EMS SOLUTIONS INTERNATIONAL

BUQUE HOSPITAL JUAN DE LA COSA. ESPAÑA

2012-03-04T16:26:00.001-05:00

Jueves, 20 de julio de 2006

El buque hospital 'Juan de la Cosa' partirá este domingo a atender a la flota del Atlántico Norte

El barco tendrá su base en Santander

El buque hospital 'Juan de la Cosa, con base en Santander, partirá el domingo hacia el Atlántico Norte, donde atenderá durante varios meses al año a la flota pesquera que acude a las costeras del bonito y el pez espada, compuesta por alrededor de 960 buques y 9.600 trabajadores del mar.

EFE/SANTANDER

Este barco, fletado por el Instituto Social de la Marina (ISM), es el segundo en España con estas características, junto al 'Esperanza del Mar' -que atiende al banco canario-sahariano-, y, además de a la flota pesquera, asiste a los marinos mercantes y presta apoyo técnico y logístico a los buques de la zona.

El secretario de Estado de la Seguridad Social, Octavio Granado, presentó hoy oficialmente el buque hospital en una rueda de prensa celebrada a bordo de la embarcación, en la que destacó el hecho de que la Seguridad Social española es la única de Europa y "una de las pocas del mundo" que cuentan con hospitales en el mar.

"Ocurra lo que ocurra, nosotros somos el único referente sanitario en ese momento", recalcó el responsable médico del 'Juan de la Cosa', José Manuel González, quien ya estuvo embarcado anteriormente en el buque 'Científico', alquilado por el ISM para atender al Atlántico Norte antes de fletar el 'Juan de la Cosa'.

González explicó que el buque está diseñado para prestar asistencia en cualquier caso, dado que, en muchas ocasiones, se encontrarán fuera del radio en el que pueden recibir ayuda y cifró entre 200 y 300 las asistencias anuales en la zona, de las que 30 ó 40 suponen un "riesgo vital" para el afectado.

El médico del 'Juan de la Cosa' indicó que los traumatismos, los trastornos digestivos y las afecciones dermatológicas son las consultas que más se atienden en los buques hospital como éste, cuyo equipo médico no necesitará trasladarse a los barcos ya que recibe consultas por teléfono en los casos más leves.

Asimismo, cuenta con un equipo para videoconferencias y con un quirófano preparado para que los médicos del buque puedan ser asistidos por especialistasen las intervenciones quirúrgicas, si fuera necesario.

La dotación hospitalaria incluye un laboratorio y salas de curas, de cuidados intensivos, de radiografías y de aislamiento (para pacientes quemados, infecciosos y psiquiátricos).

Para su labor de salvamento, tiene un helipuerto, cuatro lanchas de trabajo y un bote de rescate para transporte de enfermos o accidentados y transporte de ayuda médica, así como cinco balsas salvavidas con capacidad para 16 personas cada una.

EL BARCO, EN DATOS

Con 75 metros de eslora y 14 de manga, el barco, construido por los astilleros de Izar en Gijón y en el que se han invertido 19 millones de euros entre construcción y equipamiento, dispone de una zona de náufragos, áreas comunes, áreas de servicio y unos camarotes para enfermos equipados con conexiones informáticas y de televisión.

El 'Juan de la Cosa', que tiene una tripulación de 28 personas y puede acoger hasta 20 enfermos o náufragos, también presta asistencia técnica en casos como el enganche de redes en las hélices, de lo que se encargan submarinistas, o averías en el motor.

La consejera de Sanidad cántabra, Charo Quintana, reconoció estar "realmente impresionada" por la dotación de la embarcación, por lo que se mostró dispuesta a revisar el convenio de colaboración que mantiene el ISM con el hospital Marqués de Valdecilla. "Todo esfuerzo por nuestra parte será poco", recalcó Quintana.

Por su parte, el presidente de la Federación de Cofradías de Cantabria , Tomás Cos, resaltó que es "imprescindible" que los marineros tengan "una rápida asistencia y estén tranquilos sabiendo que tienen un auténtico hospital cerca de ellos".

El buque hospital salió a la isla de Mouro, donde hizo un simulacro para atender a un pesquero con una persona inconsciente, que fue trasladada en el helicóptero Helimer Cantábrico, y otro herido grave, asistido por los médicos que se desplazaron al barco.

El barco hospital se podrá visitar en el muelle de Albareda de Santander mañana, viernes, y el sábado, algo que hicieron hoy el presidente de Cantabria, Miguel Ángel Revilla; la vicepresidenta, Lola Gorostiaga; el delegado del Gobierno, Agustín Ibáñez; el presidente de la Autoridad Portuaria de Santander, Javier del Olmo; y el consejero de Presidencia, Vicente Mediavilla, entre otras autoridades.

Transporte Aeromedico

2012-03-04T12:53:00.000-05:00

TRANSPORTE AEROMEDICO:

Ficción y Realidad

José Ramón Aguilar

INTRODUCCION

La unión de la aviación y medicina ha traspasado los límites de las unidades de cuidados intensivos más allá de la unidad hospitalaria. La incorporación de la monitorización, ventiladores, oxígeno, aspiración, bombas de infusión, etc., permite realizar una medicina intensiva completa en el aire ¹. Hemos visto en la pasada década un aumento en el número de pacientes críticos o traumatizados transportados en medios aeromédicos para su tratamiento definitivo en centros regionales ²³. Los médicos de todas las especialidades probablemente envían o reciben pacientes por transporte aeromédico(AMT).

Desgraciadamente, muchos de los anunciados servicios de "ambulancia aérea" no son más que aviones comerciales dotados de personal paramédico o de enfermería contratados sin ninguna base por una compañía de charters aéreos ². No tienen dirección médica ni normas prácticas, calidad asegurada, educación apropiada del personal, ni control médico.

El uso apropiado y seguro del transporte aeromédico requiere unos conocimientos básicos de los aspectos médicos del vuelo y de las capacidades y restricciones del medio aeromédico. El propósito de este trabajo es revisar estos datos y proveer al sanitario no-aeromédico de una guía para el uso del AMT.

HISTORIA

La historia del AMT, como la de muchas innovaciones, está marcada por el entusiasmo, escepticismo, conservadurismo e interés.

Ya en 1784, después de las demostraciones de vuelo en globo de los Montgolfier Brothers, los médicos comenzaron a tener en cuenta de los beneficios que podráin obtener sus pacientes gracias al vuelo. Jean-François Picot teorizó que los pacientes no solo podrían tolerar el vuelo en globo sino que se beneficiarían del aire puro de las alturas ⁴. Aunque muchos creían que el advenimiento del AMT ocurría durante el secuestro de Paris, la idea romántica de que el paciente crítico o traumatizado grave fueran transportados en globo hasta la ciudad es desafortunadamente incorrecta ⁴.

El AMT usando mas que pesadas maquinas aéreas se inició en 1909, cuando el Capitán George Gosman, construyó un aeroplano específicamente con este propósito ⁵. Sin embargo, no fue fácil convencer al gobierno de que desarrollara el aeroplano de Gosman debido a su destrucción en un accidente, y nunca fue usado para el transporte de pacientes. En 1917,

the French Dorand AR II, fue la primera ambulancia aérea que transportó pacientes. En las décadas siguientes la industria de los "aviones ambulancia" creció, principalmente en el area militar. La Segunda Guerra Mundial produjo un gran aumento del uso del AMT. Se estima que 1 millón de pacientes fueron transportados de esta manera a los EEUU desde los sitios de conflicto con una mortalidad global de 4/100.000⁴.^,⁶.

La Guerra de Corea brindóa nuevos desafíos y oportunidades al AMT. En 1950, se autorizó el uso de helicópteros para la evacuación de heridos desde el frente de combate ⁴. Más de 17.000 pacientes fueron transportados por los helicópteros de la armada desde enero de 1951 hasta 1953. El sistema de evacuación médica desarrollado en la Guerra de Vietnam se basó en la experiencia obtenida durante el conflicto con Corea. El uso efectivo de helicópteros para el AMT en Vietnam y su aparición en la programación nocturna de la televisión doméstica, despertó el interés de la comunidad civil sobre su uso.

Aproximadamente al mismo tiempo, aumentó el interés en los cuidados pre-hospitalarios, y aquellos servicios que previamente solo estaban disponibles en los hospitales fueron exporatdos a las ambulancias dirigidas por un equipo de trabajadores de la salud ⁷. Al cabo de poco tiempo esta oferta externa al hospital de servicios médicos se unió a los helicópteros para formar la primera unidad de AMT de los EEUU. A partir de este momento se produce la expansión del AMT en la sociedad civil.

En 1979 había más de 500 aerotaxis que realizaban trabajo de ambulancias en los EEUU continental, y alrededor de 200 que proveían este servicio en Alaska solamente. En 1990 existían más de 170 programas aeromédicos operando en los EEUU ⁸. El número de AMT ha aumentado dramáticamente en las dos últimas décadas.

TIPOS DE AMT

En general el AMT se puede devidir en dos grandes categorías: Vuelo estable o AMT en aeroplano y AMT en helicóptero. Estos dos tipos de AMT tienen muchas características en común. El factor decisivo en la elección de un tipo u otro de transporte generalmente se relaciona con la eficacia.
El AMT en vuelo estable tiende a ser el proceso más eficaz para pacientes que deben recorrer distancias grandes de aproximadamente 200-250 millas. Para transportes de menos de 250 millas, se usa de rutina el AMT con helicóptero.
Ventajas del AMT en helicóptero
1. Velocidad: Los helicópteros modernos usados rutinariamente en misiones médicas son capaces de mantener una velocidad por encima de las 150 mph ⁹. Si le agregamos su habilidad para moverse de un punto a otro, la ventaja de la velocidad para el paciente puede traducirse en mejores tiempos de salvataje comparado con otras formas de transporte de pacientes. Es interesante que este atributo ha hecho que muchos investigadores determinen las "distancias óptimas" para el uso del helicóptero basándose en el tiempo de transporte ¹⁰.
2. Accesibilidad: La capacidad de despegue y aterrizaje vertical permite la evacuación de pacientes de áreas inaccesibles para otros vehículos de transporte. Por ejemplo accidentes durante montañismo o excursiones en áreas desérticas.
3. Personal y tecnología especializadas: La mayoría de los servicios aeromédicos dependen de centros médicos terciarios y están dirigidos por personal entrenado y altamente cualificado. Están equipados rutinariamente con sofisticada tecnología médica y brindan sus avanzadas capacidades a través de una amplia zona geográfica.
Estos atributos únicos del AMT en helicóptero deberán ser la base para considerar este modo particular de transporte.

AVIACION Y MEDICINA

La aviación continúa siendo una industria competitiva y el componente de ambulancia aérea no es la excepción. Desgraciadamente, muchos aviones utilizados para el AMT civil no han sido diseñados específicamente para este propósito. Sin embargo se requieren ciertas condiciones para administrar cuidados en el ambiente aéreo. Este ambiente además, crea nuevo o aumenta el estrés del paciente, sanitarios y equipo médico ⁹. Estos factores tienden a ser mayores en las operaciones con vuelos estables y menores con respecto a los helicópteros.
Oxígeno: La hipoxemia es el único y mayor reto de cualquiera que vuela. Los efectos fisiológicos de la hipoxemia pueden detectarse en individuos sanos a alturas menores de 10.000 pies. Esta ocurre como resultado de una caída de la presión ambiental y su magnitud se muestra en la figura 2. La presurización de las cabinas minimiza este problema en muchos aviones, pero en aquellos pacientes con alteración de su función pulmonar aumenta el riesgo de hipoxemia a las alturas alcanzadas normalmente. Una técnica útil para prevenir la hipoxemia en estos casos es mantener una presión parcial de oxígeno inspirado constante a través de todo el vuelo ⁹. La cada vez mayor disponibilidad de pulsioxímetros han disminuído la incidencia de hipoxemia en el AMT permitiendo su rápido reconocimiento.
Aceleración/Desaceleración: Los ocupantes de un avión si acelera o desacelera experimentan un cambio de velocidad. La aceleración o desaceleración es un vector de cantidad, que tiene magnitud y dirección. Por esta razón, una colocación correcta del paciente limita el estrés inducido por una aceleración sostenida ⁹.
Las fuerzas de aceleración experimentadas en los helicópteros durante operaciones de rutina tienden a ser de menor magnitud como mucho como las observadas en los vehículos de transporte sobre tierra.
Volúmenes de Gas: La presión ambiente disminuye a medida que aumenta la altitud. Los cambios de presión que acompañan a los cambios de altitud pueden afectar gran número de aparatos médicos así como a los pacientes. Al contrario de la creencia general, la presurización de la cabina no elimina este problema. La prsurización permite un vuelo confortable a altitudes que no podrían alcanzarse sin ella, pero generalmente no mantiene una altitud de la cabina equivalente a la del nivel del mar, de tal manera que tanto el equipo como el paciente se verán expuestos aalgún cambio de presión. Cualquier estructurallena de gas se convierte en un problema. El aire atrapado en los senos por ejemplo, puede expandirse y causar malestar y los aparatos que utilizan manguitos con aire pueden funcionar mal o lesionar al paciente con los cambios de altitud.
Humedad: La humedificación es un problema particular de las operaciones en vuelo estable porque la cabina incorpora aire ambiente de la atmósfera, aún en los aviones presurizados y cuando se calienta contienemuy poca humedad. Esto puede producir sequedad de las secreciones del paciente y malestar durante el vuelo ⁹.
Ruido: Los aviones modernos producen una cantidad de ruido importante. Las cabinas de muchos aviones son tranquilas para conversar y evaluar al paciente pero las cabinas de los helicópteros son tan ruidosas que impiden la auscultación pulmonar. Se requieren protectores auditivos y sistemas de intercomunicación.
Vibración: La vibración es una forma alternante y repetitiva de movimiento. Las dos mayores fuentes de vibración durante el AMT son los motores y la turbulencia del aire que atraviesa el avión. Además de causar fatiga y malestar, las vibraciones se transmiten al equipo médico durante el vuelo y pueden ser fuente de errores de monitorización y malfuncionamiento ⁹.

EQUIPOS AMT

Muchos tipos de tripulación atienden a los pacientes durante el AMT. El más pequeño de estos equipos de transporte incluye un médico. La gran mayoría de los equipos de transporte en helicóptero incluye una enfermera diplomada. Existe gran controversia sobre si la presencia del médico durante el AMT mejora la evolución del paciente. Por ejemplo, la intervención del médico en el AMT no se ha demostrado que disminuya la mortalidad después de una parada cardíaca post-traumática¹¹.
Snow y colaboradores estudiaron la necesidad de la presencia médica durante 295 vuelos en helicóptero con médico, de forma restrospectiva y determinaron que solo en el 25% de estos vuelos hubiera sido necesaria la presencia del médico ¹². La compañía de salvamento aéreo más grande y más antigua del mundo, la "Swiss Air Rescue" provee un médico en la mayoría de los transportes aeromédicos ³.
Las necesidades de los pacientes difieren, y debe seleccionarse una tripulación de vuelo apropiada a las necesidades particulares del paciente que va a transportarse.

SEGURIDAD

Aspectos de la Aviación: Los aviones de transporte aeromédico tienen una tendencia alarmante a los accidentes, con las resultantes pérdidas de vidas así como de lesiones no-fatales ¹³. En 1986, ocurrieron 14 accidentes graves de helicópteros1 EMS, destruyendo o dañando sustancialmente el 9% de la flota de helicópteros aeromédicos ². La "National Transportation Safety Board" (NTSB) realizó un estudio sobre la seguridad de las operaciones de helicópteros-ambulancia y concluyó que el mal tiempo era el mayor peligro para las operaciones EMS en helicóptero ¹⁴.
Después de la publicación del estudio del NTSB, se produjo una disminución de los accidentes en los helicóptero ¹⁵. La "Association of Air Medical Services" (AAMS), fundada hace una década, ha fomentado la dirección médica a través de sus mínmos standars de calidad y más recientemente a través de un programa piloto de acreditación y el establecimiento de una comisión de acreditación independiente.
Aspectos Médicos: Para algunas entidades, es sabido que el AMT debe realizarse con riesgos mínimos. Por ejemplo, si una persona con infarto de miocardio se puede beneficiar de un tratamiento trombolítico de urgencia, angioplastia, u otras intervenciones, puede ser necesario que deba ser trasladado en unas horas a el 10% de los hospitales que proveen estos servicios ¹⁶. Se ha demostrado un incidencia muy baja de complicaciones en una serie de casos de pacientes con infarto de miocardio aerotransportados ¹⁶^,¹⁷. Un estudio actual realizado en pacientes con infarto agudo de miocardio con terapia trombolítica trasladados y no trasladados demostró que no había aumento en la incidencia de complicaciones hemorrágicas, mortalidad u otros efectos adversos atribuíbles al AMT ¹⁸. Se han comunicado complicaciones médicas secundarias a problemas intrínsecos al vuelo. Por ejemplo, durante el AMT se ha descrito disfunción de la actividad de captación de los marcapasos que puede ser causada por los efectos de rotación del motor y vibraciones del vuelo (señales electromagnéticas exógenas) ¹⁹^,²⁰.
Por otra parte, el AMT permite al médico realizar diversos procedimientos mientras se encamina al hospital. Los precedimientos que se pueden realizar con total seguridad durante el vuelo son entre otras: infusión intraósea, colocación de una vía venosa central, colocación de tubo torácico, etc. ²¹. Obviamente, todos estos procedimientos conllevan el peligro de complicaciones propias de su colocación.

¿CUANDO USAR AMT?

El AMT debe reservarse para aquellos pacientes críticos o con enfermedades severas que requieren intervenciones no disponibles en el hospital de referencia ²². El beneficio de recibir estas intervenciones de cuidados especializados deberá sopesarse con el riesgo del transporte. En muchos casos la decisión de solicitar el transporte es muy fácil como en el caso de los pacientes que necesitan una intervención quirúrgica y no hay un neurocirujano disponible en la localidad. En otros casos este tipo de decisiones puede ser realmente difícil. Se ofrecen guías generales para tipos específicos de enfermedad. El comité de traumatismos y soporte vital de politraumatizados del American College of Surgeons ha promulgado un serie de recomendaciones para determinar la necesidad de transporte inter-hospitalario de los pacientes críticos a los centros de traumatología específicos. Estas incluyen:
- Lesión neurológica con Glasgow menor de 10
- Heridas penetrantes o fracturas de cráneo depresivas, o pacientes con signos neurológicos de lateralización.
- Sospecha de lesiones cardíacas o vasculares intratorácicas o gran traumatismo de pared torácica.
- Los pacientes de edades extremas (menores de 5 o mayores de 55 años de edad) o aquellos con alteraciones fisiológicas pre-existentes conocidas (por ej enfermedad cardiorrespiratoria) pueden ser tenidos en cuenta para que reciban atención en centros especializados.
No existen reglas organizadas que cubran el espectro de los pacientes quirúrgicos no-traumáticos u otras condiciones médicas. El análisis final y la decisión de trsladar a un paciente crítico se basa en la vañoración de los beneficios a obtener con el transporte y los riesgos asociados.
Mientras que el transporte aéreo ofrece muchos beneficios, deberán tenerse en cuenta los riesgos asociados al AMT al decidir su uso o el transporte terrestre.

PREPARACIÓN DEL PACIENTE PARA EL TRANSPORTE

La preparación del paciente para el traslado debe , por supuesto, comenzar con la estabilización de las condiciones médicas del paciente usando las medidas médicas apropiadas y a continuación contactando con el médico e institución que lo va a recibir. Es necesario asegurar el intercambio apropiado de información entre los médicos y optimizar el cuidado del paciente antes y durante el transporte ³. Los pacientes que van a ser transportados por aire deberán ser evaluados teniendo en cuenta los efectos de la presión y otras fuerzas del medio aeronáutico. Los espcios cerrados con gas deberán ser descomprimidos. Deberá considerarse la colocación de sonda nasogástrica y vesical ya que pueden contribuir significativamente al bienestar del paciente si no se habían colocado previamente.
La discusión con el equipo o servicio de traslado sobre las condiciones del paciente y el tratamiento que recibe se traducirá en recomendaciones adicionales que aligerarán el proceso de transporte ³.

REEMBOLSOS

Durante muchos años, los costes del programa de transporte al hospital en helicóptero no reflejaban los costes reales de la operación ². Los pagos realizados por pacientes provenientes de otro hospital se han usado para compensar los gastos ocasionados por el operativo. Los costes del transporte en helicóptero continúa aumentando, con un promedio de 100 millas por viaje los costes excedían los $2000 en 1990 ² . Esto representa un aumento del 40% sobre los costes promedio de un viaje de similares características del año 1989.
En muchos casos los costes quedan sin pagar. Desafortunadamente, la "pena por el paciente" en aeromedicina puede derivar a dilemas éticos, legales, profesionales para los profesionales de urgencias e instituciones sanitarias. Se ha sugerido que deberían instituirse unas normas de conducta institucionales para el transporte aeromédico de pacientes con lesiones graves o enfermedades severas, independientemente de que el paciente pague o a que clase pertenezca ²³ ^{, 24}.
Los transportes en vuelos regulados se realizan generalmente de forma urgente sin imprevistos, así que la práctica general a lo largo de todo el país es no realizar transportes en vuelos regulados con pérdidas, requiriendo el pago en el momento de realizar el servicio.

CONCLUSIONES
El sistema de urgencias aeromédicas se ha vuelto parte integral de la práctica clínica de la medicina intensiva. Estos sistemas proveen cuidados especializados a los pacientes con heridas o enfermedades graves, y puede para ello ser necesario la presencia de personal sanitario de todo tipo. La comprensión de los aspectos médicos del vuelo y las capacidades del entorno aeromédico ayudarán a los sanitarios a utilizar los recursos de una manera segura y apropiada.

REFERENCIAS

1. Wishaw KJ, Munford BJ, Roby HP. The CareFlight Stretcher Bridge: a compact mobile intensive care unit. Anaesth Intensive Care 1990; 18:234-8.
2. Fromm R, Cronin L. Issues in critical care transport. Probl Crit Care 1989; 3:439 - 46.
3. Wenker O, Steffen R, Hoefliger C: Repatriierungsfluege 1983 der Schweizerischen Rettungsflugwacht REGA. Inaugural Dissertation; Universitaet Zuerich, Switzerland; 1990.
4. Lam D. Wings of life and hope: a history of aeromedical evacuation. Probl Crit Care 1990; 4:477-94.
5. Sparks J. Rescue from the air and in space. New York: Dodd, Mead, 1963.
6. Pace J. Air evacuation in the European theater of operations. Air Surg Bull 1945; 2:323.
7. Pantridge J, Geddes J. A mobile intensive care unit in the management of myocardial infarction. Lancet 1962; 2:271-6.
8. Collett H. The conference cometh. Hosp Aviation 1989; 9:5.
9. Fromm R, Duvall J. Medical aspects of flight for civilian aeromedical transport. Probl Crit Care 1990; 4:495-507.
10. Peckler S, Rodgers R Air versus ground transport for the trauma scene: optimal distance for helicopter utilization. J Air Med Transport 1988; 8:44.
11. Wright SW, Dronen SC, Combs TJ,. Storer D. Aeromedical transport of patients with post-traumatic cardiac arrest. Ann Emerg Med 1989; 18:721 - 6.
12. Snow N, Hull G Severns J. Physician presence on helicopter emergency service: necessary or desirable? Aviat Space Environ Med 1986; 57:1176-8.
13. Cottrell JJ, Garrard G Emergency transport by aeromedical blimp. BMJ 1989; 298:869 - 70.
14. National Transportation Safety Board Emergency medical service helicopter operations. Washington, DC: National Transportation Safety Board, 1988, publication No. NTSB/SS-88/01;
15. Collett H. 1989 Accident review. J Air Med Transport 1990; 9:12.
16. Kaplan L Walsh D, Burney RE. Emergency aeromedical transport of patients with acute myocardial infarction. Ann Emerg Med 1987; 16:55-7.
17. Sternbach G, Sumchai AP. Is aeromedical transport of patients during acute myocardial infarction safe? J Emerg Med 1989; 7(1) :73-7.
18. Fromm R, Hoskins E, Gonin L, Pratt C, Spencer W, Roberts R Bleeding complications following initiation of thrombolytic therapy for acute myocardial infarction: a comparison of helicopter-transported and non-transported patients. Ann Emerg Med 1991; 20:892-5.
19. Gordon RS, Odell KB, Low RB, Blumen IJ. Activity-sensing permanent internal pacemaker dysfunction during helicopter aeromedical transport. Ann Emerg Med 1990; 19: 1260-3.
20. Sumchai A, Sternbach G, Eliastarn M, Liem LB. Pacing hazards in helicopter aeromedical transport Am J Emerg Med 1988; 6:23-40.
21. Zimmerman JJ, Coyne M, Logsdon M Implementation of intraosseous infusion technique by aeromedical transport programs. J Trauma 1989; 29:687-9.
22. Thomas F, Larsen K, Clemmer TP, et al. Impact of prospective payments on a tertiary care center receiving large numbers of critically ill patients by aeromedical transport. Crit Care Med 1986; 14:227-30.
23. La Puma J, Balskus M. When an indigent patient needs a helicopter: a case report and an accepted institutional policy. J Emerg Med 1988; 6(2):147-9.
24. Dunn JD. Legal aspects of transportation. Probl Crit Care 1990; 4:447

Enlace TRANSPORTE AEROMEDICO Ficción y Realidad por José Ramón Aguilar

The Chinese navy hospital ship Peace Ark / Hospital ship 866 (Daishando). VIDEO

2012-03-04T08:45:00.001-05:00

The Type 920 Hospital Ship is a class of hospital ship in the People's Liberation Army Navy of the Peoples' Republic of China.

920 is the type of the ship. 866 is the PLA Navy side number of this ship, 岱山岛号 (Daishandao) is the navy name, 和平方舟 (Peace Ark) is the name in peacetime.

Launched in 2007, China is one of a few nations with naval floating hospitals. The Chinese rationale for the ship was to give China a platform to provide a better means to providing quicker humanitarian response to disasters around the world, but others contend it allows China to extend the navy's blue water capabilities.^[2] The single ship of the class has a pennant number 866. The ship is assigned to the East Sea Fleet and based out of Daishandao. The ship has 300 beds, 20 ICUs, 8 operating theatres, and the capacity to accommodate 40 major surgeries a day – about as many as a large hospital in Beijing.^[2]^[3] The ship is unarmed and painted white with red crosses to conform to the Geneva Convention criteria for a civilian hospital ship.

On September 1, 2010, the hospital ship embarked on a three months mission to the Gulf of Aden with a total of 428 officers including 100 medical workers. Enroute it will also visit and provide medical treatment to the local people of Djibouti, Tanzania, Kenya, the Seychelles and Bangladesh.^[1]

General characteristics
Name:	866
Ordered:	1
Builder:	CSIC (Guangzhou Shipyard International Company Limited)
Launched:	2007
Commissioned:	December 22, 2008
Status:	in active service, as of 2012
Displacement:	approximately 14,000 tons
Length:	178 metres
Beam:	approximately 25 metres
Propulsion:	twin shaft diesel turbines
Aircraft carried:	Z-8JH (27 passengers or 15 stretchers)
Aviation facilities:	hangar

NEW BURN TREATMENT ReCell ® Spray-On Skin ™

2012-03-04T07:39:00.001-05:00

Tea-scald toddler Zed Merrick given spray-on skin

A mother of a Lincolnshire toddler who was badly burnt says the result of a spray-on skin treatment was "amazing".

Two-year-old Zed Merrick, from Ulceby, spilled a hot cup of tea over himself last October, which left him severely scalded.

Doctors carried out a procedure where Zed's skin cells were sprayed on to the injury on his chest from an aerosol.

Zed's mother Nicky Merrick said the treatment has now left her son almost scar free.

She said at the time he was "obviously in a lot of pain and screaming".

'Peeling away'

"My mum was making a cup of tea and Zed ran in so quickly and pulled it all over himself before we could see him move," Ms Merrick said.

"My mum ripped his t-shirt off him, she wanted to get the hot shirt off his chest, I threw a jug of water over his chest and our neighbour got us both into the shower to get the cold water running on him.

"Straight away the skin was peeling away, similar to when you get sunburnt and your skin starts to peel, it was very red and very sore."

Ms Merrick said her neighbour, who was a nurse, put cold towels on Zed's chest and replaced them as they got hot until the paramedic arrived.

"We didn't realise at the time how spectacular the treatment is and how amazing the results can be.

"They take a sample of skin and turn into a spray. They sprayed that on to his chest and it helped the cells renew, grow and adapt."

Ms Merrick said she had no fear of the cells being rejected because they had been taken from Zed.

"His skin was very pink at first, but over the weeks it got paler and paler now you can't even see it that much now," she said.

'Healthy skin cells'

The ReCell Spray-On Skin treatment, developed by Avita Medical, was carried out in October 2011. It has taken four months for Zed's chest to look almost scar free.

Claire Darby, the company's clinical manager, said: "Essentially, ReCell is able to harness the body's natural ability to heal itself.

"It allows the surgeon to harvest all the healthy skin cells required to form normal healthy looking skin again as a one-step procedure.

"If the patient is treated early this will reduce the risk of scarring and chance of infection."

Ms Merrick added that the alternative treatment would have been skin graft.

"That could have meant several weeks in hospital, multiple operations and very painful bandage changes," she said.

Link BBC News

Link Product Web ReCell ^® Spray-On Skin ^™

NUEVO TRATAMIENTO QUEMADURAS "Aerosol ReCell On Skin tm"

2012-03-04T05:24:00.002-05:00

El aerosol que cura quemaduras

BBC Salud

Zed Merrick tiene dos años. Hace unos meses, un accidente doméstico le provocó severas quemaduras en el pecho. Y ya está prácticamente curado gracias a un novedoso tratamiento, un aerosol que se presenta como alternativas a los injertos de piel.

Las quemaduras se las provocó una taza con té hirviendo el pasado mes de octubre. Los estragos sobre la piel del niño resultaron evidentes casi al instante.

El tratamiento por el que optaron los médicos se basó en la aplicación de un aerosol.

Gracias a ese aerosol, la madre del niño, Nicky Merrick, asegura que su hijo prácticamente ya no tiene cicatrices.

Según Merrick, el niño pasó por mucho dolor y gritó mucho. "Mi madre estaba preparando una taza de té. Zed apareció corriendo y se lo tiró todo encima antes de que pudiéramos verlo", explica Merrick.

"Mi madre enseguida le rasgó la camiseta. Estaba desesperada por sacarle la ropa hirviendo de encima. Yo le tiré una jarra de agua fría y nuestra vecina nos ayudó a meternos a los dos bajo la ducha con agua fría", relató.

"La piel se le empezó despellejar muy rápido, como cuando se pela después de quemaduras por el sol. Después se le puso muy roja e irritada".

Merrick contó cómo su vecina, enfermera, le puso toallas con agua fría y las iba reemplazando conforme se iban calentando hasta que llegó la ambulancia.

"No nos dimos cuenta en el momento de lo espectacular que es el tratamiento y lo increíbles que pueden llegar a ser los resultados".

¿Como funciona?

Según explica la fabricante del aerosol Avita Medical, el tratamiento comienza con la retirada de una pequeña muestra de piel cercana a la zona afectada para que la resultante tenga color y textura similar.

Esta biopsia de unos dos centímetros cuadrados, es tratada con el aerosol ReCell On Skin para que sane de forma adecuada.

El médico entonces usará el aerosol para esparcirla por el área afectada, lo que ayuda a las células a regenerarse, crecer y adaptarse.

El tratamiento de Zed fue llevado a cabo en octubre de 2011. El pecho del niño tardó cuatro meses en tener un aspecto casi normal.

Claire Darby, la gerente clínica de Avita Medical, explicó que "en esencia, lo que hace ReCell es aprovechar la capacidad natural del cuerpo para regenerarse".

"Le permite al cirujano cosechar todas las células sanas de la piel para formar una piel saludable en un solo paso", dijo.

"Si el paciente es tratado a tiempo, eso reducirá el riesgo de tener cicatrices y la probabilidad de una infección", aseguró.

La madre del niño comentó que un tratamiento tradicional hubiera pasado por un injerto de piel.

"Eso podría haber implicado varias semanas en un hospital, muchas operaciones y cambios de vendajes muy dolorosos".

Enlace Fuente BBCmundo

Enlace Fabricante del Aerosol ReCell On Skin

Manual de Operaciones Especiales de la Policia de Colombia

2012-03-03T15:06:00.000-05:00

Enlace www.policia.edu.co para bajar manuale en formato pdf

MEDEVAC HISTORY AND TRIBUTE. VIDEO

2012-02-29T16:56:00.002-05:00

As with many innovations in Emergency Medical Services (EMS), the concept of transporting the injured by aircraft has its origins in the military and the concept of using aircraft as ambulances is almost as old as powered flight itself.

The first written record of the term "air ambulance" is in Jules Verne's Robur le Conquérant (1866), which describes the rescue of shipwrecked sailors by an airship (balloon) named the Albatross. The first documented use of an air ambulance occurred during the Siege of Paris in 1870. when balloons were used to evacuate more than 160 soldiers from the besieged city.

During the Great War, the first true Air Ambulance flight was made when a Serbian officer was flown from the battlefield to hospital by a plane of the French Air Service. Records kept by the French at the time indicated that, if casualties could be evacuated by air within six hours of injury, the mortality rate among the wounded would fall from 60 per cent to less than 10 per cent - a staggering reduction!

During the First World War air ambulances were tested by various military organizations. Aircraft were still primitive at the time, with limited capabilities, and the effort received mixed reviews. The exploration of the idea continued, however, and by 1936 an organized military air ambulance service was evacuating wounded from the Spanish Civil War for medical treatment in Nazi Germany.

The first recorded British ambulance flight took place in 1917 in Turkey when a soldier in the Camel Corps, who had been shot in the ankle, was flown to a hospital in a de Havilland DHH within 45 minutes. The same journey by land would have taken 3 days to complete. In Britain, sick passengers were ferried by air from the Western Isles of Scotland to the mainland in the early 1930s. The first such flight to be recorded was on May 14, 1933 when a fisherman suffering from a perforated stomach, with consequent risk of peritonitis, was flown from Islay to Glasgow's Western Infirmary in a DH Dragon owned by Midland and Scottish Air Ferries.

In Switzerland, with the increasing interest in winter sports during the early post World War 2 years, the use of air ambulances evolved from the increasing difficulties experienced in mountain rescue work. Initially fixed-wing aircraft were used, landing medical teams with equipment as close as possible to the injured parties so that rapid first aid treatment could be applied prior to evacuation.

To overcome a lack of suitable landing sites close to the incident in mountainous regions, it was even at one stage proposed to parachute medical personnel with equipment and sledges into the rescue area. Although training was undertaken, there is no documentary evidence to suggest that this technique was ever put into practice.

The first documented medevac by helicopter occurred during the second World War. In April 1944, a US Army Air Forces aircraft with three wounded British soldiers on board, was forced down in the jungle behind Japanese lines near Mawlu in Burma.A new US Army Sikorsky YR-4B helicopter, flown by Lt. Carter Harman, could carry only one passenger but, over 25-26 April 1944, four return trips were made.

Following the end of the Second World War, the first civilian air ambulance in North America was established by the Saskatchewan government in Regina, Saskatchewan, Canada. Back in the United States, 1947 saw the creation of the Schaefer Air Service, the country's first air ambulance service. Founded by J. Walter Schaefer, of Schaefer Ambulance Service in Los Angeles, Schaefer Air Service was also the first FAA-certified air ambulance service in the United States. Para-medicine was still decades away, and unless the patient was accompanied by a physician or nurse, they operated primarily as medical transportation services.

The first dedicated use of helicopters by U.S. forces occurred during the Korean War, during the period from 1950-1953. While popularly depicted as simply removing casualties from the battlefield (which they did), helicopters also expanded their services to moving critical patients to more advanced hospital ships once initial emergency treatment in field hospitals had occurred. On August 4, 1950, just one month after the start of the Korean War, the first rotorwing medical evacuation was performed with a bubble-fronted Bell 47 (as seen in the TV series M*A*S*H). The wounded were transported on basket stretchers attached to the top of the landing gear on the outside of the small helicopter (Figure 3-1). They were covered with blankets in a nearly futile effort to maintain body heat and prevent wound contamination. It is estimated that more than 20,000 injured soldiers were evacuated by helicopter. The World War II casualty/death rate of 4.5 deaths per 100 casualties dropped to 2.5 per 100 casualties during the Korean War. While there were some technological advances in medicine during that period, the improvement is largely attributed to use of the helicopter to evacuate patients to definitive care more quickly. The external litter, however, did not allow for medical care during transport.

The next major advance in AM transport occurred during the Vietnam War, where the Bell UH-1 helicopter was placed into operation. Affectionately known as the Huey, this aircraft was large enough to hold patients inside, where medical personnel could begin treatment during the flight to a field hospital. The mass deployment of these aircraft as medevac units reduced the average delay until treatment to one hour. The ability to carry patients inside the aircraft was a key element in the reduction of mortality and morbidity. Military medics performed procedures previously done only by physicians: they started central lines, inserted chest tubes, and sutured bleeding wounds. This care, coupled with the initiation of specialty hospitals for the treatment of different types of injuries, resulted in a reduction in the mortality rate to 1 death per 100 casualties.

The first known civilian application of a medical helicopter was in 1958 in Etna, California. Bill Mathews, a businessman, started a helicopter service to ferry patients for Dr. Granville Ashcraft, the town's only physician. The town druggist also used the helicopter to deliver drugs during emergencies.

By 1969, in Vietnam, the use of specially trained medical corpsmen and helicopters as ambulances led U.S. researchers to conclude that servicemen wounded in battle had better rates of survival than motorists injured on California freeways. This conclusion inspired the first experiments with the use of civilian paramedics in the world.

Two programs were implemented in the U.S. to assess the impact of medical helicopters on mortality and morbidity in the civilian arena. Project CARESOM was established in Mississippi in 1969. Three helicopters were purchased through a federal grant and located strategically in the north, central, and southern areas of the state. Upon termination of the grant, the program was considered a success and each of the three communities was given the opportunity to continue the helicopter operation. Only the one located in Hattiesburg did so, and it was therefore established as the first civilian air medical program in the United States. The second program, the Military Assistance to Safety and Traffic (MAST) system, was established in Fort Sam Houston in San Antonio in 1969. This was an experiment by the Department of Transportation to study the feasibility of using military helicopters to augment existing civilian emergency medical services. These programs were highly successful at establishing the need for such services.

Also, in 1969 the state of Maryland received a grant to purchase Bell Jet Ranger helicopters and started one of the nation's first medevac programs. The four helicopters, manned by paramedics, were strategically based throughout the state for quick response to emergency situations. When they were not carrying patients, the helicopters were used for law enforcement and traffic control.

On November 1, 1970, the first permanent civil air ambulance helicopter, Christoph 1, entered service at the Hospital of Harlaching, Munich, Germany. The first civilian, hospital-based medical helicopter program in the United States began operation in 1972. Flight For Life Colorado began with a single Alouette III helicopter, based at St. Anthony Central Hospital in Denver, Colorado. In Ontario, Canada, the air ambulance program began in 1977, and featured a paramedic-based system of care. The system, operated by the Ontario Ministry of Health, began with a single rotor-wing aircraft based in Toronto. An important difference in the Ontario program involved the emphasis of service. 'On scene' calls were taken, although less commonly, and a great deal of the initial emphasis of the program was on the interfacility transfer of critical care patients.

Mercy Flight WNY was established by Douglas H. Baker in 1981 as the first air-medical service in New York State and one of the first in the country. From day one, Mercy Flight WNY has maintained its independence of any hospital and is currently one of only a handful of remaining not-for-profit providers. The majority of other US programs are operated by either for-profit organizations or hospitals. (Right: Patient being loaded in the early 80's. Paramedic on left Margaret Ferrentino, was first female paramedic in NY State and is current Mercy Flight Vice-President/CFO.)

Helicopters continue to play a vital role in miltary medevacs. UH-60 Blackhawk helicopters have been used extensively in Iraq and Afganistan to medevac wounded soldiers from the battlefield. While both countries feature harsh desert environments that take their toll on helicopters, Afganistan's mountain peaks as high as 18,000 feet further complicate the mission. Because of the vast, mountainous terrain, evacuating casualties often extends beyond what doctors call the "golden hour": that crucial 60 minutes during which a traumatically-injured person has to reach a hospital before their survival chances plummet. So medics have begun doing emergency procedures inside helicopters that would normally wait for ER doctors.

The United States has some 200 operations whose services are paid for primarily by the patients and their insurance companies. As well as Switzerland, France, Austria, Italy Scandinavia and the former West Germany all have very successful versions of the helicopter-based EMS, the benefits of which have in some instances been particularly well-documented.

In Germany for example, there is now a network of helicopters which has evolved over the past twenty years to cover the entire country. Statistics which have been gathered over this period of time show:

An average response time to the scene of the incident of just 10 minutes.
Intensive care stays in hospital have been shorted by between five and seven days.
There are 9% fewer wound infections.
A significant reduction in the number of deaths during transport to hospital.
Head injury mortality has been reduced by 15%.

Information from http://www.mercyflight.org/content/pages/medevac

Related

Helicóptero BlackHawk como Ambulancia Aérea / BlackHawk Helicopter for Medical Evac / UH-60 A

Asistencia médica para bajas sufridas en combate táctico, pdf

HELICOPTERO BELL 412 PARA EVACUACION SANITARIA OFFSHORE, RIOHACHA. COLOMBIA HK-4731

Homenaje Servicios Sanitarios de Emergencias de Madrid

2012-02-29T15:45:00.000-05:00

IATA Medical Manual / Manual Medico de IATA "International Air Transport Association"

2012-02-28T14:36:00.000-05:00

Enlace para bajar manual en formato pdf

ARAÑA RECLUSA PARDA Loxosceles reclusa. Video

2012-02-27T16:52:00.000-05:00

Fuente MedlinePlus

Araña reclusa parda

La picadura o mordedura de una araña reclusa parda es venenosa. El nombre científico de esta araña es Loxosceles reclusa.

Esto es sólo para fines de información y no para usarse en el tratamiento ni en el manejo de una exposición tóxica real. Si usted sufre una exposición, debe llamar al número local de emergencias (tal como 911 en los Estados Unidos) o al Centro Nacional de Toxicología (National Poison Control Center) a la línea 1-800-222-1222.

Elemento tóxico

Veneno de araña reclusa parda

Dónde se encuentra

La araña reclusa parda es más común en los estados del centro y sur de los Estados Unidos, especialmente en Missouri, Kansas, Arkansas, Louisiana, Oklahoma y la parte este de Texas. Sin embargo, esta araña también ha sido encontrada en varias ciudades grandes fuera de este rango.

Esta araña prefiere áreas oscuras y cubiertas, como debajo de las terrazas y en las pilas de madera.

Síntomas

Cuando a usted lo pica la araña, puede sentir un escozor fuerte o no sentir nada en absoluto. El dolor generalmente se presenta en las primeras horas después de recibida la picadura y se puede volver intenso. Los niños pueden tener reacciones más severas.

Los síntomas pueden abarcar:

Escalofríos
Picazón
Sensación general de malestar o molestia
Fiebre
Náuseas
Coloración rojiza o púrpura en un círculo alrededor de la picadura
Sudoración
Úlcera en el área de la picadura

En casos raros:

Coma
Sangre en la orina
Ictericia
Insuficiencia renal
Convulsiones

Cuidados en el hogar

Busque tratamiento médico de emergencia y llame al número local de emergencias (como el 911 en los Estados Unidos) o al Centro de Toxicología. Lave el área con agua y jabón. Envuelva hielo en un trapo o en un material similar y póngalo sobre el área de la picadura, dejándolo por intervalos de 10 minutos. Repita este proceso. Disminuya el tiempo de contacto para los individuos que tengan problemas circulatorios.

Antes de llamar a emergencias

Antes de llamar a emergencias, determine lo siguiente:

Edad, peso y estado del paciente
La parte del cuerpo afectada
Hora en que ocurrió la picadura
El tipo de araña

El paciente debe ser llevado a la sala de urgencias para que reciba tratamiento. Es posible que la picadura no parezca ser grave, pero puede demorarse algún tiempo para que se torne más severa. El tratamiento es importante para reducir las complicaciones. De ser posible, coloque la araña en un recipiente seguro y llévela a la sala de urgencias para su identificación.

Centro de Toxicología

Se puede llamar al Centro Nacional de Toxicología (National Poison Control Center) al 1-800-222-1222 desde cualquier parte de los Estados Unidos. Esta línea gratuita nacional le permitirá hablar con expertos en intoxicaciones, quienes le darán instrucciones adicionales.

Se trata de un servicio gratuito y confidencial. Todos los centros de toxicología locales en los Estados Unidos utilizan este número. Usted debe llamar si tiene cualquier inquietud acerca de las intoxicaciones o la manera de prevenirlas. No tiene que ser necesariamente una emergencia; puede llamar por cualquier razón, las 24 horas del día, los 7 días de la semana.

Ver: Número de emergencia del Centro de Toxicología

Lo que se puede esperar en la sala de urgencias

El médico medirá y vigilará los signos vitales del paciente, incluyendo la temperatura, el pulso, la frecuencia respiratoria y la presión arterial.

Los síntomas se tratarán en la forma apropiada. Debido a que las picaduras de las arañas reclusas pardas pueden ser dolorosas, se pueden administrar analgésicos. También se pueden prescribir antibióticos si la herida está infectada.

Si la herida está cerca de una articulación, como la rodilla o el codo, se puede colocar la pierna o el brazo en una férula o cabestrillo y, de ser posible, mantenerlos elevados.

La picadura de este tipo de araña puede dejar un cráter grande y una cicatriz desagradable. Es posible que se necesite una cirugía semanas después para mejorar la apariencia de dicha cicatriz.

Pronóstico

Las muertes a causa de la picadura de la araña reclusa parda son más comunes en los niños. Con atención médica apropiada, la supervivencia después de 48 horas generalmente indica que la recuperación es posible. Una úlcera puede tomar hasta 6 semanas en sanar, con los cuidados apropiados.

Nombres alternativos

Loxosceles reclusa

Referencias

Peterson ME. Brown spider envenomation. Clin Tech Small Anim Practice. 2006;21(4):191-193.

Actualizado: 10/5/2009

Versión en inglés revisada por: Clark RF, Schneir AB. Arthropod bites and stings. In: Tintinalli JE, Kelen GD, Stapczynski JS, Ma OJ, Cline DM, eds. Emergency Medicine: A Comprehensive Study Guide. 6th ed. New York, NY: McGraw-Hill; 2004:chap 194.

Traducción y localización realizada por: DrTango, Inc.

Hojee la enciclopedia

Vídeo Técnico Transporte Sanitario España

2012-02-27T14:35:00.000-05:00

Un espíritu, una meta - Transporte sanitario

Cada día en una gran ciudad se producen más de 300 emergencias. Para salvar vidas, hacen falta héroes y estos héroes deben estar bien preparados

Enlace para ver el VIDEO desde RTVE

ACREDITACIONES WEB

2012-02-27T07:52:00.000-05:00

Intoxicación por Raticidas Anticuagulantes (RACUMIN)

2012-02-25T16:50:00.000-05:00

Enlace pagina oficial RACUMIN de Bayer información técnica

Intoxicación por cumarinicos

Iván Martínez, MD

Oficina de Recursos Educacionales.

Federación Panamericana de Asociaciones

de Facultades (Escuelas) de Medicina.

Bogotá

Enlace para bajar documento en pdf

BUQUE HOSPITAL "ESPERANZA DEL MAR" ESPAÑA

2012-02-25T13:39:00.000-05:00

La construcción del barco se adjudicó en septiembre de 1999, en concurso público, al astillero Juliana Constructora Gijonesa, S.A., y se fijó un plazo máximo de entrega de 24 meses.

El buque hospital prestará asistencia sanitaria y logística a los pescadores españoles en todos los mares del mundo. Responde a un proyecto íntegramente español, construido en astilleros de nuestro país y con tecnología cien por cien española. Contará con el mejor equipamiento sanitario y con los últimos avances técnicos. Por su seguridad y maniobrabilidad, estará preparado para navegar en condiciones climatológicas extremas.

A diferencia del primer "Esperanza del Mar", que proviene de la adaptación de un carguero que se pertrechó especialmente como buque hospital en 1982, el diseño del nuevo barco es el específico de un buque hospital, con dos aspectos a destacar en este nuevo proyecto y en los que el Ministerio de Trabajo ha puesto el máximo interés: el área hospitalaria y la seguridad.SEGURIDAD Y EFICACIA
Todo el diseño del barco gira en torno a un hospital que ocupa una cubierta completa desde proa, con acceso directo al helipuerto y a la cubierta, lo que facilita el transporte de enfermos y náufragos a la zona sanitaria.

Este área estará dotada de quirófano, rayos X, laboratorio, UVI, departamento para el tratamiento de quemados, infecciosos y enfermos psiquiátricos. En ella destaca la interconexión de las salas de curas y camarotes de enfermos, así como la luminosidad y ventilación natural de los espacios sanitarios y de todos los camarotes.

La capacidad inicial del buque será de 17 pacientes en la zona hospitalaria y 30 en la de náufragos, cuyos camarotes estarán ubicados en otra de las cubiertas, independiente del área sanitaria y del resto de la tripulación.

La amplitud de los camarotes permitirá que todas las camas vayan colocadas en el sentido proa-popa y que estén ubicadas lejos de los costados del barco, lo que representa una notable contribución a la seguridad de enfermos y tripulación en caso de abordaje.

La seguridad está presente también en los dispositivos de puesta a flote y recuperación de lanchas, que ha sido resuelto mediante un moderno sistema que permite asegurar fácilmente la embarcación, elevarla y arriarla con el mínimo riesgo tanto para las personas que van a operar con ella, como para quienes se encuentren a bordo. Además, destaca por su maniobrabilidad, propulsión y emergencia, y el bajo nivel de ruidos, incluso inferior al recomendado por la Organización Marítima Internacional.

El nuevo buque hospital tendrá un sistema de compartimentos para caso de abordaje con características similares a las exigidas a los grandes barcos de pasajeros, que evitan al máximo el hundimiento del buque por entrada de agua. Esta medida garantiza su seguridad cuando tenga que enfrentarse a situaciones climatológicas extremas o a posibles emergencias.

La novedad que presenta el proyecto del nuevo barco es que, además de asistir a la flota pesquera que faena en el banco canario-sahariano, podrá acudir a otros caladeros internacionales donde se encuentren las flotas españolas alejadas de los medios asistenciales sanitarios.

La tripulación del buque hospital que sustituya al antiguo "Esperanza del Mar" estará compuesta por 38 personas, de las cuales dos serán médicos, dos ATS y dos celadores. Contará también con buzos y personal especializado en la asistencia logística para atender a aquellas embarcaciones que lo requieran.
CARACTERÍSTICAS TÉCNICAS DEL NUEVO BUQUE

- Eslora total: 97,34 metros
- Motores propulsores principales: 2 x 2.700 Kw.
- Arqueo: 4.996 GT.
- Autonomía superior a 7.000 millas
- Alojamientos individuales para 38 tripulantes
- Helipuerto para evacuación urgente de enfermos o accidentados

- Zona hospitalaria con capacidad para 17 pacientes, quirófanos, rayos X, laboratorio de análisis clínicos, medios para tratamiento de quemados, camarotes para infecciosos y enfermos psiquiátricos, sistema informático conectado con el banco de datos del Centro Radio Médico

- Dos embarcaciones auxiliares adaptadas para transporte de enfermos o accidentados y una embarcación auxiliar de mayor tamaño, provista de U.C.I. - Camarotes para 30 náufragos

- Equipos antipolución para combatir derrames de hidrocarburos y sistemas de auxilio contraincendios

- Capacidad para dar servicios de remolque, suministro de combustible, agua dulce, energía eléctrica y aire comprimido a otros buques.

© Ministerio de trabajo y Asuntos Sociales, 2000
Agustín de Bethencourt, 4 28071 - Madrid

Esta información puede se usada en parte o en su integridad citando las fuentes.

Fuente diagrama diario El Pais

The Smallest AED in the Market Fred Easyport

2012-02-25T03:27:00.000-05:00

FRED EasyPort

The Worlds First Pocket Defibrillator

The Defibrillator so small and light that it fits in a coat pocket and still meets all the requirements of a modern day AED.

Light – Only 490g (including battery)
Small – only 133 X 126 X 35 mm
High Resolution LCD

Its small size and light weight make the FRED® EasyPort the ideal companion for physicians, tour guides, golf courses, hikers, aircraft, and other areas where light portability is of the essence.

Its portability and size means that at risk patients can cary their own AED, greatky reducing the response time to treat ventricular fibrillation and tachycardias. granting the victims a much better chance of survival.

The FRED Easyport AED from Schiller because of its small size and light weight is intended for use by basic life support responders, healthcare professionals, such as doctors, paramedics and public service staff.

Cost 2000-2300 Euros

Download Brochure Enlish pdf

Enlace Informacion en Español pdf

CURSO PHTLS Advanced Prehospital Trauma Life Support

2012-02-25T03:24:00.000-05:00

Pre-Inscripción 05-20 de Febrero del 2012
Les informamos a todos los interesados en participar de este curso que deben de hacer el pago de al menos el 50% (US$125) del Curso a mas tardar el dia 20 de Febrero del 2012 Comuniquese con Alexander Pacheco al numero 1 809 849 9295 eeiird@gmail.com SON MUY POCOS CUPOS LOS QUE QUEDAN.

¿Qué es PHTLS?

El curso Prehospital Trauma Life Support (Soporte Vital Básico y Avanzado en el Trauma prehospitalario) es un programa de Educación Médica Continuada único, que busca la excelencia en el manejo de los pacientes politraumatizados.

El PHTLS ha sido concebido y estructurado de forma que, permita que los miembros del personal sanitario prehospitalario con distintos niveles de formación académica, puedan asistir juntos al curso con el objetivo de desarrollar las capacidades de trabajo en equipo.

El hecho de seguir el mismo curso teórico y realizar las mismas prácticas, permite a los diferentes miembros del personal prehospitalario aprender a conocerse, asi como a potenciar los conocimientos y competencias de cada uno de los miembros en interés del paciente. El Curso ATLS (Advanced Trauma Life Support) fue creado en 1979 por el American College of Surgeons. Su método de enseñanza supuso una revolución que estandarizó la evaluación y manejo del paciente politraumatizado en medio intrahospitalario. En vista del éxito de éste curso, la Asociación de Técnicos de Emergencias Médica (NAEMT) solicitó al Dr. Norman Mc Swain de la Facultad de Medicina de New Orleans, el desarrollo de un “ATLS prehospitalario”. Los primeros cursos tuvieron lugar en Iowa en 1983. Desde entonces más de 400 000 alumnos de 34 paises han realizado el curso. El alumno recibe en su domicilio (al menos 30 días antes del curso) el Manual PHTLS Quinta Edición. Es un requisito imprescindible, el estudio del manual antes del curso. El curso PHTLS comienza con la realización de un exámen teórico (test de 50 preguntas), junto con una evaluación práctica de casos clínicos que permiten establecer un diagnóstico teórico-práctico de los conocimientos precurso.El curso PHTLS se desarrolla en una alternancia de cursos teóricos y estaciones prácticas, durante 21 horas (dos días) que permiten poner en práctica los conocimientos adquiridos sobre pacientes simulados.El curso PHTLS finaliza con una exámen teórico (80% de las preguntas) y práctico.El diploma asi como el carnet del Prehospital Trauma Life Support acreditado por la Nacional Association of Emergency Medical Technicians, con una vigencia de 4 años, es enviado posteriormente a los alumnos que han superado el curso.

¿ Por qué es único el curso PHTLS?

Pensamiento crítico:

El PHTLS promueve el pensamiento crítico como fundamento de la asistencia de calidad en el paciente politraumatizado.

Los pioneros del PHTLS, siempre ha creído que es imprescindible ofrecer al personal prehospitalario una sólida base de conocimientos junto con unos principios fundamentales, que permitan tomar las decisiones correctas adaptadas a cada paciente.El Soporte Vital en el Trauma Prehospitalario se basa en principios, no en preferencias.

No existe una sola “forma PHTLS” de hacer las cosas. Se enseñan los principios básicos que subyacen a cada habilidad y después se presenta un método aceptable de aplicarlo.Se insiste en la comprensión de los conceptos fundamentales en lugar del aprendizaje “de memoria” de los procedimientos. De esta forma, el personal prehospitalario es capaz de adaptarse a la miríada de situaciones únicas.

Prestigio:

El curso PHTLS ha sido desarrollado por los líderes en el campo del trauma – la Nacional Association of Emergency Medical Technicians (NAEMT) y el American College of Súrgenos - Committee on Trauma.

El respaldo de una organización internacional asegura la calidad y coherencia de los Cursos PHTLS.

Actualmente el curso PHTLS se imparte en 34 países, con más de mil cursos al año, todos ellos supervisados por el PHTLS International.

Acreditado

El curso PHTLS está acreditado por the Continuing Education Coordinating Board for Emergency Medical Services (CECBEMS) con 16 CE Hours. Acreditado por la Comisión de Formación Continuad del Sistema Nacional de Salud (Consejo Vasco de Formación Continuada).

Actualizado

El programa PHTLS se inició en 1981. Es la versión extra hospitalaria del curso Advanced Trauma Life Support (ATLS) para médicos, desarrollado por el Comité de Trauma del Colegio Americano de Cirujanos (ACS COT). El Colegio Americano de Cirujanos asegura la dirección médica y la supervisión médica del programa PHTLS. Cada 4 años (1 año después del curso ATLS), el curso PHTLS es actualizado y revisado por la NAEMT en colaboración con el Colegio Americano de Cirujanos (Comité de Trauma) en función de las últimas novedades médicas y el continuo feedback con los alumnos del PHTLS.

Manual PHTLS

Es sometido a una revisión y actualización continua. De forma que cada 4 años aparece una nueva edición. Aproximadamente un año después de que el Colegio Americano de Cirujanos, publique el nuevo material ATLS. “Presenta unos contenidos de muy alto nivel, avalados por estas dos grandes instituciones, con una claridad expositiva excepcional y unos diagramas y esquemas muy didácticos que facilitan al máximo la comprensión de los los temas tratados, tanto los conceptos fisiopatológicos más complicados como las técnicas de emergencias médicas.”

Funciona

“Se ha comprobado un mejor manejo de las vías aéreas, de la oxigenación de los pacientes, de la estabilidad de la columna cervical y de las hemorragias, a partir de la introducción del programa PHTLS. Esta mejoría se ha traducido en una reducción del 15,7% a un 10,6% de la mortalidad de los pacientes politraumatizados en la zona geográfica estudiada”

Ali J, Adam Ru, Gana TJ et al. Effect of the Pre Hospital Trauma Life Support (PHTLS) program on the prehospital trauma care. The Journal of Trauma, 1997:42:786.

Beginning in 1988, the U.S. military aggressively set out to train its

medics in PHTLS. Coordinated by DMRT, the Defense Medical

Readiness Training Institute at Fort Sam Houston in Texas. PHTLS is

taught all over the United States, Europe, and Asia and anywhere the

flags of the U.S. Military fly. In 2001, the Army's 91WB program

standardized the training of over 58,000 Army medics to include

PHTLS.

Programa del Curso de PHTLS formato pdf

Link para más información sobre PHTLS formato pdf

OXYGEN PATIENT CHECK LIST DURING IN-HOSPITAL TRANSPORT

2012-02-20T10:22:00.000-05:00

The AARC has developed checklists to assist you in the providing optimum care for patients at risk of oxygen desaturation during transport within the hospital.

Oxigenation monitoring during In-Hospital Transport of Neonates and Infants pdf document

Oxigenation monitoring during In-Hospital Transport of Pediatrics and Adults pdf document

Thanks
Supported with and education grand from MASIMOtm

Information from www.aarc.org

New Seizure treatment for EMS

2012-02-18T05:20:00.001-05:00

Seizure treatment study: Implications for EMS

Being able to use an auto-injector can simplify the procedure and speed up the delivery time

By Art Hsieh

Seizures are a common call for EMS systems. Often the physical manifestations of the seizure activity is over by the time we arrive; rarely do we have to manage the more serious condition of status epilepticus.
Because of its commonality, we might not consider the impact that seizures can have upon the patient, long after we managed their acute condition.
An advance like this has the potential to dramatically improve the overall health of the individual, and possibly reduce the need for emergency services.
There are also implications for EMS providers as well. It can be a challenge to administer an intravenous benzodiazepine when the patient is actively seizing.
Being able to use an auto injector can simplify the procedure and speed up the delivery time. It might also mean that terminating an active seizure might become a basic life support procedure. This can improve a system's overall ability to respond to these common calls.
That time might be some ways off. However, it's another interesting development in our business that benefits both patients and providers alike

About the author

EMS1 Editorial Advisor Art Hsieh, MA, NREMT-P currently teaches at the Public Safety Training Center, Santa Rosa Junior College in the Emergency Care Program. In the profession since 1982, Art has worked as a line medic and chief officer in the private, third service and fire-based EMS. He has directed both primary and EMS continuing education programs. A Past President of the National Association of EMS Educators, former Chief Executive Officer of the San Francisco Paramedic Association, and a scholarship recipient of the American Society of Association Executives, Art is a published textbook author, has presented at conferences nationwide, and continues to provide patient care at a rural hospital-based ALS system. Contact Art at Art.Hsieh@ems1.com.

Study: Injection offers faster help for seizure patients Results probably will change how seizures are treated by paramedics

Link to original information

By Erin Allday
The San Francisco Chronicle
SAN FRANCISCO — Injecting patients in the thigh with a drug-loaded syringe is a safe and effective way to stop a seizure in an emergency, according to results of a national study released Wednesday, a finding that could pave the way toward making such syringes as widely available as EpiPens used to treat severe allergic reactions.
The two-year study, published in the New England Journal of Medicine, concluded that a single stab from an auto-injector was more effective in stopping a prolonged seizure than the traditional method of inserting an intravenous line and delivering the drug directly into the bloodstream.
The results probably will change how such seizures, which can be life-threatening if they're not stopped right away, are treated by paramedics. But they could have more long-term repercussions if doctors start giving the auto-injectors to epileptic patients, some of whom have several severe seizures a year, to use at home, much as people with severe allergies carry epinephrine syringes with them.
"I don't think we're ready to hand these out at epilepsy clinics for people to take home right now," said Dr. J. Claude Hemphill, chief of neurology at San Francisco General Hospital, who led the San Francisco arm of the study. "But that may be a follow-up some folks want to do."
The U.S. Department of Defense also has taken special interest in the study, because auto-injectors would be much more convenient than IV drug treatment in a large-scale bioterrorism attack involving seizure-inducing nerve gas.
"The advantage is you can give it the auto-injection faster," said Dr. Walter Koroshetz, deputy director of the National Institute of Neurological Disorders and Stroke. "If you have 100 people simultaneously seizing, no way can you do all those IVs. But you could just run around and inject everybody for their seizures."
Seizures are caused by a disruption in the brain's electrical system, and in most cases they resolve themselves after a minute or so. Roughly 2 percent of Americans have epilepsy, a condition marked by chronic seizures.
Some seizures, known as status epilepticus or prolonged seizures, can last several minutes or longer, and they may require drugs to stop them. More than 50,000 people in the United States die from prolonged seizures every year, either from brain damage due to the seizure itself or from accidents related to passing out mid-attack.
The study, which was funded primarily by the National Institutes of Health, involved 79 hospitals nationwide, including several in the Bay Area. More than 4,000 paramedics were trained to participate in the study and 893 patients were treated.
A drug and a placebo
Every patient was given both the auto-injector shot, usually to the thigh, and an intravenous injection. But in half the cases the auto-injector was filled with a placebo, and in the other half the IV drug was a placebo. Neither patients nor paramedics knew which treatment was the placebo in any given case.
Researchers found that 73 percent of patients who were given the auto-injector drug had stopped seizing by the time they reached the emergency room; 63 percent of patients who got the IV drug were seizure-free.
Patients who were given the auto-injector drug were less likely than the IV group to be admitted to the hospital after their seizure.
"This auto-injection should be the new standard of care," said Dr. James Quinn, a professor of surgery and emergency medicine at Stanford who led the study there. "It's great when you can do a study and it's probably going to change how we do things."
Although two different drugs were used in the trial - midazolam for the auto-injector and lorazepam for the intravenous injection - researchers don't believe that the drugs made a difference in how effective the treatments were. Rather, they said, the auto-injectors are simply easier to use.
It's much simpler to give a single shot than to try to start an intravenous line on a patient who is actively convulsing, doctors and paramedics said. In the study, 42 patients did not receive the intravenous treatment because the paramedic couldn't start the IV, whereas only five patients didn't receive the auto-injector shot because the syringe malfunctioned.
"It takes time to set up an IV. You have to find a vein that's going to be good, you have to isolate the arm and hold it still, you have to clean the arm, you have to insert the needle," said Judy Klofstad, a paramedic with the San Francisco Fire Department who participated in the study. "If you're really good, it can take 2 1/2 minutes."
Paramedics took on average just 20 seconds to use the auto-injector, according to the study. "You just hold their thigh down, target it, and it can go right through their clothing, through jeans even," Klofstad said.
Doctors said that because the auto-injection drug causes heavy sedation and can lead to respiratory problems and low blood pressure, more research is needed before the syringes are handed out to patients.
But Tiffany Manning, who has epilepsy and suffers a prolonged seizure every two or three months, said she's excited about someday being able to carry around an auto-injector. Her doctor at the UCSF epilepsy clinic has prescribed an oral drug that her parents can give her when she has a seizure, but it can be time-consuming and difficult to measure out the proper dosage and make sure she swallows it, she said.
"And when I wake up I have a funny taste in my mouth," said Manning, 30. "My doctor doesn't prescribe it very often. You can overdose someone on it. ... I'd rather just have a shot in the leg."

Health Information for Travelers to Dominican Republic

2012-02-17T11:44:00.002-05:00

Preparing for Your Trip to the Dominican Republic

Before visiting the Dominican Republic, you may need to get the following vaccinations and medications for vaccine-preventable diseases and other diseases you might be at risk for at your destination: (Note: Your doctor or health-care provider will determine what you will need, depending on factors such as your health and immunization history, areas of the country you will be visiting, and planned activities.)
To have the most benefit, see a health-care provider at least 4–6 weeks before your trip to allow time for your vaccines to take effect and to start taking medicine to prevent malaria, if you need it.
Even if you have less than 4 weeks before you leave, you should still see a health-care provider for needed vaccines, anti-malaria drugs and other medications and information about how to protect yourself from illness and injury while traveling.
CDC recommends that you see a health-care provider who specializes in Travel Medicine. Find a travel medicine clinic near you. If you have a medical condition, you should also share your travel plans with any doctors you are currently seeing for other medical reasons.
If your travel plans will take you to more than one country during a single trip, be sure to let your health-care provider know so that you can receive the appropriate vaccinations and information for all of your destinations. Long-term travelers, such as those who plan to work or study abroad, may also need additional vaccinations as required by their employer or school.
Be sure your routine vaccinations are up-to-date. Check the links below to see which vaccinations adults and children should get.
Routine vaccines, as they are often called, such as for influenza, chickenpox (or varicella), polio, measles/mumps/rubella (MMR), and diphtheria/pertussis/tetanus (DPT) are given at all stages of life; see the childhood and adolescent immunization schedule and routine adult immunization schedule.
Routine vaccines are recommended even if you do not travel. Although childhood diseases, such as measles, rarely occur in the United States, they are still common in many parts of the world. A traveler who is not vaccinated would be at risk for infection.

Vaccine-Preventable Diseases

Vaccine recommendations are based on the best available risk information. Please note that the level of risk for vaccine-preventable diseases can change at any time.

Vaccination or Disease	Recommendations or Requirements for Vaccine-Preventable Diseases
Routine	Recommended if you are not up-to-date with routine shots, such as measles/mumps/rubella (MMR) vaccine, diphtheria/pertussis/tetanus (DPT) vaccine, poliovirus vaccine, etc.
Hepatitis A or immune globulin (IG)	Recommended for all unvaccinated people traveling to or working in countries with an intermediate or high level of hepatitis A virus infection (see map) where exposure might occur through food or water. Cases of travel-related hepatitis A can also occur in travelers to developing countries with "standard" tourist itineraries, accommodations, and food consumption behaviors.
Hepatitis B	Recommended for all unvaccinated persons traveling to or working in countries with intermediate to high levels of endemic HBV transmission (see map), especially those who might be exposed to blood or body fluids, have sexual contact with the local population, or be exposed through medical treatment (e.g., for an accident).
Typhoid	Recommended for all unvaccinated people traveling to or working in the Caribbean, especially if staying with friends or relatives or visiting smaller cities, villages, or rural areas where exposure might occur through food or water.
Rabies	Recommended for travelers spending a lot of time outdoors, especially in rural areas, involved in activities such as bicycling, camping, or hiking. Also recommended for travelers with significant occupational risks (such as veterinarians), for long-term travelers and expatriates living in areas with a significant risk of exposure, and for travelers involved in any activities that might bring them into direct contact with bats, carnivores, and other mammals. Children are considered at higher risk because they tend to play with animals, may receive more severe bites, or may not report bites.

Malaria

Areas of the Dominican Republic with Malaria: All areas (including resort areas), except none in the cities of Santiago and Santo Domingo.
If you will be visiting an area of the Dominican Republic with malaria, you will need to discuss with your doctor the best ways for you to avoid getting sick with malaria. Ways to prevent malaria include the following:

Taking a prescription antimalarial drug
Using insect repellent and wearing long pants and sleeves to prevent mosquito bites
Sleeping in air-conditioned or well-screened rooms or using bednets

All of the following antimalarial drugs are equal options for preventing malaria in the Dominican Republic: Atovaquone-proguanil, chloroquine, doxycycline, or mefloquine. For detailed information about each of these drugs, see Table 3-11: Drugs used in the prophylaxis of malaria. For information that can help you and your doctor decide which of these drugs would be best for you, please see Choosing a Drug to Prevent Malaria.
To find out more information on malaria throughout the world, you can use the interactive CDC malaria map. You can search or browse countries, cities, and place names for more specific malaria risk information and the recommended prevention medicines for that area.

Malaria Contact for Health-Care Providers
For assistance with the diagnosis or management of suspected cases of malaria, call the CDC Malaria Hotline: 770-488-7788 (M-F, 9 am-5 pm, Eastern time). For emergency consultation after hours, call 770-488-7100 and ask to speak with a CDC Malaria Branch clinician..

More Information About Malaria

Malaria is always a serious disease and may be a deadly illness. Humans get malaria from the bite of a mosquito infected with the parasite. Prevent this serious disease by seeing your health-care provider for a prescription antimalarial drug and by protecting yourself against mosquito bites.
Travelers to malaria risk-areas in the Dominican Republic, including infants, children, and former residents of Dominican Republic, should take one of the antimalarial drugs listed in the box above.

Symptoms

Malaria symptoms may include

fever
chills
sweats
headache
body aches
nausea and vomiting
fatigue

Malaria symptoms will occur at least 7 to 9 days after being bitten by an infected mosquito. Fever in the first week of travel in a malaria-risk area is unlikely to be malaria; however, you should see a doctor right away if you develop a fever during your trip.
Malaria may cause anemia and jaundice. Malaria infections with Plasmodium falciparum, if not promptly treated, may cause kidney failure, coma, and death. Despite using the protective measures outlined above, travelers may still develop malaria up to a year after returning from a malarious area. You should see a doctor immediately if you develop a fever anytime during the year following your return and tell the physician of your travel.
A Special Note about Antimalarial Drugs
You should purchase your antimalarial drugs before travel. Drugs purchased overseas may not be manufactured according to United States standards and may not be effective. They also may be dangerous, contain counterfeit medications or contaminants, or be combinations of drugs that are not safe to use.
Halofantrine (marketed as Halfan) is widely used overseas to treat malaria. CDC recommends that you do NOT use halofantrine because of serious heart-related side effects, including deaths. You should avoid using antimalarial drugs that are not recommended unless you have been diagnosed with life-threatening malaria and no other options are immediately available.
For detailed information about these antimalarial drugs, see Choosing a Drug to Prevent Malaria.

Items to Bring With You

Medicines you may need:

The prescription medicines you take every day. Make sure you have enough to last during your trip. Keep them in their original prescription bottles and always in your carry-on luggage. Be sure to follow security guidelines, if the medicines are liquids.
Antimalarial drugs, if traveling to a malaria-risk area in Dominican Republic and prescribed by your doctor.
Medicine for diarrhea, usually over-the-counter.

Note: Some drugs available by prescription in the US are illegal in other countries. Check the US Department of State Consular Information Sheets for the country(s) you intend to visit or the embassy or consulate for that country(s). If your medication is not allowed in the country you will be visiting, ask your health-care provider to write a letter on office stationery stating the medication has been prescribed for you.

Other items you may need:

Iodine tablets and portable water filters to purify water if bottled water is not available. See A Guide to Water Filters, A Guide to Commercially-Bottled Water and Other Beverages, and Safe Food and Water for more detailed information.
Sunblock and sunglasses for protection from harmful effects of UV sun rays. See Basic Information about Skin Cancer for more information.
Antibacterial hand wipes or alcohol-based hand sanitizer containing at least 60% alcohol.
To prevent insect/mosquito bites, bring:
- Lightweight long-sleeved shirts, long pants, and a hat to wear outside, whenever possible.
- Flying-insect spray to help clear rooms of mosquitoes. The product should contain a pyrethroid insecticide; these insecticides quickly kill flying insects, including mosquitoes.
- Bed nets treated with permethrin, if you will not be sleeping in an air-conditioned or well-screened room and will be in malaria-risk areas. For use and purchasing information, see Insecticide Treated Bed Nets on the CDC malaria site. Overseas, permethrin or another insecticide, deltamethrin, may be purchased to treat bed nets and clothes.

See other suggested over-the-counter medications and first aid items for a travelers' health kit.
Note: Check the Air Travel section of the Transportation Security Administration website for the latest information about airport screening procedures and prohibited items.

Other Diseases Found in the Caribbean
Risk can vary between countries within this region and also within a country; the quality of in-country surveillance also varies.

The following are disease risks that might affect travelers; this is not a complete list of diseases that can be present. Environmental conditions may also change, and up to date information about risk by regions within a country may also not always be available.
Dengue epidemics have occurred on many of the Caribbean islands. Most islands are infested with Aedes aegypti, so these places are at risk for introduction of dengue. Protecting yourself against insect bites (see below) will help to prevent this disease.
In 2006, malaria (falciparum) was confirmed in travelers to Great Exuma, Bahamas, and Kingston, Jamaica, areas where malaria transmission typically does not occur. An outbreak of eosinophilic meningitis caused by Angiostrongylus cantonensis occurred in travelers to Jamaica.
Cutaneous larval migrans is a risk for travelers with exposures on beaches and leptospirosis is common in many areas and poses a risk to travelers engaged in recreational freshwater activities. Such activities may include whitewater rafting, kayaking, adventure racing, or hiking. Endemic leptospirosis is reported in Jamaica. Travelers to regions in Jamaica can reduce their risk to leptospirosis by avoiding activities which expose them to contaminated fresh surface water. Outbreaks of ciguatera poisoning, which results from eating toxin-containing reef fish, have occurred on many islands.
Endemic foci of histoplasmosis are found on many Caribbean islands, and outbreaks have occurred in travelers.
Anthrax is hyperendemic in Haiti but has not been reported on most of the other islands. Haiti also has a high incidence rate of tuberculosis and high HIV prevalence rates.

Staying Healthy During Your Trip

Prevent Insect Bites

Many diseases, like malaria and dengue, are spread through insect bites. One of the best protections is to prevent insect bites by:

Using insect repellent (bug spray) with 30%-50% DEET. Picaridin, available in 7% and 15% concentrations, needs more frequent application. There is less information available on how effective picaridin is at protecting against all of the types of mosquitoes that transmit malaria.
Wearing long-sleeved shirts, long pants, and a hat outdoors.
Remaining indoors in a screened or air-conditioned area during the peak biting period for malaria (dusk and dawn).
Sleeping in beds covered by nets treated with permethrin, if not sleeping in an air-conditioned or well-screened room.
Spraying rooms with products effective against flying insects, such as those containing pyrethroid.

For detailed information about insect repellent use, see Insect and Arthropod Protection.

Prevent Animal Bites and Scratches

Direct contact with animals can spread diseases like rabies or cause serious injury or illness. It is important to prevent animal bites and scratches.

Be sure you are up to date with tetanus vaccination.
Do not touch or feed any animals, including dogs and cats. Even animals that look like healthy pets can have rabies or other diseases.
Help children stay safe by supervising them carefully around all animals.
If you are bitten or scratched, wash the wound well with soap and water and go to a doctor right away.
After your trip, be sure to tell your doctor or state health department if you were bitten or scratched during travel.

For more information about rabies and travel, see the Rabies chapter of the Yellow Book or CDC's Rabies homepage. For more information about how to protect yourself from other risks related to animals, see Animal-Associated Hazards.

Be Careful about Food and Water

Diseases from food and water are the leading cause of illness in travelers. Follow these tips for safe eating and drinking:

Wash your hands often with soap and water, especially before eating. If soap and water are not available, use an alcohol-based hand gel (with at least 60% alcohol).
Drink only bottled or boiled water, or carbonated (bubbly) drinks in cans or bottles. Avoid tap water, fountain drinks, and ice cubes. If this is not possible, learn how to make water safer to drink.
Do not eat food purchased from street vendors.
Make sure food is fully cooked.
Avoid dairy products, unless you know they have been pasteurized.

Diseases from food and water often cause vomiting and diarrhea. Make sure to bring diarrhea medicine with you so that you can treat mild cases yourself.

Avoid Injuries

Car crashes are a leading cause of injury among travelers. Protect yourself from these injuries by:

Not drinking and driving.
Wearing your seat belt and using car seats or booster seats in the backseat for children.
Following local traffic laws.
Wearing helmets when you ride bikes, motorcycles, and motor bikes.
Not getting on an overloaded bus or mini-bus.
Hiring a local driver, when possible.
Avoiding night driving.

Other Health Tips

To avoid infections such as HIV and viral hepatitis do not share needles for tattoos, body piercing, or injections.
To reduce the risk of HIV and other sexually transmitted diseases always use latex condoms.
To prevent fungal and parasitic infections, keep feet clean and dry, and do not go barefoot, especially on beaches where animals may have defecated.

After You Return Home

If you are not feeling well, you should see your doctor and mention that you have recently traveled. Also tell your doctor if you were bitten or scratched by an animal while traveling.
If you have visited a malaria-risk area, continue taking your chloroquine for 4 weeks after leaving the risk area.
Malaria is always a serious disease and may be a deadly illness. If you become ill with a fever or flu-like illness either while traveling in a malaria-risk area or after you return home (for up to 1 year), you should seek immediate medical attention and should tell the physician your travel history.

Important Note: This document is not a complete medical guide for travelers to this region. Consult with your doctor for specific information related to your needs and your medical history; recommendations may differ for pregnant women, young children, and persons who have chronic medical conditions.

2010 AMERICAN HEART ASSOCIATION and AMERICAN RED CROSS FOR FIRST AID

2012-02-13T15:41:00.001-05:00

Please Follow the link to download in pdf

COAST GUARD AVIATION MEDICINE MANUAL

2012-02-07T15:47:00.000-05:00

COAST GUARD AVIATION
MEDICINE MANUAL

U.S. Department of
Homeland Security
United States
Coast Guard

Enlace para bajar manual en pdf

Vinculo mayor Riesgo de Muerte con Pildoras para Dormir

2012-02-06T18:24:00.000-05:00

SALUD

Las píldoras para dormir vinculadas a un mayor riesgo de muerte

AFP

Londres

Las pastillas para dormir comúnmente recetadas están ligadas a un riesgo cuatro veces mayor de una muerte prematura, según un estudio estadounidense publicado en la revista British Medical Journal.

Esta medicación a grandes dosis está asociada con un 35% más de riesgo de padecer cáncer en comparación con personas que no las usan, pero las razones de este vínculo todavía no son claras, señala el estudio publicado el lunes.

Los doctores dirigidos por Daniel Kripke del Centro del Sueño de la Clínica de la Familia Scripps Viterbi en La Jolla, California, estudiaron el historial médico de 10.500 adultos que viven en Pensilvania y a los que se les había recetado medicación para dormir.

Los datos fueron cotejados con los de más de 23.600 personas, comparadas por edad, salud, y origen, que no tomaba esa medicación.

El estudio se alargó durante dos años y medio y estudió las píldoras comúnmente recetadas a amplios sectores de la población para dormir, lo que incluye benzodiazepinas, no benzodiazepinas, barbitúricos y sedativos.

El número total de muertes que ocurrió durante este período fue pequeño en ambos grupos, totalizando menos de 1000 muertes.

Pero hubo una sorprendente diferencia en la mortalidad, encontraron los investigadores.

Aquellos que tomaron entre 18 y 132 dosis anuales de medicación para dormir tenían 4,6 más posibilidades de morir que el grupo de control.

Incluso aquellos que tomaron menos de 18 dosis anuales tenían 3,5 más posibilidades de morir.

"Los cálculos a grandes rasgos sugieren que en 2010 los hipnóticos (pastillas para dormir) podrían estar asociados con entre 320.000 y 507.000 excesos de muertes en Estados Unidos únicamente", afirma el estudio.

Los detalles de cómo murieron los individuos no fueron desvelados, y los autores recalcan que encontraron una relación estadística pero no una causa.

Pero hicieron sonar la alarma debido al gran número de gente que toma esta medicación.

"Estimamos que, aproximadamente, del seis al 10% de los adultos en Estados Unidos tomaron estos fármacos en 2010 y los porcentajes podrían ser mayores en algunas partes de Europa", escriben.

La media de edad de las personas del estudio fue 54 años. Los investigadores afirmaron que tomaron en cuenta factores que pudieran hacer posible la comparación entre los dos grupos, como si el individuo fumaba o tenía una problema de salud pre existente.

Sin embargo, no fueron capaces de tener en cuenta factores como depresión, ansiedad u otras cuestiones emocionales, ya que los diagnósticos se mantienen en secreto bajo la ley de Pensilvania.

Las investigaciones previas en píldoras para dormir encontraron una relación entre accidentes de coche y caídas graves, síndromes relacionados con comer por la noche, darse atracones de comida, regurgitación en el esófago y úlcera péptica.

Guidelines for the Field Triage of Injured Patients. CDC

2012-02-03T19:12:00.000-05:00

Field Triage

Guidelines for the Field Triage of Injured Patients

Injuries affect all Americans.
They are the leading cause of death for children and adults from age 1 to 44 in the United States.
At the scene of an injury, Emergency Medical Service (EMS) professionals must identify the severity and type of injury, and determine which hospital or other facility would be the most appropriate to meet the needs of the patient. This is done through a process called “field triage.”
The profound importance of daily on-scene triage decisions made by EMS professionals is reinforced by CDC-supported research that shows that the overall risk of death was 25 percent lower when care was provided at a Level I trauma center than when it was provided at a non-trauma center.
Not all injured patients can or should be transported to a Level I trauma center. Other hospitals can effectively meet the needs of patients with less severe injuries, and may be closer to the scene. Transporting all injured patients to Level I centers—regardless of injury severity—limits the availability of Level I trauma center for those patients who really need the level of care provided at those facilities. Proper field triage ensures that patients are transported to the most appropriate healthcare facility that best matches their level of need.
In 2009, the Centers for Disease Control and Prevention (CDC) published guidance on the field triage process in “Guidelines for Field Triage of Injured Patients, Recommendations of the National Expert Panel on Field Triage” in the Morbidity and Mortality Weekly Report (MMWR).
The updated Guidelines, published in the newly released MMWR reflect the results of the Panel’s deliberations and include changes made upon the best available evidence, and incorporate the experiential base that CDC has developed through its close work with states, national organizations, communities, and individual professionals.
The 2011 Guidelines for the Field Triage of the Injured Patient initiative is developed to give EMS leaders and professionals the tools they need to implement and adopt the 2011 Guidelines.

Link to CDC

Download the

Guidelines for the Field Triage of Injured Patients

Prehospital topical hemostatic agents - A review of the current literature

2012-02-02T11:47:00.000-05:00

Prehospital topical hemostatic agents – A review of the current literature

PHTLS Executive Committee

Lance E. Stuke, M.D. MPH

Background: The 7^th edition PHTLS textbook discusses the use of topical hemostatic agents which were are available for prehospital use. Products come and go from the market so it is difficult to remain current on all available products. Additionally, older products may still be in use due to surplus, although they may not be commercially available. Data on many of these products is based primarily on military reports and very little data is available on their use in the civilian prehospital setting. The vast majority of these products have been researched and developed for use in the military setting in Iraq and Afghanistan although some limited civilian data is also available. At the time of printing of the 7^th edition of PHTLS, only Combat Gauze has been recommended by the Tactical Combat Casualty Care Committee (COTCCC) for military use.

The perfect hemostatic dressing does not exist. Ideally, the dressing should be lightweight, easy to store, and able to be rapidly applied to a hemorrhaging wound. It should be conformable to the wound, allowing the hemostatic agent to reach areas of injury which are difficult to access with direct pressure (i.e. deep groin wounds). The dressing should cause minimal local tissue destruction, be easily removable from the wound, and not contain particles which can spread systemically. Finally, the dressing must not be washed away by rapid bleeding from high-flow blood vessels.

Manufacturers have tried various methods to deliver hemostatic agents into bleeding wounds. Some products are packaged into a granular form which can be poured directly into the wound. Others are incorporated into a dressing or mesh which allows the provider to apply direct pressure to the site of injury. This dressing can be formed either as a rigid bandage, a small bag, or a gauze which must be unrolled prior to application. Each method of preparation has distinct advantages and disadvantages depending on the location and type of injury being treated.

Literature and Product Review:

HemCon: HemCon dressing (Hemorrhage Control Technologies, Portland, OR), is composed of chitosan, a substance derived from arthropod skeletons. Chitosan dressings are thought to function by mechanically sealing the wound and adhering to surrounding tissue. HemCon is a dual-sided 4 x 4 inch rectangular bandage: a chitosan-containing active side which must be placed directly on the wound and a nonstick side which the provider uses to apply pressure. The efficacy of HemCon depends entirely on the bandage adhering well to the wound, which is difficult in wounds which aren’t flat and easily accessible. The bandage isn’t flexible and can break when forced into a wound. It is best applied to flat, superficial wounds which are easily accessible. HemCon has been studied in both the military and civilian settings. The military demonstrated a 97% success rate in controlling bleeding with HemCon.^1,2 The civilian experience has been less optimistic, controlling bleeding in 27 of 34 cases studied (79%). Of the seven failures, six were felt to be due to user error, possibly due to less training by civilian EMS providers in the proper use of the product.³ An additional study using a complex groin injury model in swine noted an increase in the rate of rebleeding and mortality between those treated with HemCon versus QuikClot. The authors noted that application of HemCon was more difficult than other agents and all failures of HemCon were due to the bandage not adhering to the injured tissue to which it was applied.⁴

As previously noted, a disadvantage of the HemCon dressing is that it is relatively non-conformable and difficult to pack into deeper wounds. ChitoFlex is the latest development from HemCon Medical Technologies. It utilizes the same chitosan-based hemostatic agent but packages it into a gauze form. This allows the dressing to be packed into deep bleeding wounds for improved access to the site of hemorrhage. ChitoFlex is available in several sizes, including 1”x3”, 3”x9”, and as a 3”x28” roll. In one study, ChitoFlex was found to be equivalent, but not superior to QuikClot and Celox (a chitosan granule).⁵

WoundStat: WoundStat was an FDA-approved mineral-based agent consisting of granular smectite, a nonmetallic clay. When the granules were exposed to blood they absorbed water, swelled, and formed a clay paste with strong adhesiveness to the surrounding tissue. Initial studies were promising^6,7,8 and it was used by the U.S. Army for a short time. However, later data demonstrated that the granules could cause injury to the blood vessels and make repair difficult. The granules were also shown to enter the circulatory system and cause thrombosis in distal organs.⁹ Because of these potentially serious side effects, the U.S. Army announced in April 2009 that WoundStat would no longer be used by their medical personnel.

QuikClot: QuikClot (Z-Medica, Wallingford, CT) is a granular product consisting of kaolin, which is a combination of inert minerals such as silicon, aluminum, magnesium, and sodium found in volcanic rock. When placed in a bleeding wound, it absorbs water thereby increasing the local concentration of clotting factors, platelets, and red blood cells to stimulate clot formation. A byproduct of its mechanism is a severe exothermic reaction, with heat generation of up to 70̊ C (158^o F). This heat generation causes local tissue destruction and even burns. QuikClot has been studied in both the military and civilian sector, with up to 92% effectiveness in stopping hemorrhage.¹⁰ QuikClot was issued to U.S. soldiers in the Iraq and Afghanistan conflicts. Civilian use has been by a wide range of providers, including EMT/firefighters, paramedics, and police. Examples of civilian use include treatment of severe lacerations, gunshot wounds to the neck and even hemodialysis catheter dislodgement. Trauma surgeons have also used QuikClot for successful treatment of bleeding during surgery in the chest, abdomen, and pelvis. QuikClot was noted to have two significant weaknesses. Since it is a granular powder poured into a wound, it had limited usefulness in high-pressure bleeding (i.e. femoral artery bleed) as the granules were washed away by the bleeding before they were able to form a clot. Furthermore, the heat generated from its use was associated with several burns.

QuikClot production was stopped after development of several newer generation products. These newer generation products have minimal heat production and are packaged both as gauzes and in a bagged form. Currently Z-Medica sells QuikClot packaged in 2”x2” and 4”x4” gauze pads for use on superficial lacerations which don’t have severe bleeding. QuikClot has also developed a small zeolite-impregnated pad (QuikClot ACS+) and as a laparotomy pad (QuikClot Trauma Pad) for use by trauma surgeons in the operating room for cases of severe bleeding during surgery. This later product remains in the research phase and is not yet approved for widespread use.

Combat Gauze^TM is a 3”x4 yard long roll of nonwoven gauze impregnated with kaolin. Combat Gauze has all the advantages of normal gauze (easy application, flexible, large coverage area, and easily removable) with the additional advantage of hemostatic function from the kaolin. It is designed for packing into deep wounds which are actively bleeding (i.e. arterial injury in the groin). Prehospital personnel can also use combat gauze as they would any standard Kerlix gauze. Combat Gauze was recently compared to several newer generation products, including the HemCon RTS, and found to be superior and had no apparent side effects.¹¹ A study from the Israel Defense Force reviewed fourteen uses of Combat Gauze and noted a 79% success rate.¹² The authors noted that in the three instances where Combat Gauze was unsuccessful, the soldiers had such severe injuries that only surgical control was successful. One of the three soldiers died from the severity of his wounds. Currently, Combat Gauze is the only product endorsed by the Tactical Combat Casualty Care Committee and they recommend it as first line treatment for life-threatening hemorrhage on external wounds not amendable to direct pressure and tourniquet placement.

A disadvantage of most topical hemostatic agents is they require 2-5 minutes of direct pressure to be effective. This amount of time is often not available during care under fire situations seen in combat or during a mass casualty situation. A study published in the Journal of Trauma compared Combat Gauze (used by the U.S. military), Celox Gauze (used by the United Kingdom), and standard Kerlix gauze.¹³ A 6mm side-wall injury was created in swine, 30 seconds of free hemorrhage was allowed, and wounds were packed with one of the three gauzes. The animals were resuscitated with Lactated Ringers to maintain baseline mean arterial pressure. The authors noted no difference in success of either dressing. The Kerlix gauze was packed faster than Combat and Celox Gauze. There was no difference in survival, dressing success, or blood loss between the three dressings. The authors note they were somewhat surprised by this finding and note that in care under fire situations where tourniquet use is not an option, standard gauze packed in a wound performed equally well to Combat Gauze and Celox Gauze.

A study from the Naval Medical Center in Portsmouth, VA compared several commercially available topical hemostatic agents to the application of direct pressure with standard gauze.¹⁴ The authors used a swine model with a severed femoral artery and vein to simulate a high-velocity projectile injury with jagged surrounding muscle. Combat Gauze, WoundStat, Celox-A, and ChitoFlex were applied to the created injuries per the manufacturer recommendations. They were then compared to each other and to standard gauze applied using direct pressure. Manual pressure was held for 5 minutes and any bleeding occurring after this was considered a failure of hemostasis. Primary outcome measures were failure of initial hemostasis and the incidence of rebleeding. Secondary measures included total blood loss, amount of rebleeding, and survival. WoundStat performed more poorly than Celox-A in achieving initial hemostasis and in the incidence of rebleeding. Surprising to the authors, standard gauze and direct pressure performed equally as well as the 4 commercially available topical hemostatic agents. There were no significant differences in failure of initial hemostasis, rebleeding, or death between standard gauze and the other agents.

Summary:

- Numerous topical hemostatic products have been developed and released onto the market.

- Some of these products have since been discontinued, while others are widely used.

-Economic and medical considerations continue to make this a rapidly evolving and growing area of prehospital care. It is important for the EMS provider to remain cognizant of these products and their advantages, disadvantages, and complications as they continue to evolve.

- Recent data suggests direct pressure with standard gauze may be equally effective as commercially available hemostatic agents. Providers should consider this when attempting to control hemorrhage. Principles of adequate direct pressure and wound packing continue to be the cornerstone of controlling severe traumatic bleeding from penetrating extremity wounds.

PHTLS Recommendation: Topical hemostatic agents may be used to control hemorrhage occurring in sites not amenable to tourniquet placement and which cannot be controlled by direct pressure alone.

Bibliography

1. Achneck HE, Sileshi B, Jamiolkowski RM, et al. A comprehensive review of topical hemostatic agents: Efficacy and recommendations for use. Annals of Surgery 2010; 251: 217-228.

2. Mabry R and McManus JG. Prehospital advances in the management of severe penetrating trauma. Crit Care Med. 2008:36(7);S258-266.

3. Brown MA, Daya MR, Worley JA. Experience with chitosan dressings in a civilian EMS system. J Emerg Med. 2009;62:239-243.

4. Kozen BG, Kircher SJ, Henao J, et al. An alternative hemostatic dressing: comparison of CELOX, HemCon, and QuikClot.Acad Emerg Med. 2008; 15:74-81.

5. Devlin JJ, Kircher S, Kozen BG, et al. Comparison of ChitoFlex, CELOX, and QuikClot in control of hemorrhage. J Emerg Med. 2009 Apr 1 (Epub ahead of print).

6. Ward KR, Tiba MH, Holbert WH, et al. Comparison of a new hemostatic agent to current combat hemostatic agents in a swine model of lethal arterial hemorrhage. J Trauma. 2007;63:276-284.

7. Kheirabadi BS, Edens JW, Terrazas IB, et al. Comparison of new hemostatic granules/powders with currently deployed hemostatic products in a lethal model of extremioty arterial hemorrhage in swine. J Trauma. 2009;66:316-328.

8. Arnaud F, Parreno-Sadalan D, Tomori T, et al. Comparison of 10 hemostatic dressings in a groin transaction model in swine. J Trauma. 2009;67:848-855.

9. Bheirabadi BS, Mace JE, Terrazas IB, et al. Safety evaluation of new hemostatic agents, smectite granules, and kaolin-coated gauze in a vascular injury wound model in swine. J Trauma. 2010;68:269-278.

10. Rhee P, Brown C, Martin M, et al. QuikClot use in trauma for hemorrhage control: case series of 103 documented uses. J Trauma. 2008;64:1093-1099.

11. Kheirabadi BS, Scherer MR, Estep JS, et al. Determination of efficacy of new hemostatic dressings in a model of extremity arterial hemorrhage in swine. J Trauma. 2009;67:450-460.

12. Ran Y, Hadad E, Daher S, et al. QuikClot Combat Gauze Use for Hemorrhage Control in Military Trauma: January 2009 Israel Defense Force Experience in the Gaza Strip – A Preliminary Report of 14 Cases. Prehop Disaster Med 2010;25(6):584-588.

13. Watters JM, Van PY, Hamilton GJ, et al. Advanced Hemostatic Dressings Are Not Superior to Gauze for Care Under Fire Scenarios. J Trauma. 2011;70:1413-1419.

14. Littlejohn LF, Devlin JJ, Kircher SS, et al. Comparison of Celox-A, ChitoFlex, WoundStat, and Combat Gauze Hemostatic Agents Versus Standard Gauze Dressing in Control of Hemorrhage in a Swine Model of Penetrating Trauma. Acad Emerg Med. 2011:18(4);340-350.

"Cough CPR". AHA position

2012-01-31T17:08:00.000-05:00

The American Heart Association does not endorse "cough CPR," a coughing procedure widely publicized on the Internet. As noted in the 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care, “cough CPR” is not useful for unresponsive victims and should not be taught to lay rescuers.

During a sudden arrhythmia (abnormal heart rhythm), it may be possible for a conscious, responsive person to cough forcefully and repetitively to maintain enough blood flow to the brain to remain conscious for a few seconds until the arrhythmia is treated. Blood flow is maintained by increased pressure in the chest that occurs during forceful coughs. This has been mislabeled "cough CPR," although it's not a form of traditional resuscitation.

Why isn't "cough CPR" appropriate in CPR training courses? should not be taught in lay-rescuer CPR courses because it is generally not useful in the prehospital setting. In virtually all lay-rescuer CPR courses, the finding that signals an emergency is the victim's unresponsiveness. Unresponsive victims will not be able to perform "cough CPR."

Are there situations when "cough CPR" is appropriate?“Cough” CPR may be considered in settings such as the cardiac catheterization laboratory where patients are conscious and constantly monitored (for example, with an ECG machine). A nurse or physician is also present who can instruct and coach the patients to cough forcefully every one to three seconds during the initial seconds of a sudden arrhythmia. However, as this is not effective in all patients, it should not delay definitive treatment.

AHA Recommendation
The best strategy is to be aware of the early warning signs for heart attack and cardiac arrest and respond to them by calling 9-1-1. If you're driving alone and you start having severe chest pain or discomfort that starts to spread into your arm and up into your jaw (the scenario presented in the Internet article), pull over and flag down another motorist for help or phone 9-1-1 on your mobile phone.

Link http://www.heart.org/HEARTORG/Conditions/More/CardiacArrest/Cough-CPR_UCM_432380_Article.jsp#.TyOM1Fyn_44

EMS SOLUTIONS INTERNATIONAL

BUQUE HOSPITAL JUAN DE LA COSA. ESPAÑA

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Guidelines for the Field Triage of Injured Patients. CDC

Field Triage

Guidelines for the Field Triage of Injured Patients

Guidelines for the Field Triage of Injured Patients

Prehospital topical hemostatic agents - A review of the current literature

"Cough CPR". AHA position

Other Diseases Found in the Caribbean
Risk can vary between countries within this region and also within a country; the quality of in-country surveillance also varies.