This study sought to determine the lifesaving potentials of modern resuscitation medicine as applied to a catastrophic disaster situation. Previous articles reported the preliminary results (I), and methodology (II) of a structured, retrospective interview study of the 1988 earthquake in Armenia. The present article (III) reports and discusses the definitive findings, formulates conclusions, and puts forth recommendations for future responses to catastrophic disasters anywhere in the world.

Observations include: 1) The lack of adequate construction materials and procedures in the Armenian region contributed significantly to injury and loss of life; 2) The uninjured, lay population together with medical teams including physicians in Armenia were capable of rapid response (within two hours); 3) Due to a lack of Advanced Trauma Life Support (ATLS) training for medical teams and of basic first-aid training of the lay public, and scarcity of supplies and equipment for extrication of casualties, they were unable to do much at the scene. As a result, an undetermined number of severely injured earthquake victims in Armenia died slowly without the benefit of appropriate and feasible resuscitation attempts.

1) Widespread adoption of seismic-resistant building codes for regions of high seismic risk; 2) The lay public living in these regions should be trained in life-supporting first-aid (LSFA) and basic rescue techniques; 3) Community-wide emergency medical services (EMS) systems should be developed world-wide (tai-lored to the emergency needs of each region) with ATLS capability for field resuscitation; 4) Such systems be prepared to extend coverage to mass casualties; 5) National disaster medical system (NDMS) plans should provide integration of existing trauma-EMS systems into regional systems linked with advanced (heavy) rescue (public works, fire, police); and 6) New techniques and devices for victim extrication should be developed to enable rapid extrication of earthquake casualties within 24 hours.

Casualty Collection Points (CCPs) are sites predesignated by county officials for the congregation, triage, austere medical treatment, holding, and evacuation of casualties following a major disaster. A CCP (and the simulation) is made up of a series of discrete, interrelated steps that collectively result in medical care being provided to a casualty.

A series of computer simulations was run comparing differences in personnel, supplies, and evacuation configuration for a jurisdiction that has plans in place to establish a CCP, and for one that does not. Each simulation was for 650 earthquake-related casualties.

Generally, it was found that: 1) mortality appears to be related directly to performance of triage of casualties and to where they are directed for care. The least injured did not need to be treated at a CCP; 2) survival is related directly to arrival time, mix of medical staff, and the ability to form “care teams” on-site; 3) the sudden, massive arrival of casualties will result in a “snowball” mortality effect if staff numbers are low or do not include the proper mix of training to form care teams well before the peak arrival time of casualties; 4) holding ambulances until they are filled completely before evacuation may increase mortality; 5) during the first four hours, more lives may be saved by using transportation assets to move medical staff and supplies to a CCP, if large numbers of casualties are expected to congregate there. Generally, the local jurisdiction must be prepared to mobilize a significant number of medical staff and supplies to a predesignated CCP within 4–6 hours after an event.

The simulation produced useful information. In particular, local disaster response planners need to develop rapid response methods to ensure that the best combination of medical staff are available early to care for casualties.

In recent years, several authors have begun to address the medical and legal risks associated with patients refusing or being refused transport by emergency medical services (EMS) systems. However, data regarding patient outcomes still are lacking.

The purpose of this study was to determine: 1) why patients are not transported; and 2) the subsequent outcome of these patients.

A busy, suburban, volunteer EMS service with indirect medical control, but no guidelines for non-transport of patients.

A retrospective review of the records of 158 consecutive EMS incidents in which an ambulance was called, but the patient was not transported. Follow-up was attempted by telephone contact with the patient and/or family.

Telephone follow-up was established successfully for 93 cases (59%). Of the 93 patients, 60 (64.5%) subsequently sought care from a physician, 15 of whom (25%) later were admitted. The mean hospital stay was 6.6±7.9 days (median=3 days) with a range of 1–30 days. Two were admitted to an intensive care unit (ICU) and two others died. Of the 93 study cases, 43 (46%) involved situations in which the patient refused transport. Paramedics declined transport or mutually agreed not to transport in 50 cases (54%). This latter category accounted for 11 (73%) of the 15 hospitalizations. Ten percent of patients (or their families) stated that they were dissatisfied with the non-transport decisions.

Serious, even fatal outcomes were identified in the follow-up of patients not transported by EMS. Although a direct causal relationship was not established within the context of this study, situations in which EMS personnel either denied transport (or mutually agreed with the patient not to transport by ambulance) were twice as likely to result in hospitalization than were those cases in which the patients declined transportation against the advice of the EMS personnel.

To study the natural outcome of patients refusing prehospital transportation (PT).

A total of 188 consecutive patients who refused PT in an urban, advanced life support (ALS), emergency medical services (EMS) system were studied. Of these, 77 (41 %) were male, and the average age was 51 years. Patients were entered into the study group only once.

Only 94 (50%) patients could be reached by telephone follow-up. Seven (7%) of these 94 patients had abnormal vital signs, 33 (35%) had cardiopulmonary complaints, 16 (17%) had an altered level of consciousness, nine (10%) were involved in accidents, and eight (8%) had abdominal pain. Six (6%) patients were admitted to the hospital, two (2 %) received ALS-level treatment by the paramedics and then refused conveyance, and 31 (33 %) either saw or contacted a physician. Consultation with an EMS physician was initiated for nine (5%) refusals. Of all the patients contacted, six (6%) needed PT for hospitalization.

As only 50% of the patients refusing prehospital transportation could be reached using follow-up telephone calls, the 6% figure probably underestimates the true number of patients requiring PT. Telephone follow-up is an inadequate means of determining the natural outcome for this patient population. The ALS nature of many of the complaints combined with the lack of consistent physician consultation, exposes the EMS system to an undefined medico-legal liability risk.

To evaluate the seroconversion rate of EMS personnel given the hepatitis B virus (HBV) recombinant deoxyribonucleic acid (DNA) vaccine series.

Retrospective review of paramedics and firefighters consecutively completing the HBV recombinant DNA vaccine program.

Urban, non-prof it, private, regional EMS Resource Hospital. The Chicago North EMS System is under contract with the Chicago Fire Department. This contract allows for the voluntary vaccination of EMS personnel with recombinant DNA-HBV vaccine and treatment and follow-up of paramedics and firefighters possibly exposed to HBV.

Initial 68 EMS personnel completing HBV recombinant DNA vaccine program (48 primary prophylaxis and 20 post-exposure prophylaxis).

HBV recombinant DNA vaccine series was administered voluntarily to Chicago EMS System paramedics and firefighters per manufacturers recommendations. Two weeks after completion of the vaccination series, blood samples for HBV antibody titres were drawn to determine reactivity and the need for further immunization.

Of the 68 vaccinated individuals, only two had negative titres (3%). These two individuals were given a fourth dose of vaccine with successful seroconversion.

Prehospital care personnel are known highrisk, health-care workers for acquiring HBV and should be vaccinated prophylactically. There is a high seroconversion rate (97%) utilizing HBV recombinant DNA vaccine. However, post-vaccination antibody titres must be performed to identify those rare individuals that do not seroconvert.

In a single-tier, advanced-life-support (ALS) emergency medical service (EMS) system, ALS-trained staff in ALS-equipped vehicles respond to all ambulance calls. In some two-tier systems, basic life support (BLS) vehicles respond to calls which are determined initially to be non-emergency based on dispatcher triage. I emergency requiring ALS is discovered (or recognized) by BLS personnel, then a subsequent ALS response can be requested.

The purpose of this study was to determine the frequency of ALS care provided on ambulance calls initially dispatched as non-emergency.

A single-tier, all-ALS provider, EMS system, serving an urban population of 475,000 with an annual response volume of 45,000 calls.

A retrospective review of all prehospital transports initially dispatched as non-emergency from 1 January 1989 to 1 January 1990 that resulted in an ALS intervention being performed was conducted. An ALS intervention was defined as, “administration of a medication, endotracheal intubation, attempted IV insertion, and/or ECG monitoring.”

A total of 6,362 non-emergency calls were identified; of these 309 (5%) were upgraded to emergency while the responding unit was in route. Of 6,053 non-emergency calls remaining, 710 (11.7%) involved the provision of one or more ALS interventions. Of these, 296 (42%) received an IV, 24 (3%) a medication, and three (0.4%) were intubated. Calls that were upgraded by dispatchers required one or more interventions in 144/309 calls (46.6%). This was statistically significantly different than for the non-upgraded calls.

Despite the use of strict dispatching protocols, 11.7% of patients prioritized as non-emergent unexpectedly received ALS care after evaluation by ALS personnel. These results add support for the use of a single-tier, ALS ambulance system.