Airway injuries are the second leading cause of potentially survivable battlefield death and often require airway management strategies. Airway suction, the act of using negative pressure in a patient’s upper airway, removes debris that can prevent respiration, decreases possible aspiration risks, and allows clearer viewing of the airway for intubation. The most important characteristics for a portable airway suction device for prehospital combat care are portability, strong suction, and ease of use.

This market review searched academic papers, military publications, Google searches, and Amazon to identify devices. The search included specific characteristics that would increase the likelihood that the devices would be suitable for battlefield use including weight, size, battery life, noise emission, canister size, tubing, and suction power.

Sixty portable airway suction devices were resulted, 31 of which met inclusion criteria – 11 manually powered devices and 20 battery-operated devices. One type of manual suction pump was a bag-like design with a squeezable suction pump that was extremely lightweight but had limited suction capabilities (vacuum pressure of 100mmHg). Another type of manual suction pump had a trigger-like design which is pulled back to create suction with a firm collection canister that had increased suction capabilities (vacuum pressures of 188-600mmHg), though still less than the battery operated, and was slightly heavier (0.23-0.458kg). Battery-operated devices had increased suction capabilities and were easier to use, but they were larger and weighed more (1.18-11.0kg).

Future research should work to lighten and debulk battery-operated suction devices with high suction performance.

Natural and man-made catastrophes have caused significant destruction and loss of lives throughout human history. Disasters accompany various events with multiple causes and consequences, often leading to a cascade of health-related events. Ethiopia, amongst the developing countries in the horn of Africa, is vulnerable to natural and man-made disasters. Over the last few years, Ethiopia learned the hardest way to transform its disaster management from a mere apparatus of response and recovery to preparedness and mitigation.

Review the challenges and opportunities for establishing the Ethiopian EMT and its disaster response experience.

This was a mixed-methods, cross-sectional Intra-Action Review of activities of country EMT. It included a review of documents and key informant interviews. All data were analyzed thematically.

In May 2022, the Ethiopian Federal MOH, in collaboration with WHO, adapted the WHO EMT initiative to tackle the identified challenges. Ethiopia’s EMT implementation plan was created, which included ten steps and 50 detailed activities. This initiative aims to have a classified Type I fixed EMT in the coming six months. Based on the objective evaluation of the last four months’ performance toward plan implementation, activities show that 65% of the overall plan has been completed.

Implementing the EMT initiative in Ethiopia has positively impacted the clinical quality of care, enhanced coordination, and improved health outcomes for the population served at times of great need. However, the implementation requires collaboration in support, guidance, and experience sharing from stakeholders and partners, including twinning with other organizations.

Tables and Figures (optional)

Table 1.

Ethiopian EMT Ten Steps Implementation

The goal of disaster triage at both the prehospital and in-hospital level is to maximize resources and optimize patient outcomes. Of the disaster-specific triage methods developed to guide health care providers, the Simple Triage and Rapid Treatment (START) algorithm has become the most popular system world-wide. Despite its appeal and global application, the accuracy and effectiveness of the START protocol is not well-known.

The purpose of this meta-analysis was two-fold: (1) to estimate overall accuracy, under-triage, and over-triage of the START method when used by providers across a variety of backgrounds; and (2) to obtain specific accuracy for each of the four START categories: red, yellow, green, and black.

A systematic review and meta-analysis was conducted that searched Medline (OVID), Embase (OVID), Global Health (OVID), CINAHL (EBSCO), Compendex (Engineering Village), SCOPUS, ProQuest Dissertations and Theses Global, Cochrane Library, and PROSPERO. The results were expanded by hand searching of journals, reference lists, and the grey literature. The search was executed in March 2020. The review considered the participants, interventions, context, and outcome (PICO) framework and followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Accuracy outcomes are presented as means with 95% confidence intervals (CI) as calculated using the binomial method. Pooled meta-analyses of accuracy outcomes using fixed and random effects models were calculated and the heterogeneity was assessed using the Q statistic.

Thirty-two studies were included in the review, most of which utilized a non-randomized study design (84%). Proportion of victims correctly triaged using START ranged from 0.27 to 0.99 with an overall triage accuracy of 0.73 (95% CI, 0.67 to 0.78). Proportion of over-triage was 0.14 (95% CI, 0.11 to 0.17) while the proportion of under-triage was 0.10 (95% CI, 0.072 to 0.14). There was significant heterogeneity of the studies for all outcomes (P < .0001).

This meta-analysis suggests that START is not accurate enough to serve as a reliable disaster triage tool. Although the accuracy of START may be similar to other models of disaster triage, development of a more accurate triage method should be urgently pursued.

On August 4, 2020, a massive explosion struck the Beirut Harbor in Lebanon. Approximately 220 people were killed and around 7,000 were injured, of which 12% were hospitalized. Despite being weakened by economic crisis and increasing numbers of coronavirus disease 2019 (COVID-19) cases, the national health care system responded promptly. Within a day, international health care assistance in the form of International Emergency Medical Teams (I-EMTs) started arriving. Previous studies have found that I-EMTs have arrived late and have not been adapted to the context and dominating health care needs. The aim of this study was to document the organization, type, activity, and timing of I-EMTs deployed to Beirut and to discuss their relevance in relation to medical needs.

Data on all deployed I-EMTs were retrieved from all available sources, including internet searches, I-EMT contacts, and from the World Health Organization (WHO) EMT coordination cell (EMT CC) in Lebanon. The WHO EMT classification was used to categorize deployed teams. Information on characteristics, timing, and activities was retrieved and systematically assessed.

Nine I-EMTs were deployed to Beirut following the explosion. Five were equivalent to EMT Type 2 (field hospitals), out of which three were military. The first EMT Type 2 arrived within 24 hours, while the last EMT set up one month after the explosion. Four civilian I-EMTs provided non-clinical support as EMT Specialized Care Teams. A majority of the I-EMTs were focused on trauma care. Three of the four I-EMT Specialized Care Teams were rapidly re-tasked to support COVID-19 care in public hospitals.

A majority of the deployed I-EMT Type 2 were military and focused on trauma care rather than the normal burden of disease including COVID-19. Re-tasking of EMTs requires flexible EMTs. To be better adapted, the I-EMT response should be guided by a systematic assessment of both health care capacities in the affected country as well as the varying health effects of hazards before deployment.

Portable oxygen concentrators (POCs) are medical devices that use physical means to separate oxygen from the atmosphere to produce concentrated, medical-grade gas. Providing oxygen to low-resources environments, such as austere locations, military combat zones, rural Emergency Medical Services (EMS), and during disasters, becomes expensive and logistically intensive. Recent advances in separation technology have promoted the development of POC systems ruggedized for austere use. This review provides a comprehensive summary of the available data regarding POCs in these challenge environments.

PubMed, Google Scholar, and the Defense Technical Information Center were searched from inception to November 2021. Articles addressing the use of POCs in low-resource settings were selected. Three authors were independently involved in the search, review, and synthesis of the articles. Evidence was graded using Oxford Centre for Evidence-Based Medicine guidelines.

The initial search identified 349 articles, of which 40 articles were included in the review. A total of 724 study subjects were associated with the included articles. There were no Level I systematic reviews or randomized controlled trials.

Generally, POCs are a low-cost, light-weight tool that may fill gaps in austere, military, veterinary, EMS, and disaster medicine. They are cost-effective in low-resource areas, such as rural and high-altitude hospitals in developing nations, despite relatively high capital costs associated with initial equipment purchase. Implementation of POC in low-resource locations is limited primarily on access to electricity but can otherwise operate for thousands of hours without maintenance. They provide a unique advantage in combat operations as there is no risk of explosive if oxygen tanks are struck by high-velocity projectiles. Despite their deployment throughout the battlespace, there were no manuscripts identified during the review involving the efficacy of POCs for combat casualties or clinical outcomes in combat. Veterinary medicine and animal studies have provided the most robust data on the physiological effectiveness of POCs. The success of POCs during the coronavirus disease 2019 (COVID-19) pandemic highlights the potential for POCs during future mass-casualty events. There is emerging technology available that combines a larger oxygen concentrator with a compressor system capable of refilling small oxygen cylinders, which could transform the delivery of oxygen in austere environments if ruggedized and miniaturized. Future clinical research is needed to quantify the clinical efficacy of POCs in low-resource settings.

In disaster response, smartphone applications (or apps) are being used by the layperson, emergency first responders, and health care providers to aid in everything from incident reporting to clinical decision making. However, quality apps are often diluted by the overwhelming number of apps that exist for both the lay public and first responders in the Apple iTunes (Apple Inc.; Cupertino, California USA) and Google Play (Google LLC; Mountain View, California USA) stores.

A systematic review of disaster response apps was originally completed in 2015; a follow-up review was completed here to evaluate trends and explore novel apps.

A search of the Apple iTunes and Google Play stores was performed using the following terms obtained from PubMed (National Center for Biotechnology Information; Bethesda, Maryland USA) Medical Subject Headings Database: Emergency Preparedness; Emergency Responders; Disaster; Disaster Planning; Disaster Medicine; Bioterrorism; Chemical Terrorism; Hazardous Materials; and the Federal Emergency Management Agency (FEMA [Washington, DC USA]). After excluding any unrelated apps, a working list of apps was formed and categorized based on topics. Apps were categorized by intended user (first responders or the public) and sub-categorized by topic for discussion. Sub-categories included News/Information, Reference/Education, Weather/Natural Disasters, Travel/Navigation, and Communication/Reunification.

A search of the Apple iTunes store revealed 394 unique apps and was narrowed to 342 based on relevance to the field and availability on the iPhone. A search of the Google Play store yielded 645 unique applications and was narrowed to 634 based on relevance. Of note, 49 apps appeared in both app stores using the search terms. An aggregate 927 apps from the Apple iTunes and Google Play stores were then critically reviewed by the authors. Apps were sub-categorized based on intended audience, layperson or first responder, and sorted into one of five disaster response categories. Two apps were chosen for discussion from each of the five sub-categories. The highest quality apps were determined from each group based on relevance to emergency preparedness and disaster response, rating, and number of reviews.

After comparisons with the 2015 article, many new apps have been developed and previously described apps have been updated, highlighting that this is a constantly changing field deserving of continued analysis and research.

Rapid Response Mobile Laboratories (RRML) are a crucial component of preparedness and response to health emergencies, both as a stand-alone asset and in conjunction with other rapid response capacities. The development of an RRML classification system in 20191 both defines laboratory structure and provides a foundation for the development of RRML minimum standards under the umbrella of the WHO Global Outbreak Alert and Response Network (GOARN).

These minimum standards define the requirements for RRMLs/GOARN in the field and facilitate their interoperability with other important operational assets of WHO, including Emergency Medical Teams (EMTs), contributing to the overall response and to enhanced collaboration among national and international health partners.

The development of minimum standards brought together over 30 technical experts in various disciplines from European GOARN partner institutions to conduct a systematic applied literature review and consolidate field experiences and lessons learned from infectious disease outbreaks globally, as well as addressing the complete RRML deployment life cycle2 and for each RRML type.

The RRML minimum standards focus on four workstreams: Operational Support & Logistics; Laboratory Information Management System; Biosafety & Biosecurity; and Quality Management Systems.

This standardization will ensure predictable response in the field and is the first step in strengthening RRML interoperability with other capacities and members of the global health emergency workforce, such as EMTs and Rapid Response Teams, as well as national-level counterparts.

The standards contribute to strengthening of National Laboratory capacities, provide the basis for a forthcoming monitoring and evaluation Framework, and WHO RRML recognition process.

Non-physician performed point-of-care ultrasound (POCUS) is emerging as a diagnostic adjunct with the potential to enhance current practice. The scope of POCUS utility is broad and well-established in-hospital, yet limited research has occurred in the out-of-hospital environment. Many physician-based studies expound the value of POCUS in the acute setting as a therapeutic and diagnostic tool. This study utilized a scoping review methodology to map the literature pertaining to non-physician use of POCUS to improve success of peripheral intravenous access (PIVA), especially in patients predicted to be difficult to cannulate.

Ovid MEDLINE, CINAHL Plus, EMBASE, and PubMed were searched from January 1, 1990 through April 15, 2021. A thorough search of the grey literature and reference lists of relevant articles was also performed to identify additional studies. Articles were included if they examined non-physician utilization of ultrasound-guided PIVA (USGPIVA) for patients anticipated to be difficult to cannulate.

A total of 158 articles were identified. A total of 16 articles met the inclusion criteria. The majority of participants had varied experience with ultrasound, making accurate comparison difficult. Training and education were non-standardized, as was the approach to determining difficult intravenous access (DIVA). Despite this, the majority of the studies demonstrated high first attempt and overall success rates for PIVA performed by non-physicians.

Non-physician USGPIVA appears to be a superior method for PIVA when difficulty is anticipated. Additional benefits include reduced requirement for central venous catheter (CVC) or intraosseous (IO) needle placement. Paramedics, nurses, and emergency department (ED) technicians are able to achieve competence in this skill with relatively little training. Further research is required to explore the utility of this practice in the out-of-hospital environment.

Despite the increasing risks and complexity of disasters, education for Malaysian health care providers in this domain is limited. This study aims to assess scholarly publications by Malaysian scholars on Disaster Medicine (DM)-related topics.

An electronic search of five selected journals from 1991 through 2021 utilizing multiple keywords relevant to DM was conducted for review and analysis.

A total of 154 articles were included for analysis. The mean number of publications per year from 1991 through 2021 was 5.1 publications. Short reports were the most common research type (53.2%), followed by original research (32.4%) and case reports (12.3%). Mean citations among the included articles were 12.4 citations. Most author collaborations were within the same agency or institution, and there was no correlation between the type of collaboration and the number of citations (P = .942). While a few clusters of scholars could build a strong network across institutions, most research currently conducted in DM was within small, isolated clusters.

Disaster Medicine in Malaysia is a growing medical subspecialty with a significant recent surge in research activity, likely due to the SARS-CoV-2/coronavirus disease 2019 (COVID-19) global pandemic. Since most publications in DM have been on infectious diseases, the need to expand DM-related research on other topics is essential.

Hyperkalemia (HK) is common and potentially a life-threatening condition. If untreated, HK can progress to ventricular arrhythmia and cardiac arrest. Early treatment reduces mortality in HK. This study evaluates a novel protocol for identification and empiric management of presumed HK in the prehospital setting.

This was a retrospective, observational chart review of a single, large, suburban Emergency Medical Services (EMS) system. Patients treated for presumed HK, with both a clinical concern for HK and electrocardiogram (ECG) changes consistent with HK, from February 2018 through February 2021 were eligible for inclusion. Patients were excluded if found to be in cardiac arrest on EMS arrival. Empiric treatment of HK included administration of calcium, sodium bicarbonate, and albuterol. Post-treatment, patients were placed on cardiac monitoring and adverse events recorded enroute to receiving hospital. Protocol compliance was assessed by two independent reviewers. Serum potassium (K) level was obtained from hospital medical records.

A total of 582 patients were treated for HK, of which 533 patients were excluded due to cardiac arrest prior to EMS arrival. The remaining 48 patients included in the analysis had a mean age of 56 (SD = 20) years and were 60.4% (n = 29) male with 77.1% (n = 37) Caucasian, 10.4% (n = 5) African American, and 12.5% (n = 6) Hispanic. Initial blood draw at the receiving facilities showed K >5.0mEq/L in 22 (45.8%), K of 3.5-5.0mEq/L in 23 (47.9%), and K <3.5mEq/L in three patients (6.3%). Independent review of the EMS ECG found the presence of hyperkalemic-related change in 43 (89.6%) cases, and five (10.4%) patients did not meet criteria for treatment due to lack of either appropriate ECG findings or clinical suspicion. No episodes of unstable tachyarrhythmia or cardiac arrest occurred during EMS treatment or transport.

The study evaluated a novel protocol for detecting and managing HK in the prehospital setting. It is feasible for EMS crews to administer this protocol, although a larger study is needed to make the results generalizable.

This paper provides a large-scale, per-National Hockey League (NHL) season analysis of hockey puck strike (HPS) injury data and also provides estimates of injury frequency and severity.

The study’s goal was to quantify and describe the rate and type of spectator HPS injuries at NHL games.

This was a retrospective review of summary data reports for patients evaluated by on-site health care providers over six seasons (2013-2018). Data were obtained from a single Emergency Medical Service (EMS) agency.

Location of study was one US-based NHL venue.

There were 51 HPS recorded. This accounted for 0.93% of total patient contacts translating to a patient per 10,000 (PPTT) of 0.116. This was compared to a PPTT of 12.6 for all patient contacts. The average age of a patron with a HPS was 31 years old. There was an even split between male and female patrons with HPS. The most common location for a HPS was the head or face (75%) followed by upper extremity injuries. Laceration was most frequently diagnosed followed by contusions and pain. Approximately one-quarter of people struck by hockey pucks were transported to the hospital, with the transport to hospital rate (TTHR) being 0.027, compared to the total TTHR of 2.7.

Hockey is a safe sport to watch, although HPS are the spectator hazard of concern given that pucks can travel into the stands at 100mph. Most injuries are minor and occur only one percent of the time; but when they do occur, these fans tend to need transport to the hospital. Finally, HPS tend to occur along the lateral sides of the rink where the glass level is lower and there is no protective netting.

Most injuries observed in victims of lightning strikes can be explained by electrothermal phenomena. Blast penetrating injuries caused by a lightning-strike-induced explosion of a nearby structure are rarely reported.

Here reported is the case of a patient with numerous mixed injuries caused by a lightning strike, including deep lacerations of both hips and thighs with rock fragments embedded in the wounds. Surgical removal of rock fragments from deep areas of the right hip and right lower leg was necessary. The cause of the formation of rock missiles was the lightning-strike-induced explosion of rock. Rapid evaporation of water enclosed in rock crevices was presumably the main force underlying the explosion.

Blast penetrating injuries should be considered and excluded in all patients struck by lightning, particularly when occurring in rocky terrain. The diagnosis and treatment of such injuries can be difficult and require special preparation.

Disaster management (DM) is becoming increasingly complex because of technological advancement and the multi-organization and international contexts. Effective interoperability and adequate collaboration in DM have the potential to spare the human life and to control the economic burden. For those reasons, it’s becoming important to find a way for systems and organizations that exploit, at the same time, the technological interoperability and team’s interoperability.

This study aims to provide an overview of the multi-organizational problems and solutions reflecting on achieving interoperability in multi-organizational DM.

The article is structured as a scoping review based on the Joanna Briggs Institute’s (JBI) methodology for scoping reviews. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist was used to report the results. The selected papers were assessed using the Critical Appraisal Skills Program (CASP) checklists to screen their methodological quality.

The scoping review was conducted systematically searching the databases PubMed, Google Scholar, and Web of Science. The search algorithm was developed using the three key concepts “interoperability; multi-organizational; disaster medicine” translated into different possible search and Medical Subject Headings (MeSH) terms. Studies of all research design types were considered.

The included literature is reporting experiences on interoperability and how it has been applied to health care systems and organizations interacting during a disaster event. Twelve articles were included. Specific problems and solutions were identified regarding the technological and personnel interoperability, such as ineffective integration, technical problems, lack of an interoperability language, and data filtering network. The suggested approach might involve a focus on both the technological as well the human and personnel interoperability with the aim to create a culture of interoperability through compatible technological solutions and joint trainings.

This study identified two main approaches during disasters: technology versus personnel interoperability. The suggested approach is to develop a hybrid culture of interoperability through compatible technological solutions combined to joint and multi-disciplinary trainings to achieve the development of a common language.

Further research will need a solution-focused approach on the culture and language of interoperability as thematic gathering training, socio-technical networks, and policies/procedural guidelines.

The Howard Springs Quarantine Facility (HSQF) is located in tropical Northern Australia and has 875 blocks of four rooms (3,500 rooms in total) spread over 67 hectares. The HSQF requires a large outdoor workforce walking outdoor pathways to provide individual care in the ambient climate. The personal protective equipment (PPE) required for the safety of quarantine workers varies between workgroups and limits body heat dissipation that anecdotally contributes to excessive sweating, which combined with heat stress symptoms of fatigue, headache, and irritability, likely increases the risk of workplace injuries including infection control breaches.

The purpose of this study was the description of qualitative and quantitative assessment for HSQF workers exposed to tropical environmental conditions and provision of evidenced-based strategies to mitigate the risk of heat stress in an outdoor quarantine and isolation workforce.

The study comprised two components - a cross-sectional physiological monitoring study of 18 workers (eight males/ten females; means: 41.4 years; 1.69m; 80.6kg) during a single shift in November 2020 and a subjective heat health survey completed by participants on a minimum of four occasions across the wet season/summer period from November 2020 through February 2021. The physiological monitoring included continuous core temperature monitoring and assessment of fluid balance.

The mean apparent temperature across first-half and second-half of the shift was 34.7°C (SD = 0.8) and 35.6°C (SD = 1.9), respectively. Across the work shift (mean duration 10.1 hours), the mean core temperature of participants was 37.3°C (SD = 0.2) with a range of 37.0°C - 37.7°C. The mean maximal core temperature of participants was 37.7°C (SD = 0.3). In the survey, for the workforce in full PPE, 57% reported feeling moderately, severely, or unbearably hot compared to 49% of those in non-contact PPE, and the level of fatigue was reported as moderate to severe in just over 25% of the workforce in both groups.

Heat stress is a significant risk in outdoor workers in the tropics and is amplified in the coronavirus disease 2019 (COVID-19) frontline workforce required to wear PPE in outdoor settings. A heat health program aimed at mitigating risk, including workplace education, limiting exposure times, encouraging hydration, buddy system, active cooling, and monitoring, is recommended to limit PPE breaches and other workplace injuries in this workforce.

While there are accepted triage and treatment guidelines for the entrapped and mangled extremity in civilian and military resource rich environments, there are none for resource-scarce environments.

A PRISMA systematic literature review was performed to elucidate the current triage and treatment of the entrapped and mangled extremity to understand the factors that contribute to the decision to amputate, or not amputate, and to extract data to develop clinical guidelines.

A lead researcher followed the PRISMA systematic literature review search strategy inclusion and exclusion criteria.

A first reviewer was randomly assigned sources. One of the two lead researchers was the second reviewer. Each determined the Level of Evidence (LOE) and Quality of Evidence (QE) from each source.

Five-hundred ninety-seven (597) records were screened. Fifty-eight (58) articles were entered into the final study. There was one study determined to be LOE-1, 29 LOE-2, and 28 LOE-3 with 15 determined to achieve QE-1, 37 QE-2, and six QE-3.

Data extracted included relevant information to develop clinical guidelines to include physiologic parameters, injury patterns or procedures, imaging, rehabilitation, ethics, and the informed consent process.

This systematic literature review showed that there is a lack of studies producing strong evidence to support the triage and treatment of an entrapped or mangled extremity in resource-scarce environments. A Delphi method study is suggested to adapt and modify available evidence extracted to create clinical guidelines in the resource-scarce environment.

General Practitioners (GPs) are inevitably involved when disaster strikes their communities. Evidence of health care needs in disasters increasingly suggests benefits from greater involvement of GPs, and recent research has clarified key roles. Despite this, GPs continue to be disconnected from disaster health management (DHM) in most countries.

The aim of this study was to explore the perspectives of disaster management professionals in two countries, across a range of all-hazard disasters, regarding the roles and contributions of GPs to DHM, and to identify barriers to, and benefits of, more active engagement of GPs in disaster health care systems.

A qualitative research methodology using semi-structured interviews was conducted with a purposive sample of Disaster Managers (DMs) to explore their perspectives arising from experiences and observations of GPs during disasters from 2009 through 2016 in Australia or New Zealand. These involved all-hazard disasters including natural, man-made, and pandemic disasters. Responses were analyzed using thematic analysis.

These findings document support from DM participants for greater integration of GPs into DHM with New Zealand DMs reporting GPs as already a valuable integrated contributor. In contrast, Australian DMs reported barriers to inclusion that needed to be addressed before sustained integration could occur. The two most strongly expressed barriers were universally expressed by Australian DMs: (1) limited understanding of the work GPs undertake, restricting DMs’ ability to facilitate GP integration; and (2) DMs’ difficulty engaging with GPs as a single group. Other considerations included GPs’ limited DHM knowledge, limited preparedness, and their heightened vulnerability.

Strategies identified to facilitate greater integration of GPs into DHM where it is lacking, such as Australia, included enhanced communication, awareness, and understanding between GPs and DMs.

Experience from New Zealand shows systematic, sustained integration of GPs into DHM systems is achievable and valuable. Findings suggest key factors are collaboration between DMs and GPs at local, state, and national levels of DHM in planning and preparedness for the next disaster. A resilient health care system that maximizes capacity of all available local health resources in disasters and sustains them into the recovery should include General Practice.