The accuracy of the glucose reagent strip, Chemstrip bG, for the determination of the presence of hypoglycemia, euglycemia, or hyperglycemia was assessed in the prehospital setting when used by paramedics treating patients with an altered level of consciousness. Venous blood specimens were obtained from each of sixty-two patients. Serum glucose levels of the sample were determined by paramedics in the field using the Chemstrip bG and within three hours after sample acquisition by standard laboratory techniques. The sensitivity and specificity of detecting true hypoglycemia (serum glucose<61 mg/dl) using the field reagent strips were 100% and 83.3% respectively. The corresponding 95% lower limits of confidence (LLC) were 81.3% and 83 .3%. The sensitivity and specificity of field detection of the absence of hypoglycemia (serum glucose ≥ 61 mg/dl) were 86.6 % (LLC=80.9%) and 100% (LLC=81.3%) respectively. The accuracy of the reagent strips is specific but not sensitive for the determination of the presence of hyperglycemia (serum glucose > 179 mg/dl). Thus, the Chemstrip bG is an accurate means for the rapid identification of the presence or absence of hypoglycemia in the field setting by paramedics.

Nitroglycerine (NTG) commonly is used in the prehospital emergency care setting for the treatment of chest pain suggestive of myocardial ischemia or infarction or for cardiac unloading in patients with presumed pulmonary edema. The usual form of this drug is as a 400 mcg tablet administered sublingually. Recently, NTG has become available as an aerosolized form (NTGA) in a multiple dose, pressurized canister containing 200 metered doses of 400 meg of NTG each. In this form, the drug is purported to be absorbed rapidly from the surface of the tongue.

In the field, we have noted that the sublingual tablet form of NTG occasionally remains undissolved following administration to patients complaining of chest pain. In each of these cases, clinically, the patients were unchanged on arrival at the receiving hospital and an intact tablet was discovered properly placed under the tongue. In an attempt to evaluate the ease of administration and clinical responses of patients with chest pain to the aerosolized form of the drug, we replaced NTG sublingual tablets on paramedic units in the Burbank system with the NTGA form.

The use of pulse oximetry as an adjunct to clinical evaluation of oxygenation during aeromedical transport by helicopter and fixed-wing aircraft was evaluated. As evidenced by an oxygen saturation of 90% or less, 29 of 150 patients (29%) were hypoxemic in the presence of the flight team. Airway interventions were carried out by the flight team in 17 of these 29 hypoxemic patients. In 11 of these 17 instances, desaturation noted by pulse oximeter was the first evidence that airway interventions were indicated. In the other 12 cases of hypoxemia, no new airway interventions were carried out despite oximeter evidence of desaturation. Three of these patients subsequently required aggressive airway interventions following their arrival at the receiving emergency department. Of the 32 patients transported by fixed-wing aircraft, 27% had evidence of unsuspected hypoxemia detected only by the pulse oximeter. The hypoxemia seemed related to increasing altitude in eight of this latter group. Pulse oximetry is a valuable and feasible technique for monitoring patients during aeromedical transport. Its use may allow detection of physiologic hypoxemia before such becomes apparent clinically.

Transcutaneous Pacing (TCP) is a rapidly applied “non-invasive” technique that can be used successfully in the hospital, emergency department or field setting (1–9). Although the technique has been studied for three decades (7), it is only in the last few years that commercial units have been widely available. Improvements in pad design (particularly the development of non-metallic electrodes) and pulse characteristics (a pulse width of greater than 20 msec.) have allowed the development of units which may provide high capture rates with a level of discomfort which is tolerable in the conscious patient. Transcutaneous pacing may obviate the need for emergency transvenous pacing; further, it is easily adaptable to the field setting although early application appears to be needed for success (1,2).

No study has compared the relative effectiveness of different TCP units, and there are no published data on some of the devices. The purpose of this investigation was to compare the functions of five different external pacemaker units on ten volunteers, in order to determine: 1) what percent of subjects could be captured within the limits of tolerability (the capture rate); 2) how much current was required by each unit to capture (the capture threshold); and 3) the degree of discomfort produced by each pacemaker at the capture threshold.

Recovery and reconstruction following major sociocultural upheavals, such as natural disasters and war, result in multiple changes. In addition to loss of life and property, social structures and ways of life are temporarily and sometimes permanently altered. Sources of change are both from within due to loss and damage as well as from the outside through new ideas, relief, and economic aid. Some aspects of change may be viewed positively, as a society measures the benefits, while still other aspects may be worthless or detrimental to the survival of the group.

Because of the magnitude of the 1976 Guatemalan Earthquake, as well as the unprecedented outpouring of disaster relief and reconstruction aid, a longitudinal study funded by National Science Foundation was begun in 1977 (18 months after the event) and extended through 1982 (in selected areas). Chiefly because of financial expense, most research studies of disasters are limited to short-term follow-up studies of several weeks to a year after the traumatic event. However, many scientists have urged the importance of doing longitudinal studies (1–3). This study had as an overall goal, the study of the process of recovery over a five year period post-Earthquake. A quasiexperimental design was used to compare the recovery process in 19 experimental and 7 control sites. The overall guiding research question was: Does a catastrophy or social upheaval stimulate the recovery of the society so that the level of living post-disaster is higher than the pre-disaster state? Level of Living was operationalized to include housing conditions, cost of living, as well as quality of life measures. The results of a specific portion of the 1976 Guatemalan Earthquake Study (as it is popularly called), the urban resettlements, is presented in this paper.

A new method for evaluating the capabilities and performance of a general hospital in masscasualty exercises is described. This method is based on the use of simulation techniques which are realistic relative to the types and availability of the manpower required and to the time consumed by the assessments, interventions, and administrative duties and demands for each casualty encountered and the total workload thrust on the hospital by the cumulative requirements of all of the casualties. The simulation can be accomplished only after the time and equipment required for every possible diagnostic, therapeutic, and administrative procedure has been assessed for the specific hospital. Thereafter, it is possible to define the exact type and quantity of resources, in terms of time and manpower, consumed cumulatively by every simulated casualty assessed and treated during the exercise. The simulated victims are selected from a pool of young physicians who are briefed thoroughly by senior staff physicians prior to the exercise. Thus, the simulated subjects are provided lists of problems and the appropriate options for treatment. They also serve as controllers in the definition of time and manpower consumed for their specific injury set. Given this setting, it is possible to assess the functional performance of a hospital as a unit and for each of its components and also realistically estimate its capacity to manage disaster victims using a simulation of a disaster situation with mass casualties.

Emergency Medical Services and the care of patients in the field have taken giant steps forward over the past decade. Born of the desire of physicians to influence the mortality rates of sudden cardiac death in the community, systems of advanced life support have taken root in the urban centers in the United Kingdom, Australia, the United States, and other countries (1-3). Although originally largely designed around the concept of “mobile coronary care,” these systems soon were deluged with calls for help from all sectors of the community, and faced a variety of medical problems. As trauma gradually became recognized for the killer and maimer of young lives that it is, regional programs of trauma care were developed in the United States and led gradually to the expansion of prehospital and interhospital transport systems in which critically injured patients were being moved about, often over long distances. The growth of emergency medicine as a specialty in its own right has encouraged the study and improvement of systems of disaster and mass casualty management.

Although the focus of these efforts has been largely the overall reduction of death and disability in critically ill or injured patients, controversy continues around not only the extent of field intervention but also the influence of our efforts on the outcome of these patients (4, 5). The importance of particular interventions such as intravenous line placement, administration of certain medications, the use of the pneumatic anti-shock garment, and other sacred cows of prehospital care, all have been questioned of late (6, 7).

Emergency Medicine has become an accepted specialty in the medical community, and with the recognition has come the responsibility for those of us who teach and practice it to study our clinical practices. We must be satisfied that our clinical judgments are well- founded, not only in emergency departments, but also in our special role as providers of prehospital medical care. With the advent of trauma centers and Advanced Trauma Life Support (ATLS) training, the pivotal issues of the prehospital care of the trauma victim, and the timeliness of transporting these patients to appropriate receiving hospitals have resulted in a pair of recurring criticisms in the medical literature.

The administration of IV fluids to traumatized patients in the field at first seems like a motherhood issue: It can't do any harm and might do some good, so why not use it? This rationale has resulted in its inclusion in prehospital trauma care since the advent of paramedic systems in this country approximately 15 years ago; yet it remains unproven. There are no convincing data in the literature to support the efficacy for the administration of IV fluids in the prehospital setting.

In Jerusalem, the Emergency Medical Service is the sole prehospital provider for a population of 450,000 residents. Ambulances are dispatched from a centrally located first-aid center. Separate basic and advanced life support (MICU) ambulances are provided. Basic life support units are staffed by Emergency Medical Technicians (EMTs) trained to provide first aid and cardiopulmonary resuscitation (CPR). These units are dispatched to service persons in whom advanced life support (ALS) services are not likely to be required. The MICU is staffed by paramedical personnel plus a qualified physician. In order to maximize the efficiency of the service an attempt was made to use the MICU only for patients who may benefit from ALS interventions.

Selection of patients for whom the ALS unit may be required is accomplished by switchboard operators. These personnel routinely dispatch the MICU for definite emergencies such as unconsciousness or absence of breathing. All other cases have been reported first to an on-call physician who ultimately decides whether or not to dispatch the MICU. This method of determining priority for dispatch is called the Consultation-Dispatch System (CDS). This method of determining priority seemed inefficient, so an alternative system was implemented that did not require prior physician consultation. This brief report details the impact of this change on system operation and MICU activity.

Both civilian and military authorities continually are compelled to develop and revise disaster plans in order to demonstrate that they are prepared to manage any major incident occuring within their jurisdiction. Such plans may have some distinct value in that they often contain lists of key persons and agencies to contact in the event of a major incident, or because they prospectively document local policies of operation when actions taken during the incident are subsequently criticized by second-guessers. However, elaborate plans generally are forgotten or initially disregarded at the scene of an actual emergency situation.