Medical emergencies at sea: an analysis of ambulance-supported and autonomously performed operations by lifeboat crews

BACKGROUND

Very little data is available about the involvement of lifeboat crews in medical emergencies at sea. The aim of this study is to analyze the medical operations at sea performed by the Royal Netherlands Sea Rescue Institution (KNRM).

METHODS

This is a retrospective descriptive analysis of all medical operations at sea performed by the KNRM between January 2017 and January 2020. The operations were divided in three groups: with ambulance crew aboard the lifeboat, ambulance crew on land waiting for the arrival of the lifeboat, and autonomous operations (without ambulance crew involvement). The main outcome measures were circumstances, encountered medical problems, follow-up and crew departure time.

RESULTS

The KNRM performed 282 medical operations, involving 361 persons. Operations with ambulance crew aboard the lifeboat (n = 39; 42 persons) consisted mainly of persons with serious trauma or injuries; 32 persons (76.2%) were transported to a hospital. Operations with ambulance crew on land (n = 153; 188 persons) mainly consisted of situations where time was essential, such as persons who were still in the water, with risk of drowning (n = 45, 23.9%), on-going resuscitations (n = 9, 4.8%) or suicide attempts (n = 7, 3.7%). 101 persons (53,7%) were transported to a hospital. All persons involved in the autonomous operations (n = 90; 131 persons) had minor injuries. 38 persons (29%) needed additional medical care, mainly for (suspected) fractures or stitches. In 115 (40.8%) of all operations lifeboat crews did not know that there was a medical problem at the time of departure. Crew departure time in operations with ambulance crew aboard the lifeboat (13.7 min, min. 0, max. 25, SD 5.74 min.) was significantly longer than in operations with ambulance crew on land (7.7 min, min. 0, max 21, SD 4.82 min., p < 0.001).

CONCLUSION

This study provides new information about the large variety of medical emergencies at sea and the way that lifeboat and ambulance crews are involved. Crew departure time in operations with ambulance crew aboard the lifeboat was significantly longer than in operations with ambulance crew on land. This study may provide useful indications for improvement of future medical operations at sea, such as triage, because in 40.8% of operations, it was not known at the time of departure that there was a medical problem.

2015 Revised Utstein-Style Recommended Guidelines for Uniform Reporting of Data From Drowning-Related Resuscitation: An ILCOR Advisory Statement

BACKGROUND

Utstein-style guidelines use an established consensus process, endorsed by the international resuscitation community, to facilitate and structure resuscitation research and publication. The first "Guidelines for Uniform Reporting of Data From Drowning" were published over a decade ago. During the intervening years, resuscitation science has advanced considerably, thus making revision of the guidelines timely. In particular, measurement of cardiopulmonary resuscitation elements and neurological outcomes reporting have advanced substantially. The purpose of this report is to provide updated guidelines for reporting data from studies of resuscitation from drowning.

METHODS

An international group with scientific expertise in the fields of drowning research, resuscitation research, emergency medical services, public health, and development of guidelines met in Potsdam, Germany, to determine the data that should be reported in scientific articles on the subject of resuscitation from drowning. At the Utstein-style meeting, participants discussed data elements in detail, defined the data, determined data priority, and decided how data should be reported, including scoring methods and category details.

RESULTS

The template for reporting data from drowning research was revised extensively, with new emphasis on measurement of quality of resuscitation, neurological outcomes, and deletion of data that have proved to be less relevant or difficult to capture.

CONCLUSIONS

The report describes the consensus process, rationale for selecting data elements to be reported, definitions and priority of data, and scoring methods. These guidelines are intended to improve the clarity of scientific communication and the comparability of scientific investigations.

Review of 14 drowning publications based on the Utstein style for drowning

BACKGROUND

The Utstein style for drowning (USFD) was published in 2003 with the aim of improving drowning research. To support a revision of the USFD, the current study aimed to generate an inventory of the use of the USFD parameters and compare the findings of the publications that have used the USFD.

METHODS

A search in Pubmed, Embase, the Cochrane Library, Web of Science and Scopus was performed to identify studies that used the USFD and were published between 01-10-2003 and 22-03-2015. We also searched in Pubmed, Embase, the Cochrane Library, Web of Science, and Scopus for all publications that cited the two publications containing the original ILCOR advisory statement introducing and recommending the USFD. In total we identified 14 publications by groups that explicitly used elements of the USFD for collecting and reporting their data.

RESULTS

Of the 22 core and 19 supplemental USFD parameters, 6-19 core (27-86%) and 1-12 (5-63%) supplemental parameters were used; two parameters (5%) have not been used in any publication. Associations with outcome were reported for nine core (41%) and five supplemental (26%) USFD parameters. The USFD publications also identified non-USFD parameters related to outcome: initial cardiac rhythm, time points and intervals during resuscitation, intubation at the drowning scene, first hospital core temperature, serum glucose and potassium, the use of inotropic/vasoactive agents and the Paediatric Index of Mortality 2-score.

CONCLUSIONS

Fourteen USFD based drowning publications have been identified. These publications provide valuable information about the process and quality of drowning resuscitation and confirm that the USFD is helpful for a structured comparison of the outcome of drowning resuscitation.

Physiology Of Drowning: A Review

Drowning physiology relates to two different events: immersion (upper airway above water) and submersion (upper airway under water). Immersion involves integrated cardiorespiratory responses to skin and deep body temperature, including cold shock, physical incapacitation, and hypovolemia, as precursors of collapse and submersion. The physiology of submersion includes fear of drowning, diving response, autonomic conflict, upper airway reflexes, water aspiration and swallowing, emesis, and electrolyte disorders. Submersion outcome is determined by cardiac, pulmonary, and neurological injury. Knowledge of drowning physiology is scarce. Better understanding may identify methods to improve survival, particularly related to hot-water immersion, cold shock, cold-induced physical incapacitation, and fear of drowning.

Predicting outcome of drowning at the scene: A systematic review and meta-analyses

OBJECTIVE

To identify factors available to rescuers at the scene of a drowning that predict favourable outcomes.

DESIGN

Systematic review and meta-analysis.

DATA SOURCES

PubMed, Embase and Cochrane Library were searched (1979-2015) without restrictions on age, language or location and references lists of included articles.

STUDY SELECTION

Cohort and case-control studies reporting submersion duration, age, water temperature, salinity, emergency services response time and survival and/or neurological outcomes were eligible. Two reviewers independently screened articles for inclusion, extracted data, and assessed quality using GRADE. Variables for all factors, including time and temperature intervals, were categorized using those used in the articles. Random effects meta-analyses, study heterogeneity and publication bias were evaluated.

RESULTS

Twenty-four cohort studies met the inclusion criteria. The strongest predictor was submersion duration. Meta-analysis showed that favourable outcome was associated with shorter compared to longer submersion durations in all time cutoffs evaluated: ≤5-6min: risk ratio [RR]=2.90; (95% confidence interval [CI]: 1.73, 4.86); ≤10-11min: RR=5.11 (95% CI: 2.03, 12.82); ≤15-25min: RR=26.92 (95% CI: 5.06, 143.3). Favourable outcomes were seen with shorter EMS response times (RR=2.84 (95% CI: 1.08, 7.47)) and salt water versus fresh water 1.16 (95% CI: 1.08, 1.24). No difference in outcome was seen with victim's age, water temperatures, or witnessed versus unwitnessed drownings.

CONCLUSIONS

Increasing submersion duration was associated with worse outcomes. Submersion durations <5min were associated with favourable outcomes, while those >25min were invariably fatal. This information may be useful to rescuers and EMS systems deciding when to perform a rescue versus a body recovery.

Brain resuscitation in the drowning victim

Drowning is a leading cause of accidental death. Survivors may sustain severe neurologic morbidity. There is negligible research specific to brain injury in drowning making current clinical management non-specific to this disorder. This review represents an evidence-based consensus effort to provide recommendations for management and investigation of the drowning victim. Epidemiology, brain-oriented prehospital and intensive care, therapeutic hypothermia, neuroimaging/monitoring, biomarkers, and neuroresuscitative pharmacology are addressed. When cardiac arrest is present, chest compressions with rescue breathing are recommended due to the asphyxial insult. In the comatose patient with restoration of spontaneous circulation, hypoxemia and hyperoxemia should be avoided, hyperthermia treated, and induced hypothermia (32-34 °C) considered. Arterial hypotension/hypertension should be recognized and treated. Prevent hypoglycemia and treat hyperglycemia. Treat clinical seizures and consider treating non-convulsive status epilepticus. Serial neurologic examinations should be provided. Brain imaging and serial biomarker measurement may aid prognostication. Continuous electroencephalography and N20 somatosensory evoked potential monitoring may be considered. Serial biomarker measurement (e.g., neuron specific enolase) may aid prognostication. There is insufficient evidence to recommend use of any specific brain-oriented neuroresuscitative pharmacologic therapy other than that required to restore and maintain normal physiology. Following initial stabilization, victims should be transferred to centers with expertise in age-specific post-resuscitation neurocritical care. Care should be documented, reviewed, and quality improvement assessment performed. Preclinical research should focus on models of asphyxial cardiac arrest. Clinical research should focus on improved cardiopulmonary resuscitation, re-oxygenation/reperfusion strategies, therapeutic hypothermia, neuroprotection, neurorehabilitation, and consideration of drowning in advances made in treatment of other central nervous system disorders.

The Volendam Fire: Lessons Learned from Disaster Research

Introduction:

After the Volendam fire, a multidisciplinary, integral evaluation, called the Medical Evaluation of the Disaster in Volendam (MERV), was established. This article is a discussion of disaster research methodology. It describes the organizational framework of this project and the methodological problems.

Methods:

A scientific steering group consisting of members from three hospitals prepared and guided the project. A research team wrote the final study protocol and performed the study. The project was funded by the Ministry of Health. The study protocol had a modular design in which each of the modules focused on one specific area or location. The main questions for each location were: (1) which treatment protocols were used; (2)what was the condition of the patient; and (3) was medical care provided according to existing protocols. After the fire, 241 victims were treated in hospitals; they all were included in the study. Most of the victims had burn injuries, and approximately one-third suffered from inhalation injury. All hospitals and ambulance services involved were visited in order to collect data, and interviewers obtained additional information. The government helped obtain permission for data-collection in three of the hospitals. Over 1,200 items of information about each patient and >200,000 total items were collected. During data processing, the data were re-organized, categorized, and presented in a uniform and consistent style. A cross-sectional site analysis and a longitudinal patient analysis were conducted. This was facilitated by the use of several sub-data-bases. The modular approach made it possible to obtain a complete overview of the medical care provided. The project team was guided by a multidisciplinary steering group and the research was performed by a research team. This enabled the research team to focus on the scientific aspects.

Conclusion:

The evaluation of the Volendam fire indicates that a project approach with a modular design is effective for the analysis of complex incidents. The use of several sub-databases makes it easy to combine findings and conduct cross-sectional and longitudinal analyses. The government played an important role in the funding and support of the project. To limit and structure data collection and analysis, a pilot study based on several predefined main questions should be conducted. The questions then can be specified further based on the availability of data.

Feasibility of pulse oximetry in the initial prehospital management of victims of drowning: a preliminary study

AIM

Immediate delivery of oxygen is the most important treatment for victims of drowning at the rescue site. Monitoring oxygen saturation with pulse oximetry is potentially useful, but its use may be limited by poor peripheral perfusion due to hypothermia. This preliminary study explores the feasibility of pulse oximetry in simulated minor drowning scenarios.

MATERIALS AND METHODS

Six different pulse oximeters were tested on ten healthy volunteers after brief submersion, after ten minutes of swimming in a swimming pool (warm water, temperature 21°C), and in the sea (cold water, temperature 16°C). A measured oxygen saturation reading ≤ 94% was assumed to be incorrect.

RESULTS

There was considerable variability between each pulse oximeter. In warm water, 5.8% of measurements were outside the predicted range (8.3% after submersion, 3.3% after swimming), compared to 34% in cold water (20% after submersion, 48% after swimming). The spurious measurements came from two pulse oximeters in warm water, but from all six in cold water. The best and worst performing pulse oximeters showed 5% and 33% measurements respectively outside the predicted range.

CONCLUSION

The performance of pulse oximeters varies considerably in healthy volunteers submersed or immersed in warm or cold water. Further studies are needed to understand these differences.

Public access defibrillation: time to access the public

STUDY OBJECTIVE

Public accessible automated external defibrillators (AEDs) are increasingly made available in highly frequented places, allowing coincidental bystanders to defibrillate with minimal delay if necessary. Although the public, as the largest and most readily available group of potential rescuers, is assigned a key role in this concept of "public" access defibrillation, it is unknown whether bystanders are actually sufficiently prepared. We therefore investigate knowledge and attitudes toward AEDs among the public.

METHODS

Standardized interviews were conducted at the Central Railway Station of Amsterdam, the Netherlands, a highly frequented and AED-equipped public place with a high number of travelers and visitors from all over the world.

RESULTS

Surveys from 1,018 participants from a total of 38 nations were analyzed, revealing a considerable lack of knowledge among the public. Less than half of participants (47%) would be willing to use an AED, and more than half (53%) were unable to recognize an AED. Overall, only a minority of individuals have sufficient knowledge and would be willing to use an AED. Differences between subgroups were identified, which may aid to tailor public information campaigns to specific target audiences.

CONCLUSION

Only a minority of individuals demonstrate sufficient knowledge and willingness to operate an AED, suggesting that the public is not yet sufficiently prepared for the role it is destined for. Wide-scale public information campaigns are an important next step to exploit the lifesaving potential of public access defibrillation.

[Acute pain at the emergency department: better treatment required]

Acute pain is common among patients at the emergency department and is still not being treated adequately. Repeated measurement and documentation of pain is essential for adequate pain treatment. The patient determines how much analgesia is needed. Pharmacological pain relief should not be delayed during the diagnostic process, not even in cases of abdominal pain. Opioids play a central role in the treatment of acute pain. Opiophobia is not justified. Adequate pain relief started at the emergency department must be continued throughout both hospital admission and discharge to home.

Comparison of instructor-led automated external defibrillation training and three alternative DVD-based training methods

BACKGROUND

Self-directed BLS-training, using a personal training manikin with video has been shown to be as effective as instructor-led training. This has not previously been investigated for AED-training.

MATERIALS AND METHODS

This prospective, randomized study with a non-inferiority design compared traditional instructor-led training with three DVD-based AED-training methods (2.5min DVD without practice; 4.5min DVD with manikin practice; 9min DVD with manikin practice and scenario training). After DVD BLS-training, 396 participants were assigned to one of the four AED-training methods by randomization stratified for age. Participants were tested immediately after the training (post-test) and 2 months later (retention-test) using modified Cardiff criteria. The primary endpoint was the percentage of providers scoring 70% or higher on testing. The secondary endpoints were the mean scores and differences per item per age group.

RESULTS

Comparison non-inferiority could not be accepted for the post-test or retention-test. Relative risk (RR) and 95% confidence interval (CI) of passing for DVD without practice, with manikin practice and with manikin practice and scenario training compared to instructor-led training were 0.36 (0.25-0.53), 0.35 (0.24-0.51), 0.55 (0.38-0.79), respectively for the post-test, and 0.82 (0.68-0.97), 0.82 (0.68-0.97), and 0.84 (0.70-1.00), respectively for the retention-test. The performance of participants in all DVD-based training groups was significantly higher on the retention-test than on the post-test. Those receiving scenario training scored higher on the post-test compared to the other DVD-training groups (p<0.001).

CONCLUSIONS

DVD-based AED-training without scenario is not recommended. Scenario training is a useful addition, but instructor-facilitated training remains the best method.

The role of bystanders during rescue and resuscitation of drowning victims

BACKGROUND

Bystanders make a critical difference in the survival of drowning victims. Little information on their role before arrival of the Emergency Medical Services (EMS) is available in the scientific literature. In a descriptive study, this role is investigated.

METHODS AND RESULTS

We studied 289 rescue reports (1999-2004) available from the Dutch Maatschappij tot Redding van Drenkelingen (Society to Rescue People from Drowning), an organisation that, since 1767, acknowledges awards to bystanders who have contributed to the survival of a drowning victim. There were 138 variables retrieved from these reports. The Utstein Style for Drowning (USFD) was used as a guideline. Of the 26 USFD parameters on victim and scene information, 21 were available for analysis. Eight non-USFD parameters, defined by the authors of this research, were available in >60% of the cases. There were 343 victims, rescued by 503 rescuers. 109 victims were resuscitated by bystanders. Of the 18 victims who first received resuscitation from bystanders and then consequently from pre-hospital professionals, 14 survived. Rescues often occurred in dangerous circumstances: multiple victims (n=90/343), cold or ice-cold water (n=295/341), deep water (n=316/334), swimming to the victims (n=262/376), young age of rescuers (the youngest rescuer was 5 years of age).

CONCLUSIONS

Bystander rescue and resuscitation of drowning victims seems to contribute to a positive outcome. Bystanders are prepared to take responsibility to rescue a drowning victim in spite of significant dangers. The USFD is helpful in understanding the role of bystanders in drowning situations, but may need modification to become more instrumental.

[Reduction of the drowning risk for young children, but increased risk for children of recently immigrated non-Westerners]

OBJECTIVE

To describe differences in the risk of drowning of young children (under 10 years) in the Netherlands according to ethnicity and relevant trends since 996.

DESIGN

Retrospective.

METHOD

We analysed the causes of death data for all 266 children aged 0 to 10 years who died of drowning between 1996 and 2005. Information for the cause of death was obtained from the cause of death data of Statistics Netherlands. Data about the size and composition of the population at risk (age, sex and ethnicity) were obtained from the municipal population registers.

RESULTS

Young children's risk of drowning has decreased by about one-third since 1996. This decrease took place among native Dutch children and children of the major ethnic groups, notably Turkish, Moroccan and Surinamese. However for children of recently immigrated parents of non-Western ethnicity, mainly asylum seekers, the risk of drowning was 4 to 8 times higher than that of native children aged 3 to 10 years.

CONCLUSION

Timely health education directed at newly arrived families with children could be an important measure to help them cope with the hazards of living in a water-rich environment such as the Netherlands. The education should point out the necessity of increased supervision of the youngest children and improved swimming skills for the slightly older ones.

Self-training in the use of automated external defibrillators: The same results for less money

PURPOSE

To compare the educational benefits and cost-effectiveness of initial AED training for nurses, already trained in basic life support, by a 3-h, instructor-based course, with self-training by means of an instructional poster, a resuscitation manikin, and a training AED.

METHODS

Thirty general ward nurses from a single regional hospital were randomly allocated to one of two groups for training in the use of an AED. Fifteen nurses were trained by a certified instructor and 15 nurses participated in self-training using a poster, manikin, and training AED. Each nurse was assessed on 17 aspects of performance between 13 and 16 days after training.

RESULTS

The two groups were comparable for gender, seniority, and experience in resuscitation. No significant differences in performance were found between the groups for 14 of the skills tested. For three skills, there were statistical differences, but these were not considered to be of clinical relevance. If poster self-training were to be used instead of instructor-based courses, it was calculated that there would be a saving in costs of up to 47 euros for each nurse trained.

Moderate sea states do not influence the application of an AED in rigid inflatable boats

PURPOSE

This study was to determine if the AED can be operated correctly on board rigid inflatable rescue boats (RIBs), and if downloading of data later for quality control is possible.

METHODS

Six AEDs were tested for their reliability, robustness and stability. Data were collected on three different types of RIBs, in a harbour and at sea. Each AED was connected to a volunteer and a manikin simulating VF. Data from the AED were continuously collected.

RESULTS

At one of the RIBs each AED became wet; no AED had a technical problem. When connected to the volunteer, the ECGs delivered by the AEDs showed a regular sinus rhythm. When connected to a manikin in VF, each AED was able to recognise VF and to provide a shock. There were differences in the time between first analysis and the shock. The voice prompt of the Zoll AED Plus was 'understandable', while the other AEDs were 'difficult to understand'. We had a problem with the infrared connection, which means that evaluation and quality control afterwards may be difficult.

CONCLUSION

The use of AEDs on RIBs during patient transport over calm water is possible and effective. The AED should have a screen and better features to download data. However, AEDs are only worthwhile when they fit well in the Chain of Survival (fast arrival, immediately availability of an AED, trained provider and advanced life support).

A consensus process on management of major burns accidents

PURPOSE

The optimum response to the different stages of a major burns incident is still not established. The fire in a café in Volendam on New Year's Eve 2000 was the worst incident in recent Dutch history and resulted in mass burn casualties. The fire has been the subject of several investigations concerned with organisational and medical aspects. Based on the findings in these investigations, a multidisciplinary research group started a consensus study. The aim of this study was to further identify areas of improvement in the care after mass burns incidents.

DESIGN/METHODOLOGY/APPROACH

The consensus process comprised three postal rounds (Delphi Method) and a consensus conference (modified nominal group technique). The multidisciplinary panel consisted of 26 Dutch-speaking experts, working in influential positions within the sphere of disaster management and healthcare.

FINDINGS

In response to the postal questionnaires, consensus was reached for 66 per cent of the statements. Six topics were subsequently discussed during the consensus conference; three topics were discussed within the plenary session and three during subgroup meetings. During the conference, consensus was reached for seven statements (one subject generated two statements). In total, the panel agreed on 21 statements. These covered the following topics: registration and evaluation of disaster care, capacity planning for disasters, pre hospital care of victims of burns disasters, treatment and transportation priorities, distribution of casualties (including interhospital transports), diagnosis and treatment and education and training.

ORIGINALITY/VALUE

In disaster medicine, the paper shows how a consensus process is a suitable tool to identify areas of improvement of care after mass burns incidents.

The café fire on New Year's Eve in Volendam, the Netherlands: description of events

AIM OF STUDY

The café fire at Volendam occurred shortly after midnight on the first of January 2001 and resulted in one of the worst mass burn incidents in recent Dutch history. The aim of this study was to provide insight into medical and organisational requirements of a major burns incident.

METHODS

Shortly after the fire, two university hospitals and a burn center in the region of the accident developed a plan for evaluation of medical care given during and after this major burn incident. A multidisciplinary research group investigated the management of victims at the scene, in the emergency departments (ED) and during admission in the hospitals. All 245 casualties were included in this study.

RESULTS

A brief severe fire occurred in a crowded cafe with around 350 young visitors on a small embankment of a relatively isolated town, resulting in a unusually high number of severely injured burn victims. Four died immediately. The ensuing rescue effort was hampered by poor access and chaotic circumstances. At the scene of the incident, mobile medical teams ensured orderly transport and treatment priority for the injured. There were 245 victims with a median total body surface area burned of 12%. Inhalation injury was present in 96 patients. A total of 182 victims were admitted, with 112 to intensive care. Ten patients died in the hospital. Seventy-eight patients were secondarily transported, many to specialised centers in the Netherlands and abroad. In total, 36 hospitals in three countries participated.

CONCLUSION

An incident with high numbers of burn victims poses a challenge to any health care system. The difficult circumstances at the site demonstrated the need for robust organisational structures. The primary and secondary distribution of patients required coordination, general hospitals were able to provide initial medical care to these major burn casualties.

Analysis of the pre-incident education and subsequent performance of emergency medical responders to the Volendam caf?? fire

OBJECTIVE

At this moment, in the Netherlands, rescue workers are not given any specific standardized training in disaster response or disaster management. After the café fire in Volendam, the Netherlands, on New Year's Eve 2000, around 200 rescue workers were deployed on-site. The aim of this study is to investigate the rescue workers' experiences with regard to their level of preparation for the emergency response.

METHODS

In 2002, 30 members of the medical and paramedical personnel were requested to participate in a structured interview, focused on education, task perception, triage and registration.

RESULTS

Twenty-seven participated. Twenty-two rescue workers received previous training in emergency medicine. During the alarm phase, 11 rescue workers had a clear perception of their tasks. Twenty-four were involved in triage and injury assessment. Three rescue workers used a protocol for triage and 15 for injury assessment. Twenty-five rescue workers gave on-scene treatment and 15 used a protocol. Eight registered their findings.

CONCLUSIONS

Preparation for the emergency response lacked standardized procedures. The use of triage protocols was extremely poor, as was documentation of actions. Slightly more than half of the personnel followed treatment protocols. It is advisable that all rescue workers become familiar with the basic uniform principles and protocols regarding disaster management. A dedicated and standardized national disaster management course is needed for all rescue workers.

A new definition of drowning: towards documentation and prevention of a global public health problem

Drowning is a major global public health problem. Effective prevention of drowning requires programmes and policies that address known risk factors throughout the world. Surveillance, however, has been hampered by the lack of a uniform and internationally accepted definition that permits all relevant cases to be counted. To develop a new definition, an international consensus procedure was conducted. Experts in clinical medicine, injury epidemiology, prevention and rescue from all over the world participated in a series of "electronic" discussions and face-to-face workshops. The suitability of previous definitions and the major requirements of a new definition were intensely debated. The consensus was that the new definition should include both cases of fatal and nonfatal drowning. After considerable dialogue and debate, the following definition was adopted: "Drowning is the process of experiencing respiratory impairment from submersion/immersion in liquid." Drowning outcomes should be classified as: death, morbidity, and no morbidity. There was also consensus that the terms wet, dry, active, passive, silent, and secondary drowning should no longer be used. Thus a simple, comprehensive, and internationally accepted definition of drowning has been developed. Its use should support future activities in drowning surveillance worldwide, and lead to more reliable and comprehensive epidemiological information on this global, and frequently preventable, public health problem.

Medical management after indoor fires: A review

Fires involving mass burn casualties require extreme efforts and flexibility from the regular health care system. The café fire in Volendam, which occurred shortly after midnight on the first of January 2001, resulted in the worst indoor mass burns incident in Dutch history. During the extensive medical evaluation of this disaster, it became obvious that information on similar incidents is relatively scarce in the literature. This article systematically reviews the existing information in the medical literature on indoor fires and provides findings and knowledge used in the evaluation of the medical management after indoor fires and for future mass burn casualty preparedness, mitigation and response.

METHODS

A literature review was undertaken for burn disasters with characteristics similar to the indoor Volendam fire disaster. In all fires, the following aspects were investigated: characteristics of the fire; the initial emergency response; triage and on-site treatment; primary and secondary distribution; hospital admission; severity of the sustained injuries and mortality.

RESULTS

A total of nine similar indoor fires were selected. The number of people involved was reported in seven fires (range 137-6000). All reports provided the mortality rate (range 1.4% to over 50%). Data regarding the emergency response could be collected in half of the studies. On-scene triage was performed in five fires. The number of hospitals participating in the primary distribution ranged from 1 to 19. Except for the Volendam fire, all patients were primarily distributed to general hospitals.

CONCLUSION

Characteristics of indoor fires, which are relevant for disaster preparedness, mitigation and response are not frequently reported in medical literature. The current articles on indoor fires, mainly report on numbers of casualties and the mortality. Limited data are available to provide insight in the characteristics of management and medical treatment and to come up with suggestions for improvement of future burn incidents management. The evaluation of disasters should be based on uniform methods and structured reports and effective record keeping is essential to achieve this.

[International and Dutch reanimation guidelines]

The 'Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care' have been published in a number of journals by a group of international experts. Although these guidelines are not dictated or imposed, their implementation would necessitate changes to the curriculum 'Basic Life Support' instruction for laymen. The recall of all persons ever instructed to inform them about the new Guidelines is also necessary. However, in view of the present lack of solid scientific basis, the wisdom of implementing the present guidelines in Dutch practice in an unrestricted manner has to be questioned, due to financial and human impact that would be involved.

Drowning

Recent epidemiologic data have shown that the burden of drowning is much greater than expected. Prevention and timely rescue are the most effective means of reducing the number of persons at risk. Early bystander cardiopulmonary resuscitation is the most important factor for survival after submersion. Cerebral damage is a serious threat when the hypoxic period is too long. In most situations, low body temperature is an indication of the severity of the drowning incident. Sometimes hypothermia that occurs during the submersion period can be brain protective. There is also new evidence to support the strategy of inducing mild hypothermia for a period of 12 to 24 hours in comatose drowning victims. In immersed patients, hypothermia should be treated. The most appropriate technique will depend on the available means in the hospital and the condition of the patient. Treatment of pulmonary complications depends on the lung injury that occurred during aspiration and the bacteria involved in aspiration. Understanding the pathophysiology of drowning may help us to understand lung injuries and ischemic brain injuries.