Advanced Life Support Ambulance Research Articles

Injuries and emergency medical response in the Loma Prieta earthquake

Abstract Findings are presented from selective studies of injury, health care utilization, and health service response patterns in the Loma Prieta earthquake. Our overall purpose is to explore these areas as specific demand and supply factors useful in developing earthquake casualty estimation models. Specifically, the research reported here includes a broad analysis of work-related injuries and illnesses from the entire affected region, including where the injured sought care, and a case study of emergency medical response in heavily damaged Santa Cruz County. On the demand side, the injury pattern analysis found that: (1) almost all fatalities and most serious injuries were associated with structural failure; (2) the majority of fatalities and serious casualties came from a small number of damaged structures, most notably the Cypress Viaduct collapse; (3) falling sections of URM buildings, striking passersby and falling on top of other buildings, caused deaths and serious injuries; (4) while interior nonstructural elements and building contents posed a relatively low risk to building occupants, certain elements and settings were particularly hazardous; and (5) occupant actions contributed to injuries—with many victims injured while attempting to take protective actions. On the supply side, the health care utilization analysis found that 60% of the victims were treated in nonhospital settings. The emergency medical response case study found that: (1) the Santa Cruz 911 emergency response system was severely taxed, but remained functional and responsive, with the initial heavy demand reaching a normal level by day two; (2) advanced life support ambulance transports were fewer than normal, possibly due to a drop off in motor vehicle accidents; (3) the Santa Cruz County medical system was able to accommodate the injury load because the health care system was extensive; (4) although initially disrupted the three community hospitals did not suffer severe structural damage; and (5) the demand for major medical care was light. The previous findings have three major implications for earthquake casualty modeling. First, structural damage potential remains the major predictor of serious earthquake casualties, but, because nonstructural performance remains a key source of minor injuries and a potential risk for major ones, we should evaluate and prioritize nonstructural hazards in terms of their relative risk. Second, casualty estimates based exclusively on hospital utilization data may greatly underestimate the true medical demand. Third, future casualty models should estimate the resiliency of the entire local health care system.

Level of medical care required for mass gatherings: The XV winter olympic games in Calgary, Canada

To determine the level of medical care required for mass gatherings and describe the types of medical problems encountered in a major winter event. Standard charts were available for 3,395 encounters. Interviews with medical staff showed that the few unrecorded encounters were for very minor medical problems. A four-tiered triage system (low, moderate, urgent, and emergent) developed before the Games was applied to each chart retrospectively by a single emergency physician. Chi-squared tests were used to test significant differences. This winter sporting and entertainment event had 12 urban and rural venues. Medical staff (98 physicians, 161 nurses, and 337 first-aid attendants) were based in 28 advanced life support (ALS) clinics. The medical service operated for four weeks. There were 1.8 million spectator-days. Patients included spectators, athletes, and support staff. First-aid attendants referred patients to the clinics, where nurses conducted initial assessments and referred patients to physicians at the venue, or more rarely, to local hospital emergency departments. Paramedic ambulances were stationed at the venues. The triage system was not used for patient management. Only 40 urgent and one emergent medical problems were encountered. The majority of patients could have been managed by trained nurses working alone under standing orders. Fifty patients were transported to the hospital by ground ambulance and three by helicopter. No significant differences were found in the low acuity levels experienced at indoor urban venues, outdoor urban venues, and the rural cross-country ski venue. The Alpine ski venue was characterized by significantly higher acuity and a long prehospital transfer phase. Owing to the low acuity encountered and the availability of Calgary's ALS ambulance service, we concluded that physician-based ALS teams were not required for patient management at the urban venues. Such teams were found to be required at the rural Alpine ski venue. Other reasons for using physicians are discussed, as is development of a standard triage system for mass gatherings.

Age-related Utilization of Advanced Life Support Services

AbstractPurpose:To investigate the relationship between age and Advanced Life Support (ALS) utilization.Population:All patients from 1 January 1987 to 31 December 1988 transported by ALS ambulances within Lebanon County, a rural/urban county of 112,000.Methods:All runs resulting in patient treatment by ALS personnel were tallied at five-year age intervals and sub-grouped by trauma- and non-trauma-related calls. Utilization rates for each age group were obtained by dividing the calls by the population of each group. Correlation with age was tested by Spearman's rank correlation. Treatment rates for age groups were calculated for the six most frequent medical etiologies. To illustrate the effect of age distributions, age rates were applied to projected state and national population distributions.Results:There was a significant correlation with age for all transports (p < .01; r=.93) and for those not related to trauma (p<.01; r=.98). Correlation was not detected for trauma-related responses (p>.10; r=.19). Non-trauma-related case incidence varied among age groups, ranging from 1.1/1,000 for age five through nine years to 89/1,000 for age 80–84 years. Congestive heart failure, cardiac ischemia, syncope, myocardial infarction, and cardiac arrest evidenced increased incidence with age. Seizure did not. Older populations had a higher projected utilization of ALS services than did the younger age groups.Conclusion:Non-trauma ALS utilization is highly dependent on the age of the patient. Due to projected aging of the population and increased utilization of ALS by the elderly, projected utilization will increase at a rate faster than will the population. Age:rate data can be combined with population projections to estimate future need.

The effect of base station contact on ambulance destination

Concern has been raised that a single medical control base station serving a metropolitan area may preferentially divert ambulance patients to the base station hospital. Such concern may discourage the development of regional medical control systems. During the first six months of 1988, a retrospective cross-sectional analysis was made of all advanced life support (ALS) ambulance transports and all contacts to the single base station, known as Medical Resource Hospital (MRH). Destinations of all ALS ambulance calls dispatched through the county's 911 dispatch center were analyzed to determine whether the destinations were affected by MRH contact. There were 12,396 transports to 17 area hospitals with 1,272 (10.3%) of these requiring MRH contact. We hypothesized that if MRH contact did not affect destination, the proportion of all non-MRH ALS ambulance patients received by each hospital from the 911-dispatched group would equal the proportion of patients received by each hospital after MRH contact. Five hospitals received a statistically significant (P less than .003) different percentage of MRH contact patients than their proportion of 911-dispatched patients would have predicted. The three that received more were community hospitals in outlying areas. The remaining two were a large referral hospital and a smaller community hospital located in the urban area. The MRH hospital did not have a significantly different percentage of 911-dispatched patients after MRH contact. Similarly, destinations of specific ALS ambulances (two serving in the MRH ambulance catchment area and four in distant catchment areas) were evaluated.(ABSTRACT TRUNCATED AT 250 WORDS)

A model for the allocation of advanced life support ambulance vehicles : Craig, A, Caspari, D, Department of Emergency Medicine, Toronto General Hospital, Toronto, Ontario, Canada

A model for the allocation of advanced life support ambulance vehicles : Craig, A, Caspari, D, Department of Emergency Medicine, Toronto General Hospital, Toronto, Ontario, Canada

Patient Selection for Advanced Prehospital Care in a Two-Level Emergency Medical System

In Jerusalem, the Emergency Medical Service is the sole prehospital provider for a population of 450,000 residents. Ambulances are dispatched from a centrally located first-aid center. Separate basic and advanced life support (MICU) ambulances are provided. Basic life support units are staffed by Emergency Medical Technicians (EMTs) trained to provide first aid and cardiopulmonary resuscitation (CPR). These units are dispatched to service persons in whom advanced life support (ALS) services are not likely to be required. The MICU is staffed by paramedical personnel plus a qualified physician. In order to maximize the efficiency of the service an attempt was made to use the MICU only for patients who may benefit from ALS interventions.Selection of patients for whom the ALS unit may be required is accomplished by switchboard operators. These personnel routinely dispatch the MICU for definite emergencies such as unconsciousness or absence of breathing. All other cases have been reported first to an on-call physician who ultimately decides whether or not to dispatch the MICU. This method of determining priority for dispatch is called the Consultation-Dispatch System (CDS). This method of determining priority seemed inefficient, so an alternative system was implemented that did not require prior physician consultation. This brief report details the impact of this change on system operation and MICU activity.

In Memoriam, Rudolf Frey

Rudolf Frey, known as “Rolf“ in Europe and “Rudi” in America — a leading star of anesthesiology, emergency medicine and disaster medicine — has ended his life's struggles. He influenced many lives positively. His years were rich with experiences and contributions.Surgery and anesthesiology were his base specialties. Alone, these fields would have been too narrow for him. He initiated the first professorship of anesthesiology in Germany at the University of Heidelberg in the 1950's; the first autonomous university department of anesthesiology in Germany at the Gutenberg University of Mainz in 1960; the journalDer Anaesthesist, the first textbook of anesthesiology in German; one of the first physician-staffed advanced life support ambulance and ambulance helicopter services in Europe; numerous training programs, symposia and congresses; and theClub of Mainzand its associated monograph seriesDisaster Medicine, originally published by Springer-Verlag.

Limitations of Abdominal Binding during CPR

Sudden cardiac death is the number one killer in the western world. In the USA alone, CPR attempts are justified in 200,000 cases per year. Recovery of brain function requires immediate initiation and uninterrupted maintenance of artificial ventilation and circulation by basic life support (BLS) until restoration of spontaneous circulation (ROSC) is possible with advanced life support (ALS). Presently recommended standard CPR (SCPR) produces only 6–30% of normal common carotid blood flow. For this reason, a more effective method of prolonged CPR-BLS is necessary in the absence of ALS ambulance services, which is common in rural areas.Augmentation of blood flow during CPR can be accomplished by intravenous fluid load and epinephrine, which are unavailable to BLS personnel. Sustained abdominal compression in dogs during CPR increases blood flow but produces a high incidence of hepatic trauma. The use of military anti-shock trousers (MAST) during short-term SCPR has been shown to increase common carotid blood flow (CCABF); this, however, has not been evaluated with a long-term model.