The development and implementation of a Hospital Emergency Response Team (HERT) for out-of-hospital surgical care.

Over the past two decades, Los Angeles County has implemented a Hospital Emergency Response Team (HERT) to provide on-scene, advanced surgical care of injured patients as an element of the local Emergency Medical Services (EMS) system. Since 2008, the primary responsibility of the team has been to perform surgical procedures in the austere field setting when prolonged extrication is anticipated. Following the maxim of "life over limb," the team is equipped to provide rapid amputation of an entrapped extremity as well as other procedures and medical care, such as anxiolytics and advanced pain control. This report describes the development and implementation of a local EMS system HERT.

Medical events during the 2009 Los Angeles County Station Fire: lessons for wildfire EMS planning.

BACKGROUND: Little is known about the types of injuries and medical problems encountered by fire department personnel during suppression of large campaign-type wildland fires. Such information could help to plan for response to medical incidents during future wildfires. OBJECTIVE: To describe the injuries and medical problems experienced by firefighters during the 2009 Los Angeles County Station Fire. METHODS: This was a retrospective analysis of case records of patients treated during the Los Angeles County Station Fire. Data were abstracted from two sources: the incident command medical tracking sheet and prehospital patient care reports (PCRs). RESULTS: The sample included 183 patient contacts, of which PCRs were available for 65. For the remaining 118 patients, data were abstracted from the incident command medical tracking sheet. The most common chief complaint was extremity injury, accounting for 44 patient contacts (24% of all patients), with smoke inhalation second, at 32 patient contacts (17%). Of the 65 patients with PCRs, 31 (52%) were treated with oxygen, 26 (40%) had intravenous (IV) lines started, and 15 (23%) received an IV fluid bolus. Half of the patients were transported to an emergency department (ED); the remainder were treated on scene or self-transported to a non-acute care facility. CONCLUSIONS: Most firefighter injuries and illnesses encountered during the Los Angeles Station Fire were minor. The prevalence of injuries observed should be taken into consideration in creation of protocols and mandatory equipment lists for fireline paramedics. Furthermore, advanced training for paramedics in the diagnosis and treatment of minor medical conditions may be useful.

Improved trauma system multicasualty incident response: comparison of two train crash disasters.

BACKGROUND: Two train crash multicasualty incidents (MCI) occurred in 2005 and 2008 in Los Angeles. A postcrash analysis of the first MCI determined that most victims went to local community hospitals (CHs) with underutilization of trauma centers (TCs), resulting in changes to our disaster plan. To determine whether our trauma system MCI response improved, we analyzed the distribution of patients from the scene to TCs and CHs in the two MCIs. METHODS: Data from the emergency medical services and TC records were interrogated to compare patients triage status, type of transport, and the destination in the 2008 MCI to the 2005 MCI. Clinical data from the 2008 MCI were tabulated to evaluate severity of injuries, need for immediate and delayed operation, need for intensive care unit, and need for specialty surgical services, and appropriate distribution of patients. RESULTS: In 2005, 14 (56%) of the 25 severely injured patients and 75 (71%) of the 106 total patients were transported to four CHs. In 2008, 53 (93%) of 57 of the severely injured patients were transported to TCs and only 34 (35%) of 98 of total patients were transported to nine CHs. In 2008, more TCs were used (8 vs. 5) and more patients were transported by air (34 vs. 2). In 2008, the most severely injured victims were transported to four level I TCs (median injury severity score, 16; range, 1-43; 10 emergent operations) and four level II TCs (median injury severity score, 10; range, 1-22; 4 emergent operations). Only 11 patients were admitted to CHs, and no operations were required. CONCLUSIONS: A trauma system performance improvement program allowed us to significantly improve our response to MCIs with improved utilization of TCs and improved distribution of victims according to injury severity and needs.

Characterizing of tissue microstructure with single-detector polarization-sensitive optical coherence tomography.

Assessing tissue birefringence with imaging modality polarization-sensitive optical coherence tomography (PS-OCT) could improve the characterization of in vivo tissue pathology. Among the birefringent components, collagen may provide invaluable clinical information because of its alteration in disorders ranging from myocardial infarction to arthritis. But the features required of clinical imaging modality in these areas usually include the ability to assess the parameter of interest rapidly and without extensive data analysis, the characteristics that single-detector PS-OCT demonstrates. But beyond detecting organized collagen, which has been previously demonstrated and confirmed with the appropriate histological techniques, additional information can potentially be gained with PS-OCT, including collagen type, form versus intrinsic birefringence, the collagen angle, and the presence of multiple birefringence materials. In part I, we apply the simple but powerful fast-Fourier transform (FFT) to both PS-OCT mathematical modeling and in vitro bovine meniscus for improved PS-OCT data analysis. The FFT analysis yields, in a rapid, straightforward, and easily interpreted manner, information on the presence of multiple birefringent materials, distinguishing the true anatomical structure from patterns in image resulting from alterations in the polarization state and identifying the tissue/phantom optical axes. Therefore the use of the FFT analysis of PS-OCT data provides information on tissue composition beyond identifying the presence of organized collagen in real time and directly from the image without extensive mathematical manipulation or data analysis. In part II, Helistat phantoms (collagen type I) are analyzed with the ultimate goal of improved tissue characterization. This study, along with the data in part I, advance the insights gained from PS-OCT images beyond simply determining the presence or absence of birefringence.