Life-Saving Procedures Performed While Wearing CBRNe Personal Protective Equipment: A Mannequin Randomized Trial

INTRODUCTION

Chemical-biological-radiological-nuclear-explosive (CBRNe) are complex events. Decontamination is mandatory to avoid harm and contain hazardous materials, but can delay care. Therefore, the stabilization of patients in the warm zone seems reasonable, but research is limited. Moreover, subjects involved in biological events are considered infectious even after decontamination and need to be managed while wearing personal protective equipment (PPE), as seen with Ebola and COVID-19 pandemic. With this simulation mannequin trial, we assessed the impact of CBRNe PPE on cardiopulmonary resuscitation and combat casualty care procedures.

METHODS

We compared procedures performed by emergency medicine and anesthesiology senior residents, randomized in 2 groups (CBRNe PPE vs. no PPE). Chest compression (CC) depth was defined as the primary outcome. Time to completion was calculated for the following: tourniquet application; tension pneumothorax needle decompression; peripheral venous access (PVA) and intraosseous access positioning; and drug preparation and administration. A questionnaire was delivered to evaluate participants' perception.

RESULTS

Thirty-six residents participated. No significant difference between the groups in CC depth (mean difference = 0.26 cm [95% confidence interval = -0.26 to 0.77 cm, P = 0.318]), as well as for CC rate, CC complete release, and time for drugs preparation and administration was detected. The PPE contributed to significantly higher times for tourniquet application, tension pneumothorax decompression, peripheral venous access, and intraosseous access positioning. The residents found simulation relevant to the residencies' core curriculum.

CONCLUSIONS

This study suggests that cardiopulmonary resuscitation can be performed while wearing PPE without impacting quality, whereas other tasks requiring higher dexterity can be significantly impaired by PPE.Trial Registration Number: NCT04367454, April 29, 2020 (retrospectively registered).

Should we fear "flu fear" itself? Effects of H1N1 influenza fear on ED use

BACKGROUND

Surges in patient volumes compromise emergency departments' (EDs') ability to deliver care, as shown by the recent H1N1 influenza (flu) epidemic. Media reports are important in informing the public about health threats, but the effects of media-induced anxiety on ED volumes are unclear.

OBJECTIVE

The aim of this study is to examine the effect of widespread public concern about flu on ED use.

METHODS

We reviewed ED data from an integrated health system operating 18 hospital EDs. We compared ED visits during three 1-week periods: (a) a period of heightened public concern regarding flu before the disease was present ("Fear Week"), (b) a subsequent period of active disease ("Flu Week"), and (c) a week before widespread concern ("Control Week"). Fear Week was identified from an analysis of statewide Google electronic searches for "swine flu" and from media announcements about flu. Flu Week was identified from statewide epidemiological data.

RESULTS

Data were reviewed from 22 608 visits during the study periods. Fear Week (n = 7712) and Flu Week (n = 7687) were compared to Control Week (n = 7209). Fear Week showed a 7.0% increase in visits (95% confidence interval, 6-8). Pediatric visits increased by 19.7%, whereas adult visits increased by 1%. Flu Week showed an increase over Control Week of 6.6% (95% confidence interval, 6-7). Pediatric visits increased by 10.6%, whereas adult visits increased by 4.8%.

CONCLUSION

At a time of heightened public concern regarding flu but little disease prevalence, EDs experienced substantial increases in patient volumes. These increases were significant and comparable to the increases experienced during the subsequent epidemic of actual disease.

The comprehensive medical preparedness in chemical emergencies: 'the chain of chemical survival'

Medical management of victims of chemical incidents includes supportive therapy, decontamination and antidote administration. Chemical weapons of mass destruction are available to many countries and are a possible alternative to conventional weapons for terrorist groups. During the last 5 years, some Italian institutions have made big efforts to establish a national system of antidote stockpiling and distribution. Little or no efforts have been addressed to other aspects of the medical management of patients exposed to chemical agents, such as decontamination, personal protective equipment, and specific supportive therapy. Although antidotes are indispensable instruments for some poisonings, as nerve agent and botulin intoxication, antidote stockpiling cannot be considered the only objective of a comprehensive medical preparedness for chemical emergencies. This paper addresses the medical priority when approaching victims of chemical emergencies. The priority actually is to establish a chain of chemical survival in which antidote administration is one out of several links.

Emergency department staff can effectively resuscitate in level C personal protective equipment

OBJECTIVE

ED staff are expected to perform resuscitation of trauma victims of chemical, biological and radiation incidents while wearing level C personal protective equipment (PPE). The present project assessed the subjective discomfort, physiological impact and performance of staff wearing PPE.

METHODS

A paired intervention study of ED staff in a resuscitation scenario comparing task performance wearing gown and gloves with PPE. Data were collected using a structured self-administered questionnaire and by objective and subjective measurements.

RESULTS

Seven ED doctors and 11 ED nurses were enrolled. Nine had previous PPE training although only one had used PPE clinically. Overall, ED staff felt that PPE did not affect their ability to perform trauma resuscitation. For individual tasks, staff felt that PPE impaired assessment of pulse, i.v. cannulation, i.v. line attachment, use of a mini-jet, bag and mask ventilation, and communication. However, the only objective difference in task performance was time to control haemorrhage (increase from 38 to 47 s, P = 0.02). PPE was well tolerated, with minimal physiological or psychological impact. Staff wore PPE for a median of 37 min (interquartile range: 33-38) and estimated that PPE could be worn for a further 30 min if required.

CONCLUSIONS

ED staff are able to perform resuscitation procedures in PPE without adverse physiological effects or impact on performance. Subjective concerns regarding task performance were not reflected in objective measurements. This might indicate that appropriate training and feedback could reduce the negative impression associated with activities undertaken while wearing PPE.

Viewpoint: Terrorism and Dispelling the Myth of a Panic Prone Public

Governments and commentators perceive the public to be prone to panic in response to terrorist attacks--conventional or involving chemical, biological or radiological weapons. Evidence from five such incidents suggests that the public is not prone to panic, although people can change their behaviours and attitudes to reduce the risk of themselves being exposed to a terrorist incident. Behavioural responses may be divided into acts of omission, such as not making unnecessary journeys, and acts of commission, such as taking prophylactic medication despite the inherent risk of side effects. Evidence suggests that the public are aware of these differences, and tend to adopt responses proportionate to the risk. Drawing upon the literature in the social and natural sciences, our discussion encompasses differing risk perceptions of terrorist threats and consequences of attacks. How do fear and anxiety interact with behavioural responses to amplify or attenuate perceptions that can be modified through risk communication undertaken by authorities?