Improving global prehospital and emergency health care, public health, and disaster health and preparedness

Posted by: Joseph Cuthbertson; 4 May 2016; 10:39 pm

The impact of drug trade and usage upon society is rapidly increasing. In 2012, the Australian Institute of Criminology reported Oceania as having the highest global usage and trade of methamphetamine, also known as ICE1. In Indonesia, President Joko Widodo has stated that, “Indonesia is in a state of emergency with regard to drug use.2” The Centre for Research and Epidemiology of Disasters defines a Disaster as 10 or more deceased and/or greater than 100 injured, and/or declaration by the country of a state of emergency and/or an appeal for international assistance. Utilising this definition and descriptors applied by UNSIDR3 the impact of illegal drug use and trafficking represents a contemporary, societal disaster.

The emerging impact of methamphetamines in Victoria has been labelled a crisis and led to the establishment of a workforce appointed by the incumbent government in response to a parliamentary report. The Victorian Police have publicly stated that ‘we can’t simply arrest our way out of this crisis. We need to get to the heart of the problem and listen to the experts who see the effects of this tragedy every single day.’ Additionally, like many commonly recognized disasters this impact extends across borders and countries, and disproportionally affects the vulnerable groups within communities.
Disaster risk reporting is primarily produced to identify who may be at risk (vulnerable populations) to specific events (cause).

There is a lack of discussion attempting to establish what the emerging disaster risks and consequent recognition of their potential impact. Possible reasons for this may include perceptions of these threats not being readily identifiable as disasters or fitting traditional descriptions of disasters. Nevertheless many of these emerging threats to health meet established criteria defining ‘disasters’ and as such, review of their emergence and impact is crucial for emergency managers to adequately respond. Whilst addiction has previously been identified as a causal factor of poor health, it is not construed as a risk factor within emergency management paradigms, and as a consequence the capacity to operationalise either addiction programs or trafficking action within this space is limited if not nonexistent.

The recognition of the complexity of illicit drug impact should be heeded as a call to collaborative action across professions to engage in action. Public Health practice has a unique and valuable skill set to offer, and should be engaged by leadership in this field.
 
References

  1. Schloenhardt, A., The market for amphetamine-type stimulants and their precursors in Oceania. Canberra: Australian Institute of Criminology, 2007. 81.
  2. Indonesia in State of Emergency over Drugs: President, in The Bali Times. 2014, Lestari Kala Media: Indonesia.
  3. The United Nations International Strategy for Disaster Reduction, 2009 UNISDR Terminology on Disaster Risk Reduction. 2009.

Posted by: Joseph Cuthbertson; 17 September 2016; 4:13 am

Recent WADEM Oceania committee discussions have considered what the chapters core business is and whom the chapter interacts with. This has provided the opportunity to revisit the original WADEM Chapter proposal that sought to define, what, and who WADEM Oceania is.

(Original WADEM Chapter proposal)

The term “Oceania” was originally used to indicate the intended geography of this proposed WADEM Regional Chapter. Australia and New Zealand are included in the Western Pacific Regional Office of WHO (http://www.wpro.who.int/), which extends from China to the Pitcairn Islands (http://www.who.int/about/regions/wpro/en/) . It is felt that this is too large a geographical area for a single WADEM Chapter to be effective and efficient.

OCHA includes an Oceania Region within the OCHA Regional Office for Asia Pacific, (http://www.reliefweb.int/rw/rwb.nsf/doc113?OpenForm&rc=5#show), which also roughly corresponds to the Pacific Islands Applied Geoscience Commission (SOPAC) region.

For the purposes of these Bylaws, the WADEM Oceania Region generally corresponds to that area covered by SOPAC, which includes the area supported by AusAID and NZAID, i.e. Australia, New Zealand, the Pacific Island Nations, and Papua New Guinea. Flexibility is required at this stage of the evolution of WADEM Chapters. Members located in adjacent countries, e.g. Honolulu, East Timor and Indonesia, may choose to be included in the Oceania Regional Chapter.

The original chapter proposal identifies variances that continue to exist in defining the boundaries of Oceania. With the initiation of the recently formed ‘WADEM Disaster Metrics’ Section it may be of use to consider what methods are used to describe Oceania for research purposes. The Centre for Research and Epidemiology in Disasters (CRED) is an international reference for disaster research and apply the UN regional division (http://unstats.un.org/unsd/methods/m49/m49regin.htm) for classification.

This definition of Oceania is comprised of:

Australia and New Zealand

  • Australia
  • New Zealand
  • Norfolk Island

Melanesia

  • Fiji
  • New Caledonia
  • Papua New Guinea
  • Solomon Islands
  • Vanuatu

Micronesia

  • Guam
  • Kiribati
  • Marshall Islands
  • Micronesia (Federated States of)
  • Nauru
  • Northern Mariana Islands
  • Palau

Polynesia

  • American Samoa
  • Cook Islands
  • French Polynesia
  • Niue
  • Pitcairn
  • Samoa
  • Tokelau
  • Tonga
  • Tuvalu
  • Wallis and Futuna Islands

Of note, the CRED/UN regional definition does not include Asia or South East Asia whereas the WHO classification does. This is of relevance as these regions are consistently overrepresented with the burden of disaster impact and effect. Their inclusion when assessing Oceania would considerably alter measurable disaster impact in the region.

The consideration of the WADEM definition of Oceania is complex and should articulate the broader WADEM strategy (https://wadem.org/about/misson/) and reflect the Chapter’s capacity to engage the region. Equally, in an increasingly connected world the concept of global citizenship calls into question how current and future chapters engage internally and externally to best serve humanity.

Posted by: Joseph Cuthbertson; 4 May 2016; 10:16 pm

The nature and type of risk to responders in both developed and developing countries is evolving and increasing. In the humanitarian setting this has led to programmes such as the “Health care in Danger” (HCID) initiative, intended to raise awareness and concern, and improve field practices and international response to acts of violence towards health care workers.

In other nations the increasing impact of urban violence, illicit drug trafficking, crime and terrorism has resulted in the development and implementation of the subspecialty of Tactical EMS1. Furthermore, whilst this increase has evolved as a global issue the international implementation of Tactical EMS roles has not been explored as such and primarily operates in North American countries.

Designed to provide medical support in high risk environments this skill set is in many ways reflective of origins of Emergency Medical Service from Military Medic models. The role provides medical care and support to responders within the threat area, and has evolved to meet the specific needs of civilian law enforcement2.

Utilising the PPRR Disaster cycle model as framework for assessment, the role of Tactical EMS appears to fit predominantly in the “preparedness” and “response” phase of the available literature3, 4, 5. From a “recovery” viewpoint, the future health impact of these roles on EMS professionals does not appear to have been thoroughly investigated to date.

Collaborative, international research on potential health effects of the role, the effectiveness of Tactical EMS and what prehospital systems are most appropriate for its use are needed to support this speciality as it develops.

 
References

  1. Heiskell, L. E., & Carmona, R. H. (1994). Tactical emergency medical services: an emerging subspecialty of emergency medicine. Annals of Emergency Medicine, 23(4), 778-785.
  2. Callaway, D. W., Smith, E. R., Cain, J., Shapiro, G., Burnett, W. T., McKay, S. D., & Mabry, R. (2011). Tactical Emergency Casualty Care (TECC): guidelines for the provision of prehospital trauma care in high threat environments. Journal of Special Operations Medicine, 11(3), 104-122.
  3. Tang, N., & Kelen, G. D. (2007). Role of tactical EMS in support of public safety and the public health response to a hostile mass casualty incident. Disaster Medicine and Public Health Preparedness, 1(S1), S55-S56.
  4. Metzger, J. C., Eastman, A. L., Benitez, F. L., & Pepe, P. E. (2009). The lifesaving potential of specialized on-scene medical support for urban tactical operations. Prehospital Emergency Care, 13(4), 528-531
  5. Jacobs, L. M., Wade, D. S., McSwain, N. E., Butler, F. K., Fabbri, W. P., Eastman, A. L., & Burns, K. J. (2013). The Hartford Consensus: THREAT, a medical disaster preparedness concept. Journal of the American College of Surgeons, 217(5), 947-953.

Posted by: Joseph Cuthbertson; 4 January 2017; 6:50 pm

Post written by: Dr. William Bograkos, MA, DO, FACOEP, FACOFP
Chair, WADEM Osteopathic Physicians Section; President, AOAAM

THE BEAST

The November 2016 edition of “EM News” published an article titled “Carfentanil, the New Beast on the Block.”1 Emergency Medicine News targets our colleagues in emergency medicine, emergency medical services, acute care, Tactical Emergency Medical Support, and emergency medicine academia. Our journal, Journal of Addictive Diseases serves the sub-specialty of Addiction Medicine. The “beast” doesn’t care if we are united or divided.

Deaths from opiates in the United States continue to surpass deaths from motor vehicle trauma. Overdose deaths from licit and illicit opioids have quadrupled since 1999. Ninety one Americans die every day from an opioids overdose.2 The intersection of substance use, misuse, substance use disorders, and emergency medical systems is a very dangerous intersection. Every medical specialty is aware of this intersection. Every medical specialty passes through this intersection. Our sub-specialty of Addiction Medicine should be offering its direction and guidance to colleagues as they approach this threatening intersection. Acute intoxication and chronic toxic brain injury requires attention from all public health stakeholders.

The danger and disaster associated with drugs of abuse is capable of touching all specialties. Public Health Disasters and the disaster within individuals require a response from all specialties. The opiate disaster extends beyond emergency and recovery phases. Development of positive coping skills, prevention, mitigation, and preparedness to face the triggers associated with relapse are individual and inter-disciplinary strategies. Strategic planning and execution of planning does not take place in silos.

When President Nixon declared “the war on drugs” in 1971- 1972, cash crops in the Golden Triangle served as a “point source” for the “opiate epidemic.” The “EM News” article on carfentanil importation was interesting as this cargo too crossed the Pacific. However, synthetic opiates require more narcan to reverse their effect and produce greater profits by reducing logistic supply chains. Diversion of synthetic opiates by transnational and local criminals has proved to be a clear and present danger to public health and public safety. Profits fund criminal networks, its undercurrent of associated violence, and the tsunami of public health threats that threaten our communities.

Clinicians focus on the prevention and treatment of this deliberate epidemic. We have been taught to treat one patient at a time. We seek the differential diagnosis and the etiology of the illness. Let us pause and read VADM Murthy’s discussion on the dynamics of the public health catastrophic event before us.3 Exposure to public health threats often lead to disease and outbreak scenarios. Exposure followed by the use of drugs of abuse often leads to addiction as a brain disease. Metric tons of heroin and illicit synthetic drugs enter the United States every year. Pain specialists and dedicated physicians are not the single “point source” in the opiate epidemic. Flawed drug strategies and concepts without medical consultation today, may lead to the medical professional being blamed for the outbreak of cannabis dependence tomorrow, even though the medical profession objected to the term “medical cannabis.” Flawed guidance today may prevent patients from receiving appropriate integrative pain management in the future.

All public health outbreaks need to be contained and controlled by strong coalitions of dedicated stakeholders. Drugs and bugs know no ethnic or geographic boundaries. Coalitions build bridges across silos of academies, cultures, and disciplines. As a sub-specialty, we are in a unique position to serve our patients, our communities, and our nation. The AOAAM membership demographics are unique. Our members hold a multitude of primary specialties and hold membership across academies within the American Osteopathic Association.

It is my hope that an united academy will invest in the future of the profession by encouraging the growth of Addiction Medicine student clubs across our universities and facilitating their discussions in an interdisciplinary format. The opportunity for dynamic dialogue across disciplines should be fostered at our universities. Substance use disorder is a thinking problem. Addiction is a brain disease and the circuitry is complex. Our students will require mentoring from their elders. Seasoned physicians often see more than neuroimaging. The next beast on the street will be more dangerous. As a medical sub-specialty, I hope we will encourage bridge building with stakeholders across public health and public safety.

Bridges are the first targets in war. Allow me to quote Dr. Martin Luther King and, “Let us build bridges and not walls.” Let us build bridges for the access to healthcare. As a sub-specialty, let us strengthen the bridges that connect us with all medical specialties.

 
References

  1. Gussow, Leon. “Toxicology Rounds: Who Said the Opioid Crisis Couldn’t Get Any Worse?” Emergency Medicine News 38, no. 11 (November 2016): 1, 29-30.
  2. CDC, “Understanding the Epidemic/ Drug Overdose/ CDC Injury Center.” https://www.cdc.gov/drugoverdose/epidemic/ (accessed January 1, 2017).
  3. Surgeon General. “The Surgeon Generals Report on Alcohol, Drugs, and Health.” https://addiction.surgeongeneral.gov/surgeon-generals-report.pdf (accessed January 1, 2017).

Posted by: Joseph Cuthbertson; 20 June 2016; 12:15 pm

Post written by: Dr. Sanjeev Bhoi, All India Institute of Medical Sciences (AIMMS)

Point of care sonography (POCS) done by clinicians has become popular over the past two decades1. Its use has been described as an adjunct to physical examination during resuscitation 2.Ultrasound has also been shown to be useful to emergency care providers with differing levels of training, background, and clinical focus such as trauma and emergency care 3. The Focused Assessment with Sonography in Trauma (FAST) examination has become the standard of care for the diagnosis of post-traumatic pericardial tamponade and hemoperitoneum 4. POCS is also useful in diagnosis of chest, extremity trauma, evaluation of shock states and intravascular volume depletion 4,5,6,7.

Disasters are situations which demands quick triage of large numbers of injured patients, especially in a resource limited setting 8. An immediately deployable, flexible and resource-sparing emergency medical response is key to improve survival during disaster. In disasters, the benefit from early intervention to the injured is often undermined by relative lack of healthcare personnel, a chaotic environment, and deficient stable social infrastructure 6,7.This limits the availability of most modern diagnostic tools, especially imaging modalities, because they are resource intensive and require a high degree of infrastructural integrity. Thus, in a disaster, responders may be forced to rely only on history and clinical examination which is relatively time-consuming and often inaccurate approach in this setting.

Modern ultrasound machines are portable, robust, easy to use, and inexpensive. These advances allow ultrasound to be brought to the patients to acquire diagnostic information in real time. In addition, literature describes its use in remote, austere, and resource-poor settings, including outer space, high altitudes and combat settings9. It can address triage, resuscitation and critical treatment decisions during the disaster 10,11,12,13. Virtual technology such as telemedicine can be integrated with the POCS to make critical management decisions in the field. These qualities of point of care ultrasound makes it uniquely suited for deployment in the care of patients in the setting of a disaster.
 
References

  1. Kendall JL, Hoffenberg SR, Smith RS. History of emergency and critical care ultrasound: the evolution of a new imaging paradigm. Crit Care Med.2007;35: S126–S130.
  2. Brooks A, Davies B, Smethhurst M, Connolly J. Prospective evaluation of non-radiologist performed emergency abdominal ultrasound for haemoperitoneum. Emerg Med J. 2004;21: e5.
  3. Nelson BP, Chason K. Use of ultrasound by emergency medical services: a review. Int J Emerg Med.2008; 1:253–259.
  4. 4 Rozycki GS. Surgeon-performed ultrasound: its use in clinical practice. Ann Surg. 1998; 228:16–28.
  5. Dulchavsky SA, Henry SE, Moed BR, Diebel LN, Marshburn T, Hamilton DR, et al. Advanced ultrasonic diagnosis of extremity trauma: the FASTER examination. J Trauma.2002;53:28–32.
  6. Lyon M, Blaivas M, Brannam L. Sonographic measurement of the inferior vena cava as a marker of blood loss. Am J Emerg Med. 2005; 23:45–50.
  7. Ebrahim A, Yousefifard M , Kazemi H , Rasouli H , Asady H , Jafari A Diagnostic Accuracy of Chest Ultrasonography versus Chest  Radiography for Identification of Pneumothorax: A Systematic Review and Meta-Analysis. Tanaffos.2014; 13(4): 29–40.
  8. Burkle FM Jr. Mass casualty management of a large-scale bioterrorist event: an epidemiological approach that shapes triage decisions. Emerg Med Clin North Am.2002; 20:409–436.
  9. Ma OJ, Norvell JG, Subramanian S. Ultrasound applications in mass casualties and extreme environments. Crit Care Med. 2007;35: S275–S279.
  10. Stawicki SP,Howard JM, Pryor JP, Bahner DP, Whitmill ML, Dean AJ Portable ultrasonography in mass casualty incidents: the caveat examination.World J Orthop 2010 ;1(1):10-9.
  11. Blaivas M. Triage in the trauma bay with the focused abdominal sonography for trauma (FAST) examination. J Emerg Med. 2001; 21:41–44.
  12. Mazur SM, Rippey J. Transport and use of point-of-care ultrasound by a disaster medical assistance team. Prehosp Disaster Med. 2009; 24:140–144.
  13. Wydo SM, Seamon MJ, Melanson SW , Thomas PD, Bahner P, Stawicki SP. Portable ultrasound in disaster triage: a focused review. Eur J Trauma Emerg Surg. 2016 42:151–159.