The prehospital care provider has been limited in his or her initial assessment of patients due to having available only a limited number of simple diagnostic tests. There has not been an accurate field test available to rule out significant ethanol intoxication. We designed a prospective trial for the prehospital setting to test the utility of a rapid, semi-quantitative, saliva alcohol reagent strip for patients with an altered level of consciousness. We found that these strips were useful in ruling out significant ethanol intoxication as a cause of an altered level of consciousness with a sensitivity of 85.7% and a specificity of 94.4%, but were not useful in accurately predicting the blood alcohol level. We conclude that these reagent strips are useful in the prehospital setting to provide information about patients with an altered level of consciousness.

The world population is becoming increasingly reliant upon nuclear fission for the generation of electric power. In the wake of this activity, there have been two major accidents: Three Mile Island (TMI), near Harrisburg, Pennsylvania, United States, in 1979; and Chernobyl, near Kiev, Ukraine, Soviet Union, in 1986. It is noteworthy that both of these accidents were related to human error and not to malfunction of the emergency back-up systems. So far, nuclear energy production plant accidents have occurred when either the data were misinterpreted or systems misguided by human function.

The major problem associated with a nuclear energy generating plant accident is the release of radiation. Even though the medical facilities may not be destroyed physically, they may be rendered useless because of contamination by radiation. Unfortunately, in the event of such an accidental release of radiation, all of the health-care facilities in the area will be contaminated. Therefore, all patients in hospitals and nursing homes will need to be evacuated to facilities outside of the contaminated area and not just relocated within the contaminated area.

Sound disaster preparedness and a well-organized, local and material response will considerably reduce the necessity for calling on international assistance in the event of disaster. However, despite an excellent level of preparedness, some dramatic situations in the wake of a large-scale disaster always will make the mobilization of international resources absolutely essential.

The international network for disaster relief is quite complex. Many governments have set up emergency relief teams to cope with disasters in their own countries and are able to assign these teams to international relief operations. This type of governmental assistance is provided under agreement with the other governments involved. The United Nations (UN), through the Office of the UN Disaster Relief Coordinator (UNDRO), can play a role in coordinating emergency operations.

The expansion of hospices and recognition of living wills have made it necessary for emergency care providers to re-evaluate the appropriateness of universal application of cardiopulmonary resuscitation (CPR) in the field. The prehospital care community is coming to realize that CPR is beneficial only in certain specific situations. Some believe that when CPR is not likely to be beneficial, it should be withheld. Withholding CPR seems to be a simple matter of law and science, but a number of factors complicate the issue, especially in the prehospital setting: What are the definitive signs of irreversible, sudden death? When is the application of CPR futile? What are the responsibilities of the prehospital emergency care provider who announce someone dead? What is the lay public's perception of stopping or withholding CPR? Withholding CPR in this environment is a complicated social and emotional issue as well as a scientific and legal one.

Transcutaneous cardiac pacing (TCP) is a promisingprehospital intervention, but there are little data available regarding protocols to improve patient tolerance to TCP. A 50:50 nitrous oxide:oxygen analgesic mixture aho is a commonly employed prehospital intervention. In this randomized, prospective study, we compared the discomfort experienced by 18 healthy subjects when paced in two triah at the capture threshold: one following breathing of a 50:50 nitrous oxide:oxygen mixture; and the second breathing only room air. Discomfort was rated on an analog scale from 1 (minimal discomfort) to 10 (severe pain). Of the 18 subjects, 15 (83%) reported that nitrous oxide improved the tolerance to pacing at capture threshold. The median pain scores at capture threshold in the nitrous oxide and room air group were 3.8 and 5.0 respectively (P<.05). Nine of the subjects tolerated TCP for the maximum allotted time of 30 seconds in each trial; six tolerated TCP for a longer time period in the nitrous oxide trial; three tolerated TCP longer in the room air trial. These data suggest that inhalation of a 50:50 nitrous oxide:oxygen mixture may improve tolerance to TCP in the conscious patient.

Aspects of internal contamination with radionuclides are reviewed. The possible association of this kind of accident with radiation and conventional accidents is addressed. The most important mishaps in the initial diagnosis, the need for prompt treatment, and a well-prepared plan to cope with radioisotopes at the workplace are discussed. The metabolic behavior and specific treatment for radionuclide contamination is reported.

The increasing openness (glastnost) of the Soviet authorities has brought about a new era of accountability but sadly has coincided with a series of disasters, both natural and manmade. Chernobyl, the Armenian earthquake, and recently a gas explosion which involved two passenger trains have been reported widely and medical teams from the West were invited to assist with the care of the injured. We were part of a multidisciplinary team involved in the care of victims of the train disaster.

The United States Congress presently is considering comprehensive legislation regarding emergency medical services (EMS) and trauma systems planning. This legislation amends the Public Health Service Act and, if enacted, would represent the federal government's first significant statutory mandate to exercise a leadership role in EMS since the federal EMS program was abolished in the early 1980s. On 14 November 1989, the House passed House Resolution (H.R.) 1602, Trauma Care Systems Planning and Development Act of 1989, authored by Representative Jim Bates. The Senate is considering similar legislation (S. 15) by Senator Alan Cranston, titled the Emergency Medical Services and Trauma Care Improvement Act of 1989. The Senate Bill is awaiting final action by the full Senate. If the Senate approves S. 15, a joint House and Senate conference committee will meet to present its own conference report to each of those bodies for consideration and passage.

If the tower of Babel was a language disaster, disaster itself has a language. Whether act of God or act of man, disaster often calls for multinational assistance. The many governments, agencies, professions, and individuals from different parts of the world, representing different languages, specialties, religions, and cultures, yet all imbued with one and the same spirit of providing succor to the helpless, converge on the stricken land to help the victims, who are themselves of different language and background.

Initiation of cardiopulmonary resuscitation when the death is the result of an end-stage, irreversible, and imminently terminal illness against the patient's prior request is immoral and indefensible. Medical providers should withhold treatments that are futile, and individuals have the right to refuse this invasive therapy.

The use of Do-Not-Resuscitate (DNR) orders has become a standard of medical care in health care institutions and should be incorporated into the prehospital medical care system. The American College of Emergency Physicians (ACEP) supports their use, and the National Association of Emergency Medical Services Physicians (NAEMSP) has developed a consensus paper endorsing the use of prehospital DNR orders. The Joint Commision on the Accreditation of Hospitals (JCAH) recommends the use of DNR orders and the American Heart Association (AHA), in Standards and Guidelines for Advanced Cardiac Life Support, recognizes their validity. It is time for EMS systems to develop and implement policies and procedures, with adequate safeguards, to allow the withholding of CPR in specific circumstances. The claim that DNR orders cannot be honored in the prehospital setting is a self-fulfilling prophecy. If an emergency medical services (EMS) system lacks strong medical leadership or believes that a prehospital DNR system cannot work–a communitywide DNR program never will come into existence. Dying patients will continue to suffer the indignity and burden of unnecessary and futile treatments that serve no benefit to the patient and only serve to alienate and anger the family members.

Therapy following an acute cerebrovascular insult traditionally has focused on preserving function of the uninjured cerebral tissue. However, in recent years, interest has developed on the possibility of restoration of function to the injured areas of the brain. Lessons learned in reperfusion following acute myocardial infarction have raised newer questions about the utility of reperfusion to other areas of the body subjected to acute ischemic events. In addition, studies with acute cerebral ischemia have suggested that calcium channel antagonists improve outcome, either by decreasing cerebral vasospasm, offering neuronal protection by inhibiting the formation of toxic metabolites in the injured neurons, or by some combination of these two mechanisms. Other experimental therapies, such as the use of hypervolemic hemodilution, attempt to restore cerebral blood flow following an acute vasospasmic or thromboembolic event. As these new therapies develop, we will see a major emphasis on restoring cerebral function following acute stroke.

It is a sunny day in Moscow. I am participating in an excellent meeting on Disaster Medicine. While sitting at the breakfast table eating red caviar and sturgeon, somebody started to talk of the scarce value attributed to qualitative research since it cannot be statistically evaluated. I do not recall the unfortunate statement I made that induced Dr. Birnbaum to say, “You are going to write a paper for our journal on this topic.” I did not know what to reply and thus started the day in a very troubled mood. In a status of “reverie” (almost dozing) during a presentation in the morning session, a title spontaneously presented itself for what I still do not know I am going to write—Can You Average Cheshire Cat Smiles? Perhaps the further development of this free writing will explain the title or will serve to float, as if a koan, for our meditation and interpretation.

Prehospital health-care providers regularly are called upon to assist terminally ill patients in residential or institutional, non-hospital settings such as nursing homes or hospices. Among the most crucial issues regarding such patients is whether they should be resuscitated. With alarming frequency, EMS providers are encountering vigorous and sometimes violent refusals of examination, treatment, and/or transportation from the terminally ill patient, members of the patient's family, or third persons ostensibly acting on the patient's behalf. Today, the prehospital emergency health-care provider repeatedly is faced with the legal and ethical questions that surround the issue of resuscitation and advanced life support.

Terrorism can be considered a form of low-intensity conflict. It results from extreme reactions to sociopolitical conditions. These reactions, through a variety of intellectual and emotional processes, are manifest as overt acts of violence. Terrorism includes acts by individuals or organizations which seek to change political or social conditions, make political or ideological statements, or obtain funds for sustaining ongoing terrorist or revolutionary campaigns. Terrorist incidents are increasingly prevalent. Often, they involve loss of lives and mass casualties and have special medical dimensions. As such, the role of EMS in terrorist incidents needs to be defined clearly.

Report forms are used by Emergency Medical Services (EMS) systems for documentation of services provided and for self-analysis of EMS functions. Although the EMS Systems Act of 1973 originally intended for the development and implementation of a uniform EMS report form, items recorded on EMS forms vary throughout the United States. We review the governmental sponsored development of a recommended minimum data set (MDS) for EMS forms performed in 1974, and discuss areas of needed investigation regarding data set development and usage. The concepts used to develop the recommended MDS provide a useful resource for review of the purpose and content of one's own EMS report form. However, future data set development and applications should use outcome measure guided data set selection, on-line validation of data item accuracy and recordability, psychometric analysis of the process of form completion, and incorporation of new data entry and storage technology.

Seizures are a common pediatric problem encountered by prehospital personnel. Status epilepticus is defined as seizure activity lasting longer than 15 minutes, or recurrent seizures that occur close together without a period of consciousness between ictal periods. It is estimated that 60,000 to 160,000 cases of status epilepticus occur each year within the United States. Prior to 1960, status epilepticus carried a 50% morbidity rate. However, improved anticonvulsive medications, aggressive airway management, and the spread of EMS Systems throughout the nation have reduced the morbidity rate to a range of 8% to 12%.

Prompt and vigorous treatment is paramount in the successful management of status epilepticus because delays can result in neuronal damage and death. Although intravenous diazepam currently is the drug of choice to terminate seizure activity, it may be difficult to rapidly establish a patent intravenous (IV) line during status epilepticus in young children with vigorous motor activity. Alternate routes, such as intramuscular injections, are unreliable due to unpredictable absorption. Rectal administration of diazepam may provide an useful alternate route for delivery of the drug during status epilepticus when IV attempts fail.

In this review, the authors discuss a case of status epilepticus wherein intravenous access could not be established rapidly and the patient was given diazepam rectally with favorable results.

The problem of protection and sheltering of hospitalized patients in wars and other national emergencies has been reviewed by many countries in recent years. Presently, there are wide differences in policies that range from full underground sheltering of hospitals as adopted by the Swiss, partially protected to almost fully protected facilities in hospitals as adopted by the Israelis, to no protection at all as in most other countries.