Descriptive record of the activity of military critical care transfer teams deployed to London in April 2020 to undertake transfer of patients with COVID-19.

In the face of the COVID-19 outbreak, military healthcare teams were deployed to London to assist the London Ambulance Service t transfer ventilated patients between medical facilities. This paper describes the preparation and activity of these military teams, records the lessons identified (LI) and reviews the complications encountered'. The teams each had two members. A consultant or registrar in emergency medicine (EM) and pre-hospitalemergency medicine (PHEM)E or anaesthesia and an emergency nurse or paramedic. Following a period of training, the teams undertook 52 transfers over a 14-day period. LI centred around minimising both interruption to ventilation and risk of aerosolisation of infectious particles and thus the risk of transmission of COVID-19 to the treating clinicians. Three patient-related complications (6% of all transfers) were identified. This was the first occasion on which the Defence Medical Services (DMS) were the main focus of a large-scale clinical military aid to the civil authorities. It demonstrated that DMS personnel have the flexibility to deliver a novel effect and the ability to seamlessly and rapidly integrate with a civilian organisation. It highlighted some clinical lessons that may be useful for future prehospital emergency care taskings where patients may have a transmissible respiratory pathogen. It also showed that clinicians from different backgrounds are able to safely undertake secondary transfer of ventilated patients. This approacmay enhance flexibility in future operational patient care pathways.

Blood Pressure, Orthostatic Hypotension and Falls in Patients with Advanced Cancer.

Aim Orthostatic Hypotension (OH) is an indicator of deteriorating autonomic dysfunction. Adherence to BP and OH measurement guidelines in an inpatient specialist palliative care unit (SPCU) was unknown. Compliance of BP and OH measurement in an advanced cancer cohort was audited. Methods A retrospective analysis of four consecutive months of patients admitted with an advanced cancer diagnosis to the inpatient SPCU was conducted. Data was obtained from 168 clinical records, and audited against current institutional clinical standards. Results Falls risk screening including BP and OH measurements were not measured on admission in 19% (n=32) cases as recommended by institutional guidelines. Where falls risks were identified in 94 (69%) patients only 71 (76%) of these had completed risk assessments. OH testing was incomplete or not conducted in 59% (n=42) of risk assessments. This had patient care and safety implications e.g. under-reporting falls risk. In addition, institutional guidelines were inflexible in clinical practice specific to a palliative care cohort of patient. Conclusions Institutional guidelines need regular reviewing. In cases where a healthcare professional determines it is inappropriate to perform an assessment, we recommend a modification to the tools allowing for recording of this decision. OH is an underestimated reality in hospice populations and the impact on hospice services is worthy of further study.

Health risk analysis of human exposures to soil amended with sewage sludge contaminated with polychlorinated dibenzodioxins and dibenzofurans.

The risk of cancer to humans exposed to soil treated with wastewater/sewage treatment plant sludge, known to be contaminated with small amounts of polychlorinated dibenzodioxins and dibenzofurans (PCDDs and PCDFs), was evaluated. The particulate-bound PCDDs and PCDFs are found in trace amounts in the effluent from ground water pumping (dewatering) at an abandoned wood preservation facility. The water, which was sent to a water recovery plant, underwent primary and secondary treatment prior to discharge. The residual sludge was added to agricultural soil as a conditioner. The present analysis treats the extreme case of sludge applied near the home of a target individual, a lifetime resident, who is also a farm worker in the area of the application. The successive stages of infancy, childhood and adulthood are treated separately to assess the contributions of typical age-specific indoor and outdoor activities on exposure rates. Five toxicity rating schemes using so-called TCDD equivalents, and two unit risk slopes are applied to the chemical profile in sludge to determine the cancer potency of the soil contaminants. These risk estimates range from 1 X 10-8 to 3 X 10-7.

Health risks of PCB spills from electrical equipment.

The Southern California Edison Company (SCE) has instituted a series of control strategies designed to minimize human exposure to polychlorinated biphenyls (PCBs) in electrical equipment used on its system. This paper describes a method of analyzing PCB risks using conservative estimates of human intake of PCBs originating from accidental spills from electrical equipment. The PCB releases from the Edison system were determined. The fate of these releases in soil, air, and water was analyzed to determine how much material reaches human receptors. The air and water pathways were determined to be the most likely candidates for the exposure and risk considerations. PCB intake via ingestion of soil at the spill site was neglected as an exposure pathway. Equipment spills without controls resulted in at the most 2 ng/day human intake of PCBs via the water exposure pathway. This was determined to be negligible in comparison with intake rates used in conjunction with the setting of food tolerance levels based on fish being the main dietary pathway of human exposure. The inhalation exposure of the hundred or so persons in the immediate vicinity of a spill was determined to equal the PCB intakes of the fish-eating subpopulation analyzed by the Food and Drug Administration for 2 ppm tolerance standard in the case of no controls or cleanup. Current cleanup procedures assure that even the persons in the immediate area are well below the intake of the subjects in the fish contamination analysis. All exposures were well below a "virtual safe dose" level estimated in the fish tolerance study.