Roy L. Alson

Patient-Data Collection System Used During Medical Operations After the 1994 San Fernando Valley-Northridge Earthquake

INTRODUCTION In large disasters, such as earthquakes and hurricanes, rapid, adequate, and documented medical care and distribution of patients are essential. METHODS After a major (magnitude 6.7 Richter scale) earthquake occurred in Southern California, nine disaster medical assistance teams and two Veterans Administration (VA) buses with VA personnel responded to staff four medical stations, 19 disaster-assistance centers, and two mobile vans. All were under the supervision of the medical support unit (MSU) and its supervising officer. This article describes the patient-data collection system used. All facilities used the same patient-encounter forms, log sheets, and medical treatment forms. Copies of these records accompanied the patients during every transfer. Centers for Disease Control and Prevention data classifications were used routinely. The MSU collected these forms twice each day so that all facilities had access to updated patient flow information. RESULTS Through the use of these methods, more than 11,000 victims were treated, transferred, and their cases tracked during a 12-day period. CONCLUSIONS Use of this system by all federal responders to a major disaster area led to organized care for a large number of victims. Factors enhancing this care were the simplicity of the forms, the use of the forms by all federal responders, a central data collection point, and accessibility of the data at a known site available to all agencies every 12 hours.

Disaster planning: the past, present, and future concepts and principles of managing a surge of burn injured patients for those involved in hospital facility planning and preparedness.

The 9/11 attacks reframed the narrative regarding disaster medicine. Bypass strategies have been replaced with absorption strategies and are more specifically described as “surge capacity.” In the succeeding years, a consensus has coalesced around stratifying the surge capacity into three distinct tiers: conventional, contingency, and crisis surge capacities. For the purpose of this work, these three distinct tiers were adapted specifically to burn surge for disaster planning activities at hospitals where burn centers are not located. A review was conducted involving published plans, other related academic works, and findings from actual disasters as well as modeling. The aim was to create burn-specific definitions for surge capacity for hospitals where a burn center is not located. The three-tier consensus description of surge capacity is delineated in their respective stratifications by what will hereinafter be referred to as the three “S’s”; staff, space, and supplies (also referred to as supplies, pharmaceuticals, and equipment). This effort also included the creation of a checklist for nonburn center hospitals to assist in their development of a burn surge plan. Patients with serious burn injuries should always be moved to and managed at burn centers, but during a medical disaster with significant numbers of burn injured patients, there may be impediments to meeting this goal. It may be necessary for burn injured patients to remain for hours in an outlying hospital until being moved to a burn center. This work was aimed at aiding local and regional hospitals in developing an extemporizing measure until their burn injured patients can be moved to and managed at a burn center(s).

Arteriolar and Systemic Autoregulatory Responses during the Development of Hypertension in the Spontaneously Hypertensive Rat

Abstract Pressure-flow curves were constructed to determine whether acute autoregulation in rat skeletal muscle was altered during the development of hypertension in the spontaneously hypertensive rat (SHR). Under chloralose:urethane anesthesia, hindlimb blood flow and pressure, plus diameter changes of gracilis muscle arterioles, were simultaneously measured in the 6- and 9-week Wistar-Kyoto (WKY) and SHR. Femoral blood flow was measured by electromagnetic flowmetry and hindlimb pressure controlled with an hydraulic occluder. Arteriolar diameters were measured using image shearing techniques. Acute autoregulatory capacity was assessed by comparing the closed-loop gain and the regression lines over the regulated and passive pressure ranges of the pressure-flow curves. The lower pressure limit of autoregulation (LPLAR) shifted upward as the blood pressure increased in the SHR with age; it did not shift in the WKY. Resting hindlimb flow, elevated in the SHR at 6 weeks, was also elevated at the LPLAR. At 9 weeks hindlimb blood flow was comparable in the WKY and SHR. As blood pressure was increased autoregulation was accompanied by vasoconstriction of gracilis arterioles. However, neither the gain of the autoregulatory system nor the regression lines describing the pressure-flow curves were different between the hypertensive and normotensive animals at either age. These results indicate that the acute autoregulatory response mechanism was not affected by the developing hypertension in the SHR, and is consistent with a structural basis for the chronic maintenance of the elevated peripheral vascular resistance.

Peripartum cardiomyopathy: A case report

Peripartum cardiomyopathy (PPCM) is a relatively rare form of acute heart failure. Onset is from the last trimester of pregnancy to 5 months postpartum. Diagnosis is made by excluding other causes of acute heart failure, such as infections or toxins, and by determining that the patient does not have an underlying cardiac problem that has been unmasked by pregnancy. Diagnosis in the last trimester is complicated by the fact that the early symptoms of this disorder may mimic the symptoms of normal pregnancy. PPCM must be considered in any patient who presents with new onset peripheral edema, dyspnea on exertion, or paroxysmal nocturnal dyspnea during late pregnancy or up to 5 months postpartum. Limited studies suggest that early and aggressive therapy is associated with a better outcome. Therapy is directed toward decreasing preload and improving cardiac function. Return of cardiac size to normal is associated with a better prognosis than continued cardiomegaly.

Mobile Versus Fixed Deployment of Automated External Defibrillators in Rural EMS

INTRODUCTION There is no consensus on where automated external defibrillators (AEDs) should be placed in rural communities to maximize impact on survival from cardiac arrest. In the community of Stokes County, North Carolina (USA) the Emergency Medical Services (EMS) system promotes cardiopulmonary resuscitation (CPR) public education and AED use with public access defibrillators (PADs) placed mainly in public schools, churches, and government buildings. HYPOTHESIS/PROBLEM This study tested the utilization of AEDs assigned to first responders (FRs) in their private-owned-vehicle (POV) compared to AEDs in fixed locations. METHODS The authors performed a prospective, observational study measuring utilization of AEDs carried by FRs in their POV compared to utilization of AEDs in fixed locations. Automated external defibrillator utilization is activation with pads placed on the patient and analysis of heart rhythm to determine if shock/no-shock is indicated. The Institutional Review Board of Wake Forest University Baptist Health System approved the study and written informed consent was waived. The study began on December 01, 2012 at midnight and ended on December 01, 2013 at midnight. RESULTS During the 12-month study period, 81 community AEDs were in place, 66 in fixed locations and 15 assigned to FRs in their POVs. No utilizations of the 66 fixed location AEDs were reported (0.0 utilizations/AED/year) while 19 utilizations occurred in the FR POV AED study group (1.27 utilizations/AED/year; P<.0001). Odds ratio of using a FR POV located AED was 172 times more likely than using a community fixed-location AED in this rural community. Discussion Placing AEDs in a rural community poses many challenges for optimal utilization in terms of cardiac arrest occurrences. Few studies exist to direct rural community efforts in placing AEDs where they can be most effective, and it has been postulated that placing them directly with FRs may be advantageous. CONCLUSIONS In this rural community, the authors found that placing AED devices with FRs in their POVs resulted in a statistically significant increase in utilizations over AED fixed locations.

America's Emergency Care Environment, A State-by-State Report Card:2014 Edition

Jon Mark Hirshon, MD, MPH, PhD, FACEP Report Card Task Force Chair Roy L. Alson, MD, PhD, FACEP David Blunk Douglas P. Brosnan, MD, JD, FACEP Stephen K. Epstein, MD, MPP, FACEP Angela F. Gardner, MD, FACEP Donald L. Lum, MD, FACEP Joshua B. Moskovitz, MD, MPH, FACEP Lynne D. Richardson, MD, FACEP Jennifer L. Stankus, MD, JD Paul D. Kivela, MD, FACEP, ACEP Board of Directors Liaison to the Task Force ACEP Staff

Deployable, portable, and temporary hospitals; one state's experiences through the years

This article will review the use of temporary hospitals to augment the healthcare system as one solution for dealing with a surge of patients related to war, pandemic disease outbreaks, or natural disaster. The experiences highlighted in this article are those of North Carolina (NC) over the past 150 years, with a special focus on the need following the September 11, 2001 (9/11) attacks. It will also discuss the development of a temporary hospital system from concept to deployment, highlight recent developments, emphasize the need to learn from past experiences, and offer potential solutions for assuring program sustainability. Historically, when a particular situation called for a temporary hospital, one was created, but it was usually specific for the event and then dismantled. As with the case with many historical events, the details of the 9/11 attacks will fade into memory, and there is a concern that the impetus which created the current temporary hospital program may fade, as well. By developing a broader and more comprehensive approach to disaster responses through all-hazards preparedness, it is reasonable to learn from these past experiences, improve the understanding of current threats, and develop a long-term strategy to sustain these resources for future disaster medical needs.

Air medical transport utilization review in North Carolina.

OBJECTIVE To perform a review of the collective experience of all hospital-based helicopter ambulances in the state of North Carolina for compliance with utilization review criteria. DESIGN Flight records of the six members of the North Carolina Aeromedical Affiliation for the months of November and December 1989 were compared with utilization review criteria by an independent reviewer. A secondary review was performed by a staff member for each service. Scene responses and patients flown to a hospital other than the sponsor were evaluated. SETTING All six hospital-based helicopter services in North Carolina. TYPE OF PARTICIPANTS All available flight records for November and December 1989. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 756 transports, 747 flight records were available for review. Initial review demonstrated compliance with the criteria for 713 (95.4%) patients; secondary review showed compliance for 18 of 34 flights not meeting initial review, for an overall compliance rate of 97.9%. Compliance rates for scene responses and transports taken to a hospital other than the sponsoring facility were 96.6% and 94.1%, respectively. CONCLUSIONS Review of all flights over a period of two-months by all six hospital-based helicopter services in North Carolina using utilization review criteria demonstrated a very high rate of compliance with the established criteria.

Prehospital Modified HEART Score Predictive of 30-Day Adverse Cardiac Events

Introduction The History, Electrocardiogram (ECG), Age, Risk Factors, and Troponin (HEART) score is a decision aid designed to risk stratify emergency department (ED) patients with acute chest pain. It has been validated for ED use, but it has yet to be evaluated in a prehospital setting. Hypothesis A prehospital modified HEART score can predict major adverse cardiac events (MACE) among undifferentiated chest pain patients transported to the ED. METHODS A retrospective cohort study of patients with chest pain transported by two county-based Emergency Medical Service (EMS) agencies to a tertiary care center was conducted. Adults without ST-elevation myocardial infarction (STEMI) were included. Inter-facility transfers and those without a prehospital 12-lead ECG or an ED troponin measurement were excluded. Modified HEART scores were calculated by study investigators using a standardized data collection tool for each patient. All MACE (death, myocardial infarction [MI], or coronary revascularization) were determined by record review at 30 days. The sensitivity and negative predictive values (NPVs) for MACE at 30 days were calculated. RESULTS Over the study period, 794 patients met inclusion criteria. A MACE at 30 days was present in 10.7% (85/794) of patients with 12 deaths (1.5%), 66 MIs (8.3%), and 12 coronary revascularizations without MI (1.5%). The modified HEART score identified 33.2% (264/794) of patients as low risk. Among low-risk patients, 1.9% (5/264) had MACE (two MIs and three revascularizations without MI). The sensitivity and NPV for 30-day MACE was 94.1% (95% CI, 86.8-98.1) and 98.1% (95% CI, 95.6-99.4), respectively. CONCLUSIONS Prehospital modified HEART scores have a high NPV for MACE at 30 days. A study in which prehospital providers prospectively apply this decision aid is warranted. Stopyra JP , Harper WS , Higgins TJ , Prokesova JV , Winslow JE , Nelson RD , Alson RL , Davis CA , Russell GB , Miller CD , Mahler SA . Prehospital modified HEART score predictive of 30-day adverse cardiac events. Prehosp Disaster Med. 2018;33(1):58-62.