by Dr Ramon REYES MD
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Niveles de Alerta Antiterrorista en España. Nivel Actual 4 de 5.
Fuente Ministerio de Interior de España
Saturday, April 20, 2019
Friday, April 19, 2019
Guia para la atención a las personas con discapacidad intelectual o del desarrollo y alteraciones de la salud mental y/o del comportamiento. pdf Gratis
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| Guia para la atención a las personas con discapacidad intelectual o del desarrollo y alteraciones de la salud mental y/o del comportamiento. pdf Gratis |
Enlace para DESCARGAR pdf Gratis
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Dr. Ramon Reyes, MD
http://emssolutionsint.blogspot.com.es/2016/12/dr-ramon-reyes-diaz-md-emt-t-dmo.html
Les Esperamos en nuestro Grupo en TELEGRAM Soc. IberoAmericana de Emergencias
https://t.me/joinchat/GRsTvEHYjNLP8yc6gPXQ9Q
Thursday, April 18, 2019
Faster and higher level #combat care to upgrade the golden hour to platinum 15 minutes by breakingdefense.com
faster and higher level #combat care to upgrade the golden hour to platinum 15 minutes
The Army’s Plan To Save The Wounded In Future War
Even with faster medevac aircraft, uparmored ambulances, and more medical personnel at the front, will casualties get to life-saving care within the "golden hour"?
CAPITOL HILL: The high-tech chaos of future battlefields will make it much harder to save wounded soldiers, the Army Chief of Staff warned Congress this week. Evacuating them will require not only new high-speed medevac aircraft and tank-like armored ambulances, Gen. Mark Milley said, but also a radical reorganization of the Army’s medical corps to bring care as close as possible to the front line.
We’ve covered the equipment part of this equation — more on that below — but the personnel side is equally important and quite possibly more complicated. “People can tell you how incredibly confused I was at the hearing [on] medical services last week,” Rep. Pete Visclosky, the chairman of the House defense appropriations subcommittee, told Army leaders at a hearing on the Army budget this week.
It turns out it’s confusing because two things are happening at once, Gen. Milley and Army Secretary Mark Esper explained:
There’s a military-wide reorganization — mandated by Congress — that’s consolidating Army, Air Force, and Navy/Marine medical services into a single Defense Health Agency system to provide more cost- efficient healthcare for troops and their families back in the US.
But there’s also an Army-specific reorganization intended to free up doctors, nurses, and other medical specialists from hospital duties in the US so they can train and deploy with frontline combat units.
“The Army several months ago started looking at what we need for the fielded force in terms of medics and docs and surgeons, PAs, you name it,” Sec. Esper said. (This is probably part of a much wider study of how to reorganize the Army for future multi-domain operations). “There’s a lot of change happening there,” the secretary said. “We didn’t think we had the right numbers and the right specialties for the fielded force, the units that go to war.”
“Those are two different capabilities,” Gen. Milley added. “One is [to] stay home in the medical treatment facilities, the hospitals, take care of soldiers and families. The other is a combat medical capability, distributed within tactical units: They’re going to be on the forward edge of the battlefield.”
Bell photo
Bell V-280 Valor tiltrotor in level flight with rotors facing forward. The V-280 is widely considered the leading candidate for the Future Long-Range Assault Aircraft (FLRAA)
The Air Support Problem
The problem, Milley explained, is that ground forces have gotten used to air support essentially on call 24-7. That includes rapid medical evacuation that could pick up casualties from the battlefield and quickly bring them to centralized medical facilities with lots of staff and equipment.
BAE photo
A medical variant of the BAE Armored Multi-Purpose Vehicle. AMPVs will serve as both armored ambulances and mobile operating rooms.
Against adversaries better-armed than the Taliban, that might not work. Russia and China have long-range precision missiles that can devastate big bases, forcing support services — including medical care — to disperse, hide, and keep relocating to avoid destruction. There are abundant anti-aircraft missiles to shoot down medevac aircraft, anti-tank missiles and land mines to destroy ground ambulances.
“Currently, in the combat we’re involved in now, we have dominance over the air and we pretty much can guarantee ourselves ground evacuation and/or air evacuation within this so-called golden hour,” Milley said. “If you are wounded and we get you to doctor in 60 minutes, your probability of survival is in excess of 90 percent.”
“In future combat, that may or may not be true,” Milley said. “Hence Future Vertical Lift [aircraft]…. and we’re uparmoring ground ambulances: That’s the AMPV program.” These are both ways to get casualties out of the combat zone faster without getting shot down or blown up on the way:
The Future Vertical Lift program aims to replace current helicopters with revolutionary new aircraft that are much faster, longer-ranged, and better able to evade Russian or Chinese air defenses. Its FLRAA variant in particular will replace the UH-60 Black Hawk for air assault, transport, and casualty evacuation.
The tank-like Armored Multi-Purpose Vehicle is basically an upgraded M2 Bradley troop carrier without the gun turret, which will replace the Vietnam-vintage M113 in a variety of supporting roles. While the Army has cut funding somewhat, the AMPV program will still deliver five variants, two of them medical vehicles: an ambulance and a mobile surgery.
But transporting casualties from the fight to the doctors is only half of the medevac equation. The other half is getting the doctors closer to the fight.
“Equally important,” Milley told the subcommittee, “we want to get the forward surgical teams… as far forward as possible.”
Air Force photo
Health care benefits for troops, military retirees, and their families — or, as in this picture, their pets — are an ever-growing cost to the Defense Department. Congress has directed the Pentagon to streamline the system, and the Army wants to put more medical personnel in combat units.
Mobilizing The Medics
“Today,” Milley explained to me after the hearing, “the medics, the physicians’ assistants, and the doctors, they work on a day to day basis in the MTF [on-base Medical Treatment Facilities], you know, to keep up their skills and stuff.” The base hospitals then loan medical staff to combat units before they deploy, a practice known as the Professional Filler System (PROFIS). The new system will reverse that, Miley said: “On a day to day basis, they’ll be in the tactical units, and then to keep their skills they’re go up to the hospital” as needed.
“It’s called ‘reverse PROFIS,'” Esper added. “The docs and PAs [will be] assigned to the operational units, and they get their repetitions by practicing in [the] MTF.”
Army photo
Army Secretary Mark Esper (left) and Chief of Staff Gen. Mark Milley (right) testify to Congress.
This may seem a subtle difference — Army medical personnel will still split their time between base hospitals and combat units — but it’s significant. Instead of working for base hospitals and only filling in at combat units when needed, medical personnel will belong to those combat units full-time, responsible first and foremost to operational commanders and regularly available to train for war.
Medical personnel are just one of the key “enablers,” from river-crossing companies to supply trucks, that the Army thinks it’ll need more of, in more units, over a wider area of battlefield than in the past. In future multi-domain operations, Milley told the committee, “it’s highly likely that ground forces will be cut off [and] isolated,” unable to get support from centralized logistical or medical bases in the rear.
Even with more medics at the front, however, more soldiers will be wounded in a future war with Russia or China than in Iraq or Afghanistan, and it will be much harder to get them to safety.
So, Rep. Mario Diaz-Balart asked in the hearing, can we count on evacuating soldiers in the golden hour in future conflicts?
“Probably not,” Milley said bluntly. “Evacuating soldiers in high intensity combat against a potential adversary like the Russians or Chinese or even North Korea — first of all the scale and scope of casualties will be significant, really significant, and the ability to evacuate those casualties within sixty minutes….”
The general looked grim. “We’ll try,” he said, “but I’m not guaranteeing.”
Wednesday, April 17, 2019
WHO guideline recommendations on digital interventions for health system strengthening free PDF
Publication details
Number of pages: 124
Publication date: 2019
Languages: English
ISBN: 978-92-4-155050-5
Publication date: 2019
Languages: English
ISBN: 978-92-4-155050-5
DOWNLOAD
- WHO Guideline: recommendations on digital interventions for health system strengthening
pdf, 1,3Mb - Executive summary
- Web supplement 1: evidence-to-decision frameworks
- Research considerations
- Evidence and recommendations
The key aim of this guideline is to present recommendations based on a critical evaluation of the evidence on emerging digital health interventions that are contributing to health system improvements, based on an assessment of the benefits, harms, acceptability, feasibility, resource use and equity considerations. For the purposes of this version of the guideline, the recommendations examine the extent to which digital health interventions available via mobile devices are able to address health system challenges at different layers of coverage along the pathway to universal health coverage (UHC). By reviewing the evidence of different digital interventions, as well as assessing the risks against comparative options, this guideline aims to equip health policy-makers and other stakeholders with recommendations and implementation considerations for making informed investments into digital health interventions.
This guideline urges readers to recognize that digital health interventions are not a substitute for functioning health systems, and that there are significant limitations to what digital health is able to address.
Dr. Carol Cunningham
Dr. Carol Cunningham was appointed State Medical Director for the Ohio Department of Public Safety, Division of EMS in July 2004 https://www.linkedin.com/in/carol-cunningham-m-d-090643b/
and is a board certified emergency physician at Cleveland Clinic Akron General Medical Center and an associate professor of emergency medicine at Northeast Ohio Medical University. She is the co-principal investigator for the National Association of State EMS Officials (NASEMSO) National Model EMS Clinical Guidelines project and serves on the Ohio Medical Coordination Plan Committee and Pediatric Disaster Coalition. She served as the EMS Medical Director representative on the National EMS Advisory Council (NEMSAC) for 5 years following her membership on the NEMSAC's Education and Workforce Committee.
and is a board certified emergency physician at Cleveland Clinic Akron General Medical Center and an associate professor of emergency medicine at Northeast Ohio Medical University. She is the co-principal investigator for the National Association of State EMS Officials (NASEMSO) National Model EMS Clinical Guidelines project and serves on the Ohio Medical Coordination Plan Committee and Pediatric Disaster Coalition. She served as the EMS Medical Director representative on the National EMS Advisory Council (NEMSAC) for 5 years following her membership on the NEMSAC's Education and Workforce Committee.
Dr. Cunningham received her medical degree and completed an emergency medicine residency at the University of Cincinnati. She has seven years of experience as a flight physician, eleven years of experience as a tactical EMS medical director, and is a fellow in the American Academy of Emergency Medicine and the Academy of Emergency Medical Services.
Dr. Cunningham completed the National Preparedness Leadership Initiative and the Women and Power program at the Harvard Kennedy School of Executive Education and the Homeland Security Executive Leadership Program at the Naval Postgraduate School & the U.S. Department of Homeland Security Center for Homeland Defense and Security. She is the 2012 recipient of the American Academy of Emergency Medicine's James Keaney Leadership Award.
In addition to her continued duties as a senior oral board examiner, Dr. Cunningham completed a 3-year term on the American Board of Emergency Medicine (ABEM) EMS Examination Committee in 2014 after 4 years of service as an item writer on the historic ABEM EMS Examination Task Force. She is a member of the editorial board of the Journal of EMS (JEMS), a contributing editor for the EMS Insider, and has served on several committees and panels at the National Academy of Medicine (formerly the Institute of Medicine of the National Academies), the Department of Health and Human Services' Agency for Healthcare Research and Quality, and the EMS Program Steering Committee of the National Fire Academy Board of Visitors.
Dr. Cunningham was appointed to the Executive Steering Committee of the Department of Homeland Security (DHS) Science & Technology Directorate's First Responder Resource Group and the OnStar® Public Safety Advisory Council and serves on the EMS Support Team of the Department of Homeland Security/Federal Emergency Management Agency (DHS/FEMA) National Integration Center Strategic Resource Group, the Board of Directors of the Committee for Tactical Emergency Casualty Care, and the Board of Trustees of the Rock and Roll Hall of Fame and Museum.
Monday, April 15, 2019
Incorporating Active Shooter Incident Planning into Health Care Facility Emergency Operations Plans
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Mass civilian shootings: Are we ready to face this new threat?
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| Mass civilian shootings: Are we ready to face this new threat? |
COL A Puidupin (MD), CPT C Hoffmann (MD),CPT N Cazes (MD), COL S Margerin (PCD), LTC T Provost-Fleury (MD), LTC O Gacia (MD) French Armed Forces Health Service, Paris, Clamart, Marseille
Link to download a free PDF document
Related
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The Hartford Consensus III Compendium, September 2015. PHTLS B-Con Bleeding Control for the Injured Course "Stop The Bleed" / Control de Sangrados para el Herido By NAEMT.
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The Committee for Tactical Emergency Casualty Care used the military battlefield guidelines of Tactical Combat Casualty Care (TCCC) as an evidenced based starting point in the development of civilian specific medical guidelines for high threat operations. Each phase and medical recommendation of the military TCCC guidelines was examined and discussed by the Committee, and then was re-written, annotated, or removed through consensus voting of the Guidelines Committee to create civilian specific, civilian appropriate guidance. Additionally, the Committee added and/or put specific emphasis on several medical recommendations not included in TCCC to address high threat operational aspects unique to civilian operations.
The first phase of care under TCCC is Care Under Fire (CUF). To meet the various operational scenarios and terminology utilized in the civilian sector, the first phase of care under TECC was renamed “Direct Threat Care (DTC).” The priorities of DTC remain relatively unchanged from CUF; emphasis remains on mitigating the threat, moving the wounded to cover or an area of relative safety, and managing massive hemorrhage utilizing tourniquets. Additionally, emphasis was placed on the importance of various rescue and patient movement techniques, as well as rapid positional airway management if operationally feasible. Treatment and operational requirements are the same for all levels of providers during this phase of care. The second phase of care under TCCC is Tactical Field Care. For the same reasons listed above, this phase was renamed in TECC to be called “Indirect Threat Care.” Indirect Threat Care phase can be initiated once the casualty is in an of relative safety, such as one with proper cover or one that has been cleared but not secured where there is less of chance of rescuers being injured or patients sustaining additional injuries. Similar to TCCC, assessment and treatment priorities in this phase focus on the preventable causes of death as defined by military medical evidence: Major Hemorrhage, Airway, Breathing/Respirations, Circulation, Head & Hypothermia, and Everything Else (MARCHE). Four different levels of providers were assigned to scope of practice and skill sets based on level of training and certification. The final phase of care under TECC is called “Evacuation Care.” During this phase of care, an effort is being made to move the casualty toward a definitive treatment facility. Most additional interventions during this phase of care are similar to those performed during normal EMS operations. However, major emphasis is placed on reassessment of interventions and hypothermia management. Download the TECC Guidlines » 
Almost 90% of American service men and women who die from combat wounds do so before they arrive at a medical treatment facility. This figure highlights the importance of the trauma care provided on the battlefield by combat medics, corpsmen, PJs, and even the casualties themselves and their fellow combatants. With respect to the actual care provided by combat medics on the battlefield, however, J. S Maughon noted in his paper in Military Medicine in 1970 that little had changed in the preceding 100 years. In the interval between the publication of Maughon's paper and the United States’ invasion of Afghanistan in 2001, there was also little progress made. The war years, though, have seen many lifesaving advances in battlefield trauma care pioneered by the Joint Trauma System and the Committee on Tactical Combat Casualty Care. These advances have dramatically increased casualty survival. This is especially true when all members of combat units – not just medics - are trained in Tactical Combat Casualty Care (TCCC.)
Combat medical personnel and non-medical combatants in U.S. and most coalition militaries are now being trained to manage combat trauma on the battlefield in accordance with TCCC Guidelines. |
- Stop the Bleed (US Dept. of Homeland Security)
Articles
- Report from Paris (New England Journal of Emergency Medicine, 6 December 2015)
- The medical response to multisite terrorist attacks in Paris (The Lancet, 24 November 2015)
- Arlington County, Va., Task Force Rethinks Active Shooter Incident Response (Journal of Emergency Medical Services, November 2009)
Podcasts
- Youri Yordanov: Lessons learned from the November Paris attacks (The St.Emlyn’s virtual hospital podcast 4/12/2015)
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