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This study compared 2019 values for the National Health Security Preparedness Index (NHSPI) with 2020 rates of coronavirus disease 2019 (COVID-19)-related mortality as reported by the 50 US states and Puerto Rico during the first six months of the US pandemic (March 1 - August 31, 2020).
Methods:
Data regarding provisional death counts and estimates of excess deaths for COVID-19 according to state and territory were downloaded from the Centers for Disease Control and Prevention (CDC) National Center for Health Statistics website. Reporting included the six-month-long period of March 1 - August 31, 2020. Excess mortality rates were calculated as the number of excess deaths per 100,000 persons in each state population using 2019 US Census Bureau data. Mean values for state and territorial NHSPI domain indices were compared to state and territorial rates of COVID-19-related excess mortality using multiple linear regression, including analysis of variance. Correlations between the 51 state and territorial NHSPI values and corresponding COVID-19 excess mortality rates were calculated using Pearson’s correlation coefficient.
Results:
These calculations revealed a high degree of variance (adjusted r square = 0.02 and 0.25) and poor correlation (P = .16 and .08) among values for the overall NHSPI as compared to low and high estimates of excess COVID-19 mortality rates for 50 US states and Puerto Rico.
There was also a high degree of variance (adjusted r square = 0.001 and 0.03) and poor correlation (P values ranging from .09 to .94) for values for the six individual domains of the NHSPI as compared to low and high estimates of excess COVID-19 mortality rates for 50 US states and Puerto Rico.
Conclusion:
The NHSPI does not appear to be a valid predictor of excess COVID-19 mortality rates for 50 US states and Puerto Rico during the first six months of the pandemic.
With the progress in science and technology, hazardous chemicals are becoming more essential in chemical products, industrial and agricultural production, and daily life. Hazardous chemicals have poisoning, corrosive, explosive, and combusting natures; once on fire, they can trigger a chain of catastrophic incidences, resulting in casualties, property loss, and environmental pollution and posing hazards to life and property. Using the “8–12” explosion of the Ruihai Logistics warehouse in Tianjin Port (Binhai New District, China), the present study analyzes the characteristics of trauma of the casualties in this accident and the emergency medical rescue strategies. The goals were to improve the ability of emergency rescue in such accidents and to save people’s lives and property to the maximum extent.
Although first responders (FRs) represent a high-risk group for exposure, little information is available regarding their risk of coronavirus disease 2019 (COVID-19) infection. The purpose of the current study was to determine the serological prevalence of past COVID-19 infection in a cohort of municipal law enforcement (LE) and firefighters (FFs).
Methods:
Descriptive analysis of a de-identified data reporting Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) immunoglobulin G (IgG), or COR2G, serology results for municipal FRs. As part of the serology process, FRs were surveyed for COVID-19-like symptoms since February 2020 and asked to report any prior COVID-19 nasal swab testing. Descriptive statistics and two-sided Chi Square tests with Yates correction were used to compare groups.
Results:
Of 318 FRs, 225 (80.2%) underwent serology testing (LE: 163/207 [78.7%]; FF: 92/111 [82.9%]). The prevalence of positive serology for all FRs tested was 3/255 (1.2%). Two LE (1.2%) and one FF (1.1%) had positive serology (P = 1.0). Two hundred and twenty-four FRs responded to a survey regarding prior symptoms and testing. Fifty-eight (25.9%) FRs (44 LE; 14 FFs) reported the presence of COVID-19-like symptoms. Of these, only nine (15.5%) received reverse transcriptase – polymerase chain reaction (RT-PCR) testing; none were positive. Two of the three FRs with positive serology reported no COVID-19-like symptoms and none of these responders had received prior nasal RT-PCR swabs. The overall community positive RT-PCR rate was 0.36%, representing a three-fold higher rate of positive seroprevalence amongst FRs compared with the general population (P = .07).
Conclusions:
Amongst a cohort of municipal FRs with low community COVID-19 prevalence, the seroprevalence of SARS-CoV-19 IgG Ab was three-fold greater than the general community. Two-thirds of positive FRs reported a lack of symptoms. Only 15.5% of FRs with COVID-19-like symptoms received RT-PCR testing. In addition to workplace control measures, increased testing availability to FRs is critical in limiting infection spread and ensuring response capability.
Coronavirus disease 2019 (COVID-19) pandemic influences health care facilities world-wide. The flow rate, type, and severity of cases presented to emergency departments varied during the pandemic in comparison to the past years. However, this change has not been well-described among the cases of hospital admission due to toxic exposure.
Study Objective:
Recognition of the pattern of toxic exposure among the cases refereed to Tanta Poison Control Center (TPCC; Tanta, Egypt) during the past five years, and furthermore, exploration of the impact of lockdown due to the COVID-19 pandemic on the pattern of presented cases.
Methods:
The current study is a five-year retrospective, comparative cross-sectional study carried out among acutely intoxicated patients admitted to TPCC during the spring months (March through May) of 2016-2020. A total of 1,916 patients with complete medical records were recruited. The type and manner of toxic exposure, demographic, clinical data, and outcomes were analyzed.
Results:
The current study noted that there were delays in time from toxic exposure to emergency services during the lockdown period. This was reflected in significant lower recovery rates (884.8/1,000 population; z = −3.0) and higher death rates (49.4/1,000 population; z = 2.1) despite the marked decrease in the total number of hospital admissions in comparison to the past four years. The lockdown period showed significantly higher phosphides (z = 3.5; χ2 = 34.295; P <.001) and antipsychotics exposure (z = 3.6; χ2 = 21.494; P <.001) than the previous years. However, predominance of female exposure and intentional self-poisoning was maintained over the past five years, including the lockdown.
Conclusion:
COVID-19-associated lockdown greatly reformed the usual intoxication pattern of the cases admitted to emergency room. Also, it played a role in delaying time of hospital arrival, which was reflected as lower recovery rates and higher death rates.
Prehospital blood component therapy poses a possible treatment option among patients with severe bleeding. The aim of this paper was to characterize patients receiving prehospital blood component therapy by a paramedic-doctor-staffed, ground-based prehospital critical care (PHCC) service.
Methods:
Bleeding patients with a clinical need for prehospital blood transfusion were included prospectively. The following data were collected: indication for transfusion, mechanism of injury, vital parameters, units of red blood cells (RBCs)/plasma transfused, degree of shock, demographics, and mortality.
Results:
Twenty-one patients received blood products: 12 (57%) traumatic injuries and nine (43%) non-traumatic bleeds, with a median of 1.5 (range 1.0-2.0) units of RBCs and 1.0 (range 0.0-2.0) unit of plasma. The most frequent trigger to initiate transfusion was on-going excessive bleeding and hypotension. Improved systolic blood pressure (SBP) and milder degrees of shock were observed after transfusion. Mean time from initiation of transfusion to hospital arrival was 24 minutes. In-hospital, 11 patients (61%) received further transfusion and 13 (72%) had urgent surgery within 24 hours. Overall, 28-day mortality was 29% at 24-hours and 33% at 28-days.
Conclusion:
Prehospital blood component therapy is feasible in a ground-based prehospital service in a medium-sized Scandinavian city. Following transfusion, patient physiology and degree of shock were significantly improved.
This study was aimed to assess if combining the evaluation of blood glucose level (BGL) and the Triage Revised Trauma Score (T-RTS) may result in a more accurate prediction of the actual clinical outcome, both in general adult population and in elderly patients with trauma.
Methods:
This is a retrospective cohort study, conducted in the emergency department (ED) of an urban teaching hospital, with an average ED admission rate of 75,000 patients per year. Those excluded: known diagnosis of diabetes, age <18 years old, pregnancy, and mild trauma (classified as isolate trauma of upper or lower limb, in absence of exposed fractures). A combined Revised Trauma Score Glucose (RTS-G) score was obtained adding to T-RTS: two for BGL <160mg/dL (8.9mmol/L); one for BGL ≥160mg/dL and < 200mg/dL (11.1mmol/L); and zero for BGL ≥ 200mg/dL. The primary outcome was a composite of patient’s death in ED or admission to intensive care unit (ICU). Receiver Operating Characteristic (ROC) curve analysis was used to evaluate the overall performance of T-RTS and of the combined RTS-G score.
Results:
Among a total of 68,933 traumas, 9,436 patients (4,407 females) were enrolled, aged from 18 to 103 years; 4,288 were aged ≥65 years. A total of 577 (6.1%) met the primary endpoint: 38 patients died in ED (0.4%) and 539 patients were admitted to ICU. The T-RTS and BGL were independently associated to primary endpoint at multivariate analysis. The cumulative RTS-G score was significantly more accurate than T-RTS and reached the best accuracy in elderly patients. In general population, ROC area under curve (AUC) for T-RTS was 0.671 (95% CI, 0.661 - 0.680) compared to RTS-G ROC AUC 0.743 (95% CI, 0.734 - 0.752); P <.001. In patients ≥65 years, T-RTS ROC AUC was 0.671 (95% CI, 0.657 - 0.685) compared to RTS-G ROC AUC 0.780 (95% CI, 0.768 - 0.793); P <.001.
Conclusions:
Results showed RTS-G could be used effectively at ED triage for the risk stratification for death in ED and ICU admission of trauma patients, and it could reduce under-triage of approximately 20% compared to T-RTS. Comparing ROC AUCs, the combined RTS-G score performs significantly better than T-RTS and gives best results in patients ≥65 years.
The majority of injury deaths occur outside health facilities. However, many low- and middle-income countries (LMICs) continue to lack efficient Emergency Medical Services (EMS). Understanding current first aid practices and perceptions among members of the community is vital to strengthening non-EMS, community-based prehospital care.
Study Objective:
This study sought to determine caregiver first aid practices and care-seeking behavior for common household child injuries in rural communities in Ghana to inform context-specific interventions to improve prehospital care in LMICs.
Methods:
A cluster-randomized, population-based household survey of caregivers of children under five years in a rural sub-district (Amakom) in Ghana was conducted. Caregivers were asked about their practices and care-seeking behaviors should children sustain injuries at home. Common injuries of interest were burns, laceration, choking, and fractures. Multiple responses were permitted and reported practices were categorized as: recommended, low-risk, or potentially harmful to the child. Logistic regression was used to examine the association between caregiver characteristics and first aid practices.
Results:
Three hundred and fifty-seven individuals were sampled, representing 5,634 caregivers in Amakom. Mean age was 33 years. Most (79%) were mothers to the children; 68% had only completed basic education. Most caregivers (64%-99%) would employ recommended first aid practices to manage common injuries, such as running cool water over a burn injury or tying a bleeding laceration with a piece of cloth. Nonetheless, seven percent to 56% would also employ practices which were potentially harmful to the child, such as attempting manual removal of a choking object or treating fractures at home without taking the child to a health facility. Reporting only recommended practices ranged from zero percent (burns) to 93% (choking). Reporting only potentially harmful practices ranged from zero percent (burns) to 20% (fractures). Univariate regression analysis did not reveal consistent associations between various caregiver characteristics and the employment of recommended only or potentially harmful only first aid practices.
Conclusions:
Caregivers in rural Ghanaian communities reported using some recommended first aid practices for common household injuries in children. However, they also employed many potentially harmful practices. This study highlights the need to increase context-appropriate, community-targeted first aid training programs for rural community populations of LMICs. This is important as the home-based care provided for injured children in these communities might be the only care they receive.
The aim of this paper is to further develop an existing data model for mass-gathering health outcomes.
Background:
Mass-gathering events (MGEs) occur frequently throughout the world. Having an understanding of the complexities of MGEs is important to determine required health resources. Environmental, psychosocial, and biomedical domains may be a logical starting point to determine how data are being collected and reported in the literature; however, it may be that other factors influencing health resources are not identified within these domains.
Method:
Based on an exhaustive literature synthesis, this paper is the final paper in a series that explores the collection of variables that impact biomedical presentations associated with attendance/participation in MGEs.
Findings:
The authors propose further evolution of the Arbon model to include the addition of several domains, including: event environment; command, control, and communication (C3); public health; health promotion; and legacy when reporting the health outcomes of an event.
Conclusions:
Including a variety of domains that contribute to an MGE allows for formal evaluation of the event, which in turn informs future knowledge and skill development for both the event management group and the wider community.
Sierra Leone is one of the least developed low-income countries (LICs), slowly recovering from the effects of a devastating civil war and an Ebola outbreak. The health care system is characterized by chronic shortage of skilled human resources, equipment, and essential medicines. The referral system is weak and vulnerable, with 75% of the country having insufficient access to essential health care. Consequently, Sierra Leone has the highest maternal and child mortality rates in the world. This manuscript describes the implementation of a National Emergency Medical Service (NEMS), a project aiming to create the first prehospital emergency medical system in the country. In 2017, a joint venture of Doctors with Africa (CUAMM), Veneto Region, and Research Center in Emergency and Disaster Medicine (CRIMEDIM) was developed to support the Ministry of Health and Sanitation (MOHS) in designing and managing the NEMS system, one of the very few structured, fully equipped, and free-of-charge prehospital service in the African continent. The NEMS design was the result of an in-depth research phase that included a preliminary assessment, literature review, and consultations with key stakeholders and managers of similar systems in other African countries. From May 27, 2019, after a timeframe of six months in which all the districts have been progressively trained and made operational, the NEMS became operative at national level. By the end of March 2020, the NEMS operation center (OC) and the 81 ambulances dispatched on the ground handled a total number of 36,814 emergency calls, 35,493 missions, and 31,036 referrals.
The efficacy is measured for a public health intervention related to community-based planning for population protection measures (PPMs; ie, shelter-in-place and evacuation).
Design:
This is a mixed (qualitative and quantitative) prospective study of intervention efficacy, measured in terms of usability related to effectiveness, efficiency, satisfaction, and degree of community engagement.
Setting:
Two municipalities in the Commonwealth of Puerto Rico are included.
Participants:
Community members consisting of individuals; traditional leaders; federal, territorial, and municipal emergency managers; municipal mayors; National Guard; territorial departments of education, health, housing, public works, and transportation; health care; police; Emergency Medical Services; faith-based organizations; nongovernmental organizations (NGOs); and the private sector.
Intervention:
The intervention included four community convenings: one for risk communication; two for plan-writing; and one tabletop exercise (TTX). This study analyzed data collected from the project work plan; participant rosters; participant surveys; workshop outputs; and focus group interviews.
Main Outcome Measures:
Efficacy was measured in terms of ISO 9241-11, an international standard for usability that includes effectiveness, efficiency, user satisfaction, and “freedom from risk” among users. Degree of engagement was considered an indicator of “freedom from risk,” measurable through workshop attendance.
Results:
Two separate communities drafted and exercised ~60-page-long population protection plans, each within 14.5 hours. Plan-writing workshops completed 100% of plan objectives and activities. Efficiency rates were nearly the same in both communities. Interviews and surveys indicated high degrees of community satisfaction. Engagement was consistent among community members and variable among governmental officials.
Conclusions:
Frontline communities have successfully demonstrated the ability to understand the environmental health hazards in their own community; rapidly write consensus-based plans for PPMs; participate in an objective-based TTX; and perform these activities in a bi-lingual setting. This intervention appears to be efficacious for public use in the rapid development of community-based PPMs.
Understanding the drivers of health care utilization patterns following disasters can better support health planning. This study characterized all-cause hospitalizations among older Americans after eight large-scale hurricanes.
Study Objective:
The objective of this study was to characterize all-cause hospitalizations for any cause among older Americans in the 30 days after eight large-scale hurricanes.
Methods:
A self-controlled case series study among Medicare beneficiaries (age 65+) exposed to one of eight hurricanes was conducted. The predicted probability of sociodemographic factors associated with hospitalization using logit models was estimated.
Results:
Hurricane Sandy (2012) had the highest post-hurricane admission rate, a 23% increase (incidence rate ratio [IRR] = 1.23; 95% CI, 1.22-1.24), while Hurricane Irene in 2011 had only a 10% increase (IRR = 1.10; 95% CI, 1.09-1.11). Higher likelihood of hospitalization occurring after hurricanes included being 85 or older (36.8% probability of hospitalization; 95% CI, 34.7-39.0) and being dually eligible for Medicare and Medicaid (62.8%; 95% CI, 60.7-64.9).
Conclusion:
Planning to address the surge in hospitalization for a longer time period after hurricanes and interventions targeted to support aging Americans are needed.
The primary goal of this study was to determine if ultrasound (US) use after brief point-of-care ultrasound (POCUS) training on cardiac and lung exams would result in more paramedics correctly identifying a tension pneumothorax (TPTX) during a simulation scenario.
Methods:
A randomized controlled, simulation-based trial of POCUS lung exam education investigating the ability of paramedics to correctly diagnose TPTX was performed. The US intervention group received a 30-minute cardiac and lung POCUS lecture followed by hands-on US training. The control group did not receive any POCUS training. Both groups participated in two scenarios: right unilateral TPTX and undifferentiated shock (no TPTX). In both scenarios, the patient continued to be hypoxemic after verified intubation with pulse oximetry of 86%-88% and hypotensive with a blood pressure of 70/50. Sirens were played at 65 decibels to mimic prehospital transport conditions. A simulation educator stated aloud the time diagnoses were made and procedures performed, which were recorded by the study investigator. Paramedics completed a pre-survey and post-survey.
Results:
Thirty paramedics were randomized to the control group; 30 paramedics were randomized to the US intervention group. Most paramedics had not received prior US training, had not previously performed a POCUS exam, and were uncomfortable with POCUS. Point-of-care US use was significantly higher in the US intervention group for both simulation cases (P <.001). A higher percentage of paramedics in the US intervention group arrived at the correct diagnosis (77%) for the TPTX case as compared to the control group (57%), although this difference was not significantly different (P = 0.1). There was no difference in the correct diagnosis between the control and US intervention groups for the undifferentiated shock case. On the post-survey, more paramedics in the US intervention group were comfortable with POCUS for evaluation of the lung and comfortable decompressing TPTX using POCUS (P <.001). Paramedics reported POCUS was within their scope of practice.
Conclusions:
Despite being novice POCUS users, the paramedics were more likely to correctly diagnose TPTX during simulation after a brief POCUS educational intervention. However, this difference was not statistically significant. Paramedics were comfortable using POCUS and felt its use improved their TPTX diagnostic skills.
Up until now, there is much debate about the role of asymptomatic patients and pauci-symptomatic patients in severe acute respiratory syndrome novel coronavirus 2 (SARS-CoV-2) transmission, and little is known about the kinetics of viral ribonucleic acid (RNA) shedding in these populations. This article aims to describe key features and the nature of asymptomatic and pauci-symptomatic SARS-CoV-2 infected patients. The cohort consisted of six participants, three pairs, which were infected with SARS-CoV-2 during February 2020 on board the Diamond Princess. Of the six confirmed (reverse transcription polymerase chain reaction [RT-PCR]) cases, four were initially diagnosed in Japan and two upon their arrival to Israel. Duration of infection was between four days and up to 26 days. Of the six patients, three were completely asymptomatic and the others were pauci-symptomatic. All five patients in whom a computerized tomography (CT) scan was performed had lung pathology. In one patient, infectivity was tested using cell culture and a cytopathic effect was demonstrated. A serology test was performed in three of the patients and all three had a positive immunoglobulin G (IgG) four to eight weeks after disease onset. This case series demonstrates that asymptomatic and pauci-symptomatic patients may play a role in infection transmission by demonstrating probable transmission among asymptomatic spouses and by demonstrating a viable virus via a cell culture. Additionally, asymptomatic and pauci-symptomatic patients can have lung pathology and developing IgG antibodies.
The main objective was to study different clinical presentations and outcomes of patients after acute industrial chlorine gas exposure in Oman with evaluation of overall incident management to help develop a chemical exposure incident protocol.
Methods:
This was a retrospective observational study of 15 patients exposed to chlorine gas after an accidental chlorine gas leak in a metal melting factory in Oman.
Results:
Six (40%) patients were admitted and nine (60%) patients were discharged from the emergency department (ED) after initial management. The important post-chlorine gas exposure clinical symptoms were eye irritation (66.6%), cough (73.3%), shortness of breath (40.0%), chest discomfort (66.6%), rhinorrhea (66.6%), dizziness (40.0%), vomiting (46.6%), sore throat (13.3%), and stridor (53.3%). Important signs included tachycardia (40.0%), tachypnea (40.0%), wheeze (20.0%), and use of accessory muscles for breathing (20.0%). Signs and symptoms of eye irritation, rhinorrhea, tachycardia, tachypnea, wheeze, and use of accessory muscles for breathing have shown significant correlation with outcome (admission) having P value of <.05.
Conclusion:
In the presented acute chlorine gas exposure incidence, 15 exposed persons were brought to the ED, out of which six were admitted and nine were discharged after symptomatic treatment. Signs and symptoms of eye irritation, rhinorrhea, tachycardia, tachypnea, wheeze, and use of accessory muscles of breathing show significant relation with the outcome of admission.
State governments and hospital facilities are often unprepared to handle a complex medical crisis, despite a moral and ethical obligation to be prepared for disaster. The 2019 novel coronavirus disease (COVID-19) has drawn attention to the lack of state guidance on how hospitals should provide care in a crisis. When the resources available are insufficient to treat the current patient load, crisis standards of care (CSC) are implemented to provide care to the population in an ethical manner, while maintaining an ability to handle the surge. This Editorial aims to raise awareness concerning a lack of preparedness that calls for immediate correction at the state and local level.
Analysis of state guidelines for implementation of CSC demonstrates a lack of preparedness, as only five states in the US have appropriately completed necessary plans, despite a clear understanding of the danger. States have a legal responsibility to regulate the medical care within their borders. Failure of hospital facilities to properly prepare for disasters is not a new issue; Hurricane Katrina (2005) demonstrated a lack of planning and coordination. Improving disaster health care readiness in the United States requires states to create new policy and legislative directives for the health care facilities within their respective jurisdictions. Hospitals should have clear directives to prepare for disasters as part of a “duty to care” and to ensure that the necessary planning and supplies are available to their employees.
Several aspects led to the poor control of the coronavirus disease 2019 (COVID-19) outbreak in the US from a rural emergency department (ED) perspective. These include US residents’ attitude towards political involvement in health and civil rights; lack of enough testing kits and rapid test results, or not available at all; and personal protective equipment (PPE) shortages. These obstacles related to medical supplies and resources, and lack of coordinated approach to the pandemic in the US, are important information for retrospective disaster research to understand study limitations, extrapolate accurate and valid data, and for other countries to understand how and why the US had higher numbers of COVID-19 cases and deaths compared to other countries.
The use of a long backboard and cervical collar are commonly recommended by international guidelines for spinal immobilization, but both devices may cause several side effects. In a recent study, it was reported that spinal immobilization at 20° eliminated the decrease in pulmonary function secondary to spinal immobilization performed at 0°. Spinal immobilization at 20° is a new recommendation, but other potential effects need to be explored before it can be implemented in clinical use.
Study Objective:
Hemodynamic observation is important in the management of trauma patients. The aim of this study was to investigate the effect of spinal immobilization at a 20° position instead of 0° on hemodynamic parameters.
Methods:
This study included 53 healthy volunteers who underwent spinal immobilization in the supine position (00) and in an elevated position (200). Systolic arterial pressure (SAP), diastolic arterial pressure (DAP), mean arterial pressure (MAP), heart rate (HR), left ventricular outflow tract velocity time integral (LVOT-VTI), left ventricular stroke volume (LVSV), cardiac output (CO), inferior vena cava diameter inspiration (IVC diameter insp), IVC diameter expiration (IVC diameter exp), and inferior vena cava collapsibility index (IVC-CI) were measured at the 0th and 30th minutes of spinal immobilization in both positions. The data were compared for demonstrating the efficiency of both positions in spinal immobilization.
Results:
A statistically significant difference was found in the parameters of the IVC diameter (exp), IVC diameter (insp), LVOT-VTI, LVSV, and CO through the measurements starting in the 0th minute of the transition from 0° to 20° (P <.001). Delta values (∆) of hemodynamic parameters (∆IVC diameter [exp], ∆IVC diameter [insp], ∆LVOT-VTI, ∆SV, ∆CO, ∆IVC-CI, ∆MAP, ∆SAP, ∆DAP, and ∆HR) were similar in spinal immobilization at 0° and 20°.
Conclusion:
The findings obtained from this study illustrate that spinal immobilization at 20° does not cause clinically significant hemodynamic changes in healthy subjects compared to spinal immobilization at 0°.
Humanitarian aid workers are an overlooked population within the structure of posttraumatic stress disorder (PTSD) research and assistance. This negligence is an industry-wide failure to address aid workers’ psychological health issues. The suspected numbers of death by suicide, diagnosed PTSD, depression, anxiety disorders, hazardous alcohol and drug consumption, emotional exhaustion, and other stress-related problems are impossible to quantify but are considered endemic. Tools for establishing organizational frameworks for mental health and psychosocial support are readily available. However, the capacity to implement this assistance requires the creation and practice of an open and non-judgmental culture, based on the realistic acceptance that aid work has become inherently dangerous. The possibility of developing a psychological problem because of aid work has increased along with the rise in levels of disease, injury, kidnapping, and assault. As a result, expressions of traumatic stress have become the norm rather than an exception. This commentary outlines the essential steps and components necessary to meet these requirements.