Disaster Preparedness

Emergencies happen anywhere and anytime, and sometimes, medical professionals find themselves in situations where they are the only ones who can help. 'Is There a Doctor in the House?' is a Medscape Medical News series telling these stories.

Bill Madden, MD: It was a Saturday in October of 1996. I had gone to my favorite plant nursery in Tucson with my wife, Beth, and two of my kids, Zach and Katya, who were 9 years old. I went to the back of the nursery to use the bathroom, and I heard two of the workers yelling at each other. The tone was angry. 

I went back up to the front, and Zach said that he was bored. He asked if he could go to the car and get a book, so I gave him my car keys and told him to be careful crossing the street. 

Ron Quintia, DDS: It was late in the afternoon, probably close to 4 PM. I was also at the nursery picking up some plants. 

The noise came out of nowhere. Boom! Boom! Boom! I thought, Wow, that sounds like a gun. But no, it can’t be a gun. This is a plant nursery. 

BM: When I heard the rounds being fired, I knew what that sound meant. I was in the Army for 20 years doing critical care for kids. 

I turned and a young man came running toward me out of the sun. It was hard to see, but I realized a second guy was running about 10 feet behind him. Both men were screaming. 

My wife was about 10 feet away behind a raised planter with Katya. I yelled for them to get down as I dove for the ground.

The first guy, a young Hispanic man, tried to escape through some bushes. But the shooter was catching up. I recognized him. He was from Ethiopia and worked at the nursery. I had talked to him a week earlier about his life; he used to be a farmer.

Now, he was holding a 9-mm automatic — silver, very shiny. He shot the Hispanic man twice in the chest. Then he ran toward the back of the nursery. 

RQ: When I realized what was happening, I crouched down, so I couldn’t see very much. But I heard someone screaming, “He has a gun! He has a gun!” And then I heard more shots. 

BM: I yelled at my wife, “Get out!” Then I ran for the phone at the kiosk desk to call 911. This was before most people had cell phones. But the phone was hooked up to the paging system for the nursery, and I couldn’t get it to work. I turned and ran for the wounded man.

RQ: I got to the victim first. Both lungs had been hit, and I could hear he had sucking chest wounds. He was bleeding out of his mouth, saying, “I’m going to die. I’m going to die.” I told him, “You’re not going to die,” while thinking to myself, He’s going to die. 

BM: I had never met Ron before, but we started working on the patient together. Both of his lungs were collapsing. With sucking chest wounds, the critical issue is to seal up the holes. So normally, you slap a Vaseline dressing on and tape it up real good. But obviously, we didn’t have anything. 

Ron and I took off our shirts and used them to bandage the man’s chest. He wasn’t looking good, starting to turn blue. He was dying. We were yelling for someone to call an ambulance. 

And then suddenly, the shooter was back. He was standing there yelling at us to leave so he could kill the man we were helping. The 9-mil was in his hand, ready to fire. He kept screaming, “I’m not a monkey! I’m not a monkey!”

RQ: The guy was less than 10 feet from us, and we were facing down this gun that looked like a cannon. I thought, This is it. It’s curtains. I’m going to die. We’re all going to die. 

BM: I had decided I would die too. I wasn’t frightened though. It’s hard to explain. Dying was okay because I’d gotten my family away. I just had to stay alive as long as I could in order to provide for the victim. 

It’s what I signed up for when I chose to be a doc — to do whatever was needed. And if I got killed in the process, that was just part of the story. So we started talking to the shooter.

I said, “No, you’re not a monkey. You’re a man, a human being. It’s okay.” We pleaded with him to put the weapon down and not to shoot. We did not leave the patient. Finally, the shooter ran off toward the back of the nursery.

RQ: About 30 seconds after that, we heard two more shots from that direction. 

Then there were sirens, and the place was suddenly crawling with police. The paramedics came and took over. I got up and got out of the way.

BM: A young woman ran up, her mouth covered with blood. She said that there was another victim in the back. I asked a police officer to go with us to check. We started for the back when suddenly, we heard yelling and many rounds being fired. The officer ran in the direction of the shooting. 

The woman and I kept walking through rows of plants and trees. It was like moving through a jungle. Finally, we reached the other victim, an American Indian man, lying on his back. He had a chest wound and a head wound. No respirations. No radial pulse. No carotid pulse. I pronounced him dead.

Then I heard a voice calling for help. There were two women hiding nearby in the bushes. I led them to where the police cars were.

Another officer came over and told me that they had the shooter. The police had shot him in the leg and arrested him.

RQ: The police kept us there for quite some time. Meanwhile, the TV crews arrived. I had a black Toyota 4Runner at the time. My family was home watching the news, and a bulletin came on about a shooting in Midtown. The camera panned around the area, and my wife saw our car on the street! They were all worried until I could call and let them know that I was okay.

BM: As we waited, the sun went down, and I was getting cold. My shirt was a bloody mess. Ron and I just sat there quietly, not saying a whole heck of a lot. 

Finally, an officer took our statements, a detective interviewed us, and they let us leave. I called Beth, and she and the kids came and got me. 

At home, we talked to the kids, letting them express their fears. We put them to bed. I didn’t sleep that night. 

RQ: I can’t describe how weird it was going home with this guy’s blood on my body. Needing to take a bath. Trying to get rid of the stench of what could have been a brutal killing. But it wasn’t. At least, not for our patient. 

Thankfully, there are three hospitals within a stone’s throw of the nursery. The paramedics got the man we helped to Tucson Medical Center and into the OR immediately. Then the general surgeons could get chest tubes in him to reinflate his lungs.

BM: The doctor who treated him called me later. He said that when they put the chest tubes in, they got a liter and a half of blood out of him. If it had taken another 10 minutes or so to get there, he very likely would’ve been dead on arrival in the emergency room. 

RQ: I checked on him at the hospital the next day, and he was doing okay. That was the last time I saw him. 

I only saw the shooter again in court. Dr. Madden and I were both called as witnesses at his trial. He was tried for capital murder and 12 charges of aggravated assault for every person who was at the nursery. He was found guilty on all of them and sentenced to 35 years to life in prison. 

BM: I don’t think the shooter was very well represented in court. It’s not that he didn’t kill one person and critically wound another. He did, and he deserves to be punished for that. But his story wasn’t told.

I knew that during the civil war in Ethiopia, his family had been killed by Cuban soldiers sent there to help the pro-communist government. In a way, I thought of him as two different people: the shooter and the farmer. They are both in prison, but only one of them deserves to be there.

After it happened, I wanted to visit the farmer in the hospital and tell him that, despite what he had done, he was not alone. Our family cared about him. The police wouldn’t let me see him, so I asked the Catholic chaplain of the hospital to go. He gave him my message: that despite all the sorrow and pain, in some distant way, I understood. I respected him as a human being. And I was praying for him.

RQ: It’s safe to say that the experience will affect me forever. For months, even years afterward, if somebody would ask me about what happened, I would start to cry. I would sit in the parking lot of my favorite running trail and worry about the people driving in. If I heard a car backfire, I thought about gunshots. 

It was terrifying. And thank God I’ve never found myself in that position again. But I suspect I’d probably react the same way. This is our calling. It’s what we do — protecting other people and taking care of them.

BM: I’d always wondered what I would do in a situation like this. I knew I could function in a critical care situation, a child in a hospital or in the back of an ambulance. But could I do it when my own life was threatened? I found out that I could, and that was really important to me. 

RQ: It was one of those great lessons in life. You realize how lucky you are and that your life can be snatched away from you in a millisecond. I went to a nursery to buy plants for my yard, and instead I ended up helping to save a life.Bill Madden, MD, is a retired US Army colonel and pediatrician, formerly an associate professor of Clinical Pediatrics at the College of Medicine of the University of Arizona, Tucson. 

Ron Quintia, DDS, is an oral and maxillofacial surgeon at Southern Arizona Oral & Maxillofacial Surgery in Tucson, Arizona. 

A version of this article appeared on Medscape.com .

Emergencies happen anywhere and anytime, and sometimes, medical professionals find themselves in situations where they are the only ones who can help. 'Is There a Doctor in the House?' is a Medscape Medical News series telling these stories.

Bill Madden, MD: It was a Saturday in October of 1996. I had gone to my favorite plant nursery in Tucson with my wife, Beth, and two of my kids, Zach and Katya, who were 9 years old. I went to the back of the nursery to use the bathroom, and I heard two of the workers yelling at each other. The tone was angry. 

I went back up to the front, and Zach said that he was bored. He asked if he could go to the car and get a book, so I gave him my car keys and told him to be careful crossing the street. 

Ron Quintia, DDS: It was late in the afternoon, probably close to 4 PM. I was also at the nursery picking up some plants. 

The noise came out of nowhere. Boom! Boom! Boom! I thought, Wow, that sounds like a gun. But no, it can’t be a gun. This is a plant nursery. 

BM: When I heard the rounds being fired, I knew what that sound meant. I was in the Army for 20 years doing critical care for kids. 

I turned and a young man came running toward me out of the sun. It was hard to see, but I realized a second guy was running about 10 feet behind him. Both men were screaming. 

My wife was about 10 feet away behind a raised planter with Katya. I yelled for them to get down as I dove for the ground.

The first guy, a young Hispanic man, tried to escape through some bushes. But the shooter was catching up. I recognized him. He was from Ethiopia and worked at the nursery. I had talked to him a week earlier about his life; he used to be a farmer.

Now, he was holding a 9-mm automatic — silver, very shiny. He shot the Hispanic man twice in the chest. Then he ran toward the back of the nursery. 

RQ: When I realized what was happening, I crouched down, so I couldn’t see very much. But I heard someone screaming, “He has a gun! He has a gun!” And then I heard more shots. 

BM: I yelled at my wife, “Get out!” Then I ran for the phone at the kiosk desk to call 911. This was before most people had cell phones. But the phone was hooked up to the paging system for the nursery, and I couldn’t get it to work. I turned and ran for the wounded man.

RQ: I got to the victim first. Both lungs had been hit, and I could hear he had sucking chest wounds. He was bleeding out of his mouth, saying, “I’m going to die. I’m going to die.” I told him, “You’re not going to die,” while thinking to myself, He’s going to die. 

BM: I had never met Ron before, but we started working on the patient together. Both of his lungs were collapsing. With sucking chest wounds, the critical issue is to seal up the holes. So normally, you slap a Vaseline dressing on and tape it up real good. But obviously, we didn’t have anything. 

Ron and I took off our shirts and used them to bandage the man’s chest. He wasn’t looking good, starting to turn blue. He was dying. We were yelling for someone to call an ambulance. 

And then suddenly, the shooter was back. He was standing there yelling at us to leave so he could kill the man we were helping. The 9-mil was in his hand, ready to fire. He kept screaming, “I’m not a monkey! I’m not a monkey!”

RQ: The guy was less than 10 feet from us, and we were facing down this gun that looked like a cannon. I thought, This is it. It’s curtains. I’m going to die. We’re all going to die. 

BM: I had decided I would die too. I wasn’t frightened though. It’s hard to explain. Dying was okay because I’d gotten my family away. I just had to stay alive as long as I could in order to provide for the victim. 

It’s what I signed up for when I chose to be a doc — to do whatever was needed. And if I got killed in the process, that was just part of the story. So we started talking to the shooter.

I said, “No, you’re not a monkey. You’re a man, a human being. It’s okay.” We pleaded with him to put the weapon down and not to shoot. We did not leave the patient. Finally, the shooter ran off toward the back of the nursery.

RQ: About 30 seconds after that, we heard two more shots from that direction. 

Then there were sirens, and the place was suddenly crawling with police. The paramedics came and took over. I got up and got out of the way.

BM: A young woman ran up, her mouth covered with blood. She said that there was another victim in the back. I asked a police officer to go with us to check. We started for the back when suddenly, we heard yelling and many rounds being fired. The officer ran in the direction of the shooting. 

The woman and I kept walking through rows of plants and trees. It was like moving through a jungle. Finally, we reached the other victim, an American Indian man, lying on his back. He had a chest wound and a head wound. No respirations. No radial pulse. No carotid pulse. I pronounced him dead.

Then I heard a voice calling for help. There were two women hiding nearby in the bushes. I led them to where the police cars were.

Another officer came over and told me that they had the shooter. The police had shot him in the leg and arrested him.

RQ: The police kept us there for quite some time. Meanwhile, the TV crews arrived. I had a black Toyota 4Runner at the time. My family was home watching the news, and a bulletin came on about a shooting in Midtown. The camera panned around the area, and my wife saw our car on the street! They were all worried until I could call and let them know that I was okay.

BM: As we waited, the sun went down, and I was getting cold. My shirt was a bloody mess. Ron and I just sat there quietly, not saying a whole heck of a lot. 

Finally, an officer took our statements, a detective interviewed us, and they let us leave. I called Beth, and she and the kids came and got me. 

At home, we talked to the kids, letting them express their fears. We put them to bed. I didn’t sleep that night. 

RQ: I can’t describe how weird it was going home with this guy’s blood on my body. Needing to take a bath. Trying to get rid of the stench of what could have been a brutal killing. But it wasn’t. At least, not for our patient. 

Thankfully, there are three hospitals within a stone’s throw of the nursery. The paramedics got the man we helped to Tucson Medical Center and into the OR immediately. Then the general surgeons could get chest tubes in him to reinflate his lungs.

BM: The doctor who treated him called me later. He said that when they put the chest tubes in, they got a liter and a half of blood out of him. If it had taken another 10 minutes or so to get there, he very likely would’ve been dead on arrival in the emergency room. 

RQ: I checked on him at the hospital the next day, and he was doing okay. That was the last time I saw him. 

I only saw the shooter again in court. Dr. Madden and I were both called as witnesses at his trial. He was tried for capital murder and 12 charges of aggravated assault for every person who was at the nursery. He was found guilty on all of them and sentenced to 35 years to life in prison. 

BM: I don’t think the shooter was very well represented in court. It’s not that he didn’t kill one person and critically wound another. He did, and he deserves to be punished for that. But his story wasn’t told.

I knew that during the civil war in Ethiopia, his family had been killed by Cuban soldiers sent there to help the pro-communist government. In a way, I thought of him as two different people: the shooter and the farmer. They are both in prison, but only one of them deserves to be there.

After it happened, I wanted to visit the farmer in the hospital and tell him that, despite what he had done, he was not alone. Our family cared about him. The police wouldn’t let me see him, so I asked the Catholic chaplain of the hospital to go. He gave him my message: that despite all the sorrow and pain, in some distant way, I understood. I respected him as a human being. And I was praying for him.

RQ: It’s safe to say that the experience will affect me forever. For months, even years afterward, if somebody would ask me about what happened, I would start to cry. I would sit in the parking lot of my favorite running trail and worry about the people driving in. If I heard a car backfire, I thought about gunshots. 

It was terrifying. And thank God I’ve never found myself in that position again. But I suspect I’d probably react the same way. This is our calling. It’s what we do — protecting other people and taking care of them.

BM: I’d always wondered what I would do in a situation like this. I knew I could function in a critical care situation, a child in a hospital or in the back of an ambulance. But could I do it when my own life was threatened? I found out that I could, and that was really important to me. 

RQ: It was one of those great lessons in life. You realize how lucky you are and that your life can be snatched away from you in a millisecond. I went to a nursery to buy plants for my yard, and instead I ended up helping to save a life.Bill Madden, MD, is a retired US Army colonel and pediatrician, formerly an associate professor of Clinical Pediatrics at the College of Medicine of the University of Arizona, Tucson. 

Ron Quintia, DDS, is an oral and maxillofacial surgeon at Southern Arizona Oral & Maxillofacial Surgery in Tucson, Arizona. 

A version of this article appeared on Medscape.com .

Emergencies happen anywhere and anytime, and sometimes, medical professionals find themselves in situations where they are the only ones who can help. 'Is There a Doctor in the House?' is a Medscape Medical News series telling these stories.

Bill Madden, MD: It was a Saturday in October of 1996. I had gone to my favorite plant nursery in Tucson with my wife, Beth, and two of my kids, Zach and Katya, who were 9 years old. I went to the back of the nursery to use the bathroom, and I heard two of the workers yelling at each other. The tone was angry. 

I went back up to the front, and Zach said that he was bored. He asked if he could go to the car and get a book, so I gave him my car keys and told him to be careful crossing the street. 

Ron Quintia, DDS: It was late in the afternoon, probably close to 4 PM. I was also at the nursery picking up some plants. 

The noise came out of nowhere. Boom! Boom! Boom! I thought, Wow, that sounds like a gun. But no, it can’t be a gun. This is a plant nursery. 

BM: When I heard the rounds being fired, I knew what that sound meant. I was in the Army for 20 years doing critical care for kids. 

I turned and a young man came running toward me out of the sun. It was hard to see, but I realized a second guy was running about 10 feet behind him. Both men were screaming. 

My wife was about 10 feet away behind a raised planter with Katya. I yelled for them to get down as I dove for the ground.

The first guy, a young Hispanic man, tried to escape through some bushes. But the shooter was catching up. I recognized him. He was from Ethiopia and worked at the nursery. I had talked to him a week earlier about his life; he used to be a farmer.

Now, he was holding a 9-mm automatic — silver, very shiny. He shot the Hispanic man twice in the chest. Then he ran toward the back of the nursery. 

RQ: When I realized what was happening, I crouched down, so I couldn’t see very much. But I heard someone screaming, “He has a gun! He has a gun!” And then I heard more shots. 

BM: I yelled at my wife, “Get out!” Then I ran for the phone at the kiosk desk to call 911. This was before most people had cell phones. But the phone was hooked up to the paging system for the nursery, and I couldn’t get it to work. I turned and ran for the wounded man.

RQ: I got to the victim first. Both lungs had been hit, and I could hear he had sucking chest wounds. He was bleeding out of his mouth, saying, “I’m going to die. I’m going to die.” I told him, “You’re not going to die,” while thinking to myself, He’s going to die. 

BM: I had never met Ron before, but we started working on the patient together. Both of his lungs were collapsing. With sucking chest wounds, the critical issue is to seal up the holes. So normally, you slap a Vaseline dressing on and tape it up real good. But obviously, we didn’t have anything. 

Ron and I took off our shirts and used them to bandage the man’s chest. He wasn’t looking good, starting to turn blue. He was dying. We were yelling for someone to call an ambulance. 

And then suddenly, the shooter was back. He was standing there yelling at us to leave so he could kill the man we were helping. The 9-mil was in his hand, ready to fire. He kept screaming, “I’m not a monkey! I’m not a monkey!”

RQ: The guy was less than 10 feet from us, and we were facing down this gun that looked like a cannon. I thought, This is it. It’s curtains. I’m going to die. We’re all going to die. 

BM: I had decided I would die too. I wasn’t frightened though. It’s hard to explain. Dying was okay because I’d gotten my family away. I just had to stay alive as long as I could in order to provide for the victim. 

It’s what I signed up for when I chose to be a doc — to do whatever was needed. And if I got killed in the process, that was just part of the story. So we started talking to the shooter.

I said, “No, you’re not a monkey. You’re a man, a human being. It’s okay.” We pleaded with him to put the weapon down and not to shoot. We did not leave the patient. Finally, the shooter ran off toward the back of the nursery.

RQ: About 30 seconds after that, we heard two more shots from that direction. 

Then there were sirens, and the place was suddenly crawling with police. The paramedics came and took over. I got up and got out of the way.

BM: A young woman ran up, her mouth covered with blood. She said that there was another victim in the back. I asked a police officer to go with us to check. We started for the back when suddenly, we heard yelling and many rounds being fired. The officer ran in the direction of the shooting. 

The woman and I kept walking through rows of plants and trees. It was like moving through a jungle. Finally, we reached the other victim, an American Indian man, lying on his back. He had a chest wound and a head wound. No respirations. No radial pulse. No carotid pulse. I pronounced him dead.

Then I heard a voice calling for help. There were two women hiding nearby in the bushes. I led them to where the police cars were.

Another officer came over and told me that they had the shooter. The police had shot him in the leg and arrested him.

RQ: The police kept us there for quite some time. Meanwhile, the TV crews arrived. I had a black Toyota 4Runner at the time. My family was home watching the news, and a bulletin came on about a shooting in Midtown. The camera panned around the area, and my wife saw our car on the street! They were all worried until I could call and let them know that I was okay.

BM: As we waited, the sun went down, and I was getting cold. My shirt was a bloody mess. Ron and I just sat there quietly, not saying a whole heck of a lot. 

Finally, an officer took our statements, a detective interviewed us, and they let us leave. I called Beth, and she and the kids came and got me. 

At home, we talked to the kids, letting them express their fears. We put them to bed. I didn’t sleep that night. 

RQ: I can’t describe how weird it was going home with this guy’s blood on my body. Needing to take a bath. Trying to get rid of the stench of what could have been a brutal killing. But it wasn’t. At least, not for our patient. 

Thankfully, there are three hospitals within a stone’s throw of the nursery. The paramedics got the man we helped to Tucson Medical Center and into the OR immediately. Then the general surgeons could get chest tubes in him to reinflate his lungs.

BM: The doctor who treated him called me later. He said that when they put the chest tubes in, they got a liter and a half of blood out of him. If it had taken another 10 minutes or so to get there, he very likely would’ve been dead on arrival in the emergency room. 

RQ: I checked on him at the hospital the next day, and he was doing okay. That was the last time I saw him. 

I only saw the shooter again in court. Dr. Madden and I were both called as witnesses at his trial. He was tried for capital murder and 12 charges of aggravated assault for every person who was at the nursery. He was found guilty on all of them and sentenced to 35 years to life in prison. 

BM: I don’t think the shooter was very well represented in court. It’s not that he didn’t kill one person and critically wound another. He did, and he deserves to be punished for that. But his story wasn’t told.

I knew that during the civil war in Ethiopia, his family had been killed by Cuban soldiers sent there to help the pro-communist government. In a way, I thought of him as two different people: the shooter and the farmer. They are both in prison, but only one of them deserves to be there.

After it happened, I wanted to visit the farmer in the hospital and tell him that, despite what he had done, he was not alone. Our family cared about him. The police wouldn’t let me see him, so I asked the Catholic chaplain of the hospital to go. He gave him my message: that despite all the sorrow and pain, in some distant way, I understood. I respected him as a human being. And I was praying for him.

RQ: It’s safe to say that the experience will affect me forever. For months, even years afterward, if somebody would ask me about what happened, I would start to cry. I would sit in the parking lot of my favorite running trail and worry about the people driving in. If I heard a car backfire, I thought about gunshots. 

It was terrifying. And thank God I’ve never found myself in that position again. But I suspect I’d probably react the same way. This is our calling. It’s what we do — protecting other people and taking care of them.

BM: I’d always wondered what I would do in a situation like this. I knew I could function in a critical care situation, a child in a hospital or in the back of an ambulance. But could I do it when my own life was threatened? I found out that I could, and that was really important to me. 

RQ: It was one of those great lessons in life. You realize how lucky you are and that your life can be snatched away from you in a millisecond. I went to a nursery to buy plants for my yard, and instead I ended up helping to save a life.Bill Madden, MD, is a retired US Army colonel and pediatrician, formerly an associate professor of Clinical Pediatrics at the College of Medicine of the University of Arizona, Tucson. 

Ron Quintia, DDS, is an oral and maxillofacial surgeon at Southern Arizona Oral & Maxillofacial Surgery in Tucson, Arizona. 

A version of this article appeared on Medscape.com .

A new guide offers recommendations for the nonsurgical management of major hemorrhage, which is a challenging clinical problem.

Major hemorrhage is a significant cause of death and can occur in a myriad of clinical settings.

“In Ontario, we’ve been collecting quality metrics on major hemorrhages to try and make sure that a higher percentage of patients gets the best possible care when they are experiencing significant bleeding,” author Jeannie Callum, MD, professor and director of transfusion medicine at Kingston (Ont.) Health Sciences Centre and Queen’s University, also in Kingston, said in an interview. “There were some gaps, so this is our effort to get open, clear information out to the emergency doctors, intensive care unit doctors, the surgeons, and everyone else involved in managing major hemorrhage, to help close these gaps.”

The guide was published in the Canadian Medical Association Journal.
 

Fast care essential

The guide aims to provide answers, based on the latest research, to questions such as when to activate a massive hemorrhage protocol (MHP), which patients should receive tranexamic acid (TXA), which blood products should be transfused before laboratory results are available, how to monitor the effects of blood transfusion, and when fibrinogen concentrate or prothrombin complex concentrate should be given.

Not all recommendations will be followed, Dr. Callum said, especially in rural hospitals with limited resources. But the guide is adaptable, and rural hospitals can create protocols that are customized to their unique circumstances.

Care must be “perfect and fast” in the first hour of major injury, said Dr. Callum. “You need to get a proclotting drug in that first hour if you have a traumatic or postpartum bleed. You have to make sure your clotting factors never fail you throughout your resuscitation. You have to be fast with the transfusion. You have to monitor for the complications of the transfusion, electrolyte disturbances, and the patient’s temperature dropping. It’s a complicated situation that needs a multidisciplinary team.”

Bleeding affects everybody in medicine, from family doctors in smaller institutions who work in emergency departments to obstetricians and surgeons, she added.

“For people under the age of 45, trauma is the most common cause of death. When people die of trauma, they die of bleeding. So many people experience these extreme bleeds. We believe that some of them might be preventable with faster, more standardized, more aggressive care. That’s why we wrote this review,” said Dr. Callum.
 

Administer TXA quickly  

The first recommendation is to ensure that every hospital has a massive hemorrhage protocol. Such a protocol is vital for the emergency department, operating room, and obstetric unit. “Making sure you’ve got a protocol that is updated every 3 years and adjusted to the local hospital context is essential,” said Dr. Callum.

Smaller hospitals will have to adjust their protocols according to the capabilities of their sites. “Some smaller hospitals do not have platelets in stock and get their platelets from another hospital, so you need to adjust your protocol to what you are able to do. Not every hospital can control bleeding in a trauma patient, so your protocol would be to stabilize and call a helicopter. Make sure all of this is detailed so that implementing it becomes automatic,” said Dr. Callum.

An MHP should be activated for patients with uncontrolled hemorrhage who meet the clinical criteria of the local hospital and are expected to need blood product support and red blood cells.

“Lots of people bleed, but not everybody is bleeding enough that they need a code transfusion,” said Dr. Callum. Most patients with gastrointestinal bleeds caused by NSAID use can be managed with uncrossed matched blood from the local blood bank. “But in patients who need the full code transfusion because they are going to need plasma, clotting factor replacement, and many other drugs, that is when the MHP should be activated. Don’t activate it when you don’t need it, because doing so activates the whole hospital and diverts care away from other patients.”

TXA should be administered as soon as possible after onset of hemorrhage in most patients, with the exception of gastrointestinal hemorrhage, where a benefit has not been shown.

TXA has been a major advance in treating massive bleeding, Dr. Callum said. “TXA was invented by a Japanese husband-and-wife research team. We know that it reduces the death rate in trauma and in postpartum hemorrhage, and it reduces the chance of major bleeding with major surgical procedures. We give it routinely in surgical procedures. If a patient gets TXA within 60 minutes of injury, it dramatically reduces the death rate. And it costs $10 per patient. It’s cheap, it’s easy, it has no side effects. It’s just amazing.”

Future research must address several unanswered questions, said Dr. Callum. These questions include whether prehospital transfusion improves patient outcomes, whether whole blood has a role in the early management of major hemorrhage, and what role factor concentrates play in patients with major bleeding.
 

‘Optimal recommendations’

Commenting on the document, Bourke Tillmann, MD, PhD, trauma team leader at Sunnybrook Health Sciences Centre and the Ross Tilley Burn Center in Toronto, said: “Overall, I think it is a good overview of MHPs as an approach to major hemorrhage.”

The review also is timely, since Ontario released its MHP guidelines in 2021, he added. “I would have liked to see more about the treatment aspects than just an overview of an MHP. But if you are the person overseeing the emergency department or running the blood bank, these protocols are incredibly useful and incredibly important.”

“This report is a nice and thoughtful overview of best practices in many areas, especially trauma, and makes recommendations that are optimal, although they are not necessarily practical in all centers,” Eric L. Legome, MD, professor and chair of emergency medicine at Mount Sinai West and Mount Sinai Morningside, New York, said in an interview.

“If you’re in a small rural hospital with one lab technician, trying to do all of these things, it will not be possible. These are optimal recommendations that people can use to the best of their ability, but they are not standard of care, because some places will not be able to provide this level of care,” he added. “This paper provides practical, reasonable advice that should be looked at as you are trying to implement transfusion policies and processes, with the understanding that it is not necessarily applicable or practical for very small hospitals in very rural centers that might not have access to these types of products and tools, but it’s a reasonable and nicely written paper.”

No outside funding for the guideline was reported. Dr. Callum has received research funding from Canadian Blood Services and Octapharma. She sits on the nominating committee with the Association for the Advancement of Blood & Biotherapies and on the data safety monitoring boards for the Tranexamic Acid for Subdural Hematoma trial and the Fibrinogen Replacement in Trauma trial. Dr. Tillmann and Dr. Legome reported no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

A new guide offers recommendations for the nonsurgical management of major hemorrhage, which is a challenging clinical problem.

Major hemorrhage is a significant cause of death and can occur in a myriad of clinical settings.

“In Ontario, we’ve been collecting quality metrics on major hemorrhages to try and make sure that a higher percentage of patients gets the best possible care when they are experiencing significant bleeding,” author Jeannie Callum, MD, professor and director of transfusion medicine at Kingston (Ont.) Health Sciences Centre and Queen’s University, also in Kingston, said in an interview. “There were some gaps, so this is our effort to get open, clear information out to the emergency doctors, intensive care unit doctors, the surgeons, and everyone else involved in managing major hemorrhage, to help close these gaps.”

The guide was published in the Canadian Medical Association Journal.
 

Fast care essential

The guide aims to provide answers, based on the latest research, to questions such as when to activate a massive hemorrhage protocol (MHP), which patients should receive tranexamic acid (TXA), which blood products should be transfused before laboratory results are available, how to monitor the effects of blood transfusion, and when fibrinogen concentrate or prothrombin complex concentrate should be given.

Not all recommendations will be followed, Dr. Callum said, especially in rural hospitals with limited resources. But the guide is adaptable, and rural hospitals can create protocols that are customized to their unique circumstances.

Care must be “perfect and fast” in the first hour of major injury, said Dr. Callum. “You need to get a proclotting drug in that first hour if you have a traumatic or postpartum bleed. You have to make sure your clotting factors never fail you throughout your resuscitation. You have to be fast with the transfusion. You have to monitor for the complications of the transfusion, electrolyte disturbances, and the patient’s temperature dropping. It’s a complicated situation that needs a multidisciplinary team.”

Bleeding affects everybody in medicine, from family doctors in smaller institutions who work in emergency departments to obstetricians and surgeons, she added.

“For people under the age of 45, trauma is the most common cause of death. When people die of trauma, they die of bleeding. So many people experience these extreme bleeds. We believe that some of them might be preventable with faster, more standardized, more aggressive care. That’s why we wrote this review,” said Dr. Callum.
 

Administer TXA quickly  

The first recommendation is to ensure that every hospital has a massive hemorrhage protocol. Such a protocol is vital for the emergency department, operating room, and obstetric unit. “Making sure you’ve got a protocol that is updated every 3 years and adjusted to the local hospital context is essential,” said Dr. Callum.

Smaller hospitals will have to adjust their protocols according to the capabilities of their sites. “Some smaller hospitals do not have platelets in stock and get their platelets from another hospital, so you need to adjust your protocol to what you are able to do. Not every hospital can control bleeding in a trauma patient, so your protocol would be to stabilize and call a helicopter. Make sure all of this is detailed so that implementing it becomes automatic,” said Dr. Callum.

An MHP should be activated for patients with uncontrolled hemorrhage who meet the clinical criteria of the local hospital and are expected to need blood product support and red blood cells.

“Lots of people bleed, but not everybody is bleeding enough that they need a code transfusion,” said Dr. Callum. Most patients with gastrointestinal bleeds caused by NSAID use can be managed with uncrossed matched blood from the local blood bank. “But in patients who need the full code transfusion because they are going to need plasma, clotting factor replacement, and many other drugs, that is when the MHP should be activated. Don’t activate it when you don’t need it, because doing so activates the whole hospital and diverts care away from other patients.”

TXA should be administered as soon as possible after onset of hemorrhage in most patients, with the exception of gastrointestinal hemorrhage, where a benefit has not been shown.

TXA has been a major advance in treating massive bleeding, Dr. Callum said. “TXA was invented by a Japanese husband-and-wife research team. We know that it reduces the death rate in trauma and in postpartum hemorrhage, and it reduces the chance of major bleeding with major surgical procedures. We give it routinely in surgical procedures. If a patient gets TXA within 60 minutes of injury, it dramatically reduces the death rate. And it costs $10 per patient. It’s cheap, it’s easy, it has no side effects. It’s just amazing.”

Future research must address several unanswered questions, said Dr. Callum. These questions include whether prehospital transfusion improves patient outcomes, whether whole blood has a role in the early management of major hemorrhage, and what role factor concentrates play in patients with major bleeding.
 

‘Optimal recommendations’

Commenting on the document, Bourke Tillmann, MD, PhD, trauma team leader at Sunnybrook Health Sciences Centre and the Ross Tilley Burn Center in Toronto, said: “Overall, I think it is a good overview of MHPs as an approach to major hemorrhage.”

The review also is timely, since Ontario released its MHP guidelines in 2021, he added. “I would have liked to see more about the treatment aspects than just an overview of an MHP. But if you are the person overseeing the emergency department or running the blood bank, these protocols are incredibly useful and incredibly important.”

“This report is a nice and thoughtful overview of best practices in many areas, especially trauma, and makes recommendations that are optimal, although they are not necessarily practical in all centers,” Eric L. Legome, MD, professor and chair of emergency medicine at Mount Sinai West and Mount Sinai Morningside, New York, said in an interview.

“If you’re in a small rural hospital with one lab technician, trying to do all of these things, it will not be possible. These are optimal recommendations that people can use to the best of their ability, but they are not standard of care, because some places will not be able to provide this level of care,” he added. “This paper provides practical, reasonable advice that should be looked at as you are trying to implement transfusion policies and processes, with the understanding that it is not necessarily applicable or practical for very small hospitals in very rural centers that might not have access to these types of products and tools, but it’s a reasonable and nicely written paper.”

No outside funding for the guideline was reported. Dr. Callum has received research funding from Canadian Blood Services and Octapharma. She sits on the nominating committee with the Association for the Advancement of Blood & Biotherapies and on the data safety monitoring boards for the Tranexamic Acid for Subdural Hematoma trial and the Fibrinogen Replacement in Trauma trial. Dr. Tillmann and Dr. Legome reported no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

A new guide offers recommendations for the nonsurgical management of major hemorrhage, which is a challenging clinical problem.

Major hemorrhage is a significant cause of death and can occur in a myriad of clinical settings.

“In Ontario, we’ve been collecting quality metrics on major hemorrhages to try and make sure that a higher percentage of patients gets the best possible care when they are experiencing significant bleeding,” author Jeannie Callum, MD, professor and director of transfusion medicine at Kingston (Ont.) Health Sciences Centre and Queen’s University, also in Kingston, said in an interview. “There were some gaps, so this is our effort to get open, clear information out to the emergency doctors, intensive care unit doctors, the surgeons, and everyone else involved in managing major hemorrhage, to help close these gaps.”

The guide was published in the Canadian Medical Association Journal.
 

Fast care essential

The guide aims to provide answers, based on the latest research, to questions such as when to activate a massive hemorrhage protocol (MHP), which patients should receive tranexamic acid (TXA), which blood products should be transfused before laboratory results are available, how to monitor the effects of blood transfusion, and when fibrinogen concentrate or prothrombin complex concentrate should be given.

Not all recommendations will be followed, Dr. Callum said, especially in rural hospitals with limited resources. But the guide is adaptable, and rural hospitals can create protocols that are customized to their unique circumstances.

Care must be “perfect and fast” in the first hour of major injury, said Dr. Callum. “You need to get a proclotting drug in that first hour if you have a traumatic or postpartum bleed. You have to make sure your clotting factors never fail you throughout your resuscitation. You have to be fast with the transfusion. You have to monitor for the complications of the transfusion, electrolyte disturbances, and the patient’s temperature dropping. It’s a complicated situation that needs a multidisciplinary team.”

Bleeding affects everybody in medicine, from family doctors in smaller institutions who work in emergency departments to obstetricians and surgeons, she added.

“For people under the age of 45, trauma is the most common cause of death. When people die of trauma, they die of bleeding. So many people experience these extreme bleeds. We believe that some of them might be preventable with faster, more standardized, more aggressive care. That’s why we wrote this review,” said Dr. Callum.
 

Administer TXA quickly  

The first recommendation is to ensure that every hospital has a massive hemorrhage protocol. Such a protocol is vital for the emergency department, operating room, and obstetric unit. “Making sure you’ve got a protocol that is updated every 3 years and adjusted to the local hospital context is essential,” said Dr. Callum.

Smaller hospitals will have to adjust their protocols according to the capabilities of their sites. “Some smaller hospitals do not have platelets in stock and get their platelets from another hospital, so you need to adjust your protocol to what you are able to do. Not every hospital can control bleeding in a trauma patient, so your protocol would be to stabilize and call a helicopter. Make sure all of this is detailed so that implementing it becomes automatic,” said Dr. Callum.

An MHP should be activated for patients with uncontrolled hemorrhage who meet the clinical criteria of the local hospital and are expected to need blood product support and red blood cells.

“Lots of people bleed, but not everybody is bleeding enough that they need a code transfusion,” said Dr. Callum. Most patients with gastrointestinal bleeds caused by NSAID use can be managed with uncrossed matched blood from the local blood bank. “But in patients who need the full code transfusion because they are going to need plasma, clotting factor replacement, and many other drugs, that is when the MHP should be activated. Don’t activate it when you don’t need it, because doing so activates the whole hospital and diverts care away from other patients.”

TXA should be administered as soon as possible after onset of hemorrhage in most patients, with the exception of gastrointestinal hemorrhage, where a benefit has not been shown.

TXA has been a major advance in treating massive bleeding, Dr. Callum said. “TXA was invented by a Japanese husband-and-wife research team. We know that it reduces the death rate in trauma and in postpartum hemorrhage, and it reduces the chance of major bleeding with major surgical procedures. We give it routinely in surgical procedures. If a patient gets TXA within 60 minutes of injury, it dramatically reduces the death rate. And it costs $10 per patient. It’s cheap, it’s easy, it has no side effects. It’s just amazing.”

Future research must address several unanswered questions, said Dr. Callum. These questions include whether prehospital transfusion improves patient outcomes, whether whole blood has a role in the early management of major hemorrhage, and what role factor concentrates play in patients with major bleeding.
 

‘Optimal recommendations’

Commenting on the document, Bourke Tillmann, MD, PhD, trauma team leader at Sunnybrook Health Sciences Centre and the Ross Tilley Burn Center in Toronto, said: “Overall, I think it is a good overview of MHPs as an approach to major hemorrhage.”

The review also is timely, since Ontario released its MHP guidelines in 2021, he added. “I would have liked to see more about the treatment aspects than just an overview of an MHP. But if you are the person overseeing the emergency department or running the blood bank, these protocols are incredibly useful and incredibly important.”

“This report is a nice and thoughtful overview of best practices in many areas, especially trauma, and makes recommendations that are optimal, although they are not necessarily practical in all centers,” Eric L. Legome, MD, professor and chair of emergency medicine at Mount Sinai West and Mount Sinai Morningside, New York, said in an interview.

“If you’re in a small rural hospital with one lab technician, trying to do all of these things, it will not be possible. These are optimal recommendations that people can use to the best of their ability, but they are not standard of care, because some places will not be able to provide this level of care,” he added. “This paper provides practical, reasonable advice that should be looked at as you are trying to implement transfusion policies and processes, with the understanding that it is not necessarily applicable or practical for very small hospitals in very rural centers that might not have access to these types of products and tools, but it’s a reasonable and nicely written paper.”

No outside funding for the guideline was reported. Dr. Callum has received research funding from Canadian Blood Services and Octapharma. She sits on the nominating committee with the Association for the Advancement of Blood & Biotherapies and on the data safety monitoring boards for the Tranexamic Acid for Subdural Hematoma trial and the Fibrinogen Replacement in Trauma trial. Dr. Tillmann and Dr. Legome reported no relevant financial relationships.

A version of this article originally appeared on Medscape.com.

School shootings from 2020 to 2021 climbed to the highest point in 2 decades, according to a new report from the National Center for Education Statistics and the Bureau of Justice Statistics.

There were 93 shootings with casualties at public and private K-12 schools across the United States from 2020 to 2021, as compared with 23 in the 2000-2001 school year. The latest number included 43 incidents with deaths.

The annual report, which examines crime and safety in schools and colleges, also found a rise in cyberbullying and verbal abuse or disrespect of teachers during the past decade.

“While the lasting impact of these crime and safety issues cannot be measured in statistics alone, these data are valuable to the efforts of our policymakers, school officials and community members to identify and implement preventive and responsive measures,” Peggy Carr, PhD, the commissioner for the National Center for Education Statistics, said in a statement.

The report used a broad definition of shootings, which included instances when guns were fired or flashed on school property, as well as when a bullet hit school grounds for any reason and shootings that happened on school property during remote instruction throughout the COVID-19 pandemic.

More than 311,000 children at 331 schools have gone through gun violence since the shooting at Columbine High School in 1999, according to The Washington Post.

“The increase in shootings in schools is likely a consequence of an overall increase in gun violence and not specific to schools,” Dewey Cornell, PhD, a professor of education at the University of Virginia, Charlottesville, told the newspaper.

“However, most schools will never have a shooting, and their main problems will be fighting and bullying,” he said.

Between 2009 and 2020, the rate of nonfatal criminal victimization, including theft and violent crimes, decreased for ages 12-18, the report found. The rate fell from 51 victimizations per 1,000 students to 11. A major portion of the decline happened during the first year of the pandemic.

Lower percentages of public schools reported certain issues from 2019 to 2020 than from 2009 to 2010, the report found. For instance, 15% of schools reported student bullying at least once a week, as compared with 23% a decade ago. Student sexual harassment of other students dropped from 3% to 2%, and student harassment of other students based on sexual orientation or gender identity dropped from 3% to 2%.

At the same time, teachers faced more hardships, the report found. Schools reporting verbal abuse of teachers at least once a week rose to 10% in the 2019-2020 school year, as compared with 5% in the 2009-2010 school year. Schools reporting acts of disrespect for teachers climbed from 9% to 15%.

The percentage of schools that reported cyberbullying at least once a week doubled during the decade, rising from 8% in 2009-2010 to 16% in 2019-2020, the report found. The prominence of social media has likely added to that increase, the Post reported.

What’s more, about 55% of public schools offered mental health assessments in 2019-2020, and 42% offered mental health treatment services, the report found. The low rates could be linked to not having enough funding or access to licensed professionals, the newspaper reported.

A version of this article first appeared on WebMD.com.

School shootings from 2020 to 2021 climbed to the highest point in 2 decades, according to a new report from the National Center for Education Statistics and the Bureau of Justice Statistics.

There were 93 shootings with casualties at public and private K-12 schools across the United States from 2020 to 2021, as compared with 23 in the 2000-2001 school year. The latest number included 43 incidents with deaths.

The annual report, which examines crime and safety in schools and colleges, also found a rise in cyberbullying and verbal abuse or disrespect of teachers during the past decade.

“While the lasting impact of these crime and safety issues cannot be measured in statistics alone, these data are valuable to the efforts of our policymakers, school officials and community members to identify and implement preventive and responsive measures,” Peggy Carr, PhD, the commissioner for the National Center for Education Statistics, said in a statement.

The report used a broad definition of shootings, which included instances when guns were fired or flashed on school property, as well as when a bullet hit school grounds for any reason and shootings that happened on school property during remote instruction throughout the COVID-19 pandemic.

More than 311,000 children at 331 schools have gone through gun violence since the shooting at Columbine High School in 1999, according to The Washington Post.

“The increase in shootings in schools is likely a consequence of an overall increase in gun violence and not specific to schools,” Dewey Cornell, PhD, a professor of education at the University of Virginia, Charlottesville, told the newspaper.

“However, most schools will never have a shooting, and their main problems will be fighting and bullying,” he said.

Between 2009 and 2020, the rate of nonfatal criminal victimization, including theft and violent crimes, decreased for ages 12-18, the report found. The rate fell from 51 victimizations per 1,000 students to 11. A major portion of the decline happened during the first year of the pandemic.

Lower percentages of public schools reported certain issues from 2019 to 2020 than from 2009 to 2010, the report found. For instance, 15% of schools reported student bullying at least once a week, as compared with 23% a decade ago. Student sexual harassment of other students dropped from 3% to 2%, and student harassment of other students based on sexual orientation or gender identity dropped from 3% to 2%.

At the same time, teachers faced more hardships, the report found. Schools reporting verbal abuse of teachers at least once a week rose to 10% in the 2019-2020 school year, as compared with 5% in the 2009-2010 school year. Schools reporting acts of disrespect for teachers climbed from 9% to 15%.

The percentage of schools that reported cyberbullying at least once a week doubled during the decade, rising from 8% in 2009-2010 to 16% in 2019-2020, the report found. The prominence of social media has likely added to that increase, the Post reported.

What’s more, about 55% of public schools offered mental health assessments in 2019-2020, and 42% offered mental health treatment services, the report found. The low rates could be linked to not having enough funding or access to licensed professionals, the newspaper reported.

A version of this article first appeared on WebMD.com.

School shootings from 2020 to 2021 climbed to the highest point in 2 decades, according to a new report from the National Center for Education Statistics and the Bureau of Justice Statistics.

There were 93 shootings with casualties at public and private K-12 schools across the United States from 2020 to 2021, as compared with 23 in the 2000-2001 school year. The latest number included 43 incidents with deaths.

The annual report, which examines crime and safety in schools and colleges, also found a rise in cyberbullying and verbal abuse or disrespect of teachers during the past decade.

“While the lasting impact of these crime and safety issues cannot be measured in statistics alone, these data are valuable to the efforts of our policymakers, school officials and community members to identify and implement preventive and responsive measures,” Peggy Carr, PhD, the commissioner for the National Center for Education Statistics, said in a statement.

The report used a broad definition of shootings, which included instances when guns were fired or flashed on school property, as well as when a bullet hit school grounds for any reason and shootings that happened on school property during remote instruction throughout the COVID-19 pandemic.

More than 311,000 children at 331 schools have gone through gun violence since the shooting at Columbine High School in 1999, according to The Washington Post.

“The increase in shootings in schools is likely a consequence of an overall increase in gun violence and not specific to schools,” Dewey Cornell, PhD, a professor of education at the University of Virginia, Charlottesville, told the newspaper.

“However, most schools will never have a shooting, and their main problems will be fighting and bullying,” he said.

Between 2009 and 2020, the rate of nonfatal criminal victimization, including theft and violent crimes, decreased for ages 12-18, the report found. The rate fell from 51 victimizations per 1,000 students to 11. A major portion of the decline happened during the first year of the pandemic.

Lower percentages of public schools reported certain issues from 2019 to 2020 than from 2009 to 2010, the report found. For instance, 15% of schools reported student bullying at least once a week, as compared with 23% a decade ago. Student sexual harassment of other students dropped from 3% to 2%, and student harassment of other students based on sexual orientation or gender identity dropped from 3% to 2%.

At the same time, teachers faced more hardships, the report found. Schools reporting verbal abuse of teachers at least once a week rose to 10% in the 2019-2020 school year, as compared with 5% in the 2009-2010 school year. Schools reporting acts of disrespect for teachers climbed from 9% to 15%.

The percentage of schools that reported cyberbullying at least once a week doubled during the decade, rising from 8% in 2009-2010 to 16% in 2019-2020, the report found. The prominence of social media has likely added to that increase, the Post reported.

What’s more, about 55% of public schools offered mental health assessments in 2019-2020, and 42% offered mental health treatment services, the report found. The low rates could be linked to not having enough funding or access to licensed professionals, the newspaper reported.

A version of this article first appeared on WebMD.com.

Heat waves are getting hotter and becoming more frequent because of rising rates of air pollution, putting children’s health at risk, a wide-ranging new report finds.

An article in the New England Journal of Medicine reviews current research to take a sweeping inventory of how air pollution and climate change interact to adversely affect people’s health, especially that of kids. It examined the link between fossil fuel emissions and a variety of consequences of climate change – including extreme weather events; wildfires; vector-borne illnesses such as malaria, Zika, and Lyme disease; and heat waves, a topic at the forefront of many people’s minds.

This month, for example, record-high temperatures have been reported across the United States, affecting more than 100 million people and touching locations from the Gulf Coast to the Great Lakes, the Southwest, the mid-Atlantic, and the Midwest.

In Texas, Austin has already experienced an 8-day streak of temperatures above the 100° F mark in June, according to the Austin American-Statesman.

These patterns are an important reality to note, said Frederica Perera, DrPH, PhD, the article’s lead author. “My concern is that the threats are rising as temperature is rising,” Dr. Perera, a professor at Columbia University’s Mailman School of Public Health, New York, told KHN. “Temperatures are rising because greenhouse gas emissions are rising, and that’s a great concern for everyone’s health – but especially the most vulnerable.”

Children fit into this category, wrote Dr. Perera and her coauthor, Kari Nadeau, MD, PhD, Naddisy Foundation Endowed Professor of Medicine and Pediatrics at Stanford (Calif.) University, because their ability to regulate temperature, known as thermoregulation, is not fully developed.

They are also more susceptible to heat-related stress because they’re smaller and need to drink and eat more frequently to stay healthy, said Dr. Perera. But because “young children are dependent on parents to provide, sometimes their needs go ignored,” she said.

The authors noted that heat-related illness is “a leading and increasing cause of death and illness among student athletes” in the United States. In addition, they cited studies suggesting that “the heat associated with climate change” takes a toll on the mental health of children and adolescents, as well as their ability to learn.

The review article pointed to previous research. that associated in utero exposure to heat waves with “increased risks of preterm birth or low birth weight; hyperthermia and death among infants; and heat stress, kidney disease, and other illnesses” among kids.

“Being pregnant is very physiologically demanding in itself, and then heat places additional stress on a pregnant woman,” said Dr. Robert Dubrow, a professor of epidemiology at Yale’s School of Public Health, New Haven, Conn., who was not associated with either study. “And the fetus can experience heat stress as well, which could result in adverse birth outcomes.”

And these heat-related risks are across-the-board greater for “low-income communities and communities of color,” wrote the authors of the new article.

Carbon dioxide emissions from burning fossil fuels have risen sharply in the past 70 years, according to the article. “Modeling indicates that some heat waves would be extraordinarily unlikely to occur in the absence of climate change,” it says.

The authors briefly outline solutions that they describe as “climate and environmental strategies” that “should also be seen as essential public health policy.” Beyond big-picture efforts to mitigate fossil fuel and greenhouse gas emissions, they offered various ways to protect children – steps they term “adaptation measures” – which included providing clean water to children and families facing drought or water contamination and creating shaded areas where children play, live, and go to school.

Separately, Austin-based research highlighted why this step could be meaningful.

Researchers tracked the physical activity levels and location of students ages 8 to 10 during recess at three elementary schools in 2019. They compared children’s activity at recess during two weeks in September, the hottest full month during the school year, to a cooler week in November. “We wanted to understand the impact of outdoor temperatures on children’s play in schoolyard environments,” said Dr. Kevin Lanza, the study’s lead investigator, to inform the design of “future school-based interventions for physical activity in the face of climate change.”

During the hotter periods, he said, “children engaged in less physical activity and sought shade.”

As temperatures continue to rise, he said, schools must be flexible in making sure students are getting the daily exercise they need. “Schools should consider adding shade, either by planting trees or installing artificial structures that cover spaces intended for physical activity,” said Dr. Lanza, an assistant professor at UTHealth School of Public Health, Austin, Tex. He also noted that school policies could be updated so that recesses are scheduled during cooler times of the day and moved inside during periods of extreme heat.

But the overall need to protect kids from scorching weather patterns requires action beyond such steps, Dr. Perera said, and more climate and clean air policies must be enacted.

“Governments have the responsibility to protect the population and especially those most vulnerable, which especially includes children,” Dr. Perera said. “Action must be done immediately because we’re absolutely heading in the wrong direction.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

Heat waves are getting hotter and becoming more frequent because of rising rates of air pollution, putting children’s health at risk, a wide-ranging new report finds.

An article in the New England Journal of Medicine reviews current research to take a sweeping inventory of how air pollution and climate change interact to adversely affect people’s health, especially that of kids. It examined the link between fossil fuel emissions and a variety of consequences of climate change – including extreme weather events; wildfires; vector-borne illnesses such as malaria, Zika, and Lyme disease; and heat waves, a topic at the forefront of many people’s minds.

This month, for example, record-high temperatures have been reported across the United States, affecting more than 100 million people and touching locations from the Gulf Coast to the Great Lakes, the Southwest, the mid-Atlantic, and the Midwest.

In Texas, Austin has already experienced an 8-day streak of temperatures above the 100° F mark in June, according to the Austin American-Statesman.

These patterns are an important reality to note, said Frederica Perera, DrPH, PhD, the article’s lead author. “My concern is that the threats are rising as temperature is rising,” Dr. Perera, a professor at Columbia University’s Mailman School of Public Health, New York, told KHN. “Temperatures are rising because greenhouse gas emissions are rising, and that’s a great concern for everyone’s health – but especially the most vulnerable.”

Children fit into this category, wrote Dr. Perera and her coauthor, Kari Nadeau, MD, PhD, Naddisy Foundation Endowed Professor of Medicine and Pediatrics at Stanford (Calif.) University, because their ability to regulate temperature, known as thermoregulation, is not fully developed.

They are also more susceptible to heat-related stress because they’re smaller and need to drink and eat more frequently to stay healthy, said Dr. Perera. But because “young children are dependent on parents to provide, sometimes their needs go ignored,” she said.

The authors noted that heat-related illness is “a leading and increasing cause of death and illness among student athletes” in the United States. In addition, they cited studies suggesting that “the heat associated with climate change” takes a toll on the mental health of children and adolescents, as well as their ability to learn.

The review article pointed to previous research. that associated in utero exposure to heat waves with “increased risks of preterm birth or low birth weight; hyperthermia and death among infants; and heat stress, kidney disease, and other illnesses” among kids.

“Being pregnant is very physiologically demanding in itself, and then heat places additional stress on a pregnant woman,” said Dr. Robert Dubrow, a professor of epidemiology at Yale’s School of Public Health, New Haven, Conn., who was not associated with either study. “And the fetus can experience heat stress as well, which could result in adverse birth outcomes.”

And these heat-related risks are across-the-board greater for “low-income communities and communities of color,” wrote the authors of the new article.

Carbon dioxide emissions from burning fossil fuels have risen sharply in the past 70 years, according to the article. “Modeling indicates that some heat waves would be extraordinarily unlikely to occur in the absence of climate change,” it says.

The authors briefly outline solutions that they describe as “climate and environmental strategies” that “should also be seen as essential public health policy.” Beyond big-picture efforts to mitigate fossil fuel and greenhouse gas emissions, they offered various ways to protect children – steps they term “adaptation measures” – which included providing clean water to children and families facing drought or water contamination and creating shaded areas where children play, live, and go to school.

Separately, Austin-based research highlighted why this step could be meaningful.

Researchers tracked the physical activity levels and location of students ages 8 to 10 during recess at three elementary schools in 2019. They compared children’s activity at recess during two weeks in September, the hottest full month during the school year, to a cooler week in November. “We wanted to understand the impact of outdoor temperatures on children’s play in schoolyard environments,” said Dr. Kevin Lanza, the study’s lead investigator, to inform the design of “future school-based interventions for physical activity in the face of climate change.”

During the hotter periods, he said, “children engaged in less physical activity and sought shade.”

As temperatures continue to rise, he said, schools must be flexible in making sure students are getting the daily exercise they need. “Schools should consider adding shade, either by planting trees or installing artificial structures that cover spaces intended for physical activity,” said Dr. Lanza, an assistant professor at UTHealth School of Public Health, Austin, Tex. He also noted that school policies could be updated so that recesses are scheduled during cooler times of the day and moved inside during periods of extreme heat.

But the overall need to protect kids from scorching weather patterns requires action beyond such steps, Dr. Perera said, and more climate and clean air policies must be enacted.

“Governments have the responsibility to protect the population and especially those most vulnerable, which especially includes children,” Dr. Perera said. “Action must be done immediately because we’re absolutely heading in the wrong direction.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

Heat waves are getting hotter and becoming more frequent because of rising rates of air pollution, putting children’s health at risk, a wide-ranging new report finds.

An article in the New England Journal of Medicine reviews current research to take a sweeping inventory of how air pollution and climate change interact to adversely affect people’s health, especially that of kids. It examined the link between fossil fuel emissions and a variety of consequences of climate change – including extreme weather events; wildfires; vector-borne illnesses such as malaria, Zika, and Lyme disease; and heat waves, a topic at the forefront of many people’s minds.

This month, for example, record-high temperatures have been reported across the United States, affecting more than 100 million people and touching locations from the Gulf Coast to the Great Lakes, the Southwest, the mid-Atlantic, and the Midwest.

In Texas, Austin has already experienced an 8-day streak of temperatures above the 100° F mark in June, according to the Austin American-Statesman.

These patterns are an important reality to note, said Frederica Perera, DrPH, PhD, the article’s lead author. “My concern is that the threats are rising as temperature is rising,” Dr. Perera, a professor at Columbia University’s Mailman School of Public Health, New York, told KHN. “Temperatures are rising because greenhouse gas emissions are rising, and that’s a great concern for everyone’s health – but especially the most vulnerable.”

Children fit into this category, wrote Dr. Perera and her coauthor, Kari Nadeau, MD, PhD, Naddisy Foundation Endowed Professor of Medicine and Pediatrics at Stanford (Calif.) University, because their ability to regulate temperature, known as thermoregulation, is not fully developed.

They are also more susceptible to heat-related stress because they’re smaller and need to drink and eat more frequently to stay healthy, said Dr. Perera. But because “young children are dependent on parents to provide, sometimes their needs go ignored,” she said.

The authors noted that heat-related illness is “a leading and increasing cause of death and illness among student athletes” in the United States. In addition, they cited studies suggesting that “the heat associated with climate change” takes a toll on the mental health of children and adolescents, as well as their ability to learn.

The review article pointed to previous research. that associated in utero exposure to heat waves with “increased risks of preterm birth or low birth weight; hyperthermia and death among infants; and heat stress, kidney disease, and other illnesses” among kids.

“Being pregnant is very physiologically demanding in itself, and then heat places additional stress on a pregnant woman,” said Dr. Robert Dubrow, a professor of epidemiology at Yale’s School of Public Health, New Haven, Conn., who was not associated with either study. “And the fetus can experience heat stress as well, which could result in adverse birth outcomes.”

And these heat-related risks are across-the-board greater for “low-income communities and communities of color,” wrote the authors of the new article.

Carbon dioxide emissions from burning fossil fuels have risen sharply in the past 70 years, according to the article. “Modeling indicates that some heat waves would be extraordinarily unlikely to occur in the absence of climate change,” it says.

The authors briefly outline solutions that they describe as “climate and environmental strategies” that “should also be seen as essential public health policy.” Beyond big-picture efforts to mitigate fossil fuel and greenhouse gas emissions, they offered various ways to protect children – steps they term “adaptation measures” – which included providing clean water to children and families facing drought or water contamination and creating shaded areas where children play, live, and go to school.

Separately, Austin-based research highlighted why this step could be meaningful.

Researchers tracked the physical activity levels and location of students ages 8 to 10 during recess at three elementary schools in 2019. They compared children’s activity at recess during two weeks in September, the hottest full month during the school year, to a cooler week in November. “We wanted to understand the impact of outdoor temperatures on children’s play in schoolyard environments,” said Dr. Kevin Lanza, the study’s lead investigator, to inform the design of “future school-based interventions for physical activity in the face of climate change.”

During the hotter periods, he said, “children engaged in less physical activity and sought shade.”

As temperatures continue to rise, he said, schools must be flexible in making sure students are getting the daily exercise they need. “Schools should consider adding shade, either by planting trees or installing artificial structures that cover spaces intended for physical activity,” said Dr. Lanza, an assistant professor at UTHealth School of Public Health, Austin, Tex. He also noted that school policies could be updated so that recesses are scheduled during cooler times of the day and moved inside during periods of extreme heat.

But the overall need to protect kids from scorching weather patterns requires action beyond such steps, Dr. Perera said, and more climate and clean air policies must be enacted.

“Governments have the responsibility to protect the population and especially those most vulnerable, which especially includes children,” Dr. Perera said. “Action must be done immediately because we’re absolutely heading in the wrong direction.”

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism about health issues. Together with Policy Analysis and Polling, KHN is one of the three major operating programs at KFF (Kaiser Family Foundation). KFF is an endowed nonprofit organization providing information on health issues to the nation.

Ramping up health system capacity for the coming surge of U.S. COVID-19 cases requires a commitment to boosting safety, capacity, and communication, according to a physician leader and a health workforce expert.

Polly Pittman, PhD, is hearing a lot of concern among health care workers that it’s difficult to find definitive and accurate information about how best to protect themselves and their families, she said during a webinar by the Alliance for Health Policy titled Health System Capacity: Protecting Frontline Health Workers. “The knowledge base is evolving very quickly,” said Dr. Pittman, Fitzhugh Mullan Professor of Health Workforce Equity at the Milken Institute School of Public Health, George Washington University, Washington.

Parodi_Stephen_CA_web.jpg

[embed:render:related:node:219662]

He noted that Permanente is “working hand in glove with state authorities throughout the country.” Efforts include establishing alternative sites for assessment and testing, as well as opening up closed hospitals and working with the National Guard and the Department of Defense to prepare mobile hospital units that can be deployed in areas with peak infection rates. “Having all of those options available to us is critically important,” he said.

To mitigate potential provider shortages, Dr. Pittman said, “All members of the care team could potentially do more” than their current licenses allow. Expanding the scope of practice for pharmacists, clinical laboratory staff, licensed practical nurses, and medical assistants can help with efficient care delivery.

Other measures include expedited licensing for near-graduates and nonpracticing foreign medical graduates, as well as relicensing for retired health care personnel and those who are not currently working directly with patients, she said.

Getting these things done “requires leadership on behalf of the licensing bodies,” as well as coordination with state regulatory authorities, Dr. Pittman pointed out.

Dr. Parodi called for state and federal governments to implement emergency declarations that suspend some existing health codes to achieve repurposing of staff. Getting these measures in place now will allow facilities “to be able to provide that in-time training now before the surge occurs. ... We are actively developing plans knowing that there’s going to be a need for more critical care.”

The game plan at Permanente, he said, is to repurpose critical care physicians to provide consultations to multiple hospitalists who are providing the bulk of frontline care. At the same time, they plan to repurpose other specialists to backfill the hospitalists, and to repurpose family medicine physicians to supplement staff in emergency departments and other frontline intake areas.

All the organizational measures being taken won’t be in vain if they increase preparedness for the long battle ahead, he said. “We need to double down on the work. ... We need to continue social distancing, and we’ve got to ramp up testing. Until we do that we have to hold the line on basic public health measures.”

Dr. Parodi is employed by Permanente. The panelists reported no disclosures relevant to the presentation, which was sponsored by the Alliance for Health Policy, the Commonwealth Fund, and the National Institute for Health Care Management Foundation.

koakes@mdedge.com

Ramping up health system capacity for the coming surge of U.S. COVID-19 cases requires a commitment to boosting safety, capacity, and communication, according to a physician leader and a health workforce expert.

Polly Pittman, PhD, is hearing a lot of concern among health care workers that it’s difficult to find definitive and accurate information about how best to protect themselves and their families, she said during a webinar by the Alliance for Health Policy titled Health System Capacity: Protecting Frontline Health Workers. “The knowledge base is evolving very quickly,” said Dr. Pittman, Fitzhugh Mullan Professor of Health Workforce Equity at the Milken Institute School of Public Health, George Washington University, Washington.

Parodi_Stephen_CA_web.jpg

[embed:render:related:node:219662]

He noted that Permanente is “working hand in glove with state authorities throughout the country.” Efforts include establishing alternative sites for assessment and testing, as well as opening up closed hospitals and working with the National Guard and the Department of Defense to prepare mobile hospital units that can be deployed in areas with peak infection rates. “Having all of those options available to us is critically important,” he said.

To mitigate potential provider shortages, Dr. Pittman said, “All members of the care team could potentially do more” than their current licenses allow. Expanding the scope of practice for pharmacists, clinical laboratory staff, licensed practical nurses, and medical assistants can help with efficient care delivery.

Other measures include expedited licensing for near-graduates and nonpracticing foreign medical graduates, as well as relicensing for retired health care personnel and those who are not currently working directly with patients, she said.

Getting these things done “requires leadership on behalf of the licensing bodies,” as well as coordination with state regulatory authorities, Dr. Pittman pointed out.

Dr. Parodi called for state and federal governments to implement emergency declarations that suspend some existing health codes to achieve repurposing of staff. Getting these measures in place now will allow facilities “to be able to provide that in-time training now before the surge occurs. ... We are actively developing plans knowing that there’s going to be a need for more critical care.”

The game plan at Permanente, he said, is to repurpose critical care physicians to provide consultations to multiple hospitalists who are providing the bulk of frontline care. At the same time, they plan to repurpose other specialists to backfill the hospitalists, and to repurpose family medicine physicians to supplement staff in emergency departments and other frontline intake areas.

All the organizational measures being taken won’t be in vain if they increase preparedness for the long battle ahead, he said. “We need to double down on the work. ... We need to continue social distancing, and we’ve got to ramp up testing. Until we do that we have to hold the line on basic public health measures.”

Dr. Parodi is employed by Permanente. The panelists reported no disclosures relevant to the presentation, which was sponsored by the Alliance for Health Policy, the Commonwealth Fund, and the National Institute for Health Care Management Foundation.

koakes@mdedge.com

Ramping up health system capacity for the coming surge of U.S. COVID-19 cases requires a commitment to boosting safety, capacity, and communication, according to a physician leader and a health workforce expert.

Polly Pittman, PhD, is hearing a lot of concern among health care workers that it’s difficult to find definitive and accurate information about how best to protect themselves and their families, she said during a webinar by the Alliance for Health Policy titled Health System Capacity: Protecting Frontline Health Workers. “The knowledge base is evolving very quickly,” said Dr. Pittman, Fitzhugh Mullan Professor of Health Workforce Equity at the Milken Institute School of Public Health, George Washington University, Washington.

Parodi_Stephen_CA_web.jpg

[embed:render:related:node:219662]

He noted that Permanente is “working hand in glove with state authorities throughout the country.” Efforts include establishing alternative sites for assessment and testing, as well as opening up closed hospitals and working with the National Guard and the Department of Defense to prepare mobile hospital units that can be deployed in areas with peak infection rates. “Having all of those options available to us is critically important,” he said.

To mitigate potential provider shortages, Dr. Pittman said, “All members of the care team could potentially do more” than their current licenses allow. Expanding the scope of practice for pharmacists, clinical laboratory staff, licensed practical nurses, and medical assistants can help with efficient care delivery.

Other measures include expedited licensing for near-graduates and nonpracticing foreign medical graduates, as well as relicensing for retired health care personnel and those who are not currently working directly with patients, she said.

Getting these things done “requires leadership on behalf of the licensing bodies,” as well as coordination with state regulatory authorities, Dr. Pittman pointed out.

Dr. Parodi called for state and federal governments to implement emergency declarations that suspend some existing health codes to achieve repurposing of staff. Getting these measures in place now will allow facilities “to be able to provide that in-time training now before the surge occurs. ... We are actively developing plans knowing that there’s going to be a need for more critical care.”

The game plan at Permanente, he said, is to repurpose critical care physicians to provide consultations to multiple hospitalists who are providing the bulk of frontline care. At the same time, they plan to repurpose other specialists to backfill the hospitalists, and to repurpose family medicine physicians to supplement staff in emergency departments and other frontline intake areas.

All the organizational measures being taken won’t be in vain if they increase preparedness for the long battle ahead, he said. “We need to double down on the work. ... We need to continue social distancing, and we’ve got to ramp up testing. Until we do that we have to hold the line on basic public health measures.”

Dr. Parodi is employed by Permanente. The panelists reported no disclosures relevant to the presentation, which was sponsored by the Alliance for Health Policy, the Commonwealth Fund, and the National Institute for Health Care Management Foundation.

koakes@mdedge.com

SAN DIEGO – “Working at the top of your license,” focusing only on those tasks that cannot be performed by anyone else but you, is a key strategy when handling mass casualties, according to Dr. Toree McGowan, an emergency physician who works in a critical care facility in rural Oregon.

In our video interview at the annual meeting of the American College of Emergency Physicians, she outlined key strategies for obtaining resources and delegating care when managing mass casualties from disasters.

Dr. McGowan of the St. Charles Medical Group, Culver, Ore., said that, although she is the only physician at her rural critical care center about 70% of the time, she has established plans in place for obtaining additional staff and resources in the event of disasters. During her time in the military, she was among a team that implemented a disaster plan after a toxic chemical release at a nearby factory. The response was effective because the threat had been anticipated and a plan was in place. To develop the skills and strategies she describes in this interview, Dr. McGowan recommends free training that is available from the nonprofit National Disaster Life Support Foundation.
 

SAN DIEGO – “Working at the top of your license,” focusing only on those tasks that cannot be performed by anyone else but you, is a key strategy when handling mass casualties, according to Dr. Toree McGowan, an emergency physician who works in a critical care facility in rural Oregon.

In our video interview at the annual meeting of the American College of Emergency Physicians, she outlined key strategies for obtaining resources and delegating care when managing mass casualties from disasters.

Dr. McGowan of the St. Charles Medical Group, Culver, Ore., said that, although she is the only physician at her rural critical care center about 70% of the time, she has established plans in place for obtaining additional staff and resources in the event of disasters. During her time in the military, she was among a team that implemented a disaster plan after a toxic chemical release at a nearby factory. The response was effective because the threat had been anticipated and a plan was in place. To develop the skills and strategies she describes in this interview, Dr. McGowan recommends free training that is available from the nonprofit National Disaster Life Support Foundation.
 

SAN DIEGO – “Working at the top of your license,” focusing only on those tasks that cannot be performed by anyone else but you, is a key strategy when handling mass casualties, according to Dr. Toree McGowan, an emergency physician who works in a critical care facility in rural Oregon.

In our video interview at the annual meeting of the American College of Emergency Physicians, she outlined key strategies for obtaining resources and delegating care when managing mass casualties from disasters.

Dr. McGowan of the St. Charles Medical Group, Culver, Ore., said that, although she is the only physician at her rural critical care center about 70% of the time, she has established plans in place for obtaining additional staff and resources in the event of disasters. During her time in the military, she was among a team that implemented a disaster plan after a toxic chemical release at a nearby factory. The response was effective because the threat had been anticipated and a plan was in place. To develop the skills and strategies she describes in this interview, Dr. McGowan recommends free training that is available from the nonprofit National Disaster Life Support Foundation.
 

Between late August and early November of this year, three strong Gulf Coast and Atlantic hurricanes and several intense, fast-moving northern California forest fires claimed more than 285 lives and caused countless additional injuries and illnesses. During the same period, three unnatural disasters—in Las Vegas, New York City (NYC), and now Sutherland Springs, Texas—were responsible for a total of 84 deaths and 558 injuries. Emergency physicians (EPs) and our colleagues helped deal with the aftermath of all of these incidents, saving lives and ameliorating survivors’ pain and suffering. But ironically, preventing future deaths and injuries from natural disasters may be easier than preventing loss of life from depraved human behavior.

An October 9, 2017 Wall Street Journal (WSJ) article by Jeanne Whalen entitled “Training Ground for Military Trauma Experts: U.S. Gun Violence,” describes how military surgeons helped treat victims of the Las Vegas shooting, one of several arrangements across the United States where steady gun violence provides a training ground that experts can then use on the battlefield. The article includes a photograph of Tom Scalea, MD, Chief of the R. Adams Cowley (Maryland) Shock Trauma Center and EM board member, operating with the assistance of an Air Force surgeon “embedded” at the hospital. 

Before September 11, 2001, US hospitals looked to military surgeons experienced in treating combat injuries to direct and staff their trauma centers.  Now, the military looks to US hospitals to provide their surgeons with experience treating victims of gun violence, explosives, and high-speed vehicular injuries prior to sending them into war zones! In the week before this issue of EM went to press, a terrorist driving a rental truck down an NYC bicycle path killed 8 people and injured 11 near the site of the 1993 and 2001 World Trade Center attacks. Five days later, 26 church worshipers near Austin, Texas lost their lives and 20 more were seriously injured when a lone gunman shot them with an assault rifle.

The gun violence statistics in this country are staggering. According to the nonprofit Gun Violence Archive (GVA; http://www.gunviolencearchive.org/), from January 1 through November 8, 2017 there have been 52,719 incidents resulting in 13,245 deaths and 27,111 injuries, and the Texas church attack was the 307th mass shooting* in the United States this year!

The pervasiveness of the gun culture in this country offers little hope of eliminating such incidents in the future, which makes it especially important for all EPs to be skilled in state-of-the-art trauma management. (See parts I and II of “The changing landscape of trauma care” in the July and August 2017 issues of EM [www.mdedge.com/emed-journal]). As Baltimore trauma surgeon Tom Scalea notes in the WSJ article cited earlier, “Mass shooting? That’s every weekend.…it makes me despondent….I don’t have the ability to make that go away. I have the ability to keep as many alive as I can, and we’re pretty good at it.”

As for preventing deaths from natural disasters, more accurate weather forecasting and newer technology offer more hope. Among the 134 storm-related deaths from Hurricane Irma in September, 14 were heat-related after the storm disabled a transformer supplying power to the air conditioning system of a Hollywood, Florida nursing home. A new state law will now require all nursing homes to have adequate backup generators. But for the increasing numbers of older persons with comorbidities, taking multiple medications, and living in hot climates, air conditioning must be considered life support equipment that requires immediate repair or replacement when it fails—or transfer of the residents to a cool facility.

If only we could someday also prevent terrorism and other acts of senseless violence. 

*The GVA defines a mass shooting as a single incident resulting in 4 or more people (not including the shooter) shot and/or killed at the same general time and location.

Between late August and early November of this year, three strong Gulf Coast and Atlantic hurricanes and several intense, fast-moving northern California forest fires claimed more than 285 lives and caused countless additional injuries and illnesses. During the same period, three unnatural disasters—in Las Vegas, New York City (NYC), and now Sutherland Springs, Texas—were responsible for a total of 84 deaths and 558 injuries. Emergency physicians (EPs) and our colleagues helped deal with the aftermath of all of these incidents, saving lives and ameliorating survivors’ pain and suffering. But ironically, preventing future deaths and injuries from natural disasters may be easier than preventing loss of life from depraved human behavior.

An October 9, 2017 Wall Street Journal (WSJ) article by Jeanne Whalen entitled “Training Ground for Military Trauma Experts: U.S. Gun Violence,” describes how military surgeons helped treat victims of the Las Vegas shooting, one of several arrangements across the United States where steady gun violence provides a training ground that experts can then use on the battlefield. The article includes a photograph of Tom Scalea, MD, Chief of the R. Adams Cowley (Maryland) Shock Trauma Center and EM board member, operating with the assistance of an Air Force surgeon “embedded” at the hospital. 

Before September 11, 2001, US hospitals looked to military surgeons experienced in treating combat injuries to direct and staff their trauma centers.  Now, the military looks to US hospitals to provide their surgeons with experience treating victims of gun violence, explosives, and high-speed vehicular injuries prior to sending them into war zones! In the week before this issue of EM went to press, a terrorist driving a rental truck down an NYC bicycle path killed 8 people and injured 11 near the site of the 1993 and 2001 World Trade Center attacks. Five days later, 26 church worshipers near Austin, Texas lost their lives and 20 more were seriously injured when a lone gunman shot them with an assault rifle.

The gun violence statistics in this country are staggering. According to the nonprofit Gun Violence Archive (GVA; http://www.gunviolencearchive.org/), from January 1 through November 8, 2017 there have been 52,719 incidents resulting in 13,245 deaths and 27,111 injuries, and the Texas church attack was the 307th mass shooting* in the United States this year!

The pervasiveness of the gun culture in this country offers little hope of eliminating such incidents in the future, which makes it especially important for all EPs to be skilled in state-of-the-art trauma management. (See parts I and II of “The changing landscape of trauma care” in the July and August 2017 issues of EM [www.mdedge.com/emed-journal]). As Baltimore trauma surgeon Tom Scalea notes in the WSJ article cited earlier, “Mass shooting? That’s every weekend.…it makes me despondent….I don’t have the ability to make that go away. I have the ability to keep as many alive as I can, and we’re pretty good at it.”

As for preventing deaths from natural disasters, more accurate weather forecasting and newer technology offer more hope. Among the 134 storm-related deaths from Hurricane Irma in September, 14 were heat-related after the storm disabled a transformer supplying power to the air conditioning system of a Hollywood, Florida nursing home. A new state law will now require all nursing homes to have adequate backup generators. But for the increasing numbers of older persons with comorbidities, taking multiple medications, and living in hot climates, air conditioning must be considered life support equipment that requires immediate repair or replacement when it fails—or transfer of the residents to a cool facility.

If only we could someday also prevent terrorism and other acts of senseless violence. 

*The GVA defines a mass shooting as a single incident resulting in 4 or more people (not including the shooter) shot and/or killed at the same general time and location.

Between late August and early November of this year, three strong Gulf Coast and Atlantic hurricanes and several intense, fast-moving northern California forest fires claimed more than 285 lives and caused countless additional injuries and illnesses. During the same period, three unnatural disasters—in Las Vegas, New York City (NYC), and now Sutherland Springs, Texas—were responsible for a total of 84 deaths and 558 injuries. Emergency physicians (EPs) and our colleagues helped deal with the aftermath of all of these incidents, saving lives and ameliorating survivors’ pain and suffering. But ironically, preventing future deaths and injuries from natural disasters may be easier than preventing loss of life from depraved human behavior.

An October 9, 2017 Wall Street Journal (WSJ) article by Jeanne Whalen entitled “Training Ground for Military Trauma Experts: U.S. Gun Violence,” describes how military surgeons helped treat victims of the Las Vegas shooting, one of several arrangements across the United States where steady gun violence provides a training ground that experts can then use on the battlefield. The article includes a photograph of Tom Scalea, MD, Chief of the R. Adams Cowley (Maryland) Shock Trauma Center and EM board member, operating with the assistance of an Air Force surgeon “embedded” at the hospital. 

Before September 11, 2001, US hospitals looked to military surgeons experienced in treating combat injuries to direct and staff their trauma centers.  Now, the military looks to US hospitals to provide their surgeons with experience treating victims of gun violence, explosives, and high-speed vehicular injuries prior to sending them into war zones! In the week before this issue of EM went to press, a terrorist driving a rental truck down an NYC bicycle path killed 8 people and injured 11 near the site of the 1993 and 2001 World Trade Center attacks. Five days later, 26 church worshipers near Austin, Texas lost their lives and 20 more were seriously injured when a lone gunman shot them with an assault rifle.

The gun violence statistics in this country are staggering. According to the nonprofit Gun Violence Archive (GVA; http://www.gunviolencearchive.org/), from January 1 through November 8, 2017 there have been 52,719 incidents resulting in 13,245 deaths and 27,111 injuries, and the Texas church attack was the 307th mass shooting* in the United States this year!

The pervasiveness of the gun culture in this country offers little hope of eliminating such incidents in the future, which makes it especially important for all EPs to be skilled in state-of-the-art trauma management. (See parts I and II of “The changing landscape of trauma care” in the July and August 2017 issues of EM [www.mdedge.com/emed-journal]). As Baltimore trauma surgeon Tom Scalea notes in the WSJ article cited earlier, “Mass shooting? That’s every weekend.…it makes me despondent….I don’t have the ability to make that go away. I have the ability to keep as many alive as I can, and we’re pretty good at it.”

As for preventing deaths from natural disasters, more accurate weather forecasting and newer technology offer more hope. Among the 134 storm-related deaths from Hurricane Irma in September, 14 were heat-related after the storm disabled a transformer supplying power to the air conditioning system of a Hollywood, Florida nursing home. A new state law will now require all nursing homes to have adequate backup generators. But for the increasing numbers of older persons with comorbidities, taking multiple medications, and living in hot climates, air conditioning must be considered life support equipment that requires immediate repair or replacement when it fails—or transfer of the residents to a cool facility.

If only we could someday also prevent terrorism and other acts of senseless violence. 

*The GVA defines a mass shooting as a single incident resulting in 4 or more people (not including the shooter) shot and/or killed at the same general time and location.

Between August 30 and September 16, 2017, Hurricane Irma wreaked havoc in the Caribbean and throughout Florida. In the days after the Rehabilitation Center at Hollywood Hills, Florida, lost its transformer and air conditioning due to the storm, 12 residents ranging in age from 57 to 99 years died* with body temperatures as high as 109.9°F, even though the hospital across the street continued to have full power. The nursing home staff tried in vain several times to get Florida Power and Light to restore full power. They also called a “personal” cell phone number provided by the governor for storm victims in need of help, but their voicemail messages went unanswered. Apparently, no one called 911 or tried to have the patients moved across the street before they were in extremis or began to die.

Large numbers of casualties are not an inevitable sequela of natural disasters. In August 1973 (the second month of my internship), a late summer heat wave in New York City sent 12 patients with heat stroke and heat exhaustion from nearby non-air-conditioned nursing homes to the Albert Einstein/Jacobi Hospital emergency department in just a few hours. After being packed in ice until their temperatures dropped, all but one of the patients survived, while the 12th patient died of her underlying illnesses (see “Sheldon Jacobson, MD 1938-2009,” July 2009 EM).

On August 14, 2003, a hot (92.5°F), humid day in NYC, a power outage affecting the entire northeast and northwest United States trapped many New Yorkers in elevators, subways, and train cars. Residents were also trapped in high-rise apartments with only limited battery power for respirators and other essential electrical equipment. Within a few hours, first responders had reportedly evacuated everyone from stalled elevators in about 800 buildings, and over 600 subway and commuter train cars. Others were safely evacuated from their high-rise residences and taken to EDs powered by emergency generators. Upon arrival, their life support equipment and devices were plugged into electrical outlets, while they were examined, given medications as necessary, and later returned to their homes when power was restored.

First responders and emergency physicians have become quite adept at managing heat stroke and heat-related conditions, but only in patients who are still alive. In the aftermath of Hurricane Katrina, which devastated New Orleans on August 29, 2005, 215 bodies were found in New Orleans hospitals and nursing homes—including those from 40 post-storm deaths in one hospital alone (See Sheri Fink. Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital. New York, NY: Crown Publishers; 2013). The tragic events following Katrina should have been a wake-up call for all health facilities and regulators in the US to anticipate and adequately prepare for loss of power, water, and severe heat conditions. Instead, a 2006 Florida bill that would have required adequate generators in all nursing homes was defeated, reportedly due to industry lobbying efforts.

The number of casualties and deaths due to natural disasters in this country may be fewer than those caused by such man-made incidents as the June 12, 2016 Pulse Nightclub shooting in Orlando, FL (see “The Orlando Nightclub Shooting: Firsthand Accounts and Lessons Learned,” August 2016 EM) and now the mass shooting in Las Vegas, NV on October 1, 2017, as this issue of Emergency Medicine was going to press. But natural disasters such as hurricanes, tornadoes, earthquakes, etc, are far more predictable and will reoccur with a 100% certainty in areas prone to or previously affected by such events. In these incidents, loss of life is preventable.

To quote the famous aphorism of George Santayana, “Those who cannot remember the past are condemned to repeat it.” More inexcusably, it often seems that those who can remember the past are also condemned to repeat it. 

*As of October 11, 2017, this number rose to 14 deaths.

Between August 30 and September 16, 2017, Hurricane Irma wreaked havoc in the Caribbean and throughout Florida. In the days after the Rehabilitation Center at Hollywood Hills, Florida, lost its transformer and air conditioning due to the storm, 12 residents ranging in age from 57 to 99 years died* with body temperatures as high as 109.9°F, even though the hospital across the street continued to have full power. The nursing home staff tried in vain several times to get Florida Power and Light to restore full power. They also called a “personal” cell phone number provided by the governor for storm victims in need of help, but their voicemail messages went unanswered. Apparently, no one called 911 or tried to have the patients moved across the street before they were in extremis or began to die.

Large numbers of casualties are not an inevitable sequela of natural disasters. In August 1973 (the second month of my internship), a late summer heat wave in New York City sent 12 patients with heat stroke and heat exhaustion from nearby non-air-conditioned nursing homes to the Albert Einstein/Jacobi Hospital emergency department in just a few hours. After being packed in ice until their temperatures dropped, all but one of the patients survived, while the 12th patient died of her underlying illnesses (see “Sheldon Jacobson, MD 1938-2009,” July 2009 EM).

On August 14, 2003, a hot (92.5°F), humid day in NYC, a power outage affecting the entire northeast and northwest United States trapped many New Yorkers in elevators, subways, and train cars. Residents were also trapped in high-rise apartments with only limited battery power for respirators and other essential electrical equipment. Within a few hours, first responders had reportedly evacuated everyone from stalled elevators in about 800 buildings, and over 600 subway and commuter train cars. Others were safely evacuated from their high-rise residences and taken to EDs powered by emergency generators. Upon arrival, their life support equipment and devices were plugged into electrical outlets, while they were examined, given medications as necessary, and later returned to their homes when power was restored.

First responders and emergency physicians have become quite adept at managing heat stroke and heat-related conditions, but only in patients who are still alive. In the aftermath of Hurricane Katrina, which devastated New Orleans on August 29, 2005, 215 bodies were found in New Orleans hospitals and nursing homes—including those from 40 post-storm deaths in one hospital alone (See Sheri Fink. Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital. New York, NY: Crown Publishers; 2013). The tragic events following Katrina should have been a wake-up call for all health facilities and regulators in the US to anticipate and adequately prepare for loss of power, water, and severe heat conditions. Instead, a 2006 Florida bill that would have required adequate generators in all nursing homes was defeated, reportedly due to industry lobbying efforts.

The number of casualties and deaths due to natural disasters in this country may be fewer than those caused by such man-made incidents as the June 12, 2016 Pulse Nightclub shooting in Orlando, FL (see “The Orlando Nightclub Shooting: Firsthand Accounts and Lessons Learned,” August 2016 EM) and now the mass shooting in Las Vegas, NV on October 1, 2017, as this issue of Emergency Medicine was going to press. But natural disasters such as hurricanes, tornadoes, earthquakes, etc, are far more predictable and will reoccur with a 100% certainty in areas prone to or previously affected by such events. In these incidents, loss of life is preventable.

To quote the famous aphorism of George Santayana, “Those who cannot remember the past are condemned to repeat it.” More inexcusably, it often seems that those who can remember the past are also condemned to repeat it. 

*As of October 11, 2017, this number rose to 14 deaths.

Between August 30 and September 16, 2017, Hurricane Irma wreaked havoc in the Caribbean and throughout Florida. In the days after the Rehabilitation Center at Hollywood Hills, Florida, lost its transformer and air conditioning due to the storm, 12 residents ranging in age from 57 to 99 years died* with body temperatures as high as 109.9°F, even though the hospital across the street continued to have full power. The nursing home staff tried in vain several times to get Florida Power and Light to restore full power. They also called a “personal” cell phone number provided by the governor for storm victims in need of help, but their voicemail messages went unanswered. Apparently, no one called 911 or tried to have the patients moved across the street before they were in extremis or began to die.

Large numbers of casualties are not an inevitable sequela of natural disasters. In August 1973 (the second month of my internship), a late summer heat wave in New York City sent 12 patients with heat stroke and heat exhaustion from nearby non-air-conditioned nursing homes to the Albert Einstein/Jacobi Hospital emergency department in just a few hours. After being packed in ice until their temperatures dropped, all but one of the patients survived, while the 12th patient died of her underlying illnesses (see “Sheldon Jacobson, MD 1938-2009,” July 2009 EM).

On August 14, 2003, a hot (92.5°F), humid day in NYC, a power outage affecting the entire northeast and northwest United States trapped many New Yorkers in elevators, subways, and train cars. Residents were also trapped in high-rise apartments with only limited battery power for respirators and other essential electrical equipment. Within a few hours, first responders had reportedly evacuated everyone from stalled elevators in about 800 buildings, and over 600 subway and commuter train cars. Others were safely evacuated from their high-rise residences and taken to EDs powered by emergency generators. Upon arrival, their life support equipment and devices were plugged into electrical outlets, while they were examined, given medications as necessary, and later returned to their homes when power was restored.

First responders and emergency physicians have become quite adept at managing heat stroke and heat-related conditions, but only in patients who are still alive. In the aftermath of Hurricane Katrina, which devastated New Orleans on August 29, 2005, 215 bodies were found in New Orleans hospitals and nursing homes—including those from 40 post-storm deaths in one hospital alone (See Sheri Fink. Five Days at Memorial: Life and Death in a Storm-Ravaged Hospital. New York, NY: Crown Publishers; 2013). The tragic events following Katrina should have been a wake-up call for all health facilities and regulators in the US to anticipate and adequately prepare for loss of power, water, and severe heat conditions. Instead, a 2006 Florida bill that would have required adequate generators in all nursing homes was defeated, reportedly due to industry lobbying efforts.

The number of casualties and deaths due to natural disasters in this country may be fewer than those caused by such man-made incidents as the June 12, 2016 Pulse Nightclub shooting in Orlando, FL (see “The Orlando Nightclub Shooting: Firsthand Accounts and Lessons Learned,” August 2016 EM) and now the mass shooting in Las Vegas, NV on October 1, 2017, as this issue of Emergency Medicine was going to press. But natural disasters such as hurricanes, tornadoes, earthquakes, etc, are far more predictable and will reoccur with a 100% certainty in areas prone to or previously affected by such events. In these incidents, loss of life is preventable.

To quote the famous aphorism of George Santayana, “Those who cannot remember the past are condemned to repeat it.” More inexcusably, it often seems that those who can remember the past are also condemned to repeat it. 

*As of October 11, 2017, this number rose to 14 deaths.

ED Visits by Older Patients Increase in the Weeks After a Disaster

BY KELLIE DESANTIS

Visits to an ED by adults ages 65 years and older increase significantly in the weeks following a disaster, according to a study published in Disaster Medicine and Public Health Preparedness.¹

Older adults are vulnerable to the effects of disasters because of their diminished ability to adequately prepare for and respond to the effects of a disaster. Older adults suffering from visual, auditory, proprioceptive, and cognitive impairments are especially vulnerable and have the most difficulty complying with evacuation and preparatory warnings. Individuals with multiple chronic diseases, living in long-term care facilities or suffering from cognitive impairments are among the most vulnerable.

To better understand the impact of natural disasters on this vulnerable population, researchers examined the effects of the 2012 disaster, Hurricane Sandy, on older adults living in New York City (NYC) during the disaster. Researchers turned to the New York State Department of Health (NYSDOH) for data. The NYSDOH compiles a comprehensive database of claims from all ED visits in the Statewide Planning and Research Cooperative System (SPARCS), which is the most complete source for ED utilization in New York state, and includes primary and secondary diagnosis codes and patient addresses.

Researchers evaluated ED utilization by adults 65 years and older in the weeks immediately before and after the Hurricane Sandy landfall. They excluded patients who lived in a nursing home, were incarcerated, or visited an ED associated with a specialty hospital (surgical subspecialty, oncological, or Veterans Administration). By using geographic distribution information available from SPARCS and the NYC Office of Emergency Management evacuation zones, researchers were able to compare the ED utilization for older adults living in the evacuation zones before the landfall of Hurricane Sandy and in the weeks shortly after the storm.

The analysis revealed a significant increase in ED utilization for older adults living in the evacuation zones in the 3 weeks after the storm compared to ED use before the storm. The number of weekly ED visits by older adults from all evacuation zones was 9,852 in the weeks before Hurricane Sandy and increased in the first week after the storm to 10,073. Among the most severely impacted were older adults in evacuation zone one, where ED utilization increased from 552 visits to 1,111 visits. The number of ED visits remained elevated for 3 weeks after the storm but returned to normal by the fourth week.

Researchers suggested several reasons for this increase in ED visits, including seeking refuge in the ED as a result of homelessness due to the disaster, the interruption of ongoing care for chronic illness, environmental exposure, and the lack of preparation for the lasting effect of the disaster.

To improve the response to such a disaster in the future, a NYC Hurricane Sandy Assessment report² recommended developing a door-to-door service task force for older adults to improve preparedness for this vulnerable population. The task force would be responsible for implementing an action plan to ensure that healthcare services, communication, and provisions for this population continue without interruption in the weeks following a disaster. Legal and regulatory changes would allow for Medicare recipients to be eligible for "early medication refill" and pre-storm "early dialysis" programs to improve the continuity of care of the chronically ill.

1. Malik S, Lee DC, Doran KM, et al. Vulnerability of older adults in disasters: emergency department utilization by geriatric patients after hurricane sandy. Disaster Med Public Health Prep. 2017:1-10. doi:10.1017/dmp.2017.44

2. The City of New York, Office of the Mayor. Hurricane Sandy After Action Report. Published May 2013. http://www.nyc.gov/html/recovery/downlaods/pdf/sandy_aar_5.2.13.pdf. Accessed September 1, 2017.

Digital Rectal Examination of ED Patients with Acute GI Bleeding Cuts Rates of Admissions, Pharmacotherapy, and Endoscopy

BY JEFF BAUER

Patients presenting to the ED with acute gastrointestinal (GI) bleeding who receive a digital rectal examination have significantly lower rates of admissions, pharmacotherapy, and endoscopies, according to a retrospective study published in The American Journal of Medicine. Digital rectal examinations are an established part of the physical examination of a patient with GI bleeding, but physicians often are reluctant to conduct such examinations. Previous studies have found that 10% to 35% of patients with acute GI bleeding do not receive digital rectal examinations.

In the current study, researchers analyzed data from the electronic health records (EHRs) of patients ages 18 years and older who presented to the ED of a single institution with acute GI bleeding, as identified by International Classification of Diseases, Ninth Edition codes. They collected patients’ medical histories, demographic information, and clinical and laboratory data. ED clinician notes were used to determine which patients received a digital rectal examination. The outcomes researchers assessed were hospital admission, intensive care unit (ICU) admission, initiation of medical therapy (a proton pump inhibitor or octreotide), inpatient endoscopy (upper endoscopy or colonoscopy), and packed red blood cell (RBC) transfusion.

Overall, 1237 patients presented with acute GI bleeding. Most patients were Caucasian (49.2%) or Hispanic (38.4%), 44.9% were female, and the median age was 53 years.

Slightly more than one-half of patients (55.6%) received a digital rectal examination. In total, 736 patients were admitted—including 222 admissions to the ICU; 751 were started on a proton pump inhibitor or octreotide, 274 underwent endoscopy, and 321 received an RBC transfusion.

Patients were more likely to receive a digital rectal examination if they were older, Hispanic, or receiving an anticoagulant. Patients were less likely to undergo such examinations if they presented with altered mental status or hematemesis. Compared to patients who did not receive a digital rectal examination, those who did were significantly less likely to be admitted to the hospital (P = .004), to be starting on medical therapy (P = .04), or to undergo endoscopy (P = .02). There were no significant differences between these two groups in terms of ICU admissions, gastroenterology consultations, or transfusions.

Researchers suggested that the 44% rate of patients with acute GI bleeding who did not receive digital rectal examinations was higher than had been reported in previous studies. The difference had been the result of relying solely on ED clinician notes for this data, without including notes from admitting or consulting clinicians. The authors also were unable to determine the reasons these examinations were not conducted.

Shrestha MP, Borgstrom M, Trowers E. Digital rectal examination reduces hospital admissions, endoscopies, and medical therapy in patients with acute gastrointestinal bleeding. Am J Med. 2017;130(7):819-825. doi: 10.1016/j.amjmed.2017.01.036.

ED Visits by Older Patients Increase in the Weeks After a Disaster

BY KELLIE DESANTIS

Visits to an ED by adults ages 65 years and older increase significantly in the weeks following a disaster, according to a study published in Disaster Medicine and Public Health Preparedness.¹

Older adults are vulnerable to the effects of disasters because of their diminished ability to adequately prepare for and respond to the effects of a disaster. Older adults suffering from visual, auditory, proprioceptive, and cognitive impairments are especially vulnerable and have the most difficulty complying with evacuation and preparatory warnings. Individuals with multiple chronic diseases, living in long-term care facilities or suffering from cognitive impairments are among the most vulnerable.

To better understand the impact of natural disasters on this vulnerable population, researchers examined the effects of the 2012 disaster, Hurricane Sandy, on older adults living in New York City (NYC) during the disaster. Researchers turned to the New York State Department of Health (NYSDOH) for data. The NYSDOH compiles a comprehensive database of claims from all ED visits in the Statewide Planning and Research Cooperative System (SPARCS), which is the most complete source for ED utilization in New York state, and includes primary and secondary diagnosis codes and patient addresses.

Researchers evaluated ED utilization by adults 65 years and older in the weeks immediately before and after the Hurricane Sandy landfall. They excluded patients who lived in a nursing home, were incarcerated, or visited an ED associated with a specialty hospital (surgical subspecialty, oncological, or Veterans Administration). By using geographic distribution information available from SPARCS and the NYC Office of Emergency Management evacuation zones, researchers were able to compare the ED utilization for older adults living in the evacuation zones before the landfall of Hurricane Sandy and in the weeks shortly after the storm.

The analysis revealed a significant increase in ED utilization for older adults living in the evacuation zones in the 3 weeks after the storm compared to ED use before the storm. The number of weekly ED visits by older adults from all evacuation zones was 9,852 in the weeks before Hurricane Sandy and increased in the first week after the storm to 10,073. Among the most severely impacted were older adults in evacuation zone one, where ED utilization increased from 552 visits to 1,111 visits. The number of ED visits remained elevated for 3 weeks after the storm but returned to normal by the fourth week.

Researchers suggested several reasons for this increase in ED visits, including seeking refuge in the ED as a result of homelessness due to the disaster, the interruption of ongoing care for chronic illness, environmental exposure, and the lack of preparation for the lasting effect of the disaster.

To improve the response to such a disaster in the future, a NYC Hurricane Sandy Assessment report² recommended developing a door-to-door service task force for older adults to improve preparedness for this vulnerable population. The task force would be responsible for implementing an action plan to ensure that healthcare services, communication, and provisions for this population continue without interruption in the weeks following a disaster. Legal and regulatory changes would allow for Medicare recipients to be eligible for "early medication refill" and pre-storm "early dialysis" programs to improve the continuity of care of the chronically ill.

1. Malik S, Lee DC, Doran KM, et al. Vulnerability of older adults in disasters: emergency department utilization by geriatric patients after hurricane sandy. Disaster Med Public Health Prep. 2017:1-10. doi:10.1017/dmp.2017.44

2. The City of New York, Office of the Mayor. Hurricane Sandy After Action Report. Published May 2013. http://www.nyc.gov/html/recovery/downlaods/pdf/sandy_aar_5.2.13.pdf. Accessed September 1, 2017.

Digital Rectal Examination of ED Patients with Acute GI Bleeding Cuts Rates of Admissions, Pharmacotherapy, and Endoscopy

BY JEFF BAUER

Patients presenting to the ED with acute gastrointestinal (GI) bleeding who receive a digital rectal examination have significantly lower rates of admissions, pharmacotherapy, and endoscopies, according to a retrospective study published in The American Journal of Medicine. Digital rectal examinations are an established part of the physical examination of a patient with GI bleeding, but physicians often are reluctant to conduct such examinations. Previous studies have found that 10% to 35% of patients with acute GI bleeding do not receive digital rectal examinations.

In the current study, researchers analyzed data from the electronic health records (EHRs) of patients ages 18 years and older who presented to the ED of a single institution with acute GI bleeding, as identified by International Classification of Diseases, Ninth Edition codes. They collected patients’ medical histories, demographic information, and clinical and laboratory data. ED clinician notes were used to determine which patients received a digital rectal examination. The outcomes researchers assessed were hospital admission, intensive care unit (ICU) admission, initiation of medical therapy (a proton pump inhibitor or octreotide), inpatient endoscopy (upper endoscopy or colonoscopy), and packed red blood cell (RBC) transfusion.

Overall, 1237 patients presented with acute GI bleeding. Most patients were Caucasian (49.2%) or Hispanic (38.4%), 44.9% were female, and the median age was 53 years.

Slightly more than one-half of patients (55.6%) received a digital rectal examination. In total, 736 patients were admitted—including 222 admissions to the ICU; 751 were started on a proton pump inhibitor or octreotide, 274 underwent endoscopy, and 321 received an RBC transfusion.

Patients were more likely to receive a digital rectal examination if they were older, Hispanic, or receiving an anticoagulant. Patients were less likely to undergo such examinations if they presented with altered mental status or hematemesis. Compared to patients who did not receive a digital rectal examination, those who did were significantly less likely to be admitted to the hospital (P = .004), to be starting on medical therapy (P = .04), or to undergo endoscopy (P = .02). There were no significant differences between these two groups in terms of ICU admissions, gastroenterology consultations, or transfusions.

Researchers suggested that the 44% rate of patients with acute GI bleeding who did not receive digital rectal examinations was higher than had been reported in previous studies. The difference had been the result of relying solely on ED clinician notes for this data, without including notes from admitting or consulting clinicians. The authors also were unable to determine the reasons these examinations were not conducted.

Shrestha MP, Borgstrom M, Trowers E. Digital rectal examination reduces hospital admissions, endoscopies, and medical therapy in patients with acute gastrointestinal bleeding. Am J Med. 2017;130(7):819-825. doi: 10.1016/j.amjmed.2017.01.036.

ED Visits by Older Patients Increase in the Weeks After a Disaster

BY KELLIE DESANTIS

Visits to an ED by adults ages 65 years and older increase significantly in the weeks following a disaster, according to a study published in Disaster Medicine and Public Health Preparedness.¹

Older adults are vulnerable to the effects of disasters because of their diminished ability to adequately prepare for and respond to the effects of a disaster. Older adults suffering from visual, auditory, proprioceptive, and cognitive impairments are especially vulnerable and have the most difficulty complying with evacuation and preparatory warnings. Individuals with multiple chronic diseases, living in long-term care facilities or suffering from cognitive impairments are among the most vulnerable.

To better understand the impact of natural disasters on this vulnerable population, researchers examined the effects of the 2012 disaster, Hurricane Sandy, on older adults living in New York City (NYC) during the disaster. Researchers turned to the New York State Department of Health (NYSDOH) for data. The NYSDOH compiles a comprehensive database of claims from all ED visits in the Statewide Planning and Research Cooperative System (SPARCS), which is the most complete source for ED utilization in New York state, and includes primary and secondary diagnosis codes and patient addresses.

Researchers evaluated ED utilization by adults 65 years and older in the weeks immediately before and after the Hurricane Sandy landfall. They excluded patients who lived in a nursing home, were incarcerated, or visited an ED associated with a specialty hospital (surgical subspecialty, oncological, or Veterans Administration). By using geographic distribution information available from SPARCS and the NYC Office of Emergency Management evacuation zones, researchers were able to compare the ED utilization for older adults living in the evacuation zones before the landfall of Hurricane Sandy and in the weeks shortly after the storm.

The analysis revealed a significant increase in ED utilization for older adults living in the evacuation zones in the 3 weeks after the storm compared to ED use before the storm. The number of weekly ED visits by older adults from all evacuation zones was 9,852 in the weeks before Hurricane Sandy and increased in the first week after the storm to 10,073. Among the most severely impacted were older adults in evacuation zone one, where ED utilization increased from 552 visits to 1,111 visits. The number of ED visits remained elevated for 3 weeks after the storm but returned to normal by the fourth week.

Researchers suggested several reasons for this increase in ED visits, including seeking refuge in the ED as a result of homelessness due to the disaster, the interruption of ongoing care for chronic illness, environmental exposure, and the lack of preparation for the lasting effect of the disaster.

To improve the response to such a disaster in the future, a NYC Hurricane Sandy Assessment report² recommended developing a door-to-door service task force for older adults to improve preparedness for this vulnerable population. The task force would be responsible for implementing an action plan to ensure that healthcare services, communication, and provisions for this population continue without interruption in the weeks following a disaster. Legal and regulatory changes would allow for Medicare recipients to be eligible for "early medication refill" and pre-storm "early dialysis" programs to improve the continuity of care of the chronically ill.

1. Malik S, Lee DC, Doran KM, et al. Vulnerability of older adults in disasters: emergency department utilization by geriatric patients after hurricane sandy. Disaster Med Public Health Prep. 2017:1-10. doi:10.1017/dmp.2017.44

2. The City of New York, Office of the Mayor. Hurricane Sandy After Action Report. Published May 2013. http://www.nyc.gov/html/recovery/downlaods/pdf/sandy_aar_5.2.13.pdf. Accessed September 1, 2017.

Digital Rectal Examination of ED Patients with Acute GI Bleeding Cuts Rates of Admissions, Pharmacotherapy, and Endoscopy

BY JEFF BAUER

Patients presenting to the ED with acute gastrointestinal (GI) bleeding who receive a digital rectal examination have significantly lower rates of admissions, pharmacotherapy, and endoscopies, according to a retrospective study published in The American Journal of Medicine. Digital rectal examinations are an established part of the physical examination of a patient with GI bleeding, but physicians often are reluctant to conduct such examinations. Previous studies have found that 10% to 35% of patients with acute GI bleeding do not receive digital rectal examinations.

In the current study, researchers analyzed data from the electronic health records (EHRs) of patients ages 18 years and older who presented to the ED of a single institution with acute GI bleeding, as identified by International Classification of Diseases, Ninth Edition codes. They collected patients’ medical histories, demographic information, and clinical and laboratory data. ED clinician notes were used to determine which patients received a digital rectal examination. The outcomes researchers assessed were hospital admission, intensive care unit (ICU) admission, initiation of medical therapy (a proton pump inhibitor or octreotide), inpatient endoscopy (upper endoscopy or colonoscopy), and packed red blood cell (RBC) transfusion.

Overall, 1237 patients presented with acute GI bleeding. Most patients were Caucasian (49.2%) or Hispanic (38.4%), 44.9% were female, and the median age was 53 years.

Slightly more than one-half of patients (55.6%) received a digital rectal examination. In total, 736 patients were admitted—including 222 admissions to the ICU; 751 were started on a proton pump inhibitor or octreotide, 274 underwent endoscopy, and 321 received an RBC transfusion.

Patients were more likely to receive a digital rectal examination if they were older, Hispanic, or receiving an anticoagulant. Patients were less likely to undergo such examinations if they presented with altered mental status or hematemesis. Compared to patients who did not receive a digital rectal examination, those who did were significantly less likely to be admitted to the hospital (P = .004), to be starting on medical therapy (P = .04), or to undergo endoscopy (P = .02). There were no significant differences between these two groups in terms of ICU admissions, gastroenterology consultations, or transfusions.

Researchers suggested that the 44% rate of patients with acute GI bleeding who did not receive digital rectal examinations was higher than had been reported in previous studies. The difference had been the result of relying solely on ED clinician notes for this data, without including notes from admitting or consulting clinicians. The authors also were unable to determine the reasons these examinations were not conducted.

Shrestha MP, Borgstrom M, Trowers E. Digital rectal examination reduces hospital admissions, endoscopies, and medical therapy in patients with acute gastrointestinal bleeding. Am J Med. 2017;130(7):819-825. doi: 10.1016/j.amjmed.2017.01.036.