On-site Medical Care Research Articles

Organization and Execution of On-site Health Care During a Mass Participation Event

On-site medical care should be considered essential for mass participation athletic events. Events such as road races, marathons, and triathlons may attract thousands of participants and spectators, which may overwhelm regional health care capabilities. One successful model of a mass participation event medical care system involves direction by a medical director or coordinator who is a physician and is ideally trained in emergency and/or sports medicine.

Public Medical Preparedness at the “Swiss Wrestling and Alpine Games 2013”: Descriptive Analysis of 1,533 Patients Treated at the Largest 3-Day Sporting Event in Switzerland

Introduction. Medical preparedness at mass gatherings is challenging, as little is known about the optimal planning. Most studies and case reports are based on mass casualty incidents, so the results cannot be extrapolated to mass gatherings. Aim of this study was to evaluate the preclinical medical structure and the frequency of specific injuries and medical emergencies during the event. Methods. Retrospective analysis of a prospectively collected database. Three on-site medical assistance points were set up, completed by mobile teams, and coordinated by an on-site operational management team. Medical staff requirements were calculated using Maurer's formula. Results. A total of 1,533 patients were treated during the three-day event. Overall, the medical usage rate (MUR; patients per 10,000 visitors) was 51.1. A total of 58 patients (3.8%) required a hospital transfer. In 1,063 cases (69.3%) a diagnosis was documented. Of these, 503 patients (47.3%) suffered from hymenoptera stings; the two most common non-trauma-related diagnoses were alcohol/drug intoxication (4.1%) and gastrointestinal diseases (4.0%). Conclusion. Overall, the on-site medical care worked well. However, a high frequency of hymenoptera stings occurred, resulting in a shortage of antihistamine medication. Moreover, more than half of the patients were managed at the second largest medical assistance point. Prospective and critical evaluation of medical care at mass gatherings is crucial in order to optimize on-site medical preparedness at future events.

An Impacted Tibial Plateau Fracture in an Adolescent Diver: A Case Report

The tibial plateau is a critical load-bearing surface in humans. Although tibial plateau fractures represent only 1% of all fractures, proper management by all members of the health care team, including athletic trainers, physicians, and physical therapists, is required for successful patient outcomes. A 14-year-old national-level competitive female diver injured her right knee during the precompetition warm-up period. Upon evaluation by an athletic trainer, the patient was referred for imaging and examination by a physician. She was seen by an orthopedic surgeon for consultation. The patient elected for a surgical repair of the tibial plateau fracture. Following surgery she underwent an 11-week comprehensive therapeutic exercise program with athletic trainers and physical therapists. The patient’s return-to-play progression included dry land activities, platform diving, 1-m springboard diving, and 3-m springboard diving. The patient has successfully returned to competitive diving. Proper identification of tibial fractures can be difficult considering their low occurrence in youth and their similar clinical presentation to more common youth injuries such as anterior cruciate ligament ruptures. Clinicians providing immediate on-site medical care should be thorough in their clinical exam including palpation and axial loading of the joint.

LO020: Obstacle course runs: review of acquired injuries and illnesses at a series of Canadian events (RACE)

Introduction: The growing popularity of obstacle course runs (OCRs) has led to significant concerns regarding their safety. The influx of injuries and illnesses in rural areas where OCRs are often held can impose a large burden on first responders, Emergency Medical Services (EMS) and local Emergency Departments. Literature concerning these events is minimal and mostly consists of media reports. Recognizing the lack of epidemiologic data, we sought to accurately determine the patterns and frequency of injuries and illnesses that occur at OCRs, the treatments required, and what proportion require further medical care or transfer to hospital. Methods: Data were extracted from medical charts completed for all patients presenting to the on-site medical team at OCR events across Canada from May to August, 2015. Frequency and patterns of injuries and illnesses were determined as well as treatments and disposition. There were 45 285 OCR participants in 8 events. There were 572 total patient contacts and 557 patients were included in the study. 15 patients were excluded because they were not race participants. Results: Less than 2% of participants at any event required on-site medical care. 11 patients (1.97%) required transfer to hospital by EMS. The majority of injuries were musculoskeletal in nature (74.71%). 495 patients (88.87%) returned to the event with no need for further medical care. The majority of treatments could be provided with first aid training and basic medical equipment. Conclusion: Injury and illness rates at this series of OCRs was similar to other mass gathering events. Injuries were mostly musculoskeletal in nature and required minor treatment. Having a medical team on site likely reduced local hospital and EMS volume from these events. This study raises the question of whether having a physician on site at OCRs could significantly reduce the number of patients advised to seek further medical care or the number of ambulance transfers. Prospective research is needed in order to develop plans for more appropriate resources, safety protocols, and medical staffing, thereby improving patient care and reducing the burden on local EMS and rural hospitals.

Observed Benefits to On-site Medical Services during an Annual 5-day Electronic Dance Music Event with Harm Reduction Services.

With increasing attendance and media attention, large-scale electronic dance music events (EDMEs) are a subset of mass gatherings that have a unique risk profile for attendees and promoters. Shambhala Music Festival (Canada) is a multi-day event in a rural setting with a recognized history of providing harm reduction (HR) services alongside medical care. Study/Objective This manuscript describes the medical response at a multi-day electronic music festival where on-site HR interventions and dedicated medical care are delivered as parallel public health measures. This study was a descriptive case report. Medical encounters and event-related data were documented prospectively using an established event registry database. In 2014, Shambhala Music Festival had 67,120 cumulative attendees over a 7-day period, with a peak daily attendance of 15,380 people. There were 1,393 patient encounters and the patient presentation rate (PPR) was 20.8 per one thousand. The majority of these (90.9%) were for non-urgent complaints. The ambulance transfer rate (ATR) was 0.194 per one thousand and 0.93% of patient encounters were transferred by ambulance. No patients required intubation and there were no fatalities. Harm reduction services included mobile outreach teams, distribution of educational materials, pill checking facilities, a dedicated women's space, and a "Sanctuary" area that provided non-medical peer support for overwhelmed guests. More than 10,000 encounters were recorded by mobile and booth-based preventive and educational services, and 2,786 pills were checked on-site with a seven percent discard rate. Dedicated medical and HR services represent two complementary public health strategies to minimize risk at a multi-day electronic music festival. The specific extent to which HR strategies reduce the need for medical care is not well understood. Incorporation of HR practices when planning on-site medical care has the potential to inform patient management, reduce presentation rates and acuity, and decrease utilization and cost for local, community-based health services.

Abstract 14956: Out-of-hospital Cardiac Arrest and Bystander CPR in Kent County, Michigan: A Geospatial Analysis

Introduction: Geographic clustering of OHCA & bystander CPR (bCPR) has been demonstrated in some US cities. We assessed for geospatial distribution patterns within our county. Objectives: 1) Characterize bCPR performance; 2) Test for geographic clustering of OHCA & bCPR; 3) Identify hot spots & cold spots, defined as areas with disproportionately greater and lesser chance of bystander intervention within a concentration of OHCA. Hypothesis: OHCA & bCPR is geographically clustered within our region, resulting in hot and cold spots of bystander intervention. Methods: Retrospective, observational, population-based, cohort study using the CARES dataset for Kent County, Michigan. We included adult, non-traumatic, EMS-treated OHCA from 2010-14, excluding cases with on-site medical care. We abstracted EMS dispatch addresses, bCPR, & patient characteristics, then geocoded street addresses (ArcGIS) to create a population-adjusted density map of OHCA annual incidence. Moran’s I test assessed for spatial autocorrelation of population-weighted cardiac arrest rate by census block. Difference mapping identified relative differences between cases with/without bCPR, & Getis-Ord Gi statistic assessed for spatial clustering of bCPR, identifying hot and cold spots. Results: Of 1,632 eligible subjects, 1,167 met inclusion criteria. bCPR occurred in 436 (37%), & was performed by family members (58%), lay persons (34%), & off-duty medical providers (8%). Specific techniques included compressions/ventilations (28%), compression only (35%), ventilation only (1%), & unknown (36%). Geospatial analysis revealed significant clustering of OHCA ranging from 0 to >60 annual cases per 100,000 population (p<0.001). Relative difference in bCPR ranged from -11.2 to 0.9 across geographic locales, with a paucity of bCPR (-11.2 to -2.0) in urban and suburban areas. We identified central Grand Rapids & southern suburbs as primary cold spots (99% confidence), whereas eastern & northeastern suburbs contained hot spots (99% confidence). Conclusion: The minority of OHCA received bCPR. OHCA & bCPR are geographically clustered, & bCPR is more/less likely to occur in certain areas. Distinguishing hot & cold spots affords opportunity for targeted public health initiatives.

The Current State of Head and Neck Injuries in Extreme Sports.

Background:Since their conception during the mid-1970s, international participation in extreme sports has grown rapidly. The recent death of extreme snowmobiler Caleb Moore at the 2013 Winter X Games has demonstrated the serious risks associated with these sports.Purpose:To examine the incidence and prevalence of head and neck injuries (HNIs) in extreme sports.Study Design:Descriptive epidemiological study.Methods:The National Electronic Injury Surveillance System (NEISS) was used to acquire data from 7 sports (2000-2011) that were included in the Winter and Summer X Games. Data from the NEISS database were collected for each individual sport per year and type of HNI. Cumulative data for overall incidence and injuries over the entire 11-year period were calculated. National estimates were determined using NEISS-weighted calculations. Incidence rates were calculated for extreme sports using data from Outdoor Foundation Participation Reports.Results:Over 4 million injuries were reported between 2000 and 2011, of which 11.3% were HNIs. Of all HNIs, 83% were head injuries and 17% neck injuries. The 4 sports with the highest total incidence of HNI were skateboarding (129,600), snowboarding (97,527), skiing (83,313), and motocross (78,236). Severe HNI (cervical or skull fracture) accounted for 2.5% of extreme sports HNIs. Of these, skateboarding had the highest percentage of severe HNIs.Conclusion:The number of serious injuries suffered in extreme sports has increased as participation in the sports continues to grow. A greater awareness of the dangers associated with these sports offers an opportunity for sports medicine and orthopaedic physicians to advocate for safer equipment, improved on-site medical care, and further research regarding extreme sports injuries.

Heat Stroke in Physical Activity and Sports (Original version in English)

Exertional heat stroke (EHS) is one of the leading causes of sudden death in sport and physical activity. In American Football alone, there have been 46-documented EHS fatalities in the United States between 1995 and 2010. In 2003, National Collegiate Athletics Association mandated pre-season heat acclimatization guidelines, which successfully decreased the number of heat stroke fatalities in collegiate American football. However, despite the advancement in modern medical care and increased awareness in heat safety, lack of appropriate on-site medical care is still contributing to EHS seen especially at the youth level. It is well established in scientific literature that fatalities as a result of EHS are largely preventable with proper education on the knowledge of recognition, treatment, and prevention of EHS. This document provides a review of the current best medical practices and evidence on the epidemiology, pathophysiology, risk factors, recognition, treatment, prevention, and return to play recommendations for EHS, specifically as they relate to sport and physical activity.

Are Current Approaches to Improving LTC Quality Hits or Errors?

Are Current Approaches to Improving LTC Quality Hits or Errors?

Low incidence of adverse events following varenicline initiation among opioid dependent smokers with comorbid psychiatric illness

BackgroundMost drug treatment patients smoke cigarettes, yet few data exist on the prevalence and outcomes of varenicline treatment among smokers with comorbid substance use and psychiatric disorders. MethodsWe reviewed all patient charts of opioid-dependent smokers prescribed varenicline between May 2006 and December 2009 in two urban methadone clinics that also provide on-site medical and psychiatric care. We assessed prevalence, adverse events, and effectiveness of varenicline treatment in this cohort. ResultsWe identified 575 smokers among 690 patients (83.3%), and assessed 82 courses of varenicline treatment prescribed to 70 smokers. Both cardiovascular risk factors and psychiatric illness were highly prevalent among those prescribed varenicline: hypertension, 51%; hyperlipidemia, 23%; diabetes, 20%; depression, 53%; anxiety, 30%; psychotic disorders, 10%; bipolar disorder, 8.6%. Of 82 varenicline courses, nine (11%) were discontinued due to adverse events and two due to depressive symptoms. One patient initiated new psychiatric medications within six months of initiating varenicline, but did not discontinue varenicline. There were no reports of suicidal ideation, agitation prompting clinical intervention, or psychiatric hospitalization. There were no incident cardiac or vascular events within six months of varenicline prescription. Some (8.6%) varenicline-treated smokers quit smoking, and cessation was significantly associated with varenicline treatment duration. ConclusionsDespite substantial comorbidity, opioid-dependent smokers receiving integrated substance abuse, medical and psychiatric care had few documented adverse events with varenicline treatment. Methadone patients will likely experience little harm and a great deal of benefit from treatment with varenicline for smoking cessation.

Emergency care provision at the 2009 Special Olympics Great Britain

BackgroundThe Special Olympics Great Britain (SOLGB) summer games 2009 were held in Leicester between 25 and 31 July. They involved 2413 athletes that were engaged in 21 different sports across...

Non-communicable health risks during mass gatherings

Mass gatherings (MGs) have been associated with high rates of morbidity and mortality from non-communicable diseases, accidents, and terrorist attacks, thus posing complex public health challenges. We assessed the health risks and public health responses to MGs to identify an evidence-based framework for public health interventions. Human stampedes and heat-related illnesses are the leading causes of mortality. Minor traumatic injuries and medical complaints are the main contributors to morbidity and, particularly, the need for on-site medical care. Infrastructure, crowd density and mood, weather, age, and sex determine the risks to health. Many predictive models for deployment of medical resources are proposed, but none have been validated. We identified the risks for mortality and morbidity during MGs, most efficient public health interventions, and need for robust research into health risks for non-communicable diseases during MGs.

Availability of HIV-related health services in adolescent substance abuse treatment programs

Given that alcohol and drug abuse heightens the risk of adolescents acquiring HIV, substance abuse treatment programs for youths may represent an important site of HIV prevention. In this research, we explored the adoption of three HIV-related health services: risk assessment during intake, HIV prevention programing, and HIV testing. Data were collection through telephone interviews with 149 managers of adolescent-only substance abuse treatment programs in the USA. About half of these programs had adopted HIV risk assessment and HIV prevention. On-site HIV testing was less widely adopted, with only one in four programs offering this service. At the bivariate level, the availability of on-site primary medical care and the availability of an overnight level of care were positively associated with these three types of services. The association for the measure of an overnight level of care was no longer significant once medical services were controlled. However, in a separate analysis, it was found that programs offering an overnight level of care were much more likely to offer on-site medical care than outpatient-only facilities. There was also evidence that publicly funded treatment programs were more likely to offer HIV prevention and on-site HIV testing, after controlling for other organizational characteristics. Much more research about the adoption of HIV-related services in adolescent substance abuse treatment is needed, particularly to offer greater insight into why certain types of organizations are more likely to adopt these health services.

First Do No Harm … Reduction?

An expert panel convened to discuss how to incorporate methadone's possible effect on the QT interval into clinical practice. The findings and recommendations of some of the panel members appear in...

Impact of Service Delivery Model on Health Care Access among HIV-Positive Women in New York City

As the New York City HIV=AIDS epidemic began generalizing beyond traditionally high-risk groups in the early 1990s, AIDS Service Organizations (ASO) sought to increase access to medical care and broaden service offerings to incorporate the needs of low-income women and their families. Strategies to achieve entry into and retention in medical care included the development of integrated care facilities, case management, and a myriad of supportive service offerings. This study examines a nonrandom sample of 60 HIV-positive women receiving case management and supportive services at New York City ASOs. Over 55% of the women interviewed reported high access to care, 43% reported the ability to access urgent care all of the time and 94% reported high satisfaction with obstetrics=gynecology (OB=GYN) care. This held true across race=ethnicity, income level, medical coverage, and service delivery model.Women who accessed services at integrated care facilities offering onsite medical care and case management=supportive services perceived lower access to medical specialists as compared to those who received services at nonintegrated sites. Data from this analysis indicate that supportive services increase access to and satisfaction with both HIV and non-HIV-related health care. Additionally, women who received services at a medical model agency were more likely to report accessing non-HIV care at a clinic compared to those receiving services at a nonmedical model agencies, these women were more likely to report receiving non-HIV care at a hospital.

Traumatic Brain Injury: The “Signature Injury” of the Iraq War

Traumatic Brain Injury: WAR TECH SPRING WAR TECH The “Signature Injury” of the Iraq War by Tania Aftandilians When an explosive device detonates on the battle- The number of soldiers who survive brain injuries during battle is unprecedented thanks to advanced body field, soldiers often walk away seemingly unscathed. armor and rapid on-site medical care. However, they are However, these soldiers often sustain serious injuries that often at a loss when it comes to receiving long-term care. are not readily detectable. One of the most common yet The new innovations that save so many lives also mean that overlooked war-related afflictions is Traumatic Brain more soldiers are coming home with varying degrees of Injury, or TBI. TBI is a general term that refers to brain brain injury that require treatment. Some victims sustain damage caused by sudden trauma. It can range from mild, severe, fatal, and is usually caused by a forceful blow to the minor brain damage that can be treated with rehabilitation, while others have nearly all parts of their brain affected. head. Objects that pierce the skull and enter the brain can The government is going to great lengths to save soldiers’ also be a cause of TBI. This affliction often remains undi- lives in Iraq; however, funding is severely lacking when it agnosed because signs or symptoms are not always imme- comes to preserving the diately obvious. quality of life of TBI However, if left untreated, this injury To date, at least 2,000 soldiers have been patients. Most of the can have severe con- treated for TBI, along with an estimated 7,500 funding is used to ensure that wounded sequences. For those troops returning from Iraq with some degree soldiers immediately dealing with TBI, receive care from top there are long-term of undiagnosed TBI. physicians and to guar- biological and psy- antee that they are chological effects, as granted access to expensive drugs and technology. well as emotional consequences for the patients and their According to a Harvard University budget expert, the cost families. Due to TBI’s serious symptoms as well as its of lifelong care for the soldiers engaged in Iraq is estimated inconspicuous nature, it should receive the same attention as any other long-term debilitating disease. There has been to be $35 billion, but the question of who will foot the bill is still up in the air (Dead Men Walking 2007). So far, the a rapid increase in military TBI cases in recent years, and government has not stepped up in terms of financing long- even though the government has made great advances in term care, and the families of soldiers cannot afford it. life-saving technologies, the improvements in long-term Saving the lives of TBI patients is therefore only half of the care have not kept pace. challenge. The other half, providing caring for TBI patients after “saving” their lives, requires years, perhaps a lifetime, How does TBI fit into the context of war? of expensive medical care. The United States government Studying the causes, treatments, and preventive needs to take a more active role in overseeing and ensuring measures of TBI is especially important for the current care for the men and women who put their lives on the line. engagement in Iraq, as soldiers are being deployed daily. Landmines are being heavily utilized in this war and are by What are the short- and long- term effects of TBI? far the biggest cause of TBI. In fact, TBI has become known as the “signature injury” among soldiers fighting in To comprehend the scope of TBI, one must under- Iraq. To date, at least 2,000 soldiers have been treated for stand its many symptoms and effects on family members. TBI, along with an estimated 7,500 troops returning from The short-term effects of TBI include unconsciousness, Iraq with some degree of undiagnosed TBI (Dead Men complications of other organs, and general trauma from the Walking 2007). impact. The long-term effects include post-concussion syn-

Emergency Medical Consequence Planning and Management for National Special Security Events After September 11: Boston 2004

The post-September 11 era has prompted unprecedented attention to medical preparations for national special security events (NSSE), requiring extraordinary planning and coordination among federal, state, and local agencies. For an NSSE, the US Secret Service (USSS) serves as the lead agency for all security operations and coordinates with relevant partners to provide for the safety and welfare of participants. For the 2004 Democratic National Convention (DNC), designated an NSSE, the USSS tasked the Boston Emergency Medical Services (BEMS) of the Boston Public Health Commission with the design and implementation of health services related to the Convention. In this article, we describe the planning and development of BEMS' robust 2004 DNC Medical Consequence Management Plan, addressing the following activities: public health surveillance, on-site medical care, surge capacity in the event of a mass casualty incident, and management of federal response assets. Lessons learned from enhanced medical planning for the 2004 DNC may serve as an effective model for future mass gathering events.

Medical Clinic Characteristics and Access to Behavioral Health Services for Persons With HIV

Medical Clinic Characteristics and Access to Behavioral Health Services for Persons With HIV

Marathon Race Medical Administration

Marathon race medical coverage involves coordinating many organisations, personnel and government agencies. An infrastructure of aid stations, finish-line medical tents, ambulance services, communication networks and transport vehicles support the medical professionals covering the event. Knowledge of the volume and type of medical problems that arise during a marathon allow the medical director to assemble the necessary components for a safe event. Published data and/or historical race information will assist in planning for anticipated medical utilisation. Organisers must prepare for uncommon but possible catastrophic medical events such as cardiac arrest and exertional heat stroke. Advances in point-of-care medical devices and significant increases in training and education of medical professionals providing care at these events have greatly improved the quality of on-site medical care at marathon races.

On-site medical care in methadone maintenance: Associations with health care use and expenditures

To evaluate whether long-term drug treatment with on-site medical care is associated with diminished inpatient and outpatient service use and expenditures, we linked prospective interview data to concurrent Medicaid claims of drug users in a methadone program with comprehensive medical services. Patient care was classified as follows: long-term (≥6 months) drug treatment with on-site usual source of medical care (linked care), long-term drug treatment only, or neither. Multivariate analyses adjusted for visit clustering within patients ( n = 423, with 1,161 person-years of observation). After adjustment, linked care participants had more outpatient visits ( p < .001), fewer emergency department (ED) visits (24% vs. 33%, p = .02) and fewer hospitalizations (27% vs. 40%, p = .002) than the “neither” group. Ambulatory care expenditures in the linked group were increased, whereas expenditures for other services were similar or reduced. Long-term drug treatment with on-site medical care was associated with increased ambulatory care, less ED and inpatient care, and no net increase in expenditures.