Are Belgian military students in medical sciences better educated in disaster medicine than their civilian colleagues?

INTRODUCTION: Historically, medical students have been deployed to care for disaster victims but may not have been properly educated to do so. A previous evaluation of senior civilian medical students in Belgium revealed that they are woefully unprepared. Based on the nature of their military training, we hypothesised that military medical students were better educated and prepared than their civilian counterparts for disasters. We evaluated the impact of military training on disaster education in medical science students. METHODS: Students completed an online survey on disaster medicine, training, and knowledge, tested using a mixed set of 10 theoretical and practical questions. The results were compared with those of a similar evaluation of senior civilian medical students. RESULTS: The response rate was 77.5%, mean age 23 years and 59% were males. Overall, 95% of military medical students received some chemical, biological, radiological and nuclear training and 22% took part in other disaster management training; 44% perceived it is absolutely necessary that disaster management should be incorporated into the regular curriculum. Self-estimated knowledge ranged from 3.75 on biological incidents to 4.55 on influenza pandemics, based on a 10-point scale. Intention to respond in case of an incident ranged from 7 in biological incidents to 7.25 in chemical incidents. The mean test score was 5.52; scores improved with educational level attained. A comparison of survey data from civilian senior medical master students revealed that, except for influenza pandemic, military students scored higher on knowledge and capability, even though only 27% of them were senior master students. Data on willingness to work are comparable between the two groups. Results of the question/case set were significantly better for the military students. CONCLUSIONS: The military background and training of these students makes them better prepared for disaster situations than their civilian counterparts.

Disaster medicine.

Disaster medicine. Once we define the characteristics of both a disaster in general and specific disaster categories, the unique aspects of disaster or emergency management and disaster medicine become much easier to understand. The cornerstone of disaster medicine has an ethical aspect, namely how, as medical professionals, we must move from our daily practice in which we employ almost unlimited resources as required by each patient to a collective ethics situation in which a limited set of resources must be used to maximize the number of victims treated, so as to reach an optimal general outcome.

Principles of hospital disaster management: an integrated and multidisciplinary approach.

Principles of hospital disaster management: an integrated and multidisciplinary approach. Hospitals play an important role during a disaster response, and are also at risk for internal incidents. We propose an integrated and multidisciplinary approach towards hospital disaster management and preparedness. In addition to response strategies, much attention is given to risk assessment and preparedness in the pre-incident phase and to business continuity planning (BCP) in the post-incident phase. It is essential to train key players and all personnel to understand the Hospital Incident Management System (HIMS) and to perform specific emergency procedures. All emergency procedures should be grounded in evidence-based practice resulting from essential disaster response research.

Coordination of actions in disaster situations.

Coordination of actions in disaster situations. The essential concept of disaster medicine is to create appropriate proportions of resources to needs. The different operational steps will be described in this chapter. The aim is to minimize human fatalities while reducing the risk of long- and short-term physical and psychological complications.

Is beta-glucuronidase a clinical useful biomarker for an acute organophosphorus poisoning?

beta-glucuronidase is considered a sensitive biomarker for acute organophosphorus poisoning. In this well-documented study, multiple plasma samples over time were collected. A decrease in plasma concentration of beta-glucuronidase was surprisingly observed, even within normal range. These findings do not support the hypothesis that beta-glucuronidase is a useful biomarker for acute organophosphorus poisoning in humans.

Emergency medicine radiology: a new challenge in radiology.

Emergency medicine is a recent discipline which relies much on emergency radiology. Emergency physicians are developing specific diagnostic work-ups and therapies for emergency conditions and exploring specific management of the department, attesting of a growing interest in emergency medicine radiology. In this article we give a survey of the history of emergency medicine radiology and we discuss this rather young subdiscipline of radiology.

Fatal intentional poisoning cases admitted to the University Hospitals of Leuven, Belgium from 1993 to 1996.

Between January 1993 and July 1996, a total of 2827 intentional cases of poisoning were registered in the University Hospitals of Leuven, Belgium. Ten of these cases were fatal. This study was set up to evaluate the substances involved, the circumstances, the features and the characteristics of the patients who died due to intentional poisoning. The male to female ratio of these fatal cases was 9 : 1. The median age was 43 years. Two groups of substances were revealed to be associated with fatal outcome. The first group consisted of chemicals (seven lethal cases): cholinesterase inhibitors ( =3), methanol ( =2) and paraquat ( =2). The second group consisted of benzodiazepines (three lethal cases). In the cases of poisoning with chemicals, death was directly related to product toxicity and the severity of the poisoning, whilst with benzodiazepines, which are considered to be relatively safe drugs even when taken in overdose, there was a clear relationship between a fatal outcome and a delay between ingestion and medical support. Product toxicity, complications and a delay in medical support may be considered as predictors for the effectiveness and efficacy of treatment and may influence which medical treatments need to be administered.

The 'three in one' block as locoregional analgesia in an emergency department.

The 'three in one' block is a well-known locoregional technique for per- and post-operative anaesthesia. This 'three in one' block was investigated in an emergency department with three combinations of local anaesthetics as a locoregional way of pain relief for patients with fractures of the upper femur. A double-blind prospective study was conducted with 61 consecutive patients. A good regression of the linear visual analogue scale (LVAS), good haemodynamic stability and great patient satisfaction were found for all groups of patients at different times after installation of the block. Side effects were few and are avoidable by reducing the amount of local anaesthetic given to elderly patients with a low bodyweight. The technique failed in only four patients due to technical reasons. It was concluded that the 'three in one' block is a fast, safe, reliable and easy technique for pain relief in an emergency department. Good analgesia was achieved for patients with fractures of the upper femur with no need to change the position of the patient.

Harris or axis ring: an aid in diagnosing low (type 3) odontoid fractures.

OBJECTIVE: To present our experience of diagnosing fractures of the odontoid process on lateral radiographs of the cervical spine that show the Harris (axis) ring. DESIGN: Retrospective study. SETTING: Teaching hospital, Belgium. SUBJECTS: 12 patients with multiple injuries, including cervical spine, 8 of them unconscious or uncooperative. INTERVENTIONS: Cross table lateral view of the cervical spine. MAIN OUTCOME MEASURE: Identification of otherwise hidden type 3 axial fractures. RESULTS: Diagnosis of low odontoid fractures in all cases. CONCLUSION: The Harris ring is disrupted in low odontoid fractures and intact in fractures of the odontoid process. Awareness of this sign will allow diagnosis of otherwise hidden axial fractures.

Is there an evolution in the epidemiology and follow-up of carbon monoxide poisoning victims?

A retrospective study was conducted to investigate for potential changes in the epidemiology of acute carbon monoxide (CO) poisoning and to evaluate the recommendations within the emergency department (ED) on therapy and neurological and social follow-up of these patients. One hundred and sixty-seven patients with a non-intentional CO poisoning in the time period from 1995 to 1997 were reviewed and compared with data of a similar patient population between 1988 and 1990. Both patient groups were matched for age, sex and comorbidity. Comparing the epidemiological data of the two groups, three main evolutions were observed: (1) there is a global reduction in ED admissions for CO poisoning; (2) the number of young victims has a tendency to decrease; (3) the most common CO source has become an insufficiently functioning stove instead of a defective gas water heater. Regarding treatment and follow-up strategies three conclusions could be drawn: (1) the recommendations for hyperbaric-oxygen therapy were strictly followed; (2) the neurological follow-up was poor and has to be ameliorated and revisited; (3) the systematic follow-up by the social worker on the other hand resulted in immediate actions to prevent a second CO poisoning. This recently elaborated protocol for social evaluation emphasizes the important function of the social worker in the ED and the importance of transmural follow-up organized by the ED.

The effect of helmets on the incidence and severity of head and cervical spine injuries in motorcycle and moped accident victims: a prospective analysis based on emergency department and trauma centre data.

The aim of this prospective study was to quantify the anatomic severity of head and cervical spine injuries in hospital admitted victims of motorcycle and moped accidents in relation to helmet use and controlled for non-head injuries (i.e. kinetic impact). Two hundred and twenty-three patients entered the study group, of which 152 were motorcyclists and 71 were moped riders. Our results reveal that helmets do prevent head injury in motorcycle and moped accidents, especially in those crashes involving relatively low kinetic energy transfers. Helmet use does not lead to an increase of the incidence or severity of cervical spine injury. As a result compulsory helmet laws should not be limited to motorcyclists but also focus on all moped riders and probably also bicyclists. This study illustrates that emergency departments can provide important epidemiological information for injury control purposes. However, the epidemiological use of emergency department data and hospital data in general requires cautiousness. Confounding is a common problem which should be dealt with during analysis.

An acute zinc chloride poisoning in a child: was chelator therapy effective?

An acute zinc chloride poisoning due to ingestion is a rare event. Symptoms include: corrosive pharyngeal lesions, vomiting and lethargy. Laboratory findings may include hyperglycaemia, hyperamylasaemia, exocrine pancreatic insufficiency and renal insufficiency. This case report describes an accidental zinc chloride poisoning in a child, with lethargy as the most pronounced clinical sign. Clinical evaluation and chelator therapy are discussed.

Spinal delivery of sufentanil, alfentanil, and morphine in dogs. Physiologic and toxicologic investigations.

BACKGROUND: This study examines the behavioral effects and potential neurotoxicity of sufentanil, alfentanil, and morphine after chronic daily epidural (15-day) and intrathecal (28-day) administration in dogs. METHODS: Dogs were chronically implanted with a lumbar intrathecal or epidural catheter and received daily injections for 28 or 15 days, respectively, of saline or one of three mu agonists: sufentanil (intrathecal 5, 25, or 50 micrograms/0.5 ml; epidural 10, 50, or 100 micrograms/2.0 ml), alfentanil (intrathecal 40 or 400 micrograms/0.5 ml; epidural 80 or 800 micrograms/2.0 ml), or morphine (intrathecal 0.5 or 5 mg/0.5 ml; epidural 1 or 10 mg/2.0 ml). Dogs were examined for antinociception (skin twitch) and neurobehavioral changes. When the animals were killed, cisternal cerebrospinal fluid was taken for clinical chemistry, and after perfusion fixation, spinal cord tissue was taken for histologic analysis. RESULTS: Bolus intrathecal and epidural injections of sufentanil, alfentanil, and morphine produced dose dependent antinociception, bradycardia, an initial tachypnea followed by a decrease in respiratory rate, hypothermia and somnolence. The order of potency was sufentanil > alfentanil > morphine on all measures. Over the extended period of drug delivery, a loss of response (tolerance) was observed on all measures. No abnormal morphologic or histologic effects were found when comparing the drug and dose groups. An inflammatory reaction secondary to the catheter was found in all animals. Intrathecal, but not epidural, catheters resulted in significant increases in cerebrospinal fluid protein and cell counts in vehicle animals. Values in drug treated animals did not differ significantly from the respective vehicle controls. A rapid systemic redistribution of all three drugs was observed. No differences were found in the pharmacokinetic parameters measured at day 1 and at the day of killing for any route. CONCLUSIONS: This large-animal model demonstrates the expected pharmacologic potency of these three agents and tolerance development. Based on cerebrospinal fluid and systematic histopathologic analyses, these three spinally administered agents showed no evidence of neurotoxicity over the range of doses/concentrations employed when given by the intrathecal or epidural route as compared to vehicle controls. Consideration of the toxicokinetics in this canine model suggests that it provides an appropriate test of the safety of these agents in concentrations which exceed those employed for daily intermittent epidural and intrathecal drug delivery in humans.

Spinal and systemic action of the alpha 2 receptor agonist dexmedetomidine in dogs. Antinociception and carbon dioxide response.

BACKGROUND: alpha 2 Agonists are powerful analgesics after spinal delivery. The current work characterizes the dose-dependent antinociception and effects upon respiratory function of dexmedetomidine after intrathecal, epidural, intravenous, and intracisternal delivery in chronically prepared dogs. METHODS: Dogs were prepared with chronic tracheostomies and trained to perform rebreathing studies. These animals were then prepared with chronic lumbar intrathecal, epidural, or intracisternal catheters. RESULTS: A rapid dose-dependent increase in the thermal skin twitch response latency and paw withdrawal to mechanical pinch was observed after intrathecal, epidural, and intravenous dexmedetomidine (dose required to reach 50% of maximal effect for skin twitch = 1.8, 10, and 15 micrograms, respectively) but not after intracisternal dexmedetomidine (> 15 microgram), with the maximally effective dose lasting approximately 90 min. The spinal effect was unaccompanied by effects upon behavioral alertness, motor function, or changes in CO2 response. In contrast, intravenous dexmedetomidine (1-10 micrograms/kg) resulted in a dose-dependent sedation and a significant reduction in heart rate and respiratory rate and a diminished response to increased CO2, these effects lasting approximately 2 h. Intracisternal administration of up to 15 micrograms had no effect upon the nociceptive threshold, and CO2 response, and failed to result in a significant reduction in alertness. All of the effects of dexmedetomidine were antagonized by the alpha 2-antagonist atipamezole (30-300 micrograms/kg, intravenous), but not by the opioid antagonist naloxone (30 micrograms/kg, intravenous), while atipamezole did not reverse the antinociceptive or respiratory depressant actions of intravenous sufentanil (50 micrograms), effects which were reversible by naloxone. CONCLUSIONS: Dexmedetomidine, acting through an alpha 2-receptor, produces a powerful antinociceptive effect, mediated at the spinal level, while systemic redistribution of the drug leads to a hypnotic state with significant cardiorespiratory effects.

Muscle paralysis by rocuronium during halothane, enflurane, isoflurane, and total intravenous anesthesia.

We determined the dose-response relationship, the onset time, the duration, and the recovery time of a rocuronium neuromuscular block under four anesthesia techniques. Patients were equally randomized to four different groups (n = 20) receiving 0.5%-1% halothane, 1.5%-2% enflurane, 1.2%-1.8% isoflurane end-tidal concentration in 34%/66% O2/N2O, or 6.0 mg.kg-1 x h-1 propofol without N2O for anesthesia and alfentanil for analgesia. Strength of thumb adduction in response to single and train-of-four stimulation of the ulnar nerve was quantitated. Rocuronium 0.15, 0.2, 0.25, and 0.3 mg/kg were given intravenously. When maximal depression of twitch tension occurred, supplemental doses up to a total of 0.5 mg/kg were given. If required, additional doses of 0.15 mg/kg were given at 25% recovery of control twitch tension. Standard hemodynamics, end-tidal CO2, and anesthetic gas concentrations were monitored continuously. The mean ED50 (SD) was 0.133 (+/- 0.009) mg/kg for the halothane group, 0.118 (+/- 0.012) mg/kg for the enflurane group, 0.069 (+/- 0.026) mg/kg for the isoflurane group, and 0.167 (+/- 0.007) mg/kg for the total intravenous anesthesia (TIVA) group, respectively. There was a statistically significant difference between the halothane and TIVA, and between the enflurane and TIVA groups (P < 0.05). Rocuronium has a short onset time and an intermediate duration of action. The neuromuscular blocking potency and pharmacodynamic profile are moderately influenced by volatile anesthetics.

Toxicology of baclofen continuously infused into the spinal intrathecal space of the dog.

The continuous spinal administration of baclofen has been shown to have therapeutic benefit in the management of spasticity in humans with neuraxial injuries. The present study systematically investigated the potential spinal neurotoxicity of continuous intrathecally-infused baclofen in dogs. Male beagle dogs were prepared with chronic lumbar intrathecal catheters connected to subcutaneously implanted infusion pumps. Three groups of dogs received 28 days of infusion of saline (vehicle: 1 ml/24 hrs; N = 10), 200 micrograms/ml/24 hrs baclofen (N = 10) or 2000 micrograms/ml/24 hrs baclofen (N = 10). A mild, dose-dependent anti-nociception and muscle weakness was observed. Independent assessment of spinal histopathology in dogs sacrificed and perfusion fixed at 28 days of treatment revealed a mild fibrotic reaction to the catheter, but there were no changes distinguishable from vehicle infused animals which could be ascribed to any dose of intrathecal baclofen. Cisternal CSF protein and cells in samples taken at sacrifice were also not different for the three groups. These findings with chronic intrathecally administered baclofen in this dog model jointly support the lack of toxicity of chronic intrathecal baclofen at concentrations up to 2000 micrograms/ml.

Effects of [N-(L-(1-carboxy-2-phenyl)ethyl]-L-phenylalanyl-beta-alanine (SCH32615), a neutral endopeptidase (enkephalinase) inhibitor, on levels of enkephalin, encrypted enkephalins and substance P in cerebrospinal fluid and plasma of primates.

In halothane-anesthetized and -ventilated cynomologus macaque monkeys, the effects of administering vehicle (n = 3) or the neutral endopeptidase inhibitor N-[L-(1-carboxy-2-phenyl)ethyl]-L-phenylalanyl-beta-alanine (16 mg/kg, n = 5; or 100 mg/kg, n = 3, intravenously) was examined. Cisternal CSF aliquots were examined by radioimmunoassay: 1) for Met enkephalin; 2) after trypsin and carboxypeptidase B treatment for encrypted enkephalin (X-ENK); 3) for substance P; and 4) for unmetabolized drug. Similar measures were carried out in femoral artery and femoral venous plasma, except that substance P was not assayed. In CSF, prior to drug, low, but measurable levels of enkephalin (61 pg/ml), X-ENK (285 pg/ml) and substance P (16 pg/ml) were observed. Vehicle-injected animals showed no change from baseline levels over a 4-hr sampling period in either plasma or CSF levels. In contrast, following 16 mg/kg, in CSF, there was a significant 9-fold increase in MET and 11-fold increase in X-ENK at 30 min. CSF-substance P levels rose also by a factor of 2, with the peak effect observed at 60 min. All levels displayed a significant reduction by 4 hr. There was no statistical difference between the maximum effects observed with either the 16- or 100-mg/kg dose. Plasma peptide levels of enkephalin and X-ENK were not altered by drug. CSF displayed significant drug levels by 30 min, which were between 0.1 and 1% of levels observed concurrently in plasma.(ABSTRACT TRUNCATED AT 250 WORDS)

Pharmacology of spinal opioids.

This review presents the pharmacology of spinal opioid receptor systems which are primarily involved in pain processing. The major areas upon which we will focus are: the structure and cellular functioning of the opioid receptor systems; the physiologic effects induced by spinally administered opioids, particularly in pain modulation; and pharmacokinetic and dynamic considerations, with special attention to the problem of opioid tolerance development.

Interaction of midazolam and morphine in the spinal cord of the rat.

The antinociceptive properties, as measured by the tail-flick and hot-plate tests, and the motor effects of an intrathecally-administered benzodiazepine agonist midazolam, alone, and in combination with morphine, was examined in rats. Midazolam alone produced a weak but dose-dependent (20-60 micrograms) antinociceptive effect in addition to a clear motor dysfunction at larger doses (60-100 micrograms). An inactive dose of intrathecally-administered midazolam (20 micrograms) produced a leftward shift in the dose-response curve for intrathecally administered morphine, in the thermal antinociceptive tests. This supra-additive effect was antagonized by naloxone (1 mg/kg). The data suggest a synergistic interaction between mu- and GABAA-receptors in the spinal processing of thermally-evoked pain.