数、成熟卵子数、正常受精胚胎数（2PN）、周期妊娠率和胚胎种植率等。【结果】三组治疗后超排卵天数、成熟卵子数、2PN胚胎数、移植胚胎数比较差异均无显著性（P〉0．05）;平均促性腺激素释放激素（GnRH）用量A、B组间差异无显著性（P〉0．05）,A、B显著高于C组（P〈0．05）;胚胎种植率A、C组比较无显著性差异（P〉0．05）,但均显著低于B组（P〈0．05）;临床妊娠率B组最高,c组次之,A组最低,三组比较有显著性差异（P〈0．05）。【结论】促性腺激素释放激素拮抗剂（GnRH拮抗剂）方案和改良超长方案治疗卵巢低反应是一种有效的超排卵方案,可有效的提高IVF-ET的临床妊娠率。     

Responders and Nonresponders to a Walking Intervention for Sedentary Women

Purpose: Increasing evidence has indicated that people might be differentially influenced by intervention programs. The purpose of this secondary analysis was to identify groups of women who responded differently to a walking intervention. Data used in this secondary analysis were collected in a longitudinal study of a counseling intervention to increase walking among 248 initially sedentary women.
Method: A latent growth-mixture modeling approach was used to assess treatment effects on growth in physical activity and mood over time. Subgroups of participants who were responsive versus those who were nonresponsive to intervention were also identified. Logistic-regression analysis was conducted to confirm group membership and identify predictors associated with the identified subgroups.
Results: Two subgroups (responders, nonresponders) were identified separately for physical activity and mood. Using several variables as predictors of group memberships, 92%–95% of the cases were correctly classified. The current study indicated that predictors for group membership were associated with the outcome variables.
Conclusions: These findings indicated that optimal interventions should be tailored to not only the physical, psychosocial, and environmental variables of each woman, but also to outcome variables of interest to the woman.
Clinical Relevance: Nurses practicing in community and public health settings should determine physical activity interventions that are based on scientific findings and on outcomes that are important for the individual woman.     

Training Retention of Level C Personal Protective Equipment Use by Emergency Medical Services Personnel

Objectives: To assess the six‐month training retention for out‐of‐hospital providers donning and doffing Level C personal protective equipment (PPE). Methods: In this prospective observational study, 36 out‐of‐hospital providers enrolled in a paramedic program were trained in Level C (chemical‐resistant coverall, butyl gloves, and boots and an air‐purifying respirator) PPE use. A standardized training module and checklist of critical actions developed by a hazardous materials (hazmat) technician were used to evaluate donning and doffing. Students were trained until they were able to correctly don and doff the Level C PPE. An investigator used the checklist accompanying the training module to assess proficiency and remediate mistakes. Six months after initial training, the subjects were reassessed using the same investigator and checklist. Errors were designated as either critical (resulted in major self‐contamination of the airway, such as early removal of the respirator) or noncritical (potentially resulted in minor self‐contamination not involving the airway). Results: Only five subjects (14.3%) were able to don and doff PPE without committing a critical error. The most common critical errors were premature removal of the respirator (65.7%; n= 23) and actions allowing the contaminated suit to touch the body (54.3%; n= 19). The most common noncritical error was possible self‐contamination due to the boots not being removed before exposing other body parts (37.1%; n= 13). Of the seven subjects (20%) with additional prior hazmat training, only two donned and doffed PPE without committing a critical error. Conclusions: Retention of proper donning and doffing techniques in paramedic students is poor at six months after initial training. Even in subjects with previous hazmat, firefighter, and emergency medical services training, critical errors were common, suggesting that current training may be inadequate to prevent harmful exposures in emergency medical services personnel working at a hazmat or weapons of mass destruction incident.     

Physiological Responses During Graded Treadmill Exercise in Chemical-Resistant Personal Protective Equipment

Background. As the likelihood of terrorist acts increases, prehospital personnel have been forced to train in the proper use of chemical-resistant personal protective equipment (PPE). This protective ensemble has been reported to be physiologically taxing for the wearer, imposing an additional thermal load resulting in hypohydration, hyperthermia, andreduced work time. Victim extrication, the rescue-the-rescuer role of the rapid intervention team andrapid self-extrication, typically requires high-intensity work that can be maintained only for short time intervals. The additional physiological burden imparted by the level C PPE during high-intensity work is unknown. Objective. We hypothesized that the added thermal burden resulting from work in PPE would shorten work time andresult in a higher core temperature during incremental treadmill exercise. Method. In this prospective, crossover, laboratory study, EMS providers (n = 8, 5 male) completed a Bruce treadmill test on two occasions: once in a chemical-resistant coverall andair-purifying respirator (PPE) andonce in shorts andt-shirt (CON). Oxygen consumption, vital signs, core andskin temperature, andperceptual measures of exertion, thermal sensation, andcomfort were monitored throughout the test. Results. Subjects achieved maximal oxygen consumption andmore than 90% of age-predicted maximum heart rate in both conditions. Heart rate, skin temperature, andmeasures of perceived exertion, comfort, andthermal sensation increased during the treadmill exercise but did not differ between the PPE andCON conditions. Core temperature increased in both the CON andPPE conditions (0.8 ± 0.5 vs. 0.7 ± 0.3, p = 0.40). Conclusion. High-intensity work in level C PPE is primarily limited by cardiovascular capacity. The thermal burden associated with this short bout of work in PPE (approximately 10 minutes) is not different than high-intensity work in short pants andcotton t-shirt. Consideration should be given to cardiorespiratory fitness when assigning providers to work in chemical-resistant PPE, especially on tasks that require high-intensity work.