Radiation disaster response: preparation and simulation experience at an academic medical center

OBJECTIVES: A mass casualty disaster drill involving the simulated explosion of a radiation dispersal device (dirty bomb) was performed with the participation of multiple hospitals, emergency responders, and governmental agencies. The exercise was designed to stress trauma service capacities, communications, safety, and logistic functions. We report our experience and critique of the planning, training, and execution of the exercise, with special attention to the integrated response of the Departments of Nuclear Medicine, Health Physics, and Emergency Medicine. METHODS: The Health Physics Department presented multiple training sessions to the Emergency Medicine Department, Operating Room, and ancillary staff; reviewing basics of radiation biology and risk, protection standards, and detection of radiocontamination. Competency-based simulations using Geiger-Müller detectors and sealed sources were performed. Two nuclear medicine technologists played an important role in radiation discrimination-that is, assessment of radioactive contamination with survey meters and radionuclide identification based on gamma-spectroscopy of wipe smears from patients' clothing, skin, and orifices. Three Health Physics personnel and one senior Nuclear Medicine staff member were designated the radiation control officers for assigned teams triaging or treating patients. Patients were triaged and, when indicated, decontaminated. RESULTS: Within a 2-h period, 21 simulated victims arrived at our institution's Emergency Room. Of these, 11 were randomized as noncontaminated, with 10 as contaminated. Decontamination procedures were implemented in a hazardous materials (HAZMAT) decontamination trailer and, for the 5 patients with simulated serious injuries, in a designated trauma room. A full debriefing took place at the conclusion of the exercise. Staff largely complied with appropriate radiation protection protocols, although decontamination areas were not effectively controlled. The encountered limitations included significant lapses in communications and logistics, lack of coordination in the flow of patients through the HAZMAT trailer, insufficient staff to treat acute patients in a radiation control area, additional personnel needed for transport, and insufficient radiation safety personnel to control each decontamination room. CONCLUSION: Nuclear Medicine personnel are particularly well qualified to assist Health Physics and Emergency Medicine personnel in the preparation for, and management of, mass casualty radiation emergencies. Simulation exercises, though resource intensive, are essential to an institution's determination of response capability, performance, and coordination with outside agencies.     

Trauma patient outcome in an army Deployable Medical Systems environment compared with a medical center

William Beaumont Army Medical Center is the second busiest trauma center in the Army. Recent facility renovations there necessitated the use of a temporary field hospital to serve as the Emergency Department, which included the initial evaluation and resuscitation of trauma patients by the trauma team. Although designed for the battlefield, the use of field medical equipment during renovation of military medical facilities is not a new concept. The MUST (Medical Unit Self-contained Transportable) and DEPMEDS (Deployable Medical Systems) have been used successfully during fixed-facility renovations. Previously described functions included inpatient services, outpatient care, and operating room facilities. However, no published information directly compares the use of these temporary structures with standard fixed facilities in the initial management of trauma patients. Trauma patients often present with complex concerns, are highly resource intensive, and their survival is dependent on efficient, timely care. We compared several aspects of patient outcome in the DEPMEDS versus the medical center.     

The prevention of softball injuries: the experience at Yokota

Softball injuries occur in a predictable pattern. Review of Emergency Room records at Yokota AB Hospital for three summers showed a high incidence of ankle injuries. Sliding is the cause of many of these injuries. Common sense interventions should reduce the incidence of softball injury. Use of low profile bases or the outlawing of sliding are reasonable interventions that should be considered by policy makers.     

Nucleating emergency radiology specialization in India

Emergency radiology is being recognized as an important and distinct specialty of radiology which merits utmost attention of educators, radiology program curricula committees, and radiology practices in India. Providing an accurate but timely diagnosis requires a skilled judgement and a strong process framework, particularly in acute trauma setting or a life-threatening acute illness. However, due to a shortage of radiologists in India and lack of awareness and suitable opportunities, there has been no concerted movement towards emergency radiology subspecialty training or dedicated emergency radiology positions. It was with these gaps in mind that the Society for Emergency Radiology was envisioned in 2012 and formulated in 2013. The proposed role of the Society for Emergency Radiology is to identify deficiencies in the field, namely, lack of adequate exposure, lack of mentorship by experienced emergency radiologists, lack of suitable opportunities for emergency radiologists; establish standards of practice; and promote education and implementation research to bridge the gaps. Through collaboration with other societies and partnership with the journal Emergency Radiology, the Society for Emergency Radiology hopes to promote a free exchange of ideas, protocols, and multi-institutional trials across continents.     

Extracerebral anatomic blind spots in computed tomography (CT) head: a pictorial review of non-traumatic findings

CT head has been increasingly performed in the Emergency Department for patients presented with trauma, acute neurological or psychological symptoms. Most of the emergency physicians and radiologists have undergone dedicated training and are capable of identifying and interpreting life-threatening cerebral pathologies. However, as most attention is directed to the brain, the extracerebral non-traumatic pathologies on CT head can easily be overlooked, and some of them harbour clinically significant pathologies. We categorise the extracerebral anatomic landmarks, illustrate and describe the representative pathologies from each category. The purpose of this article is to increase awareness and familiarity on the non-traumatic extracerebral pathologies, with the aim of achieving comprehensive interpretation of CT head.     

Implementation of Istanbul Protocol for effective documentation of torture - review of Sri Lankan perspectives

Documentation of torture is a multidisciplinary, multistage scientific procedure evolved over the past decades through the experience of various strata in medical and related fields. It plays a key role in effective corroboration of facts, providing redress to victims and also has a long term regulatory impact on prevention of torture in a society. The UN endorsed Istanbul protocol serves as the model for effective documentation of torture in the present context and there were many attempts in the recent years to create a systematic and uniform approach among professional bodies to document torture by adopting it to the local medico-legal and legal systems in some less resourced countries. The post independent Sri Lanka is widely known in international human rights forums for the prevalence of torture and its endemicity since 1970s. The long term struggle to ensure justice to torture victims in Sri Lanka has been greatly enhanced by the submission of detailed medico-legal reports on them to relevant courts. As strengthening of medico-legal and legal reporting strategies were more focused towards the end of twentieth century the medico-legal and legal professionals in consensus attempted to use Istanbul Protocol for documentation of torture since 2004. However Sri Lankan experience on application of Istanbul protocol for documentation of torture signifies that unless and until a political commitment is shown by the government to internalize Istanbul Protocol into legal and medico-legal systems locally the expected outcome of effective documentation would not be evident.     

Acute cardiac effects of ‘SCUD’ missile attacks on a civilian population

The ‘SCUD’ raids on Israel during the Gulf War afforded a rare opportunity to examine the effect of mass acute fear on the cardiac health of the general population. Press reports suggested an alarming rise in cardiac deaths during the first missile raids. In order to ascertain this statement, we examined the Emergency Room records of a community hospital in the affected area and all the death certificates in the local region. The periods studied were from 1 January to 28 February 1991, and the equivalent weeks in 1990. The Emergency Room records showed that there was an increased rate of cardiac complaints throughout the war, most marked during the first week. However, this was not accompanied by an increased cardiac mortality, either in the hospital or in the region as a whole, except during the first week. A similar increase in cardiac mortality occurred during the same week the previous year. The increased incidence of acute cardiac events during the first week of the war was probably a coincidence, and not a direct consequence of mass fear. Panic, occasioned by press reports, may have led to a lower threshold of referral which persisted throughout the war.     

Implementation of a Semistructured Clinical Event Documentation Tool for Acute Adverse Contrast Reactions

PurposeTo improve the efficiency and accuracy of clinicians documenting acute clinical events related to contrast agent administration using a web browser–based semistructured documentation support tool.MethodsA new tool called Contrast Incident Support and Reporting (CISaR) was developed to enable radiologists responding to contrast reactions to document inciting contrast class, type of event, severity of contrast reaction, and recommendation for future contrast use. Retrospective analysis was conducted of all CT and MRI examinations performed between February 2018 and December 2019 across our hospital system with associated contrast reaction documentation. Time periods were defined as before tool deployment, early adoption, and steady-state deployment. The primary outcome measure was the presence of event documentation by a radiologist. The secondary outcome measure was completeness of the documentation parameters.ResultsA total of 431 CT and MRI studies with reactions were included in the study, and 50% of studies had radiologist documentation during the pre-CISaR period. This increased to 66% during the early adoption period and 89% in the post-CISaR period. It took approximately 9 months from the introduction of CISaR to reach full adoption and become the main method for adverse contrast reaction documentation. The percentage of radiologist documentation that detailed provoking contrast agent class, severity of reaction, reaction type, and future contrast agent recommendation all significantly increased (P < .0001), with greater than 95% inclusion of each element.ConclusionThe implementation of a semistructured electronic application for adverse contrast reaction reporting significantly increased radiologist documentation rate and completeness of the documentation.     

Intrarenal post-traumatic pseudoaneurysm-USG colour Doppler diagnosis: a case report with review of literature

Renal artery pseudoaneurysm, although a well-known complication in patients after penetrating trauma or iatrogenic injury, has rarely been described after blunt torso trauma. A 22-year-old man suffered an accident while on a motorcycle. Upon arrival in the Emergency Room, the patient was unconscious, hypotensive and had hematuria. Initial investigations revealed a fractured shaft of the right femur, multiple rib fractures with hemothorax, extradural haematoma on the right side and a laceration in the right kidney. After the evacuation of intracranial bleed, the patient was managed conservatively. The patient recovered well and was discharged on the 15th post-trauma day. The patient was again present in the emergency room after 6 weeks with 1-week history of gross hematuria. Ultrasonography revealed an anechoic lesion in the right kidney with pulsatile flow on colour Doppler. Further investigation with computed tomography renal angiography was done, which confirmed the pseudoaneurysm of a branch of renal artery. The patient was referred to a higher centre where he was successfully managed with selective arterial coil embolisation.     

Optimising communication in the damage control resuscitation -- Damage Control Surgery sequence in major trauma management

Damage Control Resuscitation and Damage Control Surgery (DCR-DCS) is an approach to managing severely injured patients according to their physiological needs, in order to optimise outcome. Key to delivering DCR-DCS is effective communication between members of the clinical team and in particular between the surgeon and anaesthetist, in order to sequence and prioritise interventions. Although the requirement for effective communication is self-evident, the principles to achieving this can be forgotten and sub-optimal when unexpected problems arise at critical points during management of challenging cases. A system is described which builds on the 'World Health Organisation (WHO) safer surgery checklist' and formalises certain stages of communication in order to assure the effective passage of key points. We have identified 3 distinct phases: (i) The Command Huddle, once the patient has been assessed in the Emergency room; (ii) The Snap Brief, once the patient has arrived in the Operating Room but before the start of surgery; and (iii) The Sit-Reps, every 10 minutes for the entire theatre team to maintain situational awareness and allow effective anticipation and planning.     

Peroneal tendon injuries: CT analysis

Computed tomographic (CT) evaluation of the peroneal tendons was obtained in 25 normal ankles and 30 abnormal ankles studied for trauma. The tendons and associated soft-tissue and bony structures, such as the calcaneofibular ligament, superior and inferior peroneal retinacula, fibular groove, and peroneal tubercle, which have heretofore evaded documentation on routine radiographs, are illustrated and discussed. Special attention is given to normal variations such as convex fibular tip and enlarged peroneal tubercle, which predispose the peroneal tendons to abnormal mechanical stresses. Examples of CT-established peroneal tendon abnormalities in the 30 cases examined are also demonstrated. These abnormalities include subluxation, dislocation, entrapment, and tenosynovitis of the peroneal tendons. The authors believe CT has proved to be an extremely useful and relatively noninvasive imaging tool for the evaluation of peroneal tendon injuries.     

老年创伤救治与康复不容忽视

伴随社会的老龄化,创伤人群也呈现老龄化的趋势,老年创伤患者发病率和比例逐渐增加,老年创伤正在形成对公众健康的潜在危机。伤情评估、分类、早期救治对高危老年创伤患者的预后有极大影响,正确认识理解年龄相关生理变化有助于指导治疗。本文着重回顾国外老年创伤医学的发展,强调建立中国老年创伤患者的流行病学数据和国家创伤数据库的重要性。探讨老年创伤后分类、评估系统建立以及创伤并发症的预防对预后的影响,建议重症监护、营养护理、后期康复及随访管理不可或缺。同时,应注重老年医学为特点的创伤后疾病发生转归机制的基础研究,并加强向临床应用的转化。     

Efficiency of a semiautomated coding and review process for notification of critical findings in diagnostic imaging

OBJECTIVE: When a significant unexpected finding such as malignancy is noted on a study, the standard of care generally holds that the radiologist communicate the findings to the referring physician and document the communication in the radiology report. Despite this standard, for a variety of reasons it remains possible that the direct care provider might receive such notification but not initiate an appropriate workup. On the basis of prior root cause analysis, we developed and instituted a semiautomated process for notification of critical diagnostic imaging findings. We now report our 12-month experience with the process. MATERIALS AND METHODS: A diagnostic code was attached to every radiology report. When a significant unexpected finding occurred, our radiologists, in addition to contacting the appropriate clinician, gave the report the designation code 8. On a weekly basis, a list of code 8 cases was passed to the cancer registrar at our institution, who tracked the cases to ensure that they were appropriately followed up. RESULTS: In the 12-month period after initiation of this system, we performed 37,736 radiologic examinations at our institute. Of these, 395 cases were given code 8. All code 8 cases were followed up by the tumor registrar. In 35 cases, no workup was documented after 2 weeks. Of these, eight cases would have been completely lost to follow-up if this safety net had not been in place. CONCLUSION: Failures of communication, documentation errors, and various system failures may lead to an untoward outcome for the patient. We devised a simple system to ensure that significant unexpected findings on imaging received appropriate attention. An additional level of redundancy has increased the probability of optimal patient outcome.     

战时弹射跳伞多发伤飞行员的紧急救治策略（摘要）

本文系统论述了在新的作战环境下，弹射跳伞多发伤飞行员的紧急救治策略。其主要体现在以下几个方面。第一，在急救模式上表现为启用新的救护器材，缩短急救反应时间，改革现场急救模式，注重机动保障。第二，在创伤救治策略上表现为注重理论创新和新技术的应用。     

中国创伤急救10年研究现状回顾及分析

目的以文献回顾的方法了解和分析我国创伤急救近10年的关注重点和走向、研究的内容和方法,并对文献的被引用和被下载频次、文献来源做简单的分析,以确定相应的学术影响力。方法以"创伤"为关键词,并含"急救"精确匹配,运用文献计量学方法统计2002年1月～2011年12月CNKI数据库收录的全部文献,以了解创伤急救近10年研究现状。结果共检索到文献180篇,剔除年鉴形式文献,得到165篇,笔者将文献内容归纳为创伤急救的管理、创伤急救的治疗和护理、创伤急救的流行病学分析、创伤急救的培训和新技术的开展以及辅助检查7个方面。结论近10年创伤急救的发展较为迅速,创伤急救的治疗、护理和管理方面研究相对较多,热点研究也集中于此,创伤急救的流行病学分析、创伤急救的培训和新技术的开展以及辅助检查等方面的研究尚需不断的完善和发展,许多期刊对此方面的研究关注,推动了研究的不断深入。     

Application of spiral computerized tomography in the study of traumatic lesions of the thoracic aorta

PURPOSE: Acute thoracic aortic injuries account for up to 10-20% of fatalities in high-speed deceleration road accidents and have an estimated immediate fatality rate of 80-90%. Untreated survivors to acute trauma (10-20%) have a dismal prognosis: 30% of them die within 6 hours, 40-50% die within 24 hours, and 90% within 4 months. We investigated the diagnostic accuracy of Helical Computed Tomography (Helical CT) in acute traumatic injuries of the thoracic aorta, and the role of this technique in the diagnostic management of trauma patients with a strong suspicion of aortic rupture. MATERIAL AND METHODS: We compared retrospectively the chest Helical CT findings of 256 trauma patients examined June 1995 through August 1999. All patients underwent a plain chest radiograph in supine recumbency when admitted to the Emergency Room. Chest Helical CT examinations were performed according to trauma score, to associated traumatic lesions and to plain chest radiographic findings. All the examinations were performed with no intravenous contrast agent administration and the pitch 2 technique. After a previous baseline study, contrast-enhanced scans were acquired with pitch 1 in 87 patients. All examinations were assessed for the presence of mediastinal hematoma, periaortic hematoma, traumatic pseudodiverticulum, irregular aortic wall or contour and intimal flap as signs of aortic rupture. RESULTS: Helical CT showed thoracic aortic lesions in 9 of 256 patients examined. In all the 9 cases we found a mediastinal hematoma and all of them had positive plain chest radiographic findings of mediastinal enlargement. Moreover, in 6 cases aortic knob blurring was also evident on plain chest film and in 5 cases depressed left mainstem bronchus and trachea deviation rightwards were observed. All aortic lesions were identified on axial scans and located at the isthmus of level. Aortic rupture was always depicted as pseudodiverticulum of the proximal descending tract and intimal flap. We also found periaortic hematoma in 6 cases and intramural hematoma in 1 case. There were no false positive results in our series: 7 patients with Helical CT diagnosis of aortic rupture were submitted to conventional aortography that confirmed both type and extension of the lesions as detected by Helical CT, and all findings were confirmed by gross inspection at surgery. No false negative results have been recorded so far: untreated aortic ruptures are fatal within 4 months in 90% of patients, or they may evolve into chronic pseudoaneurysm in about 5% of survivors. CONCLUSIONS: In our experience Helical CT had much higher diagnostic sensitivity and specificity than plain chest radiography. In agreement with larger published series, in our small one the diagnostic accuracy of Helical CT was 100% in the evaluation of traumatic aortic ruptures. Moreover, Helical CT is faster and less invasive than conventional aortography, which makes this diagnostic modality increasingly used and markedly improves the management of the serious trauma patient. The more widespread use of this diagnostic tool has permitted to standardize the technique and now Helical CT can be used not only as a screening modality for patients that undergo digital aortography, but also as a reliable diagnostic method for surgical planning.     

胸部创伤救治现状

伤后数分钟到数小时内的早期救治是提高胸部创伤救治水平的关键.胸部创伤后的病理生理变化主要包括低氧血症、高碳酸血症和酸中毒.紧急情况下胸部创伤诊断与复苏同时进行,根据体征、诊断性胸腔穿刺或X 线片作出;血流动力学状况稳定时,则应全面检查避免漏诊危险的隐匿性损伤,有条件时应首选采用多层螺旋CT.胸部创伤急救应遵循高级创伤生命支持的原则,多数胸部创伤可采用临床观察、胸腔穿刺或引流、呼吸支持、止痛和介入治疗等处理治愈;小部分胸部创伤的病人在复苏阶段需行紧急手术干预.     

1162例严重胸部创伤的院前急救分析

目的：总结严重胸部创伤院前救治经验,提高院前救治水平。方法收集2009年1月～2014年12月经院前“120”现场救治后转入我院的严重胸部创伤（ AIS）≥3分患者病例资料1162例,其中男性827例,女性335例;年龄13～98岁,平均（45．3±10．8）岁。分析胸部损伤情况,院前、院内救治方法和救治结果等。结果1162例中,院前平均急救反应时间（46．52±17．33）min,平均急救时间（16．73±7．32） min。清除呼吸道异物31例,气管插管机械通气42例,紧急气管切开23例,张力性气胸减压25例,呼吸机正压通气纠正反常呼吸运动43例,纱垫填塞或包扎胸壁开放性伤口151例,呼吸心跳停止者现场进行徒手心肺复苏16例,胸部伤情未进行特殊处理者735例。本组死亡29例。结论院前快速准确判断,熟练正确急救为严重胸部创伤院内进一步救治创造机会和争取时间。