Richard A. Bissell

Evidence of the effectiveness of health sector preparedness in disaster response: the example of four earthquakes.

In this article, evidence that health sector preparedness improves response performance in disasters was examined. Case fatality and survival data were compared for four earthquakes, in relation to health sector emergency preparedness levels. Vast differences in performance were found. The two California systems, with a high preparedness index, had low case fatality rates (about one death per 100 injuries). Kobe, Japan, with mixed levels of preparedness, had 31 deaths per 100 injuries, and Armenia (low preparedness index) had 167. Public health and health sector preparedness made a significant difference in the ability to respond effectively to meet patient needs in disasters, although it is only one of several factors that determine the health outcome of disaster victims.

Post-disaster malaria in Costa Rica.

INTRODUCTION In recent years, controversy has surrounded the issue of whether infectious disease should be considered a serious potential consequence of natural disasters. This article contributes to this debate with evidence of a significant outbreak of malaria in Costa Ricas Atlantic region after the 1991 earthquake and subsequent floods. METHODS This study is an epidemiologic investigation of the incidence of malaria for the periods of 22 months before the April 1991 Limón earthquake and for 13 months afterward. Data were obtained from the Costa Rican Ministry of Healths malaria control program. RESULTS Some of the cantons in the region experienced increases in the incidence of malaria as high as 1,600% and 4,700% above the average monthly rate for the preearthquake period (p < or = 0.01). Causal mechanisms are postulated as relating to changes in human behavior (increased exposure to mosquitoes while sleeping outside, and a temporary pause in malaria control activities), changes in the habitat that were beneficial to mosquito breeding (landslide deforestation, river damming, and rerouting), and the floods of August 1991. CONCLUSIONS It is recommended that there be enhanced awareness of the potential consequences of disaster-wrought environmental changes. Date of Event: 22 April 1991; Type: Earthquake, 7.4 Richter scale; LOCATION Costa Rica; Number of deaths and casualties: 54 deaths and 505 moderate to severe injuries.

Differences in mortality rates among trauma patients transported by helicopter and ambulance in Maryland.

INTRODUCTION A comprehensive state-wide emergency medical services and helicopter transport system has been developed in the State of Maryland on the principle that early definitive care improves patient outcomes. The purpose of this study was to determine if empirical data exist to support the theory that air medical transportation services provided by the Maryland State Police (MSP) Aviation Division contribute to an improved trauma patient survival rate in Maryland. METHODS A retrospective study was conducted on the records of all patients transported by helicopter or ground ambulance and admitted to the R Adams Cowley Shock Trauma Center (STC) of the University of Maryland Medical System. Data were obtained from the Maryland Institute of Emergency Medical Services Systems (MIEMSS) Shock Trauma Clinical Registry for the period January 1988 through July 1995, covering 23,002 patients. Patients included those transported directly from the scene of injury to the STC as well as those from interfacility transfers. All patients were stratified by injury severity and compared by outcome (mortality) using Mantel-Haenszel statistics. RESULTS During the study period, 11,379 patients were transported by ground and 11,623 were transported by MSP helicopter. The mean Injury Severity Score (ISS) for patients transported by ground was 12.7 (SD = 12.52) and the mean ISS for patients transported by air was 14.6 (SD = 13.42), p < 0.001. Among patients classified as having a high index of injury severity, the mortality rate was lower among those transported by MSP helicopter than among those transported by ambulance. The mortality rate was significantly lower for air transported patient with an ISS higher than 31. CONCLUSION The State of Maryland has demonstrated a commitment to its citizenry and invested heavily in its public safety air medical service. This study suggests the rapid air transport of victims of traumatic events by specialized personnel in Maryland has a positive effect on the outcome of severely injured patients. Further research is necessary to clarify the causal relationships in order to more fully elucidate the value of this resource.

Change the scope of practice of paramedics? an ems/public health policy perspective

OBJECTIVE To analyze the potential for expanding the scope of practice of paramedics from public health, health planning, and health policy perspectives, utilizing data covering more than 42,000 emergency patients. METHODS The authors conducted a retrospective study of 42,918 patients seen in two Baltimore emergency departments over a six-month period, 5,259 of whom were transported by emergency ambulance. The authors constructed epidemiologic profiles of in-hospital and prehospital patients, and merged ambulance data with discharge diagnoses. RESULTS The 42,918 patients had a total of 2,118 different discharge diagnoses. The ten most frequent diagnoses of ambulance-transported patients were convulsions, injuries, asthma, congestive heart failure, chest pain, syncope and collapse, otitis media, abdominal pain, cardiac arrest, and respiratory abnormality. The ten most frequent diagnoses for all ED patients were otitis media, asthma, finger and nonspecific injuries, upper respiratory infections, chest pain, bronchitis, pharyngitis, gastroenteritis, nonspecific viral infections, and urinary tract infections. Infections accounted for 31.6% of the top 50% of diagnoses by volume, followed by injuries (24%) and cardiovascular cases (16.5%). However, 26.9% of ED patients received an assessment and diagnosis of general symptoms (no procedure). CONCLUSIONS The high number of diagnoses and the frequency of infections as a primary complaint in this patient sample reconfirm the primacy of the physician in prioritizing patients and assigning treatment pathways. The authors suggest a methodology that may allow properly trained medics to alter some of their role as physician extenders, but suggest that system planners must first ensure that any changes not reduce the public health benefits that each EMS system already provides.

Bacterial Pathogens in Ambulances: Results of Unannounced Sample Collection

The concern that the health care environment may harbor a substantial reservoir of infectious agents has been vigorously examined by microbiology andinfectious disease experts. Although universal precautions anddisposable equipment reduces risks to patients andproviders, the ambulance remains vulnerable to bacterial contamination from biological secretions. Additionally, the nature of emergency medical services creates pressures on prehospital care providers. Objective. We hypothesized that a discrepancy exists between the expectation of disinfection of reusable equipment in emergency medical services (EMS) andthe cleaning that actually occurs. Methods. We chose five areas within the ambulance for specimen collection for their reasoned propensity to yield a large spectrum of bacteria. Four first-due ambulances were selected for culturing. The crews did not have advance knowledge of the study or sample collection. Specific identifications with antibiotic susceptibility were completed, identifying three multidrug resistant organisms. Results. Specimens from all four ambulances grew moderate-to-large quantities of environmental andskin flora. Newer, automated microbiological techniques andconcerns regarding multiple-drug-resistant organism prevalence as well as the potential for biological warfare make complete identification more important. Conclusions. This study examined the bacterial pathogens found in EMS vehicles. Four of the seven species isolated were substantial nosocomial pathogens, andthree of these four possess formidable antibiotic resistance patterns. All of the organisms detected are susceptible to the disinfectant agents currently in common use by EMS agencies.

A poor association between out-of-hospital cardiac arrest location and public automated external defibrillator placement.

INTRODUCTION Much attention has been given to the strategic placement of automated external defibrillators (AEDs). The purpose of this study was to examine the correlation of strategically placed AEDs and the actual location of cardiac arrests. METHODS A retrospective review of data maintained by the Maryland Institute for Emergency Medical Services Systems (MIEMSS), specifically, the Maryland Cardiac Arrest Database and the Maryland AED Registry, was conducted. Location types for AEDs were compared with the locations of out-of-hospital cardiac arrests in Howard County, Maryland. The respective locations were compared using scatter diagrams and r2 statistics. RESULTS The r2 statistics for AED location compared with witnessed cardiac arrest and total cardiac arrests were 0.054 and 0.051 respectively, indicating a weak relationship between the two variables in each case. No AEDs were registered in the three most frequently occurring locations for cardiac arrests (private homes, skilled nursing facilities, assisted living facilities) and no cardiac arrests occurred at the locations where AEDs were most commonly placed (community pools, nongovernment public buildings, schools/educational facilities). CONCLUSION A poor association exists between the location of cardiac arrests and the location of AEDs.

Epidemic and bioterrorism preparation among emergency medical services systems.

INTRODUCTION The purpose of this research was to determine the preparedness of emergency medical services (EMS) agencies in one US state to cope with a massive epidemic event. METHODS Data were collected primarily through telephone interviews with EMS officials throughout the State. To provide a comparison, nine out-of-state emergency services agencies were invited to participate. RESULTS Emergency medical services agencies from nine of the 23 counties (39%) provided responses to some or all of the questions in the telephone survey. Seven of the nine out-of-state agencies provided responses to the survey. Most of the EMS agencies do not have broad, formal plans for response to large-scale bio-terrorist or pandemic events. CONCLUSIONS The findings indicate that EMS agencies in this state fundamentally are unprepared for a large-scale bioterrorism or pandemic event. The few existing plans rely heavily on mutual aid from agencies that may be incapable of providing such aid. Therefore, EMS agencies must be prepared to manage a response to these incidents without assistance from any agencies outside of their local community. In order to accomplish this, they must begin planning and develop close working relationships with public health, healthcare, and elected officials within their local communities.

Vaccine Administration by Paramedics: A Model for Bioterrorism and Disaster Response Preparation

The events of 11 September 2001 have had a profound effect on disaster planning efforts in the United States. This is true especially in the area of bioterrorism. One of the major tenets of bioterrorism response is the vaccination of at-risk populations. This paper investigates the efficacy of training emergency medical services paramedics to administer vaccines in public health settings as preparation for and response to bioterrorism events and other disaster events. The concept of vaccination administration by specially trained paramedics is not new. Various programs to provide immunizations for emergency services personnel and at-risk civilian populations have been reported. Vaccination programs by paramedics should follow the guidelines of the National Vaccine Advisory Committee of the Centers for Disease Control and Prevention (CDC). This paper compares the seven standards of the CDC guidelines to routine paramedic practice and education. It is concluded that paramedics are adequately trained to administer vaccines. However, specific training and protocols are needed in the areas of administrative paperwork and patient education. A proposed outline for a paramedic-training program is presented.

A medically wise approach to expanding the role of paramedics as physician extenders.

The authors examined a portion of the complex issue of the scope of practice of paramedics in light of the epidemiologic profile of emergency patients seen at two Baltimore hospitals. They suggest that the same approach could and should be used to help decide on the scope of work of prehospital personnel in any jurisdiction. The findings lead the authors to urge caution toward any potential changes to the work done by medics, because of the enormous breadth of presenting patient conditions. The authors suggest that the epidemiologic profile witnessed in Baltimore would require increased direct physician input on patient destination decisions for all medics who would be working under an expanded scope of functions, and the paper suggests a mechanism for accomplishing this goal. Finally, while there may be compelling economic reasons to change what medics do in the field, this article cautions health care managers to design changes, based on solid evidence, that will have a positive public health impact, and then work to evaluate the character of the impact after changes are implemented.

Working women at risk. results from a survey of hispanic injury patients

Women experience lower rates of occupational injury than do men in general, but subgroups are at increased risk. Based on the medical records of 2572 injury patients requesting treatment in a Washington, DC, emergency department during a 1991 survey of injured Hispanics, we found that whereas women in general had a low risk of occupational injury. Hispanic women did not realize this protection. All Hispanics were at increased risk of occupational injury, but the relative risk attributable to ethnicity for Hispanic women (3.83; 95% confidence interval, 2.85,5.14) was nearly twice that of the corresponding relative risk suffered by working Hispanic men (2.07; 95% confidence interval, 1.72,2.48). It was also found that whereas, overall, women had a lower risk of assault than did men, relative risks of assault based on sex were the same in the workplace.