Disaster triage is the allocation of limited medical resources in order to optimize patient outcome. There are several studies showing the poor use of triage tagging, but there are few studies that have investigated the reasons behind this. The aim of this study was to explore ambulance personnel attitude towards, and experiences of, practicing triage tagging during day-to-day management of trauma patients, as well as in major incidents (MIs).

A mixed method design was used. The first part of the study was in the form of a web-survey of attitudes answered by ambulance personnel. The question explored was: Is it likely that systems that are not used in everyday practice will be used during MIs? Two identical web-based surveys were conducted, before and after implementing a new strategy for triage tagging. This strategy consisted of a time-limited triage routine where ambulance services assigned triage category and applied triage tags in day-to-day trauma incidents in order to improve field triage. The second part comprised three focus group interviews (FGIs) in order to provide a deeper insight into the attitudes towards, and experience of, the use of triage tags. Data were analyzed using qualitative content analysis.

The overall finding was the need for daily routine when failure in practice. Analysis of the web-survey revealed three changes: ambulance personnel were more prone to use tags in minor accidents, the sort scoring system was considered to be more valuable, but it also was more time consuming after the intervention. In the analysis of FGIs, four categories emerged that describe the construction of the overall category: perceived usability, daily routine, documentation, and need for organizational strategies.

Triage is part of the foundation of ambulance skills, but even so, ambulance personnel seldom use this in routine practice. They fully understand the benefit of accurate triage decisions, and also that the use of a triage algorithm and color coded tags is intended to make it easier and more secure to perform triage. However, despite the knowledge and understanding of these benefits, sparse incidents and infrequent exercises lead to ambulance personnel’s uncertainty concerning the use of triage tagging during a MI and will therefore, most likely, avoid using them.

RådestadM, Lennquist MontánK, RüterA, CastrénM, SvenssonL, GrythD, FossumB. Attitudes Towards and Experience of the Use of Triage Tags in Major Incidents: A Mixed Method Study. Prehosp Disaster Med. 2016;31(4):376–385.

Karachi, Pakistan was affected by a heat wave in June 2015 during the Muslim holy month of Ramadan. Many media reports attributed the excess deaths in part to the practice of daylight fasting during Ramadan. As much of the published research reports on heat-related mortality in Europe and the United States, an exploration of the effects of extreme heat on residents of a South Asian mega-city address a gap in current disaster research.

This report investigated potential risk factors for excess mortality associated with the June 2015 heat wave in Karachi, Pakistan.

Data were obtained through manual review of death certificates at public hospitals and private clinics in Karachi, Pakistan, conducted from July 1 through July 31, 2015 by a trained physician. Demographic data for any deaths with a primary cause of death of heat-related illness were recorded in Microsoft Excel (Microsoft Corp.; Redmond, Washington USA). EpiSheet (2012; Rothman. Modern Epidemiology. Lippincott Williams & Wilkins; Philadelphia, Pennsylvania USA) was used to calculate risk differences (RD), rate ratios (RR), and 95% confidence intervals (95% CI).

Overall, residents of Karachi were approximately 17 times as likely to die of a heat-related cause of death during June 2015 (RR=17.68; 95% CI, 13.87-22.53) when compared with the reference period of June 2014. Residents with a monthly income lower than 20,000 Pakistani Rupees (US $196; RD=0.03; 95% CI, 0.01-0.05) and those with less than a fifth grade education (RD=0.03; 95% CI, 0.00-0.05) were at significantly higher risk of death during the 2015 heat wave compared to the reference period.

Fasting during Ramadan was not a significant risk factor for mortality from heat-related causes during the Karachi heat wave of June 2015. A large number of excess deaths were reported across all demographic groups, which due to the burden of record keeping in an under-resourced health system during a public health emergency, are almost certainly an underestimate.

GhummanU, HorneyJ. Characterizing the Impact of Extreme Heat on Mortality, Karachi, Pakistan, June 2015. Prehosp Disaster Med. 2016;31(3):263–266.

Influenza is a major concern for Emergency Medical Services (EMS); EMS workers’ (EMS-Ws) vaccination rates remain low despite promotion. Determinants of vaccination for seasonal influenza (SI) or pandemic influenza (PI) are unknown in this setting.

The influence of the H1N1 pandemic on EMS-W vaccination rates, differences between SI and PI vaccination rates, and the vaccination determinants were investigated.

A survey was conducted in 2011 involving 65 Swiss EMS-Ws. Socio-professional data, self-declared SI/PI vaccination status, and motives for vaccine refusal or acceptation were collected.

Response rate was 95%. The EMS-Ws were predominantly male (n=45; 73%), in good health (87%), with a mean age of 36 (SD=7.7) years. Seventy-four percent had more than six years of work experience. Self-declared vaccination rates were 40% for both SI and PI (PI+/SI+), 19% for PI only (PI+/SI-), 1.6% for SI only (PI-/SI+), and 39% were not vaccinated against either (PI-/SI-). Women’s vaccination rates specifically were lower in all categories but the difference was not statistically significant. During the previous three years, 92% of PI+/SI+ EMS-Ws received at least one SI vaccination; it was 8.3% in the case of PI-/SI- (P=.001) and 25% for PI+/SI- (P=.001). During the pandemic, SI vaccination rate increased from 26% during the preceding year to 42% (P=.001). Thirty percent of the PI+/SI+ EMS-Ws declared that they would not get vaccination next year, while this proportion was null for the PI-/SI- and PI+/SI- groups. Altruism and discomfort induced by the surgical mask required were the main motivations to get vaccinated against PI. Factors limiting PI or SI vaccination included the option to wear a mask, avoidance of medication, fear of adverse effects, and concerns about safety and effectiveness.

Average vaccination rate in this study’s EMS-Ws was below recommended values, particularly for women. Previous vaccination status was a significant determinant of PI and future vaccinations. The new mask policy seemed to play a dual role, and its net impact is probably limited. This population could be divided in three groups: favorable to all vaccinations; against all, even in a pandemic context; and ambivalent with a “pandemic effect.” These results suggest a consistent vaccination pattern, only altered by exceptional circumstances.

MoserA, MabireC, HugliO, DorriboV, ZanettiG, Lazor-BlanchetC, CarronPN. Vaccination Against Seasonal or Pandemic Influenza in Emergency Medical Services. Prehosp Disaster Med. 2016;31(2):155–162.

Primary triage in a mass-casualty event setting using low-visibility tags may lead to informational confusion and difficulty in judging triage attribution of patients. In this simulation study, informational confusion during primary triage was investigated using a method described in a prior study that applied Shannon’s Information Theory to triage.

Primary triage using a low-visibility tag leads to a risk of informational confusion in prioritizing care, owing to the intermingling of pre- and post-triage patients. It is possible that Shannon’s entropy evaluates the degree of informational confusion quantitatively and improves primary triage.

The Simple Triage and Rapid Treatment (START) triage method was employed. In Setting 1, entropy of a triage area with 32 patients was calculated for the following situations: Case 1 – all 32 patients in the triage area at commencement of triage; Case 2 – 16 randomly imported patients to join 16 post-triage patients; Case 3 – eight patients imported randomly and another eight grouped separately; Case 4 – 16 patients grouped separately; Case 5 – random placement of all 32 post-triage patients; Case 6 – isolation of eight patients of minor priority level; Case 7 – division of all patients into two groups of 16; and Case 8 – separation of all patients into four categories of eight each. In Setting 2, entropies in the triage area with 32 patients were calculated continuously with each increase of four post-triage patients in Systems A and B (System A – triage conducted in random manner; and System B – triage arranged into four categories).

In Setting 1, entropies in Cases 1-8 were 2.00, 3.00, 2.69, 2.00, 2.00, 1.19, 1.00, and 0.00 bits/symbol, respectively. Entropy increased with random triage. In Setting 2, entropies of System A maintained values the same as, or higher than, those before initiation of triage: 2.00 bits/symbol throughout the triage. The graphic waveform showed a concave shape and took 3.00 bits/symbol as maximal value when the probability of each category was 1/8, whereas the values in System B showed a linear decrease from 2.00 to 0.00 bits/symbol.

Informational confusion in a primary triage area measured using Shannon’s entropy revealed that random triage using a low-visibility tag might increase the degree of confusion. Methods for reducing entropy, such as enhancement of triage colors, may contribute to minimizing informational confusion.

AjimiY, SasakiM, UchidaY, KanekoI, NakaharaS, SakamotoT. Primary Triage in a Mass-casualty Event Possesses a Risk of Increasing Informational Confusion: A Simulation Study Using Shannon’s Entropy. Prehosp Disaster Med. 2016;31(5):498–504.

Provisions of medical direction and clinical services for ultramarathons require specific attention to heat illness. Heat stress can affect athlete performance negatively, and heat accumulation without acclimatization is associated with the development of exertional heat stroke (EHS). In order to potentially mitigate the risk of this safety concern, the Jungle Marathon (Para, Brazil) instituted mandatory rest periods during the first two days of this 7-day, staged, Brazilian ultramarathon.

Race records were reviewed retrospectively to determine the number of runners that suffered an emergency medical complication related to heat stress and did not finish (DNF) the race. Review of records included three years before and three years after the institution of these mandatory rest periods.

A total of 326 runners competed in the Jungle Marathon during the 2008-2013 period of study. During the pre-intervention years, a total of 46 athletes (21%) DNF the full race with 25 (54.3%) cases attributed to heat-related factors. During the post-intervention years, a total of 26 athletes (24.3%) DNF the full race with four (15.4%) cases attributed to heat-related factors.

Mandatory rest stops during extreme running events in hot or tropical environments, like the Jungle Marathon, are likely to improve athlete safety and improve the heat acclimatization process.

JoslinJ, MularellaJ, BailA, WojcikS, CooneyDR. Mandatory Rest Stops Improve Athlete Safety during Event Medical Coverage for Ultramarathons. Prehosp Disaster Med. 2016;31(1):43–45.

Traditionally, Emergency Medical Services (EMS) educators have divided the pediatric population into age groups to assist in targeting their clinical and didactic curriculum. Currently, the accrediting body for paramedic training programs requires student exposure to pediatric patients based entirely on age without specifying exposure to specific pathologies within each age stratification. Identifying which pathologies are most common within the different pediatric age groups would allow educators to design curriculum targeting the most prevalent pathologies in each age group and incorporating the physiologic and psychological developmental milestones commonly seen at that age.

It was hypothesized that there are unique clusterings of pathologies, represented by paramedic student primary impressions, that are found in different age groups which can be used to target provider education.

This is a retrospective review of prospectively collected data documented by paramedic students in the Fisdap (Field Internship Student Data Acquisition Project; Saint Paul, Minnesota USA) database over a one-year period. For the purposes of this study, pediatric patients were defined arbitrarily as those between the ages of 0-16 years. All paramedic student primary impressions recorded in Fisdap for patients aged 0-16 years were abstracted. Primary impression by age was calculated and graphed. The frequency of primary impression was then assessed for significance of trend by age with an alpha ≤.05 considered significant.

The following primary impressions showed clinically and statistically significant variability in prevalence among different pediatric age groups: respiratory distress, medical-other, abdominal pain, seizure, overdose/poisoning, behavioral, and cardiac. In patients less than 13 years old, respiratory and other-medical were the most common two primary impressions and both decreased with age. In patients 5-16 years old, the prevalence of abdominal pain and behavioral/psych increased. Bimodal distributions for overdose were seen with one spike in the toddler and another in the adolescent population. Seizures were most common in the age group associated with febrile seizure. Sepsis was seen most often in the youngest patients and its prevalence decreased with age.

There are statistically significant variations in the frequency of paramedic student primary impressions as a function of age in the pediatric population. Emphasizing paramedic student exposure to the most common pathologies encountered in each age group, in the context of the psychological and physiological milestones of each age, may improve paramedic student pediatric practice.

ErnestEV, BrazeltonTB, CarhartED, StudnekJR, TrittPL, PhilipGA, BurnettAM. Prevalence of Unique Pediatric Pathologies Encountered by Paramedic Students Across Age Groups. Prehosp Disaster Med. 2016; 31(4):386–391.

The objectives were to assess changes in (1) health and physical fitness, (2) the prevalence of selected health problems, (3) risk behaviors, (4) ambulance safety issues, and (5) the preparedness of Emergency Medical Services (EMS) professionals. In addition, the incidence of patient-initiated violence directed toward EMS personnel and associated factors were assessed.

Data were obtained from a sample of nationally certified EMS professionals via annual questionnaires between 1999 and 2008. Stratification was based upon national certification level, self-reported race, and experience level. Weighted percentages, averages for continuous variables, and 95% confidence intervals (CIs) were calculated. Significant changes over time were noted by lack of CI overlap.

The proportion reporting “excellent” health declined significantly from 1999 (38.5%) to 2008 (32.2%). High rates of sleeping problems (20%-27%), back problems (20%-24%), and hearing problems (7%-10%) were reported as having occurred in the past year. These rates remained constant over time. As a result of sleepiness, 8.0% of nationally certified EMS professionals reported difficulty in driving an emergency vehicle for short distances and 17.5% reported difficulty in driving long distances. The proportion of daily tobacco smokers significantly declined from over one-third (35.3%) to about one-fifth (20.3%). The proportion of providers who had ever been involved in an ambulance crash increased slightly from 2004 (14.5%) to 2008 (15.8%). In 2000, the majority of EMS professionals reported that they and/or their partner had been assaulted by a patient. Finally, there was a significant decrease in the amount of training time devoted to the recognition of biological, chemical, and nuclear (BCN) threats, use of personal protective equipment (PPE), and treatment and management of patients exposed to BCN from an average from 8.4 hours in 2003 to 6.2 hours in 2008.

The overall health and physical fitness of EMS professionals as well as their health problems, risk behaviors, ambulance safety, and patient-initiated violence in the prehospital emergency setting are areas of concern for the nation’s emergency medical system. The prevalence of these problems and overall health and physical fitness has shown little or no improvement from 1999 to 2008.

BentleyMA, LevineR. A National Assessment of the Health and Safety of Emergency Medical Services Professionals. Prehosp Disaster Med. 2016;31(Suppl. 1):s96–s104.

Injury is responsible for nearly five million annual deaths worldwide, and nearly 90% of these deaths occur in low- and middle-income countries (LMICs). Reliable clinical data detailing the epidemiology of injury are necessary for improved care delivery, but they are lacking in these regions.

A retrospective review of the Service d’Aide Medicale Urgente (SAMU; Kigali, Rwanda) prehospital database for patients with traumatic injury-related conditions from December 2012 through November 2014 was conducted. Chi-squared analysis, binomial probability test, and student’s t-test were used, where appropriate, to describe patient demographics, injury patterns, and temporal and geographic trends of injuries.

In the two-year period, 3,357 patients were managed by SAMU for traumatic injuries. Males were 76.5% of the study population, and the median age of all injured patients was 29 years (IQR=23-35). The most common causes of injury were road traffic crashes (RTCs; 73.4%), stabbings/cuts (11.1%), and falls (9.4%), and the most common anatomic regions injured were the head (55.7%), lower (45.0%) extremities, and upper (27.0%) extremities. Almost one-fourth of injured patients suffered a fracture (24.9%). The most common mechanism of injury for adults was motorcycle-related RTCs (61.4%), whereas children were more commonly injured as pedestrians (59.8%). Centrally located sectors within Kigali represented common areas for RTCs.

These data support the call for focused injury prevention strategies, some of which already are underway in Rwanda. Further research on care processes and clinical outcomes for injured patients may help identify avenues for improved care delivery.

EnumahS, ScottJW, MaineR, UwitonzeE, NyinawankusiJD, RivielloR, ByiringiroJC, KabagemaI, JayaramanS. Rwanda’s Model Prehospital Emergency Care Service: A Two-year Review of Patient Demographics and Injury Patterns in Kigali. Prehosp Disaster Med. 2016;31(6):614–620.

Inter-facility transport of critically ill patients is associated with a high risk of adverse events, and critical care transport (CCT) teams may spend considerable time at sending institutions preparing patients for transport. The effect of mode of transport and distance to be traveled on on-scene times (OSTs) has not been well-described.

Quantification of the time required to package patients and complete CCTs based on mode of transport and distance between facilities is important for hospitals and CCT teams to allocate resources effectively.

This is a retrospective review of OSTs and transport times for patients with hypoxemic respiratory failure transported from October 2009 through December 2012 from sending hospitals to three tertiary care hospitals. Differences among the OSTs and transport times based on the mode of transport (ground, rotor wing, or fixed wing), distance traveled, and intra-hospital pick-up location (emergency department [ED] vs intensive care unit [ICU]) were assessed. Correlations between OSTs and transport times were performed based on mode of transport and distance traveled.

Two hundred thirty-nine charts were identified for review. Mean OST was 42.2 (SD=18.8) minutes, and mean transport time was 35.7 (SD=19.5) minutes. On-scene time was greater than en route time for 147 patients and greater than total trip time for 91. Mean transport distance was 42.2 (SD=35.1) miles. There were no differences in the OST based on mode of transport; however, total transport time was significantly shorter for rotor versus ground, (39.9 [SD=19.9] minutes vs 54.2 [SD=24.7] minutes; P <.001) and for rotor versus fixed wing (84.3 [SD=34.2] minutes; P=0.02). On-scene time in the ED was significantly shorter than the ICU (33.5 [SD=15.7] minutes vs 45.2 [SD=18.8] minutes; P <.001). For all patients, regardless of mode of transportation, there was no correlation between OST and total miles travelled; although, there was a significant correlation between the time en route and distance, as well as total trip time and distance.

In this cohort of critically ill patients with hypoxemic respiratory failure, OST was over 40 minutes and was often longer than the total trip time. On-scene time did not correlate with mode of transport or distance traveled. These data can assist in planning inter-facility transports for both the sending and receiving hospitals, as well as CCT services.

WilcoxSR, SaiaMS, WadenH, McGahnSJ, FrakesM, WedelSK, RichardsJB. On-scene Times for Inter-facility Transport of Patients with Hypoxemic Respiratory Failure. Prehosp Disaster Med. 2016;31(3):267–271.

Early activation and use of Emergency Medical Services (EMS) are associated with improved patient outcomes in EMS priority conditions in developed EMS systems. This study describes patterns of EMS use and identifies predictors of EMS utilization in EMS priority conditions in Lebanon

This was a cross-sectional study of a random sample of adult patients presenting to the emergency department (ED) of a tertiary care center in Beirut with the following EMS priority conditions: chest pain, major trauma, respiratory distress, cardiac arrest, respiratory arrest, and airway obstruction. Patient/proxy survey (20 questions) and chart review were completed. The responses to survey questions were “disagree,” “neutral,” or “agree” and were scored as one, two, or three with three corresponding to higher likelihood of EMS use. A total scale score ranging from 20 to 60 was created and transformed from 0% to 100%. Data were analyzed based on mode of presentation (EMS vs other).

Among the 481 patients enrolled, only 112 (23.3%) used EMS. Mean age for study population was 63.7 years (SD=18.8 years) with 56.5% males. Mean clinical severity score (Emergency Severity Index [ESI]) was 2.5 (SD=0.7) and mean pain score was 3.1 (SD=3.5) at ED presentation. Over one-half (58.8%) needed admission to hospital with 21.8% to an intensive care unit care level and with a mortality rate of 7.3%. Significant associations were found between EMS use and the following variables: severity of illness, degree of pain, familiarity with EMS activation, previous EMS use, perceived EMS benefit, availability of EMS services, trust in EMS response times and treatment, advice from family, and unavailability of immediate private mode of transport (P≤.05). Functional screening, or requiring full assistance (OR=4.77; 95% CI, 1.85-12.29); acute symptoms onset ≤ one hour (OR=2.14; 95% CI, 1.08-4.26); and higher scale scores (OR=2.99; 95% CI, 2.20-4.07) were significant predictors of EMS use. Patients with lower clinical severity (OR=0.53; 95% CI, 0.35-0.81) and those with chest pain (OR=0.05; 95% CI, 0.02-0.12) or respiratory distress (OR=0.15; 95% CI, 0.07-0.31) using cardiac arrest as a reference were less likely to use EMS.

Emergency Medical Services use in EMS priority conditions in Lebanon is low. Several predictors of EMS use were identified. Emergency Medical Services initiatives addressing underutilization should result from this proposed assessment of the perspective of the EMS system’s end user.

El SayedM, TamimH, Al-Hajj ChehadehA, KazziAA. Emergency Medical Services Utilization in EMS Priority Conditions in Beirut, Lebanon. Prehosp Disaster Med. 2016;31(6):621–627.

There is a lack of knowledge about the early phase of severe infection. This report describes the early chain of care in bacteraemia as follows: (a) compare patients who were and were not transported by the Emergency Medical Services (EMS); (b) describe various aspects of the EMS chain; and (c) describe factors of importance for the delay to the start of intravenous antibiotics. It was hypothesized that, for patients with suspected sepsis judged by the EMS clinician, the delay until the onset of antibiotic treatment would be shorter.

All patients in the Municipality of Gothenburg (Sweden) with a positive blood culture, when assessed at the Laboratory of Bacteriology in the Municipality of Gothenburg, from February 1 through April 30, 2012 took part in the survey.

In all, 696 patients fulfilled the inclusion criteria. Their mean age was 76 years and 52% were men. Of all patients, 308 (44%) had been in contact with the EMS and/or the emergency department (ED). Of these 308 patients, 232 (75%) were transported by the EMS and 188 (61%) had “true pathogens” in blood cultures. Patients who were transported by the EMS were older, included more men, and suffered from more severe symptoms and signs.

The EMS nurse suspected sepsis in only six percent of the cases. These patients had a delay from arrival at hospital until the start of antibiotics of one hour and 19 minutes versus three hours and 21 minutes among the remaining patients (P =.0006). The corresponding figures for cases with “true pathogens” were one hour and 19 minutes versus three hours and 15 minutes (P =.009).

Among patients with bacteraemia, 75% used the EMS, and these patients were older, included more men, and suffered from more severe symptoms and signs. The EMS nurse suspected sepsis in six percent of cases. Regardless of whether or not patients with true pathogens were isolated, a suspicion of sepsis by the EMS clinician at the scene was associated with a shorter delay to the start of antibiotic treatment.

AxelssonC, HerlitzJ, KarlssonA, SjöbergH, Jiménez-HerreraM, BångA, JonssonA, BremerA, AnderssonH, GellerstedtM, LjungströmL. The Early Chain of Care in Patients with Bacteraemia with the Emphasis on the Prehospital Setting. Prehosp Disaster Med. 2016;31(3):272–277.

Emergency medical technicians (EMTs) and paramedics are at serious risk for work-related injuries (WRIs) during work hours. Both EMTs and paramedics have higher WRI rates, according to the literature data. This study was designed to investigate causes and characteristics of WRIs involving EMTs and paramedics staffed in Western Turkey.

All health care personnel staffed in Emergency Medical Services (EMS) in the city were interviewed face-to-face in their off-duty hours to inform them about the study. Excluded from the study were those who declined to participate in the study, those who were not on duty during the two-month study period, and those who had been working in the EMS for less than one year. The subjects were asked to answer multiple-choice questions.

A total of 163 personnel (117 EMTs and 46 paramedics) comprised the study sample. Eighty-three personnel (50.9%) were female and mean age was 29.7 years (SD=8.4 years). The most common mechanisms of WRI, as reported by the personnel, were motor vehicle accidents (MVAs; 31.9%), needlestick injuries (16.0%), ocular exposure to bodily fluids (15.4%), and sharp injuries (9.8%), respectively. Needlestick injuries commonly occurred during intravenous line procedures (59.4%) and inside the cruising ambulance (n=20; 62.5%). Working inside the cruising ambulance was the most commonly accused cause of the WRI (41.3%).

Paramedic personnel and EMTs are under high risk of WRI. Motor vehicle accidents and needlestick injuries were the most common causes of WRI. Strict measures need to be taken to restructure the interior design to protect personnel from all kinds of WRIs.

YilmazA, SerinkenM, DalO, YaylacıS, KarciogluO. Work-related Injuries Among Emergency Medical Technicians in Western Turkey. Prehosp Disaster Med. 2016;31(5):505–508.

The objective was to determine why Emergency Medical Technician (EMT)-Basics and Paramedics leave the Emergency Medical Services (EMS) workforce.

Data were collected through annual surveys of nationally registered EMT-Basics and Paramedics from 1999 to 2008. Survey items dealing with satisfaction with the EMS profession, likelihood of leaving the profession, and likelihood of leaving their EMS job were assessed for both EMT-Basics and Paramedics, along with reasons for leaving the profession. Individuals whose responses indicated that they were not working in EMS were mailed a special exit survey to determine the reasons for leaving EMS.

The likelihood of leaving the profession in the next year was low for both EMT-Basics and Paramedics. Although overall satisfaction levels with the profession were high, EMT-Basics were significantly more satisfied than Paramedics. The most important reasons for leaving the profession were choosing to pursue further education and moving to a new location. A desire for better pay and benefits was a significantly more important reason for EMT-Paramedics’ exit decisions than for EMT-Basics.

Given the anticipated increased demand for EMS professionals in the next decade, continued study of issues associated with retention is strongly recommended. Some specific recommendations and suggestions for promoting retention are provided.

BlauG, ChapmanSA. Why do Emergency Medical Services (EMS) Professionals Leave EMS?Prehosp Disaster Med. 2016;31(Suppl. 1):s105–s111.

The worldwide use of rail transport has increased, and the train speeds are escalating. Concurrently, the number of train disasters has been amplified globally. Consequently, railway safety has become an important issue for the future. High-velocity crashes increase the risk for injuries and mortality; nevertheless, there are relatively few studies on high-speed train crashes and the influencing factors on travelers’ injuries occurring in the crash phase. The aim of this study was to investigate the fatal and non-fatal injuries and the main interacting factors that contributed to the injury process in the crash phase of the 2013 high-velocity train crash that occurred at Angrois, outside Santiago de Compostela, Spain.

Hospital records (n=157) of all the injured who were admitted to the six hospitals in the region were reviewed and compiled by descriptive statistics. The instant fatalities (n=63) were collected on site. Influencing crash factors were observed on the crash site, by carriage inspections, and by reviewing official reports concerning the approximated train speed.

The main interacting factors that contributed in the injury process in the crash phase were, among other things, the train speed, the design of the concrete structure of the curve, the robustness of the carriage exterior, and the interior environment of the carriages. Of the 222 people on board (218 passengers and four crew), 99% (n=220) were fatally or non-fatally injured in the crash. Thirty-three percent (n=72) suffered fatal injuries, of which 88% (n=63) died at the crash site and 13% (n=9) at the hospital. Twenty-one percent (n=32) of those admitted to hospital suffered multi-trauma (ie, extensive, severe, and/or critical injuries). The head, face, and neck sustained 42% (n=123) of the injuries followed by the trunk (chest, abdomen, and pelvis; n=92; 32%). Fractures were the most frequent (n=200; 69%) injury.

A mass-casualty incident with an extensive amount of fatal, severe, and critical injuries is most probable with a high-velocity train; this presents prehospital challenges. This finding draws attention to the importance of more robust carriage exteriors and injury minimizing designs of both railway carriages and the surrounding environment to reduce injuries and fatalities in future high-speed crashes.

ForsbergR, VázquezJAI. A Case Study of the High-speed Train Crash Outside Santiago de Compostela, Galicia, Spain. Prehosp Disaster Med. 2016;31(2);163–168.

Using the Medical Priority Dispatch System (MPDS) – a systematic 911 triage process – to identify a large subset of low-acuity patients for secondary nurse triage in the 911 center is a largely unstudied practice in North America. This study examines the ALPHA-level subset of low-acuity patients in the MPDS to determine the suitability of these patients for secondary triage by evaluating vital signs and necessity of lights-and-siren transport, as determined by attending Emergency Medical Services (EMS) ambulance crews.

The primary objective of this study was to determine the clinical status of MPDS ALPHA-level (low-acuity) patients, as determined by on-scene EMS crews’ patient care records, in two US agencies. A secondary objective was to determine which ALPHA-level codes are suitable candidates for secondary triage by a trained Emergency Communication Nurse (ECN).

In this retrospective study, one full year (2013) of both dispatch data and EMS patient records data, associated with all calls coded at the ALPHA-level (low-acuity) in the dispatch protocol, were collected. The primary outcome measure was the number and percentage of ALPHA-level codes categorized as low-acuity, moderate-acuity, high-acuity, and critical using four common vital signs to assign these categories: systolic blood pressure (SBP), pulse rate (PR), oxygen saturation (SpO2), and Glasgow Coma Score (GCS). Vital sign data were obtained from ambulance crew electronic patient care records (ePCRs). The secondary endpoint was the number and percentage of ALPHA-level codes that received a “hot” (lights-and-siren) transport.

Out of 19,300 cases, 16,763 (86.9%) were included in the final analysis, after excluding cases from health care providers and those with missing data. Of those, 89% of all cases did not have even one vital sign indicator of unstable patient status (high or critical vital sign). Of all cases, only 1.1% were transported lights-and-siren.

With the exception of the low-acuity, ALPHA-level seizure cases, the ALPHA-level patients are suitable to transfer for secondary triage in a best-practices, accredited, emergency medical dispatch center that utilizes the MPDS at very high compliance rates. The secondary nurse triage process should identify the few at-risk patients that exist in the low-acuity calls.

ScottG, ClawsonJ, FivazMC, McQueenJ, GardettMI, SchultzB, YoungquistS, OlolaCHO. Using On-scene EMS Responders’ Assessment and Electronic Patient Care Records to Evaluate the Suitability of EMD-triaged, Low-acuity Calls for Secondary Nurse Triage in 911 Centers. Prehosp Disaster Med. 2016;31(1):46–57.

The preparedness level of Finnish Emergency Medical Services (EMS) for treating chemical emergencies is unknown. The aim of this study was to survey the preparedness level of EMS systems for managing and handling mass-casualty chemical incidents in the prehospital phase in Finland.

The study hypothesis was that university hospital districts would have better clinical capability to treat patients than would central hospital districts in terms of the number of patients treated in the field within one hour after dispatching as well as patients transported to hospital within one hour or two hours after dispatching.

This cross-sectional study was conducted as a Webropol (Wuppertal, Germany) survey. All hospital districts (n=20) in continental Finland were asked about their EMS preparedness level in terms of capability of treating and transporting chemically affected patients in the field. Their capability for decontamination of affected patients in the field was also inquired.

University hospital district-based EMS systems had at least 20% better absolute clinical capacity than central hospital-based EMS systems for treating chemically affected patients concerning all treatments inquired about, except the capacity for non-invasive ventilation (NIV)/continuous positive airway pressure (CPAP) treatment in the field. Overall, there was a good level of preparedness for treating chemical accident patients with supplemental oxygen, bronchodilators, and inhaled corticosteroids. Preparedness for providing antidote therapy in cases of cyanide gas exposure was, in general, low. The variation among the hospital districts was remarkable. Only nine of 15 central hospital district EMS had a mobile decontamination unit available, whereas four of five university hospital districts had one.

Emergency Medical Services capacity in Finland for treating chemically affected patients in the field needs to be improved, especially in terms of antidote therapy. Mobile decontamination units should be available in all hospital districts.

JamaTJ, KuismaMJ. Preparedness of Finnish Emergency Medical Services for Chemical Emergencies. Prehosp Disaster Med. 2016;31(4):392–396.

Physicians are key disaster responders in foreign medical teams (FMTs) that provide medical relief to affected people. However, few studies have examined the skills required for physicians in real, international, disaster-response situations.

The objectives of this study were to survey the primary skills required for physicians from a Japanese FMT and to examine whether there were differences in the frequencies of performed skills according to demographic characteristics, previous experience, and dispatch situations to guide future training and certification programs.

This cross-sectional survey used a self-administered questionnaire given to 64 physicians with international disaster-response site experience. The questionnaire assessed demographic characteristics (sex, age, years of experience as a physician, affiliation, and specialty), previous experience (domestic disaster-relief experience, international disaster-relief experience, or disaster medicine training experience), and dispatch situation (length of dispatch, post-disaster phase, disaster type, and place of dispatch). In addition, the frequencies of 42 performed skills were assessed via a five-point Likert scale. Descriptive statistics were used to assess the participants’ characteristics and total scores as the frequencies of performed skills. Mean scores for surgical skills, health care-related skills, public health skills, and management and coordination skills were compared according to the demographic characteristics, previous experience, and dispatch situations.

Fifty-two valid questionnaires (81.3% response rate) were collected. There was a trend toward higher skill scores among those who had more previous international disaster-relief experience (P=.03). The more disaster medicine training experience the participants had, the higher their skill score was (P<.001). Physicians reported involvement in 23 disaster-relief response skills, nine of which were performed frequently. There was a trend toward higher scores for surgical skills, health care-related skills, and management and coordination skills related to more disaster medicine training experience.

This study’s findings can be used as evidence to boost the frequency of physicians’ performed skills by promoting previous experience with international disaster relief and disaster medicine training. Additionally, these results may contribute to enhancing the quality of medical practice in the international disaster relief and disaster training curricula.

NoguchiN, InoueS, ShimanoeC, ShibayamaK, MatsunagaH, TanakaS, IshibashiA, ShinchiK. What Kinds of Skills Are Necessary for Physicians Involved in International Disaster Response?Prehosp Disaster Med. 2016;31(4):397–406.

In preparation for the London 2012 Olympic Games, existing syndromic surveillance systems operating in England were expanded to include daily general practitioner (GP) out-of-hours (OOH) contacts and emergency department (ED) attendances at sentinel sites (the GP OOH and ED syndromic surveillance systems: GPOOHS and EDSSS).

The further development of syndromic surveillance systems in time for the London 2012 Olympic Games provided a unique opportunity to investigate the impact of a large mass-gathering event on public health and health services as monitored in near real-time by syndromic surveillance of GP OOH contacts and ED attendances. This can, in turn, aid the planning of future events.

The EDSSS and GPOOHS data for London and England from July 13 to August 26, 2012, and a similar period in 2013, were divided into three distinct time periods: pre-Olympic period (July 13-26, 2012); Olympic period (July 27 to August 12); and post-Olympic period (August 13-26, 2012). Time series of selected syndromic indicators in 2012 and 2013 were plotted, compared, and risk assessed by members of the Real-time Syndromic Surveillance Team (ReSST) in Public Health England (PHE). Student’s t test was used to test any identified changes in pattern of attendance.

Very few differences were found between years or between the weeks which preceded and followed the Olympics. One significant exception was noted: a statistically significant increase (P value = .0003) in attendances for “chemicals, poisons, and overdoses, including alcohol” and “acute alcohol intoxication” were observed in London EDs coinciding with the timing of the Olympic opening ceremony (9:00 pm July 27, 2012 to 01:00 am July 28, 2012).

Syndromic surveillance was able to provide near to real-time monitoring and could identify hourly changes in patterns of presentation during the London 2012 Olympic Games. Reassurance can be provided to planners of future mass-gathering events that there was no discernible impact in overall attendances to sentinel EDs or GP OOH services in the host country. The increase in attendances for alcohol-related causes during the opening ceremony, however, may provide an opportunity for future public health interventions.

TodkillD, HughesHE, ElliotAJ, MorbeyRA, EdeghereO, HarcourtS, HughesT, EndericksT, McCloskeyB, CatchpoleM, IbbotsonS, SmithG. An Observational Study Using English Syndromic Surveillance Data Collected During the 2012 London Olympics – What did Syndromic Surveillance Show and What Can We Learn for Future Mass-gathering Events?Prehosp Disaster Med. 2016;31(6):628–634.

On-scene time (OST) previously has been shown to be a significant component of Emergency Medical Services’ (EMS’) operational delay in acute stroke. Since stroke patients are managed routinely by two-person ambulance crews, increasing the number of personnel available on the scene is a possible method to improve their performance.

Using fire engine crews to support ambulances on the scene in acute stroke is hypothesized to be associated with a shorter OST.

All patients transported to hospital as thrombolysis candidates during a one-year study period were registered by the ambulance crews using a case report form that included patient characteristics and operational EMS data.

Seventy-seven patients (41 [53%] male; mean age of 68.9 years [SD=15]; mean Glasgow Coma Score [GCS] of 15 points [IQR=14-15]) were eligible for the study. Forty-five cases were managed by ambulance and fire engine crews together and 32 by the ambulance crews alone. The median ambulance response time was seven minutes (IQR=5-10) and the fire engine response time was six minutes (IQR=5-8). The number of EMS personnel on the scene was six (IQR=5-7) and two (IQR=2-2), and the OST was 21 minutes (IQR=18-26) and 24 minutes (IQR=20-32; P =.073) for the groups, respectively. In a following regression analysis, using stroke as the dispatch code was the only variable associated with short (<22 minutes) OST with an odds ratio of 3.952 (95% CI, 1.279-12.207).

Dispatching fire engine crews to support ambulances in acute stroke care was not associated with a shorter on-scene stay when compared to standard management by two-person ambulance crews alone. Using stroke as the dispatch code was the only variable that was associated independently with a short OST.

PuolakkaT, VäyrynenT, ErkkiläE-P, KuismaM. Fire Engine Support and On-scene Time in Prehospital Stroke Care – A Prospective Observational Study. Prehosp Disaster Med. 2016;31(3):278–281.