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You go from here to there, and here you're specialized in one particular sort of thing, there you may be asked to do all sorts of things outside your specialty. How far do you go and where are the issues surrounding that?
Canadian physician discussing experiences in humanitarian aid work
Health professionals working in humanitarian relief projects encounter a range of ethical challenges. Applying professional and ethical norms may be especially challenging in crisis settings where needs are elevated, resources scarce, and socio-political structures strained. Situations when clinicians must decide whether to provide care that is near the margins of their professional competency are a source of moral uncertainty that can give rise to moral distress. The authors suggest that responding ethically to these dilemmas requires more than familiarity with ethical codes of conduct and guidelines; it requires practical wisdom, that is, the ability to relate past experience and general guidance to a current situation in order to render a morally sound action. Two sets of questions are proposed to guide reflection and deliberation for clinicians who face competency dilemmas. The first is prospective and intended to aid clinicians in evaluating an unfolding situation. The second is retrospective and designed to support debriefing about past experiences and difficult situations. The aim of this analysis is to support clinicians in evaluating competency dilemmas and provide ethical care and services.
HuntMR, SchwartzL, FraserV. “How Far Do You Go and Where Are the Issues Surrounding That?” Dilemmas at the Boundaries of Clinical Competency in Humanitarian Health Work. Prehosp Disaster Med. 2013;28(5):1-7.
Social networks play an important role in disaster situations as they have become a new form of social convergence that provides collective information. The effect of social media on people who experienced disaster should be assessed.
Hypothesis
In this study, Twitter communication during the Great East Japan Earthquake of March 11, 2011 was assessed. The hypothesis of this study was that usage of Twitter had psychological effects on victims of the disaster.
Methods
A cross-sectional questionnaire survey was carried out in cooperation with a major Japanese newspaper three months after the disaster, and 1,144 volunteer participants responded. They were asked about their health, area of residence, property damage they had experienced, information sources they used at the time of the disaster, and their usage of Twitter. Further, the Twitter users were divided into two groups—with and without disaster experience. Their psychological effects relating to feelings of relief, stress or anxiety that they experienced in using Twitter were compared between two groups, and Twitter's psychological risk of disaster experience was estimated as an odds ratio.
Results
Twitter users in this study tended to reside in disaster-affected areas and thought Twitter was a credible information source during the time of the disaster. The psychological effect of Twitter differed based on participants’ disaster experience and gender. Females with disaster experience reported more feelings of relief and stress as a result of using Twitter compared to females who did not experience the disaster. On the other hand, males with disaster experience only reported more stress experiences as a result of using Twitter compared to those without disaster experience.
Conclusion
Twitter users with disaster experience had a higher usage of Twitter than those without disaster experience. Social media might have had a material psychological influence on people who experienced disaster, and the effect differed by gender. Regardless of gender, negative feelings were transmitted easily among people who experienced the disaster. It was anticipated that the application of Twitter in a disaster situation will be expanded further by taking these findings into consideration.
UmiharaJ, NishikitaniM. Emergent Use of Twitter in the 2011 Tohoku Earthquake. Prehosp Disaster Med.2013;28(5):1-7.
The building of prehospital emergency medical care systems in developing and lower middle-income countries (as defined by the World Bank) is a critical step in those countries’ efforts to reduce unnecessary morbidity and mortality. This case report presents the development of a prehospital care system in Jaffna District, Sri Lanka and provides the results of the system's first year of operations, the likely reasons for the results, and the prospects for sustained operations of the system. The goal of this report is to add to the literature surrounding Emergency Medical Services (EMS) in developing countries by providing insight into the implementation of a prehospital emergency care system in developing and lower middle-income settings.
Methods
The level of utilization and the financial performance of the system during its first year of operation were analyzed using data from the Jaffna Regional Director of Health Services (RDHS) Call Center database and information from the implementing organization, Medical Teams International.
Results
The system responded to >2000 emergency calls in its first 11 months of operation. The most utilized ambulance of the system experienced only a US $13.50 loss during the first 12 months of operation. Factors such as up-front support, a systematic approach, and appropriateness contributed to the successful implementation of the Jaffna prehospital EMS system.
Conclusion
The implementation of a prehospital EMS system and its functioning were successful in terms of utility and, in many regards, financial stability. The system's success in development may serve as a potential model for implementing prehospital emergency medical care in other developing and lower middle-income country settings, keeping in mind factors outside of the system that were integral to its developmental success.
ZimmermanJR, BertermannKM, BollingerPJ, WoodyardDR. Prehospital System Development in Jaffna, Sri Lanka. Prehosp Disaster Med. 2013;28(5):1-8.
According to US military data, airway obstruction is the third leading cause of possibly preventable death in combat. In the absence of law enforcement-specific medical training, military experience has been translated to the law enforcement sector. The purpose of this study was to determine whether airway obstruction represents a significant cause of possibly preventable death in police officers, and whether current military combat lifesaver training programs might have prevented these fatalities.
Methods
De-identified, open-source US Federal Bureau of Investigation (FBI) Uniform Crime Report Law Enforcement Officers Killed and Assaulted (LEOKA) data for the years 1998-2007 were reviewed. Cases were included if officers were on duty at the time of fatal injury and died within one hour from time of wounding from penetrating face or neck trauma. After case identification, letters requesting autopsy reports were sent to the departments of victim officers. Reports were abstracted into a Microsoft Excel database.
Results
During the study period, 42 of 533 victim officers met inclusion criteria. Departmental response rate was 85.7%. Autopsy reports were provided for 29 officers; 23 (54.8%) cases remained in the final analysis. All officers died from gunshot wounds. No coroner specifically identified airway obstruction as either a direct cause of death or contributing factor. Based upon autopsy findings, three of 341 officers possibly succumbed to airway trauma (0.9%; 95% CI, 0.0%-1.9%). Endotracheal intubation was the most common advanced airway management technique utilized during attempted resuscitation.
Conclusion
The limited LEOKA data suggests that acute airway obstruction secondary to penetrating trauma appears to be a rare cause of possibly preventable death in police officers. Based upon the nature of airway trauma, nasopharyngeal airways would not be expected to be an effective lifesaving intervention. This study highlights the requirement for a comprehensive mortality and “near miss” database for law enforcement officers.
FisherL, CallawayD, SztajnkrycerM. Incidence of Fatal Airway Obstruction in Police Officers Feloniously Killed in the Line of Duty: A 10-Year Retrospective Analysis. Prehosp Disaster Med.2013;28(5):1-5.
During the night of February 27 and the early morning of February 28, 2010, 15 coastal municipalities situated in two French departments, Vendée and Charente-Maritime, were violently stricken by a severe windstorm named “Xynthia.” This storm caused the death of 12 individuals in Charente-Maritime and 29 people in Vendée. Houses, agricultural fields, and shellfish companies were severely flooded with seawater. Several thousand people temporarily had to leave their homes. The objective of this study was to estimate the short-term mental health impact of Xynthia, in terms of psychotropic drug delivery, on the resident population of the 15 coastal municipalities severely hit by the flooding.
Methods
The French national health insurance database was used to calculate a daily number of new psychotropic treatments from September 1, 2008 through December 24, 2010. New treatments were calculated for each of the following European Pharmaceutical Marketing Research Association (EphMRA) classes: tranquilizers (N05C), hypnotics (N05B), and antidepressants (N06A). A period of three weeks following the storm was defined as the exposure period. A generalized additive model with a Poisson distribution that allows for over-dispersion was used to analyze the correlation between the Xynthia variable and the number of new psychotropic treatments.
Results
With a relative risk (RR) of 1.54 (95% CI, 1.39-1.62) corresponding to an estimate of 409 new deliveries of psychotropic drugs during the three weeks following the storm, this study confirms the importance of the psychological impact of Xynthia. This impact is seen on all three classes of psychotropic drugs studied. The impact is greater for tranquilizers (RR of 1.78; 95% CI, 1.59-1.89) than for hypnotics (RR of 1.53; 95% CI, 1.31-1.67) and antidepressants (RR of 1.26; 95% CI, 1.06-1.40). The RR was higher for females than for males.
Conclusion
This study shows the importance of the psychological impact of the storm as observed clinically by health workers who intervened in the field during the aftermath of Xynthia. It confirms that administrative databases can be used to show a health impact of a disaster even at a local level. This is one more step in the direction of a comprehensive strategy of collecting information to allow the assessment of the health impact of an extreme event, the detection of vulnerable populations, and the orientation of the short-, mid- and long-term public health response.
MotreffY, PirardP, GoriaS, LabradorB, Gourier-FréryC, NicolauJ, Le TertreA, Chan-CheeC. Increase in Psychotropic Drug Deliveries after the Xynthia Storm, France, 2010. Prehosp Disaster Med. 2013;28(5):1-6.
Electronic medical records (EMRs) are considered superior in documentation of care for medical practice. Current disaster medical response involves paper tracking systems and radio communication for mass-casualty incidents (MCIs). These systems are prone to errors, may be compromised by local conditions, and are labor intensive. Communication infrastructure may be impacted, overwhelmed by call volume, or destroyed by the disaster, making self-contained and secure EMR response a critical capability.
Report
As the prehospital disaster EMR allows for more robust content including protected health information (PHI), security measures must be instituted to safeguard these data. The Wireless Internet Information System for medicAl Response in Disasters (WIISARD) Research Group developed a handheld, linked, wireless EMR system utilizing current technology platforms. Smart phones connected to radio frequency identification (RFID) readers may be utilized to efficiently track casualties resulting from the incident. Medical information may be transmitted on an encrypted network to fellow prehospital team members, medical dispatch, and receiving medical centers. This system has been field tested in a number of exercises with excellent results, and future iterations will incorporate robust security measures.
Conclusion
A secure prehospital triage EMR improves documentation quality during disaster drills.
DeMersG, KahnC, JohanssonP, BuonoC, ChiparaO, GriswoldW, ChanT. Secure Scalable Disaster Electronic Medical Record and Tracking System. Prehosp Disaster Med. 2013;28(5):1-4.
Patients with possible spinal injury must be immobilized properly during transport to medical facilities. The aim of this research was comparing spinal immobilization using a long backboard (LBB) with using a vacuum mattress splint (VMS) in trauma victims transported by an Emergency Medical Services (EMS) system.
Methods
In this randomized clinical trial, 60 trauma victims with possible spinal trauma were divided to two groups, each group immobilized with one of the two instruments. Speed and ease of application, immobilization rate, and the patients’ comfort were recorded.
Results
In this survey, LBB was faster to apply: 211.66 (SD = 28.53) seconds vs 654.00 (SD = 16.61) seconds. Various measures of immobilization were better by LBB. Also, LBB offered a significant improvement in comfort over a VMS for the patient with possible spinal injury. All of the results were statistically significant.
Conclusion
The results of this study showed that immobilization using LBB was easier, faster, and more comfortable for the patient, and provided additional decrease in spinal movement when compared with a VMS.
MahshidfarB, MofidiM, YariA, MehrsoroshS. Long Backboard versus Vacuum Mattress Splint to Immobilize Whole Spine in Trauma Victims in the Field: a Randomized Clinical Trial. Prehosp Disaster Med. 2013;28(5):1-4.
The frequency of occurrence of natural disasters has increased over the past several decades, which necessitates a better understanding of human vulnerability, particularly in low-resource settings. This paper assesses risk factors for injury in the March 2010 floods and landslides in Eastern Uganda, and compares the effects of location, injury type, and severity.
Methods
A stratified cluster survey of the disaster-affected populations was conducted five months after onset of the disasters. Probability proportional to size sampling was used to sample 800 households, including 400 affected by floods in Butaleja District and 400 affected by landslides in Bududa District.
Results
Flood- and landslide-affected populations were surveyed in July 2010 using a stratified cluster design. The odds of injury were 65% higher in the flood-affected groups than the landslide-affected groups in a logistic regression (OR = 0.35; 95% CI, 0.24-0.52; P < .001). The injury rate was greater in individuals under 42 years of age, and location of injury was a contributing factor. More people were injured in the flood-affected population as compared with the landslide-affected population, and injuries were more severe.
Conclusions
This study illustrates differences between populations injured by flood and landslide disasters that occurred simultaneously in Eastern Uganda in 2010. In areas where landslides are prone to occur due to massive rainfalls or floods, preventative measures, such as early warning systems and evacuation, are more likely to increase the likelihood of people surviving, while for areas with massive floods, immediate and effective medical attention can save lives and improve injury outcomes.
AgrawalS, GopalakrishnanT, GorokhovichY, DoocyS. Risk Factors for Injuries in Landslide- and Flood-Affected Populations in Uganda. Prehosp Disast Med. 2013;28(4):1-9.
This report describes the case of an 18-year-old woman who was found in the sea suffering from cardiac arrest and hypothermia, 90 minutes after she entered the water to swim. The rescue team used an automated external defibrillator to record prehospital management. This recording showed an isoelectric electrocardiogram followed by a ventricular fibrillation, an unsuccessful defibrillation, and lastly, a return of spontaneous circulation with Osborn wave. When she was admitted to the intensive care unit two hours later, the woman's central temperature was 28°C.
The case is interesting because of several points. First, to the best of the authors’ knowledge, this is the only case of cardiac arrest with severe hypothermia followed by a return of spontaneous circulation documented with an automated external defibrillator recording. Second, the hypothermia is an atypical case occurring in the summer. Hypothermia must be considered even in unlikely circumstances, such as summer in the south of France, when ambient temperatures are high. Lastly, after three days, the patient recovered successfully from cardiopulmonary arrest without cerebral dysfunction.
ClaretP-G, BobbiaX, DingemansG, OndeO, SebbaneM, de La CoussayeJ-E. Drowning, Hypothermia and Cardiac Arrest: An 18-year-old Woman with an Automated External Defibrillator Recording. Prehosp Disaster Med. 2013;28(5):1-3.
Social and political instability have become common situations in many parts of the world. Exposure to different types of traumatic circumstances may differentially affect psychological status.
Objective
The aim of this study was to compare the relationship between personal perceptions of control over the events happening in one's life and psychological distress in two groups who experienced physical trauma but differed as to whether the trauma was a result of political upheaval and violence. Views on the extent to which the state was interested in the individual were also assessed.
Methods
The sample consisted of 120 patients who were injured in the Cairo epicenter and 120 matched controls from the greater Cairo area whose injuries were from other causes. The Brown Locus of Control Scale and the Symptom Checklist-90-Revised (SCL 90-R) were administered approximately three months after the January 2011 start of the demonstrations and subsequent overthrow of the government.
Results
The groups did not differ on locus of control. For both groups, externality was associated with greater distress, suggesting a relationship between perceived helplessness in controlling one's life and distress. The Cairo group scored significantly higher than the control group on the SCL 90-R Global Severity Index (GSI) and Positive Symptom Total (PST). Perceptions of state interest in the population were low; overall, 78% viewed the state as having little or no interest in them.
Discussion
The relationship between exposure intensity and psychological distress is examined. In addition, differences in findings in populations experiencing political chaos compared with other types of disasters are considered.
Conclusion
Beliefs regarding personal control over one's life circumstances are more closely associated with psychological distress than the circumstances in which the trauma occurred.
PapanikolaouV, GadallahM, LeonG, MassouE, ProdromitisG, SkembrisA, LevettJ. Relationship of Locus of Control, Psychological Distress, and Trauma Exposure in Groups Impacted by Intense Political Conflict in Egypt. Prehosp Disaster Med. 2013;28(4):1-5.
Pain associated with pediatric trauma is often under-assessed and under-treated in the out-of-hospital setting. Administering an opioid such as fentanyl via the intranasal route is a safe and efficacious alternative to traditional routes of analgesic delivery and could potentially improve pain management in pediatric trauma patients.
Objective
The study sought to examine the effect of introducing the mucosal atomization device (MAD) on analgesia administration as an alternative to intravenous fentanyl delivery in pediatric trauma patients. The hypothesis for the study is that the introduction of the MAD would increase the administration of fentanyl in pediatric trauma patients.
Methods
The research utilized a 2-group design (pre-MAD and post-MAD) to study 946 pediatric trauma patients (age <16) transported by a large, urban EMS agency to one of eight hospitals in Marion County, which is located in Indianapolis Indiana. Two emergency medicine physicians independently determined whether the patient met criteria for pain medication receipt and a third reviewer resolved any disagreements. A comparison of the rates of fentanyl administration in both groups was then conducted.
Results
There was no statistically significant difference in the rate of fentanyl administration between the pre-MAD (30.4%) and post-MAD groups (37.8%) (P = .238). A subgroup analysis showed that age and mechanism of injury were stronger predictors of fentanyl administration.
Conclusion
Contrary to the hypothesis, the addition of the MAD device did not increase fentanyl administration rates in pediatric trauma patients. Future research is needed to address the barriers to analgesia administration in pediatric trauma patients.
O'DonnellDP, SchaferLC, StevensAC, WeinsteinE, MiramontiCM, KozakMA. Effect of Introducing the Mucosal Atomization Device for Fentanyl Use in Out-of-Hospital Pediatric Trauma Patients. Prehosp Disaster Med. 2013;28(4):1-3.
Much attention has been given to the strategic placement of automated external defibrillators (AEDs). The purpose of this study was to examine the correlation of strategically placed AEDs and the actual location of cardiac arrests.
Methods
A retrospective review of data maintained by the Maryland Institute for Emergency Medical Services Systems (MIEMSS), specifically, the Maryland Cardiac Arrest Database and the Maryland AED Registry, was conducted. Location types for AEDs were compared with the locations of out-of-hospital cardiac arrests in Howard County, Maryland. The respective locations were compared using scatter diagrams and r2 statistics.
Results
The r2 statistics for AED location compared with witnessed cardiac arrest and total cardiac arrests were 0.054 and 0.051 respectively, indicating a weak relationship between the two variables in each case. No AEDs were registered in the three most frequently occurring locations for cardiac arrests (private homes, skilled nursing facilities, assisted living facilities) and no cardiac arrests occurred at the locations where AEDs were most commonly placed (community pools, nongovernment public buildings, schools/educational facilities).
Conclusion
A poor association exists between the location of cardiac arrests and the location of AEDs.
LevyMJ, SeamanKG, MillinMG, BissellRA, JenkinsJL. A Poor Association Between Out-of-Hospital Cardiac Arrest Location and Public Automated External Defibrillator Placement. Prehosp Disaster Med. 2013;28(4):1-6.
Methods of defining hospital disaster preparedness are poorly defined in the literature, leaving wide discrepancies between a hospital's self-reported preparedness and that assessed by an objective reviewer.
Objectives
This study compared self-reported surge capacity data from individual hospitals, obtained from a previously reported long-distance tabletop drill (LDTT) prior to the 2010 FIFA World Cup tournament in Cape Town, South Africa, with surge capacity data assessed by an on-site survey inspection team.
Methods
In this prospective, observational study, contact persons used in the prior LDTT assessing hospital disaster preparedness in the lead-up to the 2010 FIFA World Cup made surge capacity assessments (licensed bed capacity plus surge capacity beds) for the respiratory intensive care unit (RICU), neonatal intensive care unit (NICU), medical intensive care unit (MICU), and general medical/surgical beds in each hospital. Following the 2010 World Cup, this data was then re-evaluated by an on-site survey team consisting of two of the authors.
Results
The contact persons for the individual hospitals from the LDTT underreported their individual hospital's surge capacity in 86% (95% CI, 46%-99%) of RICU beds; 100% (95% CI, 63%-100%) of MICU beds; 75% (95% CI, 40%-94%) of NICU beds; and 71% (95% CI, 35%-92%) of medical/surgical beds compared with the on-site inspection team.
Conclusions
The contact persons for the LDTT overwhelmingly underreported surge capacity beds compared with the surge capacity determined by the on-site inspection team.
ValeskyW, RoblinP, PatelB, AdelaineJ, ZehtabchiS, ArquillaB. Assessing Hospital Preparedness: Comparison of an On-site Survey with a Self-reported, Internet-based, Long-distance Tabletop Drill. Prehosp Disaster Med. 2013;28(4):1-4.
Dealing with major incidents requires an immediate and coordinated response by multiple organizations. Communicating and coordinating over multiple geographical locations and organizations is a complex process. One of the greatest challenges is patient tracking and tracing. Often, data about the number of victims, their condition, location and transport is lacking. This hinders an effective response and causes public distress. To address this problem, a Victim Tracing and Tracking system (ViTTS) was developed.
Methods
An online ViTTS was developed based on a wireless network with routers on ambulances, and direct online registration of victims and their triage data through barcode injury cards. The system was tested for feasibility and usability during disaster drills.
Results
The formation of a local radio network of hotspots with mobile routers and connection over General Packet Radio Service (GPRS) to the central database worked well. ViTTS produced accurately stored data, real-time availability, and a real-time overview of the patients (number, seriousness of injury, and location).
Conclusion
The ViTTS provides a system for early, unique registration of victims close to the impact site. Online application and connection of the various systems used by the different chains in disaster relief promotes interoperability and enables patient tracking and tracing. It offers a real-time overview of victims to all involved disaster relief partners, which is necessary to generate an adequate disaster response.
MarresGMH, TaalL, BemelmanM, BoumanJ, LeenenLPH. Online Victim Tracking and Tracing System (ViTTS) for Major Incident Casualties. Prehosp Disaster Med. 2013;28(4):1-9.
Emergency medical services personnel treat 22 million patients a year, yet little is known of their risk of injury and fatality.
Problem
Work-related injury and fatality rates among US paramedics and emergency medical technicians (EMTs) are higher than the national average for all occupations.
Methods
Data collected by the Department of Labor (DOL) Bureau of Labor Statistics were reviewed to identify injuries and fatalities among EMTs and paramedics from 2003 through 2007. The characteristics of fatal injuries are described and the rates and relative risks of the non-fatal injuries were calculated and compared to the national average.
Results
Of the 21,749 reported cases, 21,690 involved non-fatal injuries or illnesses that resulted in lost work days among EMTs and paramedics within the private sector. Of the injuries, 3,710 (17%) resulted in ≥31 days of lost work time. A total of 14,470 cases (67%) involved sprains or strains; back injury was reported in 9,290 of the cases (43%); and the patient was listed as the source of injury in 7,960 (37%) cases. The most common events were overexertion (12,146, 56%), falls (2,169, 10%), and transportation-related (1,940, 9%). A total of 530 assaults were reported during the study period. Forty-five percent of the cases occurred among females (females accounted for 27% of employment in this occupation during 2007). In 2007, EMTs and paramedics suffered 349.9 injuries with days away from work per 10,000 full-time workers, compared to an average of 122.2 for all private industry occupations (Relative risk = 2.9; 95% CI: 2.7–3.0). During the study period, 59 fatalities occurred among EMTs and paramedics in both the private industry and in the public sector. Of those fatalities, 51 (86%) were transportation-related and five (8%) were assaults; 33 (56%) were classified as “multiple traumatic injuries.”
Conclusions
Data from the DOL show that EMTs and paramedics have a rate of injury that is about three times the national average for all occupations. The vast majority of fatalities are secondary to transportation related-incidents. Assaults are also identified as a significant cause of fatality. The findings also indicate that females in this occupational group may have a disproportionately larger number of injuries. Support is recommended for further research related to causal factors and for the development, evaluation and promulgation of evidence-based interventions to mitigate this problem.
MaguireBJ, SmithS. Injuries and Fatalities among Emergency Medical Technicians and Paramedics in the United States. Prehosp Disaster Med. 2013;28(4):1-7.
Ambulance drivers often travel under stressful conditions at high speed while using vehicles with poor high-speed maneuverability. The occupant safety of ambulance vehicles has not yet been addressed by the automotive safety paradigm; particularly for the rear patient compartment. This study had two objectives: (1) to assess by survey the French Emergency Medical Services (EMS) to determine the layout of the vehicle most often used and the EMS personnel's behavior during transport; and (2) to conduct a crash test to analyze the injuries which may affect EMS personnel and patients in the rear patient compartment.
Method
Firstly, a survey was distributed to the 50 largest metropolitan French EMS programs. Secondly, a crash test was performed with a Mobile Intensive Care Unit (MICU) in conditions closest to reality.
Results
Forty-nine of the 50 biggest metropolitan French EMS programs responded to the survey. This represents 108 French MICUs. During the last three years, 12 of 49 EMS programs (24%) identified at least one accident with an MICU, and six of these 12 (50%) suffered at least one death in those accidents. A crash test using a typical French EMS MICU showed that after impact of a collision, the ambulance was moved more than five meters with major consequences for all passengers. A study-approved human cadaver placed in the position of a potential patient was partially thrown from the stretcher with a head impact. The accelerometric reaction of the anthropomorphic manikin head was measured at 48G.
Conclusion
The crash test demonstrated a lack of safety for EMS personnel and patients in the rear compartment. It would be preferable if each piece of medical equipment were provided with a quick release system resistant to three-dimensional 10G forces. The kinetic changes undergone by the “patient” substitute on the stretcher would probably have an effect of causing injury pathology. This study highlights the need for more research and development in this area.
FournierM, ChenaitiaH, MassonC, MicheletP, BehrM, AuffrayJP. Crew and Patient Safety in Ambulances: Results of a Personnel Survey and Experimental Side Impact Crash Test. Prehosp Disaster Med. 2013;28(4):1-6.