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Journal: Prehospital and disaster medicine

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Introduction The number of civilians killed in Iraq following the 2003 invasion has proven difficult to measure and contentious in recent years. The release of the Wikileaks War Logs (WL) has created the potential to conduct a sensitivity analysis of the commonly-cited Iraq Body Count’s (IBC’s) tally, which is based on press, government, and other public sources. Hypothesis The 66,000 deaths reported in the Wikileaks War Logs are mostly the same events as those previously reported in the press and elsewhere as tallied by iraqbodycount.org. METHODS: A systematic random sample of 2500 violent fatal War Log incidents was selected and evaluated to determine whether these incidents were also found in IBC’s press-based listing. Each selected event was ranked on a scale of 0 (no match present) to 3 (almost certainly matched) with regard to the likelihood it was listed in the IBC database. RESULTS: Of the two thousand four hundred and nine War Log records, 488 (23.8%) were found to have likely matches in IBC records. Events that killed more people were far more likely to appear in both datasets, with 94.1% of events in which ≥20 people were killed being likely matches, as compared with 17.4% of singleton killings. Because of this skew towards the recording of large events in both datasets, it is estimated that 2035 (46.3%) of the 4394 deaths reported in the Wikileaks War Logs had been previously reported in IBC. CONCLUSIONS: Passive surveillance systems, widely seen as incomplete, may also be selective in the types of events detected in times of armed conflict. Bombings and other events during which many people are killed, and events in less violent areas, appear to be detected far more often, creating a skewed image of the mortality profile in Iraq. Members of the press and researchers should be hesitant to draw conclusions about the nature or extent of violence from passive surveillance systems of low or unknown sensitivity. Carpenter D , Fuller T , Roberts L . WikiLeaks and Iraq Body Count: the sum of parts may not add up to the whole-a comparison of two tallies of Iraqi civilian deaths. Prehosp Disaster Med. 2013;28(3):1-7 .

Concepts: Violence, Iraq War, 2003 invasion of Iraq, Iraq, War, Laws of war, Iraq Body Count project, International humanitarian law

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Introduction End tidal CO2 (ETCO2) has been established as a standard for confirmation of an airway, but its role is expanding. In certain settings ETCO2 closely approximates the partial pressure of arterial CO2 (PaCO2) and has been described as a tool to optimize a patient’s ventilatory status. ETCO2 monitors are increasingly being used by EMS personnel to guide ventilation in the prehospital setting. Severely traumatized and burn patients represent a unique population to which this practice has not been validated. Hypothesis The sole use of ETCO2 to monitor ventilation may lead to avoidable respiratory acidosis. METHODS: A consecutive series of patients with burns or trauma intubated in the prehospital setting over a 24-month period were evaluated. Prehospital arrests were excluded. Absence of ETCO2 transport data and patients without an arterial blood gas (ABG) within 15 minutes of arrival were also excluded. Data collected included demographics, place and time of intubation, service performing intubation, ETCO2 maintained en-route to hospital, and ABG upon arrival. Further data included length of stay, mortality, and injury severity scores. RESULTS: One hundred sixty patients met the inclusion criteria. Prehospital ETCO2 did not correlate with measured PaCO2 (R2 = 0.08). Mean ETCO2 was significantly lower than mean PaCO2 (34 mmHg vs 44 mmHg, P < .005). Patients arriving acidotic were more likely to die. Mean pH on arrival for survivors and decedents was 7.32 and 7.19 respectively (P < .001). Mortality, acidosis, higher base deficits, and more severe injury patterns were all predictors for a worse correlation between ETCO2 and PaCO2 and increased mean difference between the two values. Decedents and patients presenting with a pH <7.2 demonstrated the greatest discrepancy between ETCO2 and PaCO2. The data suggest that patients may be hypoventilated by prehospital providers in order to obtain a prescribed ETCO2. Conclusion ETCO2 is an inadequate tool for predicting PaCO2 or optimizing ventilation in severely injured patients. Adherence to current ETCO2 guidelines in the prehospital setting may contribute to acidosis and increased mortality. Consideration should be given to developing alternate protocols to guide ventilation of the severely injured in the prehospital setting. Cooper CJ , Kraatz JJ , Kubiak DS , Kessel JW , Barnes SL . Utility of prehospital quantitative end tidal CO2?. Prehosp Disaster Med. 2013;28(2):1-6 .

Concepts: Carbon dioxide, Respiratory physiology, PH, Arterial blood gas, Bicarbonate, Acidosis, Injury Severity Score, Respiratory acidosis

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Introduction Responses to physical activity while wearing personal protective equipment in hot laboratory conditions are well documented. However less is known of medical professionals responding to an emergency in hot field conditions in standard attire. Therefore, the purpose of this study was to assess the physiological responses of medical responders to a simulated field emergency in tropical conditions. METHODS: Ten subjects, all of whom were chronically heat-acclimatized health care workers, volunteered to participate in this investigation. Participants were the medical response team of a simulated field emergency conducted at the Northern Territory Emergency Services training grounds, Yarrawonga, NT, Australia. The exercise consisted of setting up a field hospital, transporting patients by stretcher to the hospital, triaging and treating the patients while dressed in standard medical response uniforms in field conditions (mean ambient temperature of 29.3°C and relative humidity of 50.3%, apparent temperature of 27.9°C) for a duration of 150 minutes. Gastrointestinal temperature was transmitted from an ingestible sensor and used as the index of core temperature. An integrated physiological monitoring device worn by each participant measured and logged heart rate, chest temperature and gastrointestinal temperature throughout the exercise. Hydration status was assessed by monitoring the change between pre- and post-exercise body mass and urine specific gravity (USG). RESULTS: Mean core body temperature rose from 37.5°C at the commencement of the exercise to peak at 37.8°C after 75 minutes. The individual peak core body temperature was 38.5°C, with three subjects exceeding 38.0°C. Subjects sweated 0.54 L per hour and consumed 0.36 L of fluid per hour, resulting in overall dehydration of 0.7% of body mass at the cessation of exercise. Physiological strain index was indicative of little to low strain. CONCLUSIONS: The combination of the unseasonably mild environmental conditions and moderate work rates resulted in minimal heat storage during the simulated exercise. As a result, low sweat rates manifested in minimal dehydration. When provided with access to fluids in mild environmental conditions, chronically heat-acclimatized medical responders can meet their hydration requirements through ad libitum fluid consumption. Whether such an observation is replicated under a harsher thermal load remains to be investigated. Brearley MB , Heaney MF , Norton IN . Physiological responses of medical team members to a simulated emergency in tropical field conditions. Prehosp Disaster Med. 2013;28(2):1-6 .

Concepts: Health care, Health care provider, Patient, E-participation, Physiology, Temperature, Relative humidity, Normal human body temperature

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Introduction Prehospital endotracheal intubation (ETI) following traumatic brain injury in urban settings is controversial. Studies investigating admission arterial blood gas (ABG) patterns in these instances are scant. Hypothesis Outcomes in patients subjected to divergent prehospital airway management options following severe head injury were studied.

Concepts: Traumatic brain injury, Mechanical ventilation, Endotracheal tube, Arterial blood gas, Intubation, Concussion

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Introduction Smartphone applications (or apps) are becoming increasingly popular with emergency responders and health care providers, as well as the public as a whole. There are thousands of medical apps available for Smartphones and tablet computers, with more added each day. These include apps to view textbooks, guidelines, medication databases, medical calculators, and radiology images. Hypothesis/Problem With an ever expanding catalog of apps that relate to disaster medicine, it is hard for both the lay public and responders to know where to turn for effective Smartphone apps. A systematic review of these apps was conducted.

Concepts: Health care, Pharmacology, Medicine, Health, Health science, Emergency management, Smartphone, Public safety

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Use of ketamine in the prehospital setting may be advantageous due to its potent analgesic and sedative properties and favorable risk profile. Use in the military setting has demonstrated both efficacy and safety for pain relief. The purpose of this study was to assess ketamine training, use, and perceptions in the civilian setting among nationally certified paramedics (NRPs) in the United States.

Concepts: United States, Poverty in the United States, U.S. state, Opioid, Pain, American football, Nationalism, Navy

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Introduction How the burden of disease varies during different phases after floods and after storms is essential in order to guide a medical response, but it has not been well-described. The objective of this review was to elucidate the health problems following flood and storm disasters.

Concepts: Health care, Medicine, Public health, Health, Epidemiology, Storm, Tropical cyclone, Storm surge

2

Deaths at music festivals are not infrequently reported in the media; however, the true mortality burden is difficult to determine as the deaths are not yet systematically documented in the academic literature.

Concepts: Anthropology, Literature, Publishing, Music, Humanities, Art, Mass media, Music festival

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Introduction Disaster and humanitarian responders are at-risk of experiencing a wide range of physical and psychological health conditions, from minor injuries to chronic mental health problems and fatalities. This article reviews the current literature on the major health outcomes of responders to various disasters and conflicts in order to better inform individuals of the risks and to inform deploying agencies of the health care needs of responders.

Concepts: Health care, Psychology, Medicine, Mental health, Mental disorder, Hazard

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Introduction Emergency medical services personnel treat 22 million patients a year, yet little is known of their risk of injury and fatality. Problem Work-related injury and fatality rates among US paramedics and emergency medical technicians (EMTs) are higher than the national average for all occupations. METHODS: Data collected by the Department of Labor (DOL) Bureau of Labor Statistics were reviewed to identify injuries and fatalities among EMTs and paramedics from 2003 through 2007. The characteristics of fatal injuries are described and the rates and relative risks of the non-fatal injuries were calculated and compared to the national average. RESULTS: Of the 21,749 reported cases, 21,690 involved non-fatal injuries or illnesses that resulted in lost work days among EMTs and paramedics within the private sector. Of the injuries, 3,710 (17%) resulted in ≥31 days of lost work time. A total of 14,470 cases (67%) involved sprains or strains; back injury was reported in 9,290 of the cases (43%); and the patient was listed as the source of injury in 7,960 (37%) cases. The most common events were overexertion (12,146, 56%), falls (2,169, 10%), and transportation-related (1,940, 9%). A total of 530 assaults were reported during the study period. Forty-five percent of the cases occurred among females (females accounted for 27% of employment in this occupation during 2007). In 2007, EMTs and paramedics suffered 349.9 injuries with days away from work per 10,000 full-time workers, compared to an average of 122.2 for all private industry occupations (Relative risk = 2.9; 95% CI: 2.7-3.0). During the study period, 59 fatalities occurred among EMTs and paramedics in both the private industry and in the public sector. Of those fatalities, 51 (86%) were transportation-related and five (8%) were assaults; 33 (56%) were classified as “multiple traumatic injuries.” CONCLUSIONS: Data from the DOL show that EMTs and paramedics have a rate of injury that is about three times the national average for all occupations. The vast majority of fatalities are secondary to transportation related-incidents. Assaults are also identified as a significant cause of fatality. The findings also indicate that females in this occupational group may have a disproportionately larger number of injuries. Support is recommended for further research related to causal factors and for the development, evaluation and promulgation of evidence-based interventions to mitigate this problem. Maguire BJ , Smith S . Injuries and fatalities among emergency medical technicians and paramedics in the United States. Prehosp Disaster Med. 2013;28(4):1-7 .

Concepts: Relative risk, Injuries, Injury, Ambulance, Emergency medical services, Paramedic, Emergency medical technician, Private sector