Limited research has focused on the safety and security of First Responders and Receivers, including clinicians, hospital workers, public safety officials, community volunteers, and other lay personnel, during public health emergencies. These providers are, in some cases, at greater peril during large-scale disasters due to their lack of training and inadequate resources to handle major influxes of patients. Exemplified in the 1995 Tokyo sarin gas attacks and the 2008 Wenchuan earthquakes, lack of training results in poor outcomes for both patients and First Receivers.

The improvement of knowledge and comfort level of First Receivers preparing for a medical disaster via an affordable, repeatable emergency preparedness training (EPT) curriculum.

A 5-hour EPT curriculum was developed including nine learning objectives, 18 competencies, and 34 performance objectives. Following brief didactic and small group sessions, interprofessional teams of four to six trainees were observed in a large patient simulator designed to recreate environmentally challenging (ie, flood evacuation), multi-patient scenarios using a novel technique developed to utilize trainees as actors. Trained observers assessed successful completion of 16 individual and 18 team performance objectives. Prior to training, team members completed a 24-question knowledge assessment, a demographic survey, and a comfort level self-assessment. Following training, trainees repeated the 24 questions, self-assessment, and course assessment.

One hundred ninety-five participants completed the course between November 2012 and August 2013. One hundred ninety-one (98.5%), 150 (76.9%), and 66 (33.8%) participants completed the pretest, post-test, and course assessment, respectively. The mean (SD) percentage of correct answers between the pretest and post-test increased from 46.3 (13.4) to 75.3 (12.2), P < .0001. Thirty-eight participants (19.5%) reported more than three hours of disaster EPT each year while 157 participants (80.5%) reported three hours or less of yearly EPT. Sixty-six (100%) reported the course relevant to care providers and 61 (92.4%) highly recommended the course. Comfort level increased from 37.0/100 (n = 192) before training to 76.3/100 (n = 145) after training.

The Center for Health Professional Training and Emergency Response's (CHPTER's) 5-hour EPT curriculum for patient care providers recreates simultaneous multi-actor disasters, measures EPT performance, and improves trainee knowledge and comfort level to save patient and provider lives during a disaster, via an affordable, repeatable EPT curriculum. A larger-scale study, or preferably a multi-center trial, is needed to further study the impact of this curriculum and its potential to enhance the safety and security of the “Second Front.”

JonesJ, StaubJ, SeymoreA, ScottLA. Securing the Second Front: Achieving First Receiver Safety and Security through Competency-based Tools. Prehosp Disaster Med. 2014;29(6):1-5.

Lactate measurement has been used to identify critical medical illness and initiate early treatment strategies. The prehospital environment offers an opportunity for very early identification of critical illness and commencement of care.

The investigators hypothesized that point-of-care lactate measurement in the prehospital aeromedical environment would: (1) identify medical patients with high mortality; (2) influence fluid, transfusion, and intubation; and (3) increase early central venous catheter (CVC) placement.

Critically ill, medical, nontrauma patients who were transported from September 2007 through February 2009 by University of Massachusetts (UMass) Memorial LifeFlight, a university-based emergency medical helicopter service, were eligible for enrollment. Patients were prospectively randomized to receive a fingerstick whole-blood lactate measurement on an alternate-day schedule. Flight crews were not blinded to results. Flight crews were asked to inform the receiving attending physician of the results. The primary endpoint was the ability of a high, prehospital lactate value [> 4 millimoles per liter (mmol/L)] to identify mortality. Secondary endpoints included differences in post-transport fluid, transfusion, and intubation, and decrease in time to central venous catheter (CVC) placement. Categorical variables were compared between groups by Fisher's Exact Test, and continuous variables were compared by t-test.

Patients (N = 59) were well matched for age, gender, and acuity. In the lactate cohort (n = 20), mean lactate was 7 mmol/L [Standard error of the mean, SEM = 1]. Initial analysis revealed that prehospital lactate levels of ≥4 mmol/L did show a trend toward higher mortality with an odds ratio of 2.1 (95% CI, 0.3-13.8). Secondary endpoints did not show a statistically significant change in management between the lactate and non lactate groups. There was a trend toward decreased time to post-transport CVC in the non lactate faction.

Prehospital aeromedical point-of-care lactate measurement levels ≥4 mmol/L may help stratify mortality. Further investigation is needed, as this is a small, limited study. The initial analysis did not find a significant change in post-transport management.

MullenM, CerriG, MurrayR, TalbotA, SanseverinoA, McCahillP, MangoldsV, VolturoJ, DarlingC, RestucciaM. Use of Point-of-Care Lactate in the Prehospital Aeromedical Environment. Prehosp Disaster Med. 2014;29(1):1-4.

On March 4, 2012, an arms dump exploded in a densely populated area in Brazzaville, Republic of the Congo. At least 250 people were killed, 2,500 wounded, and 13,800 left homeless, of which 5,000 were relocated to a newly constructed internally displaced person (IDP) camp.

To describe the medical complaints of persons presenting to the IDP camp for medical evaluation.

All patients seen and treated by the Belgian First Aid and Support Team (B-FAST) in the IDP camp on March 10 and 11, 2012 were included. A unique number, age, gender, and inventory of complaints were registered on standard World Health Organization (WHO) forms.

Out of 245 presenting patients, 242 files were processed. One in two patients were minors (<18 years-old), the male/female ratio was 50/50 in minors and 28/72 in adults; median (range) age in minors was three years (0-17) and for adults was 32.5 years (18-68). Twenty percent of the children were determined to be malnourished. Signs and symptoms related to infectious diseases were present in 75% of minors and 53% of adults. Trauma was present in 12% of minors and 21% of adults.

One week following the disaster event, after people had relocated to IDP camps, infectious diseases became the predominate reason for seeking medical evaluation. Less than one in five people presenting to the medical post had injuries directly related to the event. Demographic data showed that around 50% of people in the IDP camp presenting for medical care were children, of which one in five was malnourished.

RoggenI, van BerlaerG, GijsG, HubloueI. Clinical Characteristics of the Inhabitants of an Internally Displaced Persons Camp in Brazzaville, Republic of Congo After the Arms Dump Blast on March 4, 2012. Prehosp Disaster Med. 2014;29(5):1-5.

Telecommunication systems are important for sharing information among health institutions to successfully provide medical response following disasters.

The aim of this study was to clarify the problems associated with telecommunication systems in the acute phase of the Great East Japan Earthquake (March 11, 2011).

All 72 of the secondary and tertiary emergency hospitals in Miyagi Prefecture were surveyed to evaluate the telecommunication systems in use during the 2011 Great Japan Earthquake, including satellite mobile phones, multi-channel access (MCA) wireless systems, mobile phones, Personal Handy-phone Systems (PHS), fixed-line phones, and the Internet. Hospitals were asked whether the telecommunication systems functioned correctly during the first four days after the earthquake, and, if not, to identify the cause of the malfunction. Each telecommunication system was considered to function correctly if the hospital staff could communicate at least once in every three calls.

Valid responses were received from 53 hospitals (73.6%). Satellite mobile phones functioned correctly at the highest proportion of the equipped hospitals, 71.4%, even on Day 0. The MCA wireless system functioned correctly at the second highest proportion of the equipped hospitals. The systems functioned correctly at 72.0% on Day 0 and at 64.0% during Day 1 through Day 3. The main cause of malfunction of the MCA wireless systems was damage to the base station or communication lines (66.7%). Ordinary (personal or general communication systems) mobile phones did not function correctly at any hospital until Day 2, and PHS, fixed-line phones, and the Internet did not function correctly at any area hospitals that were severely damaged by the tsunami. Even in mildly damaged areas, these systems functioned correctly at <40% of the hospitals during the first three days. The main causes of malfunction were a lack of electricity (mobile phones, 25.6%; the Internet, 54.8%) and damage to the base stations or communication lines (the Internet, 38.1%; mobile phones, 56.4%).

Results suggest that satellite mobile phones and MCA wireless systems are relatively reliable and ordinary systems are less reliable in the acute period of a major disaster. It is important to distribute reliable disaster communication equipment to hospitals and plan for situations in which hospital telecommunications systems do not function.

KudoD, FurukawaH, NakagawaA, AbeY, WashioT, ArafuneT, SatoD, YamanouchiS, OchiS, TominagaT, KushimotoS. Reliability of Telecommunications Systems Following a Major Disaster: Survey of Secondary and Tertiary Emergency Institutions in Miyagi Prefecture During the Acute Phase of the 2011 Great East Japan Earthquake. Prehosp Disaster Med. 2014;29(1):1-5.

The science underpinning the study of mass-gathering health (MGH) is developing rapidly. Current knowledge fails to adequately inform the understanding of the science of mass gatherings (MGs) because of the lack of theory development and adequate conceptual analysis. Defining populations of interest in the context of MGs is required to permit meaningful comparison and meta-analysis between events.

A critique of existing definitions and descriptions of MGs was undertaken. Analyzing gaps in current knowledge, the authors sought to delineate the populations affected by MGs, employing a consensus approach to formulating a population model. The proposed conceptual model evolved through face-to-face group meetings, structured breakout sessions, asynchronous collaboration, and virtual international meetings.

Reporting on the incidence of health conditions at specific MGs, and comparing those rates between and across events, requires a common understanding of the denominators, or the total populations in question. There are many, nested populations to consider within a MG, such as the population of patients, the population of medical services providers, the population of attendees/audience/participants, the crew, contractors, staff, and volunteers, as well as the population of the host community affected by, but not necessarily attending, the event.

A pictorial representation of a basic population model was generated, followed by a more complex representation, capturing a global-health perspective, as well as academically- and operationally-relevant divisions in MG populations.

Consistent definitions of MG populations will support more rigorous data collection. This, in turn, will support meta-analysis and pooling of data sources internationally, creating a foundation for risk assessment as well as illness and injury prediction modeling. Ultimately, more rigorous data collection will support methodology for evaluating health promotion, harm reduction, and clinical-response interventions at MGs. Delineating MG populations progresses the current body of knowledge of MGs and informs the understanding of the full scope of their health effects.

LundA, TurrisSA, BowlesR, SteenkampM, HuttonA, RanseJ, ArbonP. Mass-gathering Health Research Foundational Theory: Part 1 - Population Models for Mass Gatherings. Prehosp Disaster Med. 2014;29(6):1-7.

Medical history is an important contributor to diagnosis and patient management. In mass-casualty incidents (MCIs), health care providers are often overwhelmed by large numbers of casualties. An efficient, reliable, and affordable method of information collection is essential for effective health care response.

In some MCIs, self-reporting of symptoms can decrease the time required for history taking, without sacrificing the completeness of triage information.

Two resident doctors and a number of seventh graders who had previous experience of abdominal discomfort were invited to join this study. A questionnaire was developed to collect information on common symptoms in food poisoning. Each question was scored, and enrolled students were randomly divided into two groups. The experimental group students answered the questionnaire first and then were interviewed to complete the medical history. The control group students were interviewed in the traditional way to collect medical history. Time of all interviews was measured and recorded. The time needed to complete the history taking and completeness of obtained information were compared with students’ t tests, or Mann-Whitney U tests, based on the normality of data. Comprehensibility of each question, scored by enrolled students, was reported by descriptive statistics.

There were 41 students enrolled: 22 in the experimental group and 19 in the control group. Time to complete history taking in the experimental group (163.0 seconds, SD=52.3) was shorter than that in the control group (198.7 seconds, SD=40.9) (P=.010). There was no difference in the completeness of history obtained between the experimental group and the control group (94.8%, SD=5.0 vs 94.2%, SD=6.1; P=.747). Between the two doctors, no significant difference was found in the time required for history taking (185.2 seconds, SD=42.2 vs 173.1 seconds, SD=58.6; P=.449), or the completeness of information (94.1%, SD=5.9 vs 95.0%, SD=5.0; P=.601). Most of the questions were scored “good” in comprehensibility.

Self-reporting of symptoms can shorten the time of history taking during a food poisoning mass-casualty event without sacrificing the completeness of information.

HsuY, HuangYC. Does Self-reporting Facilitate History Taking in Food Poisoning Mass-casualty Incidents?Prehosp Disaster Med. 2014;29(4):1-4.

The goal of an Emergency Medical Services (EMS) system is to prevent needless death or disability from time-sensitive disease processes. Despite growing evidence that these processes contribute significantly to mortality in low- and middle- income countries (LMICs), there has been little focus on the development of EMS systems in poor countries.

The objective of this study was to understand the utilization pattern of a newly-implemented EMS system in Ruhiira, Uganda.

An EMS system based on community priorities was implemented in rural Uganda in 2009. Six months of ambulance logs were reviewed. Patient, transfer, and clinical data were extracted and analyzed.

In total, 207 cases were reviewed. Out of all transfers, 66% were for chief complaints that were obstetric related, while 12% were related to malaria. Out of all activations, 77.8% were for female patients. Among men, 34% and 28% were related to malaria and trauma, respectively. The majority of emergency transfers were from district to regional hospitals, including 52% of all obstetric transfers, 65% of malaria transfers, and 62% of all trauma transfers. There was no significant difference in the call to arrival on scene time, the time to scene or the scene to treatment time during the day and night (P > .05). Cost-benefit analysis revealed a cost of $89.95 per life saved with an estimated $0.93/capita to establish the system and $0.09/capita/year to maintain the system.

Contrary to current belief, EMS systems in rural Africa can be affordable and highly utilized, particularly for life-threatening, nontrauma complaints. Construction of a simple but effective EMS system is feasible, acceptable, and an essential component to the primary health care system of LMICs.

Stewart De RamirezS, DollJ, CarleS, AnestT, AriiM, HsiehYH, OkongoM, MoreskyR, SachsSE, MillinM. Emergency Response in Resource-poor Settings: A Review of a Newly-implemented EMS System in Rural Uganda. Prehosp Disaster Med. 2014;29(3):1-6.

Current knowledge about mass-gathering health (MGH) fails to adequately inform the understanding of mass gatherings (MGs) because of a relative lack of theory development and adequate conceptual analysis. This report describes the development of a series of event lenses that serve as a beginning “MG event model,” complimenting the “MG population model” reported elsewhere.

Existing descriptions of “MGs” were considered. Analyzing gaps in current knowledge, the authors sought to delineate the population of events being reported. Employing a consensus approach, the authors strove to capture the diversity, range, and scope of MG events, identifying common variables that might assist researchers in determining when events are similar and might be compared. Through face-to-face group meetings, structured breakout sessions, asynchronous collaboration, and virtual international meetings, a conceptual approach to classifying and describing events evolved in an iterative fashion.

Embedded within existing literature are a variety of approaches to event classification and description. Arising from these approaches, the authors discuss the interplay between event demographics, event dynamics, and event design. Specifically, the report details current understandings about event types, geography, scale, temporality, crowd dynamics, medical support, protective factors, and special hazards. A series of tables are presented to model the different analytic lenses that might be employed in understanding the context of MG events.

The development of an event model addresses a gap in the current body of knowledge vis a vis understanding and reporting the full scope of the health effects related to MGs. Consistent use of a consensus-based event model will support more rigorous data collection. This in turn will support meta-analysis, create a foundation for risk assessment, allow for the pooling of data for illness and injury prediction, and support methodology for evaluating health promotion, harm reduction, and clinical response interventions at MGs.

TurrisSA, LundA, HuttonA, BowlesR, EllersonE, SteenkampM, RanseJ, ArbonP. Mass-gathering Health Research Foundational Theory: Part 2 - Event Modeling for Mass Gatherings. Prehosp Disaster Med. 2014;29(6):1-9.

To analyze the unique factors involved in providing medical support for a long-distance, cross-border, cycling event, and to describe patient presentations and event characteristics for the British Columbia (BC) Ride to Conquer Cancer from 2010 through 2012.

This study was a 3-year, descriptive case series report. Medical encounters were documented, prospectively, from 2010-2012 using an online registry. Data for event-related variables also were reported.

Providing medical support for participants during the 2-day ride was complicated by communication challenges, weather conditions, and cross-border issues. The total number of participants for the ride increased from 2,252 in 2010 to 2,879 in 2011, and 3,011 in 2012. Patient presentation rates (PPRs) of 125.66, 155.26, and 198.93 (per 1,000 participants) were documented from 2010 through 2012. Over the course of three years, and not included in the PPR, an additional 3,840 encounters for “self-treatment” were documented.

The Ride to Conquer Cancer Series has shown that medical coverage at multi-day, cross-national cycling events must be planned carefully to face a unique set of circumstances, including legislative issues, long-distance communication capabilities, and highly mobile participants. This combination of factors leads to potentially higher PPRs than have been reported for noncycling events. This study also illuminates the additional workload “self-treatment” visits place on the medical team.

LundA, TurrisSA, WangP, MuiJ, LewisK, GutmanSJ. An Analysis of Patient Presentations at a 2-Day Mass-participation Cycling Event: The Ride to Conquer Cancer Case Series, 2010-2012. Prehosp Disaster Med. 2014;29(4):1-8.

Red Bull Stratos was a commercial program that brought a test parachutist, protected by a full-pressure suit, in a stratospheric balloon with pressurized capsule to over 127,582 ft (38,969 m), from which he free fell and subsequently parachuted to the ground. Given that the major risks to the parachutist included ebullism, negative Gz (toe-to-head) acceleration exposure from an uncontrolled flat spin, and trauma, a comprehensive plan was developed to recover the parachutist under nominal conditions and to respond to any medical contingencies that might have arisen. In this report, the project medical team describes the experience of providing emergency medical support and crew recovery for the manned balloon flights of the program.

The phases of flight, associated risks, and available resources were systematically evaluated.

Six distinct phases of flight from an Emergency Medical Services (EMS) standpoint were identified. A Medical Support Plan was developed to address the risks associated with each phase, encompassing personnel, equipment, procedures, and communications.

Despite geographical, communications, and resource limitations, the medical team was able to implement the Medical Support Plan, enabling multiple successful manned balloon flights to 71,615 ft (21,828 m), 97,221 ft (29,610 m), and 127,582 ft (38,969 m). The experience allowed refinement of the EMS and crew recovery procedures for each successive flight and could be applied to other high altitude or commercial space ventures.

BlueRS, NortonSC, LawJ, PattariniJM, AntonsenEL, GarbinoA, ClarkJB, TurneyMW. Emergency Medical Support for a Manned Stratospheric Balloon Test Program. Prehosp Disaster Med. 2014;29(5):1-6.