Bemidji State University.
Noncardiac Medical Care Routine medical issues that can be handled by the primary care provider are the health maintenance issues like smoking cessation cheap tadapox 80 mg erectile dysfunction exam what to expect, weight loss/management order 80mg tadapox visa erectile dysfunction protocol foods, hypertension/lipid screening buy tadapox 80mg visa erectile dysfunction blood pressure medications side effects, oral care, and substance abuse counseling. These include erythrocytosis, cholelithiasis, abnormal hemostasis, renal dysfunction, hyperuricemia, hypertrophic osteoarthopathy, and scoliosis. Reproductive Health A vital part of the transition process involves education regarding reproductive health issues. This information should include genetic counseling as well as how their own comorbidities and life expectancy may weigh into their family planning decisions. For female patients, education on reproductive health should be much more involved to include discussions regarding contraception and pregnancy (4,7,9,37) (see Chapter 69). Employment, Insurance, Disability, and Government Aid The importance of employment and insurance cannot be understated. Structured career counseling and employment advice has been shown to be associated with a higher rate of employment (73%) compared to those who received no counseling or advice (46%) (40). Discrimination in the workplace is unlawful and three main legislative acts protect patients with disabilities: 1. This prohibits employment discrimination based on disability by any federal employer programs that receive federal funding (41). This allows the progression of disability to be paid by a special second-injury fund to ensure that employers are protected from future losses. This prohibits disability-based discrimination by any employer who has ≥15 employees for ≥20 calendar weeks (42). It has also been shown that young adults with a chronic medical condition are eight times more likely to have unmet healthcare needs and six times more likely to have no access to routine care than insured young adults (44). Age 12 to 14 years Begin to address the patient and include them in the conversation with the parent/guardian Inform the patient of their heart defect and how it was treated P. The major responsibility for insuring a successful transition and transfer process lies with the pediatric provider(s). The primary reason for this is that most of the transition process (education, counseling, etc. The first major role of the pediatric provider is to prepare the patient and their family for the gradual shift in autonomy as the patient becomes an adult. Another important role for the pediatric provider is to identify appropriate adult providers to whom care can be transferred. Ideally, each pediatric provider will have a certain set of adult providers to involve in this transfer process to optimize communication as it evolves. In most instances, this should be a primary care provider who has experience in caring for adult survivors of chronic pediatric illnesses. While there may be an adequate number of adult cardiology providers available, the major challenge lies in increasing the number who can and will care for these patients. One key component of this education involves expanding the current core curriculum of the general adult cardiology fellowship. It would be beneficial to expand this to include a more longitudinal experience that exists throughout the training program. Also, there should be improved education after fellowship training such as regional training (e. However, there are far too few of these specialists to currently provide care for the several hundred thousand patients who require it. These specialists could form referral networks with general adult cardiologists to allow proper and continuous care. Support Personnel In addition to physician providers, there are many other people required to ensure a successful transition and transfer process. Often, the pediatric provider may not have the time required or resources available to provide proper education and transition support. An advanced level provider (nurse practitioner or physician assistant) or nurse specialist often acts as a “transition coordinator” who is placed in charge of overseeing the entire transition process (4). This person often is involved at multiple patient visits (even sometimes scheduling visits solely related to transition) providing the patient and their family information (educational, psychosocial, and administrative) related to the transition process. Each transition program should have an established referral relationship (or directly employ) a clinical psychologist with experience in providing services to adolescents and young adults with chronic disease. All transition programs should have access to a social worker with experience in transition. These providers should have experience regarding how to smoothly transition patients from their adolescent insurance to an adult program. Moreover, they should know what social and governmental resources are available for patients with chronic healthcare needs (4,9,16,48). A similar “transition” social worker should be available to the patient after transfer of care to the adult provider as many of these “financial” transitions do not occur until well into adulthood. Barriers to Transition Even in organized healthcare systems, successful transition and transfer of care occurs less than half the time (49). This relates to the multiple barriers that exist that may belie successful transition. Several of these barriers as well as potential ways to prevent their occurrence will be discussed. The main reasons for this gap in care include the patient feeling well or not knowing that follow-up was required (5). In addition, a history of missed cardiology appointments during childhood were predictive of being lost to follow-up as a young adult (50). Solution In order to decrease the number of patients who are lost to follow-up during the transfer period, it is vital to stress to the patient and his/her family the importance of lifelong follow-up. At transfer, the pediatric provider should provide the patient with medical follow-up that includes a specific location (provider), date, and reason (4). A system should be in place for the pediatric provider to follow-up and ensure that their patient went to their first appointment with the adult cardiac provider (4,51). Problem: Communication Issues Excellent communication lies at the foundation of a successful transition and transfer—and poor communication can result in failure. A recurrent theme in the literature is the desire for better communication, especially during the transfer of care from the pediatric to the adult provider (4,5,7,13,17,25,51,52). Both providers and patients desire more thorough communication during this process. These summaries often lack the rationale for the current treatment plan and leave out key events (including adverse events, reactions or failures to previous treatments) that are vital to patient care. When the adult provider does not know these key historic events, it serves to reinforce the skepticism that many patients already carry into these relationships. Solution To improve communication, it is vital that the pediatric provider provide a thorough, written, transition note to the new adult provider (4,7,16,51,52). This note should be individualized, developed by the patient/parent/provider, and include important information regarding their diagnoses, surgical history, treatment history, and rationale for current treatment plan (8,9). For more complex patients, direct communication via telephone or an in-person discussion may further strengthen the transfer process.
A history of “recurrent lower respiratory tract infections” or “asthma” is common best purchase for tadapox top erectile dysfunction pills. Referral to a cardiologist eventually occurs when cardiomegaly is noted on chest x-ray purchase tadapox 80mg fast delivery erectile dysfunction treatment after surgery. Additional common reasons for referral are abnormal physical examination findings generic tadapox 80mg without prescription erectile dysfunction quizlet. Patients who have ascites, hepatomegaly, and edema are frequently referred to a gastroenterologist first. Referral to the cardiologist occurs when additional cardiac signs or symptoms occur, a chest x-ray is noted to be abnormal or no specific gastrointestinal etiology is found for the edema and hepatomegaly. Earlier referral to a cardiologist occurs when the presenting sign is an abnormal heart sound, such as murmur, gallop, or loud P2. Syncope in this patient population may be related to ischemia, arrhythmias, or thromboembolism (11,12). Ischemia and/or arrhythmias may be the most common causes of syncope and sudden death in this patient population (7,37). In one case no definitive mechanism for syncopal episodes was found, an arrhythmia was ruled out and there were no ischemic changes on treadmill (4). A positive family history was an infrequent reason for referral in the published reports. Right and/or left ventricular hypertrophy can also be seen as well as conduction abnormalities. On autopsy she had myocardial bridging of the left anterior descending coronary artery as well as stenosed left anterior descending branch vessels due to intimal thickening. There were multiple foci of contraction band necrosis, some with early dystrophic calcification indicating ongoing ischemic injury. It is likely that the most common cause of ischemia in this patient population would be relatively diffuse hypoperfusion of the subendocardial myocardium due to the high diastolic filling pressures impairing coronary perfusion, and not coronary abnormalities per se. This type of hypoperfusion, if diffuse, would also be more difficult to detect by exercising myocardial perfusion studies. Atrial fibrillation and atrial tachycardias, Wolff–Parkinson–White syndrome with supraventricular tachycardia, symptomatic sinus bradycardia requiring pacing, and ventricular tachycardia and torsade have also been reported. High-grade second- and third-degree heart blocks were the next most commonly reported rhythm disturbances. Two deaths were caused by the development of acute heart block; an additional patient had syncope with intermittent heart block but survived as a result of the pacing features of an implanted defibrillator. Chest Radiographs The chest x-ray appears to be a useful screening test, as it is abnormal in approximately 90% of cases (3,4,5,6,7,8,9,10,11,12,14,15,16,17,18,19,20,21,22,23,24,30,37). On 2-D imaging classic cases demonstrate markedly dilated atria, often dwarfing the size of the ventricles. However, based on studies reporting systolic functional parameters, as many as 30% may present with or develop depressed shortening or ejection fractions (3,10,12,30). Reported shortening fractions have been as low as the low 20s with ejection fractions as low as the upper 30s. Both the right and left atria are severely dilated dwarfing the right and left ventricular chambers. As many as 40% have or develop mild, and sometimes progressive, left ventricular hypertrophy (3,4,10,12,30). Variable patterns of hypertrophy have been reported including, concentric, “midseptal bulge,” apical hypertrophy, and “atypical hypertrophy. During 2-D imaging thrombi should be specifically looked for as thrombotic and embolic events are not infrequent (3,4,9,10,12,26,30,83,84,85). Doppler patterns of diastolic dysfunction have been well characterized in adults and pediatric data have also been reported (86,87). Some of the children in these studies did not have complete Doppler data as all the pediatric studies have been retrospective. In the patients described the findings consistent with restrictive filling and increased left ventricular end-diastolic pressure included elevated E/A ratios, short mitral deceleration times, increased pulmonary vein atrial reversal velocity and duration, and pulmonary vein atrial reversal duration greater than mitral A duration (Fig. In their patients, mitral inflow patterns revealed a prominent mitral L wave (Fig. The left ventricular pressure curve showed a small but steady decline during middiastolic filling on cardiac catheterization, implying the driving force for filling was “ventricular suction” and not increased left atrial pressure. Two recent studies provide a cautionary note when diagnosing diastolic dysfunction by echocardiogram in children (88,93). There is a tendency to extrapolate adult data and Doppler patterns of diastolic dysfunction to children. They concluded that new diagnostic criteria for diastolic dysfunction are needed in children. Both diseases typically have an early diastolic dip and subsequent plateau pattern, also called the square root sign (Fig. In cases in which the pressures are essentially equal volume loading may bring out the differences in pressure between the right and left sides. Pulmonary hypertension is frequently present at the time of initial catheterization in addition to elevated left and/or right ventricular end-diastolic pressures (3,10,27,29,30,31,34,35,36). None of the studies predicted when or in whom fixed pulmonary vascular resistance would develop. In patients who undergo endomyocardial biopsy the majority are nondiagnostic, revealing varying degrees of fibrosis and hypertrophy (3,34,37). Increased numbers of mitochondria are seen in some patients as is an increase in glycogen (3,5,10). One case of cardiac amyloidosis in a pediatric patient has been reported, but endomyocardial biopsy is rarely diagnostic of a specific etiology (3,5,10,12,34,37). Desmin myopathy has been seen in skeletal muscle biopsy and cardiac tissue, leading to an etiologic diagnosis (26,41). This can signify impending skeletal myopathy and/or conduction system disease and should be evaluated for in any biopsy tissue obtained. However, finding a specific etiology by endomyocardial biopsy is uncommon and the procedure is not risk free in these tenuous patients (3,19,34). Therefore careful consideration of the risk–benefit ratio of the information that is likely to be obtained by the biopsy should be undertaken prior to catheterization. Pericardiectomy resulted in symptomatic improvement despite the myopathic features on endomyocardial biopsy and even though the calcified pericardium could not be completely resected. Cardiomyopathies may be difficult to classify as overlapping phenotypes occur (3,10,12,30). Since a variety of phenotypes can be seen in the same family with the same gene defect, it is not surprising that phenotypes sometimes overlap. Patients with dilated cardiomyopathy can also develop restrictive physiology (29). When mixed physiology develops in the presence of other forms of cardiomyopathy the prognosis is worse (105). Approximately half of the children die or require transplantation within 2 to 3 years of diagnosis. Sudden death occurred in 14% of the patients reported by Russo and Webber (34) and in 33% in the Hayashi et al.
Early extubation generally successful tracheal extubation in neonates and older chil- refers to tracheal extubation within a few (i order tadapox with mastercard gluten causes erectile dysfunction. Factors to consider without signifcant compromise of patient care buy 80mg tadapox with visa erectile dysfunction after radiation treatment for prostate cancer, and a low 64 Comprehensive Surgical Management of Congenital Heart Disease cheap tadapox 80 mg with amex erectile dysfunction young living, Second Edition incidence for reintubation or hemodynamic instability has They do not need to be ‘weaned’ from mechanical ventilation been reported. The surgical approach and techniques for many cardiac For other postoperative patients, the plan for weaning from procedures have also substantially changed over recent mechanical ventilation should be individualized according to years, particularly with the development of minimally inva- age, clinical status, surgery performed, and anticipated post- sive techniques in both adults and children. Nevertheless, sternotomy, it was determined that the primary advantage a thorough understanding of the anticipated postopera- of the minimally invasive approach was cosmetic, and the tive course is essential. Early tracheal extubation and ‘fast- authors were unable to demonstrate any difference in pain 130 track’ management may not be suitable for many neonates scores and other markers of postoperative recovery. The and infants undergoing complex two ventricle or reparative heterogeneity and complexity of congenital cardiac defects procedures, although such an approach has been reported for means that applying specifc management guidelines accord- selected patients. Right ventricular compliance usually procedures should still be considered with a very cautious improves during the frst 2–3 postoperative days, evident by a approach. Despite short operative times, these procedures ties and an effective diuresis; sedation and/or paralysis can often cause a signifcant hemodynamic alteration and infam- then be discontinued and the patient allowed to wean slowly matory response, and may require mechanical ventilation from mechanical ventilation. Pediatric Cardiac Intensive Care 65 Infants and Toddlers emergence from anesthesia and sedation. Infants with a ventricular hypertrophy, and this needs to be thoroughly large volume load on the ventricle prior to surgery or a labile evaluated prior to considering early extubation. Specifc management issues for these ing spontaneous ventilation because of the lower mean intra- groups are described below. In the absence of a pulmonary ventricle, the limita- Preoperative Management tions of the Fontan circulation become readily apparent in Patients are initially managed with an infusion of prosta- the immediate postoperative period if specifc complications glandin El at 0. If the patient presents outfow tract repair, including subaortic stenosis repair in a stable condition with an SaO2 of more than 65–70%, with the Konno operation or subaortic membrane resec- a PaO2 greater than 25 mmHg, and a normal pH, the sep- tion, and aortic valvuloplasty or replacement, usually have tostomy can be performed semi-electively. Occasionally, well-preserved and often hyperdynamic ventricular systolic an urgent septostomy is indicated for patients who present function. Hypertension and tachycardia are frequently a with severe hypoxemia (PaO2 less than 20–25 mmHg) and a management concern in these patients in the immediate metabolic acidosis (pH less than 7. On rare occasions 66 Comprehensive Surgical Management of Congenital Heart Disease, Second Edition when patients present with imminent circulatory collapse, treated urgently. Despite initial concerns for increased preferable to open the sternum and decompress the mediasti- neurologic injury and stroke with balloon atrial septostomy, num. However, to maintain mixing at the atrial level, volume replacement with colloid or blood products is often necessary. While the prostaglandin El infusion can usually tively supplying both systemic and pulmonary blood fow be discontinued after an adequate septostomy, it may need to (Box 4. The relative proportion of the ventricular output be continued if mixing is inadequate and the PaO2 remains to either the pulmonary or systemic vascular bed is deter- below 25 mmHg. It is always benefcial to know whether mined by the relative resistance to fow in the two circuits. A postductal saturation ing of the systemic and pulmonary venous return within a more than 5–10% higher than the preductal level, also known ‘common’ atrium. While there Surgical correction is usually performed in the frst week may be specifc management issues for certain defects with of life after the septostomy, once the patient is hemodynami- single-ventricle physiology, there are nevertheless common cally stable without signs of end organ dysfunction. The sudden • Atrioventricular valve atresia onset of heart block or ventricular tachyarrhythmia may also • Tricuspid atresia herald myocardial ischemia. It is rarely sec- • Double-inlet left or right ventricle ondary to vasospasm, and drugs such as nitroglycerin are • Unbalanced atrioventricular canal ineffective. Further investigation is essential, beginning with • Outfow tract obstruction echocardiography and often proceeding to catheterization • Shone’s complex and possible reoperation if coronary compression, kinking, • Pulmonary atresia and small right or obstruction is confrmed. The sudden onset of ischemia ventricle may indicate imminent circulatory collapse and must be Pediatric Cardiac Intensive Care 67 Balanced ﬂow acidosis and low bicarbonate level may be present, but this Qp/Qs=1:1 may not indicate poor perfusion and a lactic acidosis specif- SaO2 80–85% cally. Patients require intu- SaO2 SaO2 bation and mechanical ventilation either because of apnea secondary to prostaglandin El, because of the presence of a Volume overload Hypoxemia low cardiac output state, or for manipulation of gas exchange Ventricular failure Metabolic acidosis to assist balancing pulmonary and systemic fow. An arte- Myocardial ischemia Myocardial ischemia rial oxygen saturation of more than 90% indicates pulmo- nary overcirculation, that is, Qp/Qs substantially greater than 1. In this An alternate strategy is to add carbon dioxide to the inspira- ‘overcirculated’ state, manipulation of mechanical ventila- tory limb of the breathing circuit, which will also increase tion and inotropic support may temporarily stabilize the pulmonary vascular resistance, but because a hypoxic gas patient, but surgery should not be delayed. Preoperative management should focus on an assess- While these maneuvers might temporarily improve Q /Q , the p s ment of the balance between pulmonary (Qp) and systemic patient should be considered for early surgical intervention fow (Qs). This is best achieved by a thorough and continu- as opposed to prolonged exposure to hypoxic environments, ous re-evaluation of clinical examination for cardiac output which can have potentially deleterious neurologic conse- state and perfusion, an evaluation of the chest radiograph for quences. Adding carbon dioxide to the breathing circuit will cardiac size and pulmonary congestion, a review of labora- increase the respiratory rate and the work of breathing, and tory data for alterations in gas exchange, acid–base status, is rarely needed in the current era; the preferred approach to and end organ function, and imaging with echocardiography hypoxic gas mixtures is early surgical intervention. Decreased pulmonary blood fow small newborns and do not substitute for clinical examina- in patients with a parallel circulation is refected by hypox- tion. Initial resuscitation involves maintaining patency of the emia with a SaO of less than 75%. Preoperatively, this may 2 ductus arteriosus with a prostaglandin El infusion at a rate of be due to restricted fow across a small ductus arteriosus, 0. Sedation, paralysis, and manipulation of output is maintained without a metabolic acidosis, spontane- mechanical ventilation to maintain an alkalosis may be effec- ous ventilation is often preferable to achieve an adequate sys- tive if pulmonary vascular resistance is elevated. A mild metabolic oxygen delivery is maintained by improving the cardiac 68 Comprehensive Surgical Management of Congenital Heart Disease, Second Edition output and keeping the hematocrit near 40%. Inotropic support is often necessary procedure, a low cardiac output state is more likely second- because of ventricular dysfunction secondary to the increased ary to ventricular dysfunction. It is important to evaluate end organ per- dopamine, and occasionally epinephrine, is usually required, fusion and function. Oliguria and a rising serum creatinine titrated to systemic pressure and perfusion. Afterload reduction level may refect pre-renal insuffciency from a low car- with milrinone as second-line agents is benefcial to reduce diac output. Necrotizing enterocolitis is a risk secondary to myocardial work and improve systemic perfusion. Postoperative Management Closely linked to hemodynamic stability is the tight con- The management of patients following a Norwood-type trol of mechanical ventilation and gas exchange. Ideally, the operation is complex; intensive monitoring is essential as the pH should be 7. Pediatric Cardiac Intensive Care 69 room air, refecting a well-balanced circulation. To achieve cardiac output and inability to wean from mechanical ven- this, frequent changes in mechanical ventilation settings and tilation. Echocardiography is useful to assess valve and ven- FiO2 may be necessary, and leaving the sternum open after tricular function, although less accurate for assessing the surgery may help facilitate a balanced circulation and stable degree of residual arch obstruction.
Items of Note The Monongah mine disaster was the biggest mine disaster to date (Mine Safety and Health Administration tadapox 80 mg with mastercard impotence recovering alcoholic, 2008) buy tadapox with paypal erectile dysfunction treatment in tampa. Your code enforcement ofcer has stated that a clothing manufacturer has been cited for several fre and safety violations 80mg tadapox overnight delivery erectile dysfunction treatment in pune. The plant should be notifed that unless it com- plies with the city codes immediately, the factory will be shut down and the company will be fned on a weekly schedule until compliance is achieved. The city inspectors should be notifed that the factory will be inspected on a regular and frequent basis until compliance is achieved. As the mayor, you have code enforcement ofcers, city attorneys, and if criminal charges occur, a police department to enforce your will upon the company owners. You should contact any regu- latory agency that can apply the necessary pressure to make the company compliant, or if the company fails to be compliant, force the company to shut down. Stage 2 of the Disaster You have been alerted that a fre has broken out in the clothing factory and that there are over 500 workers trapped in the building (Zasky, 2008). You need to deploy your frst responders to the scene so that the factory workers can be evacuated safely and the fre can be prevented from spreading to any of the surrounding buildings near the fac- tory. For a large factory you will need a large amount of fre and emergency medical technicians to put out the fre and evacuate anyone who might be injured in the blaze. Stage 3 of the Disaster You have learned that a fre escape has collapsed as the workers have been attempt- ing to fee from the fre out of the building (Zasky, 2008). You will need to have the fre department create other avenues of escape for the workers. Since you do not have helicopters, Case Studies: Man-Made Disasters—Industrial Accidents ◾ 125 you will need to rely on fre equipment that would consist of ladders long enough to reach the upper foors. Since you have a large number of people poten- tially trapped inside a smoky building, you will need more medical assets and frefghters to extinguish the blaze. You will need to contact any next of kin of any worker that is injured or killed in the fre. Additionally, you will need to mobilize your fre investigators and police department once the blaze has been extinguished. Key Issues Raised from the Case Study Tis case study provides an example of why it is so important to have building codes and enforce them. If building codes had been enforced, then the fre and safety violations would have forced the company to comply with the ordinances, or the city could have had the leverage to close the factory for noncompliance. By having proper building codes in place and enforced, a governmental entity has the ability to limit liability to itself, as well as being able to prevent potential tragedy from occurring in the frst place. The single biggest failure in the case study is the failure to enforce any type of building codes for the factory. Viable avenues of escape were unavailable to work- ers when the fre broke out, which hindered efective evacuation. The fre lasted 30 minutes and resulted in the deaths of 146 employees (Zasky, 2008). Items of Note The Triangle Shirtwaist Factory fre inspired reforms for safety of workers and insti- tuted more government oversight over industrial safety (Zasky, 2008). Bhopal Industrial Chemical Accident, India, 1984 Stage 1 of the Disaster You are the director for public safety in Bhopal, India, where an industrial plant owned by Union Carbide Corporation produces a host of chemicals used to make pesticides. The plant was built using money from local shareholders and the government has a 22% share in Union Carbide India Ltd. The plant was built in a light industrial zoned area (not for hazardous industry) with access to a good transportation infrastructure net- work. The plant was eventually set up to produce raw chemicals as well as refned, * A helicopter that could be mass-produced was not truly feasible until 1938. The government has noted that there have been safety shortfalls with the plant, but the company has made no efort to have those shortfalls corrected. Perhaps this is due to the possibil- ity that the fxes may cause the company to shut down the plant, which would have a severe economic impact upon the region (Broughton, 2005). Your frst plan of action should be to note exactly what safety shortfalls exist at the plant and come up with an estimate of the consequences if those safety shortfalls cause a catastrophic failure in a popu- lated area. If the government fails to act upon your report, then prepare an evacuation plan and a containment plan for around the plant. You should forge ties with organizations that can assist your personnel to contain any type of chemical release that may occur. With a large industrial chemical plant, your staf will need additional assistance in containing any leak that may occur, and your staf will need assistance to evacuate the population. You will need to stay in regular touch with the govern- ment on the status of the plant and keep it informed on any changes in status in regard to the safety shortfalls that are noted. Additionally, you should also maintain an inventory of gas masks, vehicles for evacuation, medical resources, and frst responders in case of an emergency. You are unsure what type of gas has been released, but you can see the corpses of humans and animals alike lying in the streets of Bhopal. You are now receiving reports that almost 3,800 individuals have died instantly from the mysterious gas cloud (Broughton, 2005). The frst order of business is to equip your person- nel with respirator masks so that they can safely evacuate the area where the gas cloud has been released. Second, you will need to fnd out what type of gas Case Studies: Man-Made Disasters—Industrial Accidents ◾ 127 was released from the plant. If you cannot determine this information, medi- cal staf will have no idea on how to treat patients and you will have difculty attempting to shut down where the gas cloud is coming from at the plant. You need to immediately appeal to the population to evacuate the area before they are caught up in the gas cloud. In addition, you will need to contact the plant to see what type of chemical has been released and determine the status of sealing the leak at the factory. Outside organizations will need to be contacted for both medical assistance and to assist with evacuating the populous in the surrounding areas. The director will need to mobilize all medical resources possible as well as any frst responders that are properly equipped with respirator gear and vehicles to evacuate the area. Stage 3 of the Disaster The disaster is now into its sixth day, and up to 10,000 people have been killed and several thousand left ill due to chemical exposure. Your hospitals are completely full and no one is exactly sure what the chemical efects of methyl isocyanate will be long term on individuals exposed to the chemical (Broughton, 2005). You will need to locate all types of medi- cal resources that could be needed to combat the efects of the chemical. Furthermore, you will need to get additional frst responders on the scene to assist individuals who may be disabled by the chemical. The director will need to keep in contact with government ofcials and should convey the needs for medical resources in this time of emergency. Outside agencies and organizations should be con- tacted as well to seek additional help with medical resources. At this point, medical resources should be the most sought after items as well as facilities that can be converted into hospital space, which is currently in short supply. Additionally, you will need to locate facilities that can also serve as a temporary morgue.