Y2K medical disaster preparedness in New York City: confidence of emergency department directors in their ability to respond.

OBJECTIVES: To study the preparedness New York City for large scale medical disasters using the Year 2000 (Y2K) New Years Eve weekend as a model. METHODS: Surveys were sent to the directors of 51 of the 9-1-1-receiving hospitals in New York City before and after the Y2K weekend. Inquiries were made regarding hospital activities, contingencies, protocols, and confidence levels in the ability to manage critical incidents, including weapons of mass destruction (WMD) events. Additional information was collected from New York City governmental agencies regarding their coordination and preparedness. RESULTS: The pre-Y2K survey identified that 97.8% had contingencies for loss of essential services, 87.0% instituted their disaster plan in advance, 90.0% utilized an Incident Command System, and 73.9% had a live, mock Y2K drill. Potential terrorism influenced Y2K preparedness in 84.8%. The post-Y2K survey indicated that the threat of terrorism influenced future preparedness in 73.3%; 73.3% had specific protocols for chemical; 62.2% for biological events; 51.1% were not or only slightly confident in their ability to manage any potential WMD incidents; and 62.2% felt very or moderately confident in their ability to manage victims of a chemical event, but only 35.6% felt similarly about victims of a biological incident. Moreover, 80% felt there should be government standards for hospital preparedness for events involving WMD, and 84% felt there should be government standards for personal protective and DECON equipment. In addition, 82.2% would require a moderate to significant amount of funding to effect the standards. Citywide disaster management was coordinated through the Mayor's Office of Emergency Management. CONCLUSIONS: Although hospitals were on a heightened state of alert, emergency department directors were not confident in their ability to evaluate and manage victims of WMD incidents, especially biological exposures. The New York City experience is an example for the rest of the nation to underscore the need for further training and education of preparedness plans for WMD events. Federally supported education and training is available and is essential to improve the response to WMD threats.

Rapid sequence intubation in adults with elevated intracranial pressure: a survey of emergency medicine residency programs.

A questionnaire entitled "Survey of Protocols for Rapid Sequence Intubation in Previously Healthy Adults with Elevated Intracranial Pressure" was distributed to the program directors of all 100 emergency medicine residency programs listed in the Directory of Graduate Medical Education Programs in February 1995. The medical literature on rapid sequence intubation in patients with suspected intracranial pressure elevations was reviewed. The findings of the review were compared with the survey responses. Sixty-seven program directors responded to the survey. Sixty-five programs performed rapid sequence intubation in their institution. Five programs performed 0 to 10 procedures annually. Six performed 10 to 30 annually, 19 performed 30 to 50, 17 performed 50 to 100, and 18 performed more than 100. Succinylcholine and vecuronium were the most frequently used neuromuscular blockers. Midazolam and thiopental were the most frequently used sedative induction agents. Most programs use a defasciculating agent prior to succinylcholine administration. The majority of programs do not use a priming agent before the use of a nondepolarizing neuromuscular blocking agent. Intravenous lidocaine was routinely administered prior to neuromuscular blockade. Fentanyl was the most frequently used other pretreatment medication. Rapid sequence intubation is used to facilitate definitive, emergent airway management in patients with suspected intracranial pressure elevations in almost all of the emergency medicine residency programs that responded to the survey. Most of these programs follow the guidelines recommended in the medical literature. The majority of these guidelines, however, are based on statistical data performed in the laboratory or nonemergency environments. Further clinical studies in an emergency medicine environment must be performed to determine the optimal drug regimen for rapid sequence intubation in patients with elevated intracranial pressure.

Complete nonsurgical resolution of a spontaneous spinal epidural hematoma.

Spontaneous spinal epidural hematomas (SSEH) are heralded by spinal pain and progressive cord compression syndromes which may lead to permanent neurological disability or death if emergent neurosurgical intervention is delayed. It therefore must be considered early in the differential diagnosis of acute spinal cord compression syndrome. A case of spontaneous spinal epidural hematoma presenting as an acute myelopathy in a clarinet player who chronically used a nonsteroidal anti-inflammatory medication is presented. The case was remarkable for the rare complete spontaneous resolution of neurological function. Approximately 250 cases of SSEH have been reported in the medical literature, although only a handful of these patients have recovered spontaneously. This is the sixth report of such an event. The etiologies, contributing factors, disease progression, and treatment recommendations are discussed.

Serial electrocardiograms for chest pain patients with initial nondiagnostic electrocardiograms: implications for thrombolytic therapy.

OBJECTIVES: To determine the proportion of acute myocardial infarction (AMI) patients without ST-segment elevation who subsequently develop ST-segment elevation during their hospital courses; and to compare demographics and presenting features of AMI patient subgroups: those with initial ST-segment elevation, those with in-hospital ST-segment elevation, and those with no ST-segment elevation. METHODS: A retrospective cohort analysis of admitted chest pain patients who had a hospital discharge diagnosis of AMI was performed. Each chart was examined for initial ECG interpretation, serial ECG analysis, patient age, gender, cardiac risk factors, in-hospital survival, time between sequential ECGs, and number of ECGs performed within the first 48 hours of hospital admission. RESULTS: Of the 114 charts reviewed, 20 patients had ECGs meeting thrombolytic criteria on arrival. Of the 94 AMI patients who had nondiagnostic ECGs on arrival, 19 (20%) subsequently developed ECG changes meeting thrombolytic criteria. Seven patients developed these changes within eight hours of the initial ECG, four from eight to 12 hours after, two from 12 to 24 hours after, and six more than 24 hours after. Most patients who had documented AMIs did not develop ECG criteria for thrombolytic therapy during their hospitalizations. Male gender and smoking history were more commonly associated with late ST-segment elevation for those presenting with nondiagnostic ECGs. All the patients who had late diagnostic ECG changes survived to hospital discharge. Serial ECGs were performed more frequently in the group who had initially diagnostic ECGs and least frequently in the group who did not develop ST-segment elevation during their hospitalizations. CONCLUSIONS: Most patients with AMI do not meet ECG criteria for the administration of thrombolytic therapy. A significant minority (20%) of the admitted chest pain patients with subsequently confirmed AMIs developed ECG criteria for thrombolytics during their hospitalizations. Further attention to such patients who have delayed ST-segment elevation is warranted. A standardized in-hospital serial ECG protocol should be considered to identify admitted patients who develop criteria for thrombolytic or other coronary revascularization therapy.