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To determine if instituting an Emergency Department (ED) fast-track area would increase efficiency in patient flow, improve utilization of limited resources, and identify critical versus non-critical patients during disaster relief in Port au Prince, Haiti.
Methods
A survey was conducted at L'Hôpital de l'Université d'Etat d'Haïti (HUEH) in Port au Prince, Haiti by Emergency physicians and nurses from SUNY Downstate Medical Center on a disaster relief mission following the 2010 earthquake. The following variables were obtained to assess ED effectiveness: number of patients, acuity level, chief complaints, critical interventions, waiting times, length of stay, specialty service coverage and physical plant space. Additionally, existing practitioners were surveyed regarding existing ED practices. ED operation flow maps were created.
Results
The assessment revealed a large volume of low-acuity patients mixed with high-acuity patients without identification of acuity level, time of arrival, or designated area for treatment. Although literature reports routine use of START triage, this was not being implemented in this setting. Results of implementing a fast track area included: (1) Improved identification of patients needing immediate treatment. (2) Increased flow of low acuity patients in designated fast track areas. (3) Improved triage protocols maximized appropriate use of resources, and expedited subspecialty consultation.
Conclusion
By instituting well-accepted, validated patient flow systems and reinforcing communication regarding resources available and the use of geographic space, better management of incoming emergency patients was achieved.
Preparing for and responding to foreign animal diseases are critical missions to safeguard any nation's animal health and food supply. A specific challenge of foreign animal disease preparedness and response is the ability to rapidly incorporate and scale-up veterinary functions and countermeasures into emergency management operations during a disease outbreak. The United States Department of Agriculture, Animal and Plant Health Inspection Service, Veterinary Services has established a Foreign Animal Disease Preparedness and Response Plan (FAD PReP) which provides a framework for FAD preparedness and response. The FAD PReP goal is to integrate, synchronize, and de-conflict preparedness and response capabilities, as much as possible, before an outbreak by providing goals, guidelines, strategies, and procedures that are clear, comprehensive, easily readable, easily updated, and that comply with the National Incident Management System (NIMS). An overview of FAD PReP will be presented.
Body
The APHIS FAD PReP incorporates and synchronizes the principles of the National Response Framework (NRF), the National Incident Management System (NIMS), and the National Animal Health Emergency Management System (NAHEMS). The FAD PReP contains general plans and disease specific plans that include incident goals, guidelines, strategies, procedures and timelines for local, State, Tribal and Federal responders. The FAD PReP helps raise awareness of the required veterinary functions and countermeasures, helps identify gaps or shortcomings in current response preparedness and planning, and helps to provide a framework to the States, Tribes, and Industry sectors in developing their individual response plans for specific diseases such as HPAI and FMD. The FAD PReP will also identify resources and personnel for potential zoonotic disease outbreaks and large-scale outbreaks, define stakeholder expectations for successful and timely outcomes, identify and resolve issues that may become competing interests during an outbreak and provide a systems approach to preparedness issues that need additional time, attention and collaboration.
Facing the threats of disasters due to natural hazards and terrorist attacks, communities and nations are strategically preparing to respond rapidly to such incidents with the appropriate medical services. Both natural and complex disasters may produce a massive number of casualties that outstrip the ability of the local healthcare system to provide the required care. Damage to the healthcare infrastructure will further compromise the delivery of health services. Field hospitals (FHs) may provide care for the injured and act as a substitute for destroyed hospitals in the aftermath of sudden-onset disasters. A FH is a large mobile medical unit that temporarily provides care to casualties on-site before they can be transported safely to more permanent hospital facilities. The concept was inherited from the battlefield (such as the mobile army surgical hospital (MASH)). A FH is defined as a mobile, self-contained, self-sufficient healthcare facility capable of rapid deployment and expansion or contraction to meet immediate emergency requirements for a specified period of time. The FH may be dispatched temporarily with personnel or donated without personnel.
Methods
Field hospitals have been focused on providing emergency trauma care for the initial 48 hours following the sudden-onset disasters, but they tend to continue operations much longer after the on-set. The aim of this study was to assess the timing, activities, and capacities of the FHs deployed after a disaster, especially in severe environments, and provide guidelines on the implementation and deployment of a FH during a disaster. In particular, the activity of Italian Field Hospitals utilized during disasters, humanitarian emergencies, and mass-gatherings events will be described.
Conclusions
Field hospitals have been used successfully during disasters, and now have a crucial role in supporting affected populations and damaged healthcare infrastructures. Field hospitals also play a role in the international community response.
At approximately 06:15h on 16 April 2009, there was an explosion and subsequent fire onboard the Suspected Illegal Entry Vessel (SIEV) 36. The vessel was located in the vicinity of the Ashmore Reef, approximately 610 kilometers north of Broome in Western Australia (WA). Onboard were members of the Royal Australian Navy (RAN), 47 asylum seekers, and two crew members. Traveling with SIEV 36 were the RAN Patrol Boats, HMAS Childers, and HMAS Albany. The explosion resulted in five deaths and a large number of casualties with severe burn injuries, and a smaller number with concurrent trauma injuries. The Ashmore Reef incident was unique in that it involved the medical management and evacuation of 44 injured foreign nationals (31 seriously injured) in an extremely remote location. It resulted in an unprecedented health response from multiple agencies including local, regional, and state governments, commonwealth government agencies, non-government organizations, and private industry. The mission objective for this incident was to retrieve and evacuate multiple seriously injured casualties and stabilize them for safe transport to definitive care. The mission objective was achieved for the Ashmore Reef incident with no further deaths. As with all disasters, many lessons have been learned, and recommendations have been formulated. The logistic requirements to successfully complete such a mission have been reinforced as a result of this incident, as this was the most logistically challenging mass-casualty incident in WA history.
A Disaster is the tragedy of a natural or human made hazard that negatively affects society or environment. Disaster impacts physical, psychological, social and economic areas of the individual and family and community. Most of the time these are interlinked to each other and its total impact on the survivors is substantial. Children are more susceptible to disaster suffering, and it is noticeable in many complex psychological and behavioral symptoms. On the other hand, the post-disaster psychological effects on children are not recognized and underestimated by the mental health professionals. India is highly prone to natural disasters such as floods, droughts, cyclones, earthquakes and landslides have been recurrent phenomenon in India. Out of 602 districts in the country, 125 districts have been identified as most hazard prone areas. The recent heavy rainfall and flood between 28th September to 2nd October 2009 in the Northern region of Karnataka State caused several deaths and massive destructions. This was the first time that North Karnataka received highest rainfall. The incessant rainfall that poured for four days caused the flood and devastated and destroyed the entire social fabric of the community. Floods carry greater risks to psychological as well as physical health of children. The psychological impact of the floods on children has been carried out both qualitatively and quantitatively. The quantitative assessment was done to assess the severity of floods impact on children using the Impact of Event Scale (Dyregrov and Yule, 1995). The results showed the children showed higher level of intrusion and avoidance aftermath of floods. Boys had significantly higher psychological impact than girls. However, both boys and girls showed moderate to severe level of psychological impact on the domains of intrusion, avoidance and hypervegilence. The implication of the findings are discussed in the context of framing psychosocial programmes.
The watersheds are the home for our key natural resources and have been one of the basic elements in land use management systems throughout the hydraulic civilization of our country. “Badulla River” is one of the main watersheds in Sri Lanka extend about 1400sq.km consisting five sub catchments high steep lands. It mainly represents tea estates and agricultural lands with a weak land use pattern due to poor maintenance and unsuitable human involvements. This has contributed to reduce the rain water infiltration in to the soil increasing a huge amount of runoff water drainage. Situation has resulted frequent floods even in a small precipitation causing widespread damages to community. Hence, an initial project was started on surface water management, soil conservation and livelihoods development to control the frequent floods highlighting the urgent actions for an optimal land use management with support of field experts. Improved surface water drainage and soil conservation are the main options that might lead to mitigate the flash floods. Efforts were sharpened by integrating GIS Mapping for such initiation to enhance the effectiveness of the design. Results achieved could address many issues in relation to flood protection, habitat management, water protection and water quality management. Food risk generally related to the specific characters in a particular catchments and this model project proved that such issues can effectively be addressed through a joint program properly designed.
Many of critically ill patients are being cared for prolonged periods in ED just because of limited number of ICU beds and utilize of ED as the entry point to the health care system. The aim of this study is evaluation efficiency of APACHE III scoring system in predicting mortality rate of the mentioned patients.
Materials and Methods
This cross-sectional, observational, analytic study was performed in one year period. A hundred patients remaining in ED and necessitating ICU hospitalizing were enrolled by the convenience type of non-probability sampling. Then, the APACHE III scores, predicted and observed mortality rates were calculated using of information obtained from patients' files, interview with the patients' family and performing required physical exams and lab tests.
Results
In the assessment of 100 patients, men group were 56% (56) and women group 44% (44). The age of patients and the ED lengths of stay were 66.07 ± 19.92 years and 5.11 ± 3.79 days respectively. The average (± SD) of APACHE III score of the enrolled patients was 58.89 ± 18.24 and the predicted mortality rate calculated 32.73%; while, the total of observed mortality rate was 55%. The average (± SD) of APACHE III score of survivors and non-survivors were 48.63 ± 16.35 and 67.63 ± 14.84 respectively. So, there was a significant deference (p < 0.001). Also, there was a significant deference in the ED lengths of stay between survivors and non-survivors (3.20 ± 1.34 and 6.57 ± 4.40 respectively, p < 0.001).
Conclusion
In our study, APACHE III score and ED lengths of stay were higher versus other studies in Iran and other countries; which show more critical patients presenting to our hospital and limited ICU beds versus patients. This study results nevertheless there was significant difference between predicted and observed mortality rates, the APACHE III scoring system is applicable to evaluating care, treatment and prognosis of ED patients, as is used in ICU.
Telecommunications plays a critical enabling role in disaster response, both for the local population and for responses of external origin. However, it is common for telecommunications capacity to be reduced or disabled by the disaster or emergency. Meanwhile, the disaster stimulates demand for any remaining capacity, often resulting in total loss of telecommunications capability during the acute phase of a disaster and its response.
Discussion and Observations
The Serval Project is addressing this through the implementation of a mesh mobile telephony system that is compatible with some existing mobile telephone handsets, and can be integrated into many more models without changing handset hardware designs or cost. This technology allows mobile telephones to directly communicate with one another, and allows telephone calls to be made without infrastructure beyond the telephones themselves. Our Distributed Numbering Architecture allows the telephones to use their existing telephone numbers, so that communications can continue immediately and without impediment when needed. The telephones self-organise, and relay calls for distant telephones, thus forming their own resilient telecommunications infrastructure that is able to remain operative during all phases of a disaster and its response, thus addressing an important vulnerability of the existing infrastructure-oriented approach to telecommunications. We see applications that include supporting communities in maintaining communication in order that medical and public health effects of emergencies can be responded to more effectively and potentially providing ready access to communications for distributed teams of emergency health and humanitarian workers in disasters. Our goal in creating this technology and removing all barriers to adoption is to facilitate its ubiquitous inclusion in new mobile telephones, so that we can leverage the mass production of consumer electronics to create a resilient telecommunications capacity that can be deployed anywhere without supporting infrastructure. This would enable the creation of, for example, networks consisting solely of used telephones.
Effective function of the community care system is important during a pandemic. Self-protective behavior might help stop the spread of the disease during a pandemic and prevent system dysfunction because of personnel morbidity.
Objective
To compare the immunization rate and reported self-protective behavior of healthcare workers between hospitals and community care clinics during the peak of the winter A/H1N1 pandemic in Israel.
Methods
A questionnaire was completed by 1,147 healthcare workers in 21 hospitals and 40 primary care clinics in Israel between 26 November 2009 and 10 December 2009 (the peak of the winter A/H1N1 flu outbreak).
Results
The rate of vaccination against A/H1N1 among hospital workers (27.9%) was significantly higher compared with primary care clinics workers (19.3%) (OR = 0.691 (0.821–0.582)).
On February 22, 2011 at 12:51 pm an earthquake measuring 6.3 on the Richter scale struck the city of Christchurch, population 376,700 in the South Island of New Zealand. This followed a 7.3 magnitude earthquake in September 2010, but the shallowness (5km) and proximity of the February earthquake to the central city, resulted in far more devastation, with Modified Mercalli scores reaching ten in some areas and upward ground acceleration exceeding 2.4G. The application of the Coordinated Incident Management System (CIMS) routinely used by New Zealand Civil Defence agencies was swift, innovative and efficient, facilitating rapid deployment of local and international emergency teams and response resources. The effectiveness of this response was partially attributed to lessons learnt from the September earthquake which, with hindsight, was a practise for the more serious February event. The community response was equally remarkable, with standard approaches to measuring preparedness and resilience suggesting that community resilience in Canterbury was high. A number of initiatives by the New Zealand Ministry of Civil Defence and Emergency Management may have fostered some of this resilience,particularly community- based resilience-building projects initiated by the Regional Emergency Management Office on 2009 and 2010, supported by the Ministry of Civil Defence and Emergency Management. In addition, website education resources and media promotion (“Get Ready Get Thru”) and a travelling exhibition called “The Pandemic Roadshow” had been particularly well received and remembered by Canterbury residents. However, two key events provided an impetus for the Canterbury community to burnish its resilience. First, the Swine flu (AH1N1) pandemic in 2009 resulted in a greater awareness of public health in emergencies along with a doubling of neighbourhood support groups. Secondly, the September 2010 earthquake resulted in the establishment of the student army of volunteers and improvement of public information management. This presentation will describe the markers of community resilience following the Christchurch earthquake and discuss how such resilience can be fostered in communities where emergency preparedness is not recognised as a priority.
To compare resuscitation outcomes before and after switching from manual cardiopulmonary resuscitation (CPR) to load-distributing band (LDB) CPR in a multi-center Emergency Departments (ED) trial.
Methods
This is a phased, prospective cohort evaluation with intention-to-treat analysis of adults with non-traumatic cardiac arrest. The intervention is change in the system from manual CPR to LDB-CPR at two Urban EDs. The main outcome measure is survival to hospital discharge, with secondary outcome measures of return of spontaneous circulation (ROSC), survival to hospital admission and neurological outcome at discharge.
Results
A total of 1,011 patients were included in the study, with 459 in the manual CPR phase (January 01, 2004, to August 24, 2007) and 552 patients in the LDB-CPR phase (August 16, 2007, to December 31, 2009). In the LDB phase, the LDB device was applied in 454 patients (82.3%). Patients in the manual CPR and LDB-CPR phases were comparable for mean age, gender and ethnicity. Rates for ROSC were comparable with LDB-CPR (manual 22.4% vs. LDB 35.3%; adjusted odds ratio [OR], 1.07; 95% confidence interval [CI], 0.63-1.83). Survival to hospital admission was increased, Manual 14.2% vs. LDB 19.7%; adjusted OR, 2.50; 95% CI, 1.05-6.00. Survival to hospital discharge was increased Manual 1.3% vs. LDB 3.3%; adjusted OR, 3.99; 95% CI, 1.06-15.02. The number of survivors with Cerebral Performance Category 1 (good) (Manual 1 vs. LDB 12, p < 0.01) and Overall Performance Category 1 (good) (Manual 1 vs. LDB 10, p < 0.01) was also increased. The Number Needed to Treat (NNT) for 1 survivor was 52 (95% CI, 26-1000).
Conclusion
A resuscitation strategy using LDB-CPR in an ED environment was associated with improved survival to admission and discharge in adults with non-traumatic cardiac arrest.
On 12 January 2010 Port-au-Prince, Haiti was struck by a 7.0 Mw earthquake that devastated the city and destroyed much of the Haiti University and Educational Hospital. In the following weeks, a tent hospital was erected at the site and hundreds of patients were seen daily by expatriate healthcare volunteers. The high volumes of patients, disorganized hospital grounds, and high levels of stress among patients led to issues of crowd control.
Discussion
To improve security a new triage system was designed and implemented based on current emergency medicine models. This design addressed patient flow, triage, environmental conditions, and differentiation of emergency services. The results of this system were a streamlined triage system as well as improved safety.
Conclusions
During the chaos following the Haiti earthquake, a triage design was implemented at the HUEH that lead to improved Emergency Department patient flow and hospital safety.
People using public transportation have to put their health and even their lives in the hands of personnel authorized to drive the vehicles. But, organizers are taking unprecedented measures to protect transportation from diverse threats. However, there is often overwhelming evidence of the weak effectiveness of pertinent measures.
Method
There is a permanent threat of possible physical and/or psychological impact on persons authorized as drivers, which leads to a possible threat to the health and lives of others. Such events can be divided into two groups: (1) pre-driving; and (2) in-driving. Anthropogenic impacts while pre-driving and in-driving periods stimulate feelings of fear, which comprises different components.
Results
In the pre-driving group, drivers face overwhelming mental health impacts. This includes fear for their lives and health, fear of responsibility for family, friends, and passengers. In the in-driving group, the variation of physical and mental impacts determines the addition of fears of other categories.
Conclusion
Integrated sensors for measuring levels of blood pressure, sweating, heart rate, respiratory rate, and changes in the retina of the eye should be implemented. This hardware and software should process information about drivers. They would provide instant alerts on changes in the indicators.
The 2010 eruptions in Iceland, and on Mount Merapi in Indonesia, caused enormous disruption and opened a new chapter in the history of volcanic eruptions, emerging hazards, and disaster crisis management. A volcanic eruption can be devastating for the local wildlife as well as for the human population. Volcanic eruptions represent a different kind of hazard compared with floods, hurricanes, and earthquakes. Their onset also may be sudden, but they differ in that the danger does not necessarily decline rapidly with time, and actually may increase because of the unpredictability of the eruptive behavior and desire of a willing population to believe that the danger has passed and they can resume normal living. Volcanoes and their eruptions can result in a wide range of health impacts and kill people in a remarkably large number of ways. At least 500 million people worldwide live within potential exposure range of volcanic activity and possible eruption. The range of adverse health effects is quite broad and extensive. This presentation will provide an overview of the main causes of death and injury caused by a volcanic eruptions and the preventive health measures and public health interventions to be adopted during a volcanic eruption. Information on the causes of death and injury in eruptions is sparse, but the available literature is summarized in this report for the benefit of volcanologists and emergency planners. Healthcare workers and physicians responding to the volcanic events might find themselves involved in scenarios as varied as disaster planning, epidemiological surveillance, treating the injured, or advising on the health hazards associated with long range transport of volcanic emissions. Medical treatment only has a small role during severe volcanic eruptions. The preventive measures are paramount if injuries and loss of life are to be reduced.
Since its development in the 1970s, the paramedic profession has tried to expend its traditional role of providing prehospital emergency care in ambulances into new fields of practice (e.g. community care). Paramedics in Israel are employed almost exclusively in the emergency medical services (EMS). Similar to other countries, the manpower shortage in the Israeli health system forced policy-makers to consider the expansion of traditional roles of various healthcare professions including paramedics.
Objectives
This presentation seeks to: (1) map the current situation and challenges facing paramedics in Israel; (2) examine paramedics' professional status among policy-makers; and (3) examine the best way to integrate paramedics in the Israeli health-system.
Methods
Qualitative interviews were conducted with 20 senior policy-makers in the Israeli EMS system, Academia, Health Ministry, and military. A policy analysis of documents, laws, regulations, and public media was conducted.
Results
The Ministry of Health in Israel did not play a significant role in the regulation of the profession. Nevertheless, according to the interviewees, paramedics have gained considerable professional recognition among policy-makers, healthcare professionals, and the general public. Following the medical manpower crisis that is evolving in Israel, and the trends that are common in many western countries of expanding the traditional roles of allied health professions, most policy-makers in Israel see the paramedic role evolving into new field of practice. According to policy-makers, legislators, and EMS officials, the major challenges that the paramedic profession faces deal with legislative and professional (mainly academization) issues.
Conclusions
The paramedic profession must adapt itself to the new medical environment. More research should be conducted to build a model, adapted for different local national context, to expand the traditional role of paramedics. This will influence training, research and policy-making regarding the paramedic profession, and will change the traditional professional medical borders.
Three decades of internal conflict, displacing 300,000 civilians, in the Northern and Eastern Provinces of Sri Lanka ended in May 2009. Civilians affected by the fierce fighting in the proceeding months were ushered by the military into internally displaced persons (IDP) camps in an area called “Manik Farm” in Vavuniya District until they could be resettled. The Ministry of Health led the provision of health services to the displaced in coordination with the humanitarian health cluster at the national and field level immediately after of the war.
Methods
The Ministry of Health plans and reports were reviewed, along with reports from health sector partners and national and international guidelines on coordination in humanitarian relief operations. The way the Ministry of Health coordinated with health sector partners via the health cluster was different from other coordination models where military and civil administration were involved in providing humanitarian relief also was compared.
Conclusions
The review shows that the health sector coordination mechanism adapted in Sri Lanka had a clear leadership and guidance for health sector partners according to national plans and frameworks. It was indicated by better health outcomes like mortality and morbidity among displaced population in IDP camps in Manik Farm.
Patients with myocardial infarction can present to the Emergency Department with atypical symptoms. A 60-year-old male presented with a fever for two days and ongoing hiccups he had experienced for four hours. He also had experienced an episode of vomiting. An electrocardiograph revealed ascending limbs of the S-waves in leads V3/V4, notching > 0.05 seconds in the ascending limbs of the R-waves in leads I, aVL, V6, and the presence of a left bundle branch block.
There has been increased international awareness and a need to provide accessible and essential emergency preparedness training in developing countries that has resulted in the recognition of new teaching needs and number of new initiatives to meet these needs.
Methods
These teaching methods have been applied in Haiti before and after the 2010 earthquake. They include: - Established a “Train the trainer” model - Established civilian first responder training - Basic Life Support (BLS) and First Aid - Implemented medical training using the Meti Simulator models - Conducted post-training Disaster drill - Conduction of post training assessment - Succession model of training.
Results
A total of 54 people completed a BLS course and 67 completed a First Aid course. 12 participants completed the First Aid and BLS Instructors course. 95 program participants completed an end of course survey. 41 participants had no prior BLS/First Aid training or exposure. The course participants included 2 physicians, 22 students, 8 nursing students, 7 nurses, 20 teachers, 12 health workers, 5 drivers, and 14 laborers. 92 of those surveyed stated they would recommend this course to a friend. 88 participants stated that hands on learning helped them better learn the course material.
Conclusion
This training model has been well received in rural Haiti and can be applied in other developing countries. We would like to standardize training protocols that will serve as a foundation for self-sustaining higher-level emergency, pre-hospital, disaster training and management. This will improve the general quality of health care delivery. Our next pilot of this program will be in other parts of Haiti and in Khartoum, Sudan.
Disasters involving children are becoming more and more frequent. Thus, optimal preparedness will be a challenge for every Western pediatric disaster specialist. However, for any appropriate decision to be made, there must be a practical tool for accurately evaluating the levels of specific disaster awareness and preparedness. This tool is based on the idea that child injury prevention campaigns [n = 6] are usable as a platform for the simulation of specific pediatric disaster scenarios, and that different simulations might be able to modulate overall awareness and overall preparedness levels, as well as affect the training provided. Data are gathered from a disaster phase-related (Haddon-Matrix) set of questionnaires answered by key disaster response personnel [n = 58]. Overall awareness for a pediatric disaster scored highest for the “in the world” scenarios, with less, but with similar scores for “in the country” and “in the region” scenarios. Overall preparedness scored low for “in the world”, with higher scores for “in the country” and “in the region”. Both, overall awareness and overall preparedness scored inconsistently for “in the hospital” in the first instance, but later in the matrix, “in the hospital” had the highest scores. In general, basic knowledge about disaster plans is moderate, and knowledge about existence and activation of preparedness measures is above average. Individual position-taking and feelings of personal competency in position-taking is low, especially among junior staff. Currently, only a group of seniors are able report participation in a specific training. This platform is an upgradable tool for the awareness of and preparedness for pediatric disaster assessments, regarding phases, locations, and training, with promising trends for their modulation, especially among junior staff.
The paramedic profession is relatively new, dating to the 1970's. In Israel, it was introduced in 1980 and paralleled the introduction of advanced life support units (ALS) to Israel's national emergency medical services (EMS), Magen David Adom (MDA).The curriculum and assigned roles were adopted with minor changes from Anglo-American systems. Initially, paramedics were assigned alongside physicians, but in recent years a growing percentage of units operate without an on-board physician. Despite the increasing complexity of required tasks and the move toward paramedic-led crews, paramedic training has changed little. Most are trained through a non-academic, certificate granting tracts. In 1998, a fully academic bachelor's degree program was launched at the Ben-Gurion University (BGU).
Methods
The programs aims, curriculum, and experience are described, based on past and current curriculum and on interviews with past and current staff and students.
Results
The BGU program is a three year program that grants its graduates both a University BA and professional paramedic certification. The program is housed as a university department within the Faculty of Health Sciences. First year courses center on basic sciences. The second year centers on classroom and simulation-based learning of the clinical topics. The third is devoted mostly to clinical clerkships, in hospital wards in the first semester and on MDA ALS units in the second. To date, the program boasts more than 300 graduates, many attaining higher academic degrees in healthcare sciences and many who work in Israel's national EMS.
Discussion
The BGU academic paramedic training program is the only such program in Israel and one of a few worldwide. Questions regarding the increasing responsibility and task complexity require a move from certificate training to University degree granting learning and the possible contribution of such