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The protection of health care facility (HCF) staff from the effects of weapons of mass destruction has gained heightened attention since the 9-11 terrorist attacks. One critical component of protection is personal protective equipment (PPE). No universal standard exists for an 'essential' level of PPE for HCF staff. The absence of such a standard raises the need for development of national policy for PPE levels, particularly in HCFs. We describe a process used by the Veterans Health Administration for recommending policy for 'essential' PPE levels. Although the recommendations are specific for Veterans Health Administration, the process, findings, and applications may be useful to other institutions as they attempt to resolve this critical issue. This descriptive account will serve to generate practical scientific debate in the academic community and lead to definitive public policy recommendations for the Nation's HCFs in executing their roles in the event of a terrorist attack. Copyright © 2007 by Elsevier Inc. [ABSTRACT FROM AUTHOR]

Emergency medical vehicle collisions are an unfortunately common occurrence. Current data are insufficient to accurately describe their rate of occurrence or impact on society. Preventive efforts in education, technology, legislation, and research have promising roles in enhancing vehicular and personal safety; these include improved driver background checks, agency policies and education regarding the use of restraints and safe driving behaviors, real-time monitoring of drive-safety parameters, vehicle crash testing, and legislation to introduce vehicle crashworthiness standards. The establishment of a national emergency medical vehicle collision database could improve research in these fields. Emergency response to emergency medical vehicle collisions presents unique difficulties and hazards. [ABSTRACT FROM AUTHOR]

Scabies is a highly contagious, globally prevalent, parasitic skin infestation caused by Sarcoptes scabiei var. hominis, also known as the itch mite. There have been outbreaks not only in the developing world, but also in the developed world among refugees and asylum seekers. Once infested with scabies mites, symptomatic patients, as well as asymptomatic carriers, quickly spread the disease through direct skin-to-skin contact. Typically, symptoms of scabies are characterized by an erythematous, papular, pruritic rash associated with burrows. Treatment of scabies involves using topical or systemic scabicides and treating secondary bacterial infections, if present. Given the prevalence and contagiousness of scabies, measures to prevent its spread are essential. Through application of the novel Identify-Isolate-Inform (3I) Tool, emergency medical providers can readily identify risk factors for exposure and important symptoms of the disease, thus limiting its spread through prompt scabicide therapy; isolate the patient until after treatment; and inform local public health authorities and hospital infection prevention, when appropriate. Ultimately, these three actions can aid public health in controlling the transmission of scabies cases, thus ensuring the protection of the general public from this highly contagious skin infestation.

Background: Emergency medical services (EMS) providers must be able to identify the most appropriate destination facility when treating children with potentially severe medical illnesses. Currently, no validated tool exists to assist EMS providers in identifying children who need transport to a hospital with higher-level pediatric care. For such a tool to be developed, a criterion standard needs to be defined that identifies children who received higher-level pediatric medical care., Objective: The objective was to develop a consensus-based criterion standard for children with a medical complaint who need a hospital with higher-level pediatric resources., Methods: Eleven local and national experts in EMS, emergency medicine (EM), and pediatric EM were recruited. Initial discussions identified themes for potential criteria. These themes were used to develop specific criteria that were included in a modified Delphi survey, which was electronically delivered. The criteria were refined iteratively based on participant responses. To be included, a criterion required at least 80% agreement among participants. If an item had less than 50% agreement, it was removed. A criterion with 50% to 79% agreement was modified based on participant suggestions and included on the next survey, along with any new suggested criteria. Voting continued until no new criteria were suggested and all criteria received at least 80% agreement., Results: All 11 recruited experts participated in all seven voting rounds. After the seventh vote, there was agreement on each item and no new criteria were suggested. The recommended criterion standard included 13 items that apply to patients 14 years old or younger. They included IV antibiotics for suspicion of sepsis or a seizure treated with two different classes of anticonvulsive medications within 2 hours, airway management, blood product administration, cardiopulmonary resuscitation, electrical therapy, administration of specific IV/IO drugs or respiratory assistance within 4 hours, interventional radiology or surgery within 6 hours, intensive care unit admission, specific comorbid conditions with two or more abnormal vital signs, and technology-assisted children seen for device malfunction., Conclusion: We developed a 13-item consensus-based criterion standard definition for identifying children with medical complaints who need the resources of a hospital equipped to provide higher-level pediatric services. This criterion standard will allow us to create a tool to improve pediatric patient care by assisting EMS providers in identifying the most appropriate destination facility for ill children., (© 2018 by the Society for Academic Emergency Medicine.)

Introduction: Cannabinoid hyperemesis syndrome (CHS) is an entity associated with cannabinoid overuse. CHS typically presents with cyclical vomiting, diffuse abdominal pain, and relief with hot showers. Patients often present to the emergency department (ED) repeatedly and undergo extensive evaluations including laboratory examination, advanced imaging, and in some cases unnecessary procedures. They are exposed to an array of pharmacologic interventions including opioids that not only lack evidence, but may also be harmful. This paper presents a novel treatment guideline that highlights the identification and diagnosis of CHS and summarizes treatment strategies aimed at resolution of symptoms, avoidance of unnecessary opioids, and ensuring patient safety., Methods: The San Diego Emergency Medicine Oversight Commission in collaboration with the County of San Diego Health and Human Services Agency and San Diego Kaiser Permanente Division of Medical Toxicology created an expert consensus panel to establish a guideline to unite the ED community in the treatment of CHS., Results: Per the consensus guideline, treatment should focus on symptom relief and education on the need for cannabis cessation. Capsaicin is a readily available topical preparation that is reasonable to use as first-line treatment. Antipsychotics including haloperidol and olanzapine have been reported to provide complete symptom relief in limited case studies. Conventional antiemetics including antihistamines, serotonin antagonists, dopamine antagonists and benzodiazepines may have limited effectiveness. Emergency physicians should avoid opioids if the diagnosis of CHS is certain and educate patients that cannabis cessation is the only intervention that will provide complete symptom relief., Conclusion: An expert consensus treatment guideline is provided to assist with diagnosis and appropriate treatment of CHS. Clinicians and public health officials should identity and treat CHS patients with strategies that decrease exposure to opioids, minimize use of healthcare resources, and maximize patient safety., Competing Interests: Conflicts of Interest: By the WestJEM article submission agreement, all authors are required to disclose all affiliations, funding sources and financial or management relationships that could be perceived as potential sources of bias. No author has professional or financial relationships with any companies that are relevant to this study. There are no conflicts of interest or sources of funding to declare.

Disaster responders are frequently emergency physicians (EPs). Effective response is enhanced by the strong support of home institutions and clear policies for backfill of regular duties. A group of disaster medicine responders and researchers worked with an academic department of emergency medicine to create a policy that addresses concerns of deploying physicians, colleagues remaining at the home institution, and administrators. This article describes the process and content of this policy development work. Kahn CA , Koenig KL , Schultz CH . Emergency physician disaster deployment: issues to consider and a model policy. Prehosp Disaster Med. 2017;32(4):462-464.

For years, public health experts have been concerned about the effect of cell phone use on motor vehicle collisions, part of a phenomenon known as "distracted driving." The Morbidity and Mortality Weekly Report (MMWR) article "Mobile Device Use While Driving - United States and Seven European Countries 2011" highlights the international nature of these concerns. Recent (2011) estimates from the National Highway Traffic Safety Administration are that 10% of fatal crashes and 17% of injury crashes were reported as distraction-affected. Of 3,331 people killed in 2011 on roadways in the U.S. as a result of driver distraction, 385 died in a crash where at least one driver was using a cell phone. For drivers 15-19 years old involved in a fatal crash, 21% of the distracted drivers were distracted by the use of cell phones. Efforts to reduce cell phone use while driving could reduce the prevalence of automobile crashes related to distracted driving. The MMWR report shows that there is much ground to cover with distracted driving. Emergency physicians frequently see the devastating effects of distracted driving on a daily basis and should take a more active role on sharing the information with patients, administrators, legislators, friends and family.

Objective: We studied the complications and timing implications of prehospital activated charcoal (PAC). Appropriateness of PAC administration was also evaluated., Methods: We retrospectively reviewed prehospital records over 32 months for overdose cases, where PAC was administered. Cases were assessed for amount and type of ingestant, clinical findings, timing of PAC, timing of transport and arrival into the emergency department (ED), and complications. Encounter duration in cases of PAC was compared with that, for all cases during the study period, where an overdose patient who did not receive activated charcoal was transported., Results: Two thousand eight hundred forty-five total cases were identified. In 441 cases, PAC was given; and complications could be assessed. Two hundred eighty-one of these had complete information regarding timing of ingestion, activated charcoal administration, and transport. The average time between overdose and PAC was 49.8 minutes (range, 7-199 minutes; median, 41.0 minutes; SD, 30.4 minutes). Complications included emesis (7%), declining mental status (4%), declining blood pressure (0.4%), and declining oxygen saturation (0.4%). Four hundred seventeen cases of PAC had documentation of timing of emergency medical service (EMS) arrival on scene and arrival at the ED. Average EMS encounter time was 29 minutes (range, 10-53 minutes; median, 27.9 minutes). Two thousand forty-four poisoning patients were transported who did not receive PAC. The average EMS encounter time for this group was 28.1 minutes (range, 4-82 minutes; median, 27.3 minutes), not significantly different (P =.114)., Conclusions: Prehospital activated charcoal did not appear to markedly delay transport or arrival of overdose patients into the ED and was generally safe., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Introduction: While several reports discuss controversies regarding ambulance diversion from acute care hospitals and the mortality, financial, and resource effects, there is scant literature related to the effect of hospital characteristics., Hypothesis/problem: The objective of this study was to describe specific paramedic receiving center characteristics that are associated with ambulance diversion rates in an Emergency Medical Services system., Methods: A retrospective observational study design was used. The study was performed in a suburban EMS system with 27 paramedic receiving centers studied; one additional hospital present at the beginning of the study period (2000-2008) was excluded due to lack of recent data. Hospital-level and population-level characteristics were gathered, including diversion rate (hours on diversion/total hours open), for-profit status, number of specialty services (including trauma, burn, cardiovascular surgery, renal transplant services, cardiac catheterization capability [both interventional and diagnostic], and burn surgery), average inpatient bed occupancy rate (total patient days/licensed bed days), annual emergency department (ED) volume (patients per year), ED admission rate (percent of ED patients admitted), and percent of patients leaving without being seen. Demographic characteristics included percent of persons in each hospital's immediate census tract below the 100% and 200% poverty lines (each considered separately), and population density within the census tract. Bivariate and regression analyses were performed., Results: Diversion rates for the 27 centers ranged from 0.3%-14.5% (median 4.5%). Average inpatient bed occupancy rate and presence of specialty services were correlated with an increase in diversion rate; occupancy rate showed a 0.08% increase in diversion hours per 1% increase in occupancy rate (95% CI, 0.01%-0.16%), and hospitals with specialty services had, on average, a 4.1% higher diversion rate than other hospitals (95% CI, 1.6%-6.7%). Other characteristics did not show a statistically significant effect. When a regression was performed, only the presence of specialty services was related to the ambulance diversion rate., Conclusions: Hospitals in this study providing specialty services were more likely to have higher diversion rates. This may result in increased difficulty getting patients requiring specialty care to centers able to provide the needed level of service. Major limitations include the retrospective nature of the study, as well as reliance on multiple data systems.

Background: Prehospital ultrasound has been shown to aid in the diagnosis of multiple conditions that do not generally change prehospital management. On the other hand, the diagnoses of cardiac tamponade, tension pneumothorax, or cardiac standstill may directly impact patient resuscitation in the field., Study Objective: To determine if prehospital care providers can learn to acquire and recognize ultrasound images for several life-threatening conditions using the Prehospital Assessment with UltraSound for Emergencies (PAUSE) protocol., Methods: This is a prospective, educational intervention pilot study at an urban fire department with integrated emergency medical services (EMS). We enrolled 20 emergency medical technicians--paramedic with no prior ultrasonography training. Subjects underwent a 2-h training session on basic ultrasonography of the lungs and heart to evaluate for pneumothorax, pericardial effusion, and cardiac activity. Subjects were tested on image interpretation as well as image acquisition skills. Two bedside ultrasound-trained emergency physicians scored images for adequacy. Image interpretation testing was performed using pre-obtained ultrasound clips containing normal and abnormal images., Results: All subjects appropriately identified the pleural line, and 19 of 20 paramedics achieved a Cardiac Ultrasound Structural Assessment Scale score of ≥4. For the image interpretation phase, the mean PAUSE protocol video test score was 9.1 out of a possible 10 (95% confidence interval 8.6-9.6)., Conclusion: Paramedics were able to perform the PAUSE protocol and recognize the presence of pneumothorax, pericardial effusion, and cardiac standstill. The PAUSE protocol may potentially be useful in rapidly detecting specific life-threatening pathology in the prehospital environment, and warrants further study in existing EMS systems., (Copyright © 2013. Published by Elsevier Inc.)

Objective: The objective of this study is to assess if venous blood gas (VBG) results (pH and base excess [BE]) are numerically similar to arterial blood gas (ABG) in acutely ill trauma patients., Methods: We prospectively correlated paired ABG and VBG results (pH and BE) in adult trauma patients when ABG was clinically indicated. A priori consensus threshold of clinical equivalence was set at ± less than 0.05 pH units and ± less than 2 BE units. We hypothesized that ABG results could be predicted by VBG results using a regression equation, derived from 173 patients, and validated on 173 separate patients., Results: We analyzed 346 patients and found mean arterial pH of 7.39 and mean venous pH of 7.35 in the derivation set. Seventy-two percent of the paired sample pH values fell within the predefined consensus equivalence threshold of ± less than 0.05 pH units, whereas the 95% limits of agreement (LOAs) were twice as wide, at -0.10 to 0.11 pH units. Mean arterial BE was -2.2 and venous BE was -1.9. Eighty percent of the paired BE values fell within the predefined ± less than 2 BE units, whereas the 95% LOA were again more than twice as wide, at -4.4 to 3.9 BE units. Correlations between ABG and VBG were strong, at r(2) = 0.70 for pH and 0.75 for BE., Conclusion: Although VBG results do correlate well with ABG results, only 72% to 80% of paired samples are clinically equivalent, and the 95% LOAs are unacceptably wide. Therefore, ABG samples should be obtained in acutely ill trauma patients if accurate acid-base status is required., (Copyright © 2012 Elsevier Inc. All rights reserved.)

Study Objective: The mass casualty triage system known as simple triage and rapid treatment (START) has been widely used in the United States since the 1980s. However, no outcomes assessment has been conducted after a disaster to determine whether assigned triage levels match patients' actual clinical status. Researchers hypothesize that START achieves at least 90% sensitivity and specificity for each triage level and ensures that the most critical patients are transported first to area hospitals., Methods: The performance of START was evaluated at a train crash disaster in 2003. Patient field triage categories and scene times were obtained from county reports. Patient medical records were then reviewed at all receiving hospitals. Victim arrival times were obtained and correct triage categories determined a priori using a combination of the modified Baxt criteria and hospital admission. Field and outcomes-based triage categories were compared, defining the appropriateness of each triage assignment., Results: Investigators reviewed 148 records at 14 receiving hospitals. Field triage designations comprised 22 red (immediate), 68 yellow (delayed), and 58 green (minor) patients. Outcomes-based designations found 2 red, 26 yellow, and 120 green patients. Seventy-nine patients were overtriaged, 3 were undertriaged, and 66 patients' outcomes matched their triage level. No triage level met both the 90% sensitivity and 90% specificity requirement set forth in the hypothesis, although red was 100% sensitive (95% confidence interval [CI] 16% to 100%) and green was 89.3% specific (95% CI 72% to 98%). The Obuchowski statistic was 0.81, meaning that victims from a higher-acuity outcome group had an 81% chance of assignment to a higher-acuity triage category. The median arrival time for red patients was more than 1 hour earlier than the other patients., Conclusion: This analysis demonstrates poor agreement between triage levels assigned by START at a train crash and a priori outcomes criteria for each level. START ensured acceptable levels of undertriage (100% red sensitivity and 89% green specificity) but incorporated a substantial amount of overtriage. START proved useful in prioritizing transport of the most critical patients to area hospitals first.

To reassess problems with on-call physician coverage in California, we repeated our anonymous 2000 survey of the California chapter of the American College of Emergency Physicians. Physicians responded from 77.4% of California emergency departments (EDs), 51.0% of ED directors, and 34% of those surveyed. Of 21 specialties, on-call availability worsened since 2000 for 9, was unchanged for 11, and improved for 1. Of ED directors, 54% report medical staff rules require on-call duty, down from 72% in 2000. Hospitals have increased specialist on-call payments (from 21% to 35%, with 75% paying at least one specialty). Most emergency physicians (80.3%) report insurance status negatively affects on-call physician responsiveness, up from 42% in 2000. Emergency departments with predominantely minority or uninsured patients had fewer specialists and more trouble accessing them. Insurance status has a major negative effect on ED consultation and follow-up care. The on-call situation in California has worsened substantially in 6 years.

Since the US terrorist attacks of September 11, 2001, concern regarding use of chemical, biological, or radiological weapons is heightened. Many victims of such an attack would present directly to health care facilities without first undergoing field decontamination. This article reviews basic tenets and recommendations for health care facility-based decontamination, including regulatory concerns, types of contaminants, comprehensive decontamination procedures (including crowd control, triage, removal of contaminated garments, cleaning of body contaminants, and management of contaminated materials and equipment), and a discussion of methods to achieve preparedness.

Purpose: The purpose of the study was to determine the accuracy of adult weight estimates by emergency department personnel., Basic Procedures: This was a prospective, nonrandomized, observational study in a university tertiary referral center. All patient care staff and all adult patients were eligible. Patients were weighed at the bedside, then staff were asked individually for estimates. Data were analyzed using SPSS general linear modeling procedures (SPSS, Chicago, IL) to obtain a generalized analysis of variance., Main Findings: Eighty-seven staff provided 957 estimates on 241 patients. Providers were within 5% of true weight on 33% of estimates (95% confidence interval [CI], 28-38). In our a priori subgroups, a significant difference was noted only for body mass index (BMI); percentages of correct estimates were 16% (95% CI, 0-33; n = 33) for BMI < 18.5; 38% (95% CI, 33-43; n = 654) for 18.5 < or = BMI < or = 30; and 23% (95% CI, 17-30; n = 270) for BMI > 30 (P < .001)., Principal Conclusions: Emergency department personnel provided accurate weights in only 33% of estimates. Estimates became significantly less accurate in underweight and obese patients (defined by BMI).

This article reviews the definitions of biological weapons and mass casualties. In addition, it discusses the main operational and logistical issues of import in the medical management of mass casualties from the use of biological weapons. Strategies for medical management of specific biologic agents also are highlighted.

Background: Ambulance crashes have become an increasing source of public concern. Emergency medical services directors have little data to develop ambulance operation and risk management policies., Objective: To describe fatal ambulance crash characteristics, identifying those that differentiate emergency and nonemergency use crashes., Methods: This was a retrospective analysis of all fatal ambulance crashes on U.S. public roadways reported to the Fatality Analysis Reporting System (FARS) database from 1987 to 1997. Main outcome measures were 42 variables describing crash demographics, crash configuration, vehicle description, crash severity, and ambulance operator and vehicle occupant attributes., Results: Three hundred thirty-nine ambulance crashes caused 405 fatalities and 838 injuries. These crashes occurred more often between noon and 6 PM (39%), on improved (99%), straight (86%), dry roads (69%) during clear weather (77%), while going straight (80%), through an intersection (53%), and striking (81%) another vehicle (80%) at an angle (56%). Most crashes (202/339) and fatalities (233/405) occurred during emergency use. These crashes occurred significantly more often at intersections (p < 0.001), at an angle (p < 0.001), with another vehicle (p < 0.001). Most crashes resulted in one fatality, not in the ambulance. Thirty pedestrians and one bicyclist comprised 9% of all fatalities. In the ambulance, most serious and fatal injuries occurred in the rear (OR 2.7 vs front) and to improperly restrained occupants (OR 2.5 vs restrained). Sixteen percent of ambulance operators were cited; 41% had poor driving records., Conclusions: Most crashes and fatalities occurred during emergency use and at intersections. The greater burden of injury fell upon persons not in the ambulance. Rear compartment occupants were more likely to be injured than those in the front. Crash and injury reduction programs should address improved intersection control, screening to identify high-risk drivers, appropriate restraint use, and design modifications to the rear compartment of the ambulance.