O conhecimento da aplicação dos métodos de triagem em incidentes com múltiplas vítimas no atendimento pré-hospitalar / The knowledge of the application of screening methods in incidentswith multiple victims in pre-hospital care / El conocimiento de la aplicación de los métodos de triagen en incidentes con múltiplas víctimas en la atención pre-hospitalaria

Trata-se de um estudo exploratório descritivo de abordagem quantitativa, realizado na cidade de Sobral/CE com profissionais de um serviço pré-hospitalar, objetivando descrever o conhecimento sobre métodos de triagem em incidentes com múltiplas vítimas. Teve como amostra (n=30) de participantes entre médicos, enfermeiros e técnicos de enfermagem. Como método de coleta de dados, foi desenvolvido um formulário on-line por meio de uma plataforma digital para condensar e analisar os dados. Identificou-se por meio deste estudo uma percepção limitada expressa pelos profissionais quanto a vivência e o nível de conhecimento acerca dos métodos de triagem em incidentes com múltiplas vítimas. Apenas 50% dos casos apresentados em um teste simulado elaborado para o estudo tiveram resolubilidade aceitável. Diante dos achados sugere-se o fomento de um programa especifico de treinamento na ótica da educação permanente, assim como, a construção de atividades intersetoriais para a projeção de um plano de resposta frente a evento evolvendo múltiplas vítimas.(AU)

This is na exploratory descriptive study with a quantitative approach, carried out in the city of Sobral / CE with professionals from a prehospital service, aiming to describe the know ledge about methods of screening in multiple victim incidents. A sample of participants (n = 30) was among physicians, nurses and nursing technicians. As a methodof data collection, an online form was developed through a digital platform to condense and analyze the data. We identified through this study a limited perception expressed by the professionals regarding the experience and thel evelof know ledge about the methods of triage in incidentes with multiple victims. Only 50% of the cases presented in a simulated test prepared for the study had acceptable resolubility. In view of the findings, it is suggested the development of a specific training program in the perspective of permanente education, as well as the construction of intersectoral activities to project a response planto an eventinvolving multiple victims.(AU)

Se trata de um estúdio exploratório descriptivo de abordaje cuantitativo, realizado em la ciudad de Sobral / CE com profesionales de um servicio prehospitalario, conel objetivo de describir el conocimiento sobre métodos de clasificaciónen incidentes com múltiples víctimas. Se tuvo como muestra (n = 30) de participantes entre médicos, enfermeros y técnicos de enfermería. Como método de recolección de datos, se há desarrollado un formulário en línea a través de una plataforma digital para condensar y analizarlos datos. Se identificó por medio de este estudio una percepción limitada expresada por los professional es encuanto a la vivencia y el nivel de conocimiento acerca de los métodos de clasificación en incidentes com múltiples víctimas. Sóloel 50% de los casos presentados en una prueba simulada elaborada para el estúdio tuvieron una resolución aceptable. Ante los hallazgos se sugere el fomento de un programa específico de entrenamiento em la óptica de la educación permanente, así como la construcción de atividades intersectoriales para la proyección de unplan de respuesta frente al evento evolucionando múltiples víctimas.(AU)

La asistencia sanitaria a los heridos y enfermos del exilio republicano español en Francia: de la improvisación inicial a los campos de concentración (enero-septiembre 1939) / Healthcare to wounded and sick refugees in the spanish republican exile in france: from the initial improvisation to the concentration camps (january-september 1939)

El final de la Guerra Civil Española en Cataluña supuso un punto de inflexión en la vida de casi medio millón de refugiados españoles que traspasaron la frontera pirenaica en el invierno de 1939. En este gran afluente, existieron más de 13.000 heridos y enfermos que tuvieron que ser atendidos por toda la geografía francesa. Con esta investigación, se visibiliza cuáles fueron los itinerarios de los heridos, dónde fueron atendidos y qué características tuvo la asistencia sanitaria hasta que la mayoría de los pacientes fueron reconducidos a campos de concentración situados en el sur de Francia. Nos encontramos ante una realidad compleja que ha sido abordada con documentación localizada en una docena de archivos históricos franceses, testimonios directos y prensa general. Entre los resultados, cabe destacar la necesidad de improvisación de la III República Francesa en materia asistencial, ya que el 70% de los refugiados fueron asistidos en centros acondicionados para la ocasión. En los hospitales, quienes atendieron fueron en su mayoría profesionales sanitarios españoles. Realizaron su labor de una manera digna, a pesar de las restricciones de las autoridades francesas hacia lo que ellos consideraron "el problema español"

The end of the Spanish Civil War in Catalonia influenced the lives of almost half a million of Spanish refugees that crossed the Pyrenean border in the winter of 1939. In this large migration wave, more than 13,000 wounded and sick people had to be treated within French territory. With this research, we examine the routes of the wounded, the places where they were treated, and the features of their healthcare before they were transported to the concentration camps in southern France. This information has been analysed using documentation of 12 French historical archives, direct testimonials and general press. The results emphasize the Third French Republic’s ability to improvise in the healthcare field, where 70% of the refugees were treated in specially equipped healthcare centres. Those who treated refugees in hospitals were mostly Spanish healthcare professionals. They carried out their work in a dignified manner, despite restrictions from French authorities towards what they considered to be "the Spanish problem"

Los primeros heridos y enfermos evacuados por vía aérea en España por la Aeronáutica Militar (1923-1927). 95º aniversario del comienzo de la Aviación Sanitaria española / The First Casualties and Patients Air Evacuated by the Spanish Military Aeronautics (1923-1927). 95th Anniversary of the Beginning of Spanish Medical Aviation

La Aviación Sanitaria comenzó en nuestro país con la adquisición por parte de la Aeronáutica Militar de los primeros aviones específicos para el transporte sanitario a finales del año 1922. El desarrollo de esta actividad aeronáutica-sanitaria se realizó en los países europeos en la década de los años 20 para satisfacer las necesidades de evacuación de los heridos graves en sus distintas guerras, sobre todo las coloniales. Durante estos años el avance de las aplicaciones de la recién nacida Aviación eran imparables en todos los campos. En España los datos de la actividad de la evacuación sanitaria de estos primeros años han sido confundidos ya que no fueron recogidos de forma sistemática. Gracias al estudio de fuentes primarias de archivos militares y de la Cruz Roja Española hemos podido analizar por primera vez los datos de la actividad de los primeros aviones que realizaron transporte de heridos en la guerra de Marruecos durante los años 1923 a 1927. Esta experiencia sanitaria nos equipararía a los países europeos más desarrollados y se correspondería con el interés científico mostrado en España por este nuevo método de transporte. En el presente año se cumple el 95º aniversario del comienzo de esta actividad fundamental en la medicina militar y de urgencia por lo que queremos rendir un homenaje con la divulgación del trabajo que realizaron durante esos años

Medical aviation started in Spain with the acquisition on the part of Military Aeronautics of the first aircraft specifically designed for medical transport by the end of 1922. The development of this aeronautical-medical activity was carried out in the European countries during the 1920s to meet the needs of evacuation of those casualties severely injured in different wars, particularly in the colonies. In those days, the improvement of the newly-born aviation was unstoppable in all fields. In Spain, the data regarding the medical evacuation of these first years are very confused for they were not gathered in a systematic way. Thanks to the study of different primary sources of the military and the Spanish Red Cross archives, a complete analysis of the data regarding the activity of the first planes which transported casulaties during the Morocco War (1923-1927) has been performed for the first time. This medical experience equates our country with the most developed European countries and it corresponds to the scientific interest proved in Spain towards this mean of transport. The 95th anniversary of the beginning of this activity, termed as fundamental in emergency and medical medicine, is celebrated this year. From these pages, the authors wish both to contribute to the dissemination of the activity carrried out by the military professionals of the time and to pay them a well- deserved homage

Propuesta de tarjeta triaje en incidentes NBQ con múltiples heridos / Proposal of Triage Tag in NBQ Multi-Casualty Incidents

INTRODUCCIÓN: La amenaza por un incidente nuclear, químico o biológico (NBQ) es una preocupación que aumenta progresivamente en nuestra sociedad actual. El porcentaje de heridos en este tipo de sucesos puede ser potencialmente muy elevada. El triaje de éstos debe estar bien estructurado y adaptado a las distintas áreas de zonificación. OBJETIVO: El principal objetivo es presentar dos nuevas herramientas de diseño propio que sirvan para realizar el triaje de los heridos en escenarios NBQ con múltiples heridos. La primera de ellas es la «tarjeta triaje NBQZC» y está diseñada para su utilización en la zona contaminada. La segunda es la «tarjeta triaje NBQZNC», la cual se emplea en la zona no contaminada. Ambas están creadas para su utilización en zona de operaciones, siendo fáciles de interpretar y de cumplimentar. CONCLUSIONES: Se exponen dos tarjetas de triaje de heridos NBQ de aplicación en el ámbito militar

INTRODUCTION: Nuclear, Chemical or Biological incident's threat is a concerning issue progressively increasing in our society. In these events injures' percentage potentially might be very high. Casualties' Triage has to be well structured and adapted to the different zoning areas. OBJECTIVE: The main goal is to introduce two new own design tools assisting in the performance of CBRN triage in a Major Incident. The first one is «Triage Tag NBCZC» and it is accomplished in the contaminate zone. The second one is «Triage Tag NBCNZC» and it is filled in the not contaminate area. Both of them are created to be executed in an Area of Operations and their interpretation and completion can be made easily. CONCLUSION: Two news Triage Tag CBRN casualties are showing available to a military scene

Health Services Responses to Disasters in Numbai Sharing Experiencies

In mass disaster situations, demands frequently exceed the capacity of personnel and facilities. In the last few years, there has been an increased incidence of civil disasters; the spectrum of possible catastrophes has also dramatically increased as a result of an increasingly technologically sophisticated society. During the las 15 years, varied terrorist activities have become increasingly common as expressions of the opinions of extreme political groups, especially in India. In Mumbai itself, we have witnessed disasters such as widespread riots, terrorist bomb blasts, floods, and fires. There have been other disasters in India, such as earthquakes, floods, cyclones, as well as tsunamis. Though most of the hospitals in India manage the medical problems associated with these disasters fairly efficiently, an analysis of the situation is presented so that this may from the basis fo future planning in disaster preparedness and provide a template for other communities that may want to implement preparedness protocols. We present our experience with disaster management in Mumbai, India. A successful medical response to multi-injury civilian disaster, either natural or manmade, dictates formulation, dissemination, and periodic assessment of a contingency plan to facilitate the triage and treatment of victims of disaster. (AU)

Atención sanitaria en acontecimientos colectivos de larga duración: ¿sirve el modelo de la Exposición de Sevilla’92 para la de Zaragoza’08? / Medical care at long duration mass gatherings: is the model from the Seville Expo’92 useful for the Saragossa Expo’08?

Introducción: Los acontecimientos colectivos constituyen situaciones de riesgo previsible que precisan un modelo asistencial sanitario integral, especialmente aquéllos que por su prolongada duración requieren evitar repercusiones sobre el sistema autóctono. Presentamos la planificación, gestión y resultados del dispositivo desarrollado para la cobertura de la Exposición Universal de Sevilla (EXPO’92).Método: Analizados los datos de exposiciones previas, se estimó una demanda de escasa complejidad –ante la previsión de una población joven y sana de espectadores–con una frecuentación entre 1,8-2,4 asistencias por 1.000 visitas, 97% de capacidad resolutiva y 2% de derivaciones hospitalarias, para lo que se construyeron un centro principal(CAP) –con zonas de estabilización y observación– y cinco unidades periféricas, situadas estratégicamente en las proximidades de los pabellones o áreas más conflictivas. Se prepararon también los hospitales para las evacuaciones, especialmente los privados concertados, y distintos operativos para emergencias colectivas. Resultados: Se asistieron 82.748 casos en los 176 días de la Muestra, con una media de470 (rango 211-760), frecuentación 1,98/‰. El 92,5% fueron consideradas leves, el82,1% en pacientes entre 10 y 49 años (sólo 6,8% mayor de 60 años), el 56,9% en mujeres, el 64,7% la causa principal fue enfermedad y el 30,4% accidente casual, el 68,5% fueron visitantes y el 30,7% fueron trabajadores, el 82% fueron españoles. Los sábados fueron los días de mayor intensidad y la traumatología leve la patología más frecuente(32,7%). Ingresaron en el CAP 1.726 pacientes (9,8 al día, 2,08% de los asistidos), con 91minutos de estancia media, y el 30,8% eran mayores de 50 años. Se evacuaron 552 enfermos, e ingresaron 222 en planta convencional y 61 en intensivos. Fallecieron 2 enfermos en el recinto y 6 más en los hospitales. El plan de emergencias se activó en 47 ocasiones. Discusión y conclusiones: La ubicación específica de los dispositivos asistenciales favoreció la atención inmediata, y la gestión diferenciada de los más graves en las distintas áreas del CAP facilitó su manejo especializado. El número de consultas y su escasa complejidad, la capacidad resolutiva y la tasa de derivaciones a hospitales estuvieron acordes con las previsiones realizadas, rubricadas con una frecuentación muy baja(2‰). La existencia de patología crítica para estabilizar obliga, no obstante, a disponer de presencia continuada de facultativos especialistas en Medicina de Urgencias y Emergencias. Este modelo es perfectamente exportable a otros eventos de larga duración, como la próxima Exposición de Zaragoza 2008 (AU)

Introduction: Long duration mass gatherings involve possible risks. To avoid negative consequences to the local healthcare system an inclusive medical attention model should be established in this setting. We present the planning, management and results obtained from the emergency medical system developed for the coverage of the Universal Exhibition of Seville (EXPO’92).Methodology: after analyzing the data of previous exhibitions we forecasted that the complexity of the demand for health care would be low. The prediction was for a young and healthy crowd of spectators, a frequentation ratio between1.8-2.4 consultations per 1,000 visitors with a 97% problem solving capacity, and a 2% hospital remission rate. Considering those circumstances a primary care center (PCC), including stabilization and observation areas, and five peripheral units located strategically near the pavilions or more dangerous areas were built. Results: During the 176 days of the EXPO’92 82,748 people received medical attention (470 people/day [range 211-760]) and the frequentation ratio was 1.98/1,000. Among the cases assisted 92.5% were mild, 82.1% of patients were10-49 years old, only 6.8% were > 60 years old, and 56.9% were women. The cause of seeking attention was significant disease in 64.7%, and accidental injury in 30.4%. Among all cases 68.5% were visitors, 30.7% workers, and 82%Spaniards. Saturdays were the days with the highest level of work intensity and the most frequent pathology was mild trauma (32.7%). 1,726 patients were assisted at the PCC (9.8 per day, 2.08% of all the people who needed assistance);mean length of stay was 91 minutes and 30.8% were older than 50 years. Among the 552 patients evacuated222 were hospitalized and 61 admitted to the ICU. Two patients died in the EXPO’92 area and 6 more at the hospital. Discussion and conclusions: The specific location of the emergency care system made immediate attention of patients possible. Different management of the most seriously ill at the different PPC areas facilitated specific treatment. The number of consultations, their low complexity, the solving capacity and the amount of people remitted to hospitals met our expectations, in conjunction with a very low frequentation (0.2%). The existence of critical pathology, however, required constant presence of Emergency Medicine experts. This model is perfectly exportable to other events, such as the next Saragossa EXPO’08 (AU)

Airway Management During a Mass Casualty Event

Mass casualty respiratory failure will lead to many challenges, not the least of which is safe and secure management of the victims ariways. These patients will be sicker than those typically managed in the operating room and will requiere more emergency management fo their ariways. Mass casualty incidents involving biological or chemical agents will pose the addittional risk of exposure to pathogen. During the severe acute respiratory syndrome epidemic in Toronto, airway manipulation was clearly identified as the procedure most associated with risk to health care workers. Planning for scenarios such as these will require consideration of personal protection for health care workers to minimize these risks. Understanting the risk involved and the airway techniques required for each possible scenario will be key to planning and preparation. (AU)

Ethical Issues in Resource Triage

Mass-care events, such as pandemic influenza, could reach such devasting proportions that there will be the need to make difficult triage decisions that will ultimately result in the deaths or severe disability of patients in large numbers. The method by wich we determine how triage of scarce health care resources will be performed must be clearly defined prior to a disaster event. This paper will discuss several of the ethical principles that must be weighed in developing a mass-care triage plan, as well as steps to facilite its implementation. Development of triage policies in such an event should be developed in an open and transparent manner, be reasonable in design, include the views of the critial stakeholders, and be responsive to and provide a mechanism for accountability, with a clearly defined goal of the just triage of limited health care resources. Planning failure will result in increased deaths from poor triage processes and substantial mistrust of the health care system and ist practitioners. (AU)

Oxygen Supplies During a Mass Casualty Situation

Mass casualty and pandemic events pose a substantial challege to the resources available in our current health care system. The ability to provide adequate oxygen therapy is one of the systems that could be out-stripped in certain conditions. Natural disasters can disrupt manufacturing or delivery, and pandemic events can increase consumption beyond the available supply. Patients may require manual resuscitation, basic oxygen therapy, or positive-pressure ventilation during these scenarios. Available sources of oxygen include bulk liquid oxygen systems, compressed gas cylinders, portable liquid oxygen (LOX) systems, and oxygen concentrators. The last two are available in a variety of configurations, which include personal and home systems that are suitable for individual patients, and larger systems that can provide oxygen to multiple patients or entire institutions. Bulk oxygen system are robust and are probably sustainable during periods of high consumption, but are at risk if manufacturing or delivery is disrupted. Compressed gas cylinders offer support during temporary periods of need but are no a solution for extended periods of therapy. Personal oxygen concentrators and LOX systems are limited in their application during mass casualty scenarios. Large-capacity oxygen concentrators and LOX system may effectively provide support to alternative care sites or large institutions. They may also be appropriate selections for governmental emergency-response scenarios. Careful consideration of the strengths and limitations of each of these options can reduce the impact of a mass casualty event. (AU)

Mechanical Ventilation in Mass Casualty Scenarios: Augmenting Staff: Project XTREME

Disaster preparedness typically includes plans that address the need for surge capacity to manage mass-casualty events. A major concern of disaster preparedness in respiratory therapy focuses on responding to a sudden increase in the volume of patients who require mechanical ventilation. Plans for such disasters must include contingencies to address surge capacity in ventilator inventories and the respiratory therapy staff who will manage the ventilators. Tactics to address these situations include efforts to lower demand by transferring patients to other institutions as well as efforts to augment staffing levels. Staff can be augmented by mobilization of deployable teams of volunteers from outside the region and through exploitation of local resources. The latter includes strategies to recruit local respiratory therapists who are currently in either non-clinical or non-hospital-based positions and policies that optimize existing respiratory therapy resources within an institution by canceling elective surgeries, altering shift structure, and postponing vacactions. An alternative approach would employ non-respiratory-therapy staff to assist in the management of patients with respiratory failure. Project XTREME (Cross-Training Respiratory Extenders for Medical Emergencies) is a cross-training program developed to facilitate training of non-respiratory-therapy health professionals to assist in the management of patients who require mechanical ventilation. It includes an interactive digital video disc as well as a competency validation laboratory and is designed to be performed at the time of an emergency. Pilot testing of the program suggests it is effective. (AU)

Modified Critical Care and Treatment Space Considerations for Mass Casualty Critical Illness and Injury

Mass critical care events are increasingly likely, yet the resource challenges to augment everyday, unrestricted critical care for a surge of disaster victims are insurmountable for nearly all communities. In light of these limitations, an expert panel defined a circumscribed set of key critical are interventions that they believed could be offered to many additinal people and yet would also continue to offer substantial life-sustaining benefits for nommribund critically ill and injured people. They proposed Emergency Mass Critical Care, wich is based in the set of key interventions and includes recommendations for necessary surge medical equipment, treatment space characteristics, and staffing competencies for mass critical care response. To date, Emergency Mass Critical Care is untested, and the real benefits of implementation remain uncertain. Nonetheless, Emergency Mass Critical Care currently remains the only comprehensive construct for mass critical care preparedness and response. This paper reviews current concepts to provide life-sustaining care for hundreds or thousands of people outside of traditional critical care sites.

Severe Febrile Respiratory Illnesses As a Cause of Mass Critical Care

Febrile respiratory illnesses with respiratory failure are one of the most common reasons for admission to the intensive care unit. Most causes of febrile respiratory illness are bacterial and viral agents of community-acquired pneumonia. However, a small number of rare and higly contagious agents can initially present as febrile respiratory illnesses, which can lead to an epidemic that can greatly impact the health care system. This impact includes sustained mass critical care, with potential scarcity of critical resources (eg, positive-pressure ventialtors), spread of disease to health care workers, sustained spread within the community, and extensive morbidity and mortality. The main agents of febrile respiratory illness that would lead to an epidemic include influenza, the coronavirus that causes severe acute respiratory syndrome, smallpox, viral hemorragic fever, plague, tularemia, and anthrax. Recognition of these agents ocuurs largely based on epidemiological clues, and management consistis of antibiotics, antivirals, supportive care, and positive-pressure ventilation. Acute respiratory failure and acute respiratory distress syndrome occur with these agents, so a lung-protective (low tidal volume) ventilation strategy is indicated. Additional respiratory care measures, such as nebullized medications, bronchoscopy, humidified oxygen, and airway suctioning, potentiate aerosolization of the virus or bacteria and increase the risk of transmission to health care workers and patients. Thus, appropiate personal protective equipment, including an N95 mask or powered air-purifying respirator, is indicated. A basic understanding of the epidemiology, clinical findings, diagnosis, and treatment of these agents will provide a foundation for early isolation, evaluation, infection control, and public health involvement and response in cases of a febrile respiratory illness that causes respiratory failure. (AU)

Damage Control Orthopaedics in Patients with Delayed Referral to a Tertiary Care Center: Experiencie from a Place where Composite Trauma Centers do not exist

Background: Management of orthopaedic injuries in polytrauma cases continues to challenge the orthopaedic traumatologist. Mass disasters compound this challenge further due to delayed referral. Recently there has been increasing evidence showing that damage control surgery has advantages that are absent in the early total care modality. We studied the damage control modality in the management of polytrauma cases with orthopaedic injuries who had been referred to our hospital after more than 24 hours of sustaining their injuries in an earthquake. This study was conducted in 51 cases after reviewing their records and complete management one year after the trauma. Results: At one year, out of the 62 fractures, 3 were still under treatment, while the others had united. As per the radiological and functional scoring there were 20 excellent, 29 good, 5 fair and 5 poor results. In spite of the delayed referral there was no mortality. Conclusion: In situations of delayed referral in areas where composite trauma centers do not exist the damage control modality provides an acceptable method of treatment in the management of polytrauma cases. (AU)

Definitive Care for the Critically III During a Disaster: Medical Resources for Surge Capacity

Background: Mass numbers of critically ill disaster victims will stress the abilities of health-care system to maintain usual critical care servicies for all in need. To enhance the number of patients who can receive life-sustaining interventions, the Task Force on Mass Critical Care (hereafter termed the Task Force) has suggested a framework for providing limited, essential critical care, termed emergency mass critical care (EMCC). This article suggests medical equipment, concepts to expand treatment spaces, and staffing models for EMCC. Methods: Consensus suggestions for EMCC were derived form published clinical practice guidelines and medical resource utilization data for the everyday critical care conditions that are anticipated to predominate during mass critical care events. When necessary, expert opinion was used. Task force major suggestions: The Task Force makes the following suggestions (1) one mechanical ventilator that meets specific characteristics, as well as a set of consumable and durable medical equipment, should be provided for each EMCC patient; (2) should be provided in hospitals or similarly equipped structures; after ICUs, postanesthesia care units, and emergency depatments all reach capacity, hospital locations should be repurposed for EMCC in the following order: (A) step-down units and large procedure suites, (B) telemetrh units, and (C) hospital ward; and (3) hospitals can extend the provision of critical care using non-critical care personnel via deliberate model of delegation to match staff competencies with patient needs. Discussion: By using the Task Force suggestions for adequate supplies of medical equipment, appropiate treatment space, and trained staff, communities may better prepare to deliver augmented essential critical care in response to disasters. (AU)