Emergency Medical Services (EMS) professionals frequently care for patients experiencing acute pain. Analgesics are critical in patient comfort and satisfaction levels during the treatment of acute pain. The objective of this study was to assess the frequency of pain management in patients suffering a fall, the documented pain score, and the location of their injuries. It was hypothesized that the frequency of analgesia administration was low and would be associated with injury location.

This was a retrospective review of patients presenting with a complaint of an injury from a fall transported by a single municipal EMS system. Administration of analgesia was the primary outcome variable, with pain severity, injury location, age, gender, race, and distance of fall the independent variables of interest. Pain severity was assessed using a 0-10 scale. Injury location was defined as head/neck, extremities, back, and hip. Patients were deemed ineligible for analgesia, according to local protocol, if they reported chest or abdominal pain, or were hemodynamically unstable as determined by an assessment of pulse and blood pressure.

There were 1,200 patients who were classified as having injuries suffered from a fall, with 76 (6.3%) ineligible for analgesia. Ninety-two (8.2%) patients received analgesia, and they had a mean recorded pain score of 9.1 (95% CI, 8.7-9.5), which was higher than those who did not receive analgesia (5.8; 95% CI, 5.5-6.2). Analgesia administration was associated with injury location; patients experiencing an extremity injury (OR = 13.23; 95% CI, 5.58-31.36; P < .001) or hip injury (OR = 11.65; 95% CI, 4.64-29.24; P < .001) had increased odds of analgesia administration compared to those with head/neck injury. The odds of analgesia administration were decreased for black patients (OR = 0.19; 95% CI, 0.08-0.44; P < .001) when compared to white patients.

Analgesia administration was provided to 10% of eligible patients, and was associated with injury location. Of concern was the number of patients who suffered a fall and did not receive a documented pain score. The results from this study indicated a need for education relating to pain management in patients suffering a fall.

InfingerAE, StudnekJR. An Assessment of Pain Management Among Patients Presenting to Emergency Medical Services After Suffering a Fall. Prehosp Disaster Med. 2014;29(4):1-6.

Emergency Medical Services (EMS) routinely stage in a secure area in response to active shooter incidents until the scene is declared safe by law enforcement. Due to the time-sensitive nature of injuries at these incidents, some EMS systems have adopted response tactics utilizing law enforcement protection to expedite life-saving medical care.

Describe EMS provider perceptions of preparedness, adequacy of training, and general attitudes toward active shooter incident response after completing a tactical awareness training program.

An unmatched, anonymous, closed-format survey utilizing a five-point Likert scale was distributed to participating EMS providers before and after a focused training session on joint EMS/police active shooter rescue team response. Descriptive statistics were used to compare survey results. Secondary analysis of responses based on prior military or tactical medicine training was performed using a chi-squared analysis.

Two hundred fifty-six providers participated with 88% (225/256) pretraining and 88% (224/256) post-training surveys completed. Post-training, provider agreement that they felt adequately prepared to respond to an active shooter incident changed from 41% (92/225) to 89% (199/224), while agreement they felt adequately trained to provide medical care during an active shooter incident changed from 36% (82/225) to 87% (194/224). Post-training provider agreement that they should never enter a building with an active shooter changed from 73% (165/225) to 61% (137/224). Among the pretraining surveys, significantly more providers without prior military or tactical experience agreed they should never enter a building with an active shooter until the scene was declared safe (78% vs 50%, P = .002), while significantly more providers with prior experience felt both adequately trained to provide medical care in an active shooter environment (56% vs 31%, P = .007) and comfortable working jointly with law enforcement within a building if a shooter were still inside (76% vs 56%, P = .014). There was no difference in response to these questions in the post-training survey.

Attitudes and perceptions regarding EMS active shooter incident response appear to change among providers after participation in a focused active shooter response training program. Further studies are needed to determine if these changes are significant and whether early EMS response during an active shooter incident improves patient outcomes.

JonesJ , KueR , MitchellP , EblanG , DyerKS . Emergency Medical Services Response to Active Shooter Incidents: Provider Comfort Level and Attitudes Before and After Participation in a Focused Response Training Program. Prehosp Disaster Med. 2014;29(4):1-7.

For effective responses to emergencies, individuals must have the ability to respond and also be willing to participate in the response. A growing body of research points to gaps in response willingness among several occupational cohorts with response duties, including the Emergency Medical Services (EMS) workforce. Willingness to respond is particularly important during an influenza or other pandemic, due to increased demands on EMS workers and the potential for workforces to be depleted if responders contract influenza or stay home to care for sick dependents. State emergency preparedness laws are one possible avenue to improve willingness to respond.

Presence of certain state-level emergency preparedness laws (ie, ability to declare a public health emergency; requirement to create a public health emergency plan; priority access to health resources for responders) is associated with willingness to respond among EMS workers.

Four hundred twenty-one EMS workers from the National Registry of Emergency Medical Technicians’ (NREMT's) mid-year Longitudinal EMT Attributes and Demographics Study (LEADS) were studied. The survey, which included questions about willingness to respond during an influenza pandemic, was fielded from May through June 2009. Survey data were merged with data about the presence or absence of the three emergency preparedness laws of interest in each of the 50 US states. Unadjusted logistic regression analyses were performed with the presence/absence of each law and were adjusted for respondents’ demographic/locale characteristics.

Compared to EMS workers in states that did not allow the government to declare a public health emergency, those in states that permitted such declarations were more likely to report that they were willing to respond during an influenza pandemic. In adjusted and unadjusted analyses, this difference was not statistically significant. Similar results were found for the other state-level emergency preparedness laws of interest.

While state-level emergency preparedness laws are not associated with willingness to respond, recent research suggests that inconsistencies between the perceived and objective legal environments for EMS workers could be an alternative explanation for this study's findings. Educational efforts within the EMS workforce and more prominent state-level implementation of emergency preparedness laws should be considered as a means to raise awareness of these laws. These types of actions are important steps toward determining whether state-level emergency preparedness laws have the potential to promote response willingness among EMS workers.

RutkowL , VernickJS , ThompsonCB , PirralloRG , BarnettDJ . Emergency Preparedness Law and Willingness to Respond in the EMS Workforce. Prehosp Disaster Med. 2014;29(4):1-6.

Unacceptable practices in the delivery of international medical assistance are reported after every major international disaster; this raises concerns about the clinical competence and practice of some foreign medical teams (FMTs). The aim of this study is to explore and analyze the opinions of disaster management experts about potential deficiencies in the art and science of national and FMTs during disasters and the impact these opinions might have on competency-based education and training.

This qualitative study was performed in 2013. A questionnaire-based evaluation of experts’ opinions and experiences in responding to disasters was conducted. The selection of the experts was done using the purposeful sampling method, and the sample size was considered by data saturation. Content analysis was used to explore the implications of the data.

This study shows that there is a lack of competency-based training for disaster responders. Developing and performing standardized training courses is influenced by shortcomings in budget, expertise, and standards. There is a lack of both coordination and integration among teams and their activities during disasters. The participants of this study emphasized problems concerning access to relevant resources during disasters.

The major findings of this study suggest that teams often are not competent during the response phase because of education and training deficiencies. Foreign medical teams and medically related nongovernmental organizations (NGOs) do not always provide expected capabilities and services. Failures in leadership and in coordination among teams are also a problem. All deficiencies need to be applied to competency-based curricula.

DjalaliA , IngrassiaPL , Della CorteF , FolettiM , Ripoll GallardoA , RagazzoniL , KaptanK , LupescuO , ArculeoC , von ArnimG , FriedlT , AshkenaziM , HeselmannD , HreckovskiB , Khorrram-ManeshA , KomadinaR , LechnerK , PatruC , BurkleFMJr. , FisherP . Identifying Deficiencies in National and Foreign Medical Team Responses Through Expert Opinion Surveys: Implications for Education and Training. Prehosp Disaster Med. 2014;29(4):1-5.

An earthquake of 9.0 magnitude, followed by a tsunami, hit Japan in 2011 causing widespread destruction. Fukushima Nuclear Power Plant had been damaged, causing a spread of radioactive materials.

The aim of this study was to assess personal willingness to respond to a disaster as a part of an international delegation, to an area with unknown and unclear risk of radioactive materials. The Israeli delegation to the Japan 2011 earthquake had been chosen as a case study.

The survey was conducted during the first two weeks after the tsunami in Japan. The population was selected randomly. After distributing the survey form, 94 anonymous answers were received, which give a 69% participation rate. The sample was divided into two groups (participated or didn't participate in an international delegation in the past).

It was found that as the situation on the ground became worse, the willingness to be deployed dropped dramatically, although no significant difference was found in willingness between the two study groups. When both groups were combined into one group, significant differences were found in their willingness to be deployed in a delegation between the three levels (no radioactive leak, possible radioactive leak, and uncontrolled leak).

The willingness to serve on a delegation that responds to a scene with a potential radioactive leak will be dramatically influenced by the risk at the site.

ShenharG , RadomislenskyI , RosenfeldM , PelegK . Willingness of International Delegations to be Deployed to Areas With High Risk of Radiation. Prehosp Disaster Med. 2014;29(4):1-5.

Hurricane Sandy forced closures of many free-standing dialysis centers in New York City in 2012. Hemodialysis (HD) patients therefore sought dialysis treatments from nearby hospitals. The surge capacity of hospital dialysis services was the rate-limiting step for streamlining the emergency department flow of HD patients. The aim of this study was to determine the extent of the HD patients surge and to explore difficulties encountered by hospitals in Brooklyn, New York (USA) due to Hurricane Sandy.

A retrospective survey on hospital dialysis services was conducted by interviewing dialysis unit managers, focusing on the influx of HD patients from closed dialysis centers to hospitals, coping strategies these hospitals used, and difficulties encountered.

In total, 347 HD patients presented to 15 Brooklyn hospitals for dialysis. The number of transient HD patients peaked two days after landfall and gradually decreased over a week. Hospital dialysis services reported issues with lack of dialysis documentation from transient dialysis patients (92.3%), staff shortage (50%), staff transportation (71.4%), and communication with other agencies (53.3%). Linear regression showed that factors significantly associated with enhanced surge capacity were the size of inpatient dialysis unit (P = .040), having affiliated outpatient dialysis centers (P = .032), using extra dialysis machines (P = .014), and having extra workforce (P = .007). Early emergency plan activation (P = .289) and shortening treatment time (P = .118) did not impact the surge capacity significantly in this study.

These findings provide potential improvement options for receiving hospitals dialysis units to prepare for future events.

LinC, PierceLC, RoblinPM, ArquillaB. Impact of Hurricane Sandy on Hospital Emergency and Dialysis Services: A Retrospective Survey. Prehosp Disaster Med. 2014;29(4):1-6.

The aim of this study was to determine if a relationship exists between the development of adaptive capacity and disaster response and recovery outcomes. Hospitals and health care systems are a critical element in community planning for all phases of the disaster cycle. There is a lack of research, however, to validate the relationship between the development of these capabilities and improved response and recovery outcomes.

Two hypotheses were formulated to address the research question. The first hypothesis argued that counties or parishes that developed adaptive capacity through pre-event planning, community engagement, training, and the use of national response frameworks would have improved response and recovery performance outcomes. The second hypothesis argued that adaptive capacity, along with response and recovery performance outcomes, predicts the trajectory of recovery progression.

This study employed a quantitative cross-sectional survey methodology and existing community demographic data to explore the development of adaptive capacity and its ability to predict disaster response and recovery outcomes in communities affected by major disaster in 2011. A total of 333 counties and parishes were included in the final sample, providing a 95% confidence interval with a 5% margin of error. Data were analyzed using both descriptive and inferential statistics. Multiple, hierarchical, and robust regression were used to find the best fitting model. Multi-level modeling with random intercepts was used to control for the nesting effects associated with county, state, and the Federal Emergency Management Agency (FEMA) region sampling.

Descriptive results provide a baseline assessment of adaptive capacity development at the community level. While controlling for other variables, hypothesis testing revealed that pre-event planning, community engagement, full-scale exercises, and use of national frameworks predicated overall response and recovery performance outcomes (R 2 = .43; F13,303 = 13.34; P < .001). In terms of recovery progression, pre-event planning, overall response and recovery performance outcome, total time of disruption, and percent of people below poverty were significant (R2 = .15; F14,302 = 4.53; P < .001).

Establishment of empirical data provides communities with reinforcement to continue resilience-building activities at the local level. However, findings from this study suggest that only full-scale exercises were significant in improving response and recovery outcomes. Implications for re-evaluation of disaster training warrant further exploration.

ZukowskiRS . The Impact of Adaptive Capacity on Disaster Response and Recovery: Evidence Supporting Core Community Capabilities. Prehosp Disaster Med. 2014;29(4):1-8.

The 2003 Bam, Iran earthquake resulted in high casualties and required international and national assistance. This study explored local top and middle level managers’ disaster relief experiences in the aftermath of the Bam earthquake.

Using qualitative interview methodology, top and middle level health managers employed during the Bam earthquake were identified. Data were collected via in-depth interviews with participants. Data were analysed using thematic analysis.

Results showed that the managers interviewed experienced two main problems. First, inadequacy of preparation of local health organisations, which was due to lack of familiarity of the needs, unavailability of essential needs, and also increasing demands, which were above the participants’ expectations. Second, inappropriateness of delivered donations was perceived as a problem; for example, foods and sanitary materials were either poor quality or expired by date recommended for use. Participants also found international teams to be more well-equipped and organised.

During the disaster relief period of the response to the Bam earthquake, local health organizations were ill prepared for the event. In addition, donations delivered for relief were often poor quality or expired beyond a usable date.

MoosazadehM , ZolalaF , SheikhzadehK , SafiriS , AmiresmailiM . Response to the Bam Earthquake: A Qualitative Study on the Experiences of the Top and Middle Level Health Managers in Kerman, Iran. Prehosp Disaster Med. 2014;29(4):1-4.

Formula One returned to the United States on November 16-18, 2012, with the inaugural United States Grand Prix in Austin, Texas. Medical preparedness for motorsports events represents a unique challenge due to the potential for a high number of spectators seeking medical attention, and the possibility for a mass-casualty situation. Adequate preparation requires close collaboration across public safety agencies and hospital networks to minimize impact on Emergency Medical Services (EMS) resources.

To report the details of preparation for an inaugural mass-gathering motorsports event, and to describe the details of the medical care rendered during the 3-day event.

A retrospective analysis was completed utilizing postevent summaries, provided by the medical planning committee, by the Federation Internationale de L'Automobile (FIA), and Austin Travis County Emergency Medical Services (ATCEMS). Patient data were collected from standardized patient care records for descriptive analysis. Medical usage rates (MURs) are reported as a rate of patients per 10,000 (PPTT) participants.

A total of 566 patients received medical care over the 3-day period with the on-site care rate of 95%. Overall, MUR was 21.3 PPTT attendees. Most patients had minor problems, and there were no driver injuries or deaths.

This mass-gathering motorsport event had a moderate number of patients requiring medical attention. The preparedness plan was implemented successfully with minimal impact on EMS resources and local medical facilities. This medical preparedness plan may serve as a model to other cities preparing for an inaugural motorsports event.

SabraJP , CabañasJG , BedollaJ , BorgmannS , HawleyJ , CravenK , BrownC , ZiebellC , OlveyS . Medical Support at a Large-scale Motorsports Mass-gathering Event: The Inaugural Formula One United States Grand Prix in Austin, Texas. Prehosp Disaster Med. 2014;29(4):1-7.

Spinal cord injury (SCI) is a serious condition that may lead to long-term disabilities placing financial and social burden on patients and their families, as well as their communities. Spinal immobilization has been considered the standard prehospital care for suspected SCI patients. However, there is a lack of consensus on its beneficial impact on patients’ outcome.

This paper reviews the current literature on the epidemiology of traumatic SCI and the practice of prehospital spinal immobilization.

A search of literature was undertaken utilizing the online databases Ovid Medline, PubMed, CINAHL, and the Cochrane Library. The search included English language publications from January 2000 through November 2012.

The reported annual incidence of SCI ranges from 12.7 to 52.2 per 1 million and occurs more commonly among males than females. Motor vehicle collisions (MVCs) are the major reported causes of traumatic SCI among young and middle-aged patients, and falls are the major reported causes among patients older than 55. There is little evidence regarding the relationship between prehospital spinal immobilization and patient neurological outcomes. However, early patient transfer (8-24 hours) to spinal care units and effective resuscitation have been demonstrated to lead to better neurological outcomes.

This review reaffirms the need for further research to validate the advantages, disadvantages, and the effects of spinal immobilization on patients’ neurological outcomes.

OteirAO , SmithK , JenningsPA , StoelwinderJU . The Prehospital Management of Suspected Spinal Cord Injury: An Update. Prehosp Disaster Med. 2014;29(4):1-4.

Regardless of the capacity of the health care system of the host nation, mass gatherings require special planning and preparedness efforts within the health system. Brazil will host the 2014 Fédération Internationale de Football Association (FIFA) World Cup and the 2016 Olympics. This paper represents the first results from Project “Prepara Brasil,” which is investigating the preparedness of the health sector and pharmaceutical services for these events.

This study was designed to identify the efforts engaged in to prepare the health sector in Brazil for the FIFA World Cup 2014 event, as well as the 2016 Summer Olympics.

Key informant interviews were conducted with representatives of both the municipality and hospital sectors in each of the 12 host cities where matches will be played. A semi-structured key informant interview guide was developed, with sections for each type of participant. One of each municipality's reference hospitals was identified and seven additional general hospitals were randomly selected from all of the inpatient facilities in each municipality. The interviewers were instructed to contact a reference hospital, and two of the other hospitals, in the jurisdiction for participation in the study. Questions were asked about plans for mass-gathering events, the interaction between hospitals and government officials in preparation for the World Cup, and their perceptions of their surge capacity to meet the potential demands generated by the presence of the World Cup events in their municipalities.

In all, 11 representatives of the sampled reference hospitals, and 24 representatives of other general private and public hospitals in the municipalities, were interviewed. Most of the hospitals had some interaction with government officials in preparation for the World Cup 2014. Approximately one-third (34%) received training activities from the government. Fifty-four percent (54%) of hospitals had no specific plans for communicating with the government or other agencies during the World Cup. Approximately half (51%) had plans for surge capacity during the event, but only 27% had any surge capacity for isolation of potentially infectious patients.

Overall, although there has been mention of a great deal of planning on the part of the government officials for the World Cup 2014, hospital surge to meet the potential increase in demand still falls short.

ShoafK , Osorio de CastroCGS , MirandaES . Hospital Preparedness in Advance of the 2014 FIFA World Cup in Brazil. Prehosp Disaster Med. 2014;29(4):1-4.

Accountability in the delivery of humanitarian aid has become increasingly important and emphasized by the humanitarian community. The Humanitarian Accountability Partnership (HAP) was created in 2003 in order to improve accountability in the humanitarian sector. HAP acts as a self-regulatory body to the humanitarian system. One of the main goals of HAP is the promotion of accountability through self-regulation by members. Humanitarian nongovernmental organizations (NGOs) can become members by meeting standards of accountability and quality management set by HAP. This report describes the growth of HAP membership by the humanitarian community from its inception until present.

The hypothesis for this study was that HAP membership has grown substantially since inception, both in terms of number of member organizations and annual budgets of member organizations, but that near universal membership has not yet been achieved.

A retrospective study was conducted to determine the total number and percentage of humanitarian NGOs that are members of HAP. Total expenditures of HAP members in 2010 also was measured and compared with the total humanitarian expenditure by all humanitarian NGOs for the same year. The reference year of 2010 was chosen in order to be able to compile accurate budgets for the largest possible number of HAP members. The total number of HAP members for the years 2005 through 2012 was divided by the estimated number of humanitarian NGOs active in 2010. The total budgets for HAP members in 2010 were divided by the estimated total humanitarian expenditure of all NGOs for 2010.

As of the beginning of 2012, the percentage of humanitarian NGOs that were members of HAP was 1.6% (68 members out of 4400 organizations). The combined budgets of the member organizations of HAP in 2010 made up 62.9% of the total humanitarian expenditure for the year 2010 (US $4.65 billion/7.4 billion).

A very small proportion of humanitarian NGOs have adopted HAP membership. However, HAP members account for almost two-thirds of all humanitarian expenditures. The humanitarian sector, therefore, remains without a universal regulatory and accountability structure, although progress has been made. Efforts should be made to increase the membership within HAP of more small to medium sized organizations.

ForanMP , WilliamsAR . Global Uptake of the Humanitarian Accountability Partnership Over Its First Ten Years. Prehosp Disaster Med. 2014;29(4):1-4.

Medical history is an important contributor to diagnosis and patient management. In mass-casualty incidents (MCIs), health care providers are often overwhelmed by large numbers of casualties. An efficient, reliable, and affordable method of information collection is essential for effective health care response.

In some MCIs, self-reporting of symptoms can decrease the time required for history taking, without sacrificing the completeness of triage information.

Two resident doctors and a number of seventh graders who had previous experience of abdominal discomfort were invited to join this study. A questionnaire was developed to collect information on common symptoms in food poisoning. Each question was scored, and enrolled students were randomly divided into two groups. The experimental group students answered the questionnaire first and then were interviewed to complete the medical history. The control group students were interviewed in the traditional way to collect medical history. Time of all interviews was measured and recorded. The time needed to complete the history taking and completeness of obtained information were compared with students’ t tests, or Mann-Whitney U tests, based on the normality of data. Comprehensibility of each question, scored by enrolled students, was reported by descriptive statistics.

There were 41 students enrolled: 22 in the experimental group and 19 in the control group. Time to complete history taking in the experimental group (163.0 seconds, SD=52.3) was shorter than that in the control group (198.7 seconds, SD=40.9) (P=.010). There was no difference in the completeness of history obtained between the experimental group and the control group (94.8%, SD=5.0 vs 94.2%, SD=6.1; P=.747). Between the two doctors, no significant difference was found in the time required for history taking (185.2 seconds, SD=42.2 vs 173.1 seconds, SD=58.6; P=.449), or the completeness of information (94.1%, SD=5.9 vs 95.0%, SD=5.0; P=.601). Most of the questions were scored “good” in comprehensibility.

Self-reporting of symptoms can shorten the time of history taking during a food poisoning mass-casualty event without sacrificing the completeness of information.

HsuY , HuangYC . Does Self-reporting Facilitate History Taking in Food Poisoning Mass-casualty Incidents?Prehosp Disaster Med. 2014;29(4):1-4.

To analyze the unique factors involved in providing medical support for a long-distance, cross-border, cycling event, and to describe patient presentations and event characteristics for the British Columbia (BC) Ride to Conquer Cancer from 2010 through 2012.

This study was a 3-year, descriptive case series report. Medical encounters were documented, prospectively, from 2010-2012 using an online registry. Data for event-related variables also were reported.

Providing medical support for participants during the 2-day ride was complicated by communication challenges, weather conditions, and cross-border issues. The total number of participants for the ride increased from 2,252 in 2010 to 2,879 in 2011, and 3,011 in 2012. Patient presentation rates (PPRs) of 125.66, 155.26, and 198.93 (per 1,000 participants) were documented from 2010 through 2012. Over the course of three years, and not included in the PPR, an additional 3,840 encounters for “self-treatment” were documented.

The Ride to Conquer Cancer Series has shown that medical coverage at multi-day, cross-national cycling events must be planned carefully to face a unique set of circumstances, including legislative issues, long-distance communication capabilities, and highly mobile participants. This combination of factors leads to potentially higher PPRs than have been reported for noncycling events. This study also illuminates the additional workload “self-treatment” visits place on the medical team.

LundA , TurrisSA , WangP , MuiJ , LewisK , GutmanSJ . An Analysis of Patient Presentations at a 2-Day Mass-participation Cycling Event: The Ride to Conquer Cancer Case Series, 2010-2012. Prehosp Disaster Med. 2014;29(4):1-8.