Assessment of hospital surge capacity using the MACSIM simulation system: a pilot study.

AIM: The aim of this study was to use a simulation model developed for the scientific evaluation of methodology in disaster medicine to test surge capacity (SC) in a major hospital responding to a simulated major incident with a scenario copied from a real incident. METHODS: The tested hospital was illustrated on a system of magnetic boards, where available resources, staff, and patients treated in the hospital at the time of the test were illustrated. Casualties were illustrated with simulation cards supplying all data required to determine procedures for diagnosis and treatment, which all were connected to real consumption of time and resources. RESULTS: The first capacity-limiting factor was the number of resuscitation teams that could work parallel in the emergency department (ED). This made it necessary to refer severely injured to other hospitals. At this time, surgery (OR) and intensive care (ICU) had considerable remaining capacity. Thus, the reception of casualties could be restarted when the ED had been cleared. The next limiting factor was lack of ventilators in the ICU, which permanently set the limit for SC. At this time, there was still residual OR capacity. With access to more ventilators, the full surgical capacity of the hospital could have been utilized. CONCLUSIONS: The tested model was evaluated as an accurate tool to determine SC. The results illustrate that SC cannot be determined by testing one single function in the hospital, since all functions interact with each other and different functions can be identified as limiting factors at different times during the response.

Development and evaluation of a new simulation model for interactive training of the medical response to major incidents and disasters.

BACKGROUND AND AIMS: The need for and benefit of simulation models for interactive training of the response to major incidents and disasters has been increasingly recognized during recent years. One of the advantages with such models is that all components of the chain of response can be trained simultaneously. This includes the important communication/coordination between different units, which has been reported as the most common cause of failure. Very few of the presently available simulation models have been suitable for the simultaneous training of decision-making on all levels of the response. In this study, a new simulation model, originally developed for the scientific evaluation of methodology, was adapted to and developed for the postgraduate courses in Medical Response to Major Incidents (MRMI) organized under the auspices of the European Society for Trauma and Emergency Surgery (ESTES). The aim of the present study was to describe this development process, the model it resulted in, and the evaluation of this model. METHODS: The simulation model was based on casualty cards giving all information normally available for the triage and primary management of traumatized patients. The condition of the patients could be changed by the instructor according to the time passed since the time of injury and treatments performed. Priority of the casualties as well as given treatments could be indicated on the cards by movable markers, which also gave the time required for every treatment. The exercises were run with real consumption of time and resources for all measures performed. The magnetized cards were moved by the trainees through the scene, through the transport lines, and through the hospitals where all functions were trained. For every patient was given the definitive diagnosis and the times within certain treatments had to be done to avoid preventable mortality and complications, which could be related to trauma-scores. RESULTS: The methodology was tested in nine MRMI courses with a total of 470 participants. Based on continuous evaluations and accumulated experience, the setup of the simulation was step-wise adjusted to the present model, including also collaborating agencies such as fire and rescue services as well as the police, both on-scene and on superior command levels. The accuracy of the simulation cards for this purpose was evaluated as "very good" by 63 % of the trainees and as "good" by 33 %, the highest two of the six given alternatives. The participants' ranking of the extent that the course increased their competencies related to the given objectives on a 1-5 scale for prehospital staff had an average value of 4.25 ± 0.77 and that for hospital staff had an average value of 4.25 ± 0.72. The accuracy of the course for the training of major incident response on a 1-5 scale by prehospital staff was evaluated as 4.35 ± 0.73 and that by hospital staff as 4.30 ± 0.74. CONCLUSIONS: The simulation system tested in this study could, with adjustments based on accumulated experience and evaluations, be developed into a tool for the training of major incident response meeting the specific demands on such training based on recent experiences from major incidents and disasters. Experienced trainees in several courses evaluated the methodology to be accurate for this training, markedly increasing their perceived knowledge and skills in fields of importance for a successful outcome of the response to a major incident.

Prehospital triage, discrepancy in priority-setting between emergency medical dispatch centre and ambulance crews.

BACKGROUND: The timely provision of emergency medical services might be influenced by discrepancies in triage-setting between emergency medical dispatch centre and ambulance crews (ACR) on the scene resulting in overloaded emergency departments (ED) and ambulance activities. The aim of this study was to identify such discrepancies by reviewing ambulance transports within a metropolitan city in the western region of Sweden. METHODS: All data regarding ambulance transports in Gothenburg, Sweden, during a 6-month period were obtained and analyzed by reviewing the available registry. RESULTS: There was a discrepancy between emergency medical dispatch centre and ACR in priority setting, which may result in a number of unnecessary transports to the hospital with consequent overloading of ED and a negative impact on ambulance availability. CONCLUSION: Appropriate ambulance use is one important part of emergency preparedness. Overuse results in decreased emergency medical services (EMS) availability and ED-overcrowding. Several factors, such as an imprecise triage system and increased public demands, may influence such overutilization. Improving the triage system and comprehensive public education on appropriate use of ambulances are two important steps toward a better use of national EMS resources.

Estimation of healthcare resources at sporting events.

BACKGROUND: The consequences of a major incident at a sporting event could be catastrophic. Therefore, there should be an estimation of the healthcare resources at such events as part of the planning. Although there are National guidelines (e.g., Planning Safe Public Events: Practical Guidelines in Australia) defining the role of the healthcare system at sporting events, these guidelines either lack a simple calculating method to estimate the need for healthcare resources or the methods are complex and impractical to use. The objective of this study was to find a safe and easy method for the estimation of healthcare resources at sporting events. METHODS: A model for the estimation of healthcare resources at music events recently has been approved in Sweden. After minor adjustments, this model was used at sport events by a number of planning officers. The models' accuracy and usability was evaluated by analyzing its outcome in a pilot and a controlled study using different sporting and non-sporting scenarios. RESULTS: The pilot study showed that the model was valid and easily could be used for various sporting events. The obtained estimations were consistent with the methods used by experienced planning officers in 97% of cases. The results of the controlled study showed that by using this model, the minimum amount of resources required easily could be calculated at sporting events and by people with different backgrounds. CONCLUSIONS: This model safely can be used at sporting events.

Effects of three months of low molecular weight heparin (dalteparin) treatment after bypass surgery for lower limb ischemia--a randomised placebo-controlled double blind multicentre trial.

OBJECTIVES: To test the hypothesis that long-term postoperative dalteparin (Fragmin), Pharmacia Corp) treatment improves primary patency of peripheral arterial bypass grafts (PABG) in lower limb ischemia patients on acetylsalicylic acid (ASA) treatment. DESIGN: Prospective randomised double blind multicenter study. MATERIALS AND METHODS: Using a computer algorithm 284 patients with lower limb ischemia, most with pre-operative ischemic ulceration or partial gangrene, from 12 hospitals were randomised, after PABG, to 5000 IU dalteparin or placebo injections once daily for 3 months. All patients received 75 mg of ASA daily for 12 months. Graft patency was assessed at 1, 3 and 12 months. RESULTS: At 1 year, 42 patients had died or were lost to follow-up. Compliance with the injection schedule was 80%. Primary patency rate, in the dalteparin versus the control group, respectively, was 83 versus 80% (n.s.) at 3 months and 59% for both groups at 12 months. Major complication rates and cardiovascular morbidity were not different between the two groups. CONCLUSIONS: In patients on ASA treatment, long-term postoperative dalteparin treatment did not improve patency after peripheral artery bypass grafting. Therefore, low molecular weight heparin treatment cannot be recommended for routine use after bypass surgery for critical lower limb ischemia.

Disaster preparedness in Scandinavia.

Disaster preparedness in Scandinavia is being improved on the national level, with increased cooperation between the different countries following 9/11. However, focus so far has been largely directed against CBRN threats. The reduction of hospital beds along with centralisation of advanced care as well as financial strains will enforce a closer cooperation between the health boards. The federal health care authorities must have a clear-cut responsibility and mandate to coordinate the nations health care systems in peacetime disasters, and not only during war. This reorganisation has just merely begun.

Cardiovascular injuries associated with sternal fractures.

OBJECTIVE: To find out if the presence of a sternal fracture indicates cardiac and aortic injuries and to clarify the difference between a retrosternal haematoma and widened mediastinum. DESIGN: Retrospective study. SETTING: Teaching hospital, Sweden. SUBJECTS: 418 patients with blunt chest trauma of whom 29 had a fractured sternum (11 with retrosternal haematoma and 18 without) and 389 did not (7 with widened mediastinum and 382 without). MAIN OUTCOME MEASURES: Definitions, risk factors, morbidity, and mortality. RESULTS: Retrosternal haematomas were found adjacent to many fractures and ranged in size from a few mm to 2 cm. They were more common in fractures of the body of sternum. There was no significant difference in the number of associated lesions between patients with sternal fractures with or without a retrosternal haematoma. Conversely, patients with a widened mediastinum had a higher injury severity score, longer hospital stay (p < 0.0001), and more associated lesions (p < 0.05) than those with retrosternal haematomas. Six patients still had pain 1 month after injury of whom two had injury-related long-term disability because of pain. No serious cardiac or aortic injuries were detected in this series. The early mortality in our study was 2/29 in patients with sternal fractures and 1/7 in patients with widened mediastinum. CONCLUSIONS: Sternal fractures are more common than previously reported. An aggressive approach including early operative reduction is recommended even for a stable fracture to reduce the overhelming pain. Sternal fracture with or without retrosternal heamatoma is not a reliable indicator of cardiac and aortic injuries, while mediastinal widening is still a fairly reliable clue that should indicate further investigation.

Thoracic vascular injuries: a major problem in trauma.

OBJECTIVE: We present a review of our experience in the management of thoracic vascular injuries during the past 10 years in one of Sweden's busiest emergency departments, with morbidity and mortality as the main outcome measures. DESIGN: Of eight patients who sustained chest trauma with thoracic vascular injuries, six presented with shock. Angiography was the gold standard in diagnosing aortic and subclavian injuries. RESULTS: Lesions of the inferior vena cava, left internal mammary artery, and intercostal vessels were detected only at surgery. Two patients died of exsanguination. Managing thoracic vascular injuries is still difficult and challenging for thoracic and trauma surgeons. CONCLUSION: Early thoracotomy is important for salvage of patients with chest-wall vascular injury. Despite our limited experience, which is characteristic for Scandinavian and European countries, our results were satisfactory.

Nomenclature, classification, and signficance of traumatic extrapleural hematoma.

BACKGROUND: Extrapleural hematoma has been found mostly in single case reports as diagnoses with different names. Although huge extrapleural hematoma can cause ventilatory and circulatory disturbances and even death, it has received almost no attention in the literature. Certain basic and modern facts need to be clarified regarding the definition, classification, and significance of extrapleural hematoma in the practice of chest trauma. METHODS: A 10-year retrospective study was undertaken to analyze the incidence, diagnosis, management, morbidity, and mortality of patients with chest trauma and a documented extrapleural hematoma. RESULTS: The incidence of traumatic extrapleural hematoma was 34 of 477, 7.1%. The incidence of thoracic lesions was 86 of 34 = 2.5 lesions per patient, whereas the incidence of extrathoracic lesions was 30 of 34 = 0.9 lesions per patient. Associated rib fractures were found in 30 of 34, 88.2%. More than half of the patients had an associated hemothorax. A thoracotomy was used successfully to remove a huge hematoma in one patient. CONCLUSION: Extrapleural hematoma has been found to be more common than previously reported. Nomenclature and classification are suggested. One of the common injuries to the chest, particularly rib fracture, hemothorax, lung contusion, or pneumothorax might provide the surgeon with a reliable clinical clue that the patient is at inordinate risk to have associated extrapleural hematoma. A formal or mini-thoracotomy is the recommended procedure in cases of huge hematomas.

[Disaster management lessons can be learned from the Gothenburg fire]. / Katastrofmedicinska lärdomar kan dras av Göteborgsbranden.

On the night of October 29, 1998, a fire broke out in an old warehouse in Gothenburg, where nearly 400 teenagers had gathered for a disco party. More than 200 patients were brought to four different hospitals in the region. Sixty-one people died at the scene due to inhalation of toxic fumes caused by the fire. Another two died later in the hospital due to severe burns. Disaster management in Sweden is based on mobile medical teams consisting of hospital staff supporting ambulance crews in the event of major incidents. Only one team together with a GP was able to be mobilized during this incident. Thus, medical care at the scene was limited. The principle of OEload and go pi was used, placing the major burden of triage on the hospitals. The limited numbers of medical personnel and available supplies caused major stress for the physicians involved at the scene.

Cardiac injuries: a ten-year experience.

OBJECTIVE: To present our experience of cardiac injuries treated at one Swedish emergency department in the 10 years 1988-97. DESIGN: Retrospective study. SETTING: Teaching hospital. SUBJECTS: 11 patients (9 men and 2 women, mean age 33 years, range 19-54); in 7 they were penetrating injuries and in 4 blunt. MAIN OUTCOME MEASURES: Morbidity and mortality. RESULTS: The mechanisms of injury were stab wound (n = 7), and car crash, fall, boat crash, and abuse (n = 1 each); drug or alcohol misuse played a part in all those with penetrating injuries. The penetrating wounds involved the left ventricle (n = 3), the right ventricle (n = 2), and the pericardium (n = 2). All 5 patients with ventricular wounds presented with cardiac tamponade, in 1 of whom it was fatal (he bled to death during emergency thoracotomy). The main complications were anoxic brain damage and postpericardiotomy syndrome (1 each). There was no case of myocardial concussion. CONCLUSION: Our data reflect the Swedish experience of heart trauma: there are few cases, alcohol and drug misuse is the principal risk factor, and there were no gunshot wounds.

Outcome of lung trauma.

OBJECTIVE: To find out whether we could manage critical pulmonary haemorrhages in penetrating injuries, and to report our experience with blunt trauma of the lung. DESIGN: Retrospective study. SETTING: Teaching hospital, Sweden. SUBJECTS: 81 patients who presented with pulmonary injuries during the period January 1988-December 1997; 6 were penetrating and 75 blunt. RESULTS: There was only one patient with an isolated lung contusion. The remaining was divided into 2 groups: those with pulmonary contusion and thoracic lesions (n = 32), and those with pulmonary contusion and extrathoracic lesions (n = 42). Four patients in the penetrating group were shocked and required urgent operations; emergency room thoracotomy (n = 1), urgent thoracotomy (n = 2), and urgent thoracoabdominal exploration (n = 1) were done successfully. We correlated grade of lung injury [American Association for the Surgery of Trauma-Abbreviated Injury Scale (AIS)] with mortality. All patients with penetrating injuries survived without serious consequences. There were a mean (SD), of 6 (2) injuries/patient in those with extrathoracic injuries compared with 3 (1) injuries/patient in the group with thoracic lesions (p < 0.001). The corresponding hospital mortality was 6/42 (19%) mainly as a result of the central nervous system lesions (4/6) compared with 0/32. The mean (SD) Injury Severity Score (ISS) was 9.3 (4.8) in patients with thoracic lesions compared with 24.1 (14.7) in patients with extrathoracic lesions (p < 0.0001), and 14.9 (9.5) in all survivors compared with 49.9 (13.6) among those who died (p < 0.0001). CONCLUSIONS: An excellent outcome can be achieved managing penetrating injuries of the lung by an aggressive approach and urgent surgical intervention even when emergency room thoracotomy is essential. Pulmonary contusion is considered to be a relatively benign lesion that does not add to the morbidity or mortality in patients with blunt chest trauma. These data may help to decrease the obsession with pulmonary contusion in patients with chest trauma, with or without extrathoracic lesions, and avoid many unnecessary computed tomograms of the chest.

Intravenous ondansetron for the control of opioid-induced nausea and vomiting. International S3AA3013 Study Group.

This randomized, double-masked, placebo-controlled, multicenter trial was conducted in 9 countries to assess the safety and efficacy of 2 doses of intravenous ondansetron (8 and 16 mg) for the control of opioid-induced nausea and vomiting. A total of 2574 nonsurgical patients who presented with pain requiring treatment with an opioid analgesic agent participated in this trial. The most common presenting painful condition was back or neck pain, reported by approximately one third of patients. A total of 520 patients (317 females, 203 males) developed nausea or vomiting after opioid administration and were randomly assigned to receive a single dose of 1 of 3 study treatments: placebo (n = 94), ondansetron 8 mg (n = 215), or ondansetron 16 mg (n = 211). Ondansetron 8 and 16 mg led to complete control of emesis in 134 of 215 patients (62.3%) and 145 of 211 patients (68.7%), respectively. Results with both doses were significantly better than those seen with placebo (43 of 94 patients [45.7%]). Complete control of nausea was achieved in 6.8% of placebo patients, 14.8% of ondansetron 8-mg-treated patients, and 19.4% of ondansetron 16-mg treated patients; only ondansetron 16 mg was significantly better than placebo (P = 0.007). Significantly more patients who received ondansetron 8 mg than patients who received placebo were satisfied/very satisfied with their antiemetic treatment, as assessed by 4 patient-satisfaction questions. Significantly more patients who received ondansetron 16 mg compared with placebo were satisfied/very satisfied on 2 of 4 satisfaction questions. In conclusion, based on the observed incidence of opioid-induced nausea and vomiting in this study, it may be more appropriate to treat symptoms on occurrence rather than administering antiemetic agents prophylactically. The results of this study demonstrate that intravenous ondansetron in doses of 8 or 16 mg is an effective antiemetic agent for the control of opioid-induced nausea and vomiting in nonsurgical patients requiring opioid analgesia for pain.

Diabetes mellitus as a risk factor for early outcome after carotid endarterectomy--a population-based study.

BACKGROUND AND PURPOSE: to determine if diabetes mellitus is a risk factor for outcome after carotid endarterectomy (CEA). METHODS: the outcome and complications of all vascular procedures performed in Sweden are registered prospectively in the Swedish Vascular Registry (Swedvasc) and form the basis of this report. During the 10-year period 1987-96 2622 CEAs were analysed for notified complications. RESULTS: of the 2622 CEAs, 341 (13%) were performed on diabetics and 2281 (87%) on non-diabetics. Patients with diabetes presented at a younger age (67.1+/-8.3 years vs. 68.2+/-8.3 years p =0.028), were more likely to have a history of hypertension (61.9% vs. 50% p =0.001) and were less often smokers (34.9% vs. 43.2% p =0.001). Diabetics presented more often with minor stroke (41.3% vs. 30.8% p =0.002) and non-diabetics more often with amaurosis fugax (18.9% vs. 14.4% p =0.04). Diabetics had a higher 30-day mortality (3.2% vs. 1. 4% p =0.02). The 30-day neurologic and cardiac morbidity did not differ. The 1-year mortality was 7.9% in diabetics and 4.4% in non-diabetics (p =0.008). Non-diabetics operated on in 1992-96 compared to those operated on in 1987-91 had a significantly lower combined permanent stroke and death rate (3.7% vs. 5.7% p =0.05), a difference not found in diabetics (6.3% for 1987-92 and 6.8% for 1992-96; N.S). CONCLUSIONS: diabetics had both a higher 30-day and 1-year mortality after CEA compared to non-diabetics, mainly because of cardiac complications. However, postoperative neurologic morbidity did not differ.