The objective of this study was to determine the accuracy of emergency physicians in detecting free fluid in the abdomen when compared to radiologists during w primary survey of trauma victims by focused assessment with sonography for trauma (FAST) scan in the emergency department.

This prospective study was performed during a primary survey of the resuscitation of non-consecutive patients in the resuscitation bay. The study subjects included emergency physicians (EP) [one emergency medicine (EM) consultant, two EM residents, one orthopedic resident, and one surgical resident] who underwent training at a three-day workshop on emergency sonography and performed 10 supervised positive and negative scans for free fluid. The FAST scans were performed by the EPs and then by the radiology resident (RR). Both were blinded to each other's sonography findings. Computed tomography (CT) scan and laparatomy findings were used as gold standard. Results were compared between both groups. Intra-observer variability among EPs and level of agreement between EPs and RRs were assessed.

One hundred fifty scans performed by EPs and RRs were analyzed. The mean age of the patients was 28 [1–70] years. Out of 24 true positive patients, 18 underwent CT scan, and exploratory laparatomy was done in six patients. Intra-observer performance variation ranged from 87–97%. The sensitivity of FAST performed by EP and RR was 100%. The specificity of FAST by EPs was 95.4% vs. 98.4% by RRs. The level of agreement was 100%.

This study proves that FAST scan performed by EPs who are trained in short course of ultrasonography can be reliable and accurate when compared to a qualified radiologist.

The pyramid of pain management involves sequential drug escalation but its role is limited in an emergency department (ED). The efficacy of parental opioid analgesics versus non-opioid analgesic in acute pain management of trauma victims in the ED was evaluated to formulate protocol.

All alert patients with a baseline visual analogue scale score (≥ 7) was randomly assigned either parental non-opioid (Group A) or opioid analgesics (Group B). The emergency care providers noted the VAS in either group at 15 minutes, 30 minutes, and 60 minutes, and at the time of discharge from the ED. If the patient's VAS score did not reduce by 50% at 30 minutes, repeat parental analgesics was given. The oral analgesics prescribed at the time of discharge were documented. Ethical clearance was taken. Data was compiled and analyzed.

Of 106 patients, 99 were analyzed. The mean age in Group A was 33.2 ± 13.2 years and 32.5 ± 18 years in Group B. The male:female ratio in Group A was 1.5:1 and 7:1 in Group B. The average baseline VAS score in Group A was 7.5, and that of Group B was 8.96. The average VAS at 15, 30, and 60 minutes and at discharge in Group A was 5.4, 5.34, 4.3, and 3.5 and it was 6.1, 6, 5.1, and 4.4. Repeat parental dose of analgesics were required in 95/99 (95%) patients in Group A and 5% that of Group B. The most common prescription at discharge from ED was non-opioid analgesics.

Acute pain relief was comparable in both groups. Non-opioid analgesics may be preferred over opioid in VAS score ± 7 in a busy emergency department for early disposition.

There is an upward trend in facial injuries following changes in population pattern, increasing industrialization and urbanization, hence maxillofacial trauma is becoming a burden and a leading medical problem in emergency rooms worldwide.

A retrospective study of patients with maxillofacial fractures seen and treated at the Jai Parkash Narayan Apex Trauma Center, AIIMS, New Delhi, India between January 2007 to June 2010. Data extracted from the patients' records include aetiology, age, sex, types and sites of fractures, treatment modality and concomitant injuries.

There were 795 fractures of the maxillofacial skeleton and 86 concomitant injuries from 542 patients. Road traffic accident (56.8%) was the most common aetiologic factor, followed by falls (22.3%) and fights (18.5%). The age range was from 3 years to 75 years (mean = 34.7) with a peak incidence in the 3rd decade with a male–female sex ratio of 3.7:1. The most common location of maxillofacial fractures was the mandible 615(77%) and middle third 205(23%). With regards to mandibular fractures, the body (29.6%) was the commonest sites, followed by the angle (24.4%), ramus (19.5%), dentoalveolar (14.6%), symphysis (11.0%), condyle (0.8%) while in the middle third, the nasal bone (36.7%) was the most common, followed by zygomatic bone (27.8), Lefort II (14.4), Lefort I (7.8%), dentoalveolar (10.0%) and Lefort III (3.3%). Majority of the patients were treated by Open reduction and internal fixation (70.6). Concomitant injuries were 10.8% with orthopaedic injuries accounting for the majority (63.9%). Head injury was associated with 16.3 % of cases.

Maxillofacial fractures are on the increase. We advocate the establishment of regionalized trauma centers with basic training available to all surgical residents for initial emergency room management.

Tourniquets have reappeared in the management of massive hemorrhage and as a tool to ameliorate the effects of reperfusion injury from limb entrapment or suspension trauma, while the patient is rescued to a safer environment. Strategies to minimize subsequent reperfusion injury were investigated in this prospective, randomized study.

In the safety of an operating theater, sixteen fit and healthy patients scheduled for repair of bimalleolar ankle fractures were randomized into two groups. In the standard release group (R, n1 = 6), the tourniquet was fully deflated at the end of surgery. In the staggered release group (SR, n2 = 10), the tourniquet was fully deflated for 30 seconds and subsequently re-inflated to 300mmHg. The procedure was repeated twice at three-minute intervals prior to full removal. Hemodynamic and blood biochemistry measurements were obtained from an indwelling arterial catheter immediately prior to initial tourniquet deflation and thereafter at 1, 4, 7 and 15 minutes.

Serum Ca2 + concentrations were less in group R at 4 (1.027 ± 0.5 vs. 1.084 ± 0.07mmol/l, p = 0.046) and 7 minutes (1.045 ± 0.04 vs. 1.110 + /- 0.06mmol/l, p = 0.013). Serum lactate concentration was greater in group R compared to group SR at 1 (1.75 ± 0.19 vs. 1.33 ± 0.31mmol/l, p = 0.005) and 4 minutes (1.98 ± 0.23 vs. 1.48 ± 0.39mmol/l, p = 0.007), respectively. End-tidal CO2 was less in group SR compared to group R at 1 (4.82 ± 0.45 vs. 5.68 ± 0.26kPa, p = 0.0004) and 4 minutes (5.01 ± 0.59 vs. 5.68 ± 0.35kPa, p = 0.01), respectively. At 15 minutes, less hypotension and bradycardia was noted in group SR.

A staggered tourniquet release was associated with greater hemodynamic stability and reduced the rate of acute systemic metabolic changes associated with limb reperfusion. Re-application of a tourniquet seemed to halt further reperfusion, providing a window period for patient evaluation and management.

Response time performance for emergency calls has been used as an indicator of ambulance service quality in England since 1974. It was revised in 1996 with targets set of eight minutes for life-threatening (category A) and 19 minutes for urgent (category B) calls. Internationally, response time has been used as the benchmark for emergency medical services (EMS) performance. The evidence to support use of response times as a quality measure has been examined.

A rapid review was used to assess the evidence base for the eight minute response time target. Also, a descriptive observational study of the clinical characteristics of category B calls was performed using two months patient report form data from one English ambulance service.

Five papers were identified that have examined the relationship between response time and mortality for 911/999 emergency call populations. Four papers were from the USA, and in all cases no survival benefit was found for response times > 5 minutes even after adjustment for variables including age, sex and illness severity. This finding was replicated in one UK study. The descriptive study examined call characteristics for 26,882 category B calls. Half of the patients received no intervention other than basic vital signs measurement and 75% had assessment only. Twenty-five percent required some clinical intervention with the majority only requiring oxygen. Less than 5% received significant intervention such as drugs, intravenous cannula, or airway management.

With the exception of cardiac arrest there is consistent evidence that response time has no impact on mortality for EMS calls. Alternative indicators of quality of care should be developed that allow less focus on time targets and more effort on innovation and development of services which could better meet the needs of the majority of patients who do not have a life-threatening problem.

The World Health Organization Model Trauma System Policy suggests that Governments should undertake systematic reviews of the de facto prehospital transport systems for severely ill and injured persons. These systems, be they formal or informal, should be designed to optimize local resources with emphasis on standards of training, equipment, infrastructure and communications so as to assure delivery of prompt, quality, and equitable prehospital care. Scope of Review and Assessment a System Assessment and Gap Analysis (SAGA) tool has been developed to measure 127 key components of a high performance emergency transport system within the realms of Clinical, Organizational and Logistical functionality. The evaluation compares the current status of the specific components with those commonly expected to be seen in a formal international accredited EMS organization.

The tool utilizes a thorough investigative process sufficient to produce credible and practical data which can be used to form a “System Improvement Plan.” While the scope of the project can be seen as relatively broad, the assessment process allows for adaptation to a wide variety of EMS system models which bring specific focus to the greatest areas of improvement opportunity with practical applications and alignment with those resources which are available to a given governmental entity.

This abstract, (in both oral and poster presentation format), demonstrates a portional mock evaluation with focus on those components often overlooked by both evolving and mature formal system designs by the international EMS community. The SAGA approach is an invaluable tool for those responsible for integrating the functionality and needs of a broad range of stake holders into the overarching prehospital delivery system in building support for qualitative improvements.

To reduce nationwide door-to-balloon times (DTB) in patients presenting with acute ST-elevation myocardial infarction (STEMI) requiring primary percutaneous coronary intervention (PCI), by adoption of pre-hospital wireless 12-lead electrocardiogram (ECG) transmission by Singapore's national ambulance service.

A phased, prospective, before-after, interventional study of all patients who presented to the national ambulance service with the diagnosis of STEMI. In the ‘Before’ phase, chest pain patients only received 12-lead ECGs on arrival at the Emergency Departments (ED), where diagnosis of STEMI could be made. In the ‘After’ phase, 12-lead ECGs were performed in the field by ambulance crews and transmitted while en-route to the hospitals. Diagnoses of STEMI was made by on-duty emergency physicians (EP) prior to patients' arrival and PCI activated. Data was collected from ambulance run sheets, ECG transmission logs, EDs and cardiology units.

451 eligible patients from “Before” and 214 patients from “After” phase were included in the analysis. Median DTB time was 88 minutes in the “Before” and 52 minutes in the “After” phase (p = 0.0001). During office hours, median DTB times for ‘Before’ and ‘After’ phases were 84 minutes and 47 minutes, respectively (p = 0.0001). After office hours, median DTB times for ‘Before’ and ‘After’ phases were 95 minutes and 54 minutes, respectively (p = 0.0001). There were 11 false positive activations in “Before” phase and one in the “After” phase.

Pre-hospital ECG transmission resulted in significant reduction of DTB time; this effect occurred regardless of whether patients presented to the ED before or after office hours. No increase in false activations was found in the “After” phase. Pre-hospital ECG transmission should be adopted as “standard of care” for all STEMI cases meeting the criteria for PCI.

Overcrowding afflicts emergency departments (ED) worldwide. The CDC has reported that EDs in the metropolitan US provide 1 bed per 1800 patient visits per year on average.

We sought to improve patient flow in our 24-bed ED at Santa Clara Valley Medical Center, a large tertiary public hospital in San Jose, California.

We applied a bundle of interventions based on Lean principles aimed at improving overcrowding in our department step-wise from October 2006 to December 2010, ranging from rapid medical evaluation to physician on arrival. We measured patient volume, left without being seen (LWBS) rates, time to provider (minutes), and time to discharge (minutes) as monthly averages. We secondarily measured CMS core measure performance for pneumonia and STEMI care and patient satisfaction scores.

Our emergency patient volume doubled from an average of 192 to 412 per day (peak). Our LWBS rate decreased from 16.0 to 1.4%. Our time to provider decreased from 86 to 32 minutes. Our time to discharge decreased from 210 to 145 minutes. Core measure performance improved to 100% for all five ED-related metrics. The percentage of patients who ranked their care as excellent increased from 30% to 45%.

The bundle of interventions based on Lean principles applied in our ED appears to have enabled us to significantly improve multiple operational outcomes, despite a doubling of our patient volume in our low capacity ED. Posting a physician on arrival, as the first healthcare worker that a patient meets when they enter the ED, may have had the greatest impact on operational performance.

The prehospital management of a patient starts with a telephone call to and triage by the ambulance dispatcher centre followed by continuous evaluations by ambulance crews and staff at emergency departments.

The aim of this study was to find out if these units have the same triage systems and if the initial evaluation matches the outcome at the hospital emergency departments.

Over 27000 ambulance transports within Gothenburg were studied by evaluating the ambulance medical records with regards to initial triage performed by the ambulance dispatcher centre using a medical index and triage performed by ambulance crews and staff at the emergency departments.

There was no common triage system between these units. We also found a discrepancy between the initial triage using the medical index and physiological-anatomical triage performed by ambulance crews and staff at the emergency departments. As an example 50% of all patients triaged as priority one by the ambulance dispatcher centre were down-graded to priority 2–4 by the other units involved.

A mutual and standardized system for triage is needed. Although over-triaged by ambulance dispatcher centre may be medically motivated, the difference between priorities should be minimized to a medically accepted level (25–35%).

The most obvious deficiency in the current evaluation of disaster response is the lack of objective, quantifiable measures of performance. This frequently leads to assessments that are highly subjective depending on the evaluator, does not provide those who are planning with targets to achieve, and does not allow for measures that they have improved their preparedness. The goal of this research project is to offer recommendations for government agencies at the federal, regional, and local levels, public health departments, and health care institutions to aid in the development of pediatric emergency management performance measures.

The goal was achieved through the application of traditional quality principles to the assessment of emergency management efforts and to the use of innovative analytic methodologies to develop comprehensive approaches to performance measurement in emergency management.

When one discusses performance measures, it is important to remember that these are metrics we use to improve the quality of care. With regard to emergency management, performance measures are used to increase capacity and efficiency. A classic approach to health care performance measures is to discuss them with regard to the domains of structure, process, and outcome. Recently, in addition to these domains, volume has also become an important predictor of clinical outcomes. Although we believe that these domains can be applied to emergency management functions and the development of performance measures for disasters, there are some fundamental differences when compared with their use in development and categorization of traditional health care metrics which have been built in to our modification of these domains to emergency preparedness. This approach, quantitative methodology and consensus development process, when applied, will significantly advance pediatric preparedness. Ultimately, these pediatric specific measures must exist and be used to assess current levels of performance and guide resource allocation and targeted improvement efforts.

Emergency management education and large-scale disaster drills help to increase local capacity for dealing with a multitude of hazards. Video recordings of disaster drills offer participants with little exposure to fundamental emergency management principles an introduction to important topics and scenarios. Such resources allow ongoing training and education, thus maximizing the investment required to mount a large-scale exercise.

During emergency management exercises in Mumbai, India between 2008 and 2010, video recordings of prior exercises were used to augment training for clinicians, administrators and public health practitioners. During the exercises, videos depicting scenario-based disaster drills were produced for use as teaching and evaluation tools focused on pre-hospital care, trauma life support, and hospital operations. Videos are distributed digitally and online, extending the teaching impact of multi-day courses and serving as a benchmark for future exercises.

During the 2010 exercise in Mumbai, approximately eight hours of video footage were recorded by professional producers, and by participants in the evaluation and monitoring track of the course. That footage was added to a library from exercises in Ahmedabad and Mumbai, India, in 2007 and 2008. Video was used as a tool for immediate feedback on participant performance as well as the foundation for ongoing instruction. Videos allowed students to be sensitized to important issues prior to taking part in a drill, and to participate in the post-drill evaluation process.

Video documents of disaster management exercises serve as a valuable addition to an ongoing program of emergency management education and preparedness. Short video pieces increase the effectiveness of a teaching program by providing re-usable, easily accessible, and setting-specific teaching tools.

Limited research has been conducted to understand the relationship between heat wave warnings with public awareness and behavioral changes in the Asian population. The Hong Kong Observatory introduced the “very hot weather warning” in 2000 to alert the public of heatstroke and sunburn in Hong Kong. However, the population's behavioral responses to these weather alerts is unclear. Moreover, the relationship between perceived health risks and behavioral changes has not been examined. The goal of this study is to examine the health risk perceptions and behavioral changes following public heat wave warnings in Hong Kong.

A cross-sectional, population-based, telephone survey, using the last-birthday method was conducted within two weeks following a heat wave warning in 2009. A heat warning and a health study instrument, based on Intergovernmental Panel on Climate Change (IPCC) guidelines and related literature was developed and validated. Descriptive and multivariate logistic regression analyses were conducted.

The questionnaire was completed by 1,123 individuals whose socio-demographic characteristics were comparable to 2009 Hong Kong population census data. Of respondents, 83.6% were aware of the heat wave weather warning. Multivariate logistic regression of socio-demographic factors indicated that being female, those in middle age groups, and those with higher educational attainment was significantly associated with heat wave warning awareness. Among those aware of the public warning, the majority were unconcerned about potential adverse health effects, < 40% were aware of the community heat-related preparedness plans, and < 50% changed their behavior to mitigate the potential adverse health impacts of hot weather.

This is the first study to examine climate change and health behavioral responses in an urban Chinese population. Future research direction should further investigate correlations between awareness and health protective actions, as well as the drivers for health behavioral changes that mitigate the impact of climate change.

Recordings of heatwaves date back to the early 1900s and usually are associated with high mortality. In Australia, heatwaves have been the major cause of natural hazard-related deaths. Heatwaves usually do not carry the global media coverage associated with other disasters, and frequently, are referred to as silent disasters. The main impact of heatwaves is on health and human life.

Preliminary results are presented for the 2009 heatwave, investigating the emergency department patient presentations from three public hospitals in Adelaide, a city in the central southern area of Australia.

Demographic and syndromic data were obtained from emergency department records. Ethics permission was obtained prior to data collection. Heatwave conditions occurred from 26 January–07 February 2009. Two non-heatwave periods were day-matched approximately two weeks before and after the heatwave. Data were analyzed by age groups, gender, and ICD codes for chronic conditions.

The two largest groups of people presenting were between 15 and 64 years of age and > 75 years of age during the heatwave and non-heatwave periods. During the heatwave period, both groups had significant increases in patient presentation related to renal problems (ICD 10: N000-N3999) and dehydration and hyperthermia (ICD10: E86, T67). The latter syndrome was far more accentuated during the heatwave, with emergency department patient presentations rising from 2 (non heatwave) to 62 presentations for the 15 and 64 years cohort and from 4 (non heatwave) to 91 for the > 75 years cohort. Cardiovascular- and respiratory-related presentations showed slight increases during the heatwave, while mental health had high presentations for the 15–64 year cohort throughout heatwave and non heatwave periods.

Both young and older people were affected by heatwave, and precautionary warning should be used throughout the community to alert people of the dangers underlying extreme heat conditions.

In 2007, several atoll islands in the Federated States of Micronesia (FSM) were inexplicably flooded by sea water.

To describe the impact of an acute-onset sea-level-rise disaster in 2 coral atoll populations.

Households of Lukunoch and Oneop islands, FSM were assessed for demographics, asset damage, food availability, and water quantity and quality. Every fourth household on Lukunoch, (n = 40), was randomly selected and surveyed. All Oneop households were surveyed (n = 72). Prevalence data were analyzed.

A total of 112 total households were surveyed representing 974 inhabitants. On Lukunoch, roughly half of all households surveyed reported at a partial loss of their primary dietary staple and source of calories (taro and breadfruit). Six (15%) of 40 Lukunoch households surveyed (95% CI, 6%–30%) reported a complete loss of taro and four (10%) of the 40 households (95% Cl. 3%-24%) reported a complete loss of breadfruit. On Oneop, nearly all households reported at least a partial loss of these same food staples. Twenty four (31%) of all 76 Oneop households reported a complete loss of taro and another 24 (31%) households reported a complete loss of breadfruit. One third of all households surveyed reported a complete loss. On Lukunoch 11(28%) of 40 households, (95% Cl. 15%–43%) reported damage from well salination, but none were damaged to the point of a complete loss. Forty-nine (64%) of 76 Oneop households reported salination and five (6%) reported complete loss of their well.

These findings suggest that FSM populations experienced disastrous losses due to a sea level rise event damaging crop productivity and freshwater sources.

The Republic of Palau, like other small, island, developing states, is particularly vulnerable to climate change due to a number of factors, including: (1) small size; (2) remoteness; (3) limited natural resources; and (3) vulnerability to disasters and extreme weather events. Other factors include social and economic factors such as: (1) economies sensitive to external shocks; (2) high population growth rates and densities; (3) poorly developed infrastructure; (4) limited financial and human resources; and (5) emigration. The (US) Centers for Disease Control and Prevention (CDC) partnered with the Republic of Palau Ministry of Health (MoH) and Southern Illinois University (SIU) to investigate public health consequences in Palau. The goal of the project is to reduce morbidity and mortality due to climate change in Palau by improving awareness using three tools: (1) a photojournalism book to document the local experience in Palau; (2) a marketing campaign to increase awareness in Palau about climate change as it relates to human health; and (3) a Website to raise regional and international awareness of the findings, and act as a forum for discussion and resource-sharing.

The CDC, SIU, and Palau MoH conducted interviews with community members including government officials, traditional leadership, fishermen, gardeners, physicians, scientists and local residents to explore their experiences concerning climate change in their community. Photojournalists took thousands of images documenting locally identified effects of climate change that were perceived as having direct or indirect health consequences for the people of Palau.

Coral bleaching, beach erosion, irregular rainfall, sea level rise, and salt water inundation directly impact food security and tourism in Palau, while other less obvious, but important consequences, such as potential loss of traditional practices and cultural identity were also identified.

The people of Palau reported significant impact from climate change on agriculture, economics, health, and culture.

In the 2011 East Japan Great Earthquake over 200 DMAT immediately headed to the disaster stricken area.

Land lines and all mobile telephones had interrupted service. Radio communication could only be used at a short distance in one area. Satellite phones were the only means of communication, but since there were limited number of devices, power shortages. DMAT used a management browser called EMIS (Emergency Medical Information System) to exchange information and coordinate activity, but the internet itself did not work. Without communication equipment, the victims could not send or receive information and even DMAT had trouble understanding the situation. There was rumor of many victims in a wide range of isolated evacuation shelters that were left behind. The land was flooded, vehicles were carried away, the town was buried under debris and mud, and fires occurred one after another. The wounded and sick could not access hospitals immediately. Because of the blackout, the suspension of the water supply, and prospect of restoring heating were not in sight, an immediate confirmation of medical needs and triage of the sick and wounded were required. Therefore, as the disaster front headquarters, the fire department, police department, self-defense force, Japan Red Cross medical care relief squad, the city, the prefecture, and the public health center, many organizations in collaboration held meetings every day at 5:30 and 18:30 aiming to gather information and establish strong collaboration. Four teams from the Japan Red Cross medical care squad and 4 teams from the Ground Self-Defense force were dispatched in replacement of the insufficient DMAT to manage the disaster front. They restored roads and headed to isolated shelters and hospitals. With the cooperation of the Air Self-Defense Force, DMAT was sent by helicopter to an isolated peninsula.

We use helicopters, ambulances, and Self-Defense Force vehicles to transport as many patients to hospitals in other regions, because there was no place to return home. In one of the isolated hospitals, they had to use candlelight in a room temperature below zero, they were unable to use the aspirator, and four patients were already deceased. The remaining 38 inpatients were transported out of the disaster area and preventable death could be prevented.

Because the local staff suffered damage from the earthquake, all organizations consisted of groups dispatched from other regions. With a communications network not functioning in the disaster stricken area, it is necessary to exchange information and share the best plans. Taking this into perspective, having two disaster relief measures meetings in one day was very effective.

Upon arrival of the SUNY Downstate Medical Center team for their disaster relief mission in Port au Prince, Haiti, it was observed that obstacles to patient care were directly related to difficulty in locating supplies and medications in a timely manner. In addition, staffing schedules had not been correlated to patient flow patterns.

A survey was conducted at L'Hôpital de l'Université d'Etat d'Haïti (HUEH) in Port au Prince, Haiti by Emergency physicians and nurses from SUNY Downstate Medical Center. The following variables were obtained to assess existing resources: number and types of providers available, provider staffing schedules, medication/supply inventories and management systems. Basic ED operation and supply system flow maps were created.

The assessment revealed a large volume of patients presenting in the early morning. Night shifts were inconsistently staffed with ED physicians. Although medications and supplies were reported to be available on-site, they were not tracked, inventoried, or centrally managed. As a result, this increased time to treatment and practitioner fatigue. Process improvements included: (1) Institution of swing and night shifts accommodated peak patient volumes, decreased waiting times, provided care for critical patients during off-peak hours, and decreased physician fatigue. (2) Identification and labeling of existing medications/supplies facilitated more accurate management of inventories and decreased time to treatment and disposition.

Process improvement through systematic analysis led to better disaster resource utilization in this tent hospital.