Joost J. L. M. Bierens

Pulmonary oedema, pneumonia and mortality in submersion victims; a retrospective study in 125 patients.

ObjectiveThe identification of risk factors contributing to the development of pulmonary oedema, pneumonia and late mortality in submersion victims.DesignA retrospective study of 125 submersion victims.Setting: The medical intensive care unit in a university hospital.MethodsBaseline examination on admission consisted of history, physical examination, arterial blood gas analysis and a chest radiograph. Patients were then classified into four groups: class I, baseline examination negative; class II, baseline examination positive, but mechanical ventilation not needed on admission; class III, mechanical ventilation required on admission; class IV, patients suffering form cardiopulmonary arrest. All patients who were not succesfully resuscitated or who had expired with-in 24 h after admission were excluded for determination of the risk of pulmonary oedema and pneumonia.ResultsClass I patients did not develop pulmonary complications; neither pulmonary oedema nor pneumonia occurred in this group. In the remaining classes the incidence of pulmonary oedema was 72% and that of pneumonia, 14.7%. Stepwise logistic regression showed that pulmonary oedema was related to the type of water (seawater, ditch water, swimming pool) victims were submerged in and to the neurological state both at the time of rescue and on admission. The development of pneumonia was related to the use of mechanical ventilation (the risk was 52%). Pneumonia was not related to neurological state at the time of rescue or on admission, to body temperature on admission, to the prohylactic administration of antibiotics or to the use of corticosteroids. Mortality was high in class IV patients, but low in all other patients. Early mortality was 18.4% while late mortality was 5.6%.ConclusionsThere is no need to hospitalise submersion victims when there are no signs or symptoms of aspiration upon arrival in the emergency room. All other patients should be admitted to an intensive care unit. The risk of pneumonia is high when mechanical ventilation is necessary. Mortality is high in patients with circulatory arrest on admission, but low in all other patients.

Submersion in The Netherlands: Prognostic Indicators and Results of Resuscitation

STUDY OBJECTIVESnTo analyze prognostic indicators and the outcome of resuscitation in submersion victims (drowning and near drowning).nnnDESIGNnRetrospective study.nnnSETTINGnIntensive and Respiratory Care Unit. Between January 1, 1979, and December 31, 1985, 87 submersion victims were admitted. The files of 83 victims were available for statistical analysis. There were 66 male victims and 17 female victims; the average age was 31.4 +/- 25.8 years. There were ten salt water and 73 fresh water submersions.nnnMEASUREMENTS AND MAIN RESULTSnPredictors for better survival potentials were a young age, submersion of less than ten minutes, no signs of aspiration, and a central body temperature of less than 35 C at admission. We did not detect factors that accelerated a decrease in core body temperature at admission and assume that lethal hypoxia had preceded protective hypothermia in our submersion victims. The Orlowski score had a predictive value but at the same time we found nonindependent indicators in this score. Neurologic outcome in our patients, who were not treated according to a brain protection protocol, was not worse than the outcome published by authors who have used such a protocol. Thirty-three percent of the victims with a cardioventilatory arrest (15) and all victims with a ventilatory arrest (11) survived resuscitation and were discharged. Five nonarrest victims died due to late complications.nnnCONCLUSIONnThis study shows that no indicator at the rescue site and in the hospital is absolutely reliable with respect to death or survival.

Public access defibrillation: time to access the public.

STUDY OBJECTIVEnPublic accessible automated external defibrillators (AEDs) are increasingly made available in highly frequented places, allowing coincidental bystanders to defibrillate with minimal delay if necessary. Although the public, as the largest and most readily available group of potential rescuers, is assigned a key role in this concept of public access defibrillation, it is unknown whether bystanders are actually sufficiently prepared. We therefore investigate knowledge and attitudes toward AEDs among the public.nnnMETHODSnStandardized interviews were conducted at the Central Railway Station of Amsterdam, the Netherlands, a highly frequented and AED-equipped public place with a high number of travelers and visitors from all over the world.nnnRESULTSnSurveys from 1,018 participants from a total of 38 nations were analyzed, revealing a considerable lack of knowledge among the public. Less than half of participants (47%) would be willing to use an AED, and more than half (53%) were unable to recognize an AED. Overall, only a minority of individuals have sufficient knowledge and would be willing to use an AED. Differences between subgroups were identified, which may aid to tailor public information campaigns to specific target audiences.nnnCONCLUSIONnOnly a minority of individuals demonstrate sufficient knowledge and willingness to operate an AED, suggesting that the public is not yet sufficiently prepared for the role it is destined for. Wide-scale public information campaigns are an important next step to exploit the lifesaving potential of public access defibrillation.

Submersion cases in the Netherlands

Epidemiologic analysis of submersion cases admitted to the intensive and respiratory care unit showed that several interrelated factors preceded submersion. Accidental submersion and traffic accidents represented one third of the causes of submersion. Other relevant causes were illness (29.9%), psychosocial causes (20.1%), alcohol (18.1%), and suicide (9.1%). Age distribution, gender, and mortality rate were different in each group. Young age, submersion during recreational activities, summer months, and normothermia were epidemiologic factors with a favorable prognosis. Our data were compared with national data. WHO-ICD code 994.1 (drowning and nonfatal submersion) is the best entrance for epidemiologic analysis. Five hundred twenty deaths and 690 hospital admissions due to submersion occur in The Netherlands each year. About 460 victims die before they reach a hospital.

Developing process guidelines for trauma care in the Netherlands for severely injured patients: Results from a Delphi study

BackgroundIn organised trauma systems the process of care is the key to quality. Nevertheless, the optimal process of trauma care remains unclear due to lack of or inconclusive evidence. Because monitoring and improving the performance of a trauma system is complex, this study aimed to develop consensus-based process guidelines for trauma care in the Netherlands for severely injured patients.MethodsA five-round Delphi study was conducted with 141 participants that represent all professions involved in trauma care. Sensitivity analyses were carried out to evaluate whether consensus extended across all professions and to detect possible bias.ResultsConsensus was reached on 21 guidelines within 4 categories: timeliness, actions, competent teams and interdisciplinary process. Timeliness guidelines set specific critical limits and definitions for 10 time intervals in the time period from an emergency call until the patient leaves the trauma room. Action guidelines reflect aspects of appropriate care and strongly rely on the international Advanced Trauma Life Support principles. Competence guidelines include flow charts to assess the competence of prehospital and emergency department teams. Essential to competent teams are education and experience of all team members. The interdisciplinary process guideline focuses on cooperation, communication and feedback within and between all professions involved. Consensus was extended across all professions and no bias was detected.ConclusionsIn this Delphi study, a large expert panel agreed on a set of guidelines describing the optimal process of care for severely injured trauma patients in the Netherlands. In addition to time intervals and appropriate actions, these guidelines emphasise the importance of team competence and interdisciplinary processes in trauma care. The guidelines can be seen as a description of a best practice and a new field standard in the Netherlands. The next step is to implement the guidelines and monitor the performance of the Dutch trauma system based on the guidelines.

The Evaluation of Research Methods during Disaster Exercises: Applicability for Improving Disaster Health Management

INTRODUCTIONnThe objective of this study was to investigate whether disaster exercises can be used as a proxy environment to evaluate potential research instruments designed to study the application of medical care management resources during a disaster.nnnMETHODSnDuring an 06 April 2005 Ministerial-level exercise in the Netherlands, three functional areas of patient contact were assessed: (1) Command and Control, through the application of an existing incident management system questionnaire; (2) patient flow and quality of patient distribution, through registration of data from prehospital casualty collection points, ambulances, and participating trauma centers (with inclusion of data in a flow chart); and (3) hospital coping capacity, through timed registration reports from participating trauma centers.nnnRESULTSnThe existing incident management system questionnaire used for evaluating Command and Control during a disaster exercise would benefit from minor adaptations and validation that could not be anticipated in the exercise planning stage. Patient flow and the quality of patient distribution could not be studied during the exercise because of inconsistencies among data, and lack of data from various collection points. Coping capacity was better measured by using 10-minute rather than one hour time intervals, but provided little information regarding bottlenecks in surge capacity.nnnCONCLUSIONnResearch instruments can be evaluated and improved when tested during a disaster exercise. Lack of data recovery hampers disaster research even in the artificial setting of a national disaster exercise. Providers at every level must be aware that proper data collection is essential to improve the quality of health care during a disaster, and that predisaster cooperation is crucial to validate patient outcomes. These problems must be addressed pre-exercise by stakeholders and decision-makers during planning, education, and training. If not, disaster exercises will not meet their full potential.

The Volendam Fire: Lessons Learned from Disaster Research

INTRODUCTIONnAfter the Volendam fire, a multidisciplinary, integral evaluation, called the Medical Evaluation of the Disaster in Volendam (MERV), was established. This article is a discussion of disaster research methodology. It describes the organizational framework of this project and the methodological problems.nnnMETHODSnA scientific steering group consisting of members from three hospitals prepared and guided the project. A research team wrote the final study protocol and performed the study. The project was funded by the Ministry of Health. The study protocol had a modular design in which each of the modules focused on one specific area or location. The main questions for each location were: (1) which treatment protocols were used; (2) what was the condition of the patient; and (3) was medical care provided according to existing protocols. After the fire, 241 victims were treated in hospitals; they all were included in the study. Most of the victims had burn injuries, and approximately one-third suffered from inhalation injury. All hospitals and ambulance services involved were visited in order to collect data, and interviewers obtained additional information. The government helped obtain permission for data-collection in three of the hospitals. Over 1,200 items of information about each patient and > 200,000 total items were collected. During data processing, the data were re-organized, categorized, and presented in a uniform and consistent style. A cross-sectional site analysis and a longitudinal patient analysis were conducted. This was facilitated by the use of several sub-databases. The modular approach made it possible to obtain a complete overview of the medical care provided. The project team was guided by a multidisciplinary steering group and the research was performed by a research team. This enabled the research team to focus on the scientific aspects.nnnCONCLUSIONnThe evaluation of the Volendam fire indicates that a project approach with a modular design is effective for the analysis of complex incidents. The use of several sub-databases makes it easy to combine findings and conduct cross-sectional and longitudinal analyses. The government played an important role in the funding and support of the project. To limit and structure data collection and analysis, a pilot study based on several predefined main questions should be conducted. The questions then can be specified further based on the availability of data.

TAP CBRN Preparedness: Knowledge, Training and Networks

The main goal of this targeted agenda program (TAP) was the establishment of an international network that would be able to advise on how to improve education and training for chemical, biological, radiological, or nuclear (CBRN)) responders. By combining the members of the TAP group, the CBRN Task Force of the World Association for Disaster and Emergency Medicine (WADEM) and the European network of the Hesculaep Group, an enthusiastic and determined group has been established to achieve the defined goal. It was acknowledged that the bottlenecks for education and training for CBRN responders are mainly awareness and preparedness. For this reason, even basic education and training on CBRN is lacking. It was advised that the focus for the future should be on the development of internationally standardized protocols and standards. The face-to-face discussions of the TAP will be continued at future Hesculaep expert meetings. The intention is that during the 16WCDEM, the achievements of the established network will be presented.

Water-Related Disasters

Synopsis Synopsis Synopsis Synopsis: The aim behind this research is to develop our understanding of the relations between water-related disasters and their impacts on society, so as to improve policies for hazards mitigation. This technical report presents the results of our assessment and analysis of water-related disasters during the past four decades (1960 to 2004) in particular as reported in the OFDA/CRED Emergency Disaster Database (EMDAT), University of Louvain, Belgium. The results presented in graphics and tabular forms for each type of water-related disasters allow the reader to evaluate the current state of the global and regional trends. The outcome of the report puts emphasis on numbers of emerging issues and challenges for the concrete evaluation of social and economic vulnerabilities to water-related disasters. The findings introduced in this study were presented in front of the UN Expert Group on Risk Management led by WMO and ISDR for consideration during the production of the 2 nd Edition of the World Water Development Report (WWDR) managed by the Secretariat of the UN-World Water Assessment Programme (UN-WWAP) hosted by UNESCO. vi Foreword Foreword Water-related disasters afflict our societies in different forms and have continuously taken an enormous toll on our socioeconomic development. The increasing trend of negative socioeconomic impact worldwide affirms that there is a shortage of effective disaster preparedness and mitigation methods. This global shortage is due not only to the fact that risk reduction is not yet properly implemented as an integral part of water resource management, but also to the social, economical and political factors that force people to live in risky areas. To achieve our goals for sustainable development there are emerging needs to develop novel concepts and management strategies to tackle the multifaceted complex issues hampering our progress in water-related disaster mitigation. The development of strategic processes for water hazards mitigation requires a solid base of concrete assessment and understanding of the risk levels that our societies are facing. A holistic risk management approach is essential to build sound and sustainable policies for mitigation of water-related disasters. A critical step forward in this direction is to develop and sustain a reliable water-related disaster database to assess the vulnerability of people and property to each type of water-related disasters and propose tailored adaptive actions to secure sustainable development. Under our current preparatory activities for the establishment of the International Centre for Water Hazard and Risk Management under the …

The World Congress on Drowning 2002: A Move Towards the Future

Although much progress has been made in the diagnosis and treatment of patients who have suffered an acute myocardial event and require resuscitation, many people became aware that little progress had been made in the resuscitation of drowning victims. It was felt by many that the pathophysiological processes in drowning, which led the patient to a resuscitation situation, were fundamentally different from the cardiac patient and therefore needed a different approach in terms of diagnosis and treatment. Other observations were that therapeutic innovations were limited, outcome had not improved and reliable international data on the incidence of drowning were lacking.