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2.
Conn Med ; 80(4): 239-44, 2016 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-27265929

RESUMO

Despite advances in the response to active shooter and intentional mass casualty events, a gap remains in our national preparedness and resilience. Drawing from experiences at myriad mass casualty events, the immediate responder (volunteer responder) represents an underutilized resource, yet one capable of dramatically increasing our all-hazards (injuries from all natural and man-made causes) national resilience. The overarching principle of the Hartford Consensus, outlined in previous reports, is that no one should die from uncontrolled bleeding. We have championed the following acronym to summarize what we have determined are appropriate steps to ensure that the maximum number of victims of these tragic events can be saved: THREAT: Threat suppression. Hemorrhage control. Rapid Extrication to safety. Assessment by medical providers. Transport to definitive care.

3.
Conn Med ; 79(9): 537-41, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26630705

RESUMO

For many years tourniquets were perceived as dangerous due to the belief that they led to loss of limb because of ischemia. Their use in civilian and military environments was discouraged. Emergency medical responders were not taught about tourniquets and commercial tourniquets were not available. However, research by the United States military during the wars in Iraq and Afghanistan has demonstrated that tourniquets are safe life-saving devices. As a consequence, they have been widely deployed in combat situations and there are now calls for the use of tourniquets in the civilian prehospital setting. This article presents a report of the successful application of a tourniquet by the LIFE STAR crew to control bleeding that local emergency medical services (EMS) personnel could not control with direct pressure. Tourniquets should be readily available in public places and carried by all EMS.


Assuntos
Serviços Médicos de Emergência , Fíbula/lesões , Fraturas Ósseas/complicações , Hemorragia/terapia , Técnicas Hemostáticas , Fraturas da Tíbia/complicações , Torniquetes , Idoso , Feminino , Hemorragia/etiologia , Humanos
4.
Am J Disaster Med ; 19(2): 131-137, 2024.
Artigo em Inglês | MEDLINE | ID: mdl-38698511

RESUMO

OBJECTIVE: We hypothesized that medical students would be empowered by hemorrhage-control training and would support efforts to include Stop the Bleed® (STB) in medical education. DESIGN: This is a multi-institution survey study. Surveys were administered immediately following and 6 months after the course. SETTING: This study took place at the Association of American Medical Colleges-accredited medical schools in the United States. PARTICIPANTS: Participants were first-year medical students at participating institutions. A total of 442 students completed post-course surveys, and 213 students (48.2 percent) also completed 6-month follow-up surveys. INTERVENTION: An 1-hour, in-person STB course. MAIN OUTCOMES MEASURES: Student empowerment was measured by Likert-scale scoring, 1 (Strongly Disagree) to 5 (Strongly Agree). The usage of hemorrhage-control skills was also measured. RESULTS: A total of 419 students (95.9 percent) affirmed that the course taught the basics of bleeding control, and 169 (79.3 percent) responded positively at follow-up, with a significant decrease in Likert response (4.65, 3.87, p < 0.001). Four hundred and twenty-three students (97.0 percent) affirmed that they would apply bleeding control skills to a patient, and 192 (90.1 percent) responded positively at follow-up (4.61, 4.19, p < 0.001). Three hundred and sixty-one students (82.8 percent) believed that they were able to save a life, and 109 (51.2 percent) responded positively at follow-up (4.14, 3.56, p < 0.001). Four hundred and twenty-five students (97.0 percent) would recommend the course to another medical student, and 196 (92.0 percent) responded positively at follow-up (4.68, 4.31, p < 0.001). Six students (2.8 percent) used skills on live patients, with success in five of the six instances. CONCLUSIONS: Medical students were empowered by STB and have used hemorrhage-control skills on live victims. Medical students support efforts to include STB in medical education.


Assuntos
Hemorragia , Humanos , Hemorragia/terapia , Hemorragia/prevenção & controle , Masculino , Feminino , Estados Unidos , Estudantes de Medicina/estatística & dados numéricos , Educação de Graduação em Medicina , Currículo , Faculdades de Medicina , Inquéritos e Questionários , Adulto , Empoderamento
5.
J Trauma Acute Care Surg ; 97(2S Suppl 1): S45-S54, 2024 Aug 01.
Artigo em Inglês | MEDLINE | ID: mdl-38996420

RESUMO

BACKGROUND: Extremity tourniquets have proven to be lifesaving in both civilian and military settings and should continue to be used by first responders for trauma patients with life-threatening extremity bleeding. This is especially true in combat scenarios in which both the casualty and the first responder may be confronted by the imminent threat of death from hostile fire as the extremity hemorrhage is being treated. Not every extremity wound, however, needs a tourniquet. One of the most important aspects of controlling life-threatening extremity bleeding with tourniquets is to recognize what magnitude of bleeding requires this intervention and what magnitude of bleeding does not. Multiple studies, both military and civilian, have shown that tourniquets are often applied when they are not medically indicated. Overuse of extremity tourniquets has not caused excess morbidity in either the recent conflicts in Iraq and Afghanistan or in the US urban civilian setting. In the presence of prolonged evacuation, however, applying a tourniquet when it is not medically indicated changes tourniquet application from being a lifesaving intervention to one that may cause an avoidable amputation and the development of an array of metabolic derangements and acute kidney injury collectively called prolonged tourniquet application syndrome. METHODS: The recent literature was reviewed for papers that documented the complications of tourniquet use resulting from the prolonged casualty evacuation times being seen in the current Russo-Ukrainian war. The literature was also reviewed for the incidence of tourniquet application that was found to not be medically indicated, in both the US civilian setting and from Ukraine. Finally, an in-person meeting of the US/Ukraine Tourniquet Working Group was held in Warsaw, Poland, in December of 2023. RESULTS: Unnecessary loss of extremities and life-threatening episodes of prolonged tourniquet application syndrome are currently occurring in Ukrainian combat forces because of nonindicated tourniquet use combined with the prolonged evacuation time seen in the Russo-Ukrainian war. Specific numbers of the complications experienced as a result of tourniquet use by Ukrainian forces in the current conflict are treated as classified information and are not available, but multiple sources from the Ukrainian military medical personnel and from the US advisors providing medical assistance to Ukraine have all agreed that the problem is substantial. CONCLUSION: Unnecessary tourniquet morbidity might also occur in US forces in a variety of potential future combat scenarios in which evacuation to surgical care is delayed. Prehospital trauma training programs, including but not limited to tactical combat casualty care, place insufficient emphasis on the need to avoid leaving tourniquets in place when they are not medically indicated. This aspect of training should receive emphasis in future Tactical Combat Casualty Care (TCCC) and civilian first responder curriculum development. An interim ad hoc training solution on this topic is available at the websites noted in this articles. Additional training modalities may follow in the near future. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level V.


Assuntos
Hemorragia , Torniquetes , Humanos , Hemorragia/terapia , Hemorragia/etiologia , Ucrânia , Lesões Relacionadas à Guerra/terapia , Guerra , Medicina Militar , Extremidades/irrigação sanguínea , Extremidades/lesões
6.
Conn Med ; 77(3): 159-63, 2013 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-23589954

RESUMO

The purpose of this study was to describe the management of patients at Hartford Hospital with major blunt liver injuries. The medical records of patients admitted to Hartford Hospital between January 1, 2000 through January 31, 2010 with blunt trauma that resulted in a laceration with significant hepatic disruption were reviewed. One hundred forty-eight patients were identified from the Trauma Registry. Of those, 133 patient records were examined. Twenty-one patients (15.8%) died in the emergency department and three were transferred to other facilities. Of the 109 patients treated at Hartford Hospital, most (60.2%) had agrade IV or V liver injury; 19 had an operation and 90 were managed nonoperatively. Those managed with an operation were more severely injured and had higher mortality, P < .05. Most patients requiring an operation were identified and operated upon in a timely manner.


Assuntos
Lacerações/terapia , Fígado/lesões , Ferimentos não Penetrantes/terapia , Adolescente , Adulto , Connecticut , Feminino , Escala de Coma de Glasgow , Humanos , Escala de Gravidade do Ferimento , Lacerações/cirurgia , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Centros de Traumatologia , Ferimentos não Penetrantes/cirurgia , Adulto Jovem
7.
Conn Med ; 76(5): 291-7, 2012 May.
Artigo em Inglês | MEDLINE | ID: mdl-22685984

RESUMO

Typically risk-management strategies have been applied to the inpatient setting. In 2003, a comprehensive risk-management program was introduced to ProHealth Physicians, one of the largest primary-care practice groups in Connecticut. The program included strategies for education, practice change, incentive and compliance. Performance metrics for clinician participation and compliance were prespecified. Clinicians' attitudes and behavior change were assessed after introduction of the program. Audits were conducted by external reviewers to assess compliance. Financial data from before-to-after program implementation were compared. Results showed fewer claims and substantial cost savings. A strong commitment to the implementation of a comprehensive risk-management program can create a culture of safety in an outpatient setting.


Assuntos
Prática de Grupo/estatística & dados numéricos , Revisão da Utilização de Seguros/organização & administração , Segurança do Paciente , Planos de Incentivos Médicos/organização & administração , Médicos de Atenção Primária/organização & administração , Reembolso de Incentivo/estatística & dados numéricos , Connecticut , Humanos , Cultura Organizacional , Objetivos Organizacionais , Médicos de Atenção Primária/educação , Administração da Prática Médica , Padrões de Prática Médica/organização & administração , Desenvolvimento de Programas , Qualidade da Assistência à Saúde
8.
J Am Coll Emerg Physicians Open ; 3(5): e12833, 2022 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-36311340

RESUMO

Traumatic injuries remain the leading cause of death for those under the age of 44 years old. Nearly a third of those who die from trauma do so from bleeding. Reducing death from severe bleeding requires training in the recognition and treatment of life-threatening bleeding, as well as programs to ensure immediate access to bleeding control resources. The Stop the Bleed (STB) initiative seeks to educate and empower people to be immediate responders and provide control of life-threatening bleeding until emergency medical services arrive. Well-planned and implemented STB programs will help ensure program effectiveness, minimize variability, and provide long-term sustainment. Comprehensive STB programs foster consistency, promote access to bleeding control education, contain a framework to guide the acquisition and placement of equipment, and promote the use of these resources at the time of a bleeding emergency. We leveraged the expertise and experience of the Stop the Bleed Education Consortium to create a resource document to help inform and guide STB program developers and implementers on the key areas for consideration when crafting strategy. These areas include (1) equipment selection, (2) logistics and kit placement, (3) educational program accessibility and implementation, and (4) program oversight, facilitation, and administration.

9.
Surg Infect (Larchmt) ; 23(4): 332-338, 2022 May.
Artigo em Inglês | MEDLINE | ID: mdl-35255232

RESUMO

Background: Antibiotic prophylaxis is a common, established practice at trauma centers worldwide for patients presenting with various forms of serious injury. Many patients simultaneously present with hemorrhage. The current guidelines by the Eastern Association for the Surgery of Trauma recommend re-dosing prophylactic antibiotic agents for every 10 units of blood products administered. However, these guidelines are only mildly supported by dated research. Methods: A literature search was completed through Medline EBSCO Host using antibiotic prophylaxis and transfusion as keywords. Articles judged to be relevant to the study question were selected for full-text review. Case studies were not included. Altogether, 18 articles were cited in our results through this process. Results: Risk of infection increases in patients resuscitated with large volume of blood products. Animal models of trauma offered conflicting findings on whether blood loss and blood resuscitation altered tissue antibiotic concentrations compared with controls. Studies focused on antibiotic pharmacokinetics in non-trauma human patients revealed agreement surrounding reported decreases in serum and tissue concentrations, although there was discrepancy surrounding the clinical relevancy of the reported decreases. Conclusions: Trauma, hemorrhage, and transfusion impair the immune response resulting in increased incidence of infection. Both animal and human models of antibiotic pharmacokinetics show decreased serum and tissue concentrations during hemorrhage. However, available data are insufficient to conclude that trauma patients experiencing hemorrhage are at elevated risk of infection and thus require more frequent redosing of antibiotic agents than the current guidelines suggest. An upcoming, prospective study by our institution seeks to evaluate this question.


Assuntos
Antibioticoprofilaxia , Hemorragia , Antibacterianos/uso terapêutico , Antibioticoprofilaxia/métodos , Transfusão de Sangue , Hemorragia/tratamento farmacológico , Hemorragia/etiologia , Humanos , Estudos Prospectivos
10.
J Trauma Acute Care Surg ; 93(6): 800-805, 2022 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-35994716

RESUMO

BACKGROUND: Our trauma performance improvement initiative recognized missed treatment opportunities for patients undergoing massive transfusion. To improve patient care, we developed a novel cognitive aid in the form of a poster entitled "TACTICS for Hemorrhagic Shock." We hypothesized that this reference and corresponding course would improve the performance of trauma leaders caring for simulated patients requiring massive transfusion. METHODS: First, residents and physician assistants participated in a one-on-one, socially distanced, screen-based virtual patient simulation. Next, they watched a short presentation introducing the TACTICS visual aid. They then underwent a similar second virtual simulation during which they had access to the reference. In both simulations, the participants were assessed using a scoring system developed to measure their ability to provide appropriate predetermined interventions while leading a trauma resuscitation (score range, 0-100%). Preintervention and postintervention scores were compared using a one-group pre-post within-subject design. Participants' feedback was obtained anonymously. RESULTS: Thirty-two participants (21 residents and 11 physician assistants) completed the course. The median score for the first simulation without the use of the visual aid was 43.8% (interquartile range, 33.3.8-61.5%). Commonly missed treatments included giving tranexamic acid (success rate, 37.5%), treating hypothermia (31.3%), and reversing known anticoagulation (28.1%). All participants' performance improved using the visual aid, and the median score of the second simulation was 89.6% (interquartile range, 79.2-94.8%; p < 0.001). Ninety-two percent of survey respondents "strongly agreed" that the TACTICS visual aid would be a helpful reference during real-life trauma resuscitations. CONCLUSION: The TACTICS visual aid is a useful tool for improving the performance of the trauma leader and is now displayed in our emergency department resuscitation rooms. This performance improvement course, the associated simulations, and visual aid are easily and virtually accessible to interested trauma programs. LEVEL OF EVIDENCE: Therapeutic/Care Management; Level IV.


Assuntos
Choque Hemorrágico , Humanos , Choque Hemorrágico/terapia , Competência Clínica , Ressuscitação , Simulação de Paciente , Recursos Audiovisuais
12.
Am Surg ; 77(3): 337-41, 2011 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-21375847

RESUMO

Multidetector Computed Tomography (MDCT) technology plays an important role in the evaluation of injured patients. At our institution pelvic X-ray (PXR) is obtained routinely on trauma patients. Many also receive MDCT of the abdomen and pelvis for other indications. We hypothesized that there would be a substantial cost savings in adopting a policy of deferring PXR in a hemodynamically normal patient who will also proceed to MDCT for other indications. We retrospectively reviewed the charts of trauma patients from February 1, 2008 to February 1, 2009. We reviewed whether a PXR was done, the result, whether an MDCT was also done, and the presence or absence of pelvic fractures. We collected billing and cost data from various hospital sources. We identified 1,330 patients with PXR between February 1, 2008 and February 1, 2009. Of those patients, 810 (61%) had MDCT after PXR. Sixty-six patients (8.0%) had pelvic fractures; 39 were correctly identified on PXR (59% of fractures). Twenty-seven were detected only by MDCT (41% of fractures); all pelvic fractures were identified on MDCT. Seven hundred and forty-four patients (92% of patients with both PXR and MDCT) had negative PXR and negative MDCT. Using three methods of cost analysis, the estimated cost savings range is from $77,011 to $331,080. MDCT of the pelvis is more sensitive and more specific than PXR. In patients who are hemodynamically normal and asymptomatic, forgoing routine PXR could result in an estimated savings from $77,011 to $331,080, depending on the method used to calculate costs.


Assuntos
Traumatismos Abdominais/diagnóstico por imagem , Serviço Hospitalar de Emergência/economia , Custos Hospitalares , Ossos Pélvicos/diagnóstico por imagem , Radiografia Abdominal/economia , Tomografia Computadorizada por Raios X/economia , Traumatismos Abdominais/etiologia , Adulto , Estudos de Coortes , Análise Custo-Benefício , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Seleção de Pacientes , Ossos Pélvicos/lesões , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Estudos Retrospectivos
13.
J Law Med Ethics ; 49(2): 174-180, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34924038

RESUMO

Racial inequity has influenced both personal and public health in the United States and has impacted enrollment in medical schools and training programs. The effects of racial inequity on training and how it is perceived can differ depending on who is being affected. Recommendations are offered for positive changes through mentoring of individuals, institutional leadership, and structural changes in organizations.


Assuntos
Tutoria , Cirurgiões , Humanos , Liderança , Grupos Raciais , Estados Unidos
14.
Am J Disaster Med ; 16(3): 195-202, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34904703

RESUMO

Connecticut was impacted severely and early on by the COVID-19 pandemic due to the state's proximity to New York City. Hartford Healthcare (HHC), one of the largest healthcare systems in New England, became integral in the state's response with a robust emergency management system already in place. In this manuscript, we review HHC's prepandemic emergency operations as well as the response of the system-wide Office of Emergency Management to the initial news of the virus and throughout the evolving pandemic. Additionally, we discuss the unique acquisition of vital critical care resources and personal protective equipment, as well as the hospital personnel distribution in response to the shifting demands of the virus. The public testing and vaccination efforts, with early consideration for at risk populations, are described as well as ethical considerations of scarce resources. To date, the vaccination effort resulted in over 70 percent of the adult population being vaccinated and with 10 percent of the population having been infected, herd immunity is eminent. Finally, the preparation for reestablishing elective procedures while experiencing a second wave of the pandemic is discussed. These descriptions may be useful for other healthcare systems in both preparation and response for future catastrophic emergencies of all types.


Assuntos
COVID-19 , Pandemias , Adulto , Connecticut/epidemiologia , Atenção à Saúde , Humanos , SARS-CoV-2
15.
World J Surg ; 34(1): 164-8, 2010 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-19911221

RESUMO

BACKGROUND: The Advanced Trauma Operative Management (ATOM) course uses standardized porcine simulation to teach the repair of penetrating trauma. It is offered in 26 sites in the United States, Canada, Africa, the Middle East, and Japan. The purpose of the present study was to query ATOM participants regarding their perceptions of the value and influence of the ATOM course on knowledge, confidence, and skill to repair penetrating injuries. METHODS: An anonymous, voluntary survey was posted on the Internet at surveymonkey.com. E-mail notification was sent to all 1,001 ATOM participants through May 2008. Items requested agreement/disagreement on a 5-point Likert scale and space for comments. Agreement indicated positive perceptions of ATOM. RESULTS: A total of 962 surgeons received the request to complete the survey; 444 ATOM participants from 36 states and 17 countries participated, for a response rate of 46%. Range of agreement with all of the items was 75.4-99.0%. Results include the following: 78.9% (95% CI, 74.7-82.6%) can identify injuries more quickly; 80.7% (95% CI, 76.6-84.3%) have a more organized operative approach; 81.1% (95% CI, 77.0-84.6%) can control bleeding more quickly; 86.1% (95% CI, 82.4-89.2%) can control injuries more effectively; 86.4% (95% CI, 82.7-89.4%) are more competent trauma surgeons; 87.0% are more confident (95% CI, 83.4-89.9%), and 89.2% are more knowledgeable (95% CI, 85.8-91.8%) about repairing penetrating injuries; 99% (95% CI, 97.4-99.7%) said ATOM is worthwhile. Overall, 87.4% of the comments were positive. CONCLUSIONS: Participants worldwide perceive that ATOM is worthwhile and helps surgeons improve knowledge, confidence, and skill in repairing penetrating injuries.


Assuntos
Educação Médica Continuada/métodos , Cirurgia Geral/educação , Inquéritos e Questionários , Traumatologia/educação , Ferimentos Penetrantes/cirurgia , Animais , Competência Clínica , Currículo , Avaliação Educacional , Feminino , Humanos , Internet , Masculino , Modelos Animais , Suínos
16.
J Trauma ; 69(6): 1567-73, 2010 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-21150531

RESUMO

BACKGROUND: End-of-life care for trauma patients requires unique practice guidelines because it is fraught with difficulties not encountered in end-of-life care for terminally ill patients. The purpose of this project was to analyze survey information from nurses and physicians regarding preferences for end-of-life care in trauma that would inform best-practice guidelines. METHODS: A survey was sent via the US Postal Service to a convenience sample of trauma professionals, including physicians, nurses, and emergency medical technicians. Questions were designed to provide information on difficult issues related to death and dying from trauma. The general public was also surveyed, and all results were used to develop a best-practice model for end-of-life care. RESULTS: Seven hundred seventy-four trauma professionals returned the survey for a response rate of 51%. This included 460 nurses and 181 physicians. Some salient findings include: (1) If a loved one required resuscitation in the emergency department, more nurses (78.4%) than physicians (38.7%) prefer to be in the treatment room rather than in the waiting room; (2) similar percentages of nurses (97.7%) and physicians (99.4%) agree that life-sustaining treatment should be withdrawn in cases in whom there is no hope of recovery; and (3) a larger percentage of nurses (58.8%) than physicians (20.6%) believe that patients have the right to demand care that physicians think is medically futile. CONCLUSIONS: Nurses and physicians agree on some issues about end-of-life care in trauma but disagree on others. Education and discourse among trauma professionals are needed to bring understanding to the issues.


Assuntos
Atitude Frente a Morte , Enfermeiras e Enfermeiros/psicologia , Médicos/psicologia , Assistência Terminal , Ferimentos e Lesões/mortalidade , Distribuição de Qui-Quadrado , Tomada de Decisões , Feminino , Humanos , Masculino , Opinião Pública , Estatísticas não Paramétricas , Inquéritos e Questionários , Estados Unidos/epidemiologia
18.
JAMA Netw Open ; 3(7): e209393, 2020 07 01.
Artigo em Inglês | MEDLINE | ID: mdl-32663307

RESUMO

Importance: Trauma is the leading cause of death for US individuals younger than 45 years, and uncontrolled hemorrhage is a major cause of trauma mortality. The US military's medical advancements in the field of prehospital hemorrhage control have reduced battlefield mortality by 44%. However, despite support from many national health care organizations, no integrated approach to research has been made regarding implementation, epidemiology, education, and logistics of prehospital hemorrhage control by layperson immediate responders in the civilian sector. Objective: To create a national research agenda to help guide future work for prehospital hemorrhage control by laypersons. Evidence Review: The 2-day, in-person, National Stop the Bleed (STB) Research Consensus Conference was conducted on February 27 to 28, 2019, to identify and achieve consensus on research gaps. Participants included (1) subject matter experts, (2) professional society-designated leaders, (3) representatives from the federal government, and (4) representatives from private foundations. Before the conference, participants were provided a scoping review on layperson prehospital hemorrhage control. A 3-round modified Delphi consensus process was conducted to determine high-priority research questions. The top items, with median rating of 8 or more on a Likert scale of 1 to 9 points, were identified and became part of the national STB research agenda. Findings: Forty-five participants attended the conference. In round 1, participants submitted 487 research questions. After deduplication and sorting, 162 questions remained across 5 a priori-defined themes. Two subsequent rounds of rating generated consensus on 113 high-priority, 27 uncertain-priority, and 22 low-priority questions. The final prioritized research agenda included the top 24 questions, including 8 for epidemiology and effectiveness, 4 for materials, 9 for education, 2 for global health, and 1 for health policy. Conclusions and Relevance: The National STB Research Consensus Conference identified and prioritized a national research agenda to support laypersons in reducing preventable deaths due to life-threatening hemorrhage. Investigators and funding agencies can use this agenda to guide their future work and funding priorities.


Assuntos
Serviços Médicos de Emergência , Hemorragia , Projetos de Pesquisa , Ferimentos e Lesões , Pesquisa Biomédica/métodos , Consenso , Técnica Delphi , Serviços Médicos de Emergência/métodos , Serviços Médicos de Emergência/organização & administração , Hemorragia/etiologia , Hemorragia/mortalidade , Hemorragia/terapia , Humanos , Inquéritos e Questionários , Ferimentos e Lesões/complicações , Ferimentos e Lesões/mortalidade
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