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PubMed2005

A survey of emergency medical services in mountain areas of Europe and North America: official recommendations of the International Commission for Mountain Emergency Medicine (ICAR Medcom).

Survey of on-site treatment of patients in mountain areas of 14 countries in Europe and North America (nonresponder rate 33%) to compare emergency medical services. Around 37,535 ground rescuers and 747 helicopters are ready for evacuation of casualties and patients in mountain areas. And 1316 physicians and 50,967 paramedics take part in ground and air mountain rescue operations. In Europe, 63.2% of helicopters have a physician on board, 17.8% are staffed with a paramedic, and 19% have no medically trained personnel on board. In North America, 31.6% (p < 0.001) of helicopters are staffed with a doctor, 59.3% (p < 0.001) with a paramedic, and 9.1% (p < 0.001) have no medical personnel. The percentage of on-site treatment according to the recommendations of the International Liaison Committee on Resuscitation (ILCOR) or International Commission for Alpine Rescue (ICAR) varies among all countries (p < 0.001) and is positively related to the percentage of physician-staffed helicopters (r = 0.76, p < 0.001). Paramedics in 90.9% countries are obliged to be medically trained, but physicians only need to have a standardized training in emergency medicine in 50% (p < 0.042). On-site treatment according to ILCOR or ICAR recommendations is performed more often in countries where physicians are regularly involved in mountain rescue operations. However, no conclusions can be drawn from the data as to the efficiency of treatment. The data show a lack of medical education in specific, mountain rescue-related problems. Physicians involved should undergo suitable training.

Air Ambulances↗
PubMed2005

Availability of emergency contraception in Massachusetts emergency departments.

OBJECTIVES: To determine the availability of emergency contraception (EC) in Massachusetts emergency departments (EDs) and to identify patient, hospital, and system factors that could affect access to EC. METHODS: This was a prospective, cross-sectional study of all Massachusetts EDs using two structured scenarios: one, a patient asking for EC for condom failure (patient scenario); and the other, a social worker asking about EC for a client who was sexually assaulted the night before (social worker scenario). Calls were made during day and night shifts requesting information from a nurse or doctor. The data collected included EC availability, whether pills or prescription would be given, cost, services available to rape victims, and other institutions where EC could be obtained. Descriptive statistics and chi-square were used for comparisons. RESULTS: Responses were made by 248 of 288 nurses, ten of 288 physicians, and 30 of 288 clerks. Overall, EC was reported to be available in 80% of calls, not available in 15%, and up to the physician in 5%. In the patient scenario day shift, 53 of 72 (73%) responded that EC was available, 15 of 72 (20%) stated it was not available, and four of 72 (5%) said it was up to prescribing physician. In the social worker scenario day shift, 62 of 72 (86%) reported that EC was available, six of 72 (8%) reported it was not available, and four of 72 (5%) stated it was up to the prescribing physician. Availability did not vary comparing day vs. night shift for either scenario. Of the nine Catholic hospitals, for the patient scenario, one of nine (11%) reported that EC was available, seven of nine (78%) reported that EC was not available, and in one of nine (11%), it was up to the physician. In the social worker scenario, five of nine (56%) reported EC was available, three of nine (33%) reported it was not available, and in one of nine (11%), it was up to the physician. CONCLUSIONS: There was significant variability in access to EC in Massachusetts EDs and in services for sexual assault survivors. Hospital type and provider preference affected availability. This study suggests that access to EC is limited, and that there are not consistent services for women seeking EC, including for victims of sexual assault.

After-Hours Care↗
PubMed1994

Hospital and emergency medical services system interaction during the implementation of chest pain emergency rooms.

Knowledgeable personnel at 23 hospitals with chest pain emergency rooms (CPERs) served by nonhospital-based emergency health services (EMS) systems were surveyed. Although few hospitals had involved EMS in the planning stages of the CPER, there were no reports of a poor relationship with the local EMS system, and surveyed personnel perceived neither deterioration nor improvement in their hospital's relationship with EMS after opening the CPER. Hospitals where EMS was considered important to the functioning of the CPER were significantly more likely to have involved EMS in the CPER planning process.

Attitude of Health Personnel↗
PubMed2000

Emerging and re-emerging epidemic encephalitis: a tale of two viruses.

Two major epidemics of viral encephalitis occurred in Asia in 1997 and 1998. The first was a re-emergence of neurovirulent strains of enterovirus 71, which caused severe encephalomyelitis in children in Malaysia, Taiwan and Japan, on a background of hand, foot and mouth disease. Necropsy studies of patients who died of enterovirus 71 infection showed severe perivascular cuffing, parenchymal inflammation and neuronophagia in the spinal cord, brainstem and diencephalon, and in focal areas in the cerebellum and cerebrum. Although no viral inclusions were detected, immunohistochemistry showed viral antigen in the neuronal cytoplasm. Inflammation was often more extensive than neuronal infection, suggesting that other factors, in addition to direct viral cytolysis, may be involved in tissue damage. The second epidemic of viral encephalitis was the result of a novel paramyxovirus called Nipah, which mainly involved pig handlers in Malaysia and Singapore. Pathological evidence suggested that the endothelium of small blood vessels in the central nervous system was particularly susceptible to infection. This led to disseminated endothelial damage and syncytium formation, vasculitis, thrombosis, ischaemia and microinfarction. However, there was also evidence of neuronal infection by the virus and this may also have contributed to the neurological dysfunction in Nipah encephalitis. Some patients who seemed to recover from the acute symptoms have been re-admitted with clinical findings suggestive of relapsing encephalitis. As these two epidemics indicate, the emergence and re-emergence of viral encephalitides continue to pose considerable challenges to the neuropathologist, in establishing the diagnosis and unravelling the pathogenesis of the neurological disease.

Animals↗
PubMed2003

Preparedness for emergency response: guidelines for the emergency planning process.

Especially since the terrorist attacks of 11 September 2001, governments worldwide have invested considerable resources in the writing of terrorism emergency response plans. Particularly in the United States, the federal government has created new homeland security organisations and urged state and local governments to draw up plans. This emphasis on the written plan tends to draw attention away from the process of planning itself and the original objective of achieving community emergency preparedness. This paper reviews the concepts of community preparedness and emergency planning, and their relationships with training, exercises and the written plan. A series of 10 planning process guidelines are presented that draw upon the preparedness literature for natural and technological disasters, and can be applied to any environmental threat.

Disaster Planning↗
PubMed1993

[Polytrauma: comparison of the hospital course after air- (with emergency physician) versus ground transport (without emergency physician)].

We analyzed the influence of initial intensive care at the accident site performed by an emergency physician and followed by helicopter transport on the course during hospital stay in patients with multiple trauma. We therefore compared the dates of 107 patients transported by the swiss air rescue (REGA) and an emergency physician with 131 patients transported by an ambulance and paramedic staff. By similar case material the REGA-patients showed a higher injury severity grade. Mortality of the REGA-patients was significantly higher (21%) than of the ambulance-patients (10%), but length of stay was significantly shorter and morbidity identical. We suspect, that the higher mortality of the REGA-patients is explained by the large number of surgically nontreatable severe traumas. None of the REGA-patients arrived at hospital with circulatory insufficiency whereas 4 of the ambulance-patients were in state of shock. We assume that first of all primary treatment of the scene of injury by an emergency physician and eventually also transport by helicopter have a positive effect on the course of patients with multiple trauma during hospital stay.

Adult↗
PubMed1996

Review of emergency thoracotomy for chest injuries in patients attending a UK Accident and Emergency department.

Over a two and a half year period, 25 patients presenting to the Glasgow Royal Infirmary underwent emergency thoracotomy for suspected severe chest injuries. Eighteen (72 per cent) were performed in the Accident and Emergency (A&E) department and seven (28 per cent) in a fully equipped operating theatre after resuscitation. There were 23 men and 2 women. Twenty-three (92 per cent) had been stabbed, one (4 per cent) had been shot and one (4 per cent) had sustained a blunt injury in a road traffic accident. Eight (32 per cent) patients survived. All survivors had been stabbed and seven were well enough to undergo thoracotomy in theatre. Only one (5.6 per cent) of the patients operated upon in the A&E department survived to discharge, although three (16.8 per cent) survived the initial procedure. Three of four patients survived, in whom the diagnosis of cardiac tamponade was initially missed. Thirteen (76.5 per cent) of the 17 who did not survive had no vital signs on admission. Outcomes may be improved if appropriately trained hospital staff are immediately available and prehospital delays are minimized so that patients arrive sooner with signs of life still present. Ambulance paramedic interventions have little to offer these patients and may worsen the prognosis if they result in delayed transport to hospital. The emphasis placed on diagnosis and treatment of cardiac tamponade in Advanced Trauma Life Support programmes is appropriate and all staff involved in these cases should undergo this type of training.

Adolescent↗
PubMed2005

Impact of the application of the American College of Emergency Physicians recommendations for the admission of patients with syncope on a retrospectively studied population presenting to the emergency department.

BACKGROUND: The goal of our study was to determine the accuracy of the American College of Emergency Physicians (ACEP) clinical policy in identifying patients with a cardiac cause for their syncope and its potential effect on syncope management. METHODS: Adult patients with syncope presenting to the emergency department (ED) from January 1996 to December 1998 were identified. Diagnosis was established retrospectively by reviewing medical records. The ACEP guidelines were applied to this population. RESULTS: Of the 200 patients identified, 115 (57.5%, 95% CI 60-64) were admitted from the ED and 24 (12%) were found to have cardiogenic syncope. Of the 24 patients with cardiac syncope, 23 were admitted. By applying ACEP level B recommendations to our population, all patients who on further workup were found to have cardiac syncope would have been admitted from the ED (100% sensitivity, 95% CI 86-100) and 81% of patients with no cardiac syncope would have been discharged from the ED (81% specificity, 95% CI 75-87). The admission rate would have been 28.5% (95% CI 22-35). By extending admission to patients satisfying level C in addition to level B recommendations, the sensitivity, specificity, and admission rate would have been 100% (95% CI 86-100), 33% (95% CI 26-40), and 71.0% (95% CI 64-77), respectively. CONCLUSION: High sensitivity and specificity in identifying patients with cardiogenic syncope and significant reduction in the hospital admission rate were observed by applying ACEP level B recommendations to patients presenting to our ED. Application of level C recommendations did not offer any advantage.

Adult↗
PubMed2006

Emergency departments (EDs) in the United Kingdom (UK) are not prepared for emerging biological threats and bioterrorism.

OBJECTIVE: To assess the preparedness of emergency departments (EDs) in the United Kingdom (UK) for the management of potential biological incidents. METHODS: We telephoned all hospitals in the UK listed as having a major ED. We surveyed their ED facilities and procedures for managing patients with infectious diseases. We determined how many of the EDs had an isolation room available and, if present, whether this had an independent ventilation system and separate access from outside the ED. In addition, we determined how many of the EDs would isolate patients with suspected cases of chickenpox, tuberculosis (TB), severe acute respiratory syndrome (SARS) and other suspicious infections. RESULTS: We obtained complete data from 203 (79%) of the 257 hospitals approached. Only 49 (24%) of these hospitals had isolation facilities available in the ED. Of these 49 EDs, 30 (61%) reported an independent ventilation system and 18 (37%) reported a separate access from outside the ED. The majority of EDs would isolate patients with potential infectious diseases, however, 47 (23%) would not isolate patients with suspected chickenpox, 37 (18%) EDS would not isolate patients with suspected TB, 12 (6%) EDS would not isolate patients with suspected SARS and 55 (27%) EDS would not isolate patients with other suspicious infections. CONCLUSION: EDs in the UK are not prepared for emerging biological threats and bioterrorism. With current facilities and procedures it is highly likely that an infectious agent will spread to staff and other patients in any future biological incident.

Bioterrorism↗
PubMed1983

Impact of freestanding emergency centers on hospital emergency department use.

This study was conducted to determine whether hospital emergency department (ED) use has been affected by the presence of freestanding emergency centers (FECs) in hospitals' service areas. A sample of FECs was drawn and hospitals in their service areas identified. ED visits to those hospitals from 1970 to 1980 were compared with those of a comparison group of hospitals not studied. The presence of FECs did not lead to a decline in ED visits to hospitals in their service areas. The study documented that FECs are located near hospitals that are larger than average and that have busier EDs. Because of the relative newness of FEC development, future studies of this type should be conducted. This study could not answer the question of whether FECs caused the growth of hospital ED visits to slow. It did not attempt to measure the impact FECs have on private medical practices or determine whether FECs attract currently underserved patient groups.

Ambulatory Care Facilities↗
PubMed1986

The referral of patients from freestanding emergency centers to a hospital emergency department.

This retrospective study is a review of patients referred from a network of eight freestanding emergency centers FECs to a hospital emergency department during January and February 1984. During that time, 17,387 patients were seen at the FECs. Sixty-three (0.36%) of these patients were referred to the base hospital, of which 28 (44%) were admitted and six (9.5%) were admitted to a critical care unit. Four of the six critical care admissions arrived by ambulance. One was unstable and required cardioversion in the ED. Of the patients discharged from the hospital 70% were satisfied with FEC and 97% with hospital treatment. Of admitted patients, 89% were satisfied with FEC and 100% were satisfied with hospital treatment. For a similar illness in the future, 23% of all patients would return to a FEC, 28% would go to a private practitioner, and 48% would go directly to a hospital.

Ambulances↗
PubMedDate not supplied

Emergency department airway management before and after an emergency medicine residency.

To determine whether the start of an Emergency Medicine (EM) training program affects the appropriateness, timeliness, and safety of Emergency Department (ED) intubations, all ED intubations performed 12 months before and after the start of an EM residency were reviewed. In addition, all patients intubated within 12 h after being admitted through the ED were reviewed. We found that all ED intubations before and after the start of a residency program were deemed appropriate. Of patients intubated after admission, 13 of 20 (65%) were felt to have warranted intubation while in the ED for the pre-residency group, compared with 9 of 29 patients (31%) for the post-residency group. There were no differences between the complication rates of these groups. We conclude that an EM residency program did not increase the number of inappropriate intubations or complications, and reduced the number of patients who required but did not receive intubation in the ED.

Adolescent↗
PubMedDate not supplied

Emergency medical services and cultural determinants of an emergency in Karachi, Pakistan.

OBJECTIVES: The study was conducted to understand the prehospital system in Karachi, the mode of transport that adult inpatients use to reach the emergency departments (EDs), and the barriers to the use of ambulances. METHODS: The study consisted of two parts. The first part involved interviewing the administrators of major ambulance services in Karachi. The second part consisted of a structured interview of randomly selected adult inpatients admitted to one government and one private hospital. RESULTS: Seven ambulance service administrators were interviewed. The interviews revealed that ambulances in Karachi are mainly involved in transporting patients from hospital to hospital or to home. A large number of calls are for transporting dead bodies. A total of 92 patients were interviewed (58 male, 34 female). Admission complaints included abdominal pain (22), blunt trauma (11), penetrating trauma (3), chest pain (6), shortness of breath (4), hematemesis (3), acute focal weakness (4), high fever (4), and other (32). The most common mode of transport to the ED was taxi (53, 58%), followed by private car (21, 23%). Specific reasons for not using ambulances included a perception that the patient was not sick enough (34, 45%), slow response of the ambulance services (17, 23%), not knowing how to find one (8, 11%), and the high cost (6, 8%). CONCLUSION: In case of a medical emergency, most people in Karachi do not use ambulances. The reasons for this low usage include not only poor accessibility, but also cultural barriers and lack of education in recognition of danger signs.

Administrative Personnel↗
PubMedDate not supplied

A death education curriculum for emergency physicians, paramedics, and other emergency personnel.

Although death education is a standard component in most medical schools and nursing programs, few include instruction on dealing with sudden death. Typically, death education courses overlook instruction in areas germane to emergency medicine, e.g., making death notifications, interacting with survivors during the immediate grief period, and reducing professional stress innate to working with newly bereaved persons. This curriculum was developed to address the paucity of existing death education materials for emergency professionals. Topics include death perspectives and awareness, death typology, cultural and religious considerations, communicating with bereaved persons, making death notifications, and dealing with initial grief reactions. Units of instruction are outlined, including educational goals, descriptions of units, teaching strategies, and supplemental readings.

Adaptation, Psychological↗
PubMed2006

Psychiatric emergencies in children and adolescents: an Emergency Department audit.

OBJECTIVE: To describe a cohort of children presenting to a paediatric emergency department with mental health problems. METHODS: An Emergency Department (ED) computerized record system and hospital records were used to obtain data on children who presented to a paediatric ED with mental health problems. RESULTS: There were 291 presentations of 231 children in a 10-month period, about one per day. They were a small (0.8%) but complicated part of the ED workload. Most were first presentations and came voluntarily to ED. There were a wide variety of presenting symptoms including self-harm, suicide attempts, behavioural disorders and medical disorders with associated psychological problems. Acute psychosis was rare. CONCLUSIONS: Many children with mental health problems were seen for the first time in ED. With the growing awareness of mental health problems in this age group, it is likely that such presentations will increase. Paediatric and psychiatry services have an opportunity to work together to provide early intervention services for what is potentially a very accessible population.

Adolescent↗
PubMed1992

The Hawaii EMS-C project data: I. Reducing pediatric emergency morbidity and mortality; II. Statewide pediatric emergency registry to monitor morbidity and morality.

During a 12-month period ending on 11/30/88, data were collected on 16,010 pediatric patients who visited a pediatric emergency department (ED). These ED patients prospectively fell into one of the target areas for further study, including wheezing (15%), trauma (excluding burns; 29%), burns (1%), water-related injuries (1%), ingestions and toxic substance exposures (2%), child abuse (3%), handicapping conditions (5%), preventable incidents (33%), and ambulance arrivals (7%). Handicapped patients were more likely to require an ambulance. Younger patients, males, and patients with handicaps, wheezing, and Medicaid insurance were more likely to visit the ED on multiple occasions. Primary care physicians could be identified in 77% of the cohort. Large-scale interventions to reduce preventable pediatric morbidity and mortality have suffered from difficulties in documenting their effect in a population-based sample. A statewide pediatric emergency encounter registry is proposed.

Adolescent↗
PubMed2006

Emergency and critical care pediatrics: use of medical simulation for training in acute pediatric emergencies.

PURPOSE OF THE REVIEW: Recent data suggest that pediatric trainees receive insufficient training to manage acute pediatric emergencies. This review addresses the use of medical simulation as a way for medical learners to acquire and maintain skills needed to manage pediatric resuscitations. RECENT FINDINGS: Recent work highlights the value of deliberate practice in the context of simulated medical environments to promote development of medical expertise. Several studies demonstrate the benefit of simulation-based training for improved skill acquisition in advanced life support, emergency airway management, and nontechnical skills. Work in other fields of medicine supports the integration of simulation into pediatric training programs. SUMMARY: Medical simulation holds great promise to enhance existing pediatric training curricula by increasing skills and expertise in resuscitation. Future research is needed to identify best methods of pediatric simulation-based training.

Acute Disease↗
PubMedDate not supplied

Hospital emergency care teams: our solution to out of hours emergency care.

The implementation of the European Working Time Directive and the compulsory reduction in junior doctors hours provided the main driver and background for this project. The project aim was to implement Hospital Emergency Care Teams (HECT) on three District General Hospitals (DGHs) to provide emergency out-of-hours care. The project strategy centred on the recruitment, training and preparation of critical care nurses to undertake advanced assessment roles. Methods used to monitor and evaluate activity include the use of innovative hand-held computers. Main outcomes include, the conclusion that a multidisciplinary HECT of five could manage the overnight workload and level of acuity in a DGH of 420-500 beds, and that critical care nursing staff can be prepared for advanced supporting roles. Experiences gained provide valuable learning that could be used to influence similar projects. Implications for practice include the development of a national framework to inform areas such as multidisciplinary competency-based education and training. Scientific evidence is required to evaluate the effect of HECT on hospital mortality and morbidity and quantify the staff, inpatient experiences.

After-Hours Care↗