This study was undertaken to identify prehospital system and management deficiencies and preventable deaths between 01 January 1997 and 31 December 1998 in 243 consecutive Victorian road crash victims with fatal outcomes.

The complete prehospital and hospital records, the deposition to the coroner, and autopsy findings were evaluated by computer analysis and peer group review with multidisciplinary discussion.

One-hundred eighty-seven (77%) patients had prehospital errors or inadequacies, of which 135 (67%) contributed to death. Three-hundred ninety-four (67%) related to management and 130 (22%) to system deficiencies. Technique errors, diagnosis delays, and errors relatively were infrequent. One of 24 deaths at the crash scene or en route to hospital was considered to be preventable and two potentially preventable.

The high prevalence of prehospital deficiencies has been addressed by a Ministerial Task Force on Trauma and Emergency Services and followed by the introduction of a new trauma care system in Victoria.

Few previous studies have been conducted on the prehospital management of hypotensive trauma patients in Stockholm County. The aim of this study was to describe the prehospital management of hypotensive trauma patients admitted to the largest trauma center in Sweden, and to assess whether prehospital trauma life support (PHTLS) guidelines have been implemented regarding prehospital time intervals and fluid therapy. In addition, the effects of the age, type of injury, injury severity, prehospital time interval, blood pressure, and fluid therapy on outcome were investigated.

This is a retrospective, descriptive study on consecutive, hypotensivetrauma patients (systolic blood pressure ≤90 mmHg on the scene of injury) admitted to Karolinska University Hospital in Stockholm, Sweden, during 2001–2003. The reported values are medians with interquartile ranges. Basic demographics, prehospital time intervals and interventions, injury severity scores (ISS), type and volumes of prehospital fluid resuscitation, and 30-day mortality were abstracted. The effects of the patient's age, gender, prehospital time interval, type of injury, injury severity, on-scene and emergency department blood pressure, and resuscitation fluid volumes on mortality were analyzed using the exact logistic regression model.

In 102 (71 male) adult patients (age ≥15 years) recruited, the median age was 35.5 years (range: 27–55 years) and 77 patients (75%) had suffered blunt injury. The predominant trauma mechanisms were falls between levels (24%) and motor vehicle crashes (22%) with an ISS of 28.5 (range: 16–50). The on-scene time interval was 19 minutes (range: 12–24 minutes). Fluid therapy was initiated at the scene of injury in the majority of patients (73%) regardless of the type of injury (77 blunt [75%] / 25 penetrating [25%]) or injury severity (ISS: 0–20; 21–40; 41–75). Age (odds ratio (OR) = 1.04), male gender (OR = 3.2), ISS 21–40 (OR = 13.6), and ISS >40 (OR = 43.6) were the significant factors affecting outcome in the exact logistic regression analysis.

The time interval at the scene of injury exceeded PHTLS guidelines. The vast majority of the hypotensive trauma patients were fluid-resuscitated on-scene regardless of the type, mechanism, or severity of injury. A predefined fluid resuscitation regimen is not employed in hypotensive trauma victims with different types of injuries. The outcome was worsened by male gender, progressive age, and ISS >20 in the exact multiple regression analysis.

Personal risk behaviors are modifiable. This report describes the 2002 national baseline of behavioral health risk factors of US emergency medical technicians (EMTs) that can guide policy and program development in improving EMT well-being.

A 19-item Health Behavioral Risk Survey (Appendix) was added to the 2002 Longitudinal Emergency Medical Technician Demographic Study mail survey. Risk survey questions covering physical activity, tobacco use, and alcohol use were modeled after the Centers for Disease Control and Prevention 2002 Behavioral Risk Factor Surveillance System (BRFSS) questionnaire. Personal, non-work related seatbelt use and motor vehicle driving questions were adopted from the 2002 US National Highway Traffic Safety Administration (NHTSA) Motor Vehicle Occupant Safety Survey (MVOSS). Post-stratification adjustment factors were used to allow comparisons with BRFSS and MVOSS national estimates.

A total of 1,919 EMT respondents were compared with 239,866 BRFSS and 5,220 MVOSS respondents. These comparisons indicate that EMT-Basics drove more slowly than paramedics; male EMTs drove faster, drank more, and wore their seatbelts less often than did female EMTs; female EMTs smoked more and engaged in vigorous exercise less than males. Those EMTs who reported to be in fair or poor health, smoked more and exercised less than those who reported to be in good or excellent health. Regardless of gender, age, or race, EMTs, on average, wore their seatbelts less often, drove faster than, and were less likely to engage in moderate physical exercise, compared to US adults.

Stereotypical gender differences in risk behaviors exist among EMTs. An EMT's self-reported health positively correlates with smoking and exercising. Compared to US national estimates, except for smoking and vigorous exercise, EMTs have increased risk behaviors.

The world's new social environment dictates the need for preparedness should a disaster occur. One caveat in the realm of disaster preparedness is the vertical evacuation of hospital patients. Little data regarding the evacuation of patients are available, and the consequences of not being prepared could be devastating. Therefore, if the vertical evacuation of critically ill patients was thrust upon a community hospital, the response of emergency services and ancillary staff is largely unknown.

The vertical evacuation of 12 simulated critically ill patients from the fourth floor of a newly constructed and vacant critical care unit was undertaken by local fire fighters, on-staff nursing, residents, and ancillary staff, all under the direction of the hospital Emergency Management Committee. Four randomly selected groups of firefighters, two teams consisting of three personnel and two teams of four personnel, were timed and had vital signs assessed prior to ascending to the fourth floor to retrieve a patient and upon each subsequent decent. Each team, dressed in full turnout gear, retrieved three patients. Each simulated patient was fashioned with mock endotracheal tube, intravenous lines, monitor, and a Pleurovac® was attached in three of the four patients. Vital signs were analyzed for significant changes or patterns due to exertion and or stress during the drill. Evaluations were distributed to all participants upon completion of the drill.

Mean values for the vital signs of the members of each team showed minimal increases from baseline to completion with the exception of heart rate. A decrease in systolic blood pressure was present in both of the four member teams. Subjective evaluation by the firefighters, indicated a “minimal” increase in exertion. Mean extraction time was 14.7 minutes. Patient transfer and evacuation was completed without complication to the patients or staff. Only one firefighter requested a replacement. Completed evaluations indicated above average or outstanding performance on organization, commitment, security, and care. Comments included statements regarding equipment management during transport, better communication, stairwell width, difficulty with ventilating intubated patients, improvement of evacuation time, and organization as drill progressed; three member teams, spatially, worked better than four.

This drill reflected an impressive level of preparedness by firefighters, nurses, and ancillary staff both physically and organizationally. Should a vertical evacuation of critically ill patients be necessary, a four firefighter extraction team and accompanying nurse and respiratory therapist would be able to evacuate one patient at a rate of 3.75 minutes per floor.

This retrospective study included 75 persons with ischemic heart disease who were admitted to the Cardiac policlinic for a control check-up immediately after the suspension of air raids. Two-thirds of them were male (average age 62 ±10). Data were obtained using a specially conceived questionnaire based on recall.

Almost 40% of patients estimated that they were very anxious the week before the attacks began, but the anxiety decreased after the beginning of the air raids. Frequency of anginal pains increased after the start of the air raids, but the difference was not statisticaly significant. The intensity of pains drastically increased in the first week of war. Consequently, the average number of pain killers consumed increased from the week before the attacks to the first week of the attacks, and it reached the highest value the week after the suspension of the attacks (1.39, 1.87, and 3.02 pain pills per week, respectively). The average weekly number of medications was 3.50 in the week prior to the air raids, increased to 5.05 during the first week of air raids, and rose to 6.06 in the week after the suspension.

The adjustment on the psychological level was rapid but physical symptoms increased. This implies that physical adaptation to stress could be slower, or that the stress of the war provoked permanent changes in physical status.

Large-scale, terrorist attacks can happen in peripheral areas, which are located close to a country's borders and far from its main medical facilities and involve multi-national casualties and responders. The objective of this study was to analyze the terrorist suicide bombings that occurred on 07 October 2004, near the Israeli-Egyptian border, as representative of such a complex scenario.

Data from formal debriefings after the event were processed in order to learn about victim outcomes, resource utilization, critical events, and time course of the emergency response.

A total of 185 injured survivors were repatriated: four were severely wounded, 13 were moderately injured, and 168 were mildly injured. Thirty-eight people died. A forward medical team landed at the border town's airport, which provided reinforcement in the field and in the local hospital. Israeli and Egyptian search and rescue teams collaborated at the destruction site. One-hundred sixty-eight injured patients arrived at the small border hospital that rapidly organized itself for the mass-casualty incident, operating as an evacuation “staging hospital”. Twenty-three casualties secondarily were distributed to two major trauma centers in the south and the center of Israel, respectively, either by ambulance or by helicopter.

Large-scale, terrorist attacks at a peripheral border zone can be handled by international collaboration, reinforcement of medical teams at the site itself and at the peripheral neighboring hospital, rapid rearrangement of an “evacuation hospital”, and efficient transport to trauma centers by ambulances, helicopters, and other aircraft.

Emergency medical services have invested substantial resources to establish advanced life support (ALS) programs. However, it is unclear whether ALS care provides better outcomes to patients compared to basic life support (BLS) care.

To evaluate the current evidence regarding the benefits of ALS.

Electronic medical databases were searched to identify articles that directly compared ALS versus BLS care. A total of 455 articles were found. Articles were excluded for the following reasons: (1) the article was not written in English; (2) BLS response was not compared to an ALS response; (3) a physician or nurse was included as part of the ALS response; (4) it was an aeromedical response; or (5) defibrillation was included in the ALS, but not the BLS, scope of care. Twenty-one articles met the inclusion criteria for this literature review.

Results were divided into four categories: (1) trauma; (2) cardiac arrest; (3) myocardial infarction; and (4) altered mental status.

The majority of articles showed that ALS provided no benefits over BLS in urban trauma patients. In fact, most studies showed higher mortality rates for trauma patients receiving ALS care. Further research is needed to evaluate the benefits of ALS for rural trauma patients, and whether ALS care improves outcomes in subgroups of urban trauma patients.

Cardiac arrest studies show that early CPR plus early defibrillation provide the greatest improvement in survival. However, most cardiac arrest research includes defibrillation as an ALS skill which has now moved into the BLS scope of care. The 2004 multi-center OPALS study provided good evidence that ALS does not improve cardiac arrest survival over early defibrillation. Further research is needed to address whether any ALS interventions improve cardiac arrest outcome.

Only one study directly compared the outcome of BLS and ALS care on myocardial infarction. The study found no difference in outcomes between BLS and ALS care in an urban setting.

Only one study directly compared the outcome of BLS and ALS care on patients with altered mental status. The study found that the same number of patients had improved to “alert” on arrival at the emergency department, but there was a decreased length of emergency department stay for patients treated by ALS for hypoglycemia.

This review article does not take into account the benefits of ALS interventions, such as thrombolytics, dextrose, or nitroglycerin, since no studies directly compared these interventions to BLS care. Furthermore, only one study in this literature review was a large, multi-center trial.

ALS shows little, if any, benefits for urban trauma patients. Cardiac arrest studies show that ALS does not provide additional benefits over BLS-defibrillation care, but more research is needed in this area. In two small studies, ALS care did not provide benefits over BLS care for patients with myocardial infarctions or altered mental status. Larger-scale studies are needed to evaluate which specific ALS interventions improve patient outcomes.

The Advanced Life Support in Obstetrics (ALSO®) program is a highly structured, evidence-based, two-day course designed to provide healthcare professionals with the knowledge and skills to manage the emergency conditions that can occur during childbirth.

To document the number of ALSO®-trained clinicians and instructors in the United States and internationally and to promote ALSO® training among prehospital and disaster medicine professionals.

Records maintained by the American Academy of Family Physicians (AAFP) for each country where ALSO® is taught were reviewed for: (1) the years and locations of the ALSO® courses; (2) the number of ALSO®-trained caregivers; and (3) the number of ALSO® instructors.

Between 1991 and 2005, 54,071 ALSO®-trained caregivers and 2,251 instructors have completed provider and instructor ALSO® courses in 25 countries. Of these, 17,755 caregivers and 1,220 instructors are from outside the United States.

The ALSO® program is a popular, multi-disciplinary course for preparing maternity caregivers to manage obstetric emergencies. Limited evidence suggests it can be effective and efficient in enhancing the knowledge and skills of prehospital and disaster medicine clinicians. Hong Kong provides a model in which emergency physicians have taken the lead in promoting the ALSO® course. As the ALSO® program expands, additional research is needed to assess its impact on educational and health outcomes.