The increase in natural and man-made disasters occurring worldwide places Emergency Medicine (EM) physicians at the forefront of responding to these crises. Despite the growing interest in Disaster Medicine, it is unclear if resident training has been able to include these educational goals.

This study surveys EM residencies in the United States to assess the level of education in Disaster Medicine, to identify competencies least and most addressed, and to highlight effective educational models already in place.

The authors distributed an online survey of multiple-choice and free-response questions to EM residency Program Directors in the United States between February 7 and September 24, 2014. Questions assessed residency background and details on specific Disaster Medicine competencies addressed during training.

Out of 183 programs, 75 (41%) responded to the survey and completed all required questions. Almost all programs reported having some level of Disaster Medicine training in their residency. The most common Disaster Medicine educational competencies taught were patient triage and decontamination. The least commonly taught competencies were volunteer management, working with response teams, and special needs populations. The most commonly identified methods to teach Disaster Medicine were drills and lectures/seminars.

There are a variety of educational tools used to teach Disaster Medicine in EM residencies today, with a larger focus on the use of lectures and hospital drills. There is no indication of a uniform educational approach across all residencies. The results of this survey demonstrate an opportunity for the creation of a standardized model for resident education in Disaster Medicine.

Sarin RR , Cattamanchi S , Alqahtani A , Aljohani M , Keim M , Ciottone GR . Disaster Education: A Survey Study to Analyze Disaster Medicine Training in Emergency Medicine Residency Programs in the United States. Prehosp Disaster Med. 2017;32(4):368–373.

Social networks play an important role in disaster situations as they have become a new form of social convergence that provides collective information. The effect of social media on people who experienced disaster should be assessed.

In this study, Twitter communication during the Great East Japan Earthquake of March 11, 2011 was assessed. The hypothesis of this study was that usage of Twitter had psychological effects on victims of the disaster.

A cross-sectional questionnaire survey was carried out in cooperation with a major Japanese newspaper three months after the disaster, and 1,144 volunteer participants responded. They were asked about their health, area of residence, property damage they had experienced, information sources they used at the time of the disaster, and their usage of Twitter. Further, the Twitter users were divided into two groups—with and without disaster experience. Their psychological effects relating to feelings of relief, stress or anxiety that they experienced in using Twitter were compared between two groups, and Twitter's psychological risk of disaster experience was estimated as an odds ratio.

Twitter users in this study tended to reside in disaster-affected areas and thought Twitter was a credible information source during the time of the disaster. The psychological effect of Twitter differed based on participants’ disaster experience and gender. Females with disaster experience reported more feelings of relief and stress as a result of using Twitter compared to females who did not experience the disaster. On the other hand, males with disaster experience only reported more stress experiences as a result of using Twitter compared to those without disaster experience.

Twitter users with disaster experience had a higher usage of Twitter than those without disaster experience. Social media might have had a material psychological influence on people who experienced disaster, and the effect differed by gender. Regardless of gender, negative feelings were transmitted easily among people who experienced the disaster. It was anticipated that the application of Twitter in a disaster situation will be expanded further by taking these findings into consideration.

UmiharaJ, NishikitaniM. Emergent Use of Twitter in the 2011 Tohoku Earthquake. Prehosp Disaster Med.2013;28(5):1-7.

Knowledge of injuries of earthquake victims is important to plan relief efforts. This cross-sectional study was conducted following the 08 October 2005 earthquake in Northern Pakistan to determine the pattern of injuries sustained and their relationship with age and gender in order to identify the medical needs in an earthquake-affected zone.

The study was conducted between 13 October and 23 October 2005 at the Emergency Relief Hospital, Doraha, Mansehra. From the 1,700 patients registered in the hospital, 310 were sampled randomly for the study. Demography and details of the patients' injuries were noted by history and physical examination. Twelve cases were omitted due to incomplete data.

Of the cases, 54% were female. Children ≤10 years old formed the largest age group. Isolated bone injuries were present in 41%, soft tissue injuries in 36%, and mixed injuries in 23% of the patients.The most common bone injury was lower limb fracture (52%), while the most common non-bone injury was non-infected, soft tissue wounds on the limbs (33%). Among patients with soft tissue injuries, gangrenous wounds were present in 9%, and grossly infected wounds in 30% (20% on limbs and 10% on rest of the body).

The population injured during the earthquake showed a higher proportion of females and children ≤10 years old, and lower limb bone injuries. The data highlight the need to address orthopedic, pediatric, and women's health issues, and for logistic arrangement of relevant diagnostic and therapeutic facilities at the initial stages of relief activities after earthquakes.

The undertreatment of pediatric pain is a significant concern among families, clinicians, and researchers. Although some have examined prehospital pain management, the deterrents to pediatric analgesia administration by Emergency Medical Services (EMS) have not yet been examined in Canada.

This study describes EMS pain-management practices and prehospital provider comfort treating pediatric pain. It highlights differences in pain management between adults and children and assesses the potential barriers, misconceptions, difficulties, and needs related to provision of pediatric analgesia.

A study-specific survey tool was created and distributed to all Primary Care Paramedics (PCPs) and Advanced Care Paramedics (ACPs) over four mandatory educational seminars in the city of Edmonton (Alberta, Canada) from September through December 2008.

Ninety-four percent (191/202) of EMS personnel for the city of Edmonton completed the survey. The majority of respondents were male (73%, 139/191), aged 26-35 (42%, 80/191), and had been in practice less than 10 years (53%, 101/191). Seventy-four percent (141/191) of those surveyed were ACPs, while 26% (50/191) were PCPs. Although the majority of respondents reported using both pain scales and clinical judgement to assess pain for adults (85%, 162/191) and adolescents (86%, 165/191), children were six times more likely than adults (31%, 59/191 vs 5%, 10/191) to be assessed by clinical judgement alone. Emergency Medical Services personnel felt more comfortable treating adults than children (P < .001), and they were less likely to treat children even if they were experiencing identical types and intensities of pain as adults (all P values <.05) and adolescents (all P values < .05). Twenty-five percent of providers (37/147) assumed pediatric patients required less analgesia due to immature nervous systems. Three major barriers to treating children's pain included limited clinical experience (34%, 37/110), difficulty in communication (24%, 26/110) and inability to assess children's pain accurately (21%, 23/110).

Emergency Medical Services personnel self-report that children's pain is less rigorously measured and treated than adults’ pain. Educational initiatives aimed at increasing clinical exposure to children, as well as further education regarding simple pain measurement tools for use in the field, may help to address identified barriers and discomfort with assessing and treating children.

RahmanA, CurtisS, DeBruyneB, SookramS, ThomsonD, LutzS, AliS. Emergency Medical Services Provider Comfort with Prehospital Analgesia Administration to Children. Prehosp Disaster Med. 2015;30(1):1-6.

Immediate resuscitation is necessary in order to achieve conscious survival for persons who have lost airways or pulses. However, current literature suggests that even in medically-trained personnel, CPR skills are forgotten shortly after certification.

The purpose of this study was to determine the CPR skill and knowledge decay in those who are paid to respond to emergency situations within the workplace.

Using an unconscious victim scenario, the sequence and accuracy of CPR events were observed and recorded in 244 participants paid to act as first responders in large industrial or service industry settings.

A significant negative correlation was observed between days since training and a pre-CPR safety check variable, periodic checks for breathing and positioning. Many of the knowledge-related assessment skills (e.g., scene safety, emergency medical system (EMS) activation) appeared to deteriorate with time, although they could be contaminated by the repetition of training in those who had recertified one or more times. Skill-based components such as landmarking for chest compressions and controlling the airway declined in a more predictable fashion.

The results of this study suggest that repetition may be more important than days since last trained for skill and knowledge retention, and methods of “refreshing” skills should be examined. While skills deteriorate rapidly, changing frequency of certification is not necessarily the best way to increase retention of skill and knowledge.

Anderson GS, Gaetz M, Statz C. CPR skill retention of first aid attendants within the workplace. Prehosp Disaster Med. 2012;27(4):1-7.

The purpose of this study was to examine how agencies in South Carolina that provide in-home health care and personal care services help older and/or disabled clients to prepare for disasters.The study also examines how agencies safeguard clients' records, train staff, and how they could improve their preparedness.

The relevant research and practice literature was reviewed. Nine public officials responsible for preparedness for in-home health care and personal care services in South Carolina were interviewed. A telephone survey instrument was developed that was based on these interviews and the literature review. Administrators from 16 agencies that provide in-home personal care to 2,147 clients, and five agencies that provide in-home health care to 2,180 clients, were interviewed. Grounded theory analysis identified major themes in the resulting qualitative data; thematic analysis organized the content.

Federal regulations require preparedness for agencies providing inhome health care (“home health”). No analogous regulations were found for in-home personal care. The degree of preparedness varied substantially among personal care agencies. Most personal care agencies were categorized as “less” prepared or “moderately” prepared. The findings for agencies in both categories generally suggest lack of preparedness in: (1) identifying clients at high risk and assisting them in planning; (2) providing written materials and/or recommendations; (3) protecting records; (4) educating staff and clients; and (5) coordinating disaster planning and response across agencies. Home health agencies were better prepared than were personal care agencies.

However, some home health administrators commented that they were unsure how well their plans would work during a disaster, given a lack of training. The majority of home health agency administrators spoke of a need for better coordination and/or more preparedness training.

Agencies providing personal care and home health services would benefit from developing stronger linkages with their local preparedness systems. The findings support incorporating disaster planning in the certification requirements for home health agencies, and developing additional educational resources for administrators and staff of personal care agencies and their clients.

Road traffic injuries (RTIs) and attendant fatalities on Nigerian roads have been on an increasing trend over the past three decades. Mortality from RTIs in Nigeria is estimated to be 162 deaths/100,000 population. This study aims to compare and identify best prehospital trauma care practices in Nigeria and some other African countries where prehospital services operate.

A review of secondary data, grey literature, and pertinent published articles using a conceptual framework to assess: (1) policies; (2) structures; (3) first responders; (4) communication facilities; (5) transport and ambulance facilities, and (6) roadside emergency trauma units.

There is no national prehospital trauma care system (PTCS) in Nigeria. The lack of a national emergency health policy is a factor in this absence. The Nigerian Federal Road Safety Corps (FRSC) mainly has been responsible for prehospital services. South Africa, Zambia, Kenya, and Ghana have improved prehospital services in Africa.

Commercial drivers, laypersons, military, police, a centrally controlled communication network, and government ambulance services are feasible delivery models that can be incorporated into the Nigerian prehospital system. Prehospital trauma services have been useful in reducing morbidities and mortalities from traffic injuries, and appropriate implementation of this study's recommendations may reduce this burden in Nigeria.

AdeloyeD. Prehospital Trauma Care Systems: Potential Role Toward Reducing Morbidities and Mortalities from Road Traffic Injuries in Nigeria. Prehosp Disaster Med. 2012;27(6):1-7.

Determining the predictors of demand for emergency prehospital care can assist ambulance services in undertaking policy and planning activities.

Demand for prehospital care can be explained by demographic, health status, and economic determinants.

The study used a cross-sectional design to investigate the association of demographic, health status, and insurance factors with the use of prehospital, ambulance care. Core data items including age, gender, marital status, country of origin, triage score, diagnosis, time of presentation, method of arrival, and patient disposition were collected for every patient who pre-sented at the Emergency Department of the study hospital over a four-month period. Ambulance usage was analysed using Poisson regression.

For the 10,229 patients surveyed, only a small number were triaged as having the highest level of urgent medical need (0.8%), but the majority of these used prehospital emergency medical care (90.2%). Predictors of ambulance use included age >65years (Prevalence Ratio [Prevalence Ratio] = 2.92; 95% confidence interval [ Confidence Interval]: 2.35–3.63), being married or in a defacto relationship (Prevalence Ratio = 0.69; 95% Confidence Interval: 0.60–0.79) or divorced, separated, or widowed (Prevalence Ratio = 0.83; 95% Confidence Interval: 0.70–0.98), triage score level 1 or 2 (Prevalence Ratio = 1.95; 95% Confidence Interval: 1.68–2.28), or triage score level 3 (Prevalence Ratio = 1.54; 95% Confidence Interval: 1.38–1.72), diagnosis involving either mental (Prevalence Ratio = 4.29; 95% Confidence Interval: 1.84–10.01), nervous (Prevalence Ratio = 2.74; 95% Confidence Interval: 1.19–6.31) or trauma (Prevalence Ratio = 2.33; 95% Confidence Interval: 1.03–5.27) conditions, and insurance status (Prevalence Ratio =1.54; 95% Confidence Interval: 1.40–1.71). Ethnicity, gender, and time of day were not associated with usage.

Demand for ambulance services can be predicted by a number of demographic, medical status, and insurance variables. Age and triage levels are key influences on demand for ambulance services. Ambulance insurance status provides an economic incentive to use ambulance services regardless of the urgency of the medical condition.

Recently, there has been speculation that suicide rates increase after a disaster. Yet, in spite of anecdotal reports, it is difficult to demonstrate a systematic relationship between suicide and disaster. Suicides are fairly rare events, and single disasters rarely have covered geographic areas with large enough populations to be able to find statistically significant differences in such relatively rare events (annual suicide rates in the United States average 12/100,000 population).

Suicide rates increased in the three calendar years (1994–1996) following the Northridge earthquake as compared to the three calendar years (1991–1993) prior to the earthquake. Likewise the suicide rates for 1993 are compared with the rates in 1994. By looking at the suicide rates in a three-year period after the earthquake, the additional disasters that befell Southern California in 1995 and 1996 may have had an additive effect on psychological disorders and suicide rates that can be measured.

Data on suicide mortality were compiled for the years from 1989 through 1996. Differences in rates for 1993 compared with 1994 and for three-year periods before and after the earthquake (1991–1993 vs. 1994 –1996) were analyzed using a z-statistic.

There is a statistically significant difference in the rates for the years prior to the earthquake (1991–1993) when pooled and compared to the suicide rates for the years after the earthquake (1994–1996). The rates of suicide are lower in the three years following the earthquake (11.85 vs. 13.12/100,000 population) than they are in the three years prior to the earthquake (z = -3.85, p <0.05). Likewise, there is a similar difference when comparing 1993 to 1994 (11.77 vs. 13.84, z = -3.57, p <0.05). The patterns of suicide remain similar over time, with males and non-Hispanic Whites having the highest rates of suicide.

It does not appear that suicide rates increase as a result of earthquakes in this setting. This study demonstrates that the psychological impacts of the Northridge earthquake did not culminate in an increase in the rates of suicide.

On June 29, 2012, mid-Atlantic storms resulted in a large-scale power outage affecting up to three million people across multiple (US) states. Hemodialysis centers are dependent on electricity to provide dialysis care to end-stage renal disease patients. The objective of this study was to determine how the power outage impacted operations in a sample of hemodialysis centers in the impacted regions.

The sample consisted of all hemodialysis centers located in the District of Columbia and a total of five counties with the largest power losses in West Virginia, Virginia, and Maryland. A semi-structured interview guide was developed, and the charge nurse or supervisor in each facility was interviewed. The survey questions addressed whether their centers lost power, if so, for how long, where their patients received dialysis, whether their centers had backup generators, and if so, whether they had any problems operating them, and whether their center received patients from other centers if they had power.

Calls were placed to 90 dialysis centers in the sampled areas and a 90% response rate was achieved. Overall, hemodialysis operations at approximately 30% (n = 24) of the centers queried were impacted by the power outage. Of the 36 centers that lost power, 31% (n = 11) referred their patients to other dialysis centers, 22% (n = 8) accommodated their patients during a later shift or on a different day; the rest of the centers either experienced brief power outages that did not affect operations or experienced a power outage on days that the center is usually closed. Some centers in the study cohort reported receiving patients from other centers for dialysis 33% (n = 27). Thirty-two percent (n = 26) of the centers queried had backup generators on site. Eleven percent (n = 4) of the centers experiencing power outages reported that backup generators were brought in by their parent companies.

Comprehensive emergency planning for dialysis centers should include provisions for having backup generators on site, having plans in place for the timely delivery of a generator during a power outage, or having predesignated backup dialysis centers for patients to receive dialysis during emergencies. Most dialysis centers surveyed in this study were able to sustain continuity of care by implementing such pre-existing emergency plans.

AbirM, JanS, JubeltL, MerchantR, LurieN. The Impact of a Large-Scale Power Outage on Hemodialysis Center Operations. Prehosp Disaster Med. 2013;28(6):1-4.

This study is an evaluation of the ability of medically trained and controlled emergency medical dispatchers to use telephone triage techniques to direct the appropriate prehospital unit to an emergency scene.

Emergency dispatchers, educated in a formal emergency medical dispatch program, were assigned one of four triage priorities to incoming 9-1-1 calls. The actual field management delivered for each patient was compared with the dispatcher's triage to determine the appropriateness of triage.

A total of 1,045 consecutive calls were reviewed with 74.4% sorted as needing advanced life support (ALS) units on scene; 65.3% (95% CI, 61.9 to 68.6%) of these calls required ALS intervention. A total of 3.4% of the runs sorted to the non-ALS response groups were identified to have required ALS intervention. Comparing the need for ALS intervention, a significant difference was found between the triage groups.

Emergency medical dispatchers, using a formal system for telephone triage, are able to direct appropriate prehospital resources to the emergency scene.

To determine the ability of emergency medical services (EMS) providers to subjectively triage patients with respect to hospital admission and to determine patient characteristics associated with increased likelihood of admission.

A prospective, cross-sectional study of a consecutive sample of patients arriving by ambulance during the month of February 1997 at an urban, university hospital, Emergency Department. Emergency medical services providers completed a questionnaire asking them to predict admission to the hospital and requested patient demographic information. Predictions were compared to actual patient disposition.

A total of 887 patients were included in the study, and 315 were admitted to the hospital (36%). With respect to admission, emergency medical services providers had an accuracy rate of 79%, with a sensitivity of 72% and specificity of 83% (kappa = 0.56). Blunt traumatic injury and altered mental status were the most common medical reasons for admission. Variables significantly associated with high admission rates were patients with age > 50 years, chest pain or cardiac complaints, shortness of breath or respiratory complaints, Medicare insurance, and Hispanic ethnicity. The emergency medical services providers most accurately predicted admission for patients presenting with labor (kappa = 1.0), shortness of breath / respiratory complaints (kappa = 0.84), and chest pain (kappa = 0.77).

Emergency medical services providers can predict final patient disposition with reasonable accuracy, especially for patients presenting with labor, shortness of breath, or chest pain. Certain patient characteristics are associated with a higher rate of actual admission.

Great demands have been placed on disaster medicine educators. There is a need to develop innovative methods to educate Emergency Physicians in the ever-expanding body of disaster medicine knowledge. The authors sought to demonstrate that video-based learning (VBL) could be a promising alternative to traditional learning methods for teaching disaster medicine core competencies.

The objective was to compare VBL to traditional lecture (TL) for instructing Emergency Medicine residents in the American College of Emergency Physicians (ACEP; Irving, Texas USA) disaster medicine core competencies of patient triage and decontamination.

A randomized, controlled pilot study compared two methods of instruction for mass triage, decontamination, and personal protective equipment (PPE). Emergency Medicine resident learning was measured with a knowledge quiz, a Likert scale measuring comfort, and a practical exercise. An independent samples t-test compared the scoring of the VBL with the TL group.

Twenty-six residents were randomized to VBL (n=13) or TL (n=13). Knowledge score improvement following video (14.9%) versus lecture (14.1%) did not differ significantly between the groups (P=.74). Comfort score improvement also did not differ (P=.64) between video (18.3%) and lecture groups (15.8%). In the practical skills assessment, the VBL group outperformed the TL group overall (70.4% vs 55.5%; P<.0001), with significantly better performance in donning PPE and decontamination. Although not part of the original study design, a three-month post-hoc analysis was performed. When comparing the pre-intervention and three-month post-hoc performances, there were no significant differences in knowledge increases between VBL versus TL (P=.41) or in comfort (P=.39).

Video modules can be as effective as TL when utilized to train Emergency Medicine residents in the ACEP disaster medicine core competencies of patient triage and decontamination.

Curtis HA , Trang K , Chason KW , Biddinger PD . Video-Based Learning vs Traditional Lecture for Instructing Emergency Medicine Residents in Disaster Medicine Principles of Mass Triage, Decontamination, and Personal Protective Equipment. Prehosp Disaster Med. 2018;33(1):7–12.

Injury patterns are closely related to changes in behavior. Pandemics and measures undertaken against them may cause changes in behavior; therefore, changes in injury patterns during the coronavirus disease 2019 (COVID-19) outbreak can be expected when compared to the parallel period in previous years.

The aim of this study was to compare injury-related hospitalization patterns during the overall national lockdown period with parallel periods of previous years.

A retrospective study was completed of all patients hospitalized from March 15 through April 30, for years 2016-2020. Data were obtained from 21 hospitals included in the national trauma registry during the study years. Clinical, demographic, and circumstantial parameters were compared amongst the years of the study.

The overall volume of injured patients significantly decreased during the lockdown period of the COVID-19 outbreak, with the greatest decrease registered for road traffic collisions (RTCs). Patients’ sex and ethnic compositions did not change, but a smaller proportion of children were hospitalized during the outbreak. Many more injuries were sustained at home during the outbreak, with proportions of injuries in all other localities significantly decreased. Injuries sustained during the COVID-19 outbreak were more severe, specifically due to an increase in severe injuries in RTCs and falls. The proportion of intensive care unit (ICU) hospitalizations did not change, however more surgeries were performed; patients stayed less days in hospital.

The lockdown period of the COVID-19 outbreak led to a significant decrease in number of patients hospitalized due to trauma as compared to parallel periods of previous years. Nevertheless, trauma remains a major health care concern even during periods of high-impact disease outbreaks, in particular due to increased proportion of severe injuries and surgeries.

Previous studies have proven the success of the EsophagealTracheal Combitube (ETC) as a primary airway, but not as a rescue airway.

The object of this study was to observe success and complication rates of paramedic placement of an ETC as a rescue airway, and to compare success rates with endotracheal tube (ETT) intubation. The primary outcome indicator was placement with successful ventilation. Complication rates, esophageal placement, and return of spontaneous circulation (ROSC) were secondary measures.

A retrospective review of the records of patients who had ETC attempts by Emergency Medical Services (EMS) was conducted for a period of three years. Complications were defined a priori. The ETC is used primarily as rescue airway for a failed attempt at an endotracheal tube (ETT) intubation. A control group for ETT placements was drawn from the EMS quality assurance (QA) database for the same period.

Esophageal-Tracheal Combitube insertion was attempted on 162 patients, of which, 113 (70%) were successful, 46 (28%) failed, and the outcome of three (2%) was not recorded. Inability to place the ETC occurred in 29 (18%) patients, and accounted for 48% (22/46) of failures. The use of the ETC caused dental trauma in one patient, and one placement of the ETC was related to the onset of subcutaneous emphysema. Blood in the ETC from active upper gatrointestinal bleeding occurred in nine patients (6%), and four tubes (3%) became dislodged en route to the hospital. The a priori complication rate was 44/162 (27%). Inability to determine placement of the ETC due to emesis from both ports occurred in 21 cases. Combining these problems with the a priori complications, the overall rate was 40% (65/162). EsophagealTracheal Combitube location was noted in a subset of 90 charts, of which, 76 (84%) were esophageal, and 14 (16%) were tracheal. Thirteen of 126 (10%) patients in cardiac arrest had return of spontaneous circulation (ROSC) in the field after placement of the ETC. An ETT was attempted in 128 control patients, of which, 107 (84%) were successful, 21 (16%) failed (odds ratio (OR) for ETT vs. ETC = 2.1; 95% CI = 1.12–3.86).

Despite a low ROSC rate, the complication and success rates of ETC are acceptable for a rescue airway device. Tracheal placement of the Combitube is uncommon, but requires fail-safe discrimination. Similar to previous reports, the success ratio for ETT was greater than for the ETC.