The utility of point-of-care ultrasound in targeted automobile ramming mass casualty (TARMAC) attacks.

As terrorist actors revise their tactics to outmaneuver increasing counter-terrorism security measures, a recent trend toward less-sophisticated attack methods has emerged. Most notable of these "low tech" trends are the Targeted Automobile Ramming MAss Casualty (TARMAC) attacks. Between 2014 and November 2017, 18 TARMAC attacks were reported worldwide, resulting in 181 deaths and 679 injuries. TARMAC attack-related injuries are unique compared to accidental pedestrian trauma and other causes of mass casualty incidents (MCI), and therefore they require special consideration. No other intentional mass casualty scenario is the result of a blunt, non-penetrating trauma mechanism. Direct vehicle impact results in high-power injuries including blunt trauma to the central nervous system (CNS), and thoracoabdominal organs with crush injuries if the victims are run over. Adopting new strategies and using existing technology to diagnose and treat MCI victims with these injury patterns will save lives and limit morbidity. Point-of-care ultrasound (POCUS) is one such technology, and its efficacy during MCI response is receiving an increasing amount of attention. Ultrasound machines are becoming increasingly available to emergency care providers and can be critically important during a MCI when access to other imaging modalities is limited by patient volume. By taking ultrasound diagnostic techniques validated for the detection of life-threatening cardiothoracic and abdominal injuries in individuals and applying them in a TARMAC mass casualty situation, physicians can improve triage and allocate resources more effectively. Here, we revisit the high-yield applications of POCUS as a means of enhanced prehospital and hospital-based triage, improved resource utilization, and identify their potential effectiveness during a TARMAC incident.

District of Columbia Emergency Healthcare Coalition Burn Mass Casualty Plan: Development to Exercise Date.

The District of Columbia Emergency Healthcare Coalition (DC EHC) brought together a Burn Task Force to tackle the issue of mass burn care in a metropolitan area in light of limited local burn center resources. This article outlines the development of the mass burn care plan. Using a tiered treatment approach, mass burn victims would be transported first to burn centers within the area, followed by nonburn center trauma centers, and finally to nonburn and nontrauma center acute care facilities. Once activated the Burn Task Force would triage and coordinate transfer of mass burn patients within the District for further care at burn centers using a strong link with the Eastern Regional Burn Disaster Consortium. This plan was exercised in the spring of 2014 to test all of the components. To strengthen mass burn care, this plan, put in place for the District of Columbia, has been expanded to include the National Capital Region as well.

A proposed emergency management program for acute care facilities in response to a highly virulent infectious disease.

To address the organizational complexities associated with a highly virulent infectious disease (HVID) hazard, such as Ebola Virus Disease (EVD), an acute care facility should institute an emergency management program rooted in the fundamentals of mitigation, preparedness, response, and recovery. This program must address all known facets of the care of a patient with HVID, from unannounced arrival to discharge. The implementation of such a program not only serves to mitigate the risks from an unrecognized exposure but also serves to prepare the organization and its staff to provide for a safe response, and ensure a full recovery. Much of this program is based on education, training, and infection control measures along with resourcing for appropriate personal protective equipment which is instrumental in ensuring an organized and safe response of the acute care facility in the service to the community. This emergency management program approach can serve as a model in the care of not only current HVIDs such as EVD but also future presentations in our healthcare setting.

Confined space medicine and the medical management of complex rescues: a case series.

OBJECTIVE: A variety of hazards can precipitate the full or partial collapse of occupied structures. The rescue of entrapped survivors in these situations can be complex, require a multidisciplinary approach, and last for many hours. METHODS: The modern discipline of Urban Search and Rescue, which includes an active medical component, has evolved to address such situations. This case series spans several decades of experience and highlights the medical principles in the response to collapsed structure incidents. RESULTS: Recurring concepts of confined space medicine include rescuer safety, inter-disciplinary coordination, patient protection, medical resuscitation in austere environments, and technical extrications. CONCLUSION: Strategies have been developed to address the varied challenges in the medical response to collapsed structure incidents.

Patient-driven resource planning of a health care facility evacuation.

INTRODUCTION: The evacuation of a health care facility is a complex undertaking, especially if done in an immediate fashion, ie, within minutes. Patient factors, such as continuous medical care needs, mobility, and comprehension, will affect the efficiency of the evacuation and translate into evacuation resource needs. Prior evacuation resource estimates are 30 years old. METHODS: Utilizing a cross-sectional survey of charge nurses of the clinical units in an urban, academic, adult trauma health care facility (HCF), the evacuation needs of hospitalized patients were assessed periodically over a two-year period. RESULTS: Survey data were collected on 2,050 patients. Units with patients having low continuous medical care needs during an emergency evacuation were the postpartum, psychiatry, rehabilitation medicine, surgical, and preoperative anesthesia care units, the Emergency Department, and Labor and Delivery Department (with the exception of patients in Stage II labor). Units with patients having high continuous medical care needs during an evacuation included the neonatal and adult intensive care units, special procedures unit, and operating and post-anesthesia care units. With the exception of the neonate group, 908 (47%) of the patients would be able to walk out of the facility, 492 (25.5%) would require a wheelchair, and 530 (27.5%) would require a stretcher to exit the HCF. A total of 1,639 patients (84.9%) were deemed able to comprehend the need to evacuate and to follow directions; the remainder were sedated, blind, or deaf. The charge nurses also determined that 17 (6.9%) of the 248 adult intensive care unit patients were too ill to survive an evacuation, and that in 10 (16.4%) of the 61 ongoing surgery cases, stopping the case was not considered to be safe. CONCLUSION: Heath care facilities can utilize the results of this study to model their anticipated resource requirements for an emergency evacuation. This will permit the Incident Management Team to mobilize the necessary resources both within the facility and the community to provide for the safest evacuation of patients.

Extreme measures: field amputation on the living and dismemberment of the deceased to extricate individuals entrapped in collapsed structures.

Collapsed structures, typically as a result of earthquakes, may result in individuals entrapped by their limbs under heavy structural elements. In addition, access to living persons may be blocked by the deceased. Individuals are often critically ill by the time they are found, and rapid extrication is warranted. This and other factors may necessitate field amputation of an extremity on a living person or dismemberment of the deceased to achieve a rescue. Although case reports have described industrial, mining, and transportation accidents, few discuss this potential in collapsed structures. Also, few specifically outline the indications or the decision process and associated administrative procedures that should be addressed before conducting these procedures. This report presents a review of the literature along with a limited case series. A discussion regarding relevant decision making is provided to encourage the development of protocols. An international consensus statement on these procedures is provided.

Emergency medicine Joint Fellowship Curriculum.

BACKGROUND: The authors describe a Joint Fellowship Curriculum instituted for emergency medicine fellows in diverse fellowships. The curriculum is based on commonalities established among the varying fellowships offered within their Department of Emergency Medicine. Fellowships included in the curriculum development include Disaster/Emergency Medical Services, International Emergency Medicine, Health Policy, Ultrasonography, and Medical Toxicology. OBJECTIVES: The focus of this educational activity is to promote the development of the fellow into an expert within their field of specialization. DISCUSSION: Recognizing that topics such as scholarly activities, career development, clinical practice of medicine, business of medicine, and personal development are universally applicable to a variety of emergency medicine fellowships, the curriculum attempts to provide uniform instruction. The quality and applicability of this instruction was assessed and found to have been very well received by the participating fellows. CONCLUSION: The authors encourage academic emergency medicine departments with a number of fellowship training opportunities to consider providing such a uniform curriculum of instruction as well.

H1N1 preventive health behaviors in a university setting.

BACKGROUND: When H1N1 emerged in 2009, institutions of higher education were immediately faced with questions about how best to protect their community from the virus, yet limited information existed to help predict student preventive behaviors. METHODS: The authors surveyed students at a large urban university in November 2009 to better understand how students perceived their susceptibility to and the severity of H1N1, which preventive behaviors they engaged in, and if policies impacted their preventive health decisions. RESULTS: Preventive health behavior messaging had a mixed impact on students. Students made simple behavior changes to protect themselves from H1N1, especially if they perceived a high personal risk of contracting H1N1. Although policies were instituted to enable students to avoid classes when ill, almost no student self-isolated for the entire duration of their illness. CONCLUSIONS: These findings can help inform future decision making in a university setting to best influence preventive health behaviors.

Survival interval in earthquake entrapments: research findings reinforced during the 2010 Haiti earthquake response.

Earthquakes can result in collapsed structures with the potential to entrap individuals. In some cases, people can survive entrapment for lengthy periods. The search for and rescue of entrapped people is resource intensive and competes with other postdisaster priorities. The decision to end search and rescue activities is often difficult and in some cases protracted. Medical providers participating in response may be consulted about the probability of continued survival in undiscovered trapped individuals. Historically, many espouse a rigid time frame for viability of entrapped living people (eg, 2 days, 4 days, 14 days). The available medical and engineering data and media reports demonstrate a wide variety in survival "time to rescue," arguing against the acceptance of a single time interval applicable to all incidents. This article presents historical evidence and reports from the 2010 Haiti earthquake. Factors that may contribute to survival after entombment are listed. Finally, a decision process for projecting viability that considers the critical factors in each incident rather than adhering to a single time frame for ceasing search and rescue activities is proposed.

Accuracy of radiographic readings in the emergency department.

OBJECTIVES: A review of radiology discrepancies of emergency department (ED) radiograph interpretations was undertaken to examine the types of error made by emergency physicians (EPs). METHODS: An ED quality assurance database containing all radiology discrepancies between the EP and radiology from June 1996 to May 2005 was reviewed. The discrepancies were categorized as bone, chest (CXR), and abdomen (AXR) radiographs and examined to identify abnormalities missed by EPs. RESULTS: During the study period, the ED ordered approximately 151 693 radiographs. Of the total, 4605 studies were identified by radiology as having a total of 5308 abnormalities discordant from the EP interpretation. Three hundred fifty-nine of these abnormalities were not confirmed by the radiologist (false positive). The remainder of the discordant studies represented abnormalities identified by the radiologist and missed by the EP (false negatives). Of these false-negative studies, 1954 bone radiographs (2.4% of bone x-rays ordered) had missed findings with 2050 abnormalities; the most common missed findings were fractures and dislocations. Of the 220 AXRs (3.7% of AXRs ordered) with missed findings, 240 abnormalities were missed; the most common of these was bowel obstruction. Of the 2431 CXRs (3.8% of CXRs ordered), 2659 abnormalities were missed; the most common were air-space disease and pulmonary nodules. The rate of discrepancies potentially needing emergent change in management based solely on a radiographic discrepancy was 85 of 151 693 x-rays (0.056%). CONCLUSIONS: Approximately 3% of radiographs interpreted by EPs are subsequently given a discrepant interpretation by the radiology attending. The most commonly missed findings included fractures, dislocations, air-space disease, and pulmonary nodules. Continuing education should focus on these areas to attempt to further reduce this error rate.

Assessing physicians' in training attitudes and behaviors during the 2009 H1N1 influenza season: a cross-sectional survey of medical students and residents in an urban academic setting.

BACKGROUND: Despite concern for hospital-based transmission of influenza, little research has been carried out on perceptions and behaviors of physicians in training with regard to influenza-like illness (ILI), especially in light of the recent H1N1 pandemic. OBJECTIVES: We aimed to evaluate self-reported episodes of ILI among medical students and residents to determine the impact of ILI on school and clinical performance, absenteeism, and patterns of preventive measures used by this population both in and out of the healthcare setting. METHODS: We anonymously surveyed medical students and residents at an urban institution between November 3 and December 11, 2009. Data were analyzed separately for medical students and residents for frequency of close-ended responses. Open-ended answers were analyzed thematically. Our Institutional Review Board exempted this study from review. RESULTS: Forty-five percent of medical students and 53% of resident respondents perceived the risk of acquiring H1N1 at school or work as high, and although 43% of medical students and 66% of resident respondents had received the influenza vaccination and most reported increasing non-pharmaceutical preventive measures, 9% of medical students and 61% of residents with one or more episodes of ILI chose to continue to attend class or work when ill. CONCLUSIONS: Although students and residents report high risk of infection because of work- or school-related activities, many involved in patient care activities do not comply with recommended infection control precautions. Educational campaigns should be developed and infection control guidelines should be included in routine medical student and resident curricular activities.

H1N1 and institutions of higher education.

OBJECTIVE: Institutions of Higher Education (IHE) have been preparing for the likely resurgence of Influenza A (H1N1) virus this Fall. Amongst the multitude of factors affecting their preparatory efforts, medical considerations and evidence serve to provide the foundation for many planning decisions. DESIGN: The authors reviewed the relevant medical literature for evidence of effective measures to mitigate the consequences of H1N1. Evidence was reviewed as it pertains to IHE. The authors opted to focus on vaccination, antiviral medications, masks, hand washing, environmental cleaning, and isolation and quarantine. RESULTS: Despite the limited evidence found for the IHE setting, recommendations were made to encourage vaccination, deemphasize the role of antivirals in most IHE students, and provide surgical masks for ill students, as they may leave their living environment, while simultaneously stressing self isolation without quarantine. Additionally, frequent hand washing and high traffic fomite cleaning should be encouraged. CONCLUSION: Preparation for pandemic influenza in the IHE context is very complex and all decisions should be based on the best evidence available.

Financial burden of emergency preparedness on an urban, academic hospital.

This study assessed the direct human resource costs of a hospital's emergency preparedness planning (in 2005) by surveying participants retrospectively. Forty participants (74% of the identified population) were surveyed. Using the self-reported hourly salary of the participant, a direct salary cost was calculated for each participant. The population was 40% male and 60% female; 65% had a graduate degree or higher; 65% were administrators; 35% were clinicians; and 50% reported that their job description included a reference to emergency planning activities. All participants spent a combined total of 3,654.25 hours on emergency preparedness activities, including 20.1% on personal education/training; 11.6% on educating other people; 39.3% on paperwork or equipment maintenance; 22.2% on attendance at meetings; 5.6% on drill participation; and <1% on other activities. Considering the participants' hourly salary, direct personal costs spent on emergency preparedness activities at the institution totaled US$232,417.Ten percent, all of whom were physicians, reported no compensation for their emergency preparedness efforts at the hospital level. As much as these results illustrate the strong commitment of the institution to its community, they represent a heavy burden in light of the often unfunded mandate of emergency preparedness planning that a hospital may incur. Such responsibility is carried to some extent by all hospitals.

The financial impact of deployments on reserve health care providers.

This study retrospectively surveyed the financial impact of deployments on 17 U.S. Army Reserve health care providers. Due to multiple mobilizations, 29 separate deployments were reported. The deployments, mostly between 2001 and 2005, typically lasted 3 months during which 86% reported no civilian income and 76% reported no civilian benefits. Solo practice providers reported the greatest financial losses due to continuing financial responsibility related to their civilian practice despite being deployed. Overall, 2 deployments did not change, 9 increased, and 16 decreased the medical officer's income. Two were not reported. In this small retrospective convenience sample study, solo practice U.S. Army Reserve health care providers were found to be at highest risk of financial losses during military deployments. This being said, no price can be put on the privilege of serving our men and women in uniform.

Ketamine for procedural sedation and analgesia by nonanesthesiologists in the field: a review for military health care providers.

Military health care providers located in field environments frequently face situations in which procedural sedation and analgesia are necessary, without the advantage of sophisticated monitoring equipment. Ketamine is a unique agent that can be administered either intravenously or intramuscularly to produce predictable and profound analgesia, with an exceptional safety profile. We review the issues unique to ketamine and provide a practical guide for the use of ketamine for adult and pediatric patients in a field environment.