Amado Alejandro Báez

System compliance with out-of-hospital trauma triage criteria

BACKGROUND Emergency Medical Services (EMS) providers are the initial link to a trauma care system. Previous studies have demonstrated poor compliance with trauma triage by EMS personnel. We sought to determine the proportion of adult EMS cases within a large state meeting Trauma Triage Criteria (TTC) who are ultimately cared for in trauma centers. METHODS Merged EMS and hospital discharge records for 1996 were examined. All adult acute trauma cases were included. Single-system burns and late effects of injury were excluded. RESULTS Nine thousand one hundred seventy-four adult cases had at least one TTC, and 60.1% of these patients were transported to a non-trauma center (NTC) and 74.6% of cases with an Injury Severity Score > 15 and one TTC were taken to trauma centers. Analyzing two large urban counties, 58.2% and 27.0% of all TTC cases were still taken to NTC hospitals. CONCLUSION A significant proportion of seriously injured patients meeting TTC were transported by EMS personnel to NTCs.

Predictive effect of out-of-hospital time in outcomes of severely injured young adult and elderly patients

INTRODUCTION The importance of accessing care within the first hour after injury has been a fundamental tenet of trauma system planning for 30 years. However, the scientific basis for this belief either has been missing or largely derived from case series from trauma centers. This study sought to determine the correlation between prehospital times and outcomes among severely injured elderly patients. METHODS This is a cross-sectional, observational study. All adults (> or = 18 years of age) with acute trauma as defined by The International Classification of Diseases Ninth Edition, Clinical Modification diagnostic codes and E-codes were included. Poisonings, single system burns, and late effects of injury were excluded. Chi-square and Students t-test were used for significance testing. To assess the predictive effects of prehospital time and outcomes, three independent logistic regression models were constructed for both young and elderly groups, with hospital length of stay, mortality, and complications as individual dependent variables. Statistical significance was set at the 0.05 level. RESULTS Of 41,041 cases, 37,276 were > or = 18 years of age. Of the 1,866 with an Injury Severity Score (ISS) > 15, 1,205 were young and 661 elderly. Logistic regression results showed that prehospital time correlated significantly with hospital length of stay (p = 0.001) and complications (p = 0.016), but not with mortality (p = 0.264) among young patients, whereas in the elderly group pre-hospital time had no significant predictive effect for length of stay, complications, or mortality (p = 0.512, p = 0.512, and p = 0.954 respectively). CONCLUSION This population-based study has demonstrated that prehospital time correlates with length of stay and complications in young patients. In elderly patients, prehospital time failed to show correlation with any outcomes measured.

FAST Ultrasound as an Adjunct to Triage Using the START Mass Casualty Triage System

Objective. To determine whether the FAST examination might be a useful adjunct to simple triage andrapid treatment (START) in the secondary triage of mass-casualty victims already classified as delayed (Yellow). Methods. A retrospective chart review was conducted of all adult trauma patients evaluated by the trauma surgery service at a level 1 trauma center between January 1 andDecember 31, 2003. Patients were retrospectively triaged to one of three START categories: immediate (Red), delayed (Yellow), or expectant (Black). The FAST results were obtained from the medical records. Results. FAST results were available for 359 patients, of which 27 were classified as positive. Twenty (6.9%) of 286 patients retrospectively triaged as delayed (Yellow) had positive FAST studies. Of these, six underwent operative intervention within 24 hours of arrival. A total of 232 patients had both FAST andcomputed tomography (CT) studies performed, of which 19 FAST studies were inconclusive. In the remaining 213 patients, six of 27 had falsely positive studies, while 24 of 186 had falsely negative studies. Conclusions. Portable ultrasound technology might have identified 20 delayed (Yellow) patients with evidence of hemoperitoneum, thereby expediting evacuation to definitive care. However, only 30% of these patients subsequently underwent an operative intervention within 24 hours of arrival. Both over- andundertriage were significant problems. As such, the current study does not support the routine use of FAST ultrasound as a secondary triage tool.

Precision and reliability of the Glasgow Coma Scale score among a cohort of Latin American prehospital emergency care providers.

INTRODUCTION The Glasgow Coma Scale (GCS) is the standard measure used to quantify the level of consciousness in patients with head injuries. Rapid and accurate GCS scoring is essential for adequate assessment and treatment of critically sick and injured patients. This study sought out to determine the precision and reliability of the GCS among a cohort of Latin American Critical Care Transport Providers. METHODS The study consisted of a cross-sectional design using an Internet-based examination. The evaluation consisted of four focused clinical scenarios with a classification based on severity. For measurement of intra-rater reliability the first and fourth cases were identical. Five minutes were allocated for each scenario. For categorical variables, chi-square testing and Fishers exact testing were used to assess associations. For all tests, statistical significance was set at the 0.05 level. RESULTS A total of 62 providers participated, including 17 physicians and 45 advanced providers (nurses and paramedics). No statistically significant differences were observed between physicians and advanced providers in the correct classification of the individual scenarios. Five of the 17 physicians (29.4%) answered all cases correctly, while none of the 45 advanced providers did (p < 0.001). When evaluating the duplicated cases (Cases 1 and 4), five physicians (29.4%) and 11 advanced providers (24.4%) correctly classified the cases. This difference was not statistically significant. CONCLUSIONS This study demonstrated a poor precision and poor reliability in the use of the Glasgow Coma Scale within the study subjects.

Disaster mobile health technology: lessons from Haiti.

INTRODUCTION Mobile health (mHealth) technology can play a critical role in improving disaster victim tracking, triage, patient care, facility management, and theater-wide decision-making. PROBLEM To date, no disaster mHealth application provides responders with adequate capabilities to function in an austere environment. METHODS The Operational Medicine Institute (OMI) conducted a qualitative trial of a modified version of the off-the-shelf application iChart at the Fond Parisien Disaster Rescue Camp during the large-scale response to the January 12, 2010 earthquake in Haiti. RESULTS The iChart mHealth system created a patient log of 617 unique entries used by on-the-ground medical providers and field hospital administrators to facilitate provider triage, improve provider handoffs, and track vulnerable populations such as unaccompanied minors, pregnant women, traumatic orthopedic injuries and specified infectious diseases. CONCLUSION The trial demonstrated that even a non-disaster specific application with significant programmatic limitations was an improvement over existing patient tracking and facility management systems. A unified electronic medical record and patient tracking system would add significant value to first responder capabilities in the disaster response setting.

Prehospital Sepsis Project (PSP): Knowledge and Attitudes of United States Advanced Out-of-Hospital Care Providers

INTRODUCTION Severe sepsis and septic shock are common and often fatal medical problems. The Prehospital Sepsis Project is a multifaceted study that aims to improve the out-of-hospital care of patients with sepsis by means of education and enhancement of skills. The objective of this Project was to assess the knowledge and attitudes in the principles of diagnosis and management of sepsis in a cohort of United States out-of-hospital care providers. METHODS This was cross-sectional study. A 15-item survey was administered via the Web and e-mailed to multiple emergency medical services list-servers. The evaluation consisted of four clinical scenarios as well as questions on the basics of sepsis. For intra-rater reliability, the first and the fourth scenarios were identical. Chi-square and Fishers Exact testing were used to assess associations. Relative risk (RR) was used for strength of association. Statistical significance was set at .05. RESULTS A total of 226 advanced EMS providers participated with a 85.4% (n = 193) completion rate, consisting of a 30.7% rural, 32.3% urban, and 37.0% suburban mix; 82.4% were paramedics and 72.5% had worked in EMS >10 years. Only 57 (29.5%) participants scored both of the duplicate scenarios correctly, and only 19 of the 193 (9.8%) responded to all scenarios correctly. Level of training was not a predictor of correctly scoring scenarios (P = .71, RR = 1.25, 95% CI = 0.39-4.01), nor was years of service (P = .11, RR = 1.64, 95% CI = 0.16-1.21). CONCLUSIONS Poor understanding of the principles of diagnosis and management of sepsis was observed in this cohort, suggesting the need for enhancement of education. Survey items will be used to develop a focused, interactive Web-based learning program. Limitations include potential for self-selection and data accuracy.

Police Officer Response to the Injured Officer: A Survey-Based Analysis of Medical Care Decisions

INTRODUCTION No widely accepted, specialized medical training exists for police officers confronted with medical emergencies while under conditions of active threat. The purpose of this study was to assess medical decision-making capabilities of law enforcement personnel under these circumstances. METHODS Web-based surveys were administered to all sworn officers within the county jurisdiction. Thirty-eight key actions were predetermined for nine injured officer scenarios, with each correct action worth one point. Descriptive statistics and t-tests were used to analyze results. RESULTS Ninety-seven officers (65.1% response rate) responded to the survey. The majority of officers (68.0%) were trained to the first-responder level. Overall mean score for the scenarios was 15.5 +/- 3.6 (range 7-25). A higher level of medical training (EMT-B/P versus first responder) was associated with a higher mean score (16.6 +/- 3.4, p = 0.05 vs. 15.0 +/- 3.6, p = 0.05). Tactical unit assignment was associated with a lower score compared with non-assigned officers (13.5 +/- 2.9 vs. 16.0 +/- 3.6, p = 0.0085). No difference was noted based upon previous military experience. Ninety-two percent of respondents expressed interest in a law enforcement-oriented advanced first-aid course. CONCLUSIONS Tactical medical decision-making capability, as assessed through the nine scenarios, was sub-optimal. In this post 9/11 era, development of law enforcement-specific medical training appears appropriate.

The Prehospital Sepsis Project: out-of-hospital physiologic predictors of sepsis outcomes.

INTRODUCTION Severe sepsis and septic shock are common, expensive and often fatal medical problems. The care of the critically sick and injured often begins in the prehospital setting; there is limited data available related to predictors and interventions specific to sepsis in the prehospital arena. The objective of this study was to assess the predictive effect of physiologic elements commonly reported in the out-of-hospital setting in the outcomes of patients transported with sepsis. METHODS This was a cross-sectional descriptive study. Data from the years 2004-2006 were collected. Adult cases (≥18 years of age) transported by Emergency Medical Services to a major academic center with the diagnosis of sepsis as defined by ICD-9-CM diagnostic codes were included. Descriptive statistics and standard deviations were used to present group characteristics. Chi-square was used for statistical significance and odds ratio (OR) to assess strength of association. Statistical significance was set at the .05 level. Physiologic variables studied included mean arterial pressure (MAP), heart rate (HR), respiratory rate (RR) and shock index (SI). RESULTS Sixty-three (63) patients were included. Outcome variables included a mean hospital length of stay (HLOS) of 13.75 days (SD = 9.97), mean ventilator days of 4.93 (SD = 7.87), in-hospital mortality of 22 out of 63 (34.9%), and mean intensive care unit length-of-stay (ICU-LOS) of 7.02 days (SD = 7.98). Although SI and RR were found to predict intensive care unit (ICU) admissions, [OR 5.96 (CI, 1.49-25.78; P = .003) and OR 4.81 (CI, 1.16-21.01; P = .0116), respectively] none of the studied variables were found to predict mortality (MAP <65 mmHg: P = .39; HR >90: P = .60; RR >20 P = .11; SI >0.7 P = .35). CONCLUSIONS This study demonstrated that the out-of-hospital shock index and respiratory rate have high predictability for ICU admission. Further studies should include the development of an out-of-hospital sepsis score.

Twenty-five years of violence: the epidemiology of terrorism in South America.

INTRODUCTION Terrorism is a global public health burden. South Americans have been victims of terrorism for many decades. While the causes vary, the results are the same: death, disability, and suffering. The objective of this study was to perform a comprehensive, epidemiological, descriptive study of terrorist incidents in South America. METHODS This is a cross-sectional, descriptive study. Data from January 1971 to July 2006 was selected using the RAND Terrorism Chronology 1968-1997 and RAND-Memorial Institute for Prevention of Terrorism (MIPT) Terrorism Incident database (1998-Present). Statistical significance was set at 0.05. RESULTS The database reported a total of 2,997 incidents in South American countries that resulted in 3,435 victims with injuries (1.15 per incident) and 1,973 fatalities (0.66 per incident). The overall case fatality ratio (CFR) was 35.8%. Colombia had the majority of incidents with 57.9% (1,734 of 2,997), followed by Peru with 363 (12.1%), and Argentina with 267 (8.9%). The highest individual CFR occurred in Paraguay (83.3%), and the lowest in Chile with 4.8%. Of the total injuries and deaths, Colombia had 66.1% (2,269 of 2,997) of all injuries and 75.2% (1,443 out of 1,920) of all deaths. Living in the country of Colombia was associated with a 16 times greater likelihood of becoming a victim of terrorist violence [odds ratio (OR) 16.15; 95% CI 13.45 to 19.40; p < 0.0001]. The predominant method of choice for terrorist incidents was the use of conventional explosives with 2,543 of2,883 incidents (88.2%). CONCLUSIONS Terrorist incidents in South America have accounted for nearly 2,000 deaths, with conventional explosive devices as the predominant method of choice. Understanding the nature of terrorist attacks and the medical consequences assist emergency preparedness and disaster management officials in allocating resources and preparing for potential future events.

Integrated response to the dynamic threat of school violence.

A terrorist attack on US schools no longer can be considered a Black Swan event. Mounting evidence suggests that extremist organizations actively are targeting US schools. Equally disturbing are data suggesting that schools, universities, and communities are unprepared for large-scale violence. The Operational Medicine Institute Conference on an Integrated Response to the Modern Urban Terrorist Threat revealed significant variations in the perceived threats and critical response gaps among emergency medical providers, law enforcement personnel, politicians, and security specialists. The participants recommended several steps to address these gaps in preparedness, training, responses, and recovery.