Emergency medical services for treatment of mass casualties

The French emergency medical system (EMS) is the Service d'Aide Médicale Urgente (SAMU). In case of mass casualties, involving 100 simultaneous victims, SAMU has developed a disaster plan, "The White Plan." This plan is closely correlated to the Red Plan of the Fire Department, to provide advanced life support (ALS) at the incident site, followed in a continuum by medical transport and hospitalization in the appropriate services. To obtain the best chance of survival and recovery, there must be optimal coordination among all rescuers. This objective was approached by adopting a formal protocol designed for each city. In France, the medical organization for the treatment of casualties is operated by anesthesiologists who are qualified to perform ALS, preanesthetic evaluation en route, anesthesia for the multitrauma patient, and postanesthetic resuscitation in a continuum from the accident scene to the ICU.     

Emergency medical support units to critical care transport teams in Iraq

Early in the author's deployment in the United States Air Force to southern Iraq, his unit was exposed to the first of many mass casualties sent to his Expeditionary Medical Support System unit. Within minutes of the injured military members' arrival, the four-bed evaluation station was transformed into an open bay trauma room where patients were treated and supported until they could be evacuated to more definitive care. Patients were transitioned with awe-inspiring speed and professionalism to Critical Care Air Transport teams for care during aeromedical evacuation. The lessons learned from the frequency of these events are valuable to any similar transport case with critically ill and injured patients.     

A rural emergency medical technician with selected advanced skills

Objective. To educate rural emergency medical technician basics (EMTs) in selected advanced skills, and then evaluate the safety and effectiveness of practice. Methods. After a minimum 72 hours of training, EMTs employed three skills (Com-bitube, glucometry, automated external defibrillation) and seven medications (albuterol, nitroglycerin, naloxone, epi-nephrine, glucagon, activated charcoal, and aspirin). Written patient care records and audiotapes were reviewed. Congruence between prehospital assessment and emergency department (ED) diagnosis was assessed, along with correct use of airway skills (18 of 36 months). The completeness of documentation, appropriateness of treatment, and patient response (by explicit criteria) were determined. Errors and complications were recorded. Results. During three years of the program, 266 patients were treated, primarily for chest pain and respiratory distress. No significant errors or complications occurred. Treatment was judged 94% appropriate, with improvement in 60% of patients. Documentation had major omissions in 3% of cases. Field and ED diagnostic congruence was present in 97/129 (75%) when evaluated during the first 18 months. EMT skill levels were maintained. The mean time to traditional advanced life support (ALS) care was 41 minutes. Conclusions. Basic-level EMTs in rural areas can be trained in selected advanced skills, and provide ALS-level care quickly and appropriately. Close medical oversight involving review of care and follow-up education is an important part of the program.     

急性苯胺类化合物中毒的急救与护理

苯胺类化合物为无色或黄色油状液体，有特殊烧灼样奥味，多用于染料、橡胶、制药等化工工业，极易经无损伤的皮肤或吸人其蒸气引起急性中毒，常为化工厂生产或运输中发生，或者手工操作者直接被物料污染所致，以皮肤污染中毒颇为常见〔‘〕。我院急诊科自2(X)3年12月至2(X万年1     

Emergency medical dispatch

EMD will always remain somewhat of an imprecise science by nature. 911 is, after all, the access point for lifesaving assistance, and citizens must have absolute freedom to this service. The consequence of having the freedom to request help from any location at any time is that some individuals will use it for the wrong reasons. Present-day dispatchers must serve ever-broadening communities with multiple languages, cultural diversity, and unique health needs. Along with other essential personnel that make up the fabric of the public safety net, emergency medical dispatchers have now become essential to the provision of time-critical skills and compassion for perceived medical emergency.     

"Medical clearance" of psychiatric patients without medical complaints in the Emergency Department

This study was conducted to evaluate the benefit of comprehensive "medical clearance" (history, physical examination, vital signs, laboratory, radiography) in patients presenting to the Emergency Department (ED) with isolated psychiatric complaints. All patients 16 years and older who presented with a psychiatric complaint and required a psychiatric evaluation before discharge from the ED were included in the study. Data, obtained in a 5-month consecutive, retrospective chart review, included patient age, sex, initial complaint, past medical and psychiatric history, initial vital sign measurement, physical examination findings, laboratory analysis (electrolytes, complete blood count, toxicology screen), chest X-ray study results, and final disposition. The number of patients who could have been referred to a psychiatric unit after a history, physical examination, and stable vital signs, without additional laboratory or radiographic studies, was determined. There were 212 patients who met the inclusion criteria, and all their charts were available for review. Eighty patients (38%) presented with isolated psychiatric complaints coupled with a documented past psychiatric history. All received a comprehensive "medical clearance" in the ED followed by a psychiatric consultation. None of the patients had positive screening laboratory or radiographic results. All were either dispositioned home or to the psychiatric ED. The remaining 132 patients (62%) presented to the ED with medically based chief complaints or past medical history requiring further evaluation in the ED before discharge. The initial complaints of these patients correlated directly with the need for laboratory and radiographic "medical clearance" in the ED. Patients with a primary psychiatric complaint coupled with a documented past psychiatric history, negative physical findings, and stable vital signs who deny current medical problems may be referred to psychiatric services without the use of ancillary testing in the ED.     

The effect of pulse oximetry on emergency medical technician decision making

Objective

Relatively little is known about the use of pulse oximetry in the prehospital setting. The purpose of this study was to determine how emergency medical technicians (EMTs) use pulse oximetry information to influence their decisions regarding the involvement of advanced life support (ALS) personnel in a two-tiered emergency medical services (EMS) system.

Methods

EMTs were trained and authorized to use pulse oximetry in predefined clinical situations. The EMTs completed a questionnaire describing the influence of the oximetry information on their decision making regarding the involvement of ALS units.

Results

The EMTs reported an influence on their decisions whether to involve ALS care in 35 (12%) of 302 cases. The addition of the pulse oximetry information caused the EMTs to request ALS dispatch in 11 cases, to cancel a previously dispatched ALS response in eight cases, and not to request an ALS response from the scene when they otherwise would have requested it in 16 cases.

Conclusion

Prehospital pulse oximetry has a measurable influence on EMT decisions concerning ALS involvement in a two-tiered EMS system. It improves system efficiency by helping to match patients to an appropriate level of care.     

小儿低钙惊厥的急救与护理

在婴幼儿惊厥中,低钙血症较为常见,若不及时诊治,可导致一系列并发症的发生,严重者可并发窒息、呼吸循环衰竭甚至死亡。若能早期发现,积极救治,可使治愈率明显提高。我院儿科1998年—2 0 0 2年共收治5 0例低钙惊厥患儿,现报告如下。1　临床资料1.1　一般资料　本组5 0例,男3 2例,女18例。其中新生儿4例,婴幼儿46例;母乳喂养2 4例,混合喂养10例,人工喂养16例。发病季节5月～10月15例,11月至次年4月共3 5例。1.2　临床表现　全身抽搐13例,手足抽搐16例,局限性抽搐2 1例。其中反复呼吸暂停、面色发绀2例,吸气性呼吸困难1例。血钙1.3 2mmol/L～…     

肺栓塞病人的急救及护理

[目的]探讨肺动脉栓塞急救与护理方法,积累临床经验,以更好指导临床工作.[方法]对收治30例肺动脉栓塞病人进行急救与规范护理.[结果]该组病人中,28例康复出院,2例经抢救无效死亡.[结论]尽早对肺栓塞病人进行急救与规范护理,有助于提高病人生存率,减少并发症发生.     

56例低血容量休克患者的急救和护理

目的探讨低血容量休克患者的急救和护理经验,提高治愈率。方法对56例低血容量休克患者的临床急救资料进行回顾性分析。结果全组病例治愈53例,死亡3例。其中因为重度脑挫伤合并血气胸死亡2例,重度肝破裂合并肾破裂死亡1例。结论低血容量休克往往病情危急、处理难度大、并发症多,快速准确的判断病情,及早的复苏治疗,正确的监测护理,是提高治愈率、降低病死率的关键。     

Safe out-of-hospital treatment of chest pain without direct medical control

INTRODUCTION: The use of direct medical control (DMC) in the out-of-hospital setting often is beneficial, but has the disadvantage of consuming emergency medical services (EMS) resources. HYPOTHESIS: Uncomplicated, nontrauma, adult patients with chest pain can be treated safely and transported by paramedics without DMC. METHODS: Retrospective chart review of all nontrauma, adult patients with chest pain treated in a combined rural and suburban EMS system during a 2-year period (December 1990 through November 1992) was conducted. Before November 1991, DMC was mandatory for all patients with chest pain. Beginning 01 November 1991, if a patient had resolution of a pain either spontaneously, with administration of oxygen, or after a single dose of nitroglycerin, DMC was at the discretion of the paramedic. Using the above criteria for inclusion, three study groups were defined: Group 1, before protocol change; Group 2, after protocol change without DMC; and Group 3, after protocol change when physician contact was obtained, but not required. These groups were compared for the following parameters: 1) scene time; 2) time to administration of first dose of nitroglycerin; 3) time interval between measurement of vital signs; 4) oxygen use; 5) intravenous access; and 6) electrocardiographic monitoring. Continuous and categorical variables were analyzed by multivariate and univariate analysis of variance and chi-square tests, respectively. RESULTS: Of 308 nontrauma, adult patients with chest pain, 71 met inclusion criteria in Group 1, 40 in Group 2, and 34 in Group 3. No statistically significant differences were identified in any of the study parameters. CONCLUSION: Adult patients with chest pain who have no other symptoms or complicating conditions can be treated appropriately be paramedics without DMC.     

A comparison of four methods of testing emergency medical technician triage skills

Triage skills are requisite for all providers of prehospital care. Methods of assessing the acquisition of triage skills vary in complexity and expense. In this study, 61 prehospital care providers classified 20 cases, divided into four groups of five cases each: moulaged live trauma victims, nonmoulaged live trauma victims, nonmoulaged manikin trauma victims, and written scenarios. The providers were asked to classify the cases in each group by assigning triage tags to indicate injury severity and to rank the trauma victims in each group according to the urgency of care required. Analysis of variance revealed statistically significant differences among the four methods in both mean tagging scores (F3,235 = 8.63, P less than .0001) and mean ranking scores (F3,232 = 6.09, P less than .001). Multiple comparisons using Scheffe's test revealed that the mean tagging and ranking scores for moulaged live victims and written scenario methods were comparable and that both were significantly superior to the scores of the two other methods. However, a qualitative evaluation revealed that the providers greatly preferred triage of moulaged live victims to the other three methods.     

Emergency medical services transport of patients with headache: Mode of arrival may indicate serious etiology

Objective. To determine whether mode of arrival is associated with seriousness of etiology and use of diagnostic testing in patients treated in the emergency department for headache. Methods. This observational, retrospective study was conducted by consecutive review of the records of patients presenting to the emergency department with a chief complaint of headache from December 1994 through May 1995. Patients with altered mental status or seizures were excluded. Mode of arrival was classified as either by EMS or other (e.g., private vehicle). Patients with a final diagnosis of meningitis, intracranial hemorrhage, or central nervous system tumor were classified as having serious causes, whereas those with headache due to migraine, tension headache, or headache that was otherwise unspecified were classified as nonserious. The use of diagnostic studies, such as lumbar puncture or CT scan, and their results, was recorded. Patients were included in the category of patients having serious intracranial pathology even if the diagnosis was delayed. Statistical analysis was performed using the Yates-corrected chi-square test, and by determining odds ratios (ORs) with 95% confidence intervals. Results. For 967 patients presenting with a chief complaint of headache, 837 charts were included in the analysis. A total of 102 patients arrived by EMS, and 735 arrived by other means. Patients arriving by EMS had a higher rate of serious cause of headache than did those arriving by other means (OR = 18.5, p < 0.0001). EMS patients tended to undergo additional diagnostic testing (OR = 4.4, p < 0.001), and those tests were more likely to be abnormal than for those arriving by other means (OR = 9.4, p < 0.0001). Males had a somewhat higher rate of serious diagnosis (OR = 2.6, p < 0.05). Conclusions. In this EMS system, patients with headache who arrive by EMS are more likely to have serious causes. Mode of arrival may be of use to the clinician in assessing risk of serious illness among patients with headache. Whether this observation represents an element of self-triage or a combination of other factors remains to be determined.