Joseph A. Barbera

Buffered versus plain lidocaine as a local anesthetic for simple laceration repair

STUDY OBJECTIVE Buffered lidocaine was compared with plain lidocaine as a local anesthetic for simple lacerations. DESIGN Randomized, double-blind, prospective clinical trial. SETTING Urban emergency department. TYPE OF PARTICIPANTS Ninety-one adult patients with simple linear lacerations were enrolled. Patients with allergy to lidocaine and patients with an abnormal mental status were excluded. INTERVENTIONS Each wound edge was anesthetized with either plain or buffered lidocaine using a randomized, double-blind protocol. The pain of infiltration was measured with a previously validated visual analog pain scale. MEASUREMENTS AND MAIN RESULTS Analysis of pooled data and paired data (using patients as their own controls) revealed that infiltrating buffered lidocaine was significantly less painful than plain lidocaine (P = .03 and P = .02, respectively). There was no significant difference in the anesthetic effectiveness of the two agents during suturing. CONCLUSION Buffered lidocaine is preferable to plain lidocaine as a local anesthetic agent for the repair of simple lacerations.

Refining surge capacity: conventional, contingency, and crisis capacity.

Health care facility surge capacity has received significant planning attention recently, but there is no commonly accepted framework for detailed, phased surge capacity categorization and implementation. This article proposes a taxonomy within surge capacity of conventional capacity (implemented in major mass casualty incidents and representing care as usually provided at the institution), contingency capacity (using adaptations to medical care spaces, staffing constraints, and supply shortages without significant impact on delivered medical care), and crisis capacity (implemented in catastrophic situations with a significant impact on standard of care). Suggested measurements used to gauge a quantifiable component of surge capacity and adaptive strategies for staff and supply challenges are proposed. The use of refined definitions of surge capacity as it relates to space, staffing, and supply concerns during a mass casualty incident may aid phased implementation of surge capacity plans at health care facilities and enhance the consistency of terminology and data collection between facilities and regions.

Challenge of hospital emergency preparedness: analysis and recommendations.

In the United States, recent large-scale emergencies and disasters display some element of organized medical emergency response, and hospitals have played prominent roles in many of these incidents. These and other well-publicized incidents have captured the attention of government authorities, regulators, and the public. Health care has assumed a more prominent role as an integral component of any community emergency response. This has resulted in increased funding for hospital preparedness, along with a plethora of new preparedness guidance.Methods to objectively measure the results of these initiatives are only now being developed. It is clear that hospital readiness remains uneven across the United States. Without significant disaster experience, many hospitals remain unprepared for natural disasters. They may be even less ready to accept and care for patient surge from chemical or biological attacks, conventional or nuclear explosive detonations, unusual natural disasters, or novel infectious disease outbreaks.This article explores potential reasons for inconsistent emergency preparedness across the hospital industry. It identifies and discusses potential motivational factors that encourage effective emergency management and the obstacles that may impede it. Strategies are proposed to promote consistent, reproducible, and objectively measured preparedness across the US health care industry. The article also identifies issues requiring research.

Protective equipment for health care facility decontamination personnel: regulations, risks, and recommendations.

After recent terrorist attacks, new attention has been focused on health care facility decontamination practices. This article reviews core issues related to the selection of appropriate personal protective equipment for health care facility decontamination personnel, with an emphasis on respiratory protection. Existing federal regulations focus primarily on scene response and not on issues specific to health care facility decontamination practices. Review of existing databases, relevant published literature, and individual case reports reveal some provider health risks, especially when the exposure involves organophosphate agents. However, reported risks from secondary exposure to contaminated patients at health care facilities are low. These risks should be adequately addressed with Level C personal protective equipment, including air-purifying respirator technologies, unless the facility determines that specific local threats require increased levels of protection.

Urban search and rescue

Structural-collapse rescue is one of the most challenging and dangerous disaster response activities. Sophisticated, multidisciplinary search-and-rescue capabilities have evolved to address the difficulties in finding, reaching, and extricating deeply entombed survivors. An equally advanced medical team is required to provide health and medical support to rescuers and to optimize extrication and survival of the often critically injured victims. Adaptations in the usual approach to emergency medical services and emergency medical care are needed to evaluate and treat confined-space victims adequately.

Ems-initiated refusal and alternative methods of transport

OBJECTIVES 1) To describe characteristics of patient transport protocols in those U.S. cities that sanction EMS-initiated refusal of transport; and 2) to describe the frequency and type of alternatives to emergency ambulance transport. METHODS EMS systems in every one of the 200 largest cities in the United States were surveyed by telephone regarding EMS-initiated refusal policies, involvement of physicians in the decision-making process, and the presence or absence of alternatives to EMS transport. RESULTS 100% of the target population responded to the telephone survey. Only 34 (17%) EMS systems have written protocols that allow EMS providers to refuse emergency ambulance transport for patients judged to have minor illness or injury after examination. Twenty-one (62%) of these EMS systems do not require on-line physician approval for EMS-initiated refusals. Seven (21%) EMS systems that allow refusal of transport also have a formalized alternative transport program in place. Nationwide, only 19 (10%) cities surveyed offer some type of alternative to ambulance transport, most commonly taxi and minivan. CONCLUSION The authors report the first national survey of EMS-initiated refusal practices. Few urban EMS systems have implemented this policy to decrease utilization by persons with low-acuity illness or injury. This may be related to the fact that few EMS systems currently have alternatives to emergency ambulance transport.

Urban search and rescue medical teams: FEMA Task Force System

Recent national and international disasters involving collapsed structures and trapped casualties (Mexico City; Armenia; Iran; Philippines; Charleston, South Carolina; Loma Prieta, California; and others) have provoked a heightened national concern for the development of an adequate capability to respond quickly and effectively to this type of calamity. The Federal Emergency Management Agency (FEMA) has responded to this need by developing an Urban Search and Rescue (US&R) Response System, a national system of multi-disciplinary task forces for rapid deployment to the site of a collapsed structure incident. Each 56-person task force includes a medical team capable of providing advanced emergency medical care both for task force members and for victims located and reached by the sophisticated search, rescue, and technical components of the task force. This paper reviews the background and development of urban search and rescue, and describes the make-up and function of the Federal Emergency Management Agency (FEMA) Task Force medical teams.

Health care emergency management: establishing the science of managing mass casualty and mass effect incidents.

Particularly since 2001, the health care industry has witnessed many independent and often competing efforts to address mitigation and preparedness for emergencies. Clinicians, health care administrators, engineers, safety and security personnel, and others have each developed relatively independent efforts to improve emergency response. A broader conceptual approach through the development of a health care emergency management profession should be considered to integrate these various critical initiatives. When based on long-standing emergency management principles and practices, health care emergency management provides standardized, widely accepted management principles, application concepts, and terminology. This approach could also promote health care integration into the larger community emergency response system. The case for a formally defined health care emergency management profession is presented with discussion points outlining the advantages of this approach.

The international search and rescue response to the US Embassy bombing in Kenya: the medical team experience.

On 07 August, 1998, a terrorists bomb exploded outside of the United States Embassy in Nairobi, Kenya. The explosion caused severe damage to the Embassy and surrounding structures, including almost complete collapse of the Ufundi building adjacent to the Embassy. The U.S. response to this tragedy included the deployment of medical, rescue, and law enforcement personnel to assist the Kenyan government. An integral component of this response was the deployment of an Urban Search and Rescue Task Force to aid in the location, extrication, and rescue of entrapped victims. This Task Force was sponsored by the Office for Foreign Disaster Assistance (OFDA), a branch of the United States Agency for International Development (USAID). The Task Force included a medical team composed of two physicians and four paramedics, whose purpose was to define, create, and provide a medical care system for rescuers and victims in the austere environment at the bombsite. As an international event involving a multinational response, the characteristics and requirements of this event differed in some respects from domestic disaster emergency responses, and the medical team adjusted their operating procedures accordingly.

An emergency department-based field response team: Case report and recommendations for a “go team”

Few crises are more distressing to prehospital care providers than the inability to care for a patient who is desperately ill due to entrapment. Occasionally, these patients require medical care above and beyond the scope of practice at the paramedic level. Although a federal response system is in place to provide physician-level out-of-hospital medical care during presidential declarations of disaster,1 there is a paucity of scientific literature concerning an organized emergency department response to assist local fire/rescue or EMS agencies with patient care activities. The George Washington University Medical Center (GWUMC) Department of Emergency Medicine has developed such a prehospital emergency medicine capability in conjunction with the District of Columbia Fire and EMS Department (DCFEMSD). A case report and issues related to physician response into the prehospital environment are presented.