Ming-Che Tsai

Mass-Casualty, Terrorist Bombings: Implications for Emergency Department and Hospital Emergency Response (Part II)

This article reviews the implications of mass-casualty, terrorist bombings for emergency department (ED) and hospital emergency responses. Several practical issues are considered, including the performance of a preliminary needs assessment, the mobilization of human and material resources, the use of personal protective equipment, the organization and performance of triage, the management of explosion-specific injuries, the organization of patient flow through the ED, and the efficient determination of patient disposition. As long as terrorists use explosions to achieve their goals, mass-casualty, terrorist bombings remain a required focus for hospital emergency planning and preparedness.

Mass-casualty, terrorist bombings: epidemiological outcomes, resource utilization, and time course of emergency needs (Part I).

INTRODUCTION This article characterizes the epidemiological outcomes, resource utilization, and time course of emergency needs in mass-casualty, terrorist bombings producing 30 or more casualties. METHODS Eligible bombings were identified using a MEDLINE search of articles published between 1996 and October 2002 and a manual search of published references. Mortality, injury frequency, injury severity, emergency department (ED) utilization, hospital admission, and time interval data were abstracted and relevant rates were determined for each bombing. Median values for the rates and the inter-quartile ranges (IQR) were determined for bombing subgroups associated with: (1) vehicle delivery; (2) terrorist suicide; (3) confined-space setting; (4) open-air setting; (5) structural collapse sequela; and (6) structural fire sequela. RESULTS Inclusion criteria were met by 44 mass-casualty, terrorist bombings reported in 61 articles. Median values for the immediate mortality rates and IQRs were: vehicle-delivery, 4% (1-25%); terrorist-suicide, 19% (7-44%); confined-space 4% (1-11%); open-air, 1% (0-5%); structural-collapse, 18% (5-26%); structural fire 17% (1-17%); and overall, 3% (1-14%). A biphasic pattern of mortality and unique patterns of injury frequency were noted in all subgroups. Median values for the hospital admission rates and IQRs were: vehicle-delivery, 19% (14-50%); terrorist-suicide, 58% (38-77%); confined-space, 52% (36-71%); open-air, 13% (11-27%); structural-collapse, 41% (23-74%); structural-fire, 34% (25-44%); and overall, 34% (14-53%). The shortest reported time interval from detonation to the arrival of the first patient at an ED was five minutes. The shortest reported time interval from detonation to the arrival of the last patient at an ED was 15 minutes. The longest reported time interval from detonation to extrication of a live victim from a structural collapse was 36 hours. CONCLUSION Epidemiological outcomes and resource utilization in mass-casualty, terrorist bombings vary with the characteristics of the event.

A survey of emergency medicine in 36 countries

OBJECTIVE To assess the current level of development of emergency medicine (EM) systems in the world. DESIGN Survey of EM professionals from 36 countries during a 90-day period from Aug. 25 to Nov. 24, 1998. PARTICIPANTS Thirty-six EM professionals from 36 countries and 6 continents completed the survey. Thirty-five (97%) were physicians, of whom 25 (69%) gave presentations at 1 of 4 international EM conferences during the study period. Three potential participants from 3 countries were excluded because of language barriers. Five additional participants from 5 other countries did not respond within the study period and were excluded. MEASUREMENTS Respondents completed a 103-question questionnaire about the presence of EM specialty, academic, patient care, information and management systems and the factors influencing the future of EM in their countries. RESULTS The overall response rate was 88%. Nearly all respondents (97%) stated that their countries had hospital-based emergency departments (EDs). More than 80% of respondents reported that their countries have emergency medical services (EMS), national EMS activation phone numbers and ED systems for pediatric emergency care. More than 70% stated that their countries had national EM organizations, EM research, ED systems for patient transfer and peer review and emergency physician (EP) training in Advanced Cardiac Life Support (ACLS) and the ability to perform rapid sequence intubation. More than 60% reported ED systems for trauma care and triage and EP training in Advanced Trauma Life Support (ATLS) and the ability to perform thrombolysis for acute myocardial infarction. Fifty percent reported EM residency training programs, official recognition of EM as an independent specialty, and EM journals. CONCLUSIONS Basic emergency medicine components now exist in the majority of countries surveyed. These include many specialty, academic, patient care and administrative systems. The foundation for further EM development is widely established throughout the world.

Information-Sharing in Out-of-Hospital Disaster Response: The Future Role of Information Technology

Numerous examples exist of the benefits of the timely access to information in emergencies and disasters. Information technology (IT) is playing an increasingly important role in information-sharing during emergencies and disasters. The effective use of IT in out-of-hospital (OOH) disaster response is accompanied by numerous challenges at the human, applications, communication, and security levels. Most reports of IT applications to emergencies or disasters to date, concern applications that are hospital-based or occur during non-response phases of events (i.e., mitigation, planning and preparedness, or recovery phases). Few reports address the application of IT to OOH disaster response. Wireless peer networks that involve ad hoc wireless routing networks and peer-to-peer application architectures offer a promising solution to the many challenges of information-sharing in OOH disaster response. These networks offer several services that are likely to improve information-sharing in OOH emergency response, including needs and capacity assessment databases, victim tracking, event logging, information retrieval, and overall incident management system support.

Recommended modifications and applications of the Hospital Emergency Incident Command System for hospital emergency management.

The Hospital Emergency Incident Command System (HEICS), now in its third edition, has emerged as a popular incident command system model for hospital emergency response in the United States and other countries. Since the inception of the HEICS in 1991, several events have transformed the requirements of hospital emergency management, including the 1995 Tokyo Subway sarin attack, the 2001 US anthrax letter attacks, and the 2003 Severe Acute Respiratory Syndrome (SARS) outbreaks in eastern Asia and Toronto, Canada. Several modifications of the HEICS are suggested to match the needs of hospital emergency management today, including: (1) an Incident Consultant in the Administrative Section of the HEICS to provide expert advice directly to the Incident Commander in chemical, biological, radiological, nuclear (CBRN) emergencies as needed, as well as consultation on mental health needs; (2) new unit leaders in the Operations Section to coordinate the management of contaminated or infectious patients in CBRN emergencies; (3) new unit leaders in the Operations Section to coordinate mental health support for patients, guests, healthcare workers, volunteers, and dependents in terrorism-related emergencies or events that produce significant mental health needs; (4) a new Decedent/Expectant Unit Leader in the Operations Section to coordinate the management of both types of patients together; and (5) a new Information Technology Unit Leader in the Logistics Section to coordinate the management of information technology and systems. New uses of the HEICS in hospital emergency management also are recommended, including: (1) the adoption of the HEICS as the conceptual framework for organizing all phases of hospital emergency management, including mitigation, preparedness, response, and recovery; and (2) the application of the HEICS not only to healthcare facilities, but also to healthcare systems. Finally, three levels of healthcare worker competencies in the HEICS are suggested: (1) basic understanding of the HEICS for all hospital healthcare workers; (2) advanced understanding and proficiency in the HEICS for hospital healthcare workers likely to assume leadership roles in hospital emergency response; and (3) special proficiency in constituting the HEICS ad hoc from existing healthcare workers in resource-deficient settings. The HEICS should be viewed as a work in progress that will mature as additional challenges arise and as hospitals gain further experience with its use.

Mass casualty terrorist bombings

STUDY OBJECTIVE We compared the epidemiologic outcomes of terrorist bombings that produced 30 or more casualties and resulted in immediate structural collapse, occurred within a confined space, or occurred in open air. METHODS We identified eligible studies of bombings through a MEDLINE search of articles published between 1966 and August 2002 and a manual search of published references. Pooled and median rates of mortality, immediately injured survival, emergency department use, hospitalization, and injury were determined for each bombing type. RESULTS We found 35 eligible articles describing 29 terrorist bombings, collectively producing 8,364 casualties, 903 immediate deaths, and 7,461 immediately surviving injured. Pooled immediate mortality rates were structural collapse 25% (95% confidence interval [CI] 6% to 44%), confined space 8% (95% CI 1% to 14%), and open air 4% (95% CI 0% to 9%). Biphasic distributions of mortality were identified in all bombing types. Pooled hospitalization rates were structural collapse 25% (95% CI 6% to 44%), confined space 36% (95% CI 27% to 46%), and open air 15% (95% CI 5% to 26%). Unique patterns of injury rates were found in all bombing types. CONCLUSION Patterns of injury and health care system use vary with the type of terrorist bombing.

Mutation Analysis of STK11/LKB1 Gene in Patients with Peutz-Jeghers Syndrome in Taiwan: A Preliminary Report

Purpose: Peutz-Jeghers syndrome is an autosomal dominant disorder characterized by hamartomatous polyps in the gastrointestinal tract and pigmented macules of the lips, buccal mucosa, and digits. It was shown that germline mutations of the STK11/LKB1 gene are responsible for Peutz-Jeghers syndrome. The STK11/LKB1 gene is predicted to encode a serine/threonine kinase and might be a tumor-suppressor gene. We investigated the role of the STK11/LKB1 gene in patients with Peutz-Jeghers syndrome in Taiwan. Methods: Mutation analysis of genomic DNA was performed on one familial case (comprising three family members) and three sporadic cases with Peutz-Jeghers syndrome. All nine exons of the STK11/LKB1 gene and the flanking intron boundaries were amplified, followed by direct sequencing. Direct sequencing in each family and in normal controls further verified the mutations. Results: Mutations in the functional domains of the STK11/LKB1 gene were identified in one sporadic case only (4016G＞A, R297K), which was reported twice previously. In addition, we detected three polymorphisms in the STK11/LKB1 gene. Conclusions: We reported a mutation of the STK11/LKB1 gene in one sporadic case of Peutz-Jeghers syndrome. In the remaining one familial (three patients) and two sporadic Peutz-Jeghers syndrome cases, we found no apparent abnormalities of the STK11/LKB1gene, which could reflect the existence of locus heterogeneity in Peutz-Jeghers syndrome.

Monitoring Field Performance of Emergency Medical Service in the Tainan Region

At present, approximately eighty precent of firefighters are at EMT-︱ level, and of these 50% are at EMT-Ⅱ leavel in Taiwan. However, no formal assessment program has measured the real impact of MET training on practivce behavior. The purpose of this study is to investigate the discrepancy in field performance reports between the METs and triage nurses in the receiving hospitals.From December 22,1997 to January 21,1998, a total of 617 run reports and special review sheets were collected from 8 receiving hospitals. Ninety precent of the franctional response times in the city and county were within 6 and 10 minutes respectively. Average on-scene time and average total transport time in the city was 5.5, and 15 minutes, and in the county 5 and 25 minutes. Motor vehicle accidents comprised 64%of run requests. Procedures such as applying a neck collar, nasal cannula, splinting of fractured limbs ans CPR attempts were consistent with emerency room(ER) nurse’s observation. Categories such as controlling bleeding and bandaging, keep ing an open airway, mask ventilation, comforting patients and no specific intervention required were inconsisitently reported by staffs of the receiving Ers. We concluded that incomplete recording of pre-hospital run reports is a major barrier to deprrier to depicting the status of EMS care quality in Taiwan and it must be rectified quickly. Field preformance assessments reviewed by ER triage nurses might serve to monitor as well as evaluate the care given by EMTs. However, validation of the present review process by a designated field inspector is mandatory to carry out continuous quality improvement for future EMS in Taiwan.

A Preliminary Survey of Emergency Medicine in 12 Asian Countries

Study objective: To assess the current level of development of emergency medicine (EM) in Asia. Design: Survey of EM professionals from 12 Asian countries during a 90-day period from August to November 1998. Participants: Twelve EM professionals from 12 Asian countries completed the survey. All participants were physicians. Eight participants (67%) gave presentations at an international EM conference during the study period. Measurements: Respondents completed a 95-question questionnaire about the status of EM specialty, academic, patient care, information and management systems and the factors influencing the future of EM in their countries. Results: Ninety-two percent of respondents stated that their countries have hospital-based emergency departments (ED). More than 80% of respondents reported that their countries have emergency medical service (EMS) systems and ED systems for trauma care and patient transfer. More than 70% stated that their countries have national EM organizations, EM research, national EMS activation phone numbers, ED systems for pediatric emergency care, emergency physician (EP) training in Advance Cardiac Life Support (ACLS) and Advanced Trauma Life Support (ATLS) and peer review. More than 60% reported official recognition of EM as an independent specialty status, ED triage systems and systems for customer service. More than 50% reported EM residency training programs, EM journals and EP ability to perform rapid sequence intubation (RSI). Fifty percent reported EP ability to perform thrombolysis for acute myocardial infarction (AMI) and 33% reported EP performed ultrasonography. Ninety-two percent felt that a lack of funding posed a moderate or great obstacle to the future development of EM in their countries. Conclusion: Many essential systems of EM now exist throughout Asia.