Medical Incidents and Evacuations on Wilderness Expeditions for the Northwest Outward Bound School.

INTRODUCTION: Outdoor education (OE) expeditions travel far from definitive care and have unique epidemiology. Most OE expedition studies have examined a single organization and results may not generalize. This study examines the injuries, illnesses, medical evacuations, and nonmedical incidents of the Northwest Outward Bound School (NWOBS) to broaden our understanding and demonstrate commonalities within the field. METHODS: This retrospective database review examined incidents and evacuations on NWOBS expeditions from June 1, 2014 through October 31, 2016. Incident rates, evacuation rates, and incident type frequencies were calculated. Frequencies of incidents during different expedition time periods were compared with a 1-sample χ2 test. The odds ratio that each type of incident would require evacuation was calculated and compared with other incident types using Fisher exact test. RESULTS: The study period included 59,058 program days, 277 incidents, 143 medical incidents, 75 medical evacuations, and no fatalities. Injuries occurred at a rate of 1.64 per 1000 program days and illnesses at a rate of 0.78 per 1000 program days. The most common injuries were strains, sprains, and trauma or infection of the skin and soft tissue. Most injuries occurred while backpacking, hiking, or moving around camp. The most common illnesses were nausea, vomiting, diarrhea, abdominal pain, asthma, respiratory infections, and urinary tract infections. The medical incidents with the highest odds of evacuation were fractures, urinary tract infections, abdominal pain, and asthma. CONCLUSIONS: Results from the NWOBS database are consistent with those from other expeditionary OE programs. These findings should guide risk-management strategies and staff medical training.

Identification of high-risk communities for unattended out-of-hospital cardiac arrests using GIS.

Improving survival rates for out of hospital cardiac arrest (OHCA) at the neighborhood level is increasingly seen as priority in US cities. Since wide disparities exist in OHCA rates at the neighborhood level, it is necessary to locate neighborhoods where people are at elevated risk for cardiac arrest and target these for educational outreach and other mitigation strategies. This paper describes a GIS-based methodology that was used to identify communities with high risk for cardiac arrests in Franklin County, Ohio during the period 2004-2009. Prior work in this area used a single criterion, i.e., the density of OHCA events, to define the high-risk areas, and a single analytical technique, i.e., kernel density analysis, to identify the high-risk communities. In this paper, two criteria are used to identify the high-risk communities, the rate of OHCA incidents and the level of bystander CPR participation. We also used Local Moran's I combined with traditional map overlay techniques to add robustness to the methodology for identifying high-risk communities for OHCA. Based on the criteria established for this study, we successfully identified several communities that were at higher risk for OHCA than neighboring communities. These communities had incidence rates of OHCA that were significantly higher than neighboring communities and bystander rates that were significantly lower than neighboring communities. Other risk factors for OHCA were also high in the selected communities. The methodology employed in this study provides for a measurement conceptualization of OHCA clusters that is much broader than what has been previously offered. It is also statistically reliable and can be easily executed using a GIS.

Medical direction of wilderness and other operational emergency medical services programs.

Within a healthcare system, operational emergency medical services (EMS) programs provide prehospital emergency care to patients in austere and resource-limited settings. Some of these programs are additionally considered to be wilderness EMS programs, a specialized type of operational EMS program, as they primarily function in a wilderness setting (eg, wilderness search and rescue, ski patrols, water rescue, beach patrols, and cave rescue). Other operational EMS programs include urban search and rescue, air medical support, and tactical law enforcement response. The medical director will help to ensure that the care provided follows protocols that are in accordance with local and state prehospital standards, while accounting for the unique demands and needs of the environment. The operational EMS medical director should be as qualified as possible for the specific team that is being supervised. The medical director should train and operate with the team frequently to be effective. Adequate provision for compensation, liability, and equipment needs to be addressed for an optimal relationship between the medical director and the team.

Trauma in the neighborhood: a geospatial analysis and assessment of social determinants of major injury in North America.

OBJECTIVES: We sought to identify and characterize areas with high rates of major trauma events in 9 diverse cities and counties in the United States and Canada. METHODS: We analyzed a prospective, population-based cohort of injured individuals evaluated by 163 emergency medical service agencies transporting patients to 177 hospitals across the study sites between December 2005 and April 2007. Locations of injuries were geocoded, aggregated by census tract, assessed for geospatial clustering, and matched to sociodemographic measures. Negative binomial models were used to evaluate population measures. RESULTS: Emergency personnel evaluated 8786 major trauma patients, and data on 7326 of these patients were available for analysis. We identified 529 (13.7%) census tracts with a higher than expected incidence of major trauma events. In multivariable models, trauma events were associated with higher unemployment rates, larger percentages of non-White residents, smaller percentages of foreign-born residents, lower educational levels, smaller household sizes, younger age, and lower income levels. CONCLUSIONS: Major trauma events tend to cluster in census tracts with distinct population characteristics, suggesting that social and contextual factors may play a role in the occurrence of significant injury events.

Epidemiology and outcomes from out-of-hospital cardiac arrest in children: the Resuscitation Outcomes Consortium Epistry-Cardiac Arrest.

BACKGROUND: Population-based data for pediatric cardiac arrest are scant and largely from urban areas. The Resuscitation Outcomes Consortium (ROC) Epistry-Cardiac Arrest is a population-based emergency medical services registry of out-of-hospital nontraumatic cardiac arrest (OHCA). This study examined age-stratified incidence and outcomes of pediatric OHCA. We hypothesized that survival to hospital discharge is less frequent from pediatric OHCA than adult OHCA. METHODS AND RESULTS: This prospective population-based cohort study in 11 US and Canadian ROC sites included persons <20 years of age who received cardiopulmonary resuscitation or defibrillation by emergency medical service providers and/or received bystander automatic external defibrillator shock or who were pulseless but received no resuscitation by emergency medical services between December 2005 and March 2007. Patients were stratified a priori into 3 age groups: <1 year (infants; n=277), 1 to 11 years (children; n=154), and 12 to 19 years (adolescents; n=193). The incidence of pediatric OHCA was 8.04 per 100 000 person-years (72.71 in infants, 3.73 in children, and 6.37 in adolescents) versus 126.52 per 100,000 person-years for adults. Survival for all pediatric OHCA was 6.4% (3.3% for infants, 9.1% for children, and 8.9% for adolescents) versus 4.5% for adults (P=0.03). Unadjusted odds ratio for pediatric survival to discharge compared with adults was 0.71 (95% confidence interval, 0.37 to 1.39) for infants, 2.11 (95% confidence interval, 1.21 to 3.66) for children, and 2.04 (95% confidence interval, 1.24 to 3.38) for adolescents. CONCLUSIONS: This study demonstrates that the incidence of OHCA in infants approaches that observed in adults but is lower among children and adolescents. Survival to discharge was more common among children and adolescents than infants or adults.

Comparison of Poisson and Bernoulli spatial cluster analyses of pediatric injuries in a fire district.

BACKGROUND: With limited resources available, injury prevention efforts need to be targeted both geographically and to specific populations. As part of a pediatric injury prevention project, data was obtained on all pediatric medical and injury incidents in a fire district to evaluate geographical clustering of pediatric injuries. This will be the first step in attempting to prevent these injuries with specific interventions depending on locations and mechanisms. RESULTS: There were a total of 4803 incidents involving patients less than 15 years of age that the fire district responded to during 2001-2005 of which 1997 were categorized as injuries and 2806 as medical calls. The two cohorts (injured versus medical) differed in age distribution (7.7 +/- 4.4 years versus 5.4 +/- 4.8 years, p < 0.001) and location type of incident (school or church 12% versus 15%, multifamily residence 22% versus 13%, single family residence 51% versus 28%, sport, park or recreational facility 3% versus 8%, public building 8% versus 7%, and street or road 3% versus 30%, respectively, p < 0.001). Using the medical incident locations as controls, there was no significant clustering for environmental or assault injuries using the Bernoulli method while there were four significant clusters for all injury mechanisms combined, 13 clusters for motor vehicle collisions, one for falls, and two for pedestrian or bicycle injuries. Using the Poisson cluster method on incidence rates by census tract identified four clusters for all injuries, three for motor vehicle collisions, four for fall injuries, and one each for environmental and assault injuries. The two detection methods shared a minority of overlapping geographical clusters. CONCLUSION: Significant clustering occurs overall for all injury mechanisms combined and for each mechanism depending on the cluster detection method used. There was some overlap in geographic clusters identified by both methods. The Bernoulli method allows more focused cluster mapping and evaluation since it directly uses location data. Once clusters are found, interventions can be targeted to specific geographic locations, location types, ages of victims, and mechanisms of injury.

Prospective evaluation of ondansetron for undifferentiated nausea and vomiting in the prehospital setting.

OBJECTIVE: To evaluate the change in nausea scales and incidence of vomiting with the use of ondansetron in the treatment of nausea and vomiting in the prehospital setting. METHODS: Data were prospectively collected on all emergency medical service patients who received ondansetron for undifferentiated nausea and vomiting during a 6-month study period. Added outcome measures for this study were verbal quantitative (scale of 1-10) and qualitative "nausea scales," incidence of vomiting prior to and after administration of ondansetron, and adverse events. Patients who had this additional data collected and ones who did not were compared. Changes in the "nausea scales" and incidence of vomiting before and after administration and correlation among these measures were also compared. There was no control or placebo group. RESULTS: Ondansetron was administered to 952 patients of 20,054 patients transported during this time period (5%); of these 472 had at least some of the outcome measures documented. There were minimal differences in the two cohorts; 198 patients had paired before and after quantitative "nausea scales" documented: 7.6 +/- 2.4 and 4.6 +/- 3.1, respectively (Delta = 2.9, 95% CI: 2.5-3.4); 447 patients had a qualitative change in nausea level documented: 0.4% "a lot worse," 1.3% "a little worse," 34% "unchanged," 40% "a little better," and 25% "a lot better"; 187 patients had all three measures documented with a Pearson correlation coefficient of 0.63 between the change in the quantitative scale and the qualitative scale (95% CI: 0.14-0.20, R(2) 0.39). In 462 patients, vomiting decreased from 60% to 30% (Wilcoxon signed ranks test p < 0.001). The Pearson correlation coefficients for the change in vomiting incidence with the qualitative and quantitative "nausea scales" were poor: 0.012 (95% CI: -0.015 to 0.039, R(2) 0.00014) and 0.051 (95% CI: -0.032 to 0.118, R(2) 0.00026), respectively. There were no reported adverse events. CONCLUSIONS: Ondansetron appears to be moderately effective in decreasing nausea and vomiting in undifferentiated prehospital patients. Additional controlled trials may be needed to compare it with other antiemetics.

Children's mental health emergencies--part 2: emergency department evaluation and treatment of children with mental health disorders.

OBJECTIVE: The emergency physician should be familiar with the wide spectrum of pediatric mental health emergencies because they are commonly encountered in emergency medical practice. METHODS: A review of the literature was done in order to develop an approach for dealing with children presenting with mental health disorders in the emergency department (ED). RESULTS: Children' mental health emergencies have a wide spectrum from behavioral disturbances to major depression. An approach to the issues involved in caring for these patients is discussed which acknowledges the essential role of the emergency physician and the importance of integrating ED care with multidisciplinary services. CONCLUSIONS: The actions and directions taken in the ED are a crucial part of the child's long-term care and treatment. The ED evaluation and management of pediatric mental health emergencies may vary depending on the complaint and includes differentiation from organic etiologies, medical stabilization, and occasionally in depth psychosocial interview.

The predictive value and appropriate ranges of prehospital physiological parameters for high-risk injured children.

OBJECTIVES: To assess: (1) the relative importance of prehospital physiological measures in identifying high-risk children; (2) whether different age-based criteria should be used for each prehospital physiological measure; and (3) outcome-based appropriate ranges of physiological measures in injured children. METHODS: This was a retrospective cohort analysis of injured children 0 to 14 years transported by emergency medical services to 48 statewide hospitals from January 1, 1998, through December 31, 2003. We analyzed prehospital physiological measures, including Glasgow Coma Scale score (GCS), systolic blood pressure (SBP), respiratory rate (RR), heart rate, shock index (heart rate/SBP), and airway intervention. "High-risk" children were defined as those with in-hospital mortality, major nonorthopedic surgery, intensive care unit stay greater than or equal to 2 days, or Injury Severity Score greater than or equal to 16. Specific age groups included 0 to 2 years, 3 to 5 years, 6 to 10 years, and 11 to 14 years. RESULTS: A total of 3877 injured children were included in the analysis, of which 1111 (29%) were high risk. Prehospital GCS was the variable of greatest importance in identifying high-risk children, followed by (in order) airway intervention, RR, heart rate, SBP, and shock index. Age modified the effect of prehospital RR (P = 0.0046), heart rate (P = 0.01), and SBP (P = 0.02). There was a linear relationship between GCS and outcome that was consistent across all ages. Specific age-based ranges of other physiological measures were identified for high-risk children. CONCLUSIONS: Prehospital GCS and respiratory compromise were the most important physiological measures in identifying high-risk injured children. Age-specific criteria should be considered for RR, heart rate, and SBP.

Respiratory agents: irritant gases, riot control agents, incapacitants, and caustics.

There are many chemical respiratory agents suitable for use by terrorists. They are the oldest chemical agents used and have caused the most casualties throughout the 20th century. Many are available in large quantities for industrial use and are susceptible to potential sabotage. This paper will concentrate on respiratory agents that are readily available and have the potential to cause a large number of casualties and panic. These agents have a lower rate of lethality when compared to other chemical agents but could produce many casualties that may overwhelm the emergency medical system.

Out-of-hospital pediatric airway management in the United States.

OBJECTIVE: The objective of this study was to characterize pediatric out-of-hospital airway management interventions, success rates, and complications in the United States using the 2012 National Emergency Medical Services Information System (NEMSIS) dataset. METHODS: In 2012, NEMSIS collected data from Emergency Medical Services (EMS) encounters in 40 states. We included all patients less than 18 years of age and identified all patients who had airway interventions including endotracheal intubation (ETI), bag-valve-mask ventilation (BVM), continuous positive airway pressure/bilevel positive airway pressure (CPAP/BiPAP) and alternate airways (Combitube, King LT, Laryngeal Mask Airway (LMA), esophageal obturator airway, and cricothyroidotomy). Success and complication rates were analyzed and compared across pediatric age groups, by race, ethnicity, clinical condition, and geographic region. RESULTS: We identified a total of 949,301 pediatric patient care events in the NEMSIS 2012 dataset. 4.5% had airway management procedures (42,936 events). Invasive airway management or ventilation (ETI, cricothyroidotomy, alternate airway, CPAP/BiPAP, BVM and other ventilation) took place in 1.5% of patient care events (14,107). Of those who had invasive airway management, 29.9% were less than 1 year of age, 58.1% were male, 42.3% were white, and 83.6% were in urban areas. ETI occurred in 3124 of patient care events (329 per 100,000; 95% CI 318-341). Overall success of ETI was 81.1% (95% CI 79.7-82.6). Lower success was noted in patients with cardiac arrest (75.5%, 95% CI 72.6-78.3) and those aged 1-12 months (72.1%, 95% CI 68.3-75.6). CONCLUSIONS: Out-of-hospital pediatric advanced airway procedures were infrequently performed. Success rates are lowest in patients aged 1-12 months.

Patient satisfaction in the emergency department--a survey of pediatric patients and their parents.

OBJECTIVES: To assess and compare overall satisfaction in pediatric emergency department (ED) patients and their accompanying parents. To identify aspects of health care delivery that influence satisfaction in these groups. METHODS: Pediatric patients (ages 5-17 years) and their parents (or guardians) seen at a university hospital pediatric ED were eligible. A convenience sample of English-speaking subject pairs (n = 101 pairs) was enrolled. Questionnaires were administered to both children and their parents at the completion of their ED care. The survey instruments used a modified Wong-Baker FACES Pain Rating Scale and a six-point interval scale. Factors measured included overall satisfaction, perceptions of pain and fear, and other characteristics of the ED visit. Data were analyzed using paired Wilcoxon signed-rank tests, Spearman rank correlation coefficients, and Fischer's exact chi-square tests (alpha = 0.05) where appropriate. RESULTS: Parent satisfaction was associated with the quality of provider-patient interactions (R = 0.54, p = 0.0001), the adequacy of information provided (R = 0.47, p = 0.0001), and shorter waiting room times (R = -0.24, p = 0.01). Child satisfaction was associated with the quality of provider-patient interactions (R = 0.24, p 0.04), adequacy of information provided (R = 0.51, p = 0.003), and resolution of pain (R = 0.25, p = 0.03). Parent estimates were similar to children's initial pain scores; however, children reported greater resolution of pain than appreciated by their parents (p = 0.006). CONCLUSIONS: Satisfaction can be validly and reliably measured in pediatric patients using a visual scale instrument. Factors that influence patient satisfaction were similar among both children and their parents. The influence of pain resolution on pediatric ED satisfaction is a novel finding, which demonstrates the importance of appropriate pain and anxiety assessment and treatment in children.

Identifying high-risk geographic areas for cardiac arrest using three methods for cluster analysis.

OBJECTIVES: The objective was to identify high-risk census tracts, defined as those areas that have both a high incidence of out-of-hospital cardiac arrest (OHCA) and a low prevalence of bystander cardiopulmonary resuscitation (CPR), by using three spatial statistical methods. METHODS: This was a secondary analysis of two prospectively collected registries in the city of Columbus, Ohio. Consecutive adult (≥18 years) OHCA patients, restricted to those of cardiac etiology and treated by emergency medical services (EMS) from April 1, 2004, to April 30, 2009, were studied. Three different spatial analysis methods (Global Empirical Bayes, Local Moran's I, and SaTScan's spatial scan statistic) were used to identify high-risk census tracts. RESULTS: A total of 4,553 arrests in 200 census tracts occurred during the study period, with 1,632 arrests included in the final sample after exclusions for no resuscitation attempt, noncardiac etiology, etc. The overall incidence for OHCA was 0.70 per 1,000 people for the 6-year study period (SD = ±0.52). Bystander CPR occurred in 20.2% (n = 329), with 10.0% (n = 167) surviving to hospital discharge. Five high-risk census tracts were identified by all three analytic methods. CONCLUSIONS: The five high-risk census tracts identified may be possible sites for high-yield targeted community-based interventions to improve CPR training and cardiovascular disease education efforts and ultimately improve survival from OHCA.