Emergency medical consequence planning and management for national special security events after September 11: Boston 2004.

The post-September 11 era has prompted unprecedented attention to medical preparations for national special security events (NSSE), requiring extraordinary planning and coordination among federal, state, and local agencies. For an NSSE, the US Secret Service (USSS) serves as the lead agency for all security operations and coordinates with relevant partners to provide for the safety and welfare of participants. For the 2004 Democratic National Convention (DNC), designated an NSSE, the USSS tasked the Boston Emergency Medical Services (BEMS) of the Boston Public Health Commission with the design and implementation of health services related to the Convention. In this article, we describe the planning and development of BEMS' robust 2004 DNC Medical Consequence Management Plan, addressing the following activities: public health surveillance, on-site medical care, surge capacity in the event of a mass casualty incident, and management of federal response assets. Lessons learned from enhanced medical planning for the 2004 DNC may serve as an effective model for future mass gathering events.

Blast-related injuries from terrorism: an international perspective.

Terrorism using conventional weapons and explosive devices is a likely scenario and occurs almost daily somewhere in the world. Caring for those injured from explosive devices is a major concern for acute injury care providers. Learning from nations that have experienced conventional weapon attacks on their civilian population is critical to improving preparedness worldwide. In September 2005, a multidisciplinary meeting of blast-related injury experts was convened including representatives from eight countries with experience responding to terrorist bombings (Australia, Colombia, Iraq, Israel, United Kingdom, Spain, Saudi Arabia, and Turkey). This article describes these experiences and provides a summary of common findings that can be used by others in preparing for and responding to civilian casualties resulting from the detonation of explosive devices.

Real-time paramedic compared with blinded physician identification of ST-segment elevation myocardial infarction: results of an observational study.

The aim of the study were to determine if paramedics can accurately identify ST-segment elevation myocardial infarction (STEMI) on prehospital 12-lead (PHTL) electrocardiogram and to compare paramedic with blinded physician identification of STEMI. Paramedics identified definite STEMI, or possible acute myocardial infarction but not definite, and nondiagnostic. Two blinded readers (cardiologist and emergency physician) independently categorized each PHTL. A third reviewer assigned final diagnoses and determined whether the PHTL met STEMI criteria. One hundred sixty-six PHTL were acquired over an 8-month period. Fifteen were excluded from analysis. Sixty-two percent of the patients (94/151) were male, mean age was 61.1 years (+/-14.8 SD, range 20-92 years), and 81% had chest pain. Twenty-five patients (16.6%; 95% confidence interval [CI], 11%-23.5%) had confirmed STEMI and 16 (10.6%) had confirmed non-STEMI acute myocardial infarction. Paramedic sensitivity was 0.80 (95% CI, 0.64-0.96); specificity was 0.97 (95% CI, 0.94-1.00) with positive likelihood ratio of 25.2 and negative likelihood ratio of 0.21. Overall accuracy was similar for paramedic and physician reviewers (0.94, 0.93, 0.95). Highly trained paramedics in an urban emergency medical services system can identify patients with STEMI as accurately as blinded physician reviewers.

A laboratory comparison of emergency percutaneous and surgical cricothyrotomy by prehospital personnel.

OBJECTIVE: To compare the speeds and success rates of placement for percutaneous cricothyrotomy versus surgical or open cricothyrotomy. METHODS: Twenty-two paramedics (mean 9.7 years of experience), with training in both methods, were timed using a pig trachea in a crossover model. An emergency physician performed timing and documentation of success; timing commenced after the equipment was ready and the membrane was identified. Paramedics were randomly assigned by a coin toss to start in either group. All were actively employed by a municipal third-service emergency medical services (EMS) agency. Paramedics who did not complete one of the methods correctly were excluded from speed analysis. Data were analyzed using descriptive statistics, a t-test of paired samples, and confidence intervals for matched samples. RESULTS: Placement of a surgical cricothyrotomy was significantly faster (mean 28 seconds, range 10-78 seconds) than the percutaneous method (mean 123 seconds, range 58-257 seconds) (p < 0.001). Mean difference between the 20 matched percutaneous versus surgical pairs was 93.75 seconds (95% CI 72.3, 115.2). The surgical route had a 100% success rate at obtaining airway control, whereas the percutaneous method had a 90.9% success rate (p = 0.1). CONCLUSION: In an animal model, surgical cricothyrotomy appeared to be a preferable method for establishing a definitive airway over the percutaneous method. Further research is required to define the optimal approach in the prehospital setting for the invasive airway.

A comparison of cardiopulmonary resuscitation rates of strangers versus known bystanders.

BACKGROUND: Bystander cardiopulmonary resuscitation (CPR) improves survival. The authors attempted to determine whether the rates at which CPR is performed differ when a cardiac arrest is witnessed by someone known or unknown to the victim. METHODS: Retrospective observational cohort study of all witnessed nontraumatic cardiac arrests (Utstein) from Boston from 1994 to 1998. Cardiac arrests were excluded if the original record was unavailable or if medical or public safety personnel witnessed the cardiac arrest. The relationship between the provider of CPR and the victim was determined by the emergency medical technicians at the scene and later categorized as known or unknown. Survival (survival to hospital discharge) was determined through telephone follow-up with the arrest victim's caregivers. RESULTS: Known bystanders performed CPR 15.5% (42 of 271) of the time (95% confidence interval (95% CI], 11.2%, 19.8%). Unknown bystanders performed CPR 45.8% (66 of 144) (95% CI, 37.6%, 54.1%) of the time. The odds ratio of receiving CPR if an unknown bystander witnessed a cardiac arrest was 4.61 (95% CI, 2.89, 7.34). Arrests witnessed by unknown bystanders had a 24.3% (35 of 144) (95% CI, 17.2%, 31.4%) survival rate. Those witnessed by known bystanders had a 17.7% (95% CI, 13.1%, 22.3%) survival rate (p = 0.110). In a logistic regression model including both bystander status and location of arrest, unknown bystander status remained statistically significantly associated with having CPR performed regardless of location (OR = 3.56, p = 0.01; 95% CI, 1.64, 7.72). Location was not statistically significant in the presence of bystander status (OR = 1.17, p = 0.686). CONCLUSION: Victims of cardiac arrest are more likely to receive CPR when the event is witnessed by bystanders unknown to the victim than if the arrest is witnessed by friends or family.

Local collaborations: development and implementation of Boston's bioterrorism surveillance system.

The Boston Public Health Commission developed and implemented an active surveillance system for bioterrorism and other infectious disease emergencies. A bioterrorism Surveillance Task Force was formed with representatives from local emergency medicine, infection control, infectious diseases, public health, and emergency medical services. These local agencies worked together to develop a reliable, easy to use electronic surveillance system. Collaboration at the local level and building on existing relationships is a key component of this system. Effective follow-up systems and technology back-up plans are essential. Improved communication networks and increased bioterrorism education for clinicians and the general public have also been achieved.

Law Enforcement Agency Defibrillation (LEA-D): proceedings of the National Center for Early Defibrillation Police AED Issues Forum.

Why does LEA-D intervention seem to work in some systems but not others? Panelists agreed that some factors that delay rapid access to treatment, such as long travel distances in rural areas, may represent insurmountable barriers. Other factors, however, may be addressed more readily. These include: absence of a medical response culture, discomfort with the role of medical intervention, insecurity with the use of medical devices, a lack of proactive medical direction, infrequent refresher training, and dependence on EMS intervention. Panelists agreed that successful LEA-D programs possess ten key attributes (Table 6). In the end, the goal remains "early" defibrillation, not "police" defibrillation. It does not matter whether the rescuer wears a blue uniform--or any uniform, for that matter--so long as the defibrillator reaches the victim quickly. If LEA personnel routinely arrive at medical emergencies after other emergency responders or after 8 minutes have elapsed from the time of collapse, an LEA-D program will be unlikely to provide added value. Similarly, if police frequently arrive first, but the department is unwilling or unable to cultivate the attributes of successful LEA-D programs, efforts to improve survival may not be realized. In most communities, however, LEA-D programs have tremendous lifesaving potential and are well worth the investment of time and resources. Law enforcement agencies considering adoption of AED programs should review the frequency with which police arrive first at medical emergencies and LEA response intervals to determine whether AED programs might help improve survival in their communities. It is time for law enforcement agency defibrillation to become the rule, not the exception.