Amado Báez

The Cuban national Integrated Medical Emergeny System or "Sistema Integrado de Urgencias Medicas" (SIUM) was formed in 1997. In 1998, the SIUM began an active out-of-hospital thrombolysis program using Heberkinasa, the only streptokinase obtained through recombinant DNA techniques, produced by the Cuban Center for Genetic Engineering and Biotechnology. An active community training program has also been implemented, standardizing training for the almost 20,000 members of the national emergency medical services.

The objective of our study was to assess the diagnostic quality of low-dose computed tomography (CT) when compared to ultrasound (US) in diagnosis of urolithiasis using STONE score as a predictor of pre-test probability and the Bayesian statistical model to calculate post-test probabilities (POST) for both diagnostic tests. STONE score was used to form risk groups to obtain pre-test probabilities. Likelihood ratios (LR) were calculated from external data for low-dose CT and US. POST were obtained using pre-test probabilities and likelihood ratios with Bayesian nomogram. Absolute (ADG) and relative (RDG) gains in diagnostic value were calculated. Calculated +LR for US was 12 and -LR was 0.32; for CT, +LR was 19 and -LR 0.04. +LR and low STONE for US yielded POST 57% and RDG 470%; intermediate STONE POST 92% and RDG 84%; and high STONE POST 99% and RDG 10%. -LR and low STONE for US POST 3% and RDG -70%; intermediate POST 24% and RDG -52%; and high STONE POST 74% and RDG -17.7%. +LR an...

Introduction:No widely accepted, specialized medical training exists for police officers confronted with medical emergencies while under conditions of active threat. The purpose of this study was to assess medical decisionmaking capabilities of law enforcement personnel under these circumstances.Methods:Web-based surveys were administered to all sworn officers within the county jurisdiction.Thirty-eight key actions were predetermined for nine injured officer scenarios, with each correct action worth one point.Descriptive statistics and t-tests were used to analyze results.Results:Ninety-seven officers (65.1% response rate) responded to the survey. The majority of officers (68.0%) were trained to the first-responder level. Overall mean score for the scenarios was 15.5 ±3.6 (range 7–25). A higher level of medical training (EMT-B/P versus first responder) was associated with a higher mean score (16.6 ±3.4, p = 0.05 vs. 15.0 ±3.6, p = 0.05).Tactical unit assignment was associated with a...

Background: Bayes' theorem describes the probability of an event, based on conditions that might be related to the event.[1] We developed the Bayesian Diagnostic Gains (BDG) method as a simple tool for interpreting diagnostic impact.[2],[3],[4],[5],[6],[7] Aim: We aimed to evaluate the clinical diagnostic impact of contrast-enhanced ultrasound (CEUS) compared to traditional abdominal computed tomography (CT) and standard ultrasound (US) in a Bayesian Clinical Decision Scheme. Materials and Methods: Our mathematical method uses Bayesian Diagnostic Gains (BDG) model. For the purposes of our model, the EMTRAS was used as pretest probability and stratified as low risk (0–3 points = 10%), moderate risk (4–6 points = 42%), and high risk (7–12 points = 80%) based on mortality risk. Sensitivity and specificity for US, CT, and CEUS were obtained from pooled data and used to calculate LR- and LR+. Bayesian/Fagan nomogram was used to attain posttest probabilities using baseline probability...

Research within security studies has struggled to determine whether infectious disease (ID) represents an existential threat to national and international security. With the emergence of SARS-CoV-2 (COVID-19), it is imperative to reexamine the relationship between ID and global security. This article addresses the specific threat to security from COVID-19, asking, “Is COVID-19 a threat to national and international security?” To investigate this question, this article uses two theoretical approaches: human security and biosecurity. It argues that COVID-19 is a threat to global security by the ontological crisis posed to individuals through human security theory and through high politics, as evidenced by biosecurity. By viewing security threats through the lens of the individual and the state, it becomes clear that ID should be considered an international security threat. This article examines the relevant literature and applies the theoretical framework to a case study analysis focu...

A terrorist attack on US schools no longer can be considered a Black Swan event. Mounting evidence suggests that extremist organizations actively are targeting US schools. Equally disturbing are data suggesting that schools, universities, and communities are unprepared for large-scale violence. The Operational Medicine Institute Conference on an Integrated Response to the Modern Urban Terrorist Threat revealed significant variations in the perceived threats and critical response gaps among emergency medical providers, law enforcement personnel, politicians, and security specialists. The participants recommended several steps to address these gaps in preparedness, training, responses, and recovery.

Introduction: The novel coronavirus disease 2019 is a major health concern worldwide. The objective was to develop a Bayesian model to predict critical outcomes in patients with COVID-19. Methods: Sensitivity and specificity were obtained from previous meta-analysis. Using the IVC-COV2 index as pretest probability, likelihood ratios were integrated in a Fagan nomogram for posttest probabilities, generating IVC-COV2 + NEWS and CURB-65 scores values. Absolute and Relative Diagnostic Gains (ADG, RDG) were calculated. Results: The IVC-COV2 index was derived from a population of 1,055,746 individuals and based on mortality divided into high (71.97%) Intermediate (26.11%) and low (1.91%) risk groups. Integrating the IVC-COV2 intermediate + NEWS≥5 and CURB-65 >2 score models found that the Number Needed to Diagnose demonstrated a slight improvement for the CURB-65 model [2.00 (2) vs 2.71(3)]. When comparing diagnostic gains, no statistical differences were found on the IVC-CoV2 NEWS mod...

Background Community-acquired pneumonia (CAP) is one of the leading causes of morbidity and mortality in the USA. Our objective was to assess the predictive value on critical illness and disposition of a sequential Bayesian Model that integrates Lactate and procalcitonin (PCT) for pneumonia. Methods Sensitivity and specificity of lactate and PCT attained from pooled meta-analysis data. Likelihood ratios calculated and inserted in Bayesian/ Fagan nomogram to calculate posttest probabilities. Bayesian Diagnostic Gains (BDG) were analyzed comparing pre and post-test probability. To assess the value of integrating both PCT and Lactate in Severity of Illness Prediction we built a model that combined CURB65 with PCT as the Pre-Test markers and later integrated the Lactate Likelihood Ratio Values to generate a combined CURB 65 + Procalcitonin + Lactate Sequential value. Results The BDG model integrated a CUBR65 Scores combined with Procalcitonin (LR+ and LR-) for Pre-Test Probability Inter...

Background Dignitary medicine is an emerging field of training that involves the specialized care of diplomats, heads of state, and other high-ranking officials. In an effort to provide guidance on training in this nascent field, we convened a panel of experts in dignitary medicine and using the Delphi methodology, created a consensus curriculum for training in dignitary medicine. Methods A three-round Delphi consensus process was performed with 42 experts in the field of dignitary medicine. Predetermined scores were required for an aspect of the curriculum to advance to the next round. The scores on the final round were used to determine the components of the curriculum. Scores below the threshold to advance were dropped in the subsequent round. Results Our panel had a high degree of agreement on the required skills needed to practice dignitary medicine, with active practice in a provider’s baseline specialty, current board certification, and skills in emergency care and resuscitat...

Our objective was to evaluate the diagnostic value of computed tomography angiography (CTA) and ventilation perfusion (V/Q) scan in the assessment of pulmonary embolism (PE) by means of a Bayesian statistical model. Wells criteria defined pretest probability. Sensitivity and specificity of CTA and V/Q scan for PE were derived from pooled meta-analysis data. Likelihood ratios calculated for CTA and V/Q were inserted in the nomogram. Absolute (ADG) and relative diagnostic gains (RDG) were analyzed comparing post- and pretest probability. Comparative gain difference was calculated for CTA ADG over V/Q scan integrating ANOVA p value set at 0.05. The sensitivity for CT was 86.0% (95% CI: 80.2%, 92.1%) and specificity of 93.7% (95% CI: 91.1%, 96.3%). The V/Q scan yielded a sensitivity of 96% (95% CI: 95%, 97%) and a specificity of 97% (95% CI: 96%, 98%). Bayes nomogram results for CTA were low risk and yielded a posttest probability of 71.1%, an ADG of 56.1%, and an RDG of 374%, moderate-...

Introduction:The importance of accessing care within the first hour after injury has been a fundamental tenet of trauma system planning for 30 years. However, the scientific basis for this belief either has been missing or largely derived from case series from trauma centers. This study sought to determine the correlation between prehospital times and outcomes among severely injured elderly patients.Methods:This is a cross-sectional, observational study. All adults (<18 years of age) with acute trauma as defined byThe International Classification of Diseases Ninth Edition, Clinical Modificationdiagnostic codes and E-codes were included. Poisonings, single system burns, and late effects of injury were excluded. Chi-square and Student's ttest were used for significance testing. To assess the predictive effects of prehospital time and outcomes, three inde-pendent logistic regression models were constructed for both young and elderly groups, with hospital length of stay, mortalit...

Santo Domingo is the largest city in the Dominican Republic. In recent years this city has experienced a significant increase in ambulance services. To describe the current emergency medical services (EMS) workforce trends in Santo Domingo. This was a cross-sectional descriptive study. Emergency medical services providers working within the city of Santo Domingo filled out a nine-item self-administered questionnaire. A total of 101 providers, 48 volunteer and 53 paid, returned the survey (response rates of 75% and 91.4%, respectively). The volunteers showed a mean of 7.48 +/- 2.02 years of involvement in EMS, whereas the paid providers had a mean of 3.58 +/- 2.91 years. When asked about planned long-term involvement in EMS, 93.8% of the volunteers responded positively, compared with 58.5% of the paid group. Nine (16.98%) of the paid providers were not satisfied with their jobs, whereas all the volunteers (100%) stated that they were satisfied; 46 (86.8%) and 27 (50.9%) of the paid providers agreed that better salary and better work hours, respectively, would influence their satisfaction. Among the volunteers, 40 (83.3%) stated that occupational health insurance would improve job satisfaction; and 39 (81.3%) stated that life insurance would bring satisfaction to their job. Logistic regression analysis showed no predictive association between job satisfaction and years of service (p = 0.342). Volunteers appeared to be less educated but with a higher long-term interest in EMS. Salary and better work hours seem to be important factors affecting satisfaction of paid providers, whereas occupational health and life insurance appear to affect the satisfaction of volunteers.

A previous survey demonstrated a lack of standardization related to disaster triage among Latin-American providers. To assess the effectiveness of a short Internet-based educational intervention in disaster and mass-casualty triage. Using three Spanish Internet emergency medical services (EMS) forums, Latin-American providers were invited to participate in the study. The tool consisted of two educational modules: an introduction to disaster triage module and a START (simple triage and rapid treatment) module. Pre- and post-intervention tests were administered, each consisting of five standardized scenarios. Factorial analysis was used to measure the weight of each scenario. The first and fifth scenarios were identical for intraclass correlation. Skill retention was assessed through a one-month follow-up survey. Statistical analysis was performed using chi-square and Fisher's exact test. A total of 55 EMS providers participated in the study. Five of 55 (9.1%) participants correctly answered four or more scenarios on the pretest intervention, compared with 53 of 55 (96.4%) on the posttest [p < 0.001, relative risk 10.60 (95% CI 4.59-24.49)]. Similar findings were obtained for those accurately triaging all five scenarios, with zero of 55 (0%) in the pretest compared with 49 of 55 in the posttest (p < 0.001). Follow-up at one month was 69%. Four or more scenarios were correctly answered at follow-up by 34 of 38 (89.5%) respondents. No significant difference was noted compared with the immediate post-course survey (p = 0.18). Although initial ability of the cohort to accurately triage patients was suboptimal, a short Internet-based educational tool significantly impacted the cohort's ability to perform triage in a simulated patient environment. This improvement was maintained after one month.

IntroductionMobile health (mHealth) technology can play a critical role in improving disaster victim tracking, triage, patient care, facility management, and theater-wide decision-making.ProblemTo date, no disaster mHealth application provides responders with adequate capabilities to function in an austere environment.MethodsThe Operational Medicine Institute (OMI) conducted a qualitative trial of a modified version of the off-the-shelf application iChart at the Fond Parisien Disaster Rescue Camp during the large-scale response to the January 12, 2010 earthquake in Haiti.ResultsThe iChart mHealth system created a patient log of 617 unique entries used by on-the-ground medical providers and field hospital administrators to facilitate provider triage, improve provider handoffs, and track vulnerable populations such as unaccompanied minors, pregnant women, traumatic orthopedic injuries and specified infectious diseases.ConclusionThe trial demonstrated that even a non-disaster specific ...

Study objectives: Multiple organ failure is a major cause of mortality in the injured patient, representing a significant financial burden to the health care system. Recent studies have demonstrated the importance of early prediction and early resuscitation for multiple organ failure to improve outcome. The objective of this study is to determine the correlation between Injury Severity Score (ISS) and multiple organ failure among severely injured young (aged 18 to 54 years) and elderly (aged 55 years) patients. Methods: This was a cross-sectional observational study from a hospital-based trauma registry. Data from 1997 were collected. All adult cases (>18 years) with acute trauma as defined by International Classification of Diseases, Ninth Revision, Clinical Modification diagnostic codes and E-codes were included. Descriptive statistics were used to present group characteristics. For significance testing, χ 2 and Fisher's exact test were used for categorical variables. Severe injuries were defined by an ISS greater than 15. Presence of multiple organ failure was based on the definitions proposed by Knaus and Fry. Results: Six hundred forty-two adult trauma patients were included, with 469 classified as young and 173 as elderly. Among the 469 young adults, 193 had ISS greater than 15 (41.2%), and 35 of these developed multiple organ failure (35 of 193, or 18.1%). Among the 173 elderly patients, 88 had an ISS greater than 15 (50.9%), and 51 met the definition for multiple organ failure (51 of 173, or 29.5%). Severely injured (ISS >15) young and elderly groups were more likely to develop multiple organ failure compared with those with an ISS less than 15 ( P P P Conclusion: This study demonstrated a direct relationship between ISS greater than 15 and the development of multiple organ failure. We also observed a fivefold increase in the development of multiple organ failure among severely injured elderly patients. Future studies should focus on early resuscitative interventions based on prompt emergency department severity estimates calculated from anatomic and physiologic scoring systems. Limitations of this study are primarily related to the retrospective data collection process and the subsequent accuracy of the medical records.

Prehospital emergency services are a vital public service, and consumer access to the system is an important factor in their use. The Dominican Republic recently experienced "the epidemiological transition" leading to increased morbidity and mortality secondary to traumatic and cardiac conditions--thus, increasing the need for prompt and adequate delivery of emergency medical care. A survey was administered to 90 subjects from diverse backgrounds, all living in Santo Domingo. Survey items included questions on emergency medical services (EMS) systems knowledge (i.e., access numbers), confidence in the system, first-aid education and prior experience with the EMS system. Chi-square was used to measure statistical significance for categorical variables and Student's t-test for continuous variables (JMP 2.0 software was used for statistical processing). A total of 90 subjects were surveyed. The average age of respondents was 36 +/- 12 years SD. More than one-fifth (22.2%)...

Terrorism is a global public health burden. South Americans have been victims of terrorism for many decades. While the causes vary, the results are the same: death, disability, and suffering. The objective of this study was to perform a comprehensive, epidemiological, descriptive study of terrorist incidents in South America. This is a cross-sectional, descriptive study. Data from January 1971 to July 2006 was selected using the RAND Terrorism Chronology 1968-1997 and RAND-Memorial Institute for Prevention of Terrorism (MIPT) Terrorism Incident database (1998-Present). Statistical significance was set at 0.05. The database reported a total of 2,997 incidents in South American countries that resulted in 3,435 victims with injuries (1.15 per incident) and 1,973 fatalities (0.66 per incident). The overall case fatality ratio (CFR) was 35.8%. Colombia had the majority of incidents with 57.9% (1,734 of 2,997), followed by Peru with 363 (12.1%), and Argentina with 267 (8.9%). The highest ...

significant injury (any other AIS 3-6), mechanism of injury (penetrating vs. blunt), mode of transport (ground vs. helicopter), age, sex, use of prehospital paralytics, and the propensity score, risk of death was higher for OOH-ETI than ED-ETI (OR 4.93; 95% CI: 3.20–7.59). Of survivors, neurological status was poor in 211 and good in 1,098. Adjusted for the same covariates, risk of poor neurological status was higher for OOH-ETI than ED-ETI (OR 1.55; 95% CI: 1.01–2.37). The Horton test indicated good fit for both models (p = 0.99 and 0.58, respectively). Conclusions: OOH-ETI is associated with higher adjusted risk of death and poor neurological status after severe TBI. The nature of these associations and their impacts upon current clinical care remain undefined.

On September 22nd of 1998 the Dominican Republic was devastated by Hurricane Georges. Winds reaching more than 110 miles per hour, and an aftermath that left 283 dead, this natural phenomenon became one of the worst disasters in Dominican History. The ...

Study objectives: We determine whether focused abdominal sonography for trauma (FAST) might be a useful adjunct to simple triage and rapid treatment (START) in further triaging victims already classified as delayed. Methods: This was a retrospective chart review of all adult trauma patients evaluated by the trauma surgery service at a Level I trauma center between January 1 and December 31, 2003. All patients requiring trauma surgery evaluation were deemed nonambulatory. Patients with initial respiratory rate greater than 30 breaths/min, systolic blood pressure less than 80 mm Hg, or Glasgow Coma Scale (GCS) score of 13 or less were categorized as Immediate (Red). Individuals with a GCS score of 8 or less were categorized as Expectant (Black). All other patients were categorized as Delayed (Yellow). FAST results were obtained from the medical records. Under circumstances in which only abdominal computed tomography (CT) was obtained, results were extrapolated to a positive FAST if free fluid was noted in the abdomen, or more than a "trivial" pericardial effusion was noted. If FAST and CT results conflicted, the FAST results were used for the purpose of this study. Results: Five hundred of the 773 adult patients had either FAST, abdominal CT, or both recorded. The remainder of patients presented with isolated head injuries, orthopedic injuries, or penetrating trauma. Five of the 500 patients had data missing that precluded START classification. Forty-one (11.2%) of 367 Yellow patients had a positive FAST, whereas 11 (8.6%) of 128 Red/Black patients had a positive FAST ( P =.41, OR 1.34, 95% confidence interval [CI] 0.64 to 2.86). Pulse rate 110 beats/min or greater was not significantly associated with a positive FAST in either Yellow-triaged ( P =.74, OR 0.85, 95% CI 0.28 to 2.42) or Red/Black-triaged ( P =.48, OR 1.59, 95% CI 0.36 to 6.63) patients. Conclusion: Use of FAST ultrasonography might have detected 41 patients with intra-abdominal injury, potentially changing their triage level and expediting their care. No significant difference was noted between positive FAST rates in Red/Black-triaged and Yellow-triaged patients. Tachycardia in any triage category did not predict the presence of a positive FAST examination.

Every year, millions of individuals visit an emergency department (ED) as result of violence-related injuries. The study objective was to assess the attitudes, perceptions and challenges emergency care providers (ECP) face when caring for victims of violence (VOV). Methods The study was a cross-sectional descriptive survey. ECP completed a web-based 20-item survey including provider demographics, resources, personal experiences and perceptions about caring for VOV. Results 224 ECP participated in the survey. 45.3% were physicians, 34.4% nurses, 12.5% paramedics/EMTs, 6.2% nurse practitioners and 3.1% physician assistants. Participants have a combined professional experience of 2,730 years (mean 12.2). 90.6% of participants practice in an ED setting. Subjects estimate that they care for 484.5 trauma patients/year of which 196 (40.5%) are VOV. 64.1% of ECP characterize violence as an important health issue. 75.4% state their institution has a social service program for intimate partner violence, whereas only 34.4% have one for youth violence and only 31.1% for victims of assault. 65.6% of subjects feel their violence-related social services are suboptimal. Working in an urban center is not associated with availability of social services [p = 0.80 (RR 0.97 95% CI = 0.77 to 1.23)]. 78.1% feel they are negatively affected personally or emotionally when caring for a VOV and 57.1% of participants had been VOV themselves. 59.7% had been previously assaulted by a patient, and 50.8% feel fear when caring for a VOV. Only 62.9% routinely care for the psycho/social needs of VOV. The main barriers to addressing these needs are time (90.3%), education/training (48.4%), and financial (38.7%). Conclusions Interpersonal violence is a serious public health concern. A great number of medical providers have been personally affected by caring for VOV. The psychosocial needs of these patients are not adequately met. Limitations include the potential for self-selection and accuracy of the data. Language: en

The Glasgow Coma Scale (GCS) is the standard measure used to quantify the level of consciousness in patients with head injuries. Rapid and accurate GCS scoring is essential for adequate assessment and treatment of critically sick and injured patients. This study sought out to determine the precision and reliability of the GCS among a cohort of Latin American Critical Care Transport Providers. The study consisted of a cross-sectional design using an Internet-based examination. The evaluation consisted of four focused clinical scenarios with a classification based on severity. For measurement of intra-rater reliability the first and fourth cases were identical. Five minutes were allocated for each scenario. For categorical variables, chi-square testing and Fisher's exact testing were used to assess associations. For all tests, statistical significance was set at the 0.05 level. A total of 62 providers participated, including 17 physicians and 45 advanced providers (nurses and para...