bluuebunny/crossref_metadata_2025 huggingface dataset:
Mass-Gathering Medical Care: A Review of the Literature
Authors: Milsten Andrew M. , Maguire Brian J. , Bissell Rick A. , Seaman Kevin G.
Published: August 2016

Mass-gatherings events provide a difficult setting for which to plan an appropriate emergency medical response. Many of the variables that affect the level and types of medical needs, have not been fully researched. This review examines these variables.

Methods:

An extensive review was conducted using the computerized databasesMedlineandHealthstarfrom 1977 through May 2002. Articles selected contained information pertaining to mass-gathering variables. These articles were read, abstracted, analyzed, and compiled.

Results:

Multiple variables are present during a mass gathering, and they interact in complex and dynamic ways. The interaction of these variables contributes to the number of patients treated at an event (medical usage rate) as well as the observed injury patterns. Important variables include weather, event type, event duration, age, crowd mood and density, attendance, and alcohol and drug use.

Conclusions:

Developing an understanding of the variables associated with mass gatherings should be the first step for event planners. After these variables are considered, a thorough needs analysis can be performed and resource allocation can be based on objective data.
Locations of Cardiac Arrest: Affirmation for Community Public Access
Defibrillation (PAD) Program
Authors: Fedoruk J.C. , Currie Wayne L. , Gobet Meikel
Published: August 2016

Background:

The purpose of this study was to describe the regional locations of
cardiac arrest, and to identify public locations and the annual
incidence of arrests within the identified locations, in order to help
to determine optimal placement of Automatic External Defibrillators
(AEDs) under the regional Public Access Defibrillation (PAD) Program.
This is a retrospective study.

Methods:

The locations of cardiac arrest were abstracted from Ambulance Call
Reports (ACRs) collected by the Essex-Kent Base Hospital Centre from
regional ambulance services throughout the City of Windsor, and the
Counties of Essex and Kent, Ontario, Canada, from 01 January 1994
through 31 December 2000. Arrest locations were grouped into five
categories, and then the number of public venues was determined. Public
sites were grouped into 28 Public Locations. Also included in the Public
Sites were both General Industry and Outdoors categories. Categories
identified but excluded from Public Sites were Institutions and Private
Residences.

Results:

During the study, 2,295 arrests occurred, 152 cases were excluded,
2,142 arrests were categorized, (average annual incidence of 306 ±50.4
cardiac arrests), 329 (15.4%) of which were in Public Sites. Nineteen
public venues had an average of >1 arrest/year, and nine public
venues had an average of ≤1 arrest/year during the study, period.
Calculations of the annual incidence of arrests for each public location
were completed.

Conclusions:

These findings have significant prehospital emergency cardiac care
implications for communities that wish to strengthen/improve their
responses to out-of-hospital cardiac arrests. Public Access
Defibrillation Programs should identify the site-specific incidence of
arrest within their communities in order to provide legitimacy for
funding and planning of programs. Training and availability of AEDs will
reduce the time to first shock, thus strengthening the chain-of-survival
and will save more lives.
Prehospital Hyperventilation After Brain Injury: A Prospective Analysis of Prehospital and Early Hospital Hyperventilation of the Brain-Injured Patient
Authors: Lal Dave , Weiland Steve , Newton Monica , Flaten Anne , Schurr Michael
Published: August 2016

Background:

The Brain Trauma Foundation's Guidelines for the Management of Severe Head Injury state that the use of prophylactic hyperventilation after traumatic brain injury (TBI) should be avoided because it can compromise cerebral perfusion. The objective of this study was to assess the prevalence of unintentional hyperventilation.

Methods:

A prospective evaluation of all intubated trauma patients with a diagnosis of TBI was performed. Patients with signs of impending hernia-tion were excluded.

Results:

Forty patients were included in the study. The average Glasgow Coma Scale (GCS) was 6.3. Of these, 28 patients (70%) were unintentionally hyperventilated. Eleven (39%) of the hyperventilated patients died or were discharged in a persistent vegetative state. Of the remaining 12 patients who experienced normal ventilation, three patients (25%) died or were discharged in a vegetative state (p = ns) (Table 1).

Conclusion:

Hyperventilation was common after TBI. However, patients ventilated to a normal PaCO2 were significantly more acidotic. Prehospital personnel should undergo educational training after development of strict ventilation protocols for patients suffering TBI.
Terrorism in Bulgaria
Authors: Shanduorkov George
Published: August 2016

The Republic of Bulgaria is one of the smallest countries in
southeastern Europe and has little experience with terrorist acts. During
the past 20 years, only nine terrorism-related events have been recorded in
Bulgaria, and no unconventional weapons have been used. Factors contributing
to terrorism in Bulgaria have been: (1) Communist Party domination of the
government and political process from 1944 to 1989; (2) ethnic and religious
conflicts between the Bulgarian Orthodox Christian majority and the Turkish
Muslim minority from 1983 to 1987; and (3) the relatively high level of
organized crime after the Communist regime ended in 1990.

The structure and function of the Disaster Relief System in Bulgaria not
only are focused on the prevention of terrorism, but also on preparedness
for the emergency response to terrorism-related events. Institutional
components of the Disaster Relief System structure responsible for the
emergency response to terrorism-related events include: (1) the Government
of Bulgaria; (2) the State Agency for Civil Protection with 28 regional
directorates; (3) the Ministry of Health with five national hospitals, 28
regional hospitals, and 28 EMS systems; (4) the Ministry of Defense with
special military units for response to unconventional terrorist events,
including nuclear, biological, and chemical weapons; (5) the Ministry of
Internal Affairs with 28 police departments, 28 fire departments, and
specialized anti-terrorist units; and (6) the Bulgarian Red Cross.

A major future challenge in Bulgaria is the prevention of terrorism
through political stability, economic prosperity, ethnic and religious
tolerance, and more effective measures against organized criminal
activities. A related challenge will be to improve the level of preparedness
of all components of Disaster Relief.
Terrorism in Canada
Authors: Kollek Daniel
Published: August 2016

This paper reviews terrorism in Canada, assessing the incidence and nature of terrorist activity, the potential targets of terrorist attacks, risk factors to Canadian nationals and institutions, and the responses of the Canadian government in dealing with the threat and the effectiveness of those responses.

Despite the fact that there have been no recent high-profile terrorist events in Canada, this country has a serious terrorism problem, the key manifestation of which is the multitude of terrorist organizations that have designated Canada as a base of operations. In addition, Canadians have been attacked overseas and Canadian organizations, both local and abroad, are potential targets of terrorist activity. Canadian attempts to deal with terrorism through foreign and domestic policy have been ineffective, primarily because the policies have been poorly enforced. Until recently, terrorist organizations legally could raise funds in Canada, in direct contravention of international treaties signed by Canada. It is possible that the ineffectiveness in enforcing the anti-terrorism legislation stems from hope that placating terrorist organizations, and the countries that support them, will prevent Canada from becoming a target. Unfortunately evidence from other countries has shown this strategy to be ineffective.
Terrorism in Indonesia
Authors: Pusponegoro Aryono D.
Published: August 2016

Indonesia has had its share of natural and manmade disasters. From 1997
to 2002, Indonesia has experienced 90 incidents of terrorist bomb attacks.
In 13 (14.4%) of the terrorist attacks, the bombs did not explode. A total
of 224 persons have been killed, and 340 persons have been injured. Most of
those killed or injured were the result of the bombings in Jakarta and Bali.
Besides bombings, there have been riots, especially in Jakarta. The
Indonesian Surgeons Association established the 1–1–8 Emergency Ambulance
Service Foundation to develop the Prehospital Emergency Medical Services in
Indonesia. Despite difficulties, this service has been implemented in 18
cities. The occurrence of disasters, riots, ethnic conflicts, terrorist
attacks, and the introduction of the Advanced Trauma Life Support (ATLS)
course in 1995, have helped to convince the people and the government that
it was important to develop this 1–1–8 Emergency Ambulance Services system,
and agreed to accept a Safe Community Program. With the Safe Community
Program, Jakarta with its Integrated 1–1–8 Emergency Ambulance Service
managed to provide proper emergency medical care to the casualties caused by
terrorist bombings, riots, and in the three weeks of floods during which 75%
of Jakarta was submerged.
Terrorism in Peru
Authors: Hernandez Dora H. Barrientos , Church Adam L.
Published: August 2016

Two major domestic terrorist groups have plagued Peru over the past 20
years, the Sendero Luminoso or “Shining Path” (SL) and the Revolutionary
Movement Túpac Amaru (MRTA). On 28 August 2003, the Peruvian Truth and
Reconciliation Commission reported that an estimated 69,280 persons were
killed in the internal conflict in Peru from 1980 to 2000. Most of the
victims were farmers (56%), most attacks occurred in rural settings (79%),
and the SL was responsible for mostof the deaths (54%). Aggressive
anti-terrorism efforts by police and military during this period, often at
the expense of basic human rights, also contributed to this large burden of
terrorism on Peru. During the 1990s, terrorist attacks in Peru had spread to
its urban areas. On 17 December 1996, 22 members of MRTA took over the
Japanese ambassador's residence in Lima, holding 72 hostages until the
grounds were stormed by Peruvian special forces on 23 April 1997.

Until recently, emergency planning and preparedness for
terrorism-related events in Peru were largely underdeveloped. In the last
five years, Peru has taken two key steps towards developing a mature
emergency response system, with the establishment of the country's first
emergency medicine residency training program and the construction of the
first dedicated trauma center in Lima.
Ethical Considerations in Emergency Planning, Preparedness, and Response to Acts of Terrorism
Authors: Larkin Gregory Luke , Arnold Jeffrey
Published: August 2016

Throughout the globe, healthcare providers are increasingly challenged with the specter of terrorism and the fallout from weapons of mass destruction. Preparing for and responding to such manmade emergencies, however, threatens the ethical underpinnings of routine, individualized, patient-centered, emergency healthcare. The exigency of a critical incident can instantly transform resource rich environs, to those of austerity. Healthcare workers, who only moments earlier may have been seeing two to three patients per hour, are instantly thrust into a sea of casualties and more basic lifeboat issues of quarantine, system overload and the thornier determinations of who will be given every chance to live and who will be allowed to die. Beyond the tribulations of triage, surge capacity, and the allocation of scarce resources, terrorism creates a parallel need for a host of virtues not commonly required in daily medical practice, including prudence, courage, justice, stewardship, vigilance, resilience, and charity. As a polyvalent counterpoint to the vices of apathy, cowardice, profligacy, recklessness, inflexibility, and narcissism, the virtues empower providers at all levels to vertically integrate principles of safety, public health, utility, and medical ethics at the micro, meso, and macro levels. Over time, virtuous behavior can be modeled, mentored, practiced, and institutionalized to become one of our more useful vaccines against the threat of terrorism in the new millennium.
Mass-Casualty, Terrorist Bombings: Epidemiological Outcomes, Resource Utilization, and Time Course of Emergency Needs (Part I)
Authors: Arnold Jeffrey L. , Tsai Ming-Che , Halpern Pinchas , Smithline Howard , Stok Edita , Ersoy Gurkan
Published: August 2016

Introduction:

This article characterizes the epidemiological outcomes, resource utilization, and time course of emergency needs in mass-casualty, terrorist bombings producing 30 or more casualties.

Methods:

Eligible bombings were identified using a MEDLINE search of articles published between 1996 and October 2002 and a manual search of published references. Mortality, injury frequency, injury severity, emergency department (ED) utilization, hospital admission, and time interval data were abstracted and relevant rates were determined for each bombing. Median values for the rates and the inter-quartile ranges (IQR) were determined for bombing subgroups associated with: (1) vehicle delivery; (2) terrorist suicide; (3) confined-space setting; (4) open-air setting; (5) structural collapse sequela; and (6) structural fire sequela.

Results:

Inclusion criteria were met by 44 mass-casualty, terrorist bombings reported in 61 articles. Median values for the immediate mortality rates and IQRs were: vehicle-delivery, 4% (1–25%); terrorist-suicide, 19% (7–44%); confined-space 4% (1–11%); open-air, 1% (0–5%); structural-collapse, 18% (5–26%); structural fire 17% (1–17%); and overall, 3% (1–14%). A biphasic pattern of mortality and unique patterns of injury frequency were noted in all subgroups. Median values for the hospital admission rates and IQRs were: vehicle-delivery, 19% (14–50%); terrorist-suicide, 58% (38–77%); confined-space, 52% (36–71%); open-air, 13% (11–27%); structural-collapse, 41% (23–74%); structural-fire, 34% (25–44%); and overall, 34% (14–53%). The shortest reported time interval from detonation to the arrival of the first patient at an ED was five minutes. The shortest reported time interval from detonation to the arrival of the last patient at an ED was 15 minutes. The longest reported time interval from detonation to extrication of a live victim from a structural collapse was 36 hours.

Conclusion:

Epidemiological outcomes and resource utilization in mass-casualty, terrorist bombings vary with the characteristics of the event.
Guidelines for the Use of Foreign Field Hospitals in the Aftermath of
Sudden-Impact Disaster
Authors:   Department of Emergency
                        and Humanitarian Action,   World Health
                        Organization,   Area on Emergency
                        Preparedness and Disaster Relief,   Pan-American
                        Health Organization
Published: August 2016

Natural and complex disasters can cause a dramatic increase in the
demand for emergency medical care. Local health services can be overwhelmed,
and damage to clinics and hospitals can render them useless. Many countries
maintain mobile field hospitals for defense or humanitarian purposes.
Dispatching these facilities to disaster-affected countries would seem an
ideal response to emergency medical needs. Unfortunately, experience has
shown that in the case of natural disasters, field hospitals often have not
met the expectations of recipients and donor institutions.

In July 2003, the World Health Organization and Pan American Health
Organization sponsored a workshop in El Salvador to discuss the pros and
cons of using foreign fieldhospitals in the aftermath of natural disasters.
These guidelines are the result of that workshop. The workshop participants
identified different phases when foreign field hospitals and specialized
medical personnel are most useful. They can provide advanced trauma care and
life support if at the disaster site within 48 hours of the impact of an
event; they would provide follow-up care for trauma victims and resumption
of routine medical care in the two weeks following the event; during
rehabilitation and reconstruction phases (from two months to two or more
years), a field hospital might serve as a temporary replacement for damaged
health facilities. These guidelines propose conditions that field hospitals
and their staff should meet for each ofthese phases. The guidelines also
outline issues that authorities in donor countriesand disaster-affected
countries should discuss before mobilizing a field hospital.
The Threat of Mid-Spectrum Chemical Warfare Agents
Authors: Aas Pål
Published: August 2016

There is a spectrum of several threat agents, ranging from nerve agents
and mustard agents to natural substances, such as biotoxins and new,
synthetic, bioactive molecules produced by the chemical industry, to the
classical biological warfare agents. The new, emerging threat agents are
biotoxins produced by animals, plants, fungi, and bacteria. Examples of such
biotoxins are botulinum toxin, tetanus toxin, and ricin. Several bioactive
molecules produced by the pharmaceutical industry can be even more toxic
than are the classical chemical warfare agents. Such new agents, like the
biotoxins and bioregulators, often are called mid-spectrum agents. The
threat to humans from agents developed by modern chemical synthesis and by
genetic engineering also must be considered, since such agents may be more
toxic or more effective in causing death or incapacitation than classical
warfare agents. By developing effective medical protection and treatment
against the most likely chemical and mid-spectrum threat agents, the effects
of such agents in a war scenario or following a terrorist attack can be
reduced.
The San Diego East County School Shootings: A Qualitative Study of Community-Level Post-traumatic Stress
Authors: Palinkas Lawrence A. , Prussing Erica , Reznik Vivian M. , Landsverk John A.
Published: August 2016

Introduction:

Within one month (March 2001), two separate incidents of school shootings occurred at two different high schools within the same school district in San Diego's East County.

Objective:

To examine community-wide expressions of post-traumatic distress resulting from the shootings that may or may not fulfill DSM-IV criteria for post-traumatic stress disorder (PTSD), but which might interfere with treatment and the prevention of youth violence.

Methods:

A qualitative study was undertaken using Rapid Assessment Procedures (RAP) in four East San Diego County communities over a six-month period following the two events. Semi-structured interviews were conducted with 85 community residents identified through a maximum variation sampling technique. Interview transcripts were analyzed by coding consensus, co-occurrence, and comparison, using text analysis software.

Results:

Three community-wide patterns of response to the two events were identified: (1) 52.9% of respondents reported intrusive reminders of the trauma associated with intense media coverage and subsequent rumors, hoaxes, and threats of additional acts of school violence; (2) 44.7% reported efforts to avoid thoughts, feelings, conversations, or places (i.e., schools) associated with the events; negative assessment of media coverage; and belief that such events in general cannot be prevented; and (3) 30.6% reported anger, hyper-vigilance, and other forms of increased arousal. Twenty-three (27.1%) respondents reported symptoms of fear, anxiety, depression, drug use, and psychosomatic symptoms in themselves or others.

Conclusions:

School shootings can precipitate symptoms of post-traumatic stress disorder at the community level. Such symptoms hinder the treatment of individuals with PTSD and the implementation of effective prevention strategies and programs.
Mass-Casualty Terrorist Bombings In Istanbul, Turkey, November 2003: Report of the Events and the Prehospital Emergency Response
Authors: Rodoplu Ülkümen , Arnold Jeffrey L. , Tokyay Rifat , Ersoy Gurkan , Cetiner Serkan , Yücel Tayfun
Published: August 2016

Background:

This paper describes the two mass-casualty, terrorist attacks that occurred in Istanbul, Turkey in November 2003, and the resulting prehospital emergency response.

Methods:

A complex, retrospective, descriptive study was performed, using open source reports, interviews, direct measurements of street distances, and hospital records from the American Hospital (AH) and Taksim Education and Research State Hospital (TERSH) in Istanbul.

Results:

On 15 November, improvised explosive devices (IEDs) in trucks were detonated outside the Neve Shalom and Beth Israel Synagogues, killing 30 persons and injuring an estimated additional 300. Victims were maldistributed to 16 medical facilities. For example, AH, a private hospital located six km from both synagogues, received 69 injured survivors, of which 86% had secondary blast injuries and 13% were admitted to the hospital. The TERSH, a government hospital located 1 km from both synagogues, received 48 injured survivors. On 20 November, IEDs in trucks were detonated outside the Hong Kong Shanghai Banking Corporation (HSBC) headquarters and the British Consulate (BC), killing 33 and injuring an estimated additional 450. Victims were maldistributed to 16 medical facilities. For example, TERSH, located 18 km from the HSBC site and 2 km from the the BC received 184 injured survivors, of which 93% had secondary blast injuries and 15% were hospitalized. The AH, located 9 km from the HSBC site and 6 km from the BC, received 16 victims.

Conclusion:

The twin suicide truck bombings on 15 and 20 November 2003 were the two largest terrorist attacks in modern Turkish history, collectively killing 63 persons and injuring an estimated 750 others. The vast majority of victims had secondary blast injuries, which did not require hospitalization. Factors associated with the maldistribution of casualties to medical facilities appeared to include the distance from each bombing site, the type of medical facility, and the personal preference of injured survivors.
Efficacy of Critical Incident Monitoring for Evaluating Disaster Medical Readiness and Response During the Sydney 2000 Olympic Games
Authors: Flabouris Arthas , Nocera Antony , Garner Alan
Published: August 2016

Introduction:

Multiple casualty incidents (MCI) are infrequent events for medical systems. This renders audit and quality improvement of the medical responses difficult. Quality tools and use of such tools for improvement is necessary to ensure that the design of medical systems facilitates the best possible response to MCI.

Objective:

To describe the utility of incident reporting as a quality monitoring and improvement tool during the deployment of medical teams for mass gatherings and multiple casualty incidents.

Methods:

Voluntary and confidential reporting of incidents was provided by members of the disaster medical response teams during the period of disaster medical team deployment for the 2000 Sydney Olympic Games. Qualitative evaluations were conducted of reported incidents. The main outcome measures included the nature of incident and associated contributing factors, minimization factors, harm potential, and comparison with the post-deployment, cold debriefings.

Results:

A total of 53 incidents were reported. Management-based decisions, poor or non-existent protocols, and equipment and communicationrelated issues were the principal contributing factors. Eighty nine percent of the incidents were considered preventable. A potential for harm to patients and/or team members was documented in 58% of reports, of which 76% were likely to cause at least significant harm. Of equipment incidents, personal protective equipment (33%), medical equipment (27%), provision of equipment (22%), and communication equipment (17%) predominated. Personal protective equipment (50%) was reported as the most frequent occupational health and safety incident followed by fatigue (25%). Predeployment planning was the most important factor for future incident impact minimization.

Conclusions:

Incident monitoring was efficacious as a quality tool in identifying incident contributing factors. Incident monitoring allowed for greater systems evaluation. Further evaluation of this quality tool within different disaster settings is required.
Injuries Among Afghan Refugees: Review of Evidence
Authors: Nasir Khurram , Hyder Adnan A. , Shahbaz C. M.
Published: August 2016

Background:

Injuries are a public health problem in developing countries resulting in major financial and productivity losses. Injuries in vulnerable populations, such as refugees, make an even greater impact on loss of life. Afghan refugees in Pakistan continue to form one of the world's largest refugee populations. This study systemically reviews the literature to estimate the magnitude and prevalence of intentional and unintentional injuries in Afghan refugees, and explores the implications of the findings for refugee healthcare policy and development of potential interventions specifically for Afghan refugees.

Methods:

Electronic databases of MEDLINE, POPLINE, Refworld, and Winspirs were searched. In addition, a web search was conducted and specific organizational websites were reviewed. The search in developing countries was limited to studies in English or with an English abstract for the years 1966–2001.

Results:

The literature review identified patients with reported war injuries who presented to hospitals. Injuries to extremities (45%) were more frequent than injuries to the head or neck (36%, p <0.001), and thorax/abdomen (14%, p <0.001) regions. A majority of the injuries were caused by explosives, which included landmines (32.5%), fragmentations, such as shrapnel (33%), and firearms (27%). The mean incidence of mortality in these studies was 11%.

Conclusions:

Despite such an extensive search, limited information was found pertinent to injuries in Afghan refugees residing in refugee camps. This dearth of literature on the prevalence of injuries, risk factors, and outcomes among this vulnerable group is a research and policy gap for public health. Specific quantitive and qualitative studies in this field are required to shape refugee healthcare policies and develop intervention programs.
The Development of Conceptual Models for Mass-Gathering Health
Authors: Arbon Paul
Published: August 2016

Mass gatherings are an increasingly common feature of modern society. However, descriptive papers that focus on a single event or event type, dominate the literature, and, while these contribute to our understanding of the patient care required at such events, they do not provide an adequate analysis of the health effects of the mass-gathering phenomenon itself. This paper argues for the development of conceptual models and a research template for mass-gathering research. The development of theory and conceptual models would promote a better understanding of the health effects of mass gatherings. Two preliminary conceptual models are presented as a means to encourage further debate about the dominant influences on the health of people where crowds gather and to promote less superficial forms of analysis of the research data.

These conceptual models are based on the idea that mass-gathering health can be understood as an inter-relationship between three domains: (1) the biomedical; (2) the environmental; and (3) the psychosocial. Key features influence the rate of injury and illness and characterize each domain. These key features are more or less well-understood and combine to produce an effect—the patient presentation rate, and a response—the health plan. A new element, the latent potential for injury and illness, is introduced as a mechanism for describing a biomedical precursor state important in assessing health risk during mass gatherings.
Building the Tower of Babel: Cross-border Urgent Medical Assistance in Belgium, Germany and the Netherlands
Authors: Post G. B.
Published: August 2016

The border area between Germany, Belgium, and the Netherlands includes a substantial number of cooperative forms in the urgent medical assistance sector. Collaboration usually takes place in densely populated areas with cities or villages situated on or in proximity to the border. In some regions, definitive borders are not apparent to the extent that inhabitants often times are unaware of their existence. The border may pass directly through a builtup area with intense cross-border activity due to population residency, place of work, shopping, and recreational pursuits.

To obtain a deeper insight into cross-border Urgent Medical Assistance (UMA), the Ministry of the Interior and Kingdom Relations (IKR) and the Ministry for Health, Welfare, and Sports (HWS) in the Netherlands commissioned research into cross-border UMA impediments and solutions at administrative, judicial, and operational level. The following central questions were presented for research: what opportunities and impediments are presented in the area of cross-border, urgent medical assistance at administrative, legal, operational, and equipment employable level, and which solutions may be submitted to tackle existing impediments?

Two techniques were employed to answer the research questions. First, relevant documents were studied from extensive file and literature searches. File and literature search findings subsequently were tested in practice through interviews with relevant experts.

Dutch ambulance services provide support to both their Belgian and German counterparts and vice versa. In the instance of cross-border ambulance deployment, relevant assistance services are subject to due observance of various legislations and regulations. Such regulations may restrict effective and efficient deployment of personnel and equipment at critical moments, because regulation discrepancies may arise over ambulance personnel's authorities, ambulance content, and deployment sequence. Discrepencies also may exist in the area of financial compensation concerning ambulance deployment and hospital admission. Gaining knowledge on their disparate systems and the opportunity to utilize the medical provisions of a neighboring country potentially in closer proximity to those in the victim's own country serves the best interests of the patient. Survival chances of a traumatized patient increase with the expedited arrival of medical assistance and increased speed of transportation to an appropriate hospital.
Testing Emergency Medical Personnel Response to Patients with Suspected Infectious Disease
Authors: Klein Kelly R. , Atas Jenny G. , Collins Jerry
Published: August 2016

Objectives:

In the United States (US), hospitals are required to have disaster plans and stage drills to test these plans in order to satisfy the Joint Accreditation Commission of Healthcare Organizations. The focus of this drill was to test if emergency response personnel, both prehospital and hospital, would identify a patient with a potentially communicable infectious disease, and activate their respective disaster plan.

Methods:

Twelve urban/suburban emergency departments (ED) received patients via car and ambulance. Patients were moulaged to imitate a smallpox infection. Observers with checklists recorded what happened. The drill's endpoints were: (1) predetermined end time; (2) identification of the patient and hospital “lock-down”; and (3) breach of drill protocol.

Results:

None of the ambulance personnel correctly identified their patients. Of the total 13 mock patients assessed in the ED, seven (54%) were identified by the ED staff as possibly being infected with a highly contagious agent and, in turn, the hospital's bio-agent protocol was initiated. Of the correctly identified patients, five (71%) were placed in isolation, and the remaining two (29%), although not isolated, were identified prior to their ED discharge and the appropriate protocol was activated. The six remaining mock patients (46%) were incorrectly diagnosed and discharged. Of the hospitals that had correctly identified their “infected” patients, only two (29%) followed their notification protocol and contacted the local health department.

Conclusion:

This drill was successful in identifying this area's shortcomings, highlighted positive reactions, and raised some interesting questions about the ability to detect a patient with a possibly highly contagious disease.
Cost-Effectiveness and Benefit of Alternatives to Improve Training for Prehospital Trauma Care in Mexico
Authors: Arreola-Risa Carlos , Mock Charles , Herrera-Escamilla Alejandro J. , Contreras Ismael , Vargas Jorge
Published: August 2016

Introduction:

In Latin America, there is a preponderance of prehospital trauma deaths. However, scarce resources mandate that any improvements in prehospital medical care must be cost-effective. This study sought to evaluate the costeffectiveness of several approaches to improving training for personnel in three ambulance services in Mexico.

Methods:

In Monterrey, training was augmented with PreHospital Trauma Life Support (PHTLS) at a cost of [US]$150 per medic trained. In San Pedro, training was augmented with Basic Trauma Life Support (BTLS), Advanced Cardiac Life Support (ACLS), and a locally designed airway management course, at a cost of $400 per medic. Process and outcome of trauma care were assessed before and after the training of these medics and at a control site.

Results:

The training was effective for both intervention services, with increases in basic airway maneuvers for patients in respiratory distress in Monterrey (16% before versus 39% after) and San Pedro (14% versus 64%). The role of endotrachal intubation for patients with respiratory distress increased only in San Pedro (5% versus 46%), in which the most intensive Advanced Life Support (ALS) training had been provided. However, mortality decreased only in Monterrey, where it had been the highest (8.2% before versus 4.7% after) and where the simplest and lowest cost interventions were implemented. There was no change in process or outcome in the control site.

Conclusions:

This study highlights the importance of assuring uniform, basic training for all prehospital providers. This is a more cost-effective approach than is higher-cost ALS training for improving prehospital trauma care in environments such as Latin America.
Demystifying Bioterrorism: Misinformation and Misperceptions
Authors: Noji Eric , Goodwin Tress , Hopmeier Michael
Published: August 2016

The true threat of bioterrorism remains mysterious and elusive to the common citizen. It principally has become the dominion of a few “experts”, many of whom have limited apparent expertise, who have failed to effectively communicate the risks and realities to society, and have instead created an air of uncertainty surrounding the topic. Unlike the great classic deceptions of modern life (e.g., “the check is in the mail”), the misinformation and misperceptions associated with bioterrorism can be dangerous and are not merely humorous. Indeed, it is possible to grasp the facts as well as fallacies associated with bioterrorism, and, as a result, demystify this nightmare scenario and prepare for the “unthinkable”.
Predictors of Emotional Adjustment following Traumatic Injury: Personal, Social, and Material Resources
Authors: Cordova Matthew J. , Walser Robyn , Neff Janet , Ruzek Josef I.
Published: August 2016

Introduction:

The identification of factors influencing emotional adjustment after injury may elucidate the design of assessment and treatment procedures in emergency medicine settings and suggest targets for early intervention to prevent the later development of psychological impairment. Personal, social, and material resources may be influential factors and require further evaluation.

Hypotheses:

Greater experiential avoidance, social constraints on discussing the trauma experience, and loss of material resources would be associated with more of the symptoms of posttraumatic stress and depression following traumatic injury.

Methods:

Participants (n = 47) at a mean of 7.4 months post-injury, completed a telephone interview assessment, including evaluation of sociodemographic characteristics, conservation of resources, social constraints, acceptance and commitment, and symptoms of post-traumatic stress disorder (PTSD) and depression. Hypotheses were tested using multivariate regression analyses.

Results:

Only greater social constraints were uniquely predictive of greater PTSD symptomatology. Higher levels of experiential avoidance, social constraints, and loss of material resources all were associated with greater levels of depression.

Conclusion:

Assessment of personal coping style, receptivity of social network, and loss of potential material resources following traumatic injury may facilitate identification of individuals at-risk for poorer post-injury adaptation. Psychosocial interventions targeting such individuals may be promising.
The Incident Command System in Disasters: Evaluation Methods for a Hospital-based Exercise
Authors: Thomas Tamara L. , Hsu Edbert B. , Kim Hong K. , Colli Sara , Arana Guillermo , Green Gary B.
Published: August 2016

Objectives:

No universally accepted methods for objective evaluation of the function of the Incident Command System (ICS) in disaster exercises currently exist. An ICS evaluation method for disaster simulations was derived and piloted.

Methods:

A comprehensive variable list for ICS function was created and four distinct ICS evaluation methods (quantitative and qualitative) were derived and piloted prospectively during an exercise. Delay times for key provider-victim interactions were recorded through a system of data collection using participant and observer-based instruments. Two different post exercise surveys (commanders, other participants) were used to assess knowledge and perceptions of assigned roles, organization, and communications. Direct observation by trained observers and a structured debriefing session also were employed.

Results:

A total of 45 volunteers participated in the exercise that included 20 mock victims. First, mean, and last victim delay times (from exercise initiation) were 2.1, 4.0, and 9.3 minutes (min) until triage, and 5.2, 11.9, and 22.0 min for scene evacuation, respectively. First, mean, and last victim delay times to definitive treatment were 6.0, 14.5, and 25.0 min. Mean time to triage (and range) for scene Zones I (nearest entrance), II (intermediate) and III (ground zero) were 2.9 (2.0–4.0), 4.1 (3.0–5.0) and 5.2 (3.0–9.0) min, respectively. The lowest acuity level (Green) victims had the shortest mean times for triage (3.5 min), evacuation (4.0 min), and treatment (10.0 min) while the highest acuity level (Red) victims had the longest mean times for all measures; patterns consistent with independent rather than ICS-directed rescuer activities. Specific ICS problem areas were identified.

Conclusions:

A structured, objective, quantitative evaluation of ICS function can identify deficiencies that can become the focus for subsequent improvement efforts.
Successful Development and Implementation of a Tactical Emergency Medical Technician Training Program for United States Federal Agents
Authors: Ciccone Teriggi J. , Anderson Phillip D. , Gann Chon A.D. , Riley J. Michael , Maxwell Michael , Hopkins Robert , Ciottone Gregory
Published: August 2016

Introduction:

The emerging need for tactical operations in law enforcement often places personnel involved at risk. Tactical operations often are carried out in environments in which access to emergency care is limited. With the war against terrorism expanding, special operations involving United States federal agents are occurring worldwide. Currently, there are very few tactical medicine curricula training traditional emergency medical services (EMS) providers to operate in these high-risk missions. Trainees in existing programs must have previous EMS experience, and are selected from a wide range of backgrounds. The goal of this study is to examine a Special Agent Emergency Medical Technician (SAEMT) training curriculum developed specifically for federal special agents with prior experience in tactical operations, but without previous medical training.

Methods:

An analysis of the SAEMT Program given to federal agents of the Drug Enforcement Administration (DEA) in Quantico, Virginia between July 2000 and April 2002 was performed. The SAEMT curriculum provided enrolled agents 181.5 hours of training in tactical emergency topics, including medical mission planning, logistics, operations, evacuation, and weapons training. In addition, SAEMT concurrently provides emergency medical technician (EMT) training. All of the participants were DEA agents with no previous medical training. Upon completion of the course, all participants took the National Registry of EMT-Basic examination. Measured endpoints included course completion rate and performance on certifying examinations.

Results:

Ninety-five agents were enrolled and successfully completed the SAEMT course between July 2000 and April 2002. Of the agents enrolled, 84 (88%) passed the National Registry of EMTs-Basic examination within two attempts.

Conclusion:

The SAEMT Program provides basic emergency medical training to federal special agents with no previous medical experience. The design of this program provides a useful template to meet the expanding demand for tactical emergency medical personnel.
Triage Decisions of United Kingdom Police Firearms Officers Using a Multiple-Casualty Scenario Paper Exercise
Authors: Kilner Tim , Hall F. John
Published: August 2016

Introduction:

British police officers authorized to carry firearms may need to make judgments about the severity of injury of individuals or the relative priority of clinical need of a group of injured patients in tactical and non-tactical situations. Most of these officers receive little or no medical training beyond basic first aid to enable them to make these clinical decisions. Therefore, the aim of this study is to determine the accuracy of triage decision-making of firearms-trained police officers with and without printed decision-support materials.

Methods:

Eighty-two police firearms officers attending a tactical medicine course (FASTAid) were recruited to the study. Data were collected using a paper-based triage exercise that contained brief, clinical details of 20 adults and 10 children. Subjects were asked to assign a clinical priority of immediate or priority 1 (P1); urgent or priority 2 (P2); delayed or priority 3 (P3); or dead, to each casualty. Then, they were provided with decision-making materials, but were not given any instruction as to how these materials should be used. Subjects then completed a second triage exercise, identical to the first, except this time using the decision-support materials.

Data were analyzed using mixed between-within subjects analysis of variance. This allowed comparisons to be made between the scores for Exercise 1 (no decision-support material) and Exercise 2 (with decision-support material). It also allowed any differences between those students with previous triage training and those without previous training to be explored.

Results:

The use of triage decision-making materials resulted in a significant increase in correct responses (p <0.001). Improvement in accuracy appears to result mainly from a reduction in the extent of under-triage. There were significant differences (p <0.05) between those who had received previous triage training and those who had not, with those having received triage training doing slightly better.

Conclusion:

It appears that significant improvements in the accuracy of triage decision-making by police firearms officers can be achieved with the use of appropriate triage decision-support materials. Training may offer additional improvements in accuracy, but this improvement is likely to be small when decision-support materials are provided. With basic clinical skills and appropriate decision-support materials, it is likely that the police officer can make accurate triage decisions in a multiple-casualty scenario or make judgments of the severity of injury of a given individual in both tactical and non-tactical situations.
Symptom-Based, Algorithmic Approach for Handling the Initial Encounter with Victims of a Potential Terrorist Attack
Authors: Subbarao Italo , Johnson Christopher , Bond William F. , Schwid Howard A. , Wasser Thomas E. , Deye Greg A. , Burkhart Keith K.
Published: August 2016

Objectives:

This study intended to create symptom-based triage algorithms for the initial encounter with terror-attack victims. The goals of the triage algorithms include: (1) early recognition; (2) avoiding contamination; (3) early use of antidotes; (4) appropriate handling of unstable, contaminated victims; and (5) provisions of force protection. The algorithms also address industrial accidents and emerging infections, which have similar clinical presentations and risks for contamination as weapons of mass destruction (WMD).

Methods:

The algorithms were developed using references from military and civilian sources. They were tested and adjusted using a series of theoretical patients from a CD-ROM chemical, biological, radiological/nuclear, and explosive victim simulator. Then, the algorithms were placed into a card format and sent to experts in relevant fields for academic review.

Results:

Six inter-connected algorithms were created, described, and presented in figure form. The “attack” algorithm, for example, begins by differentiating between overt and covert attack victims (A covert attack is defined by epidemiological criteria adapted from the Centers for Disease Control and Prevention (CDC) recommendations). The attack algorithm then categorizes patients either as stable or unstable. Unstable patients flow to the “Dirty Resuscitation” algorithm, whereas, stable patients flow to the “Chemical Agent” and “Biological Agent” algorithms. The two remaining algorithms include the “Suicide Bomb/Blast/Explosion” and the “Radiation Dispersal Device” algorithms, which are inter-connected through the overt pathway in the “Attack” algorithm.

Conclusion:

A civilian, symptom-based, algorithmic approach to the initial encounter with victims of terrorist attacks, industrial accidents, or emerging infections was created. Future studies will address the usability of the algorithms with theoretical cases and utility in prospective, announced and unannounced, field drills. Additionally, future studies will assess the effectiveness of teaching modalities used to reinforce the algorithmic approach.