A unique approach to providing orientation and supervised field experience for newly graduated paramedics and for the continuing education and recognition of experienced, skilled, operational paramedics is described. A group of 30 paramedic field instructors (PFI) was selected following application, development of criteria for selection, and interviews. This program had a positive effect in both realms during its first year of operation in the emergency medical services system in which it was implemented.

The proliferation of new medical technology and pharmacology forces the medical community to ensure the efficacy and safety of new drugs and devices before their use in patient care. Although traditional medical practices have a fairly consistent means to achieve this end, prehospital medical practice often does not. In addition, it often appears that the emergency medical services marketplace does not always follow conventional supply/demand and cost/quality paradigms. This article describes a process implemented in Pennsylvania to standardize the mechanism by which new drugs and devices are introduced into prehospital medical practice.

Complex, humanitarian emergencies, the result of civil strife and armed conflict affecting large populations at the brink of extinction, represent the most compelling of disaster relief challenges. They require the coordination of the United Nations agencies, the International Committee of the Red Cross, international nongovernmental relief organizations, and military forces. An increasing number of civilian and military health-care providers find themselves involved in the planning, coordination, and direct patient-care aspects of these emergencies, often without proper initiation and understanding of the unique nature of these disasters. This article provides a primer on the concept of complex, humanitarian emergencies and the contributions, characteristics, capabilities, and limitations of each major participant.

During a record snowfall in Worcester, Massachusetts, 11–13 December 1992, 37 male patients with hand injuries suffered during snow blower operation were seen at three area hospitals. Two previous reports describe 13 patients seen over a 3-year period and 28 patients over a 12-year period. This report describes the largest number of hand injuries from snow blowers that have occurred over a 48-hour period. The snow was unusual because of the high water density in the initial 9 inches (23 cm) that fell at an average temperature of 33° F (0.6° C) with the final depth of 30 inches (76 cm), causing the machines to become clogged. Patients admitted to reaching into a running machine in 35/37 (95%) cases, 11/37 (30%) claimed the auger and impeller blades were disengaged, and 2/37 (5%) patients claimed their injuries occurred with the engines turned off. All injuries occurred when the patients placed their hands down the chute, contacting the impeller blades. Injuries involved 32 long, 15 ring, 13 index, and five small fingers and ranged from simple lacerations to partial phalangeal amputations. The majority, 27/37 (73%), were managed in emergency departments without interventions in the operating suites. Infection occurred in one patient who had the lesion repaired in the operating suite. As in previous studies, no differences were found for the variables of snow blower age, type, or horsepower, or on experience level or age of the operators. Despite the safety defaults provided on newer machines, warnings posted on equipment and in owner's manuals, or public-service announcements provided by the media during the storm, injuries continued to occur. Operator error was the common denominator, suggesting that a change in snow-blower design that prevents hand access or impeller rotation is necessary to prevent these devastating injuries.

In complex, humanitarian emergencies, professional liaison roles are just one of many that evolve from the coordination of United Nations agencies, the International Committee of the Red Cross, international and national non-governmental relief organizations, and coalition military forces. Liaison is crucial to the humanitarian relief process. Decision makers benefit from liaisons' professional experience, their knowledge of the characteristics, missions, and capabilities of each major participant in the relief process, and in their ability to coordinate and clarify professional issues in meeting the goals of a mission. Medical liaison roles develop from the awareness that complex emergencies primarily are catastrophic public-health emergencies. Unfortunately, education and training of the medical liaison currently are ill-defined. However, limited experience suggests that skills should be broadly based in principles of disaster epidemiology, assessment and management, knowledge of contributing relief resources, agencies and the military, and international humanitarian law and the Geneva Conventions.

Complex humanitarian emergencies lack a mechanism to coordinate, communicate, assess, and evaluate response and outcome for the major participants (United Nations, Intenational Committee of the Red Cross, non-governmental organizations and military forces). Success in these emergencies will depend on the ability to accomplish agreed upon measures of effectiveness (MOEs). A recent civil-military humanitarian exercise demonstrated the ability of participants to develop consensus-driven MOEs. These MOEs combined security measures utilized by the military with humanitarian indicators recognized by relief organizations. Measures of effectiveness have the potential to be a unifying disaster management tool and a partial solution to the communication and coordination problems inherent in these complex emergencies.