Irving Jacoby

Hospital Bed Surge Capacity in the Event of a Mass-Casualty Incident

INTRODUCTION Traditional strategies to determine hospital bed surge capacity have relied on cross-sectional hospital census data, which underestimate the true surge capacity in the event of a mass-casualty incident. OBJECTIVE To determine hospital bed surge capacity for the County more accurately using physician and nurse manager assessments for the disposition of all in-patients at multiple facilities. METHODS Overnight- and day-shift nurse managers from each in-patient unit at four different hospitals were approached to make assessments for each patient as to their predicted disposition at 2, 24, and 72 hours post-event in the case of a mass-casualty incident, including transfer to a hypothetical, onsite nursing facility. Physicians at the two academic institutions also were approached for comparison. Age, gender, and admission diagnosis also were recorded for each patient. RESULTS A total of 1,741 assessments of 788 patients by 82 nurse managers and 25 physicians from the four institutions were included. Nurse managers assessed approximately one-third of all patients as dischargeable at 24 hours and approximately one-half at 72 hours; one-quarter of the patients were assessed as being transferable to a hypothetical, on-site nursing facility at both time points. Physicians were more likely than were nurse managers to send patients to such a facility or discharge them, but less likely to transfer patients out of the intensive care unit (ICU). Inter-facility variability was explained by differences in the distribution of patient diagnoses. CONCLUSIONS A large proportion of in-patients can be discharged within 24 and 72 hours in the event of a mass-casualty incident (MCI). Additional beds can be made available if an on-site nursing facility is made available. Both physicians and nurse managers should be included on the team that makes patient dispositions in the event of a MCI.

The roentgenographic findings associated with air embolism in sport scuba divers

Records on all patients with arterial gas embolism (AGE) presenting to UCSD from 1982-1989 and for whom chest radiographs were available were reviewed. Of the 31 patients, 13 roentgenograms (42%) showed evidence of pulmonary barotrauma demonstrated by pneumomediastinum (N = 8), subcutaneous emphysema (N = 3), pneumocardium (N = 2), pneumoperitoneum (N = 1), or pneumothorax (N = 1). Pneumopericardium was not seen. Sixteen (52%) of the 31 patients had pulmonary infiltrates. Radiographic evidence of barotrauma was on occasion subtle, and in four cases was overlooked. Evidence of barotrauma (i.e., extra-alveolar air) was often identified along the left cardiac border, aortic arch, descending aorta, and hilar vessels. Subtle findings of ectopic air can confirm the clinical diagnosis of AGE; however, radiographic evidence of concomitant near drowning occurs more frequently.

Fatal Pulmonary Barotrauma due to Obstruction of the Central Circulation with Air

Cardiac arrest in cases of barotraumatic arterial gas embolism (AGE) is usually ascribed to reflex dysrhythmias secondary to brainstem embolization or secondary to coronary artery embolization. Several case reports suggest that obstruction of the central circulation (i.e., the heart, pulmonary arteries, aorta, and arteries to the head and neck) may play a role in the pathogenesis of sudden death in victims of pulmonary barotrauma. We report three consecutive cases of fatal AGE in patients in whom chest roentgenograms demonstrated confluent air lucencies filling the central vascular bed, the heart, and great vessels. In none of the victims was there evidence by history or at autopsy that the intravascular gas was iatrogenically introduced. Total occlusion of the central vascular bed with air is a mechanism of death in some victims of AGE, and resuscitation efforts for such patients should take this possibility into consideration.

Disaster Preparedness of Poison Control Centers in the United States

OBJECTIVE To assess the state of disaster readiness of poison control centers, a survey questionnaire was sent to all 96 institutional poison control center members of the American Association of Poison Control Centers in the US, both certified and noncertified programs. DESIGN The data reported are the results and responses from 76 of 96 (79.2%) poison control centers. RESULTS Fifty-four percent of responding centers have written disaster plans, with 25% having drills to practice the plans. Of the centers that do not have a written plan, the majority have policies and procedures in place to address physical plant damage, increased phone traffic, loss of phone systems and malfunction of computers. Eighty-six percent of respondents have a back up generator, and 82% have an uninterruptable power supply in place. Fifty-four percent have a back up phone system and 33% have cellular phone capacity. Forty-six percent of responding centers have arrangements with other agencies in the event of a disaster. Only half of the managing directors of the responding centers believe their center can meet the publics needs in the event of a disaster.