Emergency physicians are using bolus-dose vasopressors to temporize hypotensive patients until more definitive blood pressure support can be established. Despite a paucity of clinical outcome data, emergency department applications are expanding into the prehospital setting. This series presents two cases of field expedient vasopressor use by emergency medicine providers for preflight stabilization during aeromedical evacuation to a hospital ship as part of the United States Navy disaster response in Puerto Rico. A critical approach and review of the literature are discussed.

Two critically ill patients were managed in an austere environment as a result of the devastation from Hurricane Maria (Yabucoa, Puerto Rico; 2017). They both exhibited signs of respiratory distress, hemodynamic instability, and distributive shock requiring definitive airway management and hemodynamic support prior to aeromedical evacuation.

The novel use of field expedient vasopressors prior to induction for rapid sequence intubation was successfully and safely employed in both cases. Both patients had multiple risk factors for peri-induction cardiac arrest given their presenting hemodynamics. Despite their illness severity, both patients were induced, transported, and ultimately admitted to the intensive care unit (ICU) in stable condition following administration of the field expedient vasopressors.

Field expedient vasopressors were safely and effectively employed in an austere field environment during a disaster response. This case series contributes to the growing body of literature of safe bolus-dose vasopressor use by emergency physicians to temporize hypotensive patients in resource-constrained situations.

HardwickJM, MurnanSD, Morrison-PonceDP, DevlinJJ. Field Expedient Vasopressors During Aeromedical Evacuation: A Case Series from the Puerto Rico Disaster Response. Prehosp Disaster Med. 2018;33(6):668–672.

Chemical, Biological, Radiological, and Nuclear (CBRN) emergencies need specific hospital preparedness and resource availability.

Preparing to evaluate and manage victims from CBRN exposure events in one aspect of hospital preparedness, is often underestimated. Specific skills and capabilities are required to manage these events. Emergency department (ED) and hospital staff need adequate training to provide safe and effective care.

The Hospital Complex of Valtellina and Alto Lario (with three hospitals), in consideration of the geographic location amid mountains, far from urban hospital centers, decided to develop an intensive training program for the hospital emergency staff. Firstly, it was based on an eight-hour initial training program, using a combined civilian military approach that included hazard recognition, substance identification, site safety, response roles, PPE use, and decontamination procedures. The CBRN Operational Unit (for prevention of chemical-biological-radiological-nuclear risks) of the 1st Territorial Unit of the Auxiliary Military Corps of the Order of Malta Italy led such training session showing that a military approach to CBRN threats can be used with civilian and military competencies and tools in managing specific hazardous events hospital first responders may face.

A drill exercise was performed on a radiological fall-out incident to test the hospital’s emergency response staff preparedness. Hospital management and decontamination procedures were analyzed to treat victims as well as first responders and to train hospital staff with few resources available.

Hospitals need a specific level of preparedness to enable an effective response to CBRN emergencies. Skills and competencies of military personnel can be a resource in these kinds of events to train civilian personnel who are not normally acquainted to or confident to manage this kind of CBRN events, and can represent a new model and challenge of interagency cooperation in the disaster management of complex emergencies involving hazardous materials.

Health care provision depends on reliable critical infrastructure (CI) to power equipment and to provide water for medication and sanitation. Attacks on CI limiting such functions can have a profound and prolonged influence on delivery of care.

A retrospective analysis of the Global Terrorism Database (GTD) was performed of all attacks occurring from 1970-2020. Data were filtered using the internal database search function for all events where the primary target was “Utilities,” “Food or Water Supply,” and “Telecommunications.” For the purposes of this study, the subtype “Food Supply” was excluded. Events were collated based on year, country, region, and numbers killed and wounded.

The GTD listed 7,813 attacks on CI, with 6,280 of those attacks targeting utilities, leading to 1,917 persons directly killed and 1,377 persons wounded. In total, there were 1,265 attacks targeting telecommunications causing 205 direct deaths and 510 wounded. Lastly, 268 attacks targeted the water supply with 318 directly killed and 261 wounded. Regionally, South America had the most attacks with 2,236, followed by Central America and the Caribbean with 1,390. Based on infrastructure type, the most attacks on utilities occurred in El Salvador (1,061), and the most attacks on telecommunications were in India (140). Peru (46) had the most attacks on its water supply.

The regions with the highest number of total attacks targeting CI have historically been in South America, with more attacks against power and utilities than other infrastructure. Although the numbers of persons directly killed and wounded in these attacks were lower than with other target types, the true impacts on lack of health care delivery are not accounted for in these numbers. By understanding the pattern and scope of these attacks, Counter-Terrorism Medicine (CTM) initiatives can be created to target-harden health care-related infrastructure.

This report tries to capture the impact of the Project for Strengthening the ASEAN Regional Capacity on Disaster Health Management (ARCH Project) in each ASEAN Member State (AMS) and Japan as a result of the ARCH Project implementation since July 2016.

Impact on AMS: The analysis of the impact on AMS was based on a comparison of the impact of the project on management and coordination of Emergency Medical Teams (EMTs), and application of the project outcome in actual emergency operations compared to the previous status in each AMS.

Impact on Japan: The history of the development of disaster medicine in Japan was reviewed, with an aim to analyze the impact of supporting AMS through the ARCH Project on Japan, and the possibility of bi-directional cooperation in the future.

Impact on AMS: Since the initiation of the ARCH Project, AMS has made significant progress in WHO EMT accreditation, strengthening EMTCC capacity for receiving international assistance, as well as the development of legislation or strategic plans related to DHM, and application of the Project products such as standard operating procedures or regional tools in actual disasters/emergencies.

Impact on Japan: Disaster medicine in Japan originated from the Cambodian refugees’ relief mission in 1979. Since then, the management system has been strengthened including the foundation of the Japan Disaster Relief (JDR) Team, a structure with a legal foundation. The experience gained through international operations has contributed to the development of Japan’s domestic disaster response system. Japan learned the operational effectiveness of the post-disaster health surveillance system through the disaster response operation in 2013 Typhoon Yolanda Disaster in Philippines and introduced a modified system in Japan for domestic disaster response, which was later refined and proposed for an international standard.

ARCH Project is highly appreciated by AMS as the opportunity to share knowledge and experience among countries and thereby contributing to achieving the “One ASEAN, One Response” concept, as well as the driving force for each AMS to develop its capacity in DHM. While the ARCH Project started to support AMS to strengthen its regional capacity in disaster health management, it is important to build a bi-directional relationship between ASEAN and Japan in terms of mutual learning and support to tackle future disasters.

Disasters have adversely affected human life since the beginning of our existence. In response, societies have attempted to improve disaster response & reduce the consequences of disasters by developing standardized organizational arrangements, often known as Incident Command Systems (ICS). These ICS response systems have a military heritage in hierarchical organizational command & control (C2) that is authoritative by nature and fits well with bureaucratic organization. While emergency service agencies have embraced ICS, other agencies often involved in community-level disaster response, such as public health, non-government organizations and community groups, have not. Although ICS have become the backbone of disaster management (DM) policy in Australia and overseas, worldwide debate over the effectiveness of ICS continues. Therefore, this study investigated ICS systems used worldwide to aid in the development of an improved conceptual framework for managing the response to modern-day disasters, for all agencies, at all levels and across all hazard types.

Phase one involved a review and critical analysis of the literature. Phase two used inductive research methods to gain a better understanding of the barriers & facilitators of ICS to the multi-agency disaster response. Two studies were conducted in this phase: Study one used semi-structured interviews with key informants involved in the 2018 Central Queensland Bushfire & 2019 North & Far North Queensland Monsoon Trough Flood & Study two participants from any disaster. Phase three undertook a policy analysis of recent disaster reviews and inquiries. This was triangulated with previous findings and presented to an expert panel by way of a 2-round modified Delphi.

The most significant outcome of this research was the improved understanding of the strengths and weaknesses of ICS within the context of multi-agency engagement in disaster management.

Development of conceptual framework based on modifications to the ICS principles and includes other phases of the DM continuum with psychological aspects taken into consideration.

Ambulance patients who are unable to be quickly transferred to an emergency department (ED) bed represent a key contributing factor to ambulance offload delay (AOD). Emergency department crowding and associated AOD are exacerbated by multiple factors, including infectious disease outbreaks such as the coronavirus disease 2019 (COVID-19) pandemic. Initiatives to address AOD present an opportunity to streamline ambulance offload procedures while improving patient outcomes.

The goal of this study was to evaluate the initial outcomes and impact of a novel Emergency Medical Service (EMS)-based Hospital Liaison Program (HLP) on ambulance offload times (AOTs).

Ambulance offload times associated with EMS patients transported to a community hospital six months before and after HLP implementation were retrospectively analyzed using proportional significance tests, t-tests, and multiple regression analysis.

A proportional increase in incidents in the zero to <30 minutes time category after program implementation (+2.96%; P <.01) and a commensurate decrease in the proportion of incidents in the 30 to <60 minutes category (−2.65%; P <.01) were seen. The fully adjusted regression model showed AOT was 16.31% lower (P <.001) after HLP program implementation, holding all other variables constant.

The HLP is an innovative initiative that constitutes a novel pathway for EMS and hospital systems to synergistically enhance ambulance offload procedures. The greatest effect was demonstrated in patients exhibiting potentially life-threatening symptoms, with a reduction of approximately three minutes. While small, this outcome was a statistically significant decrease from the pre-intervention period. Ultimately, the HLP represents an additional strategy to complement existing approaches to mitigate AOD.

Bicycles may be useful in the delivery of out-of-hospital emergency medical services. The use of bicycles in providing emergency medical services was investigated by surveying currently existing bicycle-medic systems.

Two questionnaires were developed to gain information on service areas, injuries, gear used, missions, and specific data from bicycle-medic response.

Of 210 surveys mailed to bicyclemedics, 21 (10%) were completed and returned by the pre-established deadline. Of 11 surveys mailed to bicycle-medic supervisors, four (36%) were returned. Preliminary results showed that 76% of respondents are career providers and the remainder serve as volunteers. Mean age for respondents was 33±7.4 years, with 96% being males. Most teams have been in existence for three to four years. Job satisfaction was greater when participating on the bicycle crews than when not performing on the bicycle crew, t = 4.15, p = 0.0002. The teams varied in size (6–100 persons) with a mean value of 31. On the average, team size represented 10% of total number of personnel for the respective organizations.

The majority of bicycle teams operate all year in all conditions. Most bicycle-medic teams were initiated for special events. Nineteen percent reported injuries while on duty or in training. Ninety percent of units that responded use existing agency protocols and have no special protocols related to the bicycle team. Eighty percent of the units are dispatched through the normal agency procedures. Eighty-five percent of respondents coordinate for transport units via dispatch. Reported response times were under two minutes for special event responses. These were within established agency response times. In approximately 25% of the responses, the patients refused transport, and another 65% of the responses were for relatively minor injuries or complaints that did not require transport to a hospital.

This survey begins to characterize the utilization of bicycles as a tool to gain patient access in specialized situations. The use of bicycle-medics may be cost-effective, may help to improve employee morale, and possibly reduce employee health-care costs. Further study is needed to determine the impact of bicycle-medics on patient outcomes and response times.