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The central question this study sought to answer was whether the team members of Strategic Crisis Teams (SCTs) participating in mass-casualty incident (MCI) exercises in the Netherlands learn from their participation.
Methods
Evaluation reports of exercises that took place at two different times were collected and analyzed against a theoretical model with several dimensions, looking at both the quality of the evaluation methodology (three criteria: objectives described, link between objective and items for improvement, and data-collection method) and the learning effect of the exercise (one criterion: the change in number of items for improvement).
Results
Of all 32 evaluation reports, 81% described exercise objectives; 30% of the items for improvement in the reports were linked to these objectives, and 22% of the 32 evaluation reports used a structured template to describe the items for improvement. In six evaluation categories, the number of items for improvement increased between the first (T1) and the last (T2) evaluation report submitted by hospitals. The number of items remained equal for two evaluation categories and decreased in six evaluation categories.
Conclusion
The evaluation reports do not support the ideal-typical disaster exercise process. The authors could not establish that team members participating in MCI exercises in the Netherlands learn from their participation. More time and effort must be spent on the development of a validated evaluation system for these simulations, and more research into the role of the evaluator is needed.
Verheul MLMI, Dückers MLA, Visser BB, Beerens RJJ, Bierens JJLM. Disaster exercises to prepare hospitals for mass-casualty incidents: does it contribute to preparedness or is it ritualism? Prehosp Disaster Med. 2018;33(4):387–393
As health care systems in the United States have become pressured to provide greater value, they have embraced the adoption of innovative population health solutions. One of these initiatives utilizes prehospital personnel in the community as an extension of the traditional health care system. These programs have been labeled as Community Paramedicine (CP) and Mobile Integrated Health (MIH). While variation exists amongst these programs, generally efforts are targeted at individuals with high rates of health care utilization. By assisting with chronic disease management and addressing the social determinants of health care, these programs have been effective in decreasing Emergency Medical Services (EMS) utilization, emergency department visits, and hospital admissions for enrolled patients.
The actual training, roles, and structure of these programs vary according to state oversight and community needs, and while numerous reports describe the novel role these teams play in population health, their utilization during a disaster response has not been previously described. This report describes a major flooding event in October 2015 in Columbia, South Carolina (USA). While typical disaster mitigation and response efforts were employed, it became clear during the response that the MIH providers were well-equipped to assist with unique patient and public health needs. Given their already well-established connections with various community health providers and social assistance resources, the MIH team was able to reconnect patients with lost medications and durable medical equipment, connect patients with alternative housing options, and arrange access to outpatient resources for management of chronic illness.
Mobile integrated health teams are a potentially effective resource in a disaster response, given their connections with a variety of community resources along with a unique combination of training in both disease management and social determinants of health. As roles for these providers are more clearly defined and training curricula become more developed, there appears to be a unique role for these providers in mitigating morbidity and decreasing costs in the post-disaster response. Training in basic disaster response needs should be incorporated into the curricula and community disaster planning should identify how these providers may be able to benefit their local communities.
Gainey CE, Brown HA, Gerard WC. Utilization of mobile integrated health providers during a flood disaster in South Carolina (USA). Prehosp Disaster Med. 2018;33(4):432–435
The World Association for Disaster and Emergency Medicine (WADEM; Madison, Wisconsin USA) is a multi-disciplinary professional association whose mission is the global improvement of prehospital and emergency health care, public health, and disaster health and preparedness. In April 2017, the biennial general meeting of the World Congress for Disaster and Emergency Medicine (WCDEM) endorsed the WADEM Climate Change Position Statement, which was subsequently published in Prehospital and Disaster Medicine in July 2017. This special report examines literature used and reviews the process of development of this Position Statement as a product of WADEM.
Cuthbertson J, Archer F, Robertson A. Special report: WADEM climate change position statement. Prehosp Disaster Med. 2018;33(4):428–431
Natural and man-made disasters are becoming global concerns. Natural disasters appear to be growing in number and intensity due to global warming, population explosion, increased travel, and overcrowding of cities. In addition, man-made disasters do not seem to be diminishing.
At disaster sites, an immediate response is needed. National and international organizations; nongovernmental, military, and commercial organizations; and even private donors enlist to provide humanitarian and medical support and to send supplies, shelters, and temporary health care facilities to disaster zones.
Problem
The literature is sparse regarding the design of portable health care facilities intended for disaster zones and their adaptability to the tasks required and site areas.
Methods
Data were collected from peer-reviewed literature, scientific reports, magazines, and websites regarding health care facilities at rescue and salvage situations. Information was grouped according to categories of structure and properties, and relative strengths and weaknesses. Next, suggestions were made for future directions.
Results
Permanent structures and temporary constructed facilities were the two primary categories of health care facilities functioning at disaster zones. Permanent hospitals were independent functioning medical units that were moved or transported to and from disaster zones as complete units, as needed. These facilities included floating hospitals, flying (airborne) hospitals, or terrestrial mobile facilities. Thus, these hospitals self-powered and contained mobility aids within their structure using water, air, or land as transporting media.
Temporary health care facilities were transported to disaster zones as separate, nonfunctioning elements that were constructed or assembled on site and were subsequently taken apart. These facilities included the classical soft-type tents and solid containers that were organized later as hospitals in camp configurations. The strengths and weaknesses of the diverse hospital options are discussed.
Conclusions
Future directions include the use of innovative materials, advanced working methods, and integrated transportation systems. In addition, a holistic approach should be developed to improve the performance, accessibility, time required to function, sustainability, flexibility, and modularity of portable health care facilities.
Bitterman N, Zimmer Y. Portable health care facilities in disaster and rescue zones: characteristics and future suggestions. Prehosp Disaster Med. 2018;33(4):411–417
The proliferation of unmanned aerial vehicle (UAV) technology has the potential to change the way medical incident commanders (ICs) respond to mass-casualty incidents (MCIs) in triaging victims. The aim of this study was to compare UAV technology to standard practice (SP) in triaging casualties at an MCI.
Methods
A randomized comparison study was conducted with 40 paramedic students from the Holland College Paramedicine Program (Charlottetown, Prince Edward Island, Canada). Using a simulated motor vehicle collision (MVC) with moulaged casualties, iterations of 20 students were used for both a day and a night trial. Students were randomized to a UAV or a SP group. After a brief narrative, participants either entered the study environment or used UAV technology where total time to triage completion, GREEN casualty evacuation, time on scene, triage order, and accuracy were recorded.
Results
A statistical difference in the time to completion of 3.63 minutes (95% CI, 2.45 min-4.85 min; P=.002) during the day iteration and a difference of 3.49 minutes (95% CI, 2.08 min-6.06 min; P=.002) for the night trial with UAV groups was noted. There was no difference found in time to GREEN casualty evacuation, time on scene, or triage order. One-hundred-percent accuracy was noted between both groups.
Conclusion:
This study demonstrated the feasibility of using a UAV at an MCI. A non-clinical significant difference was noted in total time to completion between both groups. There was no increase in time on scene by using the UAV while demonstrating the feasibility of remotely triaging GREEN casualties prior to first responder arrival.
Jain T, Sibley A, Stryhn H, Hubloue I.Comparison of unmanned aerial vehicle technologyassisted triage versus standard practice in triaging casualties by paramedic students in a mass-casualty incident scenario. Prehosp Disaster Med. 2018;33(4):375–380
While the art and science of disaster triage continue to evolve, the education of the US health care student in matters pertaining to disaster preparedness and response remains stifled. Unfortunately, these students will be assuming major decision-making responsibilities regarding catastrophes that will be complicated by climate change, nuclear threats, global terrorism, and pandemics. Meanwhile, Sort, Assess, Life-Saving Interventions, Treatment, and/or Transport (SALT) triage is being advocated over the globally popular Simple Triage and Rapid Treatment (START) algorithm for multiple reasons: (1) it’s an all-hazard approach; (2) it has four medical interventions; and (3) it has an additional triage color for victims with non-survivable injuries.
Hypothesis/Problem
As present-day threats become more ominous and health care education emphasizes the needs of vulnerable populations and palliative care, the authors hypothesize that, when given a choice, health care students will prefer SALT triage.
Methods
A convenience sample of 218 interprofessional, disaster-naïve health care students received just-in-time, unbiased education on both START and SALT triage systems. Students then completed a survey asking them to decide which triage system they believe would be most effective in their community.
Results
A total of 123 health care students (56.4%) preferred SALT while 95 (43.6%) preferred START; however, only the physician assistant students showed a statistically significantly preference (28 versus six, respectively; P=.042). Interestingly, there was also a statistically significant difference in preference by gender (Chi-square=5.02; P=.025) of the observed distribution versus expected distribution in SALT and START. The females preferred SALT (61.0%) while the males preferred START (55.9%).
Among those who preferred START, START being easier to learn was the most important reason cited. Among those who preferred SALT, the most important reason cited was that the number of patient triage categories seemed more logical, comprehensible, and consistent with traditional medical care.
Conclusion:
While SALT’s preference among females and physician assistant students was based on the addition of medical interventions and the provision of palliative care, START’s preference was related to expediency. Based on this research, incorporating disaster concepts into US health care students’ curricula encourages thoughtful consideration among the future health care leaders about the most effective approach to triage care. It is critical that further research be completed to determine, without reservation, which triage system will not only save the most lives but provide the most humane care to victims.
Fink BN, Rega PP, Sexton ME, Wishner C. START versus SALT triage: which is preferred by the 21st century health care student? Prehosp Disaster Med. 2018;33(4):381–386
Conversion disorder is a form of somatoform disorders which has a high prevalence among women, individuals with lower socioeconomic status, under-educated populations, and in developing countries. However, up to one-half of patients who had been initially diagnosed with conversion disorder were eventually shown to have an underlying organic pathology–mostly neurological or non-psychiatric conditions. In this article, two patients are presented who accessed the emergency department (ED) with an initial diagnosis of conversion disorder in the ambulance that turned out to be stroke.
Serinken M, Karcioglu O. Patients with acute stroke presenting like conversion disorder. Prehosp Disaster Med. 2018;33(4):451–453
Mass gatherings are common in Australia. The interplay of variables, including crowd density and behavior, weather, and the consumption of alcohol and other drugs, can pose a unique set of challenges to attendees’ well-being. On-site health services are available at most mass gatherings and reduce the strain on community health facilities. In order to efficiently plan and manage these services, it is important to be able to predict the number and type of presenting problems at mass gatherings.
Problem
There is a lack of reliable tools to predict patient presentations at mass gatherings. While a number of factors have been identified as having an influence on attendees’ health, the exact contribution of these variables to patient load is poorly understood. Furthermore, predicting patient load at mass gatherings is an inherently nonlinear problem, due to the nonlinear relationships previously observed between patient presentations and many event characteristics.
Methods
Data were collected at 216 Australian mass gatherings and included event type, crowd demographics, and weather. Nonlinear models were constructed using regression trees. The full data set was used to construct each model and the model was then used to predict the response variable for each event. Nine-fold cross validation was used to estimate the error that may be expected when applying the model in practice.
Results
The mean training errors for total patient presentations were very high; however, the distribution of errors per event was highly skewed, with small errors for the majority of events and a few large errors for a small number of events with a high number of presentations. The error was five or less for 40% of events and 15 or less for 85% of events. The median error was 6.9 presentations per event.
Conclusion:
This study built on previous research by undertaking nonlinear modeling, which provides a more realistic representation of the interactions between event variables. The developed models were less useful for predicting patient presentation numbers for very large events; however, they were generally useful for more typical, smaller scale community events. Further research is required to confirm this conclusion and develop models suitable for very large international events.
Arbon P, Bottema M, Zeitz K, Lund A, Turris S, Anikeeva O, Steenkamp M. Nonlinear modelling for predicting patient presentation rates for mass gatherings. Prehosp Disaster Med. 2018;33(4):362–367
Improving medical record keeping is a key part of the World Health Organization’s (WHO’s; Geneva, Switzerland) drive to standardize and evaluate emergency medical team (EMT) response to sudden onset disasters (SODs).
Problem
In response to the WHO initiative, the UK EMT is redeveloping its medical record template in line with the WHO minimum dataset (MDS) for daily reporting. When changing a medical record, it is important to understand how well it functions before it is implemented.
Methods
The redeveloped medical record was piloted at a UK EMT deployment course using simulated patients in order to examine ease of use by practitioners, and rates of data capture for key MDS variables.
Results
Some parts of the form were consistently poorly filled in, and the way in which the form was completed suggested that the flow of the form did not align with the recorder’s natural thought processes when under pressure.
Conclusion:
Piloting of a single-sheet triplicate medical record during an EMT deployment simulation led to significant modifications to improve data capture and function.
Jafar AJN, Fletcher RJ, Lecky F, Redmond AD. A pilot of a UK emergency medical team (EMT) medical record during a deployment training course. Prehosp Disaster Med. 2018;33(4):441–447.
Training students has been proven to be the optimal way to deliver cardiopulmonary resuscitation (CPR) skills. However, it is somehow unknown whether or not the current recommendations appropriate for Caucasian students are also suitable for East Asian students. The purpose of this study is to explore the best age for East Asian students to receive CPR training.
Methods
Students were recruited from six schools. Students participated in a standard CPR training program provided by tutors. Each student attended a 60-minute training session with a manikin. After being trained, within one hour, the student’s compression quality was assessed.
Results
A total of 360 students who constituted 12 continuous grades were recruited for this study. Adequate compression depth and satisfactory compression rate with correct hand position could be achieved since the age of 12. However, successful compression rate and complete release could be achieved since the younger age of six.
Conclusions
Current recommendations for Caucasian students to cultivate a full-capacity CPR rescuer at the age of 12 are also appropriate for East Asian students. However, the optimal age for students to receive CPR training should be decided based on evidence and importance assessment of CPR.
He D, Huang K, Yang Y, Jiang W, Yang N, Yang H. What is the optimal age for students to receive cardiopulmonary resuscitation training? Prehosp Disaster Med. 2018;33(4):394–398.
In April 2017, some of the health impacts of the 2011 Great East Japan Earthquake, tsunamis, and resultant Fukushima Daiichi nuclear power plant disaster (Okuma, Fukushima Prefecture, Japan) were presented at the 19th Congress of the World Association for Disaster and Emergency Medicine (WADEM; Madison, Wisconsin USA) in Toronto, Canada. A panel discussion was then opened by asking audience members about their experiences in their own countries, and how they would suggest taking steps to reach the goals of the Sendai Framework for Disaster Risk Reduction 2015-2030. This paper summarizes the presentation and panel discussion, with a particular focus on the common problems identified in understanding and reducing health risks from disasters in multiple countries, such as the ethical and practical difficulties in decision making on evacuating vulnerable populations that arose similarly during the Fukushima nuclear disaster in 2011 and Hurricane Ike’s approach to Galveston (Texas USA) in 2008. This paper also highlights the need for greater integration of research, for example through increased review and collation of evidence from different disaster settings to identify common problems and possible solutions, which was identified in this panel session as a precursor to fulfilling the goals of the Sendai Framework.
Leppold C, Ochi S, Nomura S, Murray V. The Great East Japan Earthquake, tsunamis, and Fukushima Daiichi nuclear power plant disaster: lessons for evidence integration from a WADEM 2017 presentation and panel discussion. Prehosp Disaster Med. 2018;33(4):424–427
Mass gatherings are complex events that present a unique set of challenges to attendees’ health and well-being. There are numerous factors that influence the number and type of injuries and illnesses that occur at these events, including weather, event and venue type, and crowd demographics and behavior.
Problem
While the impact of some factors, such as weather conditions and the availability of alcohol, on patient presentations at mass gatherings have been described previously, the influence of many other variables, including crowd demographics, crowd behavior, and event type, is poorly understood. Furthermore, a large number of studies reporting on the influence of these variables on patient presentations are based on anecdotal evidence at a single mass-gathering event.
Methods
Data were collected by trained fieldworkers at 15 mass gatherings in South Australia and included event characteristics, crowd demographics, and weather. De-identified patient records were obtained from on-site health care providers. Data analysis included the calculation of patient proportions in each variable category, as well as the total number of patient presentations per event and the patient presentation rate (PPR).
Results
The total number of expected attendees at the 15 mass gatherings was 303,500, of which 146 presented to on-site health care services. The majority of patient presentations occurred at events with a mean temperature between 20°C and 25°C. The PPR was more than double at events with a predominantly male crowd compared to events with a more equal sex distribution. Almost 90.0% of patient presentations occurred at events where alcohol was available.
Conclusion:
The results of the study suggest that several weather, crowd, and event variables influence the type and number of patient presentations observed at mass-gathering events. Given that the study sample size did not allow for these interactions to be quantified, further research is warranted to investigate the relationships between alcohol availability, crowd demographics, crowd mobility, venue design, and injuries and illnesses.
Anikeeva O, Arbon P, Zeitz K, Bottema M, Lund A, Turris S, Steenkamp M. Patient presentation trends at 15 mass-gathering events in South Australia. Prehosp Disaster Med. 2018;33(4):368–374.
A seven-month-old girl was referred to the emergency department (ED) after a general practitioner suspected Steven-Johnson syndrome. Actually, the diagnosis of bullous pemphigoid (BP) was made based on biopsies; BP is a rare, autoimmune skin disease involving the presence of blisters known as bullae. The child was efficiently treated with topical steroids. This case shows the importance of the ED physician’s prior knowledge of BP so that a differential diagnosis with other autoimmune diseases (dermatosis, pemphigus) can be made.
Thabouillot O, Le Coz J, Roche NC. Bullous pemphigoid in an infant: a case report. Prehosp Disaster Med. 2018;33(4):448–450.
Femoral fractures are painful injuries frequently encountered by prehospital practitioners. Systemic opioids are commonly used to manage the pain after a femoral fracture; however, regional techniques for providing analgesia may provide superior targeted pain relief and reduce opioid requirements. Fascia Iliaca Compartment Block (FICB) has been described as inexpensive and does not require special skills or equipment to perform, giving it the potential to be a suitable prehospital intervention.
Problem
The purpose of this systematic review is to summarize published evidence on the prehospital use of FICB in patients of any age suffering femoral fractures; in particular, to investigate the effects of a prehospital FICB on pain scores and patient satisfaction, and to assess the feasibility and safety of a prehospital FICB, including the success rates, any delays to scene time, and any documented adverse effects.
Methods
A literature search of MEDLINE/PubMED, Embase, OVID, Scopus, the Cochrane Database, and Web of Science was conducted from January 1, 1989 through February 1, 2017. In addition, reference lists of review articles were reviewed and the contents pages of the British Journal of Anaesthesia (The Royal College of Anaesthetists [London, UK]; The College of Anaesthetists of Ireland [Dublin, Ireland]; and The Hong Kong College of Anaesthesiologists [Aberdeen, Hong Kong]) 2016 along with the journal Prehospital Emergency Care (National Association of Emergency Medical Service Physicians [Overland Park, Kansas USA]; National Association of State Emergency Medical Service Officials [Falls Church, Virginia USA]; National Association of Emergency Medical Service Educators [Pittsburgh, Pennsylvania USA]; and the National Association of Emergency Medical Technicians [Clinton, Mississippi USA]) 2016 were hand searched. Each study was evaluated for its quality and its validity and was assigned a level of evidence according to the Oxford Centre for Evidence-Based Medicine (OCEBM; Oxford, UK).
Results
Seven studies involving 699 patients were included (one randomized controlled trial [RCT], four prospective observational studies, one retrospective observational study, and one case report). Pain scores reduced after prehospital FICB across all studies, and some achieved a level of significance to support this. Out of a total of 254 prehospital FICBs, there was a success rate of 90% and only one adverse effect reported. Few studies have investigated the effects of prehospital FICB on patient satisfaction or scene time delays.
Conclusions and Relevance:
The FICB is suitable for use in the prehospital environment for the management of femoral fractures. It has few adverse effects and can be performed with a high success rate by practitioners of any background. Studies suggest that FICB is a useful analgesic technique, although further research is required to investigate its effectiveness compared to systemic opioids.
HardsM, BrewerA, BessantG, LahiriS. Efficacy of Prehospital Analgesia with Fascia Iliaca Compartment Block for Femoral Bone Fractures: A Systematic Review. Prehosp Disaster Med. 2018;33(3):299-307.
In 1994, the first World Conference on Natural Disaster Reduction held in Yokohama, Japan affirmed that “Disaster prevention, mitigation, and preparedness are better than disaster response in achieving the goals and objectives of the decade. Disaster response alone is not sufficient, as it yields only temporary results in a very high cost.” Since then, disaster risk reduction has become the mainstay for international development related to disasters.
According to the National Research Council (Washington, DC USA), “Disaster research, which has focused historically on emergency response and recovery, is incomplete without the simultaneous study of the societal hazards and risks associated with disasters, which includes data on the vulnerability of people living in hazard prone areas.” Despite over 25 years of global policy development, the National Academies of Sciences, Engineering, and Medicine (Washington, DC USA) recently noted that, “while some disaster management and public health preparedness programming may be viewed as tangentially related, a multi-sectoral and inter-disciplinary national platform for coordination and policy guidance on involving disaster risk reduction in the United States does not exist.” Today, one of the world’s “seven targets in seven years” as agreed upon in the Sendai Framework for Disaster Risk Reduction is to substantially reduce global mortality by 2030. Significant reductions in health risk (including mortality) have historically required a comprehensive approach for disease management that includes both a preventive and a curative approach. Disaster risk management has arisen as a primary means for the world’s populations to address disaster losses, including those related to health. Prevention has been proven as an effective approach for managing health risk. This report describes the role of disease prevention in managing health risk due to disasters.
KeimM. Managing Disaster-Related Health Risk: A Process for Prevention. Prehosp Disaster Med. 2018;33(3):326-334.
Effective disaster risk management requires not only management of the immediate problem (disaster-related injuries and disease), but also of the patient’s risk factors and of the underlying health determinants. This requires an accurate and well-validated process for assessment of the determinants of disease.
Ideally, disaster risk management is based on a prioritization process. Once hazards have been identified, they are assessed in terms of the probability and impact in terms of losses. The hazards associated with the greatest probability and impact loss are prioritized. In addition to prioritization, risk assessment also offers a process for ongoing research involving the interaction of health determinants, risk, and protective factors that may contribute to future adverse health outcomes.
Recently, assessments of health risk have become an integral part of local, state, and national emergency preparedness programs. One of the strengths of these assessments is the convening of multi-sectoral input for public health decision making and plans. However, this diversity of input also creates challenges in development of a common nomenclature for assessing and communicating the characteristics of this risk. Definitions remain ambiguous for many of the key indicators of disaster risk, especially those applied to health risk.
This report is intended as a primer for defining disaster-related health risk. This framework is discussed within a nomenclature that is consistent with international standards for risk management and public health prevention.
KeimM. Defining Disaster-Related Health Risk: A Primer for Prevention. Prehosp Disaster Med. 2018;33(3):308-316.
Risk assessment is a key component of public health interventions intended to prevent or reduce adverse health effects. Health risk assessments are widely used to guide public health programming, as well as multi-sectoral studies of environmental impact and developmental decision making. Analytical risk assessment is a well-validated tool that is routinely used among certain subsets of public health, including those for chemical, radiological, and microbiological risk assessment. However, this is not the case for risk assessments involving disasters in general, or more specifically, for public health emergencies involving environmental hazards (eg, technological, hydro-meteorological, and seismic).
There remains a need for a reproducible, well-validated, disaster-related health risk assessment process that is suitable for accommodating the current gaps in certainty. This report is intended to offer a practical framework and nomenclature for assessing disaster-related health risk that is: (1) accurate; (2) based upon historical evidence; (3) quantifiable in public health terms; and (4) inclusive of uncertainty.
KeimM. Assessing Disaster-Related Health Risk: Appraisal for Prevention. Prehosp Disaster Med. 2018;33(3):317-325.