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.

As wildfires and air pollution become more common across the United States, it is increasingly important to understand the burden they place on public health. Previous studies have noted relationships between air quality and use of Emergency Medical Services (EMS), but until now, these studies have focused on day-to-day air quality. The goal of this study is to investigate the effect of sustained periods of poor air quality on EMS call characteristics and volume.

Using a time-stratified case-crossover design, the effect of exposure to periods of poor air quality on number and type of EMS calls in California, USA from 2014-2019 was observed. Poor air quality periods greater than three days were identified at the United States Environmental Protection Agency’s (EPA’s) Air Quality Index (AQI) levels of Unhealthy for Sensitive Groups (AQI 100) and Unhealthy (AQI 150). Periods less than three days apart were combined. Each poor air quality period was matched with two one-week controls, the first being the closest preceding week that did not intersect a different case. The second control was the closest week at least three days after the case and not intersecting with a different case. Due to seasonal variation in EMS usage, from the initial cases, cases were used only if it was possible to identify controls within 28 days of the case. A conditional Poisson regression calculated risk ratios for EMS call volume.

Comparing the case periods to the controls, significant increases were found at AQI >100 for total number of calls, and the primary impressions categories of emotional state or behavior, level of consciousness, no patient complaint, other, respiratory, and abdominal. At an AQI >150, significance was found for the primary impressions categories of other, pain, respiratory, and digestive.

These data demonstrate increased EMS calls during sustained poor air quality, and that several EMS primary impression categories are disproportionately affected. This study is limited by the imprecision of the primary impression’s classification provided by the EMS clinician responding to the EMS call. More research is needed to understand the effects of periods of poor air quality on the EMS system for more efficient deployment of resources.

The Gaza Strip lives in a protracted emergency crisis and experienced several Israeli escalations. These escalations have overwhelmed the hospitals and highlighted the need to optimize Primary Health Care Centers (PHCCs) to form part of the emergency response system. This study, therefore, aimed to assess the emergency preparedness of the Ministry of Health (MoH)-run level-four PHCCs in the Gaza Strip (where Emergency Medical Services are provided along with preventive and curative services).

The study was cross-sectional, used quantitative methods, and utilized two tools. The first tool was a self-administered structured questionnaire exploring Primary Care Providers’ ([PCPs]; doctors and nurses) experiences, perceived capabilities, and training needs. The second tool was an observational checklist used to assess the preparedness of the emergency rooms (ERs) at level-four PHCCs in the Gaza Strip.

Two hundred and thirty-eight PCPs (34.5% doctors and 65.5% nurses) working in 16 level-four PHCCs were included. Overall, 64.4% of the participants had experience working in PHCCs during Israeli escalations, though 35.3% of them were unaware of the contingency plan (CP) of PHCCs. More nurses were aware of CPs than doctors (66.9% versus 42.7%; P <.001). Moreover, 65.7%, 46.7%, and 42.5% of the participants were trained in Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS), and Primary Trauma Care (PTC), respectively. However, many had received the training for more than two years, and none of the PHCCs had all its staff trained. Only 36.8% of the participants were trained in Post-Trauma/Post-Operative Care (wound care and dressing), and the percentage of trained nurses was significantly higher than those of doctors (36.8% versus 13.9%; P <.001). The majority of the participants admitted they need ACLS training (89.2%), PTC training (89%), BLS training (81.1%), and Post-Trauma/Post-Operative Care training (76.8%). Only 29.63% of emergency drugs and 37.5% of the equipment and disposables were available in the ERs of all PHCCs, and none of the PHCCs had all the essential emergency drugs, equipment, and disposables available.

Level-four PHCCs in the Gaza Strip are not adequately prepared to respond to emergencies. Generally, PCPs lack appropriate competencies for emergency response, and many PHCCs lack the infrastructure to support Primary Emergency Care (PEC). Thus, PCPs need continuous education and training in disaster preparedness and response and PEC.

Mass gatherings are vulnerable to terrorist attacks and are considered soft targets with potential to inflict high numbers of casualties. The objective of this study was to identify and characterize all documented terrorist attacks targeted at concerts and festivals reported to the Global Terrorism Database (GTD) over a 50-year period.

The GTD was searched for all terrorist attacks against concerts and festivals that occurred world-wide from 1970 through 2019. Analyses were performed on temporal factors, location, target type, attack and weapon type, attacker type, and number of casualties or hostages. Ambiguous incidents were excluded if there was doubt about whether they were exclusively acts of terrorism. Chi-square tests were performed to evaluate trends over time and differences in attack types.

In total, 146 terrorist attacks were identified. In addition to musical concerts, festivals included religious, cultural, community, and food festivals. With 53 incidents, South Asia was the most heavily hit region of the world, followed by the Middle East & North Africa with 25 attacks. Bombings and explosions were the most common attack types. The attacks targeted attendees, pilgrims, politicians, or police/military members who secured the concerts and festivals.

This analysis of the GTD, which identified terrorist attacks aimed at concerts and festivals over a 50-year period, demonstrates that the threat is significant, and not only in world regions where terrorism is more prevalent or local conflicts are going on. The findings of this study may help to create or enhance contingency plans.

The coronavirus disease 2019 (COVID-19) pandemic enabled a situational type of terrorism with mixed racist, anti-government, anti-science, anti-5G, and conspiracy theorist backgrounds and motives.

The objective of this study was to identify and characterize all documented COVID-19-related terrorist attacks reported to the Global Terrorism Database (GTD) in 2020.

The GTD was searched for all COVID-19-related terrorist attacks (aimed at patients, health care workers, and at all actors involved in pandemic containment response) that occurred world-wide in 2020. Analyses were performed on temporal factors, location, target type, attack and weapon type, attacker type, and number of casualties or hostages. Ambiguous incidents were excluded if there was doubt about whether they were exclusively acts of terrorism.

In total, 165 terrorist attacks were identified. With 50% of incidents, Western Europe was the most heavily hit region of the world. Nonetheless, most victims were listed in Southeast Asia (19 fatalities and seven injured). The most frequent but least lethal attack type concerned arson attacks against 5G telephone masts (105 incidents [60.9%] with only one injured). Armed assaults accounted for most fatalities, followed by assassinations. Incendiary and firearms were the most devastating weapon types.

This analysis of the GTD, which identified 165 COVID-19-related terrorist attacks in 2020, demonstrates that the COVID-19 pandemic truly resulted in new threats for COVID-19 patients, aid workers, hospitals, and testing and quarantine centers. It is anticipated that vaccination centers have become a new target of COVID-19-related terrorism in 2021 and 2022.

Previous studies have demonstrated the use of virtual reality (VR) in mass-casualty incident (MCI) simulation; however, it is uncertain if VR simulations can be a substitute for in-person disaster training. Demonstrating that VR MCI scenarios can elicit the same desired stress response achieved in live-action exercises is a first step in showing non-inferiority. The primary objective of this study was to measure changes in sympathetic nervous system (SNS) response via a decrease in heart rate variability (HRV) in subjects participating in a VR MCI scenario.

An MCI simulation was filmed with a 360º camera and shown to participants on a VR headset while simultaneously recording electrocardiography (EKG) and HRV activity. Baseline HRV was measured during a calm VR scenario immediately prior to exposure to the MCI scenarios, and SNS activation was captured as a decrease in HRV compared to baseline. Cognitive stress was measured using a validated questionnaire. Wilcoxon matched pairs signed rank analysis, Welch’s t-test, and multivariate logistic regression were performed with statistical significance established at P <.05.

Thirty-five subjects were enrolled: eight attending physicians (two surgeons, six Emergency Medicine [EM] specialists); 13 residents (five Surgery, eight EM); and 14 medical students (six pre-clinical, eight clinical-year students). Sympathetic nervous system activation was observed in all groups during the MCI compared to baseline (P <.0001) and occurred independent of age, sex, years of experience, or prior MCI response experience. Overall, 23/35 subjects (65.7%) reported increased cognitive stress in the MCI (11/14 medical students, 9/13 residents, and 3/8 attendings). Resident and attending physicians had higher odds of discordance between SNS activation and cognitive stress compared to medical students (OR = 8.297; 95% CI, 1.408-64.60; P = .030).

Live-actor VR MCI simulation elicited a strong sympathetic response across all groups. Thus, VR MCI training has the potential to guide acquisition of confidence in disaster response.

In Australia, aeromedical retrieval provides a vital link for rural communities with limited health services to definitive care in urban centers. Yet, there are few studies of aeromedical patient experiences and outcomes, or clear measures of the service quality provided to these patients.

This study explores whether a previously developed quality framework could usefully be applied to existing air ambulance patient journeys (ie, the sequences of care that span multiple settings; prehospital and hospital-based pre-flight, flight transport, after-flight hospital in-patient, and disposition). The study aimed to use linked data from aeromedical, emergency department (ED), and hospital sources, and from death registries, to document and analyze patient journeys.

A previously developed air ambulance quality framework was used to place patient, prehospital, and in-hospital service outcomes in relevant quality domains identified from the Institutes of Medicine (IOM) and Dr. Donabedian models. To understand the aeromedical patients’ journeys, data from all relevant data sources were linked by unique patient identifiers and the outcomes of the resulting analyses were applied to the air ambulance quality framework.

Overall, air ambulance referral pathways could be classified into three categories: Intraregional (those retrievals which stayed within the region), Out of Region, and Into Region. Patient journeys and service outcomes varied markedly between referral pathways. Prehospital and in-hospital service variables and patient outcomes showed that the framework could be used to explore air ambulance service quality.

The air ambulance quality framework can usefully be applied to air ambulance patient experiences and outcomes using linked data analysis. The framework can help guide prehospital and in-hospital performance reporting. With variations between regional referral pathways, this knowledge will aid with planning within the local service. The study successfully linked data from aeromedical, ED, in-hospital, and death sources and explored the aeromedical patients’ journeys.

Major incidents (MIs) put great demands on the medical response to effectively organize and redistribute resources and personnel, in prehospital care as well as hospital care, and coordinating functions. Studies indicate that regular training and well-established contingency plans are vital for the medical response to MIs. Previous assessments have concluded that Swedish disaster preparedness requires improved organization and coordination. There is currently no method to easily follow-up the preparedness work of the prehospital medical response organizations for MIs in Sweden.

The aim of the study was to assess qualifications and training requirements for central individual roles, to examine frequency and focus of training and simulation, as well as to examine current regional routines for MIs in Sweden. The aim was also to identify, to evaluate, and to investigate areas for improvement in prehospital health care preparedness for MIs in Sweden.

Descriptive comparative study of Sweden’s prehospital organization, planning, education, and training for MIs through a web-based survey sent to all 21 regions in Sweden. The survey included 64 questions and was based on national legislation and guidelines for preparedness and previous investigations of real MIs.

A total of 37 answers to the survey were collected representing 17/21 regions (80.9%) from which Regional Management Individuals (RMIs) were selected from 15 regions and used as representative primary responses. The initial routines regarding alarm and establishment of management functions were mainly in-line with national guidelines. Staffing and qualification requirements for certain leadership roles differed substantially between regions. The requirements for the health care staff’s knowledge of the contingency plan were generally low and routines for follow-up were often lacking. The frequency of exercises in certain areas were deficient.

The results of the study showed several potential areas for improvement within the prehospital emergency medical preparedness for MIs in Sweden. Methodology and adherence of national guidelines for medical response preparedness differ between regions in Sweden, which motivates recurring assessments. It is possible to use a well-prepared questionnaire study to follow-up and to examine parts of the regional prehospital preparedness work and organization for MIs.

The coronavirus disease 2019 (COVID-19) pandemic had detrimental impacts across multiple sectors of the Mexican health care system. The prehospital care system, however, remains largely under-studied. The first objective of this study was to calculate the monthly per capita rates of injury-related 9-1-1 calls, traffic accidents, and crime at the state-level (Mexico City) during the early pandemic period (January 1 through June 30, 2020), while the second objective was to conduct these calculations at the borough-level for the same outcomes and time period. The third objective was to compare monthly per capita rates of injury-related 9-1-1 calls, traffic accidents, and crime at the state-level (Mexico City) during the pre-pandemic (January 1 through June 30, 2019), early pandemic (January 1 through June 30, 2020), and later pandemic periods (January 1 through June 30, 2021).

A retrospective analysis was conducted to examine injury-related 9-1-1 calls, traffic accidents, and crime at the state-level (Mexico City) and borough-levels. Monthly per capita rates were calculated using four datasets, including Mexico City’s Public Release 9-1-1 Emergency Calls, National Institute of Statistics and Geography’s (INEGI) Traffic Accidents Micro-Dataset, Mexico City’s Attorney General’s Office Crime Dataset, and Projections of the Population of the Municipalities of Mexico, 2015 to 2030. All statistical analyses were conducted using STATA 17.0.

During the early pandemic period, injury-related 9-1-1 emergency calls, traffic accidents, and crime experienced similar trends in monthly per capita rates at the state-level and borough-levels. While the monthly per capita rates remained constant from January to March 2020, starting in March, there was a precipitous decrease across all three outcomes, although decline rates varied across boroughs. The monthly per capita rates across the three outcomes were higher during the pre-pandemic period compared to the early pandemic period. As the COVID-19 pandemic progressed, the monthly per capita rates during the later pandemic period increased across the three outcomes compared to the early pandemic period, although they did not reach pre-pandemic levels during the study period.

The precipitous decline in injury-related 9-1-1 calls, traffic accidents, and crime in Mexico City occurred at the same time as the issuance of the first wave of public health orders in March 2020. The largest decrease across the three outcomes occurred one to two months post-issuance of the orders.

The objective is to identify research priorities in prehospital care in Spain.

This was a Delphi-type study of three rounds with a panel of experts made up of members of the Red de Investigación en Emergencias Prehospitalarias (RINVEMER; Prehospital Emergency Research Network) Network and the Sociedad Española de Medicina de Urgencias y Emergencias (SEMES; Spanish Society of Emergency Medicine) Emergency Secretariat. In the first round, each participant identified up to 15 priorities. In the second round, they scored the 30 thematic areas on a Likert scale. In the third round, they ordered and scored from one to ten the first ten priorities among those that obtained a median greater than or equal to four in the second round. After adding the assigned scores, the ten priorities with the highest total score were obtained.

The ten identified research priorities were: special clinical codes and time-dependent conditions; mass-casualty incident (MCI) coordination and management; innovation in Emergency Medical Services (EMS); human factor in decision making; triage, analysis, and management of calls in the Emergency Call Center; new technologies, telemedicine, and emergencies; adverse events, clinical safety, and quality in emergencies; cardiac arrest; continuous education and training (methodology, quality, and evaluation); and big data and emergencies.

The research priorities perceived by emergency professionals are related to clinical care and organizational aspects of EMS, in addition to the need to incorporate innovative aspects and new data analysis technologies.

The motorcycle ambulance is used for quick access to patients. The response time to reach the patient takes less time than with a van ambulance. Moreover, accidents involving ambulances tend to be higher. However, at present, there is no study regarding the appropriate situation used of motorcycle ambulances in Emergency Medical Services (EMS) in Thailand.

This study aims to optimize the travel distance and the operation time of motorcycle ambulances used.

This study was a prospective, randomized controlled study at the EMS unit of Srinagarind Hospital, Thailand. The data collection period was from November 2021 through May 2022. All data involving dispatch of both ambulances in need were collected.

A total of 2,398 cases of EMS operation were examined. The mean age of the patients in the motorcycle ambulance group was 42.5 (SD = 6.5) years, and 51.3% (n = 616) were male. The response time for motorcycle ambulances and van ambulances during the operation time between 6:00am-9:00am was 6.2 minutes and 9.1 minutes, respectively. The response times for motorcycle ambulances and van ambulances regarding distance traveled from 0-5km were 4.2 minutes and 7.5 minutes, respectively (P <.001); distance traveled from 5-10km were 6.3 minutes and 8.2 minutes, respectively (P = .010).

The motorcycle ambulance can reach patients faster than the ambulance at the operation time from 6:00am-9:00am and 3:00pm-6:00pm. This study focused on the distance less than 10 kilometers.

Poor outcome is still a challenging concern in patients with out-of-hospital cardiac arrest (OHCA) world-wide and there are large differences between European countries regarding not only incidence rates, but survival rates as well. In 2014, Serbian Resuscitation Council initiated regular data collection on epidemiology of OHCA, according to the European Registry of Cardiac Arrest (EuReCa) study protocol.

The aim of this study is to analyze the results of the first five-year period after initiation of EuReCa study protocol elements implementation in OHCA epidemiological data collection in Serbia.

The observed period in this study is about the data on OHCA, collected within the observed area of 16 municipalities covering 1,604,015 citizens, during the period from October 1, 2014 – December 31, 2019. The study included data on all-cause OHCA in both adult and pediatric patients, according to the EuReCa One study protocol, of which all segments were observed.

Within the study period, 5,196 OHCA patients were observed with annual incidence of 83.60/100,000. Of all registered events, 43.9% were witnessed. The most common collapse location was patient’s residence (88.7%). Within the group of initiated cardiopulmonary resuscitation (CPR), cardiac etiology was observed in 80.5% of cases and shockable rhythm in 21.7%. Return of spontaneous circulation (ROSC) prior to hospital admission was significantly more frequently achieved and maintained on admission in witnessed cases, cases occurring out of patient’s residence, and in cases with shockable initial rhythm (P <.01).

The OHCA incidence in Serbia is comparable with the incidence in the majority of European countries, and survival rates are now significantly higher in Utstein events compared to previous results from Serbia. Enrolment of witnessing bystanders in initiating CPR measures remains a concern requiring effort towards understanding of CPR initiation importance and education of general population in administering CPR measures.

The use of personal protective equipment (PPE) in prehospital emergency care has significantly increased since the onset of the coronavirus disease 2019 (COVID-19) pandemic. Several studies investigating the potential effects of PPE use by Emergency Medical Service providers on the quality of chest compressions during resuscitation have been inconclusive.

This study aimed to determine whether the use of PPE affects the quality of chest compressions or influences select physiological biomarkers that are associated with stress.

This was a prospective randomized, quasi-experimental crossover study with 35 Emergency Medical Service providers who performed 20 minutes of chest compressions on a manikin. Two iterations were completed in a randomized order: (1) without PPE and (2) with PPE consisting of Tyvek, goggles, KN95 mask, and nitrile gloves. The rate and depth of chest compressions were measured. Salivary cortisol, lactate, end-tidal carbon dioxide (EtCO2), and body temperature were measured before and after each set of chest compressions.

There were no differences in the quality of chest compressions (rate and depth) between the two groups (P >.05). After performing chest compressions, the group with PPE did not have elevated levels of cortisol, lactate, or EtCO2 when compared to the group without PPE, but did have a higher body temperature (P <.001).

The use of PPE during resuscitation did not lower the quality of chest compressions, nor did it lead to higher stress-associated biomarker levels, with the exception of body temperature.

Placing an endotracheal tube is a life-saving measure. Direct laryngoscopy (DL) is traditionally the default method. Video laryngoscopy (VL) has been shown to improve efficiency, but there is insufficient evidence comparing VL versus DL in the prehospital settings. This study, comprising a systematic review and random-effects meta-analysis, assesses current literature for the efficacy of VL in prehospital settings.

PubMed and Scopus databases were searched from their beginnings through March 1, 2022 for eligible studies. Outcomes were the first successful intubation, overall success rate, and number of total DL versus VL attempts in real-life clinical situations. Cochrane’s Risk of Bias (RoB) tool and the Newcastle-Ottawa Scale (NOS) were applied to assess risk of bias and study quality; Q-statistics and I2 values were used to assess heterogeneity.

The search yielded seven studies involving 23,953 patients, 6,674 (28%) of whom underwent intubation via VL. Compared to DL, VL was associated with a statistically higher risk ratio for first-pass success (Risk Ratio [RR] = 1.116; 95% CI, 1.005-1.239; P = .041; I2 = 87%). The I2 value for the subgroup of prospective studies was 0% compared to 89% for retrospective studies. In addition, VL was associated with higher likelihood of overall success rate (RR = 1.097; 95% CI, 1.01-1.18; P = .021; I2 = 85%) and lower mean number of attempts (Mean Difference = -0.529; 95% CI, -0.922 to -0.137; P = .008).

The meta-analysis suggested that VL was associated with higher likelihood of achieving first-pass success, greater overall success rate, and lower number of intubation attempts for adults in the prehospital settings. This study had high heterogeneity, likely presenced by the inclusion of retrospective observational studies. Further studies with more rigorous methodology are needed to confirm these results.

An Emergency Medical Service (EMS) is defined as a complete system that responds to public medical and surgical emergencies with prompt and adequate emergency care. Ambulance services are also classified as EMS in modern medical history. In the Nepalese context, prehospital care is very limited, and the EMS system is still a new concept in Nepal. In a study in the emergency room at Patan Hospital in Kathmandu, only 9.9% of patients came by ambulance, 53.6% by taxi, 11.4% by private car, 13.5% by bus, 5.4% by bicycle, and another 6.2% came with alternative routes.

This study aims to investigate the constraints, challenges, and achievements made by ambulances services during the coronavirus disease 2019 (COVID-19) pandemic.

The study design was phenomenological and the method was qualitative. In-depth interviews (IDIs) were conducted with six human resources working from the COVID-19 first wave pandemic in the ambulance service of Nepal Ambulance Service (NAS), Kathmandu.

Four themes were generated from IDIs: (1) challenges in service delivery; (2) constraints on service delivery; (3) working experiences; and (4) achievements of ambulatory service providers during the COVID-19 pandemic. Under these four themes, 12 sub-themes were constructed. The new nature of disease (COVID-19) in the first wave led to fear and anxiety, which also forced them to think about quitting the job; however, later on with proper training and safety measures, it led to working for COVID-19 patient transfers from home to hospital, as well as hospital to hospital, and proper prehospital care services were provided. The major challenges faced by ambulatory service providers were long working hours, wearing a single personal protective equipment (PPE) for long hours, confusing locations to pick up patients, and both stigma and discrimination.

From IDIs, it was concluded that although constraints and challenges arise during a pandemic, from proper guidance and support through NAS, they are able to provide proper prehospital care for the patient. Challenges like fear, heavy workload, PPE, and other material barriers do not hamper in service delivery.

While the pressure points technique for proximal hemorrhage control is long known, it is not recommended in standard prehospital guidelines based on a study showing the inability to maintain occlusion for over two minutes.

This report details a gunshot wound to the left axillary area with complete transection of the axillary artery, leading to profuse junctional hemorrhage and profound hemorrhagic shock.

Proximal pressure of the subclavian artery was applied against the first rib (the pressure points technique) and maintained for 28 minutes.

Cessation of apparent bleeding and excellent, enduring physiologic response to blood transfusion were observed.

The pressure points technique can be life-saving in junctional arterial hemorrhage and should be reconsidered in prehospital guidelines.