Planning for major burns incidents in the UK using an accelerated Delphi technique

BACKGROUND: Major incidents require careful planning if they are to be managed well. Although a generic plan to deal with all major incidents is essential, a number of "special incidents" deserve special consideration because of their potential to impact on specialist services. This paper examines the problems of managing a major incident involving large numbers of burns casualties. METHOD: A three-round Delphi study was conducted using a multidisciplinary panel of experts from prehospital care, emergency medicine, burns surgery, intensive care and emergency planning. RESULTS: A series of consensus statements on the management of burns incidents are presented. An accompanying paper describes the practical implementation of this guidance. CONCLUSION: Specific consideration should be given to the problems of managing a major incident involving burns casualties.     

Training of endotracheal intubation for an emergency medical technician and three cases of endotracheal intubation during emergency situation

It is said that airway management is an important part of lifesaving at the prehospital care for a seriously ill emergency patient. We performed the training of endotracheal intubation for an emergency medical technician, and in this report we discussed the results of trainings and examined 3 cases of endotracheal intubation in the emergency situation after training. Various kinds of problem arose through this training, for example, difficulty to get the consent from patients, overlap of a case for clinical resident and emergency medical technician, large responsibility of the anesthesiologist as a teaching staff. In addition, there may be no useful case for lifesaving at the emergency situation in 3 cases of endotracheal intubation. We consider that it may be difficult, but possibility cannot deny if endotracheal intubation by emergency medical technicians contribute to lifesaving rate improvement from viewpoint of prehospital care.     

Medical management after indoor fires: a review

Fires involving mass burn casualties require extreme efforts and flexibility from the regular health care system. The café fire in Volendam, which occurred shortly after midnight on the first of January 2001, resulted in the worst indoor mass burns incident in Dutch history. During the extensive medical evaluation of this disaster, it became obvious that information on similar incidents is relatively scarce in the literature. This article systematically reviews the existing information in the medical literature on indoor fires and provides findings and knowledge used in the evaluation of the medical management after indoor fires and for future mass burn casualty preparedness, mitigation and response. METHODS: A literature review was undertaken for burn disasters with characteristics similar to the indoor Volendam fire disaster. In all fires, the following aspects were investigated: characteristics of the fire; the initial emergency response; triage and on-site treatment; primary and secondary distribution; hospital admission; severity of the sustained injuries and mortality. RESULTS: A total of nine similar indoor fires were selected. The number of people involved was reported in seven fires (range 137-6000). All reports provided the mortality rate (range 1.4% to over 50%). Data regarding the emergency response could be collected in half of the studies. On-scene triage was performed in five fires. The number of hospitals participating in the primary distribution ranged from 1 to 19. Except for the Volendam fire, all patients were primarily distributed to general hospitals. CONCLUSION: Characteristics of indoor fires, which are relevant for disaster preparedness, mitigation and response are not frequently reported in medical literature. The current articles on indoor fires, mainly report on numbers of casualties and the mortality. Limited data are available to provide insight in the characteristics of management and medical treatment and to come up with suggestions for improvement of future burn incidents management. The evaluation of disasters should be based on uniform methods and structured reports and effective record keeping is essential to achieve this.     

Medizinische Leitungsfunktionen im deutschen Rettungsdienst

The chief emergency physician in the field and the medical director of emergency medical services (EMS) are both managerial positions in the German system of prehospital emergency medicine. The chief emergency physician in the field is the medical supervisor in the field to manage major accidents and medical mass casualties. The director of emergency medical services is the medical expert for emergency medicine in the governmental organization responsible for EMS and public healthcare. Both functions are important cornerstones of a high quality prehospital emergency system. Based on different State laws in the Federal Republic of Germany, there are no uniform requirements. This review compares and evaluates the requirements and performance profiles of these management functions between the different German State laws and describes the recommendations of the professional societies.     

Strategien zur Optimierung notärztlicher Kompetenz in der Flugrettung

PURPOSE: Preclinical emergency medical treatment necessitates a comprehensive interdisciplinary knowledge by the emergency physician as well as a high level of manual dexterity. The quality of treatment therefore depends on the level of education and continuous training in emergency medical techniques. Based on an evaluation of the frequency of life-saving interventions by a physician-staffed rescue helicopter system, strategies for in-hospital training of relevant skills are suggested. MATERIAL AND METHODS: At the outset, 10 important areas of treatment (e.g. intubation, chest tube etc.) and their frequency in emergency medical services were defined as the standard to be attained by emergency physicians within 1 year. The selection of the areas of treatment was based to some extent on international recommendations. The actual frequencies of the prehospital interventions were compared to the required minimum numbers by retrospective analysis of the helicopter rescue database (NACA-X). RESULTS: During the observation period of 1 year, 20 emergency physicians responded to 956 prehospital emergency calls. A life-threatening condition requiring an on-site intervention occurred in only 521 (54.5%) patients, so that the majority of physicians did not perform the required minimum number of interventions. In order to maintain their level of skill, the emergency physicians were required to undertake additional training at the local university hospital. CONCLUSION: The frequency of on-site life-saving interventions in emergency medicine is insufficient to fulfill the quota necessary to maintain adequate training of emergency physicians. Only a link-up program at a hospital for primary care can ensure an adequate training level.     

Future anesthesiologists will be as much outside as inside operating theaters

During the first decade of the new millennium the intense reorganization of hospitals and of medical care will be replaced by stability and long-term goals. An anesthesiologist is now as active outside as within the operating theater, being a predominant resource in intensive care, pain management, emergency and prehospital care. The anesthesiologist will also have a key part to play in risk analysis of patients scheduled for various kinds of advanced treatment. Anesthesiologists are now also more involved in primary home care where, together with other physicians and categories of health care providers, they offer qualified treatment of various diseases at home – the environment preferred by the patient.     

Evidenzbasierte Medizin in der notfallmedizinischen Fort- und Weiterbildung

Evidence of benefits of specific procedures is fundamental in prehospital emergency medicine settings and is the basis for patient-oriented treatment. Emergency physicians involved in goal-directed therapy of critically ill patients on-site should rely on good continuing education reflecting this evidence, but in fact these demands are not consistently considered in postgraduate concepts for emergency medical care. Various studies have shown that analysis of the quality of management as well as assessing applied standards reveal deficits in the medical rescue service with respect to the education of emergency physicians. From this it becomes clear that there is hardly any other medical sub-discipline which is so dictated by subjective opinions as prehospital emergency medicine. This article focuses on possible approaches for optimizing the training of emergency physicians. In the future education and training concepts should provide uniform content regarding diagnosis and treatment strategies, which meet the criteria of evidence-based medicine.     

Schulung in Notfallsonographie bei Trauma

In the last decade prehospital focused abdominal sonography for trauma (P-FAST) could be established as a valid on-site diagnostic tool for both air and ground rescue medical services in Germany. An appropriate use of P-FAST demands a standardized training concept. Therefore a 1-day training program was developed by the working group ?emergency ultrasound“ in Frankfurt/Main and was introduced in 2003. The training consists of lectures on general and specific aspects of emergency ultrasound techniques with demonstrations of numerous pathological findings, intensive hands-on training with patients and volunteers, as well as simulated on-site training. After completing the P-FAST course the participants gained competency to perform prehospital emergency ultrasound with high accuracy. Strict application of the exact technique as well as appropriate integration of the adjunct into the algorithm of prehospital care are the most important prerequisites for successful use of P-FAST. From February 2003 to March 2008 540 participants were trained in P-FAST in the 1-day course.     

Medical care for mechanical trauma of the chest and abdomen at the prehospital stage

The authors describe specific features of the diagnosis and emergency medical care at the prehospital period developed on the basis of treatment of more than 5000 patients with isolated and combined injuries of the chest and abdomen. The importance of using the resuscitation-surgical teams, the syndrome diagnostics and stabilization of vital functions at the place of the accident is stressed as well as admittance of the casualties as quickly as possible to an up-to-date specialized multitype traumatology center.     

Evacuation priorities in mass casualty terror-related events: implications for contingency planning

OBJECTIVE: To assess evacuation priorities during terror-related mass casualty incidents (MCIs) and their implications for hospital organization/contingency planning. SUMMARY BACKGROUND DATA: Trauma guidelines recommend evacuation of critically injured patients to Level I trauma centers. The recent MCIs in Israel offered an opportunity to study the impositions placed on a prehospital emergency medical service (EMS) regarding evacuation priorities in these circumstances. METHODS: A retrospective analysis of medical evacuations from MCIs (29.9.2000-31.9.2002) performed by the Israeli National EMS rescue teams. RESULTS: Thirty-three MCIs yielded data on 1156 casualties. Only 57% (506) of the 1123 available and mobilized ambulances were needed to provide 612 evacuations. Rescue teams arrived on scene within <5 minutes and evacuated the last urgent casualty within 15-20 minutes. The majority of non-urgent and urgent patients were transported to medical centers close to the event. Less than half of the urgent casualties were evacuated to more distant trauma centers. Independent variables predicting evacuation to a trauma center were its being the hospital closest to the event (OR 249.2, P < 0.001), evacuation within <10 minutes of the event (OR 9.3, P = 0.003), and having an urgent patient on the ambulance (OR 5.6, P < 0.001). CONCLUSIONS: Hospitals nearby terror-induced MCIs play a major role in trauma patient care. Thus, all hospitals should be included in contingency plans for MCIs. Further research into the implications of evacuation of the most severely injured casualties to the nearest hospital while evacuating all other casualties to various hospitals in the area is needed. The challenges posed by terror-induced MCIs require consideration of a paradigm shift in trauma care.     

Massenanfall von Verletzten

Any emergency physician can be confronted at any time with major emergency incidents and mass casualties. The first emergency physician to arrive on the scene is called the emergency physician in charge and takes over these duties until arrival of the senior emergency physician. The emergency physician in charge has to deal with unusual organizational and medical challenges such as rapid situation assessment and arranging of the deployment area as well as triage, emergency treatment and coordinated transport of the patients. All actions must be forced in accordance with “work and go”: immediate and adequate clinical treatment is the main goal even in major emergency incidents with mass casualties.     

The anesthesiologist's role in the French emergency medical system

The present system of French emergency medicine and its philosophy were described from my experience at SAMU (service d'aide medicale urgente). Three factors of emergency medicine; pre-hospital care, emergency transport and emergency information service are managed by anesthesiologists. Anesthesiologists on duty at the tele-medicine center give medical team instructions to start at once. The team is composed of an anesthesiologist, a nurse and an ambulancier. They start to give intensive care medicine to critically ill patients on the spot. The philosophy of SAMU is that doctors should go out of the hospital. Anesthesiologists in the area organize the emergency medical system in France.     

Australian major incident nomenclature: it may be a 'disaster' but in an 'emergency' it is just a mess

Background : A standardized major incident nomenclature has practical applications for medical communication and audit of the medical response to incidents. Methods : A telephone and fax survey of major incident nomenclature in State and Territory health service emergency management plans and ‘disaster’ legislation was carried out on 13 August 1999. Results : Within Australia there were a total of 13 different terms to describe incidents that could produce casualties: there were four definitions of the word ‘disaster’, eight definitions of the word ‘emergency’ and one definition of the word ‘incident’. Conclusion : Australia lacks a uniform system of classifying and recording mass casualty incidents. This prevents both the independent clinical audit of the medical response to an incident and the cross‐border comparison of the effectiveness of trauma systems to deal with multiple casualties. Australia’s geography highlights the need to develop a nomenclature that allows medical practitioners, in isolated environments, to accurately describe an incident and the medical support that is required. The Potential Injury‐Creating Event (PICE) nomenclature is a simple system to describe the functional impact of an event upon a community and the level of medical support required. It can be used to provide the basis for the uniform reporting of the medical management of major incidents within Australia.     

Bestandsaufnahme des Bayerischen Staatsministeriums des Innern zur Fußball-WM 2006

Many innovative concepts especially for coping with mass casualty incidents have been invented and implemented for the FIFA World Cup 2006 in Germany. Concepts for the triage of casualties and their distribution on hospitals, for setting up treatment facilities, for a hospital atlas, for the decontamination of reclined casualties and for psychosocial emergency prevention were developed. To advance these concepts to concepts, that fulfill the needs of daily routine, and to implement them, if applicable, overall Bavaria is wish and task of the Bavarian States Ministry of the Interior, which is responsible for disaster management. Improving the medical care of people affected by mass casualty incidents is a very important challenge.     

Aktuelle prähospitale und frühe klinische Therapie des akuten Koronarsyndroms (ACS)

A symposium on “Current prehospital and early clinical treatment of acute coronary syndrome (ACS)” was held in Heidelberg on 14.01.2006. In the course of this event the present importance of preclinical thrombolysis in emergency medical treatment of ACS was discussed, as were the challenges to preclinical emergency medical treatment of ACS from the viewpoint of a specialised intervention centre. In addition, reports were received on the actual emergency medical and early clinical care of ACS patients in Germany. Special emphasis was given to temporally optimal efficient patient care and friction-free link-up of prehospital and clinical care. The creation of interdisciplinary supraregional emeregency medical networks with particular reference to local infrastructure was discussed as an essential element in care. In a final digression, the question of whether the indications for prehospital thrombolysis might need to be widened in future and whether thrombolysis in cardiac attest (TROICA) will have a place was examined.     

The identification of criteria to evaluate prehospital trauma care using the Delphi technique

OBJECTIVE: Current trauma system performance improvement emphasizes hospital- and patient-based outcome measures such as mortality and morbidity, with little focus upon the processes of prehospital trauma care. Little data exist to suggest which prehospital criteria should serve as potential filters. This study identifies the most important filters for auditing prehospital trauma care using a Delphi technique to achieve consensus of expert opinion. METHODS: Experts in trauma care from the United States (n = 81) were asked to generate filters of potential utility in monitoring the prehospital aspect of the trauma system, and were then required to rank these questions in order of importance to identify those of greatest importance. RESULTS: Twenty-eight filters ranking in the highest tertile are proposed. The majority (54%) pertains to aspects of emergency medical services, which comprise 7 of the top 10 (70%) filters. Triage filters follow in priority ranking, comprising 29% of the final list. Filters concerning interfacility transfers and transportation ranked lowest. CONCLUSION: This study identifies audit filters representing the most important aspects of prehospital trauma care that merit continued evaluation and monitoring. A subsequent trial addressing the utility of these filters could potentially enhance the sensitivity of identifying deviations in prehospital care, standardize the performance improvement process, and translate into an improvement in patient care and outcome.     

Prehospital advanced life support provided by specially trained physicians: is there a benefit in terms of life years gained?

BACKGROUND: The benefit of prehospital advanced life support (ALS) is disputed, as is the prehospital use of specially trained, hospital-based physicians. The purpose of the study was to assess the health benefit from an anesthesiologist-manned prehospital emergency medical service (EMS), and to separate the benefit of the anesthesiologist from that of rapid transport. METHODS: The anesthesiologist-manned helicopter and rapid response car service at Rogaland Central Hospital assisted 1106 patients at the scene during the 18-month study period. Two expert panels assessed patients with a potential health benefit for life years gained (LYG) using a modified Delphi technique. The probability of survival as a result of the studied EMS was multiplied by the life expectancy of each patient. The benefit was attributed either to the anesthesiologist, the rapid transport or a combination of both. RESULTS: The expert panels estimated a benefit of 504 LYG in 74 patients (7% of the total study population), with a median age of 54 years (range 0-88). The cause of the emergency was cardiac diseases (including cardiac arrest) in 61% of the 74 patients, trauma in 19%, and cardio-respiratory failure as a result of other conditions in 20%. The LYG were equally divided between air and ground missions, and the majority (88%) were attributed solely to ALS by the anesthesiologist. CONCLUSION: The expert panels found LYG in every 14th patient assisted by this anesthesiologist-manned prehospital EMS. There was no difference in LYG between the helicopter and the rapid response car missions. The role of the anesthesiologist was crucial for health benefits.     

A systematic literature review of criteria and models for casualty distribution in trauma related mass casualty incidents

IntroductionMass casualty incidents impose a large burden on the emergency medical systems, hospitals and community infrastructures. The pre-hospital and hospital capacities are usually bear the burden of casualties large numbers. One of the challenging issues in mass casualty incidents is the distribution of casualties among the suitable health care facilities.ObjectiveTo review models and criteria affecting the distribution of casualties during the trauma-related mass causality incidents.Materials and methodsA systematic literature search in the scientific databases which included: PubMed, Scopus and Web of Science was conducted. Relevant literature which was published before August 2017 was searched. Neither the publication date nor language limitations were considered in the literature search. All the trauma-related mass casualty incidents are included in this study. Two independent reviewers conducted the data extraction and quality assessment of the documents was considered using a checklist developed by the researchers.ResultsLiterature search yielded 4540 documents of which 493 were duplicated and removed. After reviewing the titles and abstracts of the remaining documents (4047), only 73 documents were considered relevant. Finally, the inclusion and exclusion criteria were applied and only 30 documents were considered for data extraction and quality assessment. The study found 491 criteria to be affecting the distribution of casualties following trauma-related mass casualty incidents. These are categorized as pre-hospital (triage, treatment and transport); hospital (space, staff, stuff, system / structure); incidents’ characteristics and others. The criteria which were extracted from the models are termed as “model extracted” while the other labeled as “author suggested”.ConclusionTo the best of our knowledge, this is the first systematic literature review on criteria affecting distribution of casualties following trauma-related mass casualty incidents based on the pre-hospital and hospital capacities.Systematic review registration numberThis review was registered in international prospective register of systematic reviews (PROSPERO) with registration number CRD42016049115.     

The modified vital index in prehospital emergency care

Many vital indices and scores have been proposed and used, particularly in relation to trauma. Most were primarily designed for and, within limits, are successful in hospital application. Attempts to use all or part of these in the prehospital context are misguided. There is a major difference between this phase of emergency care and hospital care, and that is the inability to provide a definitive end-point of treatment. A new score is proposed, the modified vital index (MVI) based on vital signs and other parameters important in the prehospital context. The value of the MVI lies in its adaptability to emergency medical care systems at all stages of development. The necessity for the MVI is outlined, as is the detailed working of the system. The hope is expressed that through adaptation of the MVI in different areas a consolidated prehospital scoring system may be achieved.     

Multicenter Canadian study of prehospital trauma care

OBJECTIVE: To evaluate whether the type of on-site care a trauma patient receives affects outcome. SUMMARY BACKGROUND DATA: The controversy regarding the prehospital care of trauma patients between Advanced Life Support (ALS) and Basic Life Support (BLS) is ongoing. Due to this unresolved controversy, as well as historical, cultural, and political factors, there are significant variations with respect to the type of prehospital care available for trauma patients. METHODS: This prospective cohort study compared three types of prehospital trauma care systems: Montreal, where physicians provide ALS (MD-ALS); Toronto, where paramedics provide ALS (PMD-ALS); and Quebec City, where emergency medical technicians provide BLS only (EMT-BLS). The study took advantage of this variation to evaluate the association between the type of on-site care and mortality in patients with major life-threatening injuries. All patients were treated at highly specialized tertiary (level I) trauma hospitals. The main outcome measure was death as a result of injury. Follow-up was to hospital discharge. RESULTS: The overall mortality rates by type of on-site personnel were physicians 35%, paramedics 24%, and EMTs 18%. For patients with major but survivable trauma, the overall mortality rates were physicians 32%, paramedics 28%, and EMTs 26%. The overall mortality rate of patients receiving only BLS at the scene was 18% compared to 29% for patients receiving ALS. For the subgroup of patients with major but survivable injuries, the mortality rates were 30% for ALS and 26% for BLS. The adjusted increased risk for mortality in patients receiving ALS at the scene was 21%. CONCLUSIONS: In urban centers with highly specialized level I trauma centers, there is no benefit in having on-site ALS for the prehospital management of trauma patients.