During the 1999 conflict in Kosovo, an estimated 850,000 people were displaced from Kosovo. Many thousands of these people arrived in the Former Yugoslav Republic of Macedonia (FYROM), for whom a humanitarian evacuation programme (HEP) was conducted by the United Nations High Commissioner for Refugees (UNHCR) and the International Organization for Migration (IOM). More than 91,000 people were moved to third countries under this programme.

A health assessment tool was designed, validated, and implemented to document the health status of the refugees prior to departure. The IOM evaluated 41,652 pre-travel “fitness to travel” medical assessments for refugees transported by the Organization. A colour coding system for fitness-to-travel was used to clearly identify refugees to the receiving health authorities according to their health condition at the time of departure.

A total of 41,652 fitness-to-travel assessments were performed between 05 April and 25 June 1999, and were entered into a database. There were 21,923 females and 19,566 males. The average age was 25.3 years (women, 26 years; men, 24.3 years). Of these assessments, 4,647 (11.2%) individuals who were deemed fit-to-travel required medical assessment at the host destination, and of those 1,204 required urgent care. The majority of health complaints were acute respiratory tract infections and hypertension.

A rapid and efficient system for fitness-to-travel was created to assist in the management of health issues related to the urgent and mass movement of refugees. The collected health information was of use to health-care planners during the crisis and for those responsible for the health-care of newly arrived refugees. The lessons learned have implications for future similar operations and for the development of research and education programs for both the refugees and the host recipient nations.

To identify the vulnerabilities of elderly to disasters, and to develop strategies to address these vulnerabilities.

A relevant literature search of journal articles, government training materials, news reports, and materials from senior organizations was conducted.

The vulnerability of the elderly to disasters is related to their impaired physical mobility, diminished sensory awareness, chronic health conditions, and social and economic limitations that prevent adequate preparation for disasters, and hinder their adaptability during disasters. Frail elderly, those with serious physical, cognitive, economic, and psycho-social problems, are at especially high risk.

This segment of the population is growing rapidly. Therefore, it is important that emergency management recognize the frail elderly as a special needs population, and develop targeted strategies that meet their needs. Several management strategies are presented and recommendations for further action are proposed.

The objective was to test, in this trauma system, the North American hypothesis that exceeding the 60-minute limit for the entire prehospital time (“golden hour of shock”) increases mortality of blunt polytrauma patients.

In a prospective, observational, cohort study conducted between 1990 and 1996, a severity characterization of trauma (ASCOT) score was used to compare the actual mortality with the predicted mortality in 107 blunt polytrauma patients (Group 1) with prehospital rescue periods ≤60 minutes (time from accident until arrival at the emergency department). The same comparison was performed for 147 blunt polytrauma patients (Group 2) with rescue periods >60 minutes. Inclusion criteria were blunt trauma of at least two body sites, an Injury Severity Score (ISS) of ≥8, and direct admission to the trauma centre. Multivariate regression analysis was performed to test for bias and confounding, and to identify factors that might influence mortality. Odd ratio (OR) and 95% confidence interval (CI) were calculated.

The mortality in Group 1 was 14%, and was not statisticvally significantly higher than the 10.2% observed for Group 2. 4.8 patients, or 47% more than predicted, died in Group 1 (p = 0.057). The corresponding figures in Group 2 were 4.2 patients or 22% fewer than predicted (p = 0.19). Multivariate logistic regression confirmed this trend with a significant mortality odds ratio of 8 (95% CI 1.7 to 38.5) for Group 1 compared to Group 2. Significantly more patients in Group 2 were treated by emergency physicians.

It appears in this trauma system, in which emergency physicians often are deployed, that the ‘golden hour of shock’ can be extended safely in many blunt polytrauma patients, since this was associated with better survival figures than in those patients for whom the time was <1 hour.

Diversion of ambulances by hospital emergency departments has become a day-to-day occurrence in many jurisdictions within Canada. Yet, despite the increasing prevalence of this phenomenon, its impact on transported patients, on the EMS system, and on the health care system overall has not, to date, been well quantified. Despite the increasing sophistication and capabilities of North American EMS systems, it is difficult to argue with the principle that unstable or potentially unstable patients are best served by expeditious transport for definitive care to acute care facilities. T o this end, this study represents an effort to assess the systemic and patient care impacts of ambulance diversions.

Patient-care and corresponding ambulance trip records for all patients transported by this EMS system for a five week period were abstracted to identify those patients in which an ambulance was diverted from its initial destination. Adverse events include hypotensive episodes, airway compromise, changes in level of consciousness, and the onset of violent behavior. Response and transport times also were abstracted, comparisons utilized student's t-test and 95% Confidence Intervals. Results: Ambulance diversions increased EMS response times and prehospital transport times. Adverse medical events occurred during 4.3% of diverted ambulance runs. Patients, when faced with the prospect of transport to other than their hospital of choice, not infrequently cancelled EMS transport and sought other means of transport. Subsequent interfacility transport was required for 4.3% of the diverted patients.

Diversion of ambulances impacts the EMS system by increasing response and transport times; the region, by generating subsequent interfacility transports; and patients, as adverse medical events can occur during the diverted transport.

To evaluate characteristics and outcome of out-of-hospital cardiac arrest (OHCA) patients presenting to the Emergency Department (ED), and to examine factors that could be used to determine to prolong or abort resuscitation for these patients.

All OHCA patients presenting to the ED were studied over a three-month period from November 2001 through January 2002. Patient with traumatic cardiac arrest were excluded. Data were collected from the ambulance case records, ED resuscitation charts, and the ED Very High Frequency (VHF) radio case-log sheet. Information collected included the patient's demographic characteristics, timings (time from call to ambulance arrival on scene, time from arrival at scene to departure from scene, time from scene to arrival in the ED) recorded in the pre-hospital setting, the outcome of the resuscitation, and the final outcome for patients who survived ED resuscitation.

Ninety-three non-traumatic patients with an OHCA were studied during the three-month period. Of the 93 patients, 15 (16.1%) survived ED resuscitation, and one survived to hospital discharge. There were no statistically significant differences for age, race, or gender with regards to the outcome of the resuscitation. The initial cardiac rhythms were asystole (65), pulseless electrical activity (21), and ventricular fibrillation (7). Fourteen (15%) received bystander cardiopulmonary resuscitation (CPR). All seven patients with return of spontaneous circulation (ROSC) on arrival in the ED survived ED resuscitation. The ambulance took an average of 11.80 ±3.36 minutes for the survivors and 11.8 ±4.22 minutes for the non-survivors from the time of call to get to these patients. The average of the scene times was 12.5 ±4.61 minutes for the survivors and 12.0 ±4.02 minutes for the non-survivors. Transport time from the scene to the ED took an average of 39.1 ±8.32 minutes for the survivors and 37.2 ±9.00 minutes for the non-survivors.

The survival rate for patients with OHCA after ED resuscitation is similar to the results from other studies. There is a need to increase the awareness and delivery of basic life support by public education. Automatic External Defibrillators (AED) should be available widely to ensure that the chance of early defibrillation is increased. Prolonged resuscitation efforts appear to be futile for OHCA patients if the time from cardiac arrest until arrival in the ED is ≥30 minutes coupled with no ROSC, and if continuous asystole has been documented for >10 minutes.

For patients who suffer out-of-hospital cardiac arrest, the time from collapse to initial defibrillation is the single most important factor that affects survival to hospital discharge. The purpose of this study was to compare the survival rates of cardiac arrest victims within an institution that has a rapid defibrillation program with those of its own urban community, tiered EMS system.

A logistic regression analysis of a retrospective data series (n = 23) and comparative analysis to a second retrospective data series (n = 724) were gathered for the study period September 1994 to September 1999. The first data series included all persons at Casino Windsor who suffered a cardiac arrest. Data collected included: age, gender, death/survival (neurologically intact discharge), presenting rhythm (ventricular fibrillation (VF), ventricular tachycardia (VT), or other), time of collapse, time to arrival of security personnel, time to initiation of cardiopulmonary resuscitation (CPR) prior to defibrillation (when applicable), time to arrival of staff nurse, time to initial defibrillation, and time to return of spontaneous circulation (if any). Significantly, all arrests within this series were witnessed by the surveillance camera system, allowing time of collapse to be accurately determined rather than estimated. These data were compared to those of similar events, times, and intervals for all patients in the greater Windsor area who suffered cardiac arrest. This second series was based upon the Ontario Prehospital Advanced Life Support (OPALS) Study database, as coordinated by the Clinical Epidemiology Unit of the Ottawa Hospital, University of Ottawa.

The Casino Windsor had 23 cases of cardiac arrests. Of the cases, 13 (56.5%) were male and 10 (43.5%) were female. All cases (100%) were witnessed. The average of the ages was 61.1 years, of the time to initial defibrillation was 7.7 minutes, and of the time for EMS to reach the patient was 13.3 minutes. The presenting rhythm was VF/VT in 91% of the case. Fifteen patients were discharged alive from hospital for a 65% survival rate. The Greater Windsor Study area included 668 cases of out-of-hospital cardiac arrest: Of these, 410 (61.4%) were male and 258 (38.6%) were female, 365 (54.6%) were witnessed, and 303 (45.4%) were not witnessed. The initial rhythm was VF/VT was in 34.3%. Thirty-seven (5.5%) were discharged alive from the hospital.

This study provides further evidence that PAD Programs may enhance cardiac arrest survival rates and should be considered for any venue with large numbers of adults as well as areas with difficult medical access.

To study the rate of prehospital mortality before establishment of a rescue system for victims of land-mines in Iran.

Survey at rural clinics in mine-affected areas, and retrospective review of public patient records.

A total of 36.4% of casualties from land-mines in the study area died during the period of 1989–1999. The mortality seems highest in those victims who were torso injured.

The mortality rate from accidents involving land-mines in the study area was high. Most fatalities seemingly occurred in the prehospital setting.