While suicide bombings in the context of warfare have existed throughout history, there was an exponential rise in such attacks in the decade following the initiation of the War on Terror. The health care implications of such attacks are a growing concern across the emergency response sector, and this study is an epidemiological examination of all terrorism-related bombings sustained from 1970-2019, comparing the rates of fatal injuries (FI) and non-fatal injuries (NFI) between suicide bombing attacks (SBA) versus non-suicide bombing attacks (NSBA).

Data collection was performed using a retrospective database search through the Global Terrorism Database (GTD). The GTD database was downloaded and searched using the internal database search functions for all events that occurred from January 1, 1970 - December 31, 2019. Bombing/explosion as a primary “attack type” and explosives as a primary “weapon type” were selected for the purpose of this study, and events were further sub-classified as either “suicide attack” or “non-suicide attack.” Results were exported into an Excel spreadsheet (Microsoft Corp.; Redmond, Washington USA) for analysis.

There were 82,217 bombing/explosion terrorist attacks using explosives documented during the study period with 135,807 fatalities and 352,500 NFI.

A total of 5,416 events (6.59% of all events) were sub-classified as SBA causing 52,317 FI (38.52% of all FI) and 107,062 NFI (30.37% of all NFI).

Mean SBA FI was 9.66 per event and mean SBA NFI was 19.77 per event compared to a mean NSBA FI of 1.09 per event and mean NSBA NFI of 3.20 per event.

Suicide bombing attacks are a unique terrorist methodology that can inflict wide-spread psychological damage as well as significantly higher death and injury tolls when compared to more traditional NSBA. They have been increasing in popularity amongst terrorist organizations and groups, and Counter-Terrorism Medicine (CTM) specialists need to be aware of the unique injury patterns and potential risk mitigation strategies associated with SBA depending on the target type, location, and gender of the perpetrator.

Cultural awareness is an important part of organizational success when interacting with multiple cultures. Research has shown a dearth of standardized cultural awareness training programs for non-governmental humanitarian organization staff.

This study aims to develop an expert-consensus set of cultural awareness competencies as the basis for development of humanitarian staff cultural awareness trainings.

A modified Delphi process was selected. The first round of surveys collected a list of cultural awareness competencies from experts in the fields of non-governmental organization (NGO) operations and cultural awareness education and research. This collated list of competencies was then used as the basis of a survey obtaining ratings by the group on a five-point Likert scale. Competencies which achieved an average rating of 4.0 or higher were considered to be “important” for inclusion in future training programs.

A total of 67.9% of contacted experts agreed to participate, with 84.2% of those completing all rounds of the survey. This group developed a list of ten competencies, including: Cultural Awareness/Sensitivity and Intercultural Communication; Cultural Intelligence; Unconscious Bias/Diversity Awareness; a Universal Declaration of Ethical Principles; Gender and Lesbian, Gay, Bisexual, Transgender, Queer, and Other Sexual Identities (LGBTQ+) Issues and Safety; Analytical and Critical Thinking Skills; Negotiation; Program Mission; Power Dynamics; and Empathy.

This study defined a set of ten expert-consensus cultural awareness competencies which can be a basis for future NGO staff training. Future work can both use these competencies to create educational programs and further define and expand the set of competencies based on analyses of their implementation.

Some studies in countries affected by the coronavirus disease of 2019 (COVID-19) pandemic have shown that the missions of Emergency Medical Service (EMS) have changed during the COVID-19 pandemic, and the rate of death and out-of-hospital cardiac arrest (OHCA) has been increased due to the direct and indirect effects of COVID-19.

The aim of this study was to determine the effect of the COVID-19 pandemic on the process of EMS missions, death, and OHCA.

This cross-sectional study was performed in Tehran, Iran. All conducted missions in the first six months of the three consecutive solar years of March 21 until September 22 of 2018-2020, which were registered in the registry bank of the Tehran EMS center, were assessed and compared. Based on the opinion of experts, the technician’s on-scene diagnoses were categorized into 14 groups, and then death and OHCA cases were compared.

In this study, the data of 1,050,376 missions performed in three study periods were analyzed. In general, the number of missions in 2020 was 17.83% fewer than that of 2019 (P < .001); however, the number of missions in 2019 was 30.33% more than that of 2018. On the other hand, the missions of respiratory problems, cardiopulmonary arrest, infectious diseases, and poisoning were increased in 2020 compared to that of 2019. The raw number of OHCA and death cases respectively in 2018, 2019, and 2020 were 25.0, 22.7, and 28.6 cases per 1,000 missions. Of all patients who died in 2020, 4.9% were probable/confirmed COVID-19 cases. The history of heart disease, hypertension, diabetes, and respiratory disease in patients in 2020 was more frequent than that of the other two years.

This study showed that the number of missions in the Tehran EMS in 2020 were decreased compared to that of 2019, however the number of missions in 2019 was more than that of 2018. Respiratory problems, infectious diseases, poisoning, death, and OHCA were increased compared to the previous two years and cardiovascular complaints, neurological problems, and motor vehicle collisions (MVCs) in 2020 were fewer than that of the other two years

Different disaster activities should be performed smoothly. In relation to this, human resources for disaster activities must be secured. To achieve a stable supply of human resources, it is essential to improve the intentions of individuals responding to each type of disaster. However, the current intention of Disaster Medical Assistance Team (DMAT) members has not yet been assessed.

To facilitate a smooth disaster response, this survey aimed to assess the intention to engage in each type of disaster activity among DMAT members.

An anonymous web questionnaire survey was conducted. Japanese DMAT members in the nuclear disaster-affected area (Group A; n = 79) and the non-affected area (Group N; n = 99) were included in the analysis. The outcome was the answer to the following question: “Will you actively engage in activities during natural, human-made, and chemical (C), biological (B), radiological/nuclear (R/N), and explosive (E) (CBRNE) disasters?” Then, questionnaire responses were compared according to disaster type.

The intention to engage in C (50), B (47), R/N (58), and E (52) disasters was significantly lower than that in natural (82) and human-made (82) disasters (P <.001). The intention to engage in CBRNE disasters among younger participants (age ≤39 years) was significantly higher in Group A than in Group N. By contrast, the intention to engage in R/N disasters alone among older participants (age ≥40 years) was higher in Group A than in Group N. However, there was no difference between the two groups in terms of intention to engage in C, B, and E disasters. Moreover, the intention to engage in all disasters between younger and older participants in Group A did not differ. In Group N, older participants had a significantly higher intention to engage in B and R/N disasters.

Experience with a specific type of calamity at a young age may improve intention to engage in not only disasters encountered, but also other types. In addition, the intention to engage in CBRNE disasters improved with age in the non-experienced population. To respond smoothly to specific disasters in the future, measures must be taken to improve the intention to engage in CBRNE disasters among DMAT members.

As the understanding of health care worker lived experience during coronavirus disease 2019 (COVID-19) grows, the experiences of those utilizing emergency health care services (EHS) during the pandemic are yet to be fully appreciated.

The objective of this research was to explore lived experience of EHS utilization in Victoria, Australia during the COVID-19 pandemic from March 2020 through March 2021.

An explorative qualitative design underpinned by a phenomenological approach was applied. Data were collected through semi-structured, in-depth interviews, which were transcribed verbatim and analyzed using Colaizzi’s approach.

Qualitative data were collected from 67 participants aged from 32 to 78-years-of-age (average age of 52). Just over one-half of the research participants were male (54%) and three-quarters lived in metropolitan regions (75%). Four key themes emerged from data analysis: (1) Concerns regarding exposure and infection delayed EHS utilization among participants with chronic health conditions; (2) Participants with acute health conditions expressed concern regarding the impact of COVID-19 on their care, but continued to access services as required; (3) Participants caring for people with sensory and developmental disabilities identified unique communication needs during interactions with EHS during the COVID-19 pandemic; communicating with emergency health care workers wearing personal protective equipment (PPE) was identified as a key challenge, with face masks reported as especially problematic for people who are deaf or hard-of-hearing; and (4) Children and older people also experienced communication challenges associated with PPE, and the need for connection with emergency health care workers was important for positive lived experience during interactions with EHS throughout the pandemic.

This research provides an important insight into the lived experience of EHS utilization during the COVID-19 pandemic, a perspective currently lacking in the published peer-reviewed literature.

Excited delirium, which has been defined as combativeness, agitation, and altered sensorium, requires immediate treatment in prehospital or emergency department (ED) settings for the safety of both patients and caregivers. Prehospital ketamine use is prevalent, although the evidence on safety and efficacy is limited. Many patients with excited delirium are intoxicated with illicit substances. This investigation explores whether patients treated with prehospital ketamine for excited delirium with concomitant substance intoxication have higher rates of subsequent intubation in the ED compared to those without confirmed substance usage.

Over 28 months at two large community hospitals, all medical records were retrospectively searched for all patients age 18 years or greater with prehospital ketamine intramuscular (IM) administration for excited delirium and identified illicit and prescription substance co-ingestions. Trained abstractors collected demographic characteristics, history of present illness (HPI), urine drug screens (UDS), alcohol levels, and noted additional sedative administrations. Substance intoxication was determined by UDS and alcohol positivity or negativity, as well as physician HPI. Patients without toxicological testing or documentation of substance intoxication, or who may have tested positive due to ED sedation, were excluded from relevant analyses. Subsequent ED intubation was the primary pre-specified outcome. Odds ratios (OR) and 95% confidence intervals (CI) were calculated to compare variables.

Among 86 patients given prehospital ketamine IM for excited delirium, baseline characteristics including age, ketamine dose, and body mass index were similar between those who did or did not undergo intubation. Men had higher intubation rates. Patients testing positive for alcohol, amphetamines, barbiturates, benzodiazepines, ecstasy, marijuana, opiates, and synthetic cathinones, both bath salts and flakka, had similar rates of intubation compared to those negative for these substances. Of 27 patients with excited delirium and concomitant cocaine intoxication, nine (33%) were intubated compared with four of 50 (8%) without cocaine intoxication, yielding a 5.75 OR (95%, CI 1.57 to 21.05; P = .009).

Patients treated with ketamine IM for excited delirium with concomitant cocaine intoxication had a statistically significant 5.75-fold increased rate of subsequent intubation in the ED. Amongst other substances, no other trends with intubation were noted, but further study is warranted.

Out-of-hospital cardiac arrest (OHCA) is a life-threatening condition with an overall survival rate that generally does not exceed 10%. Several factors play essential roles in increasing survival among patients experiencing cardiac arrest outside the hospital. Previous studies have reported that implementing a dispatcher-assisted cardiopulmonary resuscitation (DA-CPR) program increases bystander CPR, quality of chest compressions, and patient survival. This study aimed to assess the effectiveness of a DA-CPR program developed by the Thailand National Institute for Emergency Medicine (NIEMS).

This was an experimental study using a manikin model. The participants comprised both health care providers and non-health care providers aged 18 to 60 years. They were randomly assigned to either the DA-CPR group or the uninstructed CPR (U-CPR) group and performed chest compressions on a manikin model for two minutes. The sequentially numbered, opaque, sealed envelope method was used for randomization in blocks of four with a ratio of 1:1.

There were 100 participants in this study (49 in the DA-CPR group and 51 in the U-CPR group). Time to initiate chest compressions was statistically significantly longer in the DA-CPR group than in the U-CPR group (85.82 [SD = 32.54] seconds versus 23.94 [SD = 16.70] seconds; P <.001). However, the CPR instruction did not translate into better performance or quality of chest compressions for the overall sample or for health care or non-health care providers.

Those in the CPR-trained group applied chest compressions (initiated CPR) more quickly than those who initiated CPR based upon dispatch-based CPR instructions.

Over the past decade, Emergency Medical Service (EMS) systems decreased backboard use as they transition from spinal immobilization (SI) protocols to spinal motion restriction (SMR) protocols. Since this change, no study has examined its effect on the neurologic outcomes of patients with spine injuries.

The object of this study is to determine if a state-wide protocol change from an SI to an SMR protocol had an effect on the incidence of disabling spinal cord injuries.

This was a retrospective review of patients in a single Level I trauma center before and after a change in spinal injury protocols. A two-step review of the record was used to classify spinal cord injuries as disabling or not disabling. A binary logistic regression was used to determine the effects of protocol, gender, age, level of injury, and mechanism of injury (MOI) on the incidence of significant disability from a spinal cord injury.

A total of 549 patients in the SI period and 623 patients in the SMR period were included in the analysis. In the logistic regression, the change from an SI protocol to an SMR protocol did not demonstrate a significant effect on the incidence of disabling spinal injuries (OR: 0.78; 95% CI, 0.44 - 1.36).

This study did not demonstrate an increase in disabling spinal cord injuries after a shift from an SI protocol to an SMR protocol. This finding, in addition to existing literature, supports the introduction of SMR protocols and the decreased use of the backboard.

Securing the airway is a crucial stage of trauma care. Cricothyroidotomy (CRIC) is often addressed as a salvage procedure in complicated cases or following a failed endotracheal intubation (ETI). Nevertheless, it is a very important skill in prehospital settings, such as on the battlefield.

This study aimed to review the Israel Defense Forces (IDF) experience with CRIC over the past two decades.

The IDF Trauma Registry (IDF-TR) holds data on all trauma casualties (civilian and military) cared for by military medical teams since 1997. Data of all casualties treated by IDF from 1998 through 2018 were extracted and analyzed to identify all patients who underwent CRIC procedures.

Variables describing the incident scenario, patient’s characteristics, injury pattern, treatment, and outcome were extracted. The success rate of the procedure was described, and selected variables were further analyzed and compared using the Fisher’s-exact test to identify their effect on the success and failure rates. Odds Ratio (OR) was further calculated for the effect of different body part involvement on success and for the mortality after failed ETI.

One hundred fifty-three casualties on which a CRIC attempt was made were identified from the IDF-TR records. The overall success rate of CRIC was reported at 88%. In patients who underwent one or two attempts, the success rate was 86%. No difference was found across providers (physician versus paramedic). The CRIC success rates for casualties with and without head trauma were 80% and 92%, respectively (P = .06). Overall mortality was 33%.

This study shows that CRIC is of merit in airway management as it has shown to have consistently high success rates throughout different levels of training, injuries, and previous attempts with ETI. Care providers should be encouraged to retain and develop this skill as part of their tool box.

Mass-casualty incident (MCI) algorithms are used to sort large numbers of patients rapidly into four basic categories based on severity. To date, there is no consensus on the best method to test the accuracy of an MCI algorithm in the pediatric population, nor on the agreement between different tools designed for this purpose.

This study is to compare agreement between the Criteria Outcomes Tool (COT) to previously published outcomes tools in assessing the triage category applied to a simulated set of pediatric MCI patients.

An MCI triage category (black, red, yellow, and green) was applied to patients from a pre-collected retrospective cohort of pediatric patients under 14 years of age brought in as a trauma activation to a Level I trauma center from July 2010 through November 2013 using each of the following outcome measures: COT, modified Baxt score, modified Baxt combined with mortality and/or length-of-stay (LOS), ambulatory status, mortality alone, and Injury Severity Score (ISS). Descriptive statistics were applied to determine agreement between tools.

A total of 247 patients were included, ranging from 25 days to 13 years of age. The outcome of mortality had 100% agreement with the COT black. The “modified Baxt positive and alive” outcome had the highest agreement with COT red (65%). All yellow outcomes had 47%-53% agreement with COT yellow. “Modified Baxt negative and <24 hours LOS” had the highest agreement with the COT green at 89%.

Assessment of algorithms for triaging pediatric MCI patients is complicated by the lack of a gold standard outcome tool and variability between existing measures.

To validate the Belgian Plan Risk Manifestations (PRIMA) model, actual patient presentation rates (PPRs) from Belgium’s largest football stadium were compared with predictions provided by existing models and the Belgian PRIMA model.

Actual patient presentations gathered from 41 football games (2010-2019) played at the King Baudouin Stadium (Brussels, Belgium) were compared with predictions by existing models and the PRIMA model. All attendees who sought medical help from in-event health services (IEHS) in the stadium or called 1-1-2 within the closed perimeter around the stadium were included. Data were analyzed by ANOVA, Pearson correlation tests, and Wilcoxon singed-rank test.

A total of 1,630,549 people attended the matches, with 626 people needing first aid. Both the PRIMA and the Hartman model over-estimated the number of patient encounters for each occasion. The Arbon model under-estimated patient encounters for 9.75% (95% CI, 0.49-19.01) of the events. When comparing deviations in predictions between the PRIMA model to the other models, there was a significant difference in the mean deviation (Arbon: Z = −5.566, P <.001, r = −.61; Hartman: Z = −4.245, P <.001, r = .47).

When comparing the predicted patient encounters, only the Arbon model under-predicted patient presentations, but the Hartman and the PRIMA models consistently over-predicted. Because of continuous over-prediction, the PRIMA model showed significant differences in mean deviation of predicted PPR. The results of this study suggest that the PRIMA model can be used during planning for domestic and international football matches played at the King Baudouin Stadium, but more data and further research are needed.

Paramedics commonly administer intravenous (IV) dextrose to severely hypoglycemic patients. Typically, the treatment provided is a 25g ampule of 50% dextrose (D50). This dose of D50 is meant to ensure a return to consciousness. However, this dose may cause harm and lead to difficulties regulating blood glucose levels (BGLs) post-treatment. It is hypothesized that a lower concentration, such as 10% dextrose (D10), may improve symptoms while minimizing harm.

PubMed, Embase, CINAHL, and Cochrane Central were systematically searched on September 15, 2020. The PRISMA guidelines were followed. GRADE and risk of bias were applied to determine the certainty of the evidence. Primary literature investigating the use of IV dextrose in hypoglycemic diabetic patients presenting to paramedics or the emergency department was included. Outcomes of interest included safety, efficacy (symptom resolution), and BGL.

Of 680 abstracts screened, 51 full-text articles were reviewed, with eleven studies included. Data from three randomized controlled trials (RCTs) and eight observational studies were analyzed. A single RCT comparing D10 to D50 was identified. The primary significant finding of the study was an increased post-treatment glycemic profile by 3.2mmol/L in the D50 group; no other outcomes had significant differences between groups. When comparing pooled data from all the included studies, there was greater symptom resolution in the D10 group (95.9%) compared to the D50 group (88.8%). However, the mean time to resolution was approximately four minutes longer in the D10 group (4.1 minutes [D50] versus 8.0 minutes [D10]). There was a greater need for subsequent doses with the use of D10 (19.5%) compared to D50 (8.1%). The post-treatment glycemic profile was lower in the D10 group at 6.2mmol/L versus 8.5mmol/L in the D50 group. Both treatments had nearly complete resolution of hypoglycemia: 98.7% (D50) and 99.2% (D10). No adverse events were observed in the D10 group (0/1057) compared to 13/310 adverse events in the D50 group.

Studies show D10 may be as effective as D50 at resolving symptoms and correcting hypoglycemia. Although the desired effect can take several minutes longer, there appear to be fewer adverse events. The post-D10-treatment BGL may result in fewer untoward hyperglycemic episodes.

Considering the pediatric peculiarities and the difficulty of assisting this population in mass-casualty situations, this study aims to identify the main topics regarding children’s health care in mass-casualty incidents (MCIs) that are discussed in the Emergency Medicine area.

This systematic review was performed according to the recommendations of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and registered with the PROSPERO database of systematic reviews with the number CRD42021229552. The last update of the search in the databases was on May 27, 2021 and resulted in 45 documents to be analyzed. The inclusion criteria included the peer-reviewed academic papers in English, Portuguese, Spanish, and Italian languages; the databases used were PubMed, Scopus, MEDLINE/Bireme (Virtual Library of Health - VLH), and Web of Science, which execute the query on the topic, keywords, or abstracts. Also, to be included, documents that were available with full-text access through CAPES, Google, or Google Scholar. Books, non-academic research, and content in languages other than the presented ones were represented as exclusion criteria.

From the resulting papers, 21 articles served as the basis for this analysis. Revealed were the year of publication, the first author’s institution nationality, topic, and disaster management phase for each study, which allow other researchers to understand the main topics regarding children’s health care in MCIs.

The topics regarding child’s health care in MCIs found in the primary studies of this review, in order of frequency, were: Disaster Response (including the following sub-topics: simulation, education, quality of care, use of technological tools, and damage analysis); Triage; and Disaster Planning. The Emergency Medicine operation was focused on harm reduction after the occurrence of an MCI. Further studies focusing on the pre-disaster and post-disaster phases are needed.

Massive hemorrhage (MH) is a growing pathology in military settings and increasingly in civilian settings; it is now considered a public health problem in the United States with large-scale programs. Tourniquets are the fastest and most effective intervention in MH if direct pressure is not effective.

The Liaison Committee on Resuscitation (ILCOR) recognizes a knowledge gap in optimal education techniques for first aid providers. This review aims to describe training and evaluation methods for teaching tourniquet use to both health care and military professionals.

The MEDLINE, CINAHL, WEB of Science, and Scopus databases were reviewed (from 2010 through April 2020). The quality of the selected studies was assessed using the Consolidated Standards of Reporting Trials (CONSORT) scale. Studies that met at least 65% of the included items were included. Data were extracted independently by two reviewers.

Ten of the 172 articles found were selected, of which three were randomized clinical trials. Heterogeneity was observed in the design of the studies and in the training and evaluative methods that limit the comparison between studies.

The results suggest that the training strategies studied are effective in improving knowledge, attitudes, and practical skills. There is no universal method, learning is meaningful but research should be directed to find out which ones work best.

The proliferation of unmanned aerial vehicle (UAV) technology has the potential to change the situational awareness of medical incident commanders’ (ICs’) scene assessment of mass gatherings. Mass gatherings occur frequently and the potential for injury at these events is considered higher than the general population. These events have generated mass-casualty incidents (MCIs) in the past. The aim of this study was to compare UAV technology to standard practice (SP) in scene assessment using paramedic students during a mass-gathering event (MGE).

This study was conducted in two phases. Phase One consisted of validation of the videos and accompanying data collection tool. Phase One was completed by 11 experienced paramedics from a provincial Emergency Medical Services (EMS) service. Phase Two was a randomized comparison with 47 paramedic students from the Holland College Paramedicine Program (Charlottetown, Prince Edward Island, Canada) of the two scene assessment systems. For Phase Two, the paramedic students were randomized into a UAV or a SP group. The data collection tool consisted of two board categories: primary importance with 20 variables and secondary importance with 25 variables. After a brief narrative, participants were either shown UAV footage or the ground footage depending on their study group. After completion of the videos, study participants completed the data collection tool.

The Phase One validation showed good consensus in answers to most questions (average 79%; range 55%-100%). For Phase Two, a Fisher’s exact test was used to compare each variable from the UAV and SP groups using a P value of .05. Phase Two demonstrated a significant difference between the SP and UAV groups in four of 20 primary variables. Additionally, significant differences were found for seven out of 25 secondary variables.

This study demonstrated the accurate, safe, and feasible use of a UAV as a tool for scene assessment by paramedic students at an MGE. No observed statistical difference was noted in a majority of both primary and secondary variables using a UAV for scene assessment versus SP.

It is well-established that heatwaves increase demand for emergency transport in metropolitan areas; however, little is known about the impact of heat events on demand for prehospital retrieval services in rural and remote areas, or how heatwaves are defined in this context.

Papers were eligible for inclusion if they reported on the impact of a heat event on the activity of a prehospital and retrieval service in a rural or remote area.

A search of PubMed, Cochrane, Science Direct, CINAHL, and Google Scholar databases was undertaken on August 18, 2020 using search terms related to emergency medical transport, extreme heat, and rural or remote. Data relevant to the impact of heat on retrieval service activity were extracted, as well as definitions of extreme heat.

Two papers were identified, both from Australia. Both found that heat events increased the number of road ambulance call-outs. Both studies used the Excess Heat Factor (EHF) to define heatwave periods of interest.

This review found almost no primary literature on demand for prehospital retrieval services in rural and remote areas, and no data specifically related to aeromedical transport. The research did recognize the disproportionate impact of heat-related increase in service demand on Australian rural and regional health services. With the effects of climate change already being felt, there is an urgent need for more research and action in this area.