Application of pressure infusion bags may increase intravenous (IV) flow rates three-fold. Commercially available pressure infusers, manual squeezing of the IV fluid bag, inflating a blood pressure (BP) cuff around the bag, and kneeling on the bag have been used by prehospital personnel attempting to augment fluid infusion rates. To test the efficacy of each these methods, seven experienced paramedics were asked to employ each method in two trials using a 1-liter bag of saline though a 14-gauge, 5.7cm catheter and a standard administration set. Gravity flow from 80cm served as the control.

Pressure infusers generated flow rates of 257±54 ml/min and 296±53 ml/min when inflated to 300 mmHg and maximum pressure respectively. This rate was 2–2.5 times that of gravity flow (123±2 ml/min) and significantly greater than those rates obtained by any other method (p<.0005). Manually squeezing the bag also was significantly better than was gravity flow with flow rates of 184±46 ml/min and 173±40 ml/min achieved by each of two different squeezing methods (p<.01). Neither blood pressure (BP) cuff application and inflation (135±28 ml/min) nor kneeling on the bag (125±36 ml/min) was better than gravity alone.

These results indicate that pressure infusers should be used to the exclusion of other field methods of supplying infusion pressure. If pressure infusers are not available, manually squeezing the bag is the only alternative acceptable in the field.

Patients evaluated by paramedics but not transported by ambulance to the hospital (“no-patient” runs or NPR) form a large part of the volume of ambulance runs in many emergency medical service (EMS) systems and account for 50–90 % of litigation brought against paramedics. Since there are no published studies of this important population, this paper provides a demographic description of the encounters and the prehospital patient disposition in one EMS system. Of all EMS runs for 1987 in the system studied, 2,698 (26.1 %) met NPR criteria. Mean run time for the NPR was 18.5±10.5 min versus 43.1 min for patients transported. The proportion of NPR was unrelated to sex or EMS response type, but was increased in those over age 40 years (p<.001) (Chi square), but was less for those over age 50 years (p<.001) compared to all ages. The proportion of NPR was associated with hour of the day (p<.01), with the highest proportion seen between 0000–0559 hours when overall run volume was lowest. The most frequent prehospital assessments in NPR were minor trauma (25.3 % of NPR), blunt head trauma (18.5%), and no illness or injury (15.9%). Most NPR patients were evaluated by medics and released (46.5%), while 22.7% sought medical care by private vehicle. Treatment or monitoring was performed in 17.6% and refused in 23.8% of NPR cases. Patient disposition was: released to friends/relatives (39.1%); presumed alone (35.5%); to police (18.2%); or other medical care (7.3 %). Medical control physician contact was not required, but was used in 2.1% of NPR cases.

This is the first study of NPR in an EMS system. It describes patient demographics, disposition, and differences from transported patients. Emergency Medical Services providers specifically should examine this population in their systems to maintain patient care standards and decrease medicolegal risks.

Prolonged EMS response times are a significant problem in rural areas. In this study, VHF radios and personal medical kits were placed in the private vehicles of rescue squad members. By coordinating the responses using radios, higher level EMTs were sent directly to the scene to initiate patient assessment and other procedures while others proceeded to an unstaffed station to pick up the rescue truck.

Using this response system, EMTs arrived at the scene prior to the rescue vehicle on 30 of 35 calls (85.7%). In 25 of 35 calls (71.4%), the first person at the scene was at an advanced EMT level even though the majority of responses (56%) were made by Basic EMTs (p<0.001). The mean response time for EMTs using privately owned vehicles was 9±4 minutes (means±SD) compared with 16±9 minutes for the rescue truck (p<0.01). There also was a significant difference in response times between the privately owned vehicles and the rescue truck when the time between the receipt of the call and the initial acknowledgement of response was measured (1±1 minutes vs. 7±3 minutes; p<0.01).

An effective EMS response can be made in rural areas by sending EMTs directly to a scene in private vehicles. Providing EMTs with VHF radios and personal medical kits enhances this response.

Medical emergencies occur in every country regardless of its level of socio-economic development. Little comparative data are available which define the characteristics of the system by which some emergencies are managed. Without such comparisons, it is difficult for countries to establish appropriate priorities within their geographic, cultural, and economic constraints. In an effort to gather some of these needed data, a survey was distributed to the participants in an International Conference on Emergency Health Care (EHC) Development convened in Washington, D. C, in August 1989. Each country participating was classified as Industrialized (INDUS), Developing (DC), or Least Developed (LDC) in accordance with World Health Organization definitions. Responses are expressed as proportion of total participants.

There were 450 participants from 74 countries. Only 17% of the surveys were returned. The sample included 78 participants from 40 (57%) countries. (INDUS: 30%; DC: 48%; LDC: 22%). All showed considerable dependence on ambulance services, but DC and LDC indicated substantial reliance on friends, neighbors, community health workers, and physician's offices. Prehospital EHC services were available to 93% of INDUS, 63% of DC, and possibly one-third of the LDC. Emergency Health Care is taken to the patients in the same proportions as noted above. The types of manpower dispatched varied widely with a great proportion of the respondents from DC and LDC indicating that care was delivered by non-professionally trained individuals. Interestingly, INDUS had the greatest proportion of volunteers. Response and transport times were shorter for INDUS than for DC. When no prehospital EHC services were available, patients reached the receiving facilities by alternate means such as walking (33%), private automobile (48%), or public transportation (33%). Central emergency access was available for 80%. Considerable variation exists as to the mechanisms by which such services are financed: poorer countries depend more on government support than do INDUS who rely heavily on donations and fee-for-service. Lastly, regardless of level of economic development, cardiovascular disease, trauma, and medical illness comprise the most important reasons for accessing the EHC systems.

This preliminary study points to the need for individualizing EHC systems in concert with the priorities of the country for which they are designed. Direct application of operational systems across countries does not seem an appropriate mechanism for the development of EHC. However, the delivery of EHC must be made an important element of overall health care in all the countries of the world.

The study of a disaster which has occurred cannot be researched using the traditional techniques as it is not possible to conceive or conduct controlled, randomized experiments for such an event. Paper I of this series described non-experimental, scientific methodologies which were applied to study the detection-extrication-resuscitation activities which occurred following the devastating 1988 earthquake in the Republic of Armenia, USSR. This paper critically evaluates the methodologies used for the Armenia study and proposes modifications in these methods for application to the study of future disasters.

Approaches which could be applied to the study of future disasters are defined and critically evaluated from the view of reliability, validity, costs, and practicability. The revised set of protocols is discussed in terms of: 1) the structured interview process; 2) training of personnel to conduct, synthesize, and evaluate the interviews; 3) the time required to complete the interview process; 4) sampling techniques; 5) mechanisms for cross-checking the data; and 6) the addition of preliminary data collection immediately following or during the event. Use of this revised approach should assist in the collection and analysis of data associated with future disasters so that it is possible to: 1) further enhance life-saving and reduce mortality; 2) improve relief efforts; 3) reduce damage to communities; 4) evaluate the long-term effects of such events; and 5) assist in better preparation for future events.

The study of disasters has become a new, applied science. The increasing global population is dependent on fragile links of communication and transportation, and the modern technology of weaponry has led to new forms of armed conflict. These combined factors have made our need to understand the process of disaster research ever more pressing. Similarly, workers and researchers in the field must reappraise their methodologies and their contributions to the literature of catastrophe. The end result of good research and its promulgation in journals, articles, and even press conferences should lead to the saving of lives, the protection of property, and the stability of our communities. Hastily performed research and misleading reporting can and does lead to unnecessary death and injury, and to the wasteful expenditure of scarce resources.