The goal of this study was to test the hypothesis that the prehospital time between injury and arrival at a trauma center for critically injured children is associated with patient injury severity and mode of transport.

Secondary analysis of prospectively collected data on children 0-17 years of age admitted with traumatic injuries to a designated Level I pediatric trauma center from January 1, 2006 through September 30, 2007 was conducted. Multivariate regression methods were used to assess for factors independently associated with prehospital time.

Of 1,175 admissions during the study period, only 355 (30%) had a prehospital time within 60 minutes of injury. Prehospital time within 60 minutes of injury was associated with higher frequency of coma, higher mean injury severity scores (ISS), and greater frequency of admission to the intensive care unit when compared with prehospital time beyond 60 minutes of injury. Children who arrived at the trauma center within 60 minutes versus beyond 60 minutes were 13-fold (odds ratio [OR]: 12.9; 95% Confidence Interval [CI], 7.6-22.0) more likely to be transported via air ambulance than a private vehicle, and had 4.8-fold greater odds (95% CI, 2.2-10.3) of transport via ground ambulance than private vehicle. For each kilometer of distance between the injury zip code and the trauma center, the odds of arrival within 60 minutes versus beyond 60 minutes decreased by 15% (OR: 0.85; 95% CI, 0.79-0.91).

Field triage and decision making appeared to correlate with severity of patient injury with expeditious transport of the most severely injured children to definitive trauma care. This finding serves as important groundwork that might enable further study into factors that influence triage and overall prehospital care for critically injured children.

OdetolaFO, MannNC, HansenKW, BrattonSL. Factors Associated with Time to Arrival at a Regional Pediatric Trauma Center. Prehosp Disaster Med. 2016;31(1):4–9.

This report explores nurses’ perspectives following the Canterbury (New Zealand) 2010-2011 earthquake sequence and the subsequent recovery process.

Little is known about the experiences of health care professionals during a disaster recovery process, and this research generates insights about the challenges faced.

Qualitative semi-structured interviews were undertaken with 11 nurses from the Christchurch (New Zealand) area to explore the challenges faced by the nurses during and following the earthquakes. The interviews took place three years after the start of the earthquake experience to enable exploration of longer term aspects of the recovery process. The interview transcripts were analyzed and coded using a grounded theory approach.

The data analysis identified that the nurses had faced a number of challenges and these were characterized as practical, emotional, and professional. While some of the challenges were short-lived in the aftermath of the earthquakes, some were long-lasting due to the extended nature of the recovery process. Dealing with house damage, insurance negotiations, and working in damaged environments had a negative impact on the nurses. The nurses experienced a range of emotions, both negative and positive, after the disaster, though many had needed time to elapse before feeling able to reflect on their experiences.

The findings suggest that secondary stressors have a negative impact on the psychosocial recovery process. The nurses recognized that they received support from others and were also required to focus on others. Keeping busy appeared to be the most common coping strategy. This lack of reflection on their experiences may have resulted in delayed emotional responses. Some of the nurses changed their work role, hours, and responsibilities suggesting that working in this environment was having a detrimental impact.

The research indicates the challenges faced by nurses in the initial impact of the earthquakes and during the longer term recovery process. There is a need to consider the psychosocial impact of working and living in a post-disaster context and to develop support packages to ensure the health and well-being of nurses in this environment.

JohalSS, MounseyZ, BrannellyP, JohnstonDM. Nurse Perspectives on the Practical, Emotional, and Professional Impacts of Living and Working in Post-earthquake Canterbury, New Zealand. Prehosp Disaster Med. 2016;31(1):10–16.

Many survivors of a major disaster die shortly after the event. Hypertension (HT) is one of the most important risk factors for these disaster-related diseases. An urgent need exists to establish methods to detect disaster survivors with HT and start medication immediately, as those with no injuries or symptoms may not be examined and medical teams cannot measure all survivors’ blood pressure (BP) because they often do not have sufficient time.

The goals of this report were: (1) to evaluate the importance of taking antihypertensive drugs continuously for patients with HT during the sub-acute phase after a major earthquake, when patients cannot attend a clinic because of destruction of the local infrastructure; and (2) to establish simple and reliable predictors to detect evacuees with HT, who require clinical examination and treatment at evacuation shelters or in their homes after a major earthquake.

Medical rounds were performed at evacuation shelters in Iwate Prefecture after the Great East Japan Earthquake. Forty evacuees were enrolled in a cross-sectional study. The effect of taking antihypertensive drugs continuously was evaluated and predictors of HT in evacuees were identified using multiple logistic regression analysis.

Twenty-eight evacuees were hypertensive (70%), nine of whom were asymptomatic (32%). Most evacuees who had discontinued antihypertensive medication (92%; 11/12) had very high BP, while those who had continued antihypertensive medication (80%; 8/10) were mildly hypertensive. The systolic BP of those who had discontinued antihypertensive drugs was significantly higher than that of those who had continued hypertensive drugs in the whole cohort (n=40), and also in evacuees diagnosed as having HT at evacuation shelters (n=28; P<.01 for both comparisons). A history of HT (adjusted odds ratio [aOR], 11.40; 95% confidence interval [CI], 1.03-126.08) or age >55 years (aOR, 1.10; 95% CI, 1.01-1.21) predicted HT with a sensitivity of 0.96 and specificity of 0.80.

The results of this study suggest that continuity of antihypertensive medication prevents serious HT at evacuation shelters in the first 10 days after a major earthquake. Onsite medical rounds focusing on simple predictors in an early stage after disasters may be an effective means of detecting and treating hypertensive disaster victims before they succumb to a fatal disease.

TanakaR, OkawaM, UjikeY. Predictors of Hypertension in Survivors of the Great East Japan Earthquake, 2011: A Cross-sectional Study. Prehosp Disaster Med. 2016;31(1):17–26.

Communicable disease management (CDM) is an important component of disaster public health response operations. However, there is a lack of any performance assessment (PA) framework and related indicators for the PA. This study aimed to develop a PA framework and indicators in CDM in disasters.

In this study, a series of methods were used. First, a systematic literature review (SLR) was performed in order to extract the existing PA frameworks and indicators. Then, using a qualitative approach, some interviews with purposively selected experts were conducted and used in developing the PA framework and indicators. Finally, the analytical hierarchy process (AHP) was used for weighting of the developed indicators.

The input, process, products, and outcomes (IPPO) framework was found to be an appropriate framework for CDM PA. Seven main functions were revealed to CDM during disasters. Forty PA indicators were developed for the four categories.

There is a lack of any existing PA framework in CDM in disasters. Thus, in this study, a PA framework (IPPO framework) was developed for the PA of CDM in disasters through a series of methods. It can be an appropriate framework and its indicators could measure the performance of CDM in disasters.

BabaieJ, ArdalanA, VatandoostH, GoyaMM, AkbarisariA. Developing a Performance Assessment Framework and Indicators for Communicable Disease Management in Natural Disasters. Prehosp Disaster Med. 2016;31(1):27–35.

Standards for immobilizing potentially spine-injured patients in the prehospital environment are evolving. Current guidelines call for more research into treatment practices. Available research into spinal immobilization (SI) reveals a number of limitations.

There are currently few techniques for measuring head and neck motion that address identified limitations and can be adapted to clinically relevant scenarios. This study investigates one possible method.

Study participants were fitted with miniaturized accelerometers to record head motion. Participants were exposed to three levels of restraint: none, cervical-collar only, and full immobilization. In each condition, participants were instructed to move in single planes, with multiple iterations at each of four levels of effort. Participants were also instructed to move continuously in multiple planes, with iterations at each of three levels of simulated patient movement. Peak and average displacement and acceleration were calculated for each immobilization condition and level of effort. Comparisons were made with video-based measurement. Participant characteristics also were tracked.

Acceleration and displacement of the head increased with effort and decreased with more restraint. In some conditions, participants generated measurable acceleration with minimal displacement. Continuous, multi-dimensional motions produced greater displacement and acceleration than single-plane motions under similar conditions.

Study results suggest a number of findings: acceleration complements displacement as a measure of motion in potentially spine-injured patients; participant effort has an effect on outcome measures; and continuous, multi-dimensional motion can produce results that differ from single-plane motions. Miniaturized accelerometers are a promising technology for future research to investigate these findings in realistic, clinically relevant scenarios.

PryceR, McDonaldN. Prehospital Spinal Immobilization: Effect of Effort on Kinematics of Voluntary Head-neck Motion Assessed using Accelerometry. Prehosp Disaster Med. 2016;31(1):36–42.

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.

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 introduction of advanced practitioner roles has challenged the traditional boundaries of health care. While studies have been undertaken to understand the role of physicians in respect of mass-gathering medicine, the role of advanced nurse practitioners (ANPs) has not been investigated.

Does the presence of an ANP reduce the referral rates of patients presenting for medical care at mass-gathering events to external health care resources?

A prospective observational study was undertaken to determine whether the presence of an ANP would reduce the patient referral rate to external health care services by first aiders and paramedics working within an event medical team. Patients identified as requiring referral were reviewed by an ANP as part of the on-site medical provision for four mass-gathering events in the south of England. Additionally, information was gathered identifying which patients would have been transported to hospital by ambulance compared to those actually transported following ANP review. Statistical analysis was undertaken for three key measures (referrals to all local health resources, referrals to hospital-based acute services, and transfers to hospital by ambulance).

A rounded total of 842,000 people attended four mass-gathering events held over 14 days. Of these, 652 presented for medical care, many self-referring.

Using a one-tailed Fisher’s Exact Test and Phi analysis, this study demonstrated statistically significant reductions in the overall referral of patients to all external health care resources (P<.001; φ=0.44), to the emergency department (ED; P<.001; φ=0.43), and a reduction in ambulance transport (P<.001; φ=0.42). Effect size analysis demonstrated a medium-sized effect evident for all of the above, which was also demonstrated in economic terms.

The event medical team would have referred 105 (16.3%) of the 652 patient presentations to external health care services; 47 (7.2%) would have been transported by ambulance. In comparison, the ANP referred 23 patients (3.5%) with 11 (1.7%) being transported by ambulance. It also was noted that the first aiders and paramedics could be more selective in their referral habits that were focused primarily on the ED.

Appropriately trained and experienced ANPs working within event medical teams have a positive impact on referral rates from mass-gathering events.

KempAE. Mass-gathering Events: The Role of Advanced Nurse Practitioners in Reducing Referrals to Local Health Care Agencies. Prehosp Disaster Med. 2016;31(1):58–63.

Paramedicine is experiencing significant growth in scope of practice, autonomy, and role in the health care system. Despite clinical governance models, the degree to which paramedicine ultimately can be safe and effective will be dependent on the individuals the profession deems suited to practice. This creates an imperative for those responsible for these decisions to ensure that assessments of paramedic competence are indeed accurate, trustworthy, and defensible.

The purpose of this study was to explore and synthesize relevant theoretical foundations and literature informing best practices in performance-based assessment (PBA) of competence, as it might be applied to paramedicine, for design or evaluation of assessment programs.

A narrative review methodology was applied to focus intentionally, but broadly, on purpose relevant, theoretically derived research that could inform assessment protocols in paramedicine. Primary and secondary studies from a number of health professions that contributed to and informed best practices related to the assessment of paramedic clinical competence were included and synthesized.

Multiple conceptual frameworks, psychometric requirements, and emerging lines of research are forwarded. Seventeen practice implications are derived to promote understanding as well as best practices and evaluation criteria for educators, employers, and/or licensing/certifying bodies when considering the assessment of paramedic competence.

The assessment of paramedic competence is a complex process requiring an understanding, appreciation for, and integration of conceptual and psychometric principles. The field of PBA is advancing rapidly with numerous opportunities for research.

TavaresW, BoetS. On the Assessment of Paramedic Competence: A Narrative Review with Practice Implications. Prehosp Disaster Med. 2016;31(1):64–73.

When disaster strikes, the number of patients requiring treatment can be overwhelming. In low-income countries, resources to assist the injured in a timely fashion may be limited. As a consequence, necrosis and wound infection in disaster patients is common and frequently leads to adverse health outcomes such as amputations, chronic wounds, and loss of life. In such compromised health care environments, low-tech and cheap wound care options are required that are in ready supply, easy to use, and have multiple therapeutic benefits. Maggot debridement therapy (MDT) is one such wound care option and may prove to be an invaluable tool in the treatment of wounds post-disaster.

This report provides an overview of the wound burden experienced in various types of disaster, followed by a discussion of current treatment approaches, and the role MDT may play in the treatment of complex wounds in challenging health care conditions. Maggot debridement therapy removes necrotic and devitalized tissue, controls wound infection, and stimulates wound healing. These properties suggest that medicinal maggots could assist health care professionals in the debridement of disaster wounds, to control or prevent infection, and to prepare the wound bed for reconstructive surgery. Maggot debridement therapy-assisted wound care would be led by health care workers rather than physicians, which would allow the latter to focus on reconstructive and other surgical interventions. Moreover, MDT could provide a larger window for time-critical interventions, such as fasciotomies to treat compartment syndrome and amputations in case of life-threatening wound infection.

There are social, medical, and logistic hurdles to overcome before MDT can become widely available in disaster medical aid. Thus, research is needed to further demonstrate the utility of MDT in Disaster Medicine. There is also a need for reliable MDT logistics and supply chain networks. Integration with other disaster management activities will also be essential.

In the aftermath of disasters, MDT could play an important role facilitating timely and efficient medical treatment and improving patient outcomes. Existing social, medical, and logistic barriers will need to be overcome for MDT to be mainstreamed in Disaster Medicine.

StadlerF, ShabanRZ, TathamP. Maggot Debridement Therapy in Disaster Medicine. Prehosp Disaster Med. 2016;31(1):79–84.

Minimal preparation time is a feature of responding to sudden onset disasters. While equipment and supplies are prepared for deployment at short notice, less is known of the physical preparation of medical responders. With many disaster-prone areas classified as tropical regions, there is potential for responders to endure a combination of high ambient temperatures and relative humidity during deployment. Heat acclimatization, defined as the physiological and perceptual adaptations to frequent elevations of core body temperature (Tc), is a key strategy to improve tolerance of hot conditions by medical responders.

Pre-deployment heat acclimatization guidelines were developed based upon the duration of physical training and the subjective rate of perceived exertion (session RPE). An objective of individual training sessions was the perception of body temperature as warm to hot. The guidelines were implemented for Team Bravo (2nd rotation) of the Australian Medical Assistance Team (AusMAT) deployed to Tacloban, Philippines following Typhoon Haiyan in November 2013. The guidelines were distributed electronically five to seven days prior to deployment and were followed by a consultation. A group training session in hot conditions was undertaken prior to departure.

The AusMAT responders to utilize the guidelines were based in cool or temperate climates that required extra layers of clothing, training during warmer parts of the days, or warm indoor conditions to achieve session objectives. Responders reported the guidelines were simple to use, applicable to their varied training regimens, and had improved their confidence to work in the heat despite not completing the entire 14 day period.

The pre-deployment heat acclimatization guidelines provided AusMAT responders the ability to quantify their physical training and promoted physiological adaptations to maximize health, safety, and performance during deployment. While maintaining year-round heat acclimatization is considered essential for medical responders, these guidelines may facilitate beneficial adaptations once notified of deployment.

BrearleyMB. Pre-deployment Heat Acclimatization Guidelines for Disaster Responders. Prehosp Disaster Med. 2016;31(1):85–89.

The Emergency Medical Services (EMS) approach to emergency prehospital care in the United States (US) has global influence. As the 50-year anniversary of modern US EMS approaches, there is value in examining US EMS education development over this period. This report describes US EMS education milestones and identifies themes that provide context to readers outside the US.

As US EMS education is described mainly in publications of federal US EMS agencies and associations, a Google search and hand searching of documents identified publications in the public domain. MEDLINE and CINAHL Plus were searched for peer reviewed publications. Documents were reviewed using both a chronological and thematic approach.

Seventy-eight documents and 685 articles were screened, the full texts of 175 were reviewed, and 41 were selected for full review. Four historical periods in US EMS education became apparent: EMS education development (1966-1980); EMS education consolidation and review (1981-1989); EMS education reflection and change (1990-1999); and EMS education for the future (2000-2014). Four major themes emerged: legislative authority, physician direction, quality, and development of the profession.

Documents produced through broad interprofessional consultations, with support from federal and US EMS authorities, reflect the catalysts for US EMS education development. The current model of US EMS education provides a structure to enhance educational quality into the future. Implementation evaluation of this model would be a valuable addition to the US EMS literature. The themes emerging from this review assist the understanding of the characteristics of US EMS education.

BrooksIA, SayreMR, SpencerC, ArcherFL. An Historical Examination of the Development of Emergency Medical Services Education in the US through Key Reports (1966-2014). Prehosp Disaster Med. 2016;31(1):90–97.

The development of medical school courses on medical responses for disaster victims has been deemed largely inadequate. To address this gap, a 2-week elective course on Terror Medicine (a field related to Disaster and Emergency Medicine) has been designed for fourth year students at Rutgers New Jersey Medical School in Newark, New Jersey (USA). This elective is part of an overall curricular plan to broaden exposure to topics related to Terror Medicine throughout the undergraduate medical education.

A course on Terror Medicine necessarily includes key aspects of Disaster and Emergency Medicine, though the converse is not the case. Courses on Disaster Medicine may not address features distinctively associated with a terror attack. Thus, a terror-related focus not only assures attention to this important subject but to accidental or naturally occurring incidents as well.

The course, implemented in 2014, uses a variety of teaching modalities including lectures, videos, and tabletop and hands-on simulation exercises. The subject matter includes biological and chemical terrorism, disaster management, mechanisms of injury, and psychiatry. This report outlines the elective’s goals and objectives, describes the course syllabus, and presents outcomes based on student evaluations of the initial iterations of the elective offering.

All students rated the course as “excellent” or “very good.” Evaluations included enthusiastic comments about the content, methods of instruction, and especially the value of the simulation exercises. Students also reported finding the course novel and engaging.

An elective course on Terror Medicine, as described, is shown to be feasible and successful. The student participants found the content relevant to their education and the manner of instruction effective. This course may serve as a model for other medical schools contemplating the expansion or inclusion of Terror Medicine-related topics in their curriculum.

ColeLA, NatalB, FoxA, CooperA, KennedyCA, ConnellND, SugalskiG, KulkarniM, FeravoloM, LambaS. A Course on Terror Medicine: Content and Evaluations. Prehosp Disaster Med. 2016;31(1):98–101.

Firefighting is a physically demanding profession. Heart disease remains the number one killer of firefighters. Many firefighters have multiple risk factors, putting them at risk for sudden cardiac events. The purpose of this study was to describe the prevalence of risk factors for heart disease in a convenience sample of Pennsylvania (USA) firefighters.

A convenience sample of 160 firefighters in western Pennsylvania had height, weight, waist circumference, blood pressure, and body mass index (BMI) assessed, and then were surveyed to measure their knowledge of cardiovascular risk factors. Data analysis included subgroup comparisons of age, BMI, waist circumference, and exercise for their impact on health risks in the study cohort. In particular, the researchers were interested in understanding whether the knowledge of risk was associated with lower measures of risk.

Eighteen firefighters (4%) reported a history of coronary artery disease (including stents/interventions). In this group, 69% to 82% correctly identified age, hypertension (HTN), high cholesterol, smoking, obesity, sedentary lifestyle, and family history as risk factors for coronary artery disease. Fourteen percent were smokers, 41% had HTN, 38% had pre-HTN with only 12% receiving treatment, and 13.5% were treated for high cholesterol. Fifty-eight percent exercised regularly.

While a majority of firefighters were able to identify risk factors for coronary artery disease, many could not. Eighteen (4%) had a history of coronary artery disease, including interventions. Many had several of the risk factors indicated, which highlights the need for an organized national approach to address the medical screening/evaluation, nutrition, and exercise components of firefighter fitness.

RisaviBL, StaszkoJ. Prevalence of Risk Factors for Coronary Artery Disease in Pennsylvania (USA) Firefighters. Prehosp Disaster Med. 2016;31(1):102–107.