Glenn Asaeda

Triage accuracy at a multiple casualty incident disaster drill: the Emergency Medical Service, Fire Department of New York City experience.

We sought to evaluate the accuracy and speed for the triage of multiple patients during a disaster drill by Emergency Medical Service (EMS) personnel. During a disaster drill (train collision with blast injury and chemical release), the accuracy and speed of triage of 130 patient-actors by the Fire Department of New York City (FDNY) EMS personnel was evaluated using the Simple Triage and Rapid Treatment (START) triage system. All EMS personnel had been previously trained in START, but refresher training was not administered before the drill. Overall triage accuracy was 78%. In patients that had additional changes in their status during the triage process (injects), 62% were retriaged appropriately. Because of security and decontamination procedures, triage at the triage/treatment area began 40 minutes after the drill commenced. It took 2 hours and 38 minutes to completely clear the scene of all patients. On average, the time from the start of triage to transport was 1 hour and 2 minutes. Despite the fact that triage is a skill practiced by every EMS system in the country on a daily basis, few studies regarding triage accuracy are available. Limited data suggest that the triage accuracy rates using different triage strategy algorithms are approximately 45% to 55%. During this drill, FDNY-EMS triage accuracy using the START system exceeded these expectations. This study provides insight as to the triage experience of a large urban EMS system operating at a disaster drill.

Pediatric nerve agent poisoning: medical and operational considerations for emergency medical services in a large American city.

Abstract: Most published recommendations for treatment of pediatric nerve agent poisoning are based on standard resuscitation doses for these agents. However, certain medical and operational concerns suggest that an alternative approach may be warranted for treatment of children by emergency medical personnel after mass chemical events. (1) There is evidence both that suprapharmacological doses may be warranted and that side effects from antidote overdosage can be tolerated. (2) There is concern that many emergency medical personnel will have difficulty determining both the age of the child and the severity of the symptoms. Therefore, the Regional Emergency Medical Advisory Committee of New York City and the Fire Department, City of New York, Bureau of Emergency Medical Services, in collaboration with the Center for Pediatric Emergency Medicine of the New York University School of Medicine and the Bellevue Hospital Center, have developed a pediatric nerve agent antidote dosing schedule that addresses these considerations. These doses are comparable to those being administered to adults with severe symptoms and within limits deemed tolerable after inadvertent nerve agent overdose in children. We conclude that the above approach is likely a safe and effective alternative to weight-based dosing of children, which will be nearly impossible to attain under field conditions.

Utilization of air medical transport in a large urban environment: a retrospective analysis.

Objective. To determine the utility of air medical transport in a large urban environment. Methods. The authors conducted a retrospective analysis of all air medical transports of patients in the Fire Department of the City of New York EMS (emergency medical services) Command for the period of January 1, 1996, to December 31, 1999. These data were evaluated for frequency of air medical transport, patient condition at time of flight, and necessity of air evacuation. Results. During the study period, some form of air medical transport was used 182 times. Of this number, 32 were for transports of patients from a scene of an incident to a hospital within New York City; 18 for interfacility transport of patients from a hospital facility within New York City to another facility within New York City; 122 for interfacility transfers of patients from medical facilities outside of the New York City area to a facility in New York City; and ten for transport of patients from New York City medical facilities to facilities out of the area. Conclusion. The Fire Department of the City of New York EMS Command utilizes air medical evacuation for patient transports very infrequently. The parameters of New York Citys large urban environment may not be conducive to air medical transport. These data seem to be consistent with experiences of other large urban cities.

A modified simple triage and rapid treatment algorithm from the New York City (USA) Fire Department

INTRODUCTION The objective of this study was to determine if modification of the Simple Triage and Rapid Treatment (START) system by the addition of an Orange category, intermediate between the most critically injured (Red) and the non-critical, non-ambulatory injured (Yellow), would reduce over- and under-triage rates in a simulated mass-casualty incident (MCI) exercise. METHODS A computer-simulation exercise of identical presentations of an MCI scenario involving a 2-train collision, with 28 case scenarios, was provided for triaging to two groups: the Fire Department of the City of New York (FDNY; n=1,347) using modified START, and the Emergency Medical Services (EMS) providers from the Eagles 2012 EMS conference (Lafayette, Louisiana USA; n=110) using unmodified START. Percent correct by triage category was calculated for each group. Performance was then compared between the two EMS groups on the five cases where Orange was the correct answer under the modified START system. RESULTS Overall, FDNY-EMS providers correctly triaged 91.2% of cases using FDNY-START whereas non-FDNY-Eagles providers correctly triaged 87.1% of cases using unmodified START. In analysis of the five Orange cases (chest pain or dyspnea without obvious trauma), FDNY-EMS performed significantly better using FDNY-START, correctly triaging 86.3% of cases (over-triage 1.5%; under-triage 12.2%), whereas the non-FDNY-Eagles group using unmodified START correctly triaged 81.5% of cases (over-triage 17.3%; under-triage 1.3%), a difference of 4.9% (95% CI, 1.5-8.2). CONCLUSIONS The FDNY-START system may allow providers to prioritize casualties using an intermediate category (Orange) more properly aligned to meet patient needs, and as such, may reduce the rates of over-triage compared with START. The FDNY-START system decreases the variability in patient sorting while maintaining high field utility without needing computer assistance or extensive retraining. Comparison of triage algorithms at actual MCIs is needed; however, initial feedback is promising, suggesting that FDNY-START can improve triage with minimal additional training and cost.

Public-access defibrillation—New York City's experience☆☆☆

form, accounts for nearly 1 million deaths in the United States annually.1 Oftentimes, the first symptom may be sudden cardiac arrest (SCA), accounting for nearly 250,000 of these deaths per year.2 According to the American Heart Association (AHA) Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care,3 the highest potential survival rate from cardiac arrest can be achieved only when the following sequence of events occurs as rapidly as possible: 1) recognition of early warning signs, 2) activation of the emergency medical services (EMS) system, 3) basic cardiopulmonary resuscitation (CPR), 4) early defibrillation, 5) management of the airway and ventilation, and 6) intravenous administration of medications as part of “the chain of survival.”4 Recent changes in the New York State Public Health Law allow the lay public (meaning those persons who are not certified health care personnel) to utilize automated external defibrillators (AEDs) under certain conditions.5,6 This is referred to as public-access defibrillation (PAD). For example, an organization may wish to have key personnel, such as security guards, trained in the use of AEDs, which analyze the heart’s rhythm and help treat victims of sudden cardiac arrest.7 The AHA cites defibrillation as the most effective intervention in the provision of emergency cardiac care. Cardiac care studies have shown that the closer the interventions of CPR and defibrillation are to the time of collapse in cases of certain lethal rhythms, the greater the chance of survival. With reported survival rates of up to 49% in cases of cardiac arrest when early defibrillation is available,8 PAD has the potential of being the single greatest advancement in the treatment of prehospital sudden cardiac arrest. The goal of a PAD program is to achieve a response time of 3–4 minutes from collapse to first defibrillation shock since studies have shown that the chance of successful resuscitation decreases 7–10% for each minute of delay. To this end, the AHA has identified early PAD along with early EMS intervention as vital in the chain of survival. New York City, recognizing the potential benefits of early access defibrillation, implemented such a program in the summer of 2001. This paper presents issues pertaining to implementation of the New York City PAD Program.

Preparing the Health System to Respond to Ebola Virus Disease in New York City, 2014.

The worlds largest outbreak of Ebola virus disease began in West Africa in 2014. Although few cases were identified in the United States, the possibility of imported cases led US public health systems and health care facilities to focus on preparing the health care system to quickly and safely identify and respond to emerging infectious diseases. In New York City, early, coordinated planning among city and state agencies and the health care delivery system led to a successful response to a single case diagnosed in a returned health care worker. In this article we describe public health and health care system preparedness efforts in New York City to respond to Ebola and conclude that coordinated public health emergency response relies on joint planning and sustained resources for public health emergency response, epidemiology and laboratory capacity, and health care emergency management. (Disaster Med Public Health Preparedness. 2017;11:370-374).

Freestanding emergency critical care during the aftermath of Hurricane Sandy: implications for disaster preparedness and response

OBJECTIVE To assess the impact of an emergency intensive care unit (EICU) established concomitantly with a freestanding emergency department (ED) during the aftermath of Hurricane Sandy. METHODS We retrospectively reviewed records of all patients in Bellevues EICU from freestanding ED opening (December 10, 2012) until hospital inpatient reopening (February 7, 2013). Temporal and clinical data, and disposition upon EICU arrival, and ultimate disposition were evaluated. RESULTS Two hundred twenty-seven patients utilized the EICU, representing approximately 1.8% of freestanding ED patients. Ambulance arrival occurred in 31.6% of all EICU patients. Median length of stay was 11.55 hours; this was significantly longer for patients requiring airborne isolation (25.60 versus 11.37 hours, P<0.0001 by Wilcoxon rank sum test). After stabilization and treatment, 39% of EICU patients had an improvement in their disposition status (P<0.0001 by Wilcoxon signed rank test); upon interhospital transfer, the absolute proportion of patients requiring ICU and SDU resources decreased from 37.8% to 27.1% and from 22.2% to 2.7%, respectively. CONCLUSIONS An EICU attached to a freestanding ED achieved significant reductions in resource-intensive medical care. Flexible, adaptable care systems should be explored for implementation in disaster response. (Disaster Med Public Health Preparedness. 2016;10:496-502).