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April 14th, 2014 posted by Paul Rega, MD, FACEP April 14, 2014 @ 5:06 am

Active shooter in the ER: Training

Am J Disaster Med. 2014 Winter;9(1):39-51. doi: 10.5055/ajdm.2014.0140.
Active shooter in the emergency department: A scenario-based training approach for healthcare workers.
Kotora JG1, Clancy T2, Manzon L3, Malik V3, Louden RJ4, Merlin MA5.


An active shooter in the emergency department (ED) presents a significant danger to employees, patients, and visitors. Very little education on this topic exists for healthcare workers. Using didactic and scenario-based training methods, the authors constructed a comprehensive training experience to better prepare healthcare workers for an active shooter.


Thirty-two residents, nurses, and medical students participated in a disaster drill onboard a US military base. All were blinded to the scenarios. The study was approved by the institutional review board, and written consent was obtained from all participants. Each participant completed a 10-item pretest developed from the Department of Homeland Security’s IS:907 Active Shooter course. Participants were exposed to a single active shooter scenario followed by a didactic lecture on hostage recovery and crisis negotiation. Participants were then exposed to a scenario involving multiple shooters. Many of the participants were held hostage for several hours. The training concluded with a post-test and debrief. Paired Student’s t-test determined statistical significance between the pretest and post-test questionnaire scores.


Paired Student’s t-tests confirmed a statistically significant difference between the pretest and post-test scores for the subjects, as a whole (p < 0.002 [-0.177, -0.041]). There was no difference in scores for nurses (p = 1 [-1.779, 1.779]). The scores for resident physicians (p < 0.01 [-0.192, -0.032]) and medical students (p < 0.01 [-0.334, -0.044]) were found to be significant.


Didactic lectures, combined with case-based scenarios, are an effective method to teach healthcare workers how to best manage an active shooter incident

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April 12th, 2014 posted by Paul Rega, MD, FACEP April 12, 2014 @ 5:28 am

Hospitals responding to the stabbings……

Emergency & Disaster Medicine, Hospitals

At hospitals, well-rehearsed drills created a ready response for victims

April 9, 2014 11:30 PM

By Jon Schmitz / Pittsburgh Post-Gazette

“……At both hospitals, the first word of a possible mass-casualty incident touched off a well-rehearsed response that involved quick notification and mobilization of a wide variety of personnel, including surgeons, nurses and support staff.

Both set up emergency command posts to bring together representatives of the various departments that would have a role in treatment of the victims, and to send out alerts to those who needed to be called in.

Ms. Egyud said each department reported on its capabilities — how many operating rooms were staffed and ready, how many beds were available in the intensive care unit, and the supplies and medicine that were on hand.

At UPMC East, two surgeons went to the emergency department, joining three doctors already on duty there, and additional nursing staff was called in, said Tamra Minton, chief nursing officer…..”

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April 9th, 2014 posted by Paul Rega, MD, FACEP April 9, 2014 @ 4:45 am

Philadelphia Department of Health advisory: Heroin cut with fentanyl

Education, Emergency & Disaster Medicine

Overdoses from Tainted Opioids/Recommendations for Management

Health Advisory

Philadelphia Department of Health

Jan. 28, 2014;

Numerous incidents of tainted heroin in the western and northwestern areas of Pa.

Sold in brand-name packages such as “Theraflu,” “Bud Light,” “Bud Ice,” “Diesel,” and “Coors Light.”

Fentanyl causes more severe opioid-induced intoxication and greatly increases the risk of death. Fentanyl will respond to naloxone administration, but greater doses of naloxone may be required for fentanyl-associated intoxication.

It may require 3-5 times that for near-death from heroin if fentanyl is the culprit.

Most abusers who happen to encounter fentanyl-contaminated heroin die before help arrives.

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April 6th, 2014 posted by Paul Rega, MD, FACEP April 6, 2014 @ 4:25 am

NIH: Survival of patients with septic shock was the same regardless of whether they received treatment based on specific protocols or the usual high-level standard of care

Emergency & Disaster Medicine

Sepsis study comparing three treatment methods shows same survival rate

NIH-funded clinical trial tested specific protocols against usual high-level care

Survival of patients with septic shock was the same regardless of whether they received treatment based on specific protocols or the usual high-level standard of care, according to a five-year clinical study. The large-scale randomized trial, named ProCESS for Protocolized Care for Early Septic Shock, was done in 31 academic hospital emergency departments across the country and was funded by the National Institute of General Medical Sciences (NIGMS), a component of the National Institutes of Health.


A five-year, randomized clinical trial indicated that survival of patients with septic shock was the same regardless of whether they received treatment based on specific protocols or the usual high-level standard of care. Sepsis affects more than 800,000 Americans annually and is the most expensive condition treated in U.S. hospitals.

The results of the trial, led by Derek C. Angus, M.D., M.P.H., and Donald M. Yealy, M.D., of the University of Pittsburgh, appear online on March 18, 2014, in The New England Journal of Medicine.

“ProCESS set out to determine whether a specific protocol would increase the survival rates of people with septic shock. What it showed is that regardless of the method used, patient survival was essentially the same in all three treatment groups, indicating that sepsis patients in these clinical settings were receiving effective care,” said Sarah Dunsmore, Ph.D., who managed the ProCESS trial for NIGMS.

Sepsis is a body-wide inflammation, usually triggered by an infection. It can lead to a dangerous drop in blood pressure, called septic shock, that starves tissues of oxygen and chokes out major organs: lungs, kidneys, liver, intestines, heart. It remains frustratingly hard to identify, predict, diagnose and treat.

According to the Centers for Disease Control and Prevention, sepsis affects more than 800,000 Americans annually and is the ninth leading cause of disease-related deaths. The Agency for Healthcare Research and Quality lists sepsis as the most expensive condition treated in U.S. hospitals, costing more than $20 billion in 2011.

The ProCESS trial set out to test three approaches to sepsis care. It enrolled 1,341 patients randomly divided into these groups:

Group 1: Early Goal-Directed Therapy

Doctors inserted a central venous catheter—a long, thin tube placed close to a patient’s heart—to continuously monitor blood pressure and blood oxygen levels. For the first six hours of care, doctors kept these levels within tightly specified ranges using intravenous fluids, cardiovascular drugs and blood transfusions. This protocol was based on a 2001 study in an urban emergency department that noted a striking increase in sepsis survival using this approach.

Group 2: Protocolized Standard Care

This alternative tested a less invasive protocol that did not require central venous catheter insertion. Doctors used standard bedside measures like blood pressure (taken using an arm cuff), heart rate and clinical judgment to evaluate patient status and guide treatment decisions. Doctors kept patient blood pressure and fluid levels within specified ranges for the first six hours of care.

Group 3: Standard Care

Patients received the same high level of care they would typically get in an academic hospital emergency department. Their doctors did not follow specific guidelines or protocols associated with the study.

After using an array of statistical analysis tools, the ProCESS investigators concluded that the three treatment arms produced results that were essentially indistinguishable for a range of patient outcomes. These outcomes included survival at 60 days, 90 days and one year; heart and lung function; length of hospital stay; and a standardized measurement of health status at discharge.

“ProCESS helps resolve a long-standing clinical debate about how best to manage sepsis patients, particularly during the critical first few hours of treatment,” said Yealy.

“The good news from this study is that, as long as sepsis is recognized promptly and patients are adequately treated with fluid and antibiotics, there is not a mandated need for more invasive care in all patients,” added Angus.

In addition to clarifying sepsis treatment options, ProCESS was a milestone for NIGMS.

“ProCESS was the first large-scale clinical trial to be supported by NIGMS, which primarily funds basic, non-disease-targeted research,” said Dunsmore. “We hope that ProCESS and other NIGMS- and NIH-funded sepsis research efforts will help improve treatment, speed recovery and increase survival rates for sepsis patients.”

Research reported in this release was supported by the National Institute of General Medical Sciences of the National Institutes of Health under grant number P50 GM076659. For more information about clinical trial NCT00510835, visit

To arrange an interview with NIGMS program director Sarah Dunsmore, Ph.D., contact the NIGMS Office of Communications and Public Liaison at 301-496-7301 or

For more information about sepsis, see the fact sheet at

NIGMS is a part of NIH that supports basic research to increase our understanding of life processes and lay the foundation for advances in disease diagnosis, treatment and prevention. For more information on the Institute’s research and training programs, see

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March 24th, 2014 posted by Paul Rega, MD, FACEP March 24, 2014 @ 4:08 am

HHS issues emergency preparedness proposal to regulate 68,000 medical facilities; calls emergency preparedness an ‘urgent public health issue’

Emergency & Disaster Medicine, Hospitals

A Proposed Rule by the Centers for Medicare & Medicaid Services on     12/27/2013

Medicare and Medicaid Programs; Emergency Preparedness Requirements for Medicare and Medicaid Participating Providers and Suppliers

Action:    Proposed Rule.


This proposed rule would establish national emergency preparedness requirements for Medicare- and Medicaid-participating providers and suppliers to ensure that they adequately plan for both natural and man-made disasters, and coordinate with federal, state, tribal, regional, and local emergency preparedness systems. It would also ensure that these providers and suppliers are adequately prepared to meet the needs of patients, residents, clients, and participants during disasters and emergency situations.

We are proposing emergency preparedness requirements that 17 provider and supplier types must meet to participate in the Medicare and Medicaid programs. Since existing Medicare and Medicaid requirements vary across the types of providers and suppliers, we are also proposing variations in these requirements. These variations are based on existing statutory and regulatory policies and differing needs of each provider or supplier type and the individuals to whom they provide health care services. Despite these variations, our proposed regulations would provide generally consistent emergency preparedness requirements, enhance patient safety during emergencies for persons served by Medicare- and Medicaid-participating facilities, and establish a more coordinated and defined response to natural and man-made disasters.

Publication Date:Friday, December 27, 2013

Agencies:Department of Health and Human ServicesCenters for Medicare & Medicaid Services

Dates:To be assured consideration, comments must be received at one ofEntry Type:Proposed RuleAction:Proposed rule.Document Citation:78 FR 79081Page:      79081      -79200 (120 pages)

CFR:42 CFR 40342 CFR 41642 CFR 41842 CFR 44142 CFR 46042 CFR 48242 CFR 48342 CFR 48442 CFR 48542 CFR 48642 CFR 49142 CFR 494

Agency/Docket Number:CMS-3178-PRIN:0938-AO91

Document Number:2013-30724

Shorter URL:

U.S. calls emergency preparedness an ‘urgent public health issue’

HHS issues proposal to regulate 68,000 medical facilities.
        By JC Sevcik    |           March. 11, 2014 at 3:35 PM  |  Updated March. 11, 2014 at 4:04 PM

“…..The proposed regulations require facilities to maintain emergency lighting, fire safety systems, sewage and waste disposal, air conditioning and heating during power losses. Facilities will also need to have systems in place to track displaced patients, manage volunteers and provide alternate care sites.

Critics of the regulations claim the proposed $225 million dollar price tag is not enough to cover the costs of updating and retrofitting old systems to meet new requirements. In a member advisory issued in January, the American Hospital Association said HHS “may have significantly underestimated the burden and cost associated with complying with this rule.”……..”
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March 16th, 2014 posted by Paul Rega, MD, FACEP March 16, 2014 @ 5:50 am

Mortality from ruptured abdominal aortic aneurysms

Emergency & Disaster Medicine

Mortality from ruptured abdominal aortic aneurysms:  clinical lessons from a comparison of outcomes in England  and the USA,

Alan Karthikesalingam, Peter J Holt, Alberto Vidal-Diez, Baris A Ozdemir, Jan D Poloniecki, Robert J Hinchliffe, Matthew M Thompson,

The Lancet (2014),  Volume 383, Issue 9921,  Pages 963 – 969, 15 March 2014

“….In-hospital survival from r[uptured]AAA, intervention rates, and uptake of endovascular repair are lower in England than in the USA. In England and the USA, the lowest mortality for rAAA was seen in teaching hospitals with larger bed capacities and doing a greater proportion of cases with endovascular repair. These common factors suggest strategies for improving outcomes for patients with rAAA.”


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March 6th, 2014 posted by Paul Rega, MD, FACEP March 6, 2014 @ 12:27 am

Contamination of Stethoscopes and Physicians’ Hands

Emergency & Disaster Medicine

Mayo Clinic Proceedings

Volume 89, Issue 3, March 2014, Pages 291–299

Contamination of Stethoscopes and Physicians’ Hands After a Physical Examination

Yves Longtin, et al


“…..These results suggest that the contamination level of the stethoscope is substantial after a single physical examination and comparable to the contamination of parts of the physician’s dominant hand…..”

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