What emergency medicine can teach emergency managers

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When a tsunami hit Japan in 2011 and crippled the Fukushima Daiichi nuclear power plant, the American Ambassador called in a team of radiation, health, communications, and nuclear power plant experts to join him in Tokyo to provide Americans visiting or living in Japan with information they needed. The team used a real-time, medical decision model and now recommends that model to emergency managers as they make key decisions during an incident.

Used daily in emergency medicine, medical decision-making provides timely decisions and relies on on-site subject matter experts. Decisions are made based on the best information available at the time, and these decisions are modified the course as new information emerges.

Consider the process for treating cancer. When recommending a treatment plan, doctors look at the likelihood of the treatment’s effectiveness and risk of toxicity on the patient’s overall medical condition. They consider the properties of the tumor (not all of which will be immediately known), and current scientific data. They may consult with other experts as they identify a course of action to avoid tumor growth and dissemination. Then working closely with patients and their families, doctors develop a treatment plan, initiate it in a timely manner, monitor its effectiveness, and modify its course as appropriate.

This approach contrasts to the deliberative, multistep, and more time-consuming decision-making process that waits for a great degree of certainty when more of the outcome is known before making a decision. This deliberative approach can go on in the background and provide advice and guidance.

Like traditional approaches to disaster response, the medical decision model uses experts and committees for consultation and advice, but the medical decision model differs in that those experts are on-site, not “back at headquarters,” and decision makers are empowered to make time-critical decisions based on information, experience, and data from the on-site experts. Those decisions are made refined as new data becomes available.

Using the medical decision model, emergency response officials can act without undue delay using readily available and high-level scientific, medical, communication, and policy expertise. The decisions they make are appropriately modified as the information changes. Ongoing assessment, consultation, and adaption to the changing conditions and additional information play prominently in this model.

In Japan, the decisions about the health-related consequences of the disaster encompassed more than just the potential risk from the radiation, which dominated the media and public conversation. The team also had to consider risks associated with evacuation and public relocation, the impact on physical and mental health from disruptions to normal life, economic losses, and the ongoing anxiety of living through a widespread physical and economic disaster.

Using the medical decision model requires decision makers to be open and transparent with the public about what is known and unknown and that recommended courses of action may change as they learn more data becomes available. The American ambassador embraced this concept and fostered public trust and credibility as a result.

In emergency response, the medical decision model would use the same lines of command and local control abdicated in the National Response Framework. Given the central role of health and medical issues in all disasters, the model should be considered in effective management of complex, large-scale, and large-consequence incidents.

Learn more about applying the medical decision model to emergency response (paper freely available for a limited time).

 

Early versus delayed cord clamping at birth: in sickness and in health

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Written by : David J R Hutchon FRCOG
Past president of the North of England Obstetrical and Gynaecological Society

Early cord clamping, often within 10 seconds of the birth of the baby, is a common obstetric and midwifery intervention largely based now on habit. Originally thought to be important for preventing post partum haemorrhage, the intervention has persisted since it was shown to be unnecessary by the WHO.

A major reason why early cord clamping has persisted in both term and preterm births is a poor understanding of the details of fetal to neonatal transition together with the impression that the intervention is benign and may even assist transition of the baby from placental to pulmonary respiration. Early cord clamping is the intervention, not delaying the clamp until the umbilical circulation has ceased, and therefore approximating to the natural physiology. The immediate effects of early clamping on the circulation may not be obvious but when poor condition of the baby after early cord clamping occurs it is always attributed to other reasons such as intrapartum hypoxia.

Recent studies in Melbourne by  Bhatt et al[i]  have shown that in lambs there was a marked bradycardia after early cord clamping, which was followed by a marked hypotension with a fall in cardiac output and cerebral circulation. In humans the bradycardia can be seen in the standard normal newborn heart rate charts (Dawson et al[ii]) with the mean heart rate at one minute after birth of 80bpm ( range 20 to 140). All these babies had standard obstetric 3rd stage management of early cord clamping. By 3 minutes the cardiovascular system had recovered and the heart rate was 160bpm. Thus from the normal fetal heart rate of 110 to 160bpm the bradycardia was the result of something occurring at birth.

A study in 1964 by Brady et al[iii] attributed the bradycardia directly to early cord clamping and a very recent study published at the Birmingham conference showed no significant bradycardia after late cord clamping[iv].

Such a severe insult on the neonatal circulation cannot be acceptable, and may have adverse effects on both healthy and sick neonates. Randomised controlled studies show the significant harm of early cord clamping in the vulnerable preterm neonate. In theory early clamping will lead to hypoxia and ischaemia in the cerebral circulation and incomplete vasodilatation in the pulmonary circulation. Most babies recover and appear to tolerate the insult which results failure of randomised controlled trials to find any serious outcomes. Most babies recover which is the reason so little attention has been given to the intervention of early cord clamping.

The perceived need for resuscitation usually in the form of initiation of ventilation on a remote resuscitaire is currently preventing wider abandonment of early cord clamping. The paper shows how resuscitation with the cord intact at the side of the mother can be achieved. Arguments are put forwards to show other drivers for early cord clamping, the need for cord blood gases, the need for cord blood banking and the risk of jaundice are not logical and are put into perspective.

This opinion paper, published in Fetal and Maternal Medicine Review, is freely available for one month via the following link:  http://journals.cambridge.org/fmr/clamping13


Endnotes:
[i]
 Bhatt S, Alison BJ, Wallace EM, Crossley KJ, Gill AW, Kluckow M, et al. Delaying cord clamping until ventilation onset improves cardiovascular function at birth in preterm lambs. J Physiol 2013 591(Pt 8): 2113–26.
[ii] Dawson JA, Kamlin COF, Wong C, te Pas AB, Vento M, Cole TJ, et al. Changes in heart rate in the first minutes after birth. Arch Dis Child Fetal Neonatal Ed 2010 95: F177–81
[iii] Brady J P and James LS American Journal of Obstetrics and Gynaecology, vol 84 number 1 July 1 1962, pages 1 – 12
[iv] Hutchon DJR. Cutting the Cord: an International Conference INFANT; 2013 9(5): 162. This was referenced in the original paper

A new journal from Cambridge – Global Mental Health

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Cambridge University Press announces a major new open access journal, Global Mental Health (GMH), focusing on mental health research and issues from the global perspective.

GMH seeks to cultivate the emerging discipline of Global Mental Health. It will provide a forum for the publication of new perspectives and paradigms developing in this field, with a particular focus on four key aspects: Interventions; Etiology; Policy and Systems; and Teaching and Learning. Original Research Papers, both quantitative and qualitative, which contribute to advancing a global discourse in any of these areas will be particularly welcome.

Editor-in-Chief Gary Belkin, New York University, said, “Mental health is finally becoming established within the global health and emerging social development agendas.  Staying on those agendas will mean succeeding at closing treatment gaps to an order of a billion people with unmet needs through prevention, promotion, the right social and economic policies, and smart treatment delivery design.  All of these strategies will be shaped by the need to act on the deep connections that mental and behavioral health and emotional wellbeing have with social outcomes and other health conditions.  As the new field of Global Mental Health emerges, it needs to offer tools and a knowledge base that live up to the demands and ambition of this scope of action and impact. It needs to accelerate the participation and integration of other disciplines and fields under the umbrella of Global Mental Health, rather than emerge as another niche field. Developing a global point of view on mental health in these ways, and substantially enlarging the reach and diversity of the community of scholars and implementers who contribute to and learn from it, is what this new journal is about.”

 

Katy Christomanou, Publishing Director for STM Journals at Cambridge University Press added: “GMH appears at a time when health, development, and social policy are evolving within a global framework. New perspectives and innovative ways of approaching problems and their solutions are constantly emerging. This journal will provide a forum for sharing knowledge amongst the growing international research community in this evolving field.  The launch of GMH complements the Press’ publishing programme and reflects our commitment to growth across health sciences including psychology and psychiatry.”

Find out more about our new journal here.

 

The variability of prescribing antipsychotic drugs in nursing homes

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The March International Psychogeriatrics Article of the Month is entitled ‘Variability between nursing homes in prevalence of antipsychotic use in patients with dementia’ by Bart C. Kleijer, Rob J. van Marum, Dinnus H. M. Frijters et al.

Patients with dementia are often treated with antipsychotic drugs (APD) to alleviate behavioural symptoms, even though there is little evidence of their efficacy for this indication and it has never been shown that long-term APD therapy in patients with dementia positively influences quality of life.

Despite uncertainties about the benefits and risks of APDs in the elderly, the prevalence of APD use in the elderly population remains high, especially in long term care facilities (LTCF) globally.

The objective of the authors’ study was to examine if differences in facility-level prevalence of APD use in a sample of LTCFs for patients with dementia can be explained by patient and facility-related characteristics.

In total, 20 LTCFs in The Netherlands providing care for 1,090 patients with dementia were investigated. Overall, 31% of patients used an APD. Facilities with a high prevalence of APD use were often large, situated in urban communities, and scored below average on staffing, personal care, and recreational activities.

There was considerable variation between the participating LTCFs in the prevalence of APD use. Variability was related to LTCF characteristics and patient satisfaction. This indicated potential inappropriate prescribing because of differences in institutional prescribing culture.

Alice Bonner, the commentary paper author observed, “The authors make the point that in many countries, rates of APD use in people with dementia living in nursing homes are high nationally, despite a documented lack of efficacy of these drugs in this population. This presents a golden opportunity for the international dementia care community to come together and actively promote and test person-centered, individualized solutions and new models of nursing home care.”

 

The full paper “Variability between nursing homes in prevalence of antipsychotic use in patients with dementia” is available free of charge for one month here.

The commentary on the paper, “Dementia care in nursing homes: a golden opportunity” is also available free of charge for one month here.

 

 

Imagine the brain

Brain statue in New Brunswick, NJ. Photo: Dan Century via CreativeCommons.

Brain statue in New Brunswick, NJ. Photo: Dan Century, used under CreativeCommons.

Imagine the brain, that shiny mound of being, that mouse-gray parliament of cells, that dream factory, that petit tyrant inside a ball of bone, that huddle of neurons calling all the plays, that little everywhere, that fickle pleasuredome, that wrinkled wardrobe of selves stuffed into the skull like too many clothes into a gym bag. – Diane Ackerman (‘An Alchemy of Mind. The Marvel and Mystery of the Brain‘, Simon & Schuster, 2004).

Writing a book where each specimen represents a person’s humanity was a challenge, and being a neuropathologist may not be everyone’s cup of tea. However for me examination of the brain and spinal cord is key to the understanding of disease and each patient has provided a legacy that will benefit future generations.

For example, in the past no one could understand why patients suffering road traffic accidents were in coma, but there was nothing to see on their head scans.

Careful examination of the brain by neuropathologists revealed that the rotational injury suffered in many car accidents actually shears the axons- the main transport system of the nerve cells so stopping their function- (so-called diffuse traumatic axonal injury).

And from this observation and others, a number of clinical measures including cooling the brain to slow metabolism and the secondary effects of traumatic head injury are now routine clinical practice.

Similarly there are cases of infections such as meningitis, which have not been diagnosed during life, which can be seen in the brain- that have implications for living contacts. And variant Creutzfeldt-Jakob disease (so-called mad cow disease) was discovered entirely by examining the brain in the diseased. The variant CJD form is now virtually unheard of in the UK, although sporadic- or by chance cases still occur.

I guess for me, though, although sometimes upsetting, some of the most rewarding cases are infant brains where playing a part in the diagnosis of a developmental or inherited disorder- such as a mitochondrial or metabolic disorder has implications for whole families and can give some kind of comfort to grieving mothers.

Every case is a mystery and a marvel and a privilege I never underestimate.

Atlas of Gross Neuropathology - Kathreena M KurianKathreena M. Kurian is co-author of ‘Atlas of Gross Neuropathology: A Practical Approach‘ (2014).

International Ear Care day 2014

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The International Ear Care day was the outcome of the Beijing Declaration made during the 1st International Conference on Prevention and Rehabilitation of Hearing Loss in 2007. The date ‘3 March’ was selected due to the similarity of the figures 3.3 with the shape of our ears. The day is observed with a designated theme, decided by WHO in collaboration with its partners, collaborating centres and experts. The ‘day’ provides a unique opportunity to work together to draw the attention of media, policy-makers, administrators, health professionals and the general public towards the cause of hearing loss. By observing this day, we can all help create a global movement, which will compel others to give ear and hearing care the attention it deserves and to persons with hearing loss, their due respect.

The 2014 theme is Ear care can avoid hearing loss. At least half of all cases of hearing loss are avoidable through primary prevention, including healthy ear care practices.

Dr Shelly Chadha, Technical Officer, Prevention of Blindness and Deafness, World Health Organization, Geneva, commented, “In order to raise the profile of ear and hearing care on the global health agenda, all of us: ear and hearing care professionals; nongovernmental organizations; collaborating centres; persons with hearing loss and their caregivers, must be a part of this movement. As members of the health profession, we dedicate ourselves every day to caring for our patients and their wellbeing. By devoting one day to the public health aspect of our chosen field, we can reach many more and be a part of a worldwide effort to raise awareness and resources for ear and hearing care.”

In 2012, WHO released estimates which suggest that 360 million persons across the world live with disabling hearing loss. Amongst persons above 65 years of age, one out of three is reported to have hearing loss, yet less than 3% of persons receive the hearing aids they require.

Despite the fact that two thirds of people with hearing loss live in developing countries, services for hearing care remain elusive where they are most needed. The number of ENT surgeons per million ranges from 0 to 4 in low-income countries as compared to 9-178 in high-income countries. In 18 countries of sub-Saharan Africa, there is an average of less than 1 ENT surgeon per 100 000 persons. Moreover, the current global health priorities for developing countries have yet to pay attention to hearing loss. The overall low level of awareness about ear diseases and hearing loss at all levels within the society adds to the growing burden.

This blog post is based on the Editorial that Dr Chadha wrote for the March issue of The Journal of Laryngology & Otology, the full article can be read free of charge here.

Find out more about the WHO International Ear Care Day here.

Turn down the Volume? An examination of the effects of nightclubs on hearing

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There is a growing body of evidence that suggests excessive noise levels in nightclubs have an adverse effect on hearing, and may ultimately be responsible for noise-induced hearing loss.

A study by researchers at the University of Birmingham found that although students didn’t want to alter their attendance, the majority would rather see noise limits reduced to safe limits, contrary to the widely held preconception that high volume levels in nightclubs are demanded by young people.

The hearing of all employees in the music and entertainment sector is now protected by The Control of Noise at Work Regulations (2005), which require employers to prevent or reduce risks to employees’ hearing in the workplace when exposed to noise levels above 85 dB. However, this law does not apply to members of the public attending nightclubs, as it is presumed they are making an informed decision to attend such venues.

This study investigated the prevalence of symptoms related to noise-induced hearing loss that were experienced by students after attending nightclubs. It also aimed to explore students’ awareness of the association between noise-induced hearing loss and nightclub attendance, and examine their attitudes towards this.

A questionnaire was distributed to students entering or leaving the University of Birmingham Medical School over a 5-day period during March 2012, with a total of 357 individuals completing the questionnaire, with almost half the students attending a nightclub at least once per week.

Of those students surveyed in the present study (excluding those who never attended nightclubs and those with pre-existing hearing problems), 88% had experienced transient tinnitus after attending a nightclub. This finding is important because transient tinnitus can also be a precursor to other noise-induced hearing loss symptoms, including permanent tinnitus, hyperacusis or irreversible hearing loss.

The majority of students in the sample population (90%) were aware that current nightclub noise levels are potentially damaging to hearing. However, most students who attended nightclubs (73%) reported that they would not alter their attendance, despite being told that the noise levels could lead to permanent hearing loss. Nonetheless, 70% of nightclub attendees agreed that noise levels should be limited to volumes that are not damaging to hearing.

Mr Oliver Johnson, one of the paper’s authors, commented. “This is encouraging for policy makers, as noise levels could potentially be lowered below the threshold for hearing damage without nightclub attendance being significantly compromised. The implementation of relevant legislation could therefore potentially reduce the long-term risks of irreversible hearing loss in this young age group without damaging the nightclub industry.”

The study also demonstrated that 87% of students with normal hearing had never received information about noise-induced hearing loss or had earplugs recommended in the nightclub setting. The findings and those of other research groups indicate that young people attending nightclubs are at high risk of noise-induced hearing loss, and it is therefore of the utmost importance that they should be provided with adequate information regarding the potential damage that excessive music levels in nightclubs may cause.

Mr Johnson added, “We believe the current assumption implied by legislation, namely that nightclub attendees are consenting to the risks of hearing damage, is spurious, as the majority of young people in nightclubs are likely to be unaware of these risks.”

The full paper “British university students’ attitudes towards noise-induced hearing loss caused by nightclub attendance” is published in The Journal of Laryngology & Otology and can be read free of charge for a limited time here.

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