The world is facing the devastating impact a biological event can have on human health, economies, and political stability. COVID-19 has revealed that national governments and the international community are woefully unprepared to respond to pandemics—underscoring our shared vulnerability to future catastrophic biological threats that could meet or exceed the severe consequences of the current pandemic. This study examines potential threats related to deliberate Russian military use and misuse of the tools of modern biology or an accident caused by a CBRN event evolving rapidly in the highly volatile political environment in and around Ukraine and other conflicts.

A participatory foresight, co-creative, future and transformation-oriented methodology was used to structure a transformative model for a disciplined exploration of scenarios to confront complex challenges and facilitate improved outcomes. Foresight helps to evaluate current policy priorities and potential new policy directions; see how the impact of possible policy decisions may combine with other developments; inform, support and link policy-making in and across a range of sectors; identify future directions, emerging technologies, new societal demands and challenges; and anticipate future developments, disruptive events, risks and opportunities.

The study found that the “mitigation scenarios” are based on the “Confront, Regulate, Overcome” metamodel combined with the “Security, Rescue, Care” response modalities. These require the cooperation/coordination of law enforcement forces along with military forces, fire departments and civil security resources, hospital and first-line responder teams, in order to appropriately address populations, assets and territories issues elicited by the identified threat, which drives key decision makers’ tasks at the strategic level.

The participatory foresight exercise demonstrated gaps in national and international biosecurity and pandemic preparedness architectures highlighted by the challenges of the Ukraine war—exploring opportunities for better cooperation to improve prevention and response capabilities for high-consequence biological events, and generate actionable recommendations for the international community.

Emergency department (ED) staff in Belgium is simultaneously involved in patient care in the ED and in prehospital interventions as part of a Mobile Medical Team (MMT) or a Paramedic Intervention Team (PIT). There is a growing concern that the MMT is often over-qualified for the prehospital interventions they are dispatched to, while their absence from the ED results in insufficient human resources there.

The current study aims to investigate whether this perception is correct in the EDs of two different regions, while also examining the differences between a two-tiered (2T) and a three-tiered (3T) Emergency Medical Services (EMS) region.

A specially developed and pre-tested registration form was completed by physicians and nurses before and after each MMT intervention. The form included information on the composition of the MMT, the perceived need for MMT intervention pre-departure from the ED, the subjective appreciation of the need for the MMT after an intervention, and the therapeutic intervention(s) performed, in order to obtain a more objective appreciation of the actual need for an MMT. Data from a 2T and a 3T region were analyzed to rate the appropriateness of the interventions.

Although the 2T and 3T regions showed differences regarding MMT composition, dispatching, and logistics, the outcome of the study was identical in both regions. Before the intervention, physicians and nurses estimated that the MMT intervention would not be necessary in 37.7% of cases. However, following the intervention, it was subjectively deemed unnecessary in 65.7% of cases. Based on therapeutic interventions performed, the MMT was viewed as being over-qualified for carrying these out in 85.6% of cases. Post-intervention, the initial prediction that the MMT was over-qualified for the call was confirmed by the same physicians and nurses in 87.6% of cases, whilst their prediction was correct in 92.8% of cases in terms of the intervention that was carried out.

In two different Belgian regions, the MMT is over-qualified in a vast majority of interventions. Physicians and nurses within the MMT can generally already predict that the MMT is over-qualified when leaving the ED. These findings suggest that there may be significant opportunities to improve the efficacy of human resources in the ED once there are less interventions carried out by an over-qualified MMT.

Many Emergency Medical Service (EMS) systems in the United States restrict albuterol therapy by scope of practice to Advanced Life Support (ALS). The State of Delaware has a two-tiered EMS system in which Basic Life Support (BLS) arrives on scene prior to ALS in the majority of respiratory distress calls.

This study sought to evaluate the safety, efficacy, and expedience of albuterol administration by BLS compared to ALS.

This retrospective observational study used data collected from July 2015 through January 2017 throughout a State BLS albuterol pilot program. Pilot BLS agencies participated in a training session on the indications and administration of albuterol, and were then authorized to carry and administer nebulized albuterol. Heart rate (HR), respiratory rate (RR), and pulse oximetry (spO2) were obtained before and after albuterol administration by BLS and ALS. The times from BLS arrival to the administration of albuterol by pilot BLS agencies versus ALS were compared. Study encounters required both BLS and ALS response. Data were analyzed using chi-square and t-test as appropriate.

Three hundred eighty-eight (388) incidents were reviewed. One hundred eighty-five (185) patients received albuterol by BLS pilot agencies and 203 patients received albuterol by ALS. Of note, the population treated by ALS was significantly older than the population treated by BLS (61.9 versus 51.6 years; P <.001). A comparison of BLS arrival time to albuterol administration time showed significantly shorter times in the BLS pilot group compared to the ALS group (3.50 minutes versus 8.00 minutes, respectively; P <.001). After albuterol administration, BLS pilot patients showed improvements in HR (P <.01), RR (P <.01), and spO2 (P <.01). Alternately, ALS treatment patients showed improvement in spO2 (P <.01) but not RR (P = .17) or HR (P = 1.00). Review by ALS or hospital staff showed albuterol was indicated in 179 of 185 BLS patients and administered correctly in 100% of these patients.

Patients both received albuterol significantly sooner and showed superior improvements in vital signs when treated by BLS agencies carrying albuterol rather than by BLS agencies who required ALS arrival for albuterol. Two-tiered EMS systems should consider allowing BLS to carry and administer albuterol for safe, effective, and expedient treatment of respiratory distress patients amenable to albuterol therapy.

The coronavirus disease 2019 (COVID-19) pandemic had important consequences on the health system. Emergency Medical Services (EMS) were a key element in the response and were forced to modify their daily procedures. The main objective of this study was to find out if there were differences in response times and in the profile of patients treated by the Advanced Life Support (ALS) units of Servicio de Asistencia Médica Urgente (SAMU)-Asturias, the EMS of the Principality of Asturias, between the pre-pandemic period and the pandemic period.

This was a descriptive, cross-sectional, observational, and retrospective study that included all patients treated by SAMU-Asturias ALS from January 1, 2019 through December 31, 2020.

The pandemic has had an impact on daily activity of SAMU-Asturias, with a 9.2% decrease in daily ALS services during the pandemic, longer prehospital times during the pandemic period (mean = 54’35”; SD = 0’48”; P = 0.00) mainly due to an increase in scene time (mean = 28’01”; SD = 12’57”; P = 0.00), and a slight increase in the average age of patients during the pandemic in relation to the pre-pandemic period. No differences were found between the types of incidents for ALS or between the resolution of the patients.

The COVID-19 pandemic mainly affects prehospital times in an emergency service, with no differences being observed in types of incidents; in EMS future pandemic planning, this should be taken into consideration.

Disaster Medicine (DM) is the clinical specialty whose expertise includes the care and management of patients and populations outside conventional care protocols. While traditional standards of care assume the availability of adequate resources, DM practitioners operate in situations where resources are not adequate, necessitating a modification in practice. While prior academic efforts have succeeded in developing a list of core disaster competencies for emergency medicine residency programs, international fellowships, and affiliated health care providers, no official standardized curriculum or consensus has yet been published to date for DM fellowship programs based in the United States.

The objective of this work is to define the core curriculum for DM physician fellowships in the United States, drawing consensus among existing DM fellowship directors.

A panel of DM experts was created from the members of the Council of Disaster Medicine Fellowship Directors. This council is an independent group of DM fellowship directors in the United States that have met annually at the American College of Emergency Physicians (ACEP)’s Scientific Assembly for the last eight years with meeting support from the Disaster Preparedness and Response Committee. Using a modified Delphi technique, the panel members revised and expanded on the existing Society of Academic Emergency Medicine (SAEM) DM fellowship curriculum, with the final draft being ratified by an anonymous vote. Multiple publications were reviewed during the process to ensure all potential topics were identified.

The results of this effort produced the foundational curriculum, the 2023 Model Core Content of Disaster Medicine.

Members from the Council of Disaster Medicine Fellowship Directors have developed the 2023 Model Core Content for Disaster Medicine in the United States. This living document defines the foundational curriculum for DM fellowships, providing the basis of a standardized experience, contributing to the development of a board-certified subspecialty, and informing fellowship directors and DM practitioners of content and topics that may appear on future certification examinations.

Due to climate change, many countries are exploring nuclear power as a clean, sustainable, and alternative energy source. However, radiophobia stemming from a history of major accidents at nuclear power plants (most recently Fukushima Daiichi) inhibits the expansion of this industry. In an unlikely event of a large-scale accident, the risks posed to humans are minimal when mitigation measures are followed. This includes appropriate Personal Protective Equipment (PPE) for first responders, and medical professionals responding to these emergencies. An examination of the PPE recommendations for these scenarios will highlight best practices for minimizing exposures, and the effects of radiation.

A systematic literature review will provide a historical baseline of the PPE worn during previous nuclear power plant events. Additionally, current recommendations for PPE levels in response to these emergencies will be explored. Five databases will be utilized for this study, including PubMed, Web of Science, and SCOPUS.

Many studies examine different types of nuclear radiological exposures, but few focus on nuclear power plant scenarios. More than 5,000 articles emerged from a preliminary survey of the five databases. However, less than 1% of them satisfied the extraction criteria, and reviewed PPE for nuclear power plant accidents. Medical responders caring for “exposed” individuals who present at Emergency Departments have minimal exposure once they’re decontaminated, and everyday PPE is maintained. However, data on PPE recommendations for on-site response remains unexplored. Airtight suits and full-face respirators emerged as industry gold standard for protection, but a closer examination of these types of suits, and responders' self-efficacy utilizing the gear would clarify their actual protective qualities.

While nuclear power plant accidents do not occur often, many remain fearful of their impact. Maintaining proper PPE (including respiratory habiliment) for event responders is one way to minimize the adverse health effects of these nuclear radiological exposures.

This study aims to determine and compare the effectiveness of Drop, Cover, and Hold On versus Fetal Position in the Triangle of Life regarding reducing casualties during earthquakes and establishing a consensus among medical search and rescue experts.

In this study, the data collected from ten experienced medical search and rescue professionals were analyzed using a three-stage Delphi technique to compare Drop, Cover, and Hold On versus Fetal Position in the Triangle of Life.

At the end of the first round of Delphi, all of the experts mentioned the following factors: age, position, and surface area of the injured person. A victim’s time under rubble and the experience of search and rescue teams are two prominent factors related to search and rescue. After the earthquake simulation in the second round, mannequin damage rates were examined by opening rubble pavement and tunnels. Following the second round of ratings, a third round of questionnaires was administered. As part of this questionnaire, participants were asked to give a score from one to ten based on their level of agreement. Whether they agreed or disagreed with Fetal Position in the Triangle of Life and Drop, Cover, and Hold On using a ten-point Likert scale, and the agreement rates were measured and compared. Experts completed a comparison of the two positions in the third round.

According to this expert consensus, the Fetal Position in the Triangle of Life has the following advantages over Drop, Cover, and Hold On: reduced surface area, less crush injuries, protection of a larger body part from injury, better protection from hypothermia, and better maintenance of basal metabolism.

During a major earthquake, escape attempts or collapsed buildings can result in injury, disability, and even death for victims. The aim of this study is to examine the demographic characteristics, clinical outcomes, and injuries of victims admitted to the emergency department within the first week after an earthquake.

This is a retrospective observational study conducted on earthquake victims who were admitted to the emergency services of a tertiary medical faculty and a training and research hospital in the city of Diyarbakir, located in the Southeastern Anatolia Region of Turkey, from February 6 through February 12, 2023.

Of the eligible 662 earthquake victims, the mean age was 10.66 (SD = 4.78 [min 0, max 17]) in children, 36.87 (SD = 4.78 [min 18, max 63]) in adults, and 72.85 (SD = 5.83 [min 65, max 84]) in the elderly. Women constituted 52.8% of the victims, 19.7% were children, and 8.0% were elderly. Sixty-one percent (61.0%) of earthquake victims were admitted to emergency services in the first three days following the disaster; 37.7% of all victims were transferred from other affected cities to Diyarbakır. In all, 80.2% of the victims were admitted as survivors to the emergency services (36.8% were rescued under rubble, 40.1% with injuries while attempting to escape the earthquake, and 3.3% with nontraumatic reasons) and 19.8% were deceased under rubble. The majority of the 131 deceased victims were women (52.7%), 20.6% were children, and 7.6% were elderly. An estimated 38.3% of victims were hospitalized (20.9% in the ward and 17.4% in the intensive care unit [ICU]). For all age groups that survived under the rubble, the extremities were most injured (53.6% for children, 53.1% for adults, and 55.5% for the elderly). Of adult survivors, 26.6% needed only fluid therapy, renal replacement treatment (hemodialysis) was required 20.7%, and 11.8% required amputation. Of children survivors under the rubble, renal replacement treatment (hemodialysis) was required for only four, seven required amputation, and 12 needed only fluid resuscitation for crush injury. Of elderly survivors, two needed only fluid therapy, renal replacement treatment (hemodialysis) was required for two, and no amputation was required. Six patients survived under the rubble and died in the ICU.

The definition of the demographic characteristics and clinical outcomes of earthquake patients is critical to the development of preparedness, response, and recovery policies for future disasters.

Terrorism remains a major threat and concern in many countries around the world. Pediatric populations represent approximately 30% of the world population, and in the event of a terrorist attack, can either be primary targets, to include the possibility of abduction, or unintended victims. They are unique in their vulnerabilities and, therefore, require special consideration.

This study is a semi-quantitative, epidemiological analysis of all terrorism-related pediatric fatalities and injuries sustained from 1970-2019. Data collection was performed using a retrospective database search through the Global Terrorism Database (GTD). Summaries of events including search terms associated with pediatric population were individually reviewed and those describing the deaths, injuries, or abductions were tallied.

Of the over 200,000 terror events, 2,302 events met inclusion criteria. This represented 1.14% of total events which involved death, injury, or abduction. Of 2,032 events, a total of 2,275 pediatric fatal injuries (FI) were recorded, as well as 2,280 pediatric non-fatal injuries (NFI). The most common weapons used in all attacks involving the pediatric population were explosives (1,539 [66.8%]), firearms (543 [23.5%]), other (169 [7.3%]), and melee (83 [3.6%]). A total of 275 of the 2,032 events were related to abductions, with 71 cases involving the abduction of 10 individuals or more.

Pediatric casualties in terrorist events represent a small proportion of overall victims. However, it should be understood that the pediatric population has unique vulnerabilities, and when directly impacted by terrorism, can have long-term physical and psychosocial sequelae, as well as a devastating emotional impact on the community.

This study aims to explore the evaluation of lactic acid (Lac) and neutrophil gelatinase-associated lipocalin (NGAL) on the condition and prognosis of patients with diquat (DQ) poisoning.

A total of 79 cases of DQ poisoning treated in one hospital from January 2019 through February 2023 were included: 10 cases of mild poisoning, 49 cases of moderate to severe poisoning, and 20 cases of fulminant poisoning. According to the Kidney Disease: Improving Global Outcomes-acute kidney injury (KDIGO-AKI) criteria, the patients were divided into 60 cases in the AKI group and 19 cases in the non-acute kidney injury (NAKI) group. According to the AKI diagnostic indicators, AKI patients were divided into Grade I, Grade II, and Grade III. According to prognosis, the patients were divided into survivor group and non-survivor group. During the same period, 30 healthy subjects were selected as the healthy group. The changes of blood Lac, NGAL, cystatin C (CysC), and serum creatinine (Scr) levels of patients were detected, the 28-day survival of patients was recorded, and the correlation between blood Lac, NGAL levels, and renal injury grade in patients with AKI caused by DQ poisoning was analyzed. The receiver operator characteristic (ROC) curve was used to evaluate the predictive value and prognostic value of Lac, NGAL, and their combination in patients with AKI caused by DQ poisoning.

There were significant differences in AKI grade, Lac, NGAL, CysC, and Scr levels among different degrees of poisoning groups (P < .05). There were significant differences in the levels of Lac, NGAL, CysC, and Scr among patients with different AKI grades (P < .05). The levels of Lac, NGAL, CysC, and Scr in the survivor group were significantly lower than those in the non-survivor group (P < .05). The blood Lac and NGAL levels were positively correlated with AKI grades in patients with DQ poisoning (r = 0.752, 0.836; P = .000, .000). The combined detection of blood Lac and NGAL had higher predictive value for AKI and assessed value for death in DQ poisoning than either of them alone.

The combined detection of Lac and NGAL have a certain clinical value in AKI grading and evaluating AKI prognosis caused by DQ poisoning.

Out-of-hospital cardiac arrest (OHCA) is a significant global cause of mortality, and Emergency Medical Services (EMS) response interval is critical for survival and a neurologically-favorable outcome. Currently, it is unclear whether EMS response interval, neurologically-intact survival, and overall survival differ between snowy and non-snowy periods at heavy snowfall areas.

A nation-wide population-based cohort of OHCA patients, registered from 2017 through 2019 in the All-Japan Utstein Registry, was divided into four groups according to areas (heavy snowfall area or other area) and seasons (winter or non-winter): heavy snowfall-winter, heavy snowfall-non-winter, other area-winter, and other area-non-winter. The first coprimary outcome was EMS response interval, and the secondary coprimary outcome was one-month survival and a neurologically-favorable outcome at one month.

A total of 337,781 OHCA patients were divided into four groups: heavy snowfall-winter (N = 15,627), heavy snowfall-non-winter (N = 97,441), other area-winter (N = 32,955), and other area-non-winter (N = 191,758). Longer EMS response intervals (>13 minutes) were most likely in the heavy snowfall-winter group (OR = 1.86; 95% CI, 1.76 to 1.97), and also more likely in heavy snowfall areas in non-winter (OR = 1.44; 95% CI, 1.38 to 1.50). One-month survival in winter was worse not only in the heavy snowfall area (OR = 0.86; 95% CI, 0.78 to 0.94) but also in other areas (OR = 0.91; 95% CI, 0.87 to 0.94). One-month neurologically-favorable outcomes were also comparable between heavy snowfall-winter and other area-non-winter groups.

This study showed OHCA in heavy snowfall areas in winter resulted in longer EMS response intervals. However, heavy snowfall had little effect on one-month survival or neurologically-favorable outcome at one month.

An exhausted, isolated, increasingly desperate Russia, still in possession of over 4,400 nuclear warheads, puts the world at risk. Since the outbreak of war in Ukraine, Russian rhetoric and military doctrine have evinced an increasing nonchalance toward the employment of tactical nuclear weapons as stockpiles of conventional weapons are depleted. Poor targeting control (or outright perfidy), demonstrated by recent events in Poland possibly violating NATO’s collective defense clause, have only incensed an imminently combustible situation. Given this threat, it behooves medical professionals to gain thorough acquaintance with Acute Radiation Sickness (ARS), including an assessment of sources of exposure, presentation, prognostic indicators, immediate treatments, long-term concerns, and sources of consultant support.

Through thorough review of military and civilian sources, training courses, historical cases, injury mechanisms, first-responder concerns, hospitalization parameters, and laboratory indicators, the ARS spectrum will be explored. Surgical, anesthetic, and intensive care implications will be discussed, as will infection and nutritional concerns. Emerging practices, specialized therapy, and long-term medical sequelae will be covered.

A thorough discussion of potential sources (civil and military), clinical recognition, and presentation of ARS will focus on best clinical guidance, providing the most up-to-date treatment strategies, and will give clear guidance regarding how best to prepare, treat, and obtain specialist consultation.

It is the earnest hope of the presenter (a senior naval physician with nuclear power experience, anesthesiology consultant/board examiner, and intensivist, who studied radiation safety and injury for much of his career and wrote a Diploma in the Medical Care of Catastrophes dissertation on radiologic injury management) that the audience will never face the horror of a single radiologic casualty. However, the likelihood of such wishful thinking seems as remote as ever. Attendees will not only learn guidance for treatment and prognostication, but will know how to obtain support and expert consultation.

Emergency medical technicians (EMTs) and paramedics respond to 40 million calls for assistance every year in the United States; these paramedicine clinicians are a critical component of the nation’s health care, disaster response, public safety, and public health systems. The study objective is to identify the risks of occupational fatalities among paramedicine clinicians working in the United States.

To determine fatality rates and relative risks, this cohort study focused on 2003 through 2020 data of individuals classified as EMTs and paramedics by the United States Department of Labor (DOL). Data provided by the DOL and accessed through its website were used for the analyses. The DOL classifies EMTs and paramedics who have the job title of fire fighter as fire fighters and so they were not included in this analysis. It is unknown how many paramedicine clinicians employed by hospitals, police departments, or other agencies are classified as health workers, police officers, or other and were not included in this analysis.

An average of 206,000 paramedicine clinicians per year were employed in the United States during the study period; approximately one-third were women. Thirty percent (30%) were employed by local governments. Of the 204 total fatalities, 153 (75%) were transportation-related incidents. Over one-half of the 204 cases were classified as “multiple traumatic injuries and disorders.” The fatality rate for men was three-times higher than for women (95% confidence interval [CI], 1.4 to 6.3). The fatality rate for paramedicine clinicians was eight-times higher than the rate for other health care practitioners (95% CI, 5.8 to 10.1) and 60% higher than the rate for all United States workers (95% CI, 1.24 to 2.04).

Approximately 11 paramedicine clinicians are documented as dying every year. The highest risk is from transportation-related events. However, the methods used by the DOL for tracking occupational fatalities means that many cases among paramedicine clinicians are not included. A better data system, and paramedicine clinician-specific research, are needed to inform the development and implementation of evidence-based interventions to prevent occupational fatalities. Research, and the resulting evidence-based interventions, are needed to meet what should be the ultimate goal of zero occupational fatalities for paramedicine clinicians in the United States and internationally.