Marvin L. Birnbaum

Effect of advanced cardiac life-support training in rural, community hospitals.

ObjectivesTo define the effectiveness of training personnel in rural, community hospitals in advanced cardiac life support (ACLS) and the changes that result in the process and quality of care to patients with ischemic heart disease that can be attributed to participation by team members in an ACLS course. DesignCase-controlled, retrospective abstraction of hospital records of 869 consecutive patients with ischemic heart disease, who were admitted during the year preceding and the year following the ACLS course. SettingSeven rural, community hospitals in Wisconsin. SubjectsPhysicians, nurses, and other critical care staff (others). InterventionsTraining in ACLS using 12 3-hr sessions in an interdisciplinary format by a multidisciplinary faculty. Measurements and Main ResultsRates of successful attainment of the terminal behavior objectives by physicians and nurses-were 84.0% and 78.8%, respectively. Less than 50% of others achieved a satisfactory level of competence. Performance on an examination of cognitive ability improved significantly for all groups (p < .005 for nurses; p < .05 for physicians). Enhancement of knowledge base and integrative skills occurred in all areas of designated ACLS content. Difficulty remained apparent relative to the pharmacologic effects of epinephrine and atropine. No statistically significant deterioration in didactic knowledge base could be detected 1 to 2 yrs after completion of the ACLS course. Slight deterioration in intubation and defibrillation skills occurred in <3 months after completion of the course. Substantial costs were encumbered by the hospitals, despite the free training provided to the institutions. After ACLS training had been given, overall mortality rates decreased from 17.4% to 13.4% (p < .05). A pooled estimate of the decrease in the mortality rate was 1.4 ± 3.8%/quarter. Across the entire spectrum of severity of illness, the probabilities for survival increased at a given severity of illness following completion of the course (p = .06). When extremes of severity of illness were excluded from the analysis, the differences in probability for survival over the midrange of severity were statistically significant (p < .05). ConclusionsTraining directed to the entire team likely to participate in the provision of ACLS in the community hospital favorably affects the overall practice of ACLS and the survival rate of patients with ischemic heart disease. (Crit Care Med 1994; 22:741–749)

Accentuate the Positive

In business today performance management, assessment centre activity and training and development interventions tend to focus on what is failing: identifying individual and collective areas for development and forming an action plan around the steps to take to improve these. In this article the authors argue for accentuating the positive, placing more weight on identifying and building on personal strengths as a way of enhancing performance. They outline why and how this need can be addressed.

A Proposed Universal Medical and Public Health Definition of Terrorism

The lack of a universally applicable definition of terrorism has confounded the understanding of terrorism since the term was first coined in 18th Century France. Although a myriad of definitions of terrorism have been advanced over the years, virtually all of these definitions have been crisis-centered, frequently reflecting the political perspectives of those who seek to define it. In this article, we deconstruct these previously used definitions of terrorism in order to reconstruct a definition of terrorism that is consequence-centered, medically relevant, and universally harmonized. A universal medical and public health definition of terrorism will facilitate clinical and scientific research, education, and communication about terrorism-related events or disasters. We propose the following universal medical and public definition of terrorism: The intentional use of violence--real or threatened--against one or more non-combatants and/or those services essential for or protective of their health, resulting in adverse health effects in those immediately affected and their community, ranging from a loss of well-being or security to injury, illness, or death.

The Pressor Effect of Hemoglobin-Good or Bad?

When Bayliss infused hemolyzed blood into cats 75 years ago, he found that solution to “raise blood pressure, if it was low, and increase the secretion of urine” (Bayliss 1920) Amberson further explored this “vasoconstrictor action of dissolved hemoglobin,” finding that infusions of hemoglobin “always raise the blood pressure” (Amberson 1937). He stated that in the case of large-volume infusions into animals “this pressor action may be ascribed in part to the high colloidal osmotic pressure of hemoglobin-saline solutions which draw fluid into the blood and so raise its volume.” But even when small volumes were infused into humans, he “usually observed an elevation in blood pressure,” concluding that “a chemical pressor effect is also present” (Amberson, Jennings and Rhodes 1949).

The Sumatra-Andaman Earthquake and Tsunami of 2004: The Hazards, Events, and Damage

The Sumatra-Andaman Earthquake and subsequent Asian Tsunami of 26 December 2004 affected multiple countries in the Indian Ocean and beyond, creating disasters of a scale unprecedented in recorded history. Using the Conceptual Framework and terminology described in the Disaster Health Management: Guidelines for Evaluation and Research in the Utstein Style, the hazard, events, and damage associated with the Earthquake and Tsunami are described. Many gaps in the available information regarding this event are present. Standardized indicators and reporting criteria are necessary for research on future disasters and the development of best practice standards internationally.

Guidelines for reports on health crises and critical health events

IntroductionThe proposed guidelines for a common structure for reports on health crisesand critical health events are an attempt of capturing the experiences gainedand a further step for promoting a standardized methodology for sharingresults and experiences. Such a common and standardized approach will facil-itate the analysis and comparison of findings in order to improve preparednessplanning and response and advance international collaboration and learning.If future reporting follows common standards, then the documented findingswould be comparable and could be used to learn and apply lessons within anindividual field of activity and to apply those lessons learned also to otherrelated preparedness activities. It could also facilitate the implementation ofjoint activities and joint reports involving different sectors. Globally applied tools, such as the Initial Rapid Assessment tool (IRA)

Research and Evaluations of the Health Aspects of Disasters, Part II: The Disaster Health Conceptual Framework Revisited.

A Conceptual Framework upon which the study of disasters can be organized is essential for understanding the epidemiology of disasters, as well as the interventions/responses undertaken. Application of the structure provided by the Conceptual Framework should facilitate the development of the science of Disaster Health. This Framework is based on deconstructions of the commonly used Disaster Management Cycle. The Conceptual Framework incorporates the steps that occur as a hazard progresses to a disaster. It describes an event that results from the changes in the release of energy from a hazard that may cause Structural Damages that in turn, may result in Functional Damages (decreases in levels of function) that produce needs (goods and services required). These needs can be met by the goods and services that are available during normal, day-to-day operations of the community, or the resources that are contained within the communitys Response Capacity (ie, an Emergency), or by goods and services provided from outside of the affected area (outside response capacities). Whenever the Local Response Capacity is unable to meet the needs, and the Response Capacities from areas outside of the affected community are required, a disaster occurs. All responses, whether in the Relief or Recovery phases of a disaster, are interventions that use the goods, services, and resources contained in the Response Capacity (local or outside). Responses may be directed at preventing/mitigating further deterioration in levels of functions (damage control, deaths, injuries, diseases, morbidity, and secondary events) in the affected population and filling the gaps in available services created by Structural Damages (compromise in available goods, services, and/or resources; ie, Relief Responses), or may be directed toward returning the affected community and its components to the pre-event functional state (ie, Recovery Responses). Hazard Mitigation includes interventions designed to decrease the likelihood that a hazard will cause an event, and should an event occur, that the amount of energy released will be reduced. Capacity Building consists of all interventions undertaken before an event occurs in order to increase the resilience of the community to an event related to a hazard that exists in an area-at-risk. Resilience is the combination of the Absorbing, Buffering, and Response Capacities of a community-at-risk, and is enhanced through Capacity-Building efforts. A disaster constitutes a failure of resilience.

Health-related relief in the former Yugoslavia: needs, demands, and supplies.

INTRODUCTION Many organizations rally to areas to provide assistance to a population during a disaster. Little is known about the ability of the materials and services provided to meet the actual needs and demands of the affected population. This study sought to identify the perceptions of representatives of the international organizations providing this aid, the international workers involved with the delivery of this aid, the workers who were employed locally by the international organizations, the recipients, and the local authorities. This study sought to identify the perceptions of these personnel relative to the adequacies of the supplies in meeting the needs and demands of the population during and following the war in Bosnia-Herzegovina. METHODS Structured interviews were conducted with representatives of international organizations and workers providing aid and with locally employed workers, recipients of the assistance, and the authorities of the areas involved. Descriptive and inferential statistics were used to assist in the analysis of the data. RESULTS Eighty-eight interviews were conducted. A total of 246 organizations were identified as providing assistance within the area, and 54% were involved with health-related activities including: 1) the provision of medications; 2) public health measures; and 3) medical equipment or parts for the same. Internationals believed that a higher proportion of the needs were being met by the assistance (73.4 +/- 16.4%) than did the nationals (52.1 +/- 23.3%; p < 0.001). All groups believed that approximately 50% of the demands of the affected population were being addressed. However, 87% of the international interviewees believed that the affected population was requesting more than it actually needed. While 27% of the international participants believed that > or = 25% of what was provided was unusable, 80% of the recipients felt that > or = 25% of the provisions were not usable. Whereas two-thirds of the international participants believed that > or = 25% of the demands for assistance by the affected community could not be justified, only 20% of the recipients and authorities believed > or = 25% of the demands were unjustified. CONCLUSIONS Many organizations are involved in the provision of medical assistance during a disaster. However, international organizations and workers believe their efforts are more effective than do the recipients.

Education issues in disaster medicine: summary and action plan

INTRODUCTION Change must begin with education. Theme 8 explored issues that need attention in Disaster Medicine education. METHODS Details of the methods used are provided in the introductory paper. The chairs moderated all presentations and produced a summary that was presented to an assembly of all of the delegates. The chairs then presided over a workshop that resulted in the generation of a set of action plans that then were reported to the collective group of all delegates. RESULTS Main points developed during the presentations and discussion included: (1) formal education, (2) standardized definitions, (3) integration, (4) evaluation of programs and interventions, (5) international cooperation, (6) identifying the psychosocial consequences of disaster, (7) meaningful research, and (8) hazard, impact, risk and vulnerability analysis. DISCUSSION Three main components of the action plans were identified as evaluation, research, and education. The action plans recommended that: (1) education on disasters should be formalized, (2) evaluation of education and interventions must be improved, and (3) meaningful research should be promulgated and published for use at multiple levels and that applied research techniques be the subject of future conferences. CONCLUSIONS The one unanimous conclusion was that we need more and better education on the disaster phenomenon, both in its impacts and in our response to them. Such education must be increasingly evidence-based.

Research and Evaluations of the Health Aspects of Disasters, Part VI: Interventional Research and the Disaster Logic Model

Disaster-related interventions are actions or responses undertaken during any phase of a disaster to change the current status of an affected community or a Societal System. Interventional disaster research aims to evaluate the results of such interventions in order to develop standards and best practices in Disaster Health that can be applied to disaster risk reduction. Considering interventions as production functions (transformation processes) structures the analyses and cataloguing of interventions/responses that are implemented prior to, during, or following a disaster or other emergency. Since currently it is not possible to do randomized, controlled studies of disasters, in order to validate the derived standards and best practices, the results of the studies must be compared and synthesized with results from other studies (ie, systematic reviews). Such reviews will be facilitated by the selected studies being structured using accepted frameworks. A logic model is a graphic representation of the transformation processes of a program [project] that shows the intended relationships between investments and results. Logic models are used to describe a program and its theory of change, and they provide a method for the analyzing and evaluating interventions. The Disaster Logic Model (DLM) is an adaptation of a logic model used for the evaluation of educational programs and provides the structure required for the analysis of disaster-related interventions. It incorporates a(n): definition of the current functional status of a community or Societal System, identification of needs, definition of goals, selection of objectives, implementation of the intervention(s), and evaluation of the effects, outcomes, costs, and impacts of the interventions. It is useful for determining the value of an intervention and it also provides the structure for analyzing the processes used in providing the intervention according to the Relief/Recovery and Risk-Reduction Frameworks.