Search

Response to terrorism and mass casualty incidents has become a focal point for many public service agencies. Public health agencies and the emergency response community must work together to effectively and efficiently respond to any future incidents. Historically, collaboration has been a challenge since these agencies have functioned independently from one another, maintaining separate infrastructures that are not adequately interoperable. This article will summarize the consensus achieved during a meeting of multidisciplinary stakeholders held to discuss linkages between acute care, emergency medical services, and public health. The relevancy of these findings to public health, as well as the benefits from development of an interoperable infrastructure to public health, will be opined. [ABSTRACT FROM AUTHOR]

Public health agencies at all levels are now under increasing pressure to prepare for and respond to emerging natural and manmade threats to the health and wellness of those they serve. In particular, local health departments must be prepared to provide front-line defense and first response as threats of terrorism have become increasingly real. Success in meeting this monumental task will be highly dependent on funding as well as the availability of other resources. Although local health departments serving smaller counties may have fewer resources and receive less preparedness funding, they must still develop similar plans, surveillance systems, and response capabilities as local health departments serving larger counties (albeit on a smaller scale). Although local health departments serving larger counties may have more resources and receive more preparedness funding, they may face a greater chance of an intentional terrorist act and could benefit from support from local health departments serving smaller counties. Regional planning and response solutions to this challenge will allow partnerships of small and large local health departments to pool their resources and cooperatively provide more services with less duplication using whatever funding is available. This article describes that process as it is occurring in western New York among eight local county health departments. [ABSTRACT FROM AUTHOR]

To protect the citizens of the United States from the use of dangerous biological agents, the Center for Disease Control and Prevention (CDC) has been actively preparing to deal with the consequences of such an attack. Their plans include the deployment of mass immunization clinics to handle postevent vaccinations. As part of the planning efforts by the Western New York Public Health Alliance, a Webbased electronic patient registration and tracking system was developed and tested at a recent trial smallpox vaccination clinic. Initial goals were to determine what the pitfalls and benefits of using such a system might be in comparison to other methods of data collection. This exercise proved that use of an electronic system capable of scanning two-dimensional bar codes was superior to both paper-based and optical character recognition (OCR) methods of data collection and management. Major improvements in speed and/or accuracy were evident in all areas of the clinic, especially in patient registration, vaccine tracking and postclinic data analysis. [ABSTRACT FROM AUTHOR]

Objective: Paramedics often intubate in challenging environments. We evaluated whether patient position might affect prehospital intubation success rates utilizing a cadaver model., Methods: The study was conducted in two phases: a cross-sectional survey and an experimental model in which paramedics were asked to demonstrate intubation skills on cadavers in three positions. New York State certified paid and volunteer paramedics and critical care emergency medical technicians were recruited from multiple agencies. To assess past experience, participants self-reported the number of patients they attempted to intubate in the previous 12 months and the patient positions in which they attempted those intubations. Participants attempted to intubate nonembalmed cadavers in a controlled environment in three positions: on the floor, on a low stretcher to simulate the patient care compartment of an ambulance, and on an elevated stretcher. Paramedics were allowed a maximum of three intubation attempts of one minute each per cadaver. Endotracheal tube placement was verified by a single attending emergency physician using direct visualization., Results: Self-reports of intubation attempts in the previous 12 months indicated that participants had attempted to intubate a mean of 6.4 patients per paramedic. Self-reported positions of patient intubations were 57% on the floor, 33% in the ambulance, 7% on a stretcher of unspecified height, and 3% in some other position. During the study, 84 paramedics performed 251 intubations on 42 cadavers. First-attempt and cumulative first- and second-attempt success rates were 77.4 and 89.3% for the floor position, 74.7 and 94.0% for the low stretcher (ambulance) position, and 86.9 and 96.4% for the elevated stretcher position, respectively. First attempt success was higher in the elevated stretcher position compared to the low stretcher position (OR = 2.25, 95% CI 1.01-5.00). No other position contributed to greater odds of ETI success either on the first or second attempt., Conclusions: Endotracheal intubation success was higher with the cadaver positioned on an elevated stretcher compared to a low stretcher. Paramedics must be aware of patient position when performing prehospital intubation.

Emergency mental health (EMH), a field that is often not well represented when considering emergency preparedness, is nonetheless a vital component to any disaster response. Emergency mental health issues must be considered not only for victims of disasters and their families, friends, and coworkers but also for both on-scene and off-scene responders and members of the community who may have witnessed the disaster. This article describes the EMH preparation for and response to the crash of Continental Airlines flight 3407 in western New York on February 12, 2009, killing all 49 crew and passengers on board and 1 person on the ground. It describes aspects of the response that went as planned and highlights areas for improvement. The lessons learned from this EMH preparation and response can be used to inform future planning for disaster response.

Objectives: To determine the proportion of out-of-hospital cardiac arrest (OOHCA) patients who received chest compressions, before EMS arrival, from bystanders who called the EMS emergency telephone number (9-1-1) at dispatch centers that provided telephone CPR instructions and to describe barriers to following instructions., Methods: A retrospective case series was conducted in 2004 at three dispatch centers all of which provided sequential airway, breathing and chest compression pre-arrival instructions. All calls for which the call-taker established that the patient was in OOHCA were identified, and the recorded interaction was reviewed using a structured data collection tool. Data included whether the caller performed compressions, the sequence of instructions, whether there were barriers to performing CPR and characteristics of the caller, call taker and patient. Descriptive statistics were used to evaluate the data., Results: 343 calls were reviewed. 3 were excluded because it was unclear whether compressions were provided. 172 calls were not eligible for pre-arrival instructions (e.g. obviously dead, already receiving CPR). Of the 168 calls eligible for CPR instructions, chest compressions were actually given to 25 patients (15%, 95% confidence interval 10-21%) before EMS arrival. Leading reasons for not following CPR instructions included: caller disconnected phone before directions were complete (19%), caller's refusal (18%), emotional state of the caller (14%), inability to listen to telephone instructions and care for patient at the same time (13%) and physical limitations of the caller (8%). Failure to complete airway and breathing steps prevented 8% of callers from providing compressions., Conclusions: Few 9-1-1 callers provided chest compressions following telephone CPR instructions that included airway and breathing steps. The majority of callers were unwilling or emotionally or physically unable to follow the instructions.

Objective: To determine whether there were associations between the characteristics of first-responder automated external defibrillator (AED) training and AED application rates., Methods: This multicenter retrospective cohort study analyzed data from ten emergency medical services systems where first responders were trained and equipped with AEDs. Data were provided for all out-of-hospital cardiac arrests (OHCAs) occurring over two years, including whether the first-responder AED was applied (pads attached to patient). Systems were surveyed to determine the characteristics of their initial and continuing AED training. Data were analyzed using odds ratios (ORs) with 95% confidence intervals (95% CIs)., Results: Overall, the first-responder AED was applied to 53% of 2,181 OHCAs. First responders applied AEDs to 60% of OHCAs when a national AED training curriculum was used and to 49% of OHCAs when a locally created curriculum was used (OR=1.58; 95% CI=1.32-1.88). First responders applied AEDs to 61% of OHCAs when they were trained to the level of Certified First Responder or higher and to 28% of OHCAs when they were trained only in cardiopulmonary resuscitation (OR=3.97; 95% CI=3.20-4.93). First responders applied AEDs to 66% of OHCAs when they each had an opportunity to apply the AED during continuing training and to 17% of OHCAs when they did not have this opportunity (OR=9.04; 95% CI=7.15-11.42). First responders applied AEDs to 59% of OHCAs when they had not received continuing training within one year of their initial training and to 42% of OHCAs when they had received continuing training in the first year (OR=2.00; 95% CI=1.67-2.40)., Conclusion: Use of a national AED training curriculum, training to the level of Certified First Responder or higher, and the ability for each first responder to apply the AED during continuing training were associated with higher AED application rates. Continuing training within the first year did not appear to be as important as actually using the AED during the training.

The objective of this study was to determine whether simultaneously dispatched first-response firefighters (fire) arrive before transporting EMS providers (ambulance) and the amount of time fire has on scene to initiate care. Fire and ambulance dispatch records were obtained for all 9-1-1 responses from four 1-month intervals. Only incidents to which both agencies had been simultaneously dispatched were included. Response time for each agency was determined by subtracting the time of dispatch from the time of arrival. The difference between fire and ambulance response time was the time fire had to initiate care. Both agencies were simultaneously dispatched to 4752 incidents. Average response time for all incidents was 4.0 +/- 2.6 min for fire and 5.3 +/- 2.0 min for ambulance. Fire had 1.3 +/- 3.2 min on average to initiate care. Fire arrived before ambulance for 69% (3262) of requests and for these calls had 2.8 +/- 1.7 min on average to initiate care. Utilization of densely staged first-response fire apparatus in a midsize city may be appropriate because firefighters frequently arrive before ambulances and may have adequate time to initiate lifesaving interventions.

To determine whether paramedics can safely treat and discharge insulin-dependent diabetic patients experiencing uncomplicated hypoglycemic events, we conducted a prospective, observational study with a convenience sample of diabetic patients whose hypoglycemia resolved after intravenous administration of dextrose and before they were transported by paramedics. On-line medical control was contacted to obtain approval and informed consent for participation from interested patients who met all eligibility criteria for the study. Participating patients were given instructions upon discharge from the study and were contacted by telephone 24 hours later to ascertain their medical outcomes and their opinions of the study protocol. We enrolled a total of 36 patients with 38 incidents of hypoglycemia. Of these, 91% reported no complications after discharge. Two patients developed recurrent hypoglycemia but treated themselves and did not require further emergency care. One further patient was found unresponsive on the morning following discharge and was subsequently admitted to a long-term care facility with hypoglycemic encephalopathy. Of the study participants, 85% were very satisfied with not being transported to an emergency department (ED) and 91% were very satisfied with the care they had received. All (100%) of the patients surveyed favored a permanent protocol allowing discharge of hypoglycemic patients without admission to an ED. We conclude that paramedics successfully treated, without complication, most of the patients with uncomplicated hypoglycemic events who were examined in our study. These patients generally preferred discharge without transportation to an ED., (Copyright 2003, Elsevier Science (USA). All rights reserved.))

The objective of this study was to determine the knowledge, utilization, and experience of primary care physicians (PCPs) with nonhospital do-not-resuscitate (NH-DNR) orders. An anonymous survey was sent to all PCPs in a single northeastern county. Up to two surveys were mailed to each PCP. Descriptive statistics were used to report provider responses. The main variable of interest was issuance of NH-DNR orders. Surveys were mailed to 820 PCPs; 348 (42%) were returned. Respondents had practiced an average 17 +/- 11 years, and cared for an average of 720 patients per month, 7 of whom were terminally ill. Seventy percent issued NH-DNR orders. Twenty-five percent reported resuscitation had been attempted for at least one patient with a NH-DNR order; 64% reported this had happened more than once. Of respondents who had a NH-DNR order ignored, 14% had instructed family members to call police, fire, or EMS following death of the patient. Of the PCPs who did not issue NH-DNR orders, 71% reported not caring for any appropriate patients, yet 41% reported caring for at least 1 terminally ill patient per month. Seventy-nine percent disagreed that intubation and mechanical ventilation were appropriate treatment for DNR patients in severe respiratory distress, and 71% disagreed that cardioversion was appropriate treatment for an unconscious DNR patient with unstable ventricular tachycardia. In conclusion, a majority of respondents issued NH-DNR orders and one quarter reported these orders had not been followed. A majority felt intubation, mechanical ventilation, and cardioversion should not be performed for noncardiac arrest DNR patients with an indication, but not in cardiac arrest.

The objective of this study was to evaluate human immunodeficiency virus (HIV) counseling, testing, and referral practices of emergency department health care professionals (i.e., medical doctors [MD], physician assistants [PA], nurse practitioners [NP], and registered nurses [RN]) for patients presenting with other sexually transmitted diseases (STD). All health care professionals from 10 emergency departments in a northeastern county were asked to complete an anonymous survey. The surveys were returned by 154 (41%) health care professionals (RN = 99, NP = 5, PA = 7, MD = 39, other = 4). The average years in practice were 11. Only 7% of respondents were certified to provide state mandated HIV pretest counseling (certification not required for MD). Respondents reported caring for an average of 13 patients per week with suspected STD. Fifty-five percent of respondents reported that they always or usually warn STD patients of their HIV risk, yet only 10% always or usually encouraged these patients to consent to HIV testing in their emergency department (RN = 7%, NP = 25%, PA = 0%, MD = 16%). Reasons for not offering HIV testing in their emergency department were follow-up concerns (51%), not certified to provide pretest/posttest counseling (45%), and too time consuming (19%). Twenty-seven percent of respondents indicated HIV testing was not available in their emergency department despite all hospital laboratories reporting HIV testing capability. Ninety-three percent of respondents were aware that confidential testing sites were available, but only 35% always or usually referred patients not tested in the emergency department elsewhere for testing. Emergency department health care professionals frequently fail to provide HIV counseling, testing, and/or referral for patients with suspected STD.

Objectives: To determine the rate at which fire and police first responders (FRs) apply automated external defibrillators (AEDs) and to ascertain reasons for not applying them., Methods: Twenty-one emergency medical services (EMS) systems whose FRs had been supplied with AEDs by a philanthropic foundation provided data for all out-of-hospital cardiac arrest (OHCA) patients. Data including the incidence of AED application and explanations for not applying AEDs were analyzed using descriptive statistics., Results: A total of 2,456 OHCAs were reported. AED application information was available for 2,439 patients and revealed that FRs had not applied AEDs to 1,025 patients (42%). Fire FRs were more likely than police FRs to have applied AEDs (relative risk 1.87, 95% confidence interval 1.65-2.12). Reasons for not applying AEDs were listed for 664 (65%) of the OHCA patients to whom AEDs had not been applied. The predominant reason the FRs did not apply an AED was that the transporting ambulance defibrillator had already been applied (74%). However, when response times for FRs and the transporting ambulances were compared for these OHCA patients, it was found that the transporting ambulances arrived after the FRs 23% the time, simultaneously with the FRs 45% of the time, and before the FRs only 32% of the time., Conclusion: Fire and police FRs did not apply AEDs to a significant number of OHCA patients. Use of the transport ambulance defibrillator was the primary reason given for not applying the FR AED. Given low AED application rates by FRs, future studies are needed to determine the characteristics of communities in which equipping FRs with AEDs is the most beneficial deployment strategy, and how to increase AED application by FRs in communities with FR AED programs.

This study determined demographic factors associated with reported seatbelt use among injured adults admitted to a trauma center. A retrospective chart review was conducted including all patients admitted to a trauma center for injuries from motor vehicle crashes (MVC). E-codes (i.e. ICD-9 external cause of injury codes) were used to identify all patients injured in a MVC between January 1995 and December 1997. Age, sex, race, residence zip code (i.e. a proxy for income based on geographic location of residence), position in the vehicle, and seatbelt use were obtained from the trauma registry. Forward logistic regression was used to identify significant predictors of seatbelt use. Complete data was available for 1366 (82%) patients. Seatbelt use was reported for 45% of patients under age of 25 years, 52% of those 25-60 years, and 68% of those over 60 years. Overall, seatbelt use was reported for 45% of men and 63% of women, as well as for 56% of Caucasians (i.e. Whites) and 34% of African Americans. In addition, seatbelt use was reported for 33% of those earning less than $20,000 per year and 55% of those earning over $20,000. Finally, seatbelt use was reported for 57% of drivers and 43% of passengers. Logistic regression revealed that age, female gender, Caucasian race, natural log of income, and driver were all significant predictors of reported seatbelt use. These results show that seatbelt use was more likely to be reported for older persons, women, Caucasians, individuals with greater incomes, and drivers. Seatbelt use should be encouraged for everyone; however, young people, men, African Americans, individuals with lower incomes, and passengers should be targeted specifically.

Objective: To determine whether the lay public expects public safety answering points (PSAPs) to provide prearrival instructions., Methods: Two thousand telephone numbers were randomly generated from all listed residential numbers in a county containing urban, suburban, and rural communities served by 26 enhanced 9-1-1 PSAPs. Only a minority of the PSAPs provided prearrival instructions. Research assistants made two attempts to contact an individual at each telephone number. A survey was administered to any person who answered the telephone provided the person was at least 18 years of age and gave verbal consent. The respondents were asked their age, level of education, and gender. They were also asked what number they would call for first aid or an ambulance and whether they would expect telephone instructions from the dispatcher if a close relative was choking, not breathing, bleeding, or giving birth., Results: One thousand twenty-four individuals were successfully contacted; and 524 (51%) were at least 18 years of age and agreed to participate. The respondents' mean age was 50 (standard deviation 19 years). Sixty-five percent of the respondents were female; and 90% had at least a high school diploma. Only 37% had previously called 9-1-1 (nine-one-one) for an emergency. Ninety-seven percent said they would dial either 9-1-1 (85%) or 9-11 (nine-eleven) (12%) in an emergency. Seventy-six percent (95% CI: 73%-80%) expected prearrival instructions for all four medical conditions. Specifically, prearrival instructions were expected by: 88% for choking (95% CI: 85%-90%), 87% for not breathing (95% CI: 84%-90%), 89% for bleeding (95% CI: 86%-91%), and 88% for childbirth (95% CI: 86%-91%). Ninety-nine of 117 respondents (81%) served by a PSAP that did not provide prearrival instructions expected to receive phone instructions for all four emergencies. Logistic regression revealed that knowing to dial 9-1-1 or 9-11 in an emergency was the only significant predictor of prearrival instruction expectation [p < 0.03, odds ratio 3.4 (95% CI: 1.16-9.78)]. Age, gender, service by a PSAP providing prearrival instructions, and level of education were not predictive., Conclusion: The lay public expects prearrival instructions when calling 9-1-1, although they may not currently receive this service.

Objective: To determine whether a geographic information system (GIS) and historical transport data can be used to create a map that identifies locations (zones) from which either ambulance or helicopter transport will result in shorter out-of-hospital times., Methods: A retrospective, cross-sectional review of a trauma registry was conducted in a two-county region served by a single trauma center. Data were gathered for all patients transported directly to the trauma center between 1993 and 1996. Incident locations and times from first 911 contact until arrival at the trauma center (out-of-hospital time) were extracted. A GIS was used to create a reference map with all incident locations plotted and given z-coordinates corresponding to out-of-hospital time. Two contour surfaces were interpolated: one for all helicopter transports and one for all ground transports. Areas where the helicopter surface was lower than the ambulance surface were designated air zones since helicopter transport resulted in shorter out-of-hospital times. The remaining area was designated a ground zone since ambulance transport resulted in shorter out-of-hospital times. The mean out-of-hospital times were calculated for each mode of transport in both zones and were compared using a two-tailed t-test., Results: An air zone was identified beginning between 5 and 16 miles from the trauma center. Mean (+/-SD) out-of-hospital time from the air zone was 50 +/- 9 minutes for helicopter transport (n = 54) and 63 +/- 14 minutes for ambulance transport (n = 140). The difference between the means was 13 minutes (p < 0.000001; 95% CI = 8.95 to 17.05). Mean out-of-hospital time from the ground zone was 68 +/-16 minutes for helicopter transport (n = 122) and 32 +/- 14 minutes for ambulance transport (n = 2,047). The difference between the means was 36 minutes (p < 0.000001; 95% CI = 33.59 to 38.41)., Conclusions: A GIS and historical transport data can be used to create a map identifying locations from which either helicopter or ambulance transport will minimize out-of-hospital time. Inappropriate choice of transport mode is associated with increased out-of-hospital time.

Objectives: To compare the incidences and severities of pain experienced by healthy volunteers undergoing spinal immobilization in the neutral position with and without occipital padding. To compare the incidence of pain when immobilized in the neutral position with the incidence in a nonneutral position., Methods: Thirty-nine healthy volunteers over the age of 18 years who had no acute pain or illness, were not pregnant, and had no history of back problems or surgery voluntarily participated in a prospective, randomized, crossover study conducted in a clinical laboratory setting. Appropriately sized rigid cervical collars were applied to the subjects, who were then immobilized on wooden backboards with their cervical spines maintained in the neutral position using towels (padded) or plywood (unpadded) under their occiputs. The subjects were secured to the board with straps, soft head blocks, and tape for 15 minutes to simulate a typical ambulance transport time. The straps, head blocks, and tape were removed, and the subjects remained on the board for an additional 45 minutes to simulate a typical emergency department experience. The subjects were then asked to identify the location(s) of any pain on anterior and posterior body outlines and to indicate the corresponding severity of pain on a 10-cm visual analog scale. The subjects were also asked questions about movement, respiratory symptoms, and strap discomfort in an attempt to distract them from the true focus of the study (i.e., pain). A similar survey was given to each participant to complete 24 hours later. The same subjects were immobilized with the alternate occipital material a minimum of two weeks later utilizing the same procedure. They again completed both surveys., Results: Pain was reported by 76.9% of the subjects following removal from the backboard for the unpadded trial and 69.2% of the subjects following the padded trial (p < 0.45). Twenty-three percent (23.1%) of the subjects reported neck pain after the unpadded trial, while 38.5% reported neck pain after the padded trial (p < 0.07). Occipital pain was reported by 35.9% in the unpadded trial and 25.6% in the padded trial (p < 0.29). Twenty-four hours later, pain was reported by 17.9% of the subjects following the unpadded trial and 23.1% of the subjects following the padded trial (p < 0.63). Eight percent (7.7%) reported neck pain 24 hours after the and unpadded trial and 12.8% after the padded trial (p < 0.5). Occipital pain was reported by 7.7% of the subjects 24 hours after the unpadded trial and 2.6% after the padded trial (p < 0.63). This study had a power of 0.90 to detect a difference of 30% between the trials. The authors found a significantly lower incidence of pain (p < 0.01) and occipital pain (p < 0.01) in their unpadded trial compared with that reported by Chan et al., who used neither padding nor neutral positioning to immobilize subjects., Conclusions: Pain is frequently reported by healthy volunteers following spinal immobilization. Occipital padding does not appear to significantly decrease the incidence or severity of pain. Alignment of the cervical spine in the neutral position may reduce the incidence of pain, but further studies should be conducted to substantiate this observation.

The emergency physician should be aware of the sensitivity and specificity of any radiologic study being considered. Radiographic examinations should be used to answer specific questions raised by the history and physical examination. The need to obtain a given radiologic evaluation should be based on the potential information it may reveal and the likelihood that this information will alter patient care. This cost-effective approach minimizes unnecessary radiation exposure and has been advocated by many authorities. The emergency physician should resist the "knee jerk" tendency to order radiographs to reassure himself or herself of the safety of the patient at discharge. Documentational and legal concerns are equally invalid reasons, as is the feeling that "it's what we always order for patients with this abdominal complaint." A given study may be indicated if the yield is acceptable and treatment of the patient may be altered by the results.

Objectives: To determine the social and demographic factors associated with medically unnecessary ambulance utilization, and to determine the willingness of patients to use alternate modes of transportation to the ED., Methods: A multisite prospective survey was conducted of all patients arriving by ambulance to 1 suburban and 4 urban EDs in New York State during a 1-week period., Results: For 626 patients surveyed, 71 (11.3%) transports were judged medically unnecessary by the receiving emergency physicians using preestablished guidelines. The patient's type of medical insurance and age were significant predictors of unnecessary ambulance transport (stepwise forward logistic regression analysis). Of the 71 patients whose ambulance transports were deemed medically unnecessary, 42 (59%) were Medicaid recipients and 53 (74%) were < 40 years of age. The most common reason for using ambulance transport was lack of an alternate mode of transportation (38.5%), although 82% would have been willing to use an alternate mode of transportation if it had been available. Of those who had medically unnecessary ambulance use, 30% indicated that they would not pay for the ambulance service if billed and 50% believed the cost of their ambulance transports was < $100. More than 85% of the patients whose ambulance transports were deemed medically unnecessary were unemployed; and nearly 85% reported a net annual income of < $20,000. While 33% had a primary care provider, only 22% had attempted to contact their doctors before requesting an ambulance., Conclusions: Patient age < 40 years and Medicaid coverage were associated with medically unnecessary ambulance use. Those patients for whom ambulance use was considered medically unnecessary commonly had no alternate means of transportation. Providing alternate means of unscheduled transportation may reduce the incidence of unnecessary ambulance use.