Airway management is the most critical and potentially life-saving intervention performed by emergency medical service (EMS) providers. Invasive airway management often is required in non-cardiac-arrest patients who are combative or otherwise uncooperative. The success of prehospital invasive airway management in this patient population was evaluated.

A retrospective review was undertaken of the records of all such patients requiring endotracheal intubation over a three-year period (1987–1989). The study population included 278 patients enrolled by five advanced life support (ALS) units serving a suburban population of 425,000. Field trip sheets were reviewed for diagnosis, intubation method and success, number of intubation attempts, provider experience, reasons for unsuccessful intubations, and complications.

A total of 394 invasive airway management attempts were performed on 278 patients. The overall successful intubation rate was 75% (41 % orotracheal, 52% nasotracheal, 7% other or unknown). The most common diagnoses were COPD and pulmonary edema (30%) and trauma (24%). Experienced providers were successful on the first attempt in 57% of cases compared to 50% by inexperienced providers (p=.24). Multiple intubation attempts were required in 33% of the patients. There was no statistically significant difference in success rates between the orotracheal and nasotracheal methods (p=.51). The most common reason for unsuccessful intubation was altered level of consciousness. Complications occurred with 7% of successful attempts and in 18% of unsuccessful attempts (p<.001). Forty-six percent of the patients who were not intubated successfully in the field and required intubation in the emergency department (ED) received a neuromuscular blocking agent prior to successful intubation.

Prehospital providers can intubate a high but improvable proportion of non-cardiac-arrested patients by both the orotracheal and nasotracheal routes. The use of pharmacologic adjuncts to facilitate the prehospital intubation of selected, non-cardiac-arrested patients is a promising adjunct that needs further evaluation.

A 7.0 magnitude earthquake struck Haiti on January 12, 2010, resulting in 222,000 deaths and 300,000 injuries. Three weeks after the initial quake, the New Mexico Disaster Medical Assistance Team (NM DMAT-1) was deployed to Haiti for ongoing medical relief. During this deployment, a portable handheld ultrasound machine was tested for usefulness in aiding with patient care decisions.

The utility of portable ultrasound to help with triage and patient management decisions in a major disaster setting was evaluated.

Retrospective observational non-blinded images were obtained on 51 patients voluntarily presenting to the Gheskio Field clinic at Port-au-Prince. Ultrasound was used for evaluation of undifferentiated hypotension, torso trauma, pregnancy, non-traumatic abdominal pain, deep venous thrombosis and pulmonary embolism, and dyspnea-chest pain, as well as for assisting with procedures. Scans were obtained using a Signos personal handheld ultrasound machine with images stored on a microSD card. Qualitative data were reviewed to identify whether ultrasound influenced management decisions, and results were categorized in terms of percent of scans that influenced management.

Fifty-one ultrasound scans on 50 patients were performed, with 35% interpreted as positive, 41% as negative, and 24% as equivocal. The highest yields of information were for abdominal ultrasound and ultrasound related to pregnancy. Ultrasound influenced decisions on patient care in 70% of scans. Most of these decisions were reflected in the clinician's confidence in discharging a patient with or without non-emergent follow-up.

The use of a handheld portable ultrasound machine was effective for patient management decisions in resource-poor settings, and decreased the need to triage selected patients to higher levels of care. Ultrasound was very useful for evaluation of non-traumatic abdominal pain. Dynamic capability is necessary for ultrasound evaluation of undifferentiated hypotension and cardiac and lung examinations. Ultrasound also was useful for guidance during procedural applications, and for aiding in the diagnosis of parasitic diseases.

Shorter M, Macias D. Portable handheld ultrasound in austere environments: use in the Haiti disaster. Prehosp Disaster Med. 2012;27(2):1-6.

To document the existence and nature of variation in times to trauma care between urban and rural locations; to assess the impact of identified variations on outcome.

Retrospective case review

Washington state, 1986

Motor-vehicle-collision fatalities

Previously unreported definitions of urban and rural location and possibly preventable death were used to conduct a comparative analysis of urban and rural fatalities. Trauma care times in the prehospital and the emergency department (ED) phases of care were abstracted. Their relationships to corresponding crude death rates and possibly preventable death rates also were examined.

Prehospital times averaged two times longer in rural locations than in urban areas. First-physician contact in the ED averaged six times longer in rural locations than in urban settings. Concomitantly, the crude death rate in rural settings was three times that of the urban areas. The overall possibly preventable death rate was double the urban rates in rural incidents. When stratified by phase of care, rate of possibly preventable death showed no urban/rural variation for the prehospital phase, but was three times greater for the ED phase in rural areas than in urban ones.

Trauma care times and adverse outcome appear to be associated. Allocation of resources to decrease length of and geographic variation in time to definitive care, particularly in the ED phase, seems appropriate.

The potential for disasters exists in all communities. To mitigate the potential catastrophes that confront humanity in the new millennium, an evidence-based approach to disaster management is required urgently. This study moves toward such an evidence-based approach by identifying peer-reviewed publications following a range of disasters and events over the past three decades.

Peer-reviewed, event-specific literature was identified using a comprehensive search of the electronically indexed database, MEDLINE (1956–January 2009). An extended comprehensive search was conducted for one event to compare the event-specific literature indexed in MEDLINE to other electronic databases (EMBASE, CINAHL, AMED, CENTRAL, Psych Info, Maternity and Infant Care, EBM Reviews).

Following 25 individual disasters or overwhelming crises, a total of 2,098 peer-reviewed, event-specific publications were published in 789 journals (652 publications following disasters/events caused by natural hazards, 966 following human-made/technological disasters/events, and 480 following conflict/complex humanitarian events).The event with the greatest number of peer-reviewed, event-specific publications was the 11 September 2001 terrorist attacks (686 publications). Prehospital and Disaster Medicine published the greatest number of peer-reviewed, event-specific publications (54), followed by Journal of Traumatic Stress (42), Military Medicine (40), and Psychiatric Services (40). The primary topics of event-specific publications were mental health, medical health, and response. When an extended, comprehensive search was conducted for one event, 75% of all peer-reviewed, event-specific publications were indexed in MEDLINE.

A broad range of multi-disciplinary journals publish peer-reviewed, event-specific publications. While the majority of peer-reviewed, event-specific literature is indexed in MEDLINE, comprehensive search strategies should include EMBASE to increase yield.

The objective of this study was to evaluate the frequency of posttraumatic stress disorder (PTSD) among the participants of the Turkish Red Crescent Disaster Relief Team after the Tsunami in Asia.

The Clinician Administered PTSD Scale-1 (CAPS-1) was administered to 33 of 36 team members one month after their Disaster Relief Team duty. Along with the CAPS-1 interview, demographic features, profession, previous professional experience, previous experience with traumatic events and disasters also were recorded. To be classified as present, a symptom must have a frequency score of “1” and an intensity score of “2” at the CAPS-1 interview. For a diagnosis of PTSD, at least one re-experiencing, three avoidance and numbing, and two increased arousal symptoms should be present.

The PTSD was diagnosed in eight of the 33 (24.2%) participants. No significant difference was detected in the distribution of PTSD diagnosis according to gender, age, profession, professional experience, previous disaster experience, and/or previous experience of traumatic events. However, the severity of PTSD symptoms as measured by the CAPS-1 score was significantly higher in women, nurses, and participants with <3 previous disaster duty experiences.

Post-traumatic stress disorder is prevalent within disaster teams and healthcare workers, and measures should be taken to prevent PTSD within this group.

A scoping exercise to establish how common hospital evacuations are, identify hospital evacuation policies and review case studies to identify trig-gers, processes and challenges involved in the evacuation of hospitals globally.

A systematic search of PubMed and disaster agency online resources, search of grey literature and media reports.

This study showed that hospitals are vulnerable to both natural and man made disasters and that hospital evacuations do occur globally. It highlighted the paucity of published data and policy on hospital evacuation and emphasised the vital need to collect data on triggers, reasons for evacuation, sheltering facilities and the process of evacuation.

This study recommends the collection of case studies and the development of a database to assist with the research and development of well tailored hospital evacuation plans. These recommendations reflect and support the 2008-2009 World Disaster Reduction Campaign on Hospitals Safe from Disasters and the timely 2009 Global Platform priority that, ‘Critical services and infrastructure such as health facilities and schools must be safe from disasters.

This paper is a report on an exercise designed to reveal the extent of belief in the common myths about disasters held by members of four groups of students from the University of Massachusetts and three groups of trainee emergency workers from Italy.

A questionnaire was administered in which students and trainees were asked to agree or disagree with 19 statements about disasters. These statements were based on common misconceptions about disasters and are at least statements untenable in statistical terms, if not downright wrong. In each case, a Likert scale was used to assess the strength of the students' and trainees' agreement or disagreement with the statements.

The results suggest that some of the misconceptions (for example, that panic and looting are widespread reactions to disaster) were strongly held, whereas others (for instance, that disasters cannot be managed) were less well-rooted. Despite years of refutation by experts, all groups firmly believed that dead bodies constitute a health hazard if they are not disposed of quickly. Attitudes to the proposition that technology offers a solution to the disaster problem were equivocal.

Though the results of the study by no means were homogeneous, students and emergency workers, on either side of the Atlantic, bring many of the same misconceptions that the mass media continually propagates. These beliefs represent a serious challenge for the instructor who wants to ensure that disasters and emergencies are not misconstrued.

On 26 December 2003, an earthquake measuring 6.5 on the Richter scale occurred in the city of Bam in southeastern Iran. Bam was destroyed completely, >43,000 people were killed, and 30,000 were injured. The national and international responses were quick and considerable. Many field hospitals werecreated and large numbers of patients were evacuated from their homes and transported to hospitals throughoutIran. Nearly 700 patients were transferred to Chamran hospital in Shiraz within the first 48 hours after the earthquake.

This is a retrospective study based on the medical records of earthquake casualties dispatched to Chamran Hospital. A screening tunnel composed of multiple stations was prepared before patients entered to facilitate the large influx of patients. Each of the victims was passed through this screening tunnel and assigned into one of three groups: (1) those needing emergency surgical intervention; (2) those needing less urgent surgery; and (3) those needing elective operations, supportive care, observation, and/or rehabilitation.

Among the 708 patients, 392 were male (male/female ratio: 1.24) with a mean value of their ages of 30.5 years. (range: 1.5 months–70 years). Extremity fractures (136, 19%) were more common than were axial skeleton fractures (28, 4%). Out of the total 708 patients, 152 (21.5%) patients needed emergency operations, 26 (4%) needed less urgent surgery, and 530 (74.5%) required wound care or antibiotic therapy and other forms of supportive care. Some complications occurred, such as two patients with compartment syndromes of theleg, three required below-the-knee amputation, eight suffered acute renal failure, two developed fat emboli syndrome, and one had a brain injury that resulted in death.

A comprehensive disaster plan is required to ensure a prompt disaster response and coordinated management of a multi-casualty incident. This can influence the outcomes of patients directly. A patient screening tunnel has advantages in rapid and effective evaluation and management of victims in any multi-casualty incident.

Music festivals, including electronic dance music events (EDMEs), increasingly are common in Canada and internationally. Part of a US $4.5 billion industry annually, the target audience is youth and young adults aged 15-25 years. Little is known about the impact of these events on local emergency departments (EDs).

Drawing on prospective data over a 2-day EDME, the authors of this study employed mixed methods to describe the case mix and prospectively compared patient presentation rate (PPR) and ambulance transfer rate (ATR) between a first aid (FA) only and a higher level of care (HLC) model.

There were 20,301 ticketed attendees. Seventy patient encounters were recorded over two days. The average age was 19.1 years. Roughly 69% were female (n=48/70). Forty-six percent of those seen in the main medical area were under the age of 19 years (n=32/70). The average length of stay in the main medical area was 70.8 minutes. The overall PPR was 4.09 per 1,000 attendees. The ATR with FA only would have been 1.98; ATR with HLC model was 0.52. The presence of an on-site HLC team had a significant positive effect on avoiding ambulance transfers.

Twenty-nine ambulance transfers and ED visits were avoided by the presence of an on-site HLC medical team. Reduction of impact to the public health care system was substantial.

Electronic dance music events have predictable risks and patient presentations, and appropriate on-site health care resources may reduce significantly the impact on the prehospital and emergency health resources in the host community.

LundA , TurrisSA . Mass-gathering Medicine: Risks and Patient Presentations at a 2-Day Electronic Dance Music Event. Prehosp Disaster Med. 2015;30(3):1 8

The Telemedicine Spacebridge, a satellite-mediated, audio-video-fax link between four United States and two Armenian and Russian medical centers, permitted remote American consultants to assist Armenian and Russian physicians in the management of medical problems following the December 1988 earthquake in Armenia and the June 1989 gas explosion near Ufa.

During 12 weeks of operations, 247 Armenian and Russian and 175 American medical professionals participated in 34 half-day clinical conferences. A total of 209 patients were discussed, requiring expertise in 20 specialty areas.

Telemedicine consultations resulted in altered diagnoses for 54, new diagnostic studies for 70, altered diagnostic processes for 47 and modified treatment plans for 47 of 185 Armenian patients presented. Simultaneous participation of several US medical centers was judged beneficial; quality of data transmission was judged excellent.

These results suggest that interactive consultation by remote specialists can provide valuable assistance to on-site physicians and favorably influence clinical decisions in the aftermath of major disasters.

The objective was to test, in this trauma system, the North American hypothesis that exceeding the 60-minute limit for the entire prehospital time (“golden hour of shock”) increases mortality of blunt polytrauma patients.

In a prospective, observational, cohort study conducted between 1990 and 1996, a severity characterization of trauma (ASCOT) score was used to compare the actual mortality with the predicted mortality in 107 blunt polytrauma patients (Group 1) with prehospital rescue periods ≤60 minutes (time from accident until arrival at the emergency department). The same comparison was performed for 147 blunt polytrauma patients (Group 2) with rescue periods >60 minutes. Inclusion criteria were blunt trauma of at least two body sites, an Injury Severity Score (ISS) of ≥8, and direct admission to the trauma centre. Multivariate regression analysis was performed to test for bias and confounding, and to identify factors that might influence mortality. Odd ratio (OR) and 95% confidence interval (CI) were calculated.

The mortality in Group 1 was 14%, and was not statisticvally significantly higher than the 10.2% observed for Group 2. 4.8 patients, or 47% more than predicted, died in Group 1 (p = 0.057). The corresponding figures in Group 2 were 4.2 patients or 22% fewer than predicted (p = 0.19). Multivariate logistic regression confirmed this trend with a significant mortality odds ratio of 8 (95% CI 1.7 to 38.5) for Group 1 compared to Group 2. Significantly more patients in Group 2 were treated by emergency physicians.

It appears in this trauma system, in which emergency physicians often are deployed, that the ‘golden hour of shock’ can be extended safely in many blunt polytrauma patients, since this was associated with better survival figures than in those patients for whom the time was <1 hour.

To characterize the types of occupational exposures and injuries reported by emergency medical service (EMS) workers.

A blinded review of accidents/exposures among EMS workers employed by a Baltimore County fire department was conducted. Medical records for 1992 were reviewed.

Two hundred and twenty-six reports were filed by EMS workers (n = 197) employed by a large, urban fire department in 1992. The most commonly reported injuries were sprains (23%), strains (20%), and exposure to blood and body fluids (15%). The body site most commonly injured was the back (20%) followed by the respiratory system (10%). Most incidents were treated at the employee health clinic, and 13% of the incidents resulted in a hospital visit. Fifteen percent of the injuries resulted in more than seven lost work days. Most incidents were caused by stretcher mishaps, especially during transport of heavy patients. Walkway impediments (e.g., icy steps, wet leaves, broken and uneven pathways) also played an important role in creating slipping and tripping hazards.

These results suggest a variety of prevention strategies aimed at reducing accidents and exposures among EMS workers.

The resuscitation rate from out-of-hospital cardiac arrest is low. There are many factors to be considered as contributing to this phenomenon. One factor not previously considered is the impact of a moving ambulance environment on the ability to perform closed-chest compressions.

Proper closed-chest compressions can be performed in a moving ambulance.

A cardiopulmonary resuscitation (CPR) training mannequin with an attached skill meter (Skillmeter ResusciAnnie®, Laerdal, Armonk, N. Y., USA) that measures each chest compression for proper depth and hand placement was used. Ten emergency medical technician-basic (EMT-B) certified prehospital providers were assigned into one of five teams. Each team performed a total of four sessions of five minutes of continuous closed-chest compressions on the mannequin. Two sessions were done by each team: one in the control environment with the mannequin placed on the floor, and the other in the experimental environment with the mannequin placed in the back of a moving ambulance. The ambulance was operated without warning lights and siren, and all traffic rules were obeyed. The percentage of correct closed-chest compressions was recorded for each session, and the mean values were compared using Student's t-test with alpha set at 0.01 for statistical significance.

Ten sessions of compressions were done in both environments. The mean percentage of correct compressions was 77.6 ±15.6 for the control group and 45.6 ±18.3 for the ambulance group (p = 0.0005).

A moving ambulance environment appears to impair the ability to perform closed-chest compressions.