Introduction:Anecdotal observations about prehospital emergency medical care in major natural and human-made disasters, such as earthquakes, have suggested that some injured victims survive the initial impact, but eventually die because of a delay in the application of life-saving medical therapy.Methods:A multidisciplinary, retrospective structured interview methodology to investigate injury risk factors, and causes and circumstances of prehospital death after major disasters was developed. In this study, a team of United States researchers and Costa Rican health officials conducted a survey of lay survivors and health care professionals who participated in the emergency medical response to the earthquake in Costa Rica on 22 April 1991.Results:Fifty-four deaths occurred prior to hospitatization (crude death rate = 0.4/1,000 population). Seventeen percent of these deaths (9/54) were of casualties who survived the initial impact but died at the scene or during transport. Twenty-two percent (2/9) were judged preventable if earlier emergency medical care had been available. Most injuries and deaths occurred in victims who were inside wooden buildings (p <.O1) as opposed to other building types or were pinned by rubble from building collapse. Autopsies performed on a sample of victims showed crush injury to be the predominant cause of death.Conclusions:A substantial proportion of earthquake mortality in Costa Rica was protracted. Crush injury was the principal mechanism of injury and cause of death. The rapid institution of enhanced prehospital emergency medical services may be associated with a significant life- saving potential in these events.
Introduction:The 1991 earthquake in the Limón area of Costa Rica presented the opportunity to examine the effectiveness of a decade of disaster preparedness.Hypothesis:Costa Rica's concentrated work in disaster preparedness would result in significantly better management of the disaster response than was evident in earlier disasters in Guatemala and Nicaragua, where disaster preparedness largely was absent.Methods:Structured interviews with disaster responders in and outside of government, and with victims and victims' neighbors. Clinical and epidemiologic data were collected through provider agencies and the coroner's office.Results:Medical aspects of the disaster response were effective and well-managed through a network of clinic-based radio communications. Nonmedical aspects showed confusion resulting from: 1) poor government understanding of the roles and responsibilities of the central disaster coordinating agency; and 2) poor extension of disaster preparedness activities to the rural area that was affected by the earthquake.Conclusion:To be effective, disaster preparedness activities need to include all levels of government and rural, as well as urban, populations.
Objective: To develop an evaluation method for comparing the performance of emergency medical services (EMS) systems in telephone assessment. Methods: An analysis of the telephone assessment task reveals three functional sub-tasks which may or may not be present in any EMS system: 1) "triage," or deciding whether or not to send EMS vehicle (s); 2) "prioritization," or deciding about the optimal delay of intervention; and 3) choice of the level of intervention. Each of these sub-tasks may generate false positive and false negative errors of various magnitudes ("costs"). With a sufficient sample of cases for which the "ideal" decisions are known, the sensitivity and specificity of each sub-task can be measured as well as the average costs of errors per call. EMS systems often differ between countries, and even within the same country, in their implementation of the three sub-tasks and in their local context (health care system, social values, etc.). A matrix (real decisions x ideal decisions) of the values ("costs") of all possible types of errors can be established locally by consensus for each particular EMS system. Using the same range of values for these matrices, the performance of EMS systems in telephone assessment can be compared based on the average cost of errors per call. Longitudinal and individual measurements also may be used locally for quality improvement within each EMS system. Results: This method has been applied successfully at the Montreal EMS system, Urgences Sante (detailed results will be presented in another paper by the same authors). Interested participants at the Congress will be encouraged to join in an international study.
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