Usefulness of the system using a front type doctor car bearing the mission of pre-hospital medical care has not yet been established. To establish a useful doctor car dispatch system as a 3rd emergency facility in the central part of the metropolis, we investigated how to select a serious case at a stage of 119 call, and clarified the utility, safety and problems of pre-hospital medical care using the doctor car dispatch system. A flow chart to extract patients with suspicion of a stroke, an acute coronary syndrome or a serious external injury using contents of 119 calls was made, and the doctor car dispatch system was employed for 87 days. The 94 dispatch operations have been taken up as subjects. Time needed perception of the 119 call to arrival of ambulance and the doctor car at scene was 4.88 ± 0.20 minutes (n=74) and 10.01 ± 0.53 minutes (n=90), respectively. The mean activity time of the rescue team at scene was 13.37 ± 0.66 minutes (n=73), and the mean time from perception of the 119 call to admission into the medical center was 23.22 ± 0.86 minutes (n=60). Out of 42 strokes and 13 acute coronary syndromes suspected on the 119 calls, those actually determined as failures in the central nerve system or the cardiovascular system were 42.5% and 61.5%. A ratio of the patients noted as the triage of tertiary emergency was about 10%. Medical care by the dispatch medical team was carried out in 23 cases (24.5%), wherein 3 cases were evaluated as appropriate treatment corresponding with final diagnosis. The mean activity time of the rescue team at scene with and without medical care by the dispatch medical team was 13.78 ± 1.04 minutes and 13.18 ± 0.85 minutes, respectively, revealing no significant difference. The mean conveyance time of 10 patients without medical care by the dispatch medical team at scene out of 18 patients who presented serious illnesses at the time of contact was 1.49 minutes. Referring to the doctor car dispatch system taken up in this study, there was no timely disadvantage, while the fixed flow chart was considered appropriate. However, in the large metropolitan area, the conveyance time is greatly concerned with the usefulness of medical care by the dispatch medical team at scene. The patient extraction whose validity is high is very important. Further, it also requires an ability of allowing nearly 90% of so-called over-triage, to which the community as a whole should have to work hard for building up the system.

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Objectives: This study aimed to examine the modality of stroke care by elucidating the current situation of prehospital emergency medical transportation, treatment, and rehabilitation for stroke patients in the city of Funabashi, Japan. Methods: We conducted an observational study of 21,853 cases of emergency medical transportation provided by the fire department ambulatory unit in the city of Funabashi (population: 560,000) between April 2002 and March 2003. This study conducted an analysis of data from 868 patients who were diagnosed with stroke (e.g., intracerebral hemorrhage, subarachnoid hemorrhage, and cerebral infarction). Results: Of the 868 stroke patients transported during the one-year period in which this study was conducted, 29.6% were 75 years of age or older and 87.6% were transported to hospitals within Funabashi. There were 532 cerebral infarction patients (61%), of which 48.3% were 75 years of age or older. Forty-seven cerebral infarction patients (10.9%) were transported to Funabashi Municipal Medical Center and the remaining 384 cerebral infarction patients to other medical facilities within the city. Eighty-seven percent of stroke patients received treatment in the department of internal medicine followed by rehabilitation. Outcomes after two weeks indicated a significantly higher mortality rate in subarachnoid hemorrhage patients compared to other categories of stroke. The number of cerebral infarction patients who were able to return home was limited to 102 (19%), whereas most required long-term hospitalization and rehabilitation. Outcomes after three months showed that 194 (40.2%) of 484 hospitalized patients returned home. Discussion: The goal of stroke care is to establish a community healthcare system that provides services ranging from acute treatment to rehabilitation. Stroke care in Funabashi would further improve with the following measures: (i) transporting stroke patients back to medical facilities within the city, (ii) providing complete acute treatment such as fibrinolytic therapy, and (iii) establishing local rehabilitation facilities. Conclusion: Currently, an insufficient number of local rehabilitation facilities provide a full stroke care ranging from acute treatment to rehabilitation therapy. More facilities are needed to better the community emergency care system for stroke in Funabashi, Japan.

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We report two cases of severe methemoglobinemia caused by accidental oral ingestion of volatile nitrites. Amyl nitrite, isobutyl nitrite, and other volatile nitrites are used as aromas and video head cleaners. However, they are also inhaled and abused to achieve arousal and mood-enhancement. Case 1 was a 26-year-old female who accidentally drank one 10 ml bottle of the inhaled stimulant “KIX^®”, the primary ingredient of which is amyl nitrite and experienced dizziness, vomiting, and prominent systemic cyanosis. Arterial blood gas analysis demonstrated a Met-hemoglobin value of 58.3 percent. One hour after intravenous administration of 1.0 mg/kg methylene blue, Met-hemoglobin had decreased to 17.4 percent, and cyanosis had also disappeared. Case 2 was a 45-year-old male who accidentally drank a 9 ml bottle of the inhaled stimulant “RUSH^®”, the primary ingredient of which is isobutyl nitrite. After 30 minutes, the subject experienced vomiting, loss of consciousness, prominent systemic cyanosis, and urinary and fecal incontinence. Arterial blood gas analysis demonstrated a Met-hemoglobin value of 54.7 percent. One hour after intravenous administration of 1.0 mg/kg methylene blue, Met-hemoglobin had decreased to 3.8 percent, and cyanosis had also disappeared. Intravenous administration of methylene blue was effective against methemoglobinemia caused by volatile nitrite poisoning. In severe methemoglobinemia, the proportion of oxygenated hemoglobin is reduced and exposes tissues to a hypoxic state in the first hour after treatment, even if oxygen partial pressure by arterial blood gas is high. In the interest of rapid treatment, we believe that pharmacies at emergency treatment facilities should prepare aqueous solutions of methylene blue in advance.

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A 29-year-old male patient, who was injured in a motor vehicle accident, was hemodynamically unstable, and lost consciousness. X-rays and computed tomographies revealed fractures of the odontoid process, a right hemopneumothorax, injuries to the liver, spleen, and right kidney, and open fractures of the bilateral femoral shaft (ISS 50). A transarterial embolism (TAE) was performed for the abdominal hemorrhage, and external fixations were undertaken to temporarily stabilize the femoral fractures. Resuscitation and treatment of the subsequent complications- ARDS, DIC, and acute renal failure- were provided in the intensive care unit. MRI revealed cervical spinal cord injury. For the definitive fixation, a Magerl and Brooks' operation on the odontoid process fracture was performed six days after admission, and the internal fixation of the bilateral femoral fractures using Ender nails were performed on the 21st day after admission. The patient's general status did not deteriorate before and after these operations, and the timing of these definitive operations was optimal. The abdominal organ injuries, tetraplesia, and the femoral fractures improved gradually, and the patient was discharged on crutches five months later. The concepts of damage control orthopedics are essential in improving the clinical outcome and decreasing the mortality of such severely traumatized patients.

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