Robert A. De Lorenzo

Mass Gathering Medicine: A Review

The provision for emergency medical care for spectators and participants at large events is a growing area of interest. This article describes the definition and characteristics of medical care at mass gatherings. The literature is reviewed with regard to the planning, organization, personnel, and staffing required at these events. The equipment and transportation assets needed are also discussed. Disaster and mass casualty planning implications also are described.

Optimal positioning for cervical immobilization.

STUDY OBJECTIVEnWe hypothesized that optimal positioning of the head and neck to protect the spinal cord during cervical spine immobilization can be determined with reference to external landmarks. In this study we sought to determine the optimal position for cervical spine immobilization using magnetic resonance imaging (MRI) and to define this optimal position in a clinically reproducible fashion.nnnMETHODSnOur subjects were 19 healthy adult volunteers (11 women, 8 men). In each, we positioned the head to produce various degrees of neck flexion and extension. This positioning was followed by quantitative MRI of the cervical spine.nnnRESULTSnThe mean ratio of spinal canal and spinal cord cross-sectional areas was smallest at C6 but exceeded 2.0 at all levels from C2 to T1 (P < .05). At the C5 and C6 levels, the maximal area ratio was most consistently obtained with slight flexion (cervical-thoracic angle of 14 degrees) (P < .05). For a patient lying flat on a backboard, this corresponds to raising the occiput 2 cm. More extreme flexion or extension produced variable results.nnnCONCLUSIONnIn healthy adults, a slight degree of flexion equivalent to 2 cm of occiput elevation produces a favorable increase in spinal canal/spinal cord ration at levels C5 and C6, a region of frequent unstable spine injuries.

Out-of-Hospital Combat Casualty Care in the Current War in Iraq

STUDY OBJECTIVEnWe describe outcomes for battle casualties receiving initial treatment at a US Army consolidated battalion aid station augmented with emergency medicine practitioners, advanced medic treatment protocols, and active medical direction. Battalion aid stations are mobile facilities integral to combat units, providing initial phases of advanced trauma life support and then evacuation. The setting was a forward base in central Iraq, with units engaged in urban combat operations.nnnMETHODSnThis was a retrospective observational study. Rates of battle casualties, mechanism, evacuations, and outcome were calculated. Corresponding Iraqi theater-wide US casualty rates were also calculated for indirect comparison.nnnRESULTSnThe study population consisted of 1.1% of the total US military population in the Iraqi theater. Data were available for all battle casualties. The study facilitys battle casualty rate was 22.2%. The case fatality rate was 7.14%, and the out-of-theater evacuation rate was 27%. Analysis of evacuated patients revealed a study average Injury Severity Score of 10 (95% confidence interval [CI] 8 to 12). Concurrent theater aggregate US casualty rates are provided for contextual reference and include battle casualty rate of 6.7%, case fatality rate of 10.45%, out-of-theater evacuation rate of 18%, and average out-of-theater evacuation casualty Injury Severity Score of 10 (95% CI 9.5 to 10.5).nnnCONCLUSIONnThe study battalion aid station experienced high casualty and evacuation rates while also demonstrating relatively low case fatality rates. A relatively high proportion of patients were evacuated out of the combat zone, reflecting both the battle casualty rate and number of patients surviving. Future effort should focus on improving out-of-hospital combat casualty data collection and prospective validation of emergency medicine-based out-of-hospital battlefield care and medical direction.

Analyzing clinical case distributions to improve an emergency medicine clerkship

Recommendations for a core curriculum for undergraduate emergency medicine education have been published. It is expected that a combination of bedside teaching and didactic sessions will cover all aspects of the curriculum, but this has not been demonstrated. This study describes a method of using the distribution of clinical cases to shape the mix of clinical and didactic learning in an emergency medicine clerkship. All senior students at the Albany Medical College participate in a four-week emergency medicine rotation. A brief log describing each clinical encounter is maintained by the students. Data from one year were sorted into 32 categories adapted from American College of Emergency Physicians guidelines and were tabulated. A criterion of 80% of students encountering at least one case in each category was chosen to ensure a reasonable level of exposure to a particular case or topic. One hundred twenty-three students were exposed to an average of 63.7 +/- 27.5 (SD) patients. Seven categories met the criterion, and the remaining 25 categories failed the criterion. Results indicate that exposure to certain categories of patients with appropriate monitoring can be reasonably ensured in our clinical setting. The didactic portion of the curriculum can be adjusted so that categories not meeting the clinical criterion will be emphasized, whereas those meeting the criterion will be de-emphasized. A method has been described that identifies gaps in the clinical exposure of students and permits appropriate identification of didactic sessions to create a clerkship more consistent with recommended guidelines.

Lights and siren: A review of emergency vehicle warning systems

Emergency medical services providers routinely respond to emergencies using lights and siren. This practice is not without risk of collision. Audible and visual warning devices and vehicle markings are integral to efficient negotiation of traffic and reduction of collision risk. An understanding of warning system characteristics is necessary to implement appropriate guidelines for prehospital transportation systems. The pertinent literature on emergency vehicle warning systems is reviewed, with emphasis on potential health hazards associated with these techniques. Important findings inferred from the literature are 1) red flashing lights alone may not be as effective as other color combinations, 2) there are no data to support a seizure risk with strobe lights, 3) lime-yellow is probably superior to traditional emergency vehicle colors, 4) the siren is an extremely limited warning device, and 5) exposure to siren noise can cause hearing loss. Emergency physicians must ensure that emergency medical services transportation systems consider the pertinent literature on emergency vehicle warning systems.

Effect of crowd size on patient volume at a large, multipurpose, indoor stadium

A prediction of patient volume expected at mass gatherings is desirable in order to provide optimal on-site emergency medical care. While several methods of predicting patient loads have been suggested, a reliable technique has not been established. This study examines the frequency of medical emergencies at the Syracuse University Carrier Dome, a 50,500-seat indoor stadium. Patient volume and level of care at collegiate basketball and football games as well as rock concerts, over a 7-year period were examined and tabulated. This information was analyzed using simple regression and nonparametric statistical methods to determine level of correlation between crowd size and patient volume. These analyses demonstrated no statistically significant increase in patient volume for increasing crowd size for basketball and football events. There was a small but statistically significant increase in patient volume for increasing crowd size for concerts. A comparison of similar crowd size for each of the three events showed that patient frequency is greatest for concerts and smallest for basketball. The study suggests that crowd size alone has only a minor influence on patient volume at any given event. Structuring medical services based solely on expected crowd size and not considering other influences such as event type and duration may give poor results.

A review of spinal immobilization techniques

Immobilization of the spine is an important skill for all emergency providers. This article reviews the literature regarding the equipment, adjuncts, and techniques involved in spinal immobilization. Current prehospital practice is to apply spinal immobilization liberally in cases of suspected neck or back injury. Rigid cervical collars, long backboards, and straps remain the standard implements for immobilizing supine patients. Tape, foam blocks, and towels can complement the basic items and improve stability. Padding may improve positioning and comfort. Intermediate-stage devices include the short backboard and newer commercial devices. Properly used, all provide reasonable immobilization of the sitting patient. Future directions for study include refinement of optimal body position, dynamic performance of all devices, and broadening study populations to include children and the elderly.

How Shall We Train

ABSTRACT The prosecution of modern war and the competing missions of peacekeeping, humanitarian missions, and beneficiary care place great demands on the military medical system. Meeting the military medical training challenges of the new millennium requires the best trained and most experienced medical personnel possible. Various strategies for initial and sustainment (continuing) medical training are available to ensure that the medical force is ready for the next mission. Accredited programs both in and out of the military are the mainstay of training for both enlisted personnel and officers, with professional certification serving as the standard for competency. Clinical sustainment training can take place in military medical treatment facilities, civilian institutions, or a combination of the two. When direct patient care opportunities cannot provide the proper mixture of experiences to maintain certain skills, short courses, distance education, and patient simulators can play important roles. Becaus...

A proposed model for a residency experience in mass gathering medicine: The United States air show

STUDY OBJECTIVEnMass gathering medicine is an increasingly important responsibility for emergency physicians. A formal experience in mass gathering medicine can introduce emergency medicine residents to this aspect of community medicine.nnnDESIGNnEducational model based on field experience and retrospective chart review from 1981 through 1991.nnnSETTINGnThe US Air Show is a summer event that attracts an average of 223,000 spectators annually. Medical care is provided by physicians, nurses, and technicians operating within an organized system of care. Emergency medicine resident physicians (first-, second-, and third-year) evaluate and treat patients appropriate for the residents level of responsibility. Residents provide immediate medical control and are integrated into the event disaster plan. On-site attending physician supervision is available at all times. Didactic instruction and event orientation are integrated into the residency curriculum. Residents participate in the planning stages of the event.nnnRESULTSnDuring the study period, 2,091 patients were seen. The most common presenting problems were heat illness (28%), blisters and scrapes (25%), headaches (23%), fractures and lacerations (9%), and eye injuries (5%). One hundred forty-eight patients (7%) required transportation to the hospital. Approximately 16 residents participate each year and treat an average of 13.7 patients during their four-hour shift. A resident training model for a mass gathering experience is proposed to include adequate crowd size to generate useful patient volumes; a regularly scheduled event; organized medical and disaster preparations meeting local or published standards; didactic instruction on history, principles, and current issues; on-site attending supervision; degree of responsibility appropriate for training level; participation in planning and organizing the event; and postevent debriefing.nnnCONCLUSIONnA residency experience and training program in mass gathering medicine can introduce the principles of planning and providing care for crowds attending large public events.

Ethical Challenges in Emergency Medical Services: Controversies and Recommendations

Emergency Medical Services (EMS) providers face many ethical issues while providing prehospital care to children and adults. Although provider judgment plays a large role in the resolution of conflicts at the scene, it is important to establish protocols and policies, when possible, to address these high-risk and complex situations. This article describes some of the common situations with ethical underpinnings encountered by EMS personnel and managers including denying or delaying transport of patients with non-emergency conditions, use of lights and sirens for patient transport, determination of medical futility in the field, termination of resuscitation, restriction of EMS provider duty hours to prevent fatigue, substance abuse by EMS providers, disaster triage and difficulty in switching from individual care to mass-casualty care, and the challenges of child maltreatment recognition and reporting. A series of ethical questions are proposed, followed by a review of the literature and, when possible, recommendations for management.