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Terrorists increasingly aim at so-called soft targets, such as hospitals. However, little is known about terrorist attacks against Emergency Medical Services (EMS).
Objective:
This study aims to review all documented terrorist attacks against EMS that occurred world-wide from 1970-2019 using the Global Terrorism Database (GTD).
Methods:
Reports of terrorist attacks against EMS were extracted from the GTD from 1970-2019. Data collection included temporal factors, attack and weapon type, number of casualties, and if it was a primary or secondary attack (secondary attack: deliberate attack against the first responders of an initial terrorist attack). Reports were excluded if EMS were not a target or if it was unclear whether they were a target. Chi-square tests were performed to evaluate trends over time.
Results:
There were 184 terrorist attacks against EMS, resulting in 748 deaths and 1,239 people injured. Terrorist attacks against EMS significantly increased over the past two decades. The “Middle East & North Africa” was the most frequently affected region with 81 attacks (44.0%) followed by “South Asia” with 41 attacks (22.3%). Bombings and explosions were the most common attack type (85 incidents; 46.2%) followed by armed assaults (68 incidents; 35.3%). Combined prehospital and hospital attacks were first reported in 2005 and occurred seven times. The first secondary attack against EMS dates from 1997, after which an increase was observed from 10 to 39 incidents in the periods 2000-2009 and 2010-2019, respectively.
Conclusions:
This analysis of the GTD, which identified 184 terrorist attacks against EMS over a 50-year period, demonstrates that terrorist attacks against EMS have significantly increased during the years and that secondary attacks are an emerging risk. Bombings and explosions are the most common attack type. Terrorist attacks against EMS are most prevalent in countries with high level of internal conflicts, however, they have also occurred in western countries. These incidents may hold valuable information to prevent future attacks.
Paramedics are a vital component of the Emergency Medical Services (EMS) workforce and the United States health care system. The continued provision of high-quality care demands constantly improving education at accredited institutions. To date, only limited characteristics of paramedic education in the United States have been documented and studied in the literature. The objective of this study was to describe the educational infrastructure of accredited paramedic programs in the United States in 2018.
Methods:
This is a retrospective, cross-sectional evaluation of the 2018 paramedic program annual report from The Committee on Accreditation of Educational Programs for the EMS Professions (CoAEMSP; Rowlett, Texas USA). The dataset includes detailed program metrics. Additionally, questions concerning program characteristics, demographics, and resources were asked as part of the evaluation. Resource availability was assessed via the Resource Assessment Matrix (RAM) with a benchmark of 80%. Included in the analysis are all paramedic programs with students enrolled. Descriptive statistics were calculated (median, [interquartile range/IQR]).
Results:
A total of 677 programs submitted data (100% response rate). Of these, 626 met inclusion criteria, totaling 17,422 students. Program annual enrollment varied greatly from one to 362 with most programs having small sizes (18 students [IQR 12-30]). Program duration was 12 months [IQR 12-16] with total hours of instruction being approximately 1,174 [IQR 1069-1304], 19% of which were dedicated to clinical experience. Full-time faculty sizes were small (two faculty members [IQR 1-3]) with most programs (80%) having annual operating budgets below USD$500,000. For programs with an annual budget below USD$100,000 (34% of programs), annual enrollment was approximately 14 students [IQR 9-21]. Degrees conferred by programs included certificates (90%), associate degrees (55%), and bachelor’s degree (2%). Simulation access was assessed with nearly all (100%) programs reporting simple task trainers and 84% of programs investing in advanced simulation manikins. Seventy-eight percent of programs met the RAM benchmark.
Conclusion:
Most paramedic educational programs in the United States have small annual enrollments with low numbers of dedicated faculty and confer certificates and associate degrees. Nearly one-quarter of paramedic educational programs are not adequately resourced. This study is limited by self-reported data to the national accreditation agency. Future work is needed to identify program characteristics that are associated with high performance.
The prime aim of Project for Strengthening the ASEAN Regional Capacity on Disaster Health Management (ARCH Project) is to strengthen the disaster health management (DHM) capacity in the context of personal level, Emergency Medical Team (EMT), and the regional collaboration. The ARCH Project was implemented with reference to international trends of DHM and seeks to contribute to the development of global standards.
Methods:
The project established the Project Working Groups that consisted of representatives of ASEAN Member States (AMS) to develop standard operating procedures (SOP) for international EMT (I-EMT) coordination. Furthermore, it aimed to organize training sessions along with implementation of the regional collaboration drill (RCD) in accordance with I-EMT minimum requirements and in line with coordination standards set by the WHO.
Results:
The ARCH Project developed the SOP and common platform for I-EMT coordination, organized training, and conducted RCDs with reference to the WHO’s EMT initiative. Furthermore, it also contributed to the development of the EMT Minimum Data Set (MDS), an international standard DHM tool that underwent testing at the RCDs before the WHO endorsement and its utilization in actual disaster response.
Conclusion:
In the process of strengthening ASEAN regional capacity in DHM, the project is constantly capturing international trends and also making significant contributions in the development of global systems and tools.
The Project for Strengthening the ASEAN Regional Capacity on Disaster Health Management (ARCH Project) developed Regional Collaboration Drills (RCDs) and is proposing an ASEAN Academic Network to strengthen capacity in disaster health management (DHM) in ASEAN Member States (AMS), as well as developing a standard training curriculum in DHM. This study aims to clarify the impacts and sustainability of the ARCH Project.
Methods:
The four previous RCDs and the enhancement of academic activities were reviewed.
Results:
The ARCH Project developed the RCDs with simulation exercises based on possible disaster scenarios in each host country to test and validate the capacity of AMS International Emergency Medical Teams (I-EMTs), the Standard Operating Procedure (SOP) for I-EMT coordination, and regional tools, as well as the relevant domestic SOPs of the host countries for receiving international assistance. Following the RCD in Thailand, three AMS: Viet Nam, Philippines, and Indonesia, all of which are considered disaster-prone, successfully hosted RCDs with significant improvements. The project also established a sub-working group (SWG) to develop a standard curriculum in DHM. Two curricula developments, the Basic Course on DHM and In-Country Course for Coordination on EMTs, are on-going as part of the project activity. The establishment of the ASEAN Academic Network and the ASEAN Institute for DHM (AIDHM) are currently in the endorsement process of the ASEAN health sector.
Conclusion:
The RCDs are very effective to test and to validate the SOP and regional tools developed, providing opportunities for AMS I-EMT to familiarize the tools, as well as for host countries to assess their coordination capacity for receiving international assistance and identifying the country’s specific challenges, and verifying ASEAN regional coordination mechanism. The development of the standard curriculum can enhance regional capacity both in supporting disaster-affected countries and in receiving international assistance. A sustainable capacity development mechanism in DHM is envisaged through the establishment of the ASEAN Academic Network and AIDHM toward the goal of One ASEAN One Response.
This report tries to capture the impact of the Project for Strengthening the ASEAN Regional Capacity on Disaster Health Management (ARCH Project) in each ASEAN Member State (AMS) and Japan as a result of the ARCH Project implementation since July 2016.
Methods:
Impact on AMS: The analysis of the impact on AMS was based on a comparison of the impact of the project on management and coordination of Emergency Medical Teams (EMTs), and application of the project outcome in actual emergency operations compared to the previous status in each AMS.
Impact on Japan: The history of the development of disaster medicine in Japan was reviewed, with an aim to analyze the impact of supporting AMS through the ARCH Project on Japan, and the possibility of bi-directional cooperation in the future.
Results:
Impact on AMS: Since the initiation of the ARCH Project, AMS has made significant progress in WHO EMT accreditation, strengthening EMTCC capacity for receiving international assistance, as well as the development of legislation or strategic plans related to DHM, and application of the Project products such as standard operating procedures or regional tools in actual disasters/emergencies.
Impact on Japan: Disaster medicine in Japan originated from the Cambodian refugees’ relief mission in 1979. Since then, the management system has been strengthened including the foundation of the Japan Disaster Relief (JDR) Team, a structure with a legal foundation. The experience gained through international operations has contributed to the development of Japan’s domestic disaster response system. Japan learned the operational effectiveness of the post-disaster health surveillance system through the disaster response operation in 2013 Typhoon Yolanda Disaster in Philippines and introduced a modified system in Japan for domestic disaster response, which was later refined and proposed for an international standard.
Conclusion:
ARCH Project is highly appreciated by AMS as the opportunity to share knowledge and experience among countries and thereby contributing to achieving the “One ASEAN, One Response” concept, as well as the driving force for each AMS to develop its capacity in DHM. While the ARCH Project started to support AMS to strengthen its regional capacity in disaster health management, it is important to build a bi-directional relationship between ASEAN and Japan in terms of mutual learning and support to tackle future disasters.
Southeast Asia is the second biggest region in the world in terms of the total number of natural disasters since 1900. Therefore, the Association of Southeast Asian Nations (ASEAN) initiated regional challenges toward strengthening regional collaboration for disaster prevention and response since the earthquake of Sumatra in Indonesia occurred in 2004. Moreover, ASEAN Leaders signed “the ASEAN Declaration on One ASEAN, One Response” in 2016. Under these circumstances, ASEAN decided to implement the Project for Strengthening the ASEAN Regional Capacity on Disaster Health Management (ARCH Project).
Objectives:
The objective of the ARCH Project is to strengthen coordination on disaster health management (DHM) for rapid and effective response to disasters occurring in the ASEAN region and to enhance the capacity of each ASEAN Member State (AMS) on DHM. This article aims to overview the outline and its strategy, and review the progress of the project.
Methods:
ARCH Project is an ASEAN official project supported by Japan’s official development assistance. Five outputs were launched for: (1) coordination platform on DHM; (2) framework of regional collaboration practices; (3) tools for effective regional collaboration; (4) enhancement of academic network on DHM; and (5) capacity development activities for each AMS. The Project was reviewed in terms of accomplishment and evaluation criteria.
Results:
Regional Coordination Committee on DHM was established as a coordination platform to: Oversee the implementation of the ARCH Project for the Output 1; Regional Collaboration Drill was developed and conducted for the Output 2; The standard operating procedure for coordination of emergency medical teams (EMTs) in ASEAN was developed for the Output 3; Various presentations on ARCH were made in academic conferences for the Output 4; and Several training programs and educational curricula were developed for the Output 5. The Project has accomplished its Project Purpose and satisfied all the indicators set. ARCH Project has high Relevance, Impact, Sustainability, and Effectiveness, while some improvements in Efficiency are needed.
Conclusions:
ARCH Project is the first-ever successful regional cooperation mechanism and standardization of DHM in ASEAN, one of the most disaster-prone regions. It also contributes to the capacity building of AMS. The ARCH Project has a remarkable impact on the resilience and flexible medical response to disasters, although continuous efforts of stakeholders to make this initiative sustainable are necessary.
New care paradigms are required to enable remote life-saving interventions (RLSIs) in extreme environments such as disaster settings. Informatics may assist through just-in-time expert remote-telementoring (RTM) or video-modelling (VM). Currently, RTM relies on real-time communication that may not be reliable in some locations, especially if communications fail. Neither technique has been extensively developed however, and both may be required to be performed by inexperienced providers to save lives. A pilot comparison was thus conducted.
Methods:
Procedure-naïve Search-and-Rescue Technicians (SAR-Techs) performed a tube-thoracostomy (TT) on a surgical simulator, randomly allocated to RTM or VM. The VM group watched a pre-prepared video illustrating TT immediately prior, while the RTM group were remotely guided by an expert in real-time. Standard outcomes included success, safety, and tube-security for the TT procedure.
Results:
There were no differences in experience between the groups. Of the 13 SAR-Techs randomized to VM, 12/13 (92%) placed the TT successfully, safely, and secured it properly, while 100% (11/11) of the TT placed by the RTM group were successful, safe, and secure. Statistically, there was no difference (P = 1.000) between RTM or VM in safety, success, or tube security. However, with VM, one subject cut himself, one did not puncture the pleura, and one had barely adequate placement. There were no such issues in the mentored group. Total time was significantly faster using RTM (P = .02). However, if time-to-watch was discounted, VM was quicker (P = .000).
Conclusions:
Random evaluation revealed both paradigms have attributes. If VM can be utilized during “travel-time,” it is quicker but without facilitating “trouble shooting.” On the other hand, RTM had no errors in TT placement and facilitated guidance and remediation by the mentor, presumably avoiding failure, increasing safety, and potentially providing psychological support. Ultimately, both techniques appear to have merit and may be complementary, justifying continued research into the human-factors of performing RLSIs in extreme environments that are likely needed in natural and man-made disasters.
This paper aims to clarify how the Project for Strengthening the ASEAN Regional Capacity on Disaster Health Management (ARCH Project) strengthened regional collaboration mechanisms on disaster health management (DHM) in ASEAN.
Methods:
The political process and the relevant documents of the ARCH Project were reviewed.
Results:
The ARCH Project established the Regional Coordination Committee as a coordination platform for providing strategic direction to the project and strengthening the regional coordination of DHM. Also, the Project Working Groups and Sub-Working Groups were set up as implementation bodies for the project activities with representatives of ASEAN Member States (AMS). With support from DHM experts of Japan and Thailand, a series of discussions were conducted for the development of a Standard Operating Procedure (SOP) for the Coordination of International Emergency Medical Teams (I-EMTs), regional tools, and collective measures supporting AMS to overcome challenges, and thereby meeting the minimum requirements set by the WHO EMT Initiative. The progress and outputs of the ARCH Project are subsequently elevated to the ASEAN Health Sector for endorsement, the updates are further shared to the Joint Task Force to Promote Synergy with Other Relevant ASEAN Bodies on Humanitarian Assistance and Disaster Relief (JTF-HADR) for the implementation of the ASEAN Declaration on One ASEAN One Response. The initiation of the ARCH Project in July 2016 has resulted in the development of the ASEAN regional collaboration framework, including the establishment of the Regional Coordination Committee on Disaster Health Management (RCCDHM), the SOP for ASEAN I-EMT coordination, and regional tools, such as forms for Medical Record for Emergency and Disaster and Health Needs Assessment. Moreover, further discussions on ASEAN Collective Measures that aim to support AMS to meet the WHO EMT minimum standards and strengthening I-EMT coordination capacity were also conducted. As adopted by the ASEAN Health Ministers Meeting (AHMM) in 2019, the RCCDHM was established as one of the mechanisms to operationalize the Plan of Action to implement the ASEAN Leaders’ Declaration on DHM.
Conclusion:
The contribution of the ARCH Project to strengthen the ASEAN regional capacity in DHM has enhanced the regional coordination platform, with a formalization of RCCDHM as ASEAN’s official regional mechanism, and of the on-going integration process of the SOP for EMT coordination into the ASEAN SASOP.
The coronavirus disease 2019 (COVID-19) pandemic has created challenges in maintaining the safety of prehospital providers caring for patients. Reports have shown increased rates of Emergency Medical Services (EMS) provider infection with COVID-19 after patient care exposure, especially while utilizing aerosol-generating procedures (AGPs). Given the increased risk and rising call volumes for AGP-necessitating complaints, development of novel devices for the protection of EMS clinicians is of great importance.
Drawn from the concept of the powered air purifying respirator (PAPR), the AerosolVE helmet creates a personal negative pressure space to contain aerosolized infectious particles produced by patients, making the cabin of an EMS vehicle safer for providers. The helmet was developed initially for use in hospitals and could be of significant use in the prehospital setting. The objective of this study was to determine the efficacy and safety of the helmet in mitigating simulated infectious particle spread in varied EMS transport platforms during AGP utilization.
Methods:
Fifteen healthy volunteers were enrolled and distributed amongst three EMS vehicles: a ground ambulance, a medical helicopter, and a medical jet. Sodium chloride particles were used to simulate infectious particles, and particle counts were obtained in numerous locations close to the helmet and around the patient compartment. Counts near the helmet were compared to ambient air with and without use of AGPs (non-rebreather mask [NRB], continuous positive airway pressure mask [CPAP], and high-flow nasal cannula [HFNC]).
Results:
Without the helmet fan on, the particle generator alone and with all AGPs produced particle counts inside the helmet significantly higher than ambient particle counts. With the fan on, there was no significant difference in particle counts around the helmet compared to baseline ambient particle counts. Particle counts at the filter exit averaged less than one despite markedly higher particle counts inside the helmet.
Conclusion:
Given the risk to EMS providers by communicable respiratory diseases, development of devices to improve safety while still enabling use of respiratory therapies is of paramount importance. The AerosolVE helmet demonstrated efficacy in creating a negative pressure environment and provided significant filtration of simulated respiratory droplets, thus making the confined space of transport vehicles potentially safer for EMS personnel.
The rapid popularization of unmanned aerial vehicles (UAVs; also referred to as drones), in both the recreational and industrial sectors, has paved the way for rapid developments in drone capabilities. Although the threat of UAVs used by terrorists has been recognized by specialists in both Counter-Terrorism and Counter-Terrorism Medicine (CTM), there are limited data on the extent and characteristics of drone use by terrorist organizations.
Methods:
Data collection was performed using a retrospective database search through the Global Terrorism Database (GTD). The GTD was searched using the internal database search functions for all terrorist attacks using UAVs from January 1, 1970 - December 31, 2019. Years 2020 and 2021 were not yet available at the time of the study. Primary weapon type, number and type of UAVs used, related attacks, location (country, world region), and number of deaths and injuries were collated. Results were exported into an Excel spreadsheet (Microsoft Corp.; Redmond, Washington USA) for analysis.
Results:
There were 76 terrorist attacks using UAVs. The first attack occurred in 2016, and the number of attacks per year varied considerably (range: 4-36). Forty-seven of the 76 attacks (70%) were successful. Twenty-seven individually listed events (36%) were related and part of nine coordinated, multi-part incidents. A total of 50 deaths and 132 injuries were recorded, which equated to 1.09 deaths (range: 0-6) and 2.89 injuries (range: 0-20) per successful attack. The mean number of UAVs used in an attack was 1.28 (range: 1-5) and multiple UAVs were used in 22% of attacks.
Conclusion:
The use of UAVs to carry out terrorist attacks is on the rise. Seventy-six terrorist attacks using this novel method were recorded since 2016, killing 50 and injuring 132 people. While the use of UAV-related explosives appears less lethal than traditional explosive attacks, advancing technologies and swarming capabilities, increasing ability to carry larger payloads, and the possibility of UAVs to disperse chemical, biological, radiological, and nuclear (CBRN) weapons will likely increase UAV lethality in the future, requiring CTM specialists be more proactive.
This article outlines a disaster medicine team response to the Texas-Mexico border during a coronavirus disease 2019 (COVID-19) surge. The team consisted of emergency medicine attending providers, as well as a nurse practitioner and a physician assistant, who were asked to work in the intensive care unit (ICU) under the guidance of an intensivist. The article highlights the medicolegal and ethical implications of providers working outside of their designated scope of practice. A framework for future staff augmentation during a disaster is explained.
Analysts have warned on multiple occasions that hospitals are potential soft targets for terrorist attacks. Such attacks will have far-reaching consequences, including decreased accessibility, possible casualties, and fear among people. The extent, incidence, and characteristics of terrorist attacks against hospitals are unknown. Therefore, the objective of this study was to identify and to characterize terrorist attacks against hospitals reported to the Global Terrorism Database (GTD) over a 50-year period.
Methods:
The GTD was used to search for all terrorist attacks against hospitals from 1970-2019. Analyses were performed on temporal factors, location, attack and weapon type, and number of casualties or hostages. Chi-square tests were performed to evaluate trends over time and differences in attack types per world region.
Results:
In total, 454 terrorist attacks against hospitals were identified in 61 different countries. Of these, 78 attacks targeted a specific person within the hospital, about one-half (52.6%) involved medical personnel. There was an increasing trend in yearly number of attacks from 2008 onwards, with a peak in 2014 (n = 41) and 2015 (n = 41). With 179 incidents, the “Middle East & North Africa” was the most heavily hit region of the world, followed by “South Asia” with 125 attacks. Bombings and explosions were the most common attack type (n = 270), followed by 77 armed assaults. Overall, there were 2,746 people injured and 1,631 fatalities. In three incidents, hospitals were identified as secondary targets (deliberate follow-up attack on a hospital after a primary incident elsewhere).
Conclusion:
This analysis of the GTD identified 454 terrorist attacks against hospitals over a 50-year period. It demonstrates that the threat is real, especially in recent years and in world regions where terrorism is prevalent. The findings of this study may help to create or further improve contingency plans for a scenario wherein the hospital becomes a target of terrorism.
The treatment of open lower limb fractures represents a major challenge for any trauma surgeon, and this even more so in resource-limited areas. The aim of the study is to describe the intervention, report the treatment plan, and observe the effectiveness of the Norwegian Open Fracture Management System in saving lower limbs in rural settings.
Materials and Methods:
A retrospective and prospective interventional study was carried out in the period 2011 through 2017 in six rural hospitals in Cambodia. The fractures were managed with locally produced external fixators and orthosis developed in 2007. Based on skills and living locations, two local surgeons and one paramedic without reconstructive surgery experience were selected to reach the top of the reconstructive ladder and perform limb salvage surgeries. This study evaluated 56 fractures using the Ganga Hospital Open Injury Score (GHOIS) for Gustilo-Anderson Type IIIA and Type IIIB open fracture classification groups.
Results:
The primary success rate in open tibia fractures was 64.3% (95% CI, 50.3 - 76.3). The average treatment time to complete healing for all of the patients was 39.6 weeks (95% CI, 34.8 - 44.4). A percentage of 23.2% (95% CI, 13.4 - 36.7) experienced a deep infection. Fifteen of the patients had to undergo soft tissue reconstruction and 22 flaps were performed. Due to non-union, a total of 15 bone grafts were performed. All of the 56 patients in the study gained limb salvage and went back to work.
Conclusion:
The given fracture management program proves that low-resource countries are able to produce essential surgical tools at high quality and low price. Treatment with external fixation and functional bracing, combined with high-level training of local surgeons, demonstrates that a skilled surgical team can perform advanced limb salvage surgery in low-resource settings.