Standard gauze field dressings and direct pressure occasionally are inadequate for the control of hemorrhage. QuikClot® Combat Gauze™ (QCG) combines surgical gauze with an inorganic material and is approved by the Food and Drug Administration and by the Israeli Standards Institute for external hemorrhage control. The purpose of this article is to report clinical use of this dressing during Operation Cast Lead in the Gaza strip during January 2009.

QuikClot Combat Gauze and the QCG guidelines were issued to advanced life support (ALS) providers during the preparations for the Operation.

All cases of injuries involving hemorrhage were reviewed, as well as interviews with the ALS providers (physicians and paramedics) and injured soldiers.

Fourteen uses of QCG were reported and reviewed (out of a total of 56 hemostatic interventions in 35 cases). Dressings were applied to injuries to the head, neck, axilla, buttocks, abdomen, back, and pelvis in 10 cases, and to extremities in four cases. In 13 cases (93%), injuries were caused by blast or gunshot mechanisms. The success rate was reported as 79% (11/14). Failure to control hemorrhage was reported in three cases in three different locations: neck, buttock, and thigh. All failures were attributed to severe soft tissue and vascular injuries. No complications or adverse events were reported.

This report on the clinical field use of the QCG dressing by ALS providers suggests that it is an effective and safe product, and applicable for prehospital treatment of combat casualties. This report further suggests that QCG should be issued to medics as well as ALS providers. Larger clinical investigations are needed to confirm these findings.

Mass gatherings create difficult environments for which to plan emergency medical responses. The purpose of this study was to identify those variables that are associated with increased medical usage rates (MURs) and certain injury patterns that can be used to facilitate the planning process.

Patient information collected at three types of mass gatherings (professional American football and baseball games and rock concerts) over a three-year period was reviewed retrospectively. Specific variables were abstracted: (1) event type; (2) gender; (3) age; (4) weather; and (5) attendance. All 216 events (total attendance9,708,567) studied were held in the same metropolitan region. All MURs are reported as patients per 10,000 (PPTT).

The 5,899 patient encounters yielded a MUR of 6.1 PPTT. Patient encounters totaled 3,659 for baseball games (4.85 PPTT), 1,204 for football games (6.75 PPTT), and 1,036 for rock concerts (30 PPTT). The MUR for Location A concerts (no mosh pits) was 7.49 PPTT, whereas the MUR for the one Location B concert (with mosh pits) was110 PPTT. The MUR for Location A concerts was higher than for baseball, but not football games (p = 0.005). Gender distribution was equal among patrons seeking medical care. The mean values for patient ages were 29 years at baseball games, 33 years at football games, and 20 years at concerts. The MUR at events held when the apparent temperature was £80°F significantly lower statistically than that at events conducted at temperatures <80°F were (18°C) (4.90 vs. 8.10 PPTT (p = 0.005)). The occurrence of precipitation and increased attendance did not predict an increased MUR. Medical care was sought mostly for minor/basic-level care (84%) and less so for advanced-level care (16%). Medical cases occurred more often atsporting events (69%), and were more common than were cases with traumatic injuries (31%). Concerts with precipitation and rock concerts had a positive association withthe incidence of trauma and the incidence of injuries; whereas age and gender were not associated with medical or traumatic diagnoses.

Event type and apparent temperature were the variables that best predicted MUR as well as specific injury patterns and levels of care.

To test the hypothesis that a prehospital time threshold (PhTT) exists that when exceeded, significantly increases the mortality of trauma patients transported directly from the scene of injury to a trauma center rather than to the closest hospital.

Review of data contained within the Illinois Trauma Registry encompassing the period from fall 1989 through spring 1991.

A total of 5,215 injured persons with an Injury Severity Score (ISS) >10, cared for in an Illinois level-I or -II trauma center outside of the city of Chicago.

Injury severity expressed as ISS, scene time (ST), transport time (TrT), total emergency medical services time (TEMST), and outcome were determined for each patient. Patients were stratified into groups on the basis of ISS.

Patient outcomes were significantly different statistically between ISS groups (p <0.001, X2). Mean ST and TEMST, but not TrT, were significantly different statistically between ISS groups (p <0.001, analysis of variance). Lower ISS was associated with longer times. Mean ST, TrT, and TEMST were significantly different statistically between survivors and nonsurvivors (p <0.001, two-sample t-tests). Survival was associated with longer times. Each of the mean times remained significantly different between survivors and nonsurvivors after controlling for severity of injury (p <0.001, two-way analysis of variance).

No PhTT beyond which time patient transport to the closest hospital would have decreased mortality was identifiable, because no prehospital time <90 minutes exerted a significant adverse effect upon survival.

The “Stop the Bleed” campaign advocates for non-medical personnel to be trained in basic hemorrhage control. However, it is not clear what type of education or the duration of instruction needed to meet that requirement. The objective of this study was to determine the impact of a brief hemorrhage control educational curriculum on the willingness of laypersons to respond during a traumatic emergency.

This “Stop the Bleed” education initiative was conducted by the University of Texas Health San Antonio Office of the Medical Director (San Antonio, Texas USA) between September 2016 and March 2017. Individuals with formal medical certification were excluded from this analysis. Trainers used a pre-event questionnaire to assess participants knowledge and attitudes about tourniquets and responding to traumatic emergencies. Each training course included an individual evaluation of tourniquet placement, 20 minutes of didactic instruction on hemorrhage control techniques, and hands-on instruction with tourniquet application on both adult and child mannequins. The primary outcome in this study was the willingness to use a tourniquet in response to a traumatic medical emergency.

Of 236 participants, 218 met the eligibility criteria. When initially asked if they would use a tourniquet in real life, 64.2% (140/218) responded “Yes.” Following training, 95.6% (194/203) of participants responded that they would use a tourniquet in real life. When participants were asked about their comfort level with using a tourniquet in real life, there was a statistically significant improvement between their initial response and their response post training (2.5 versus 4.0, based on 5-point Likert scale; P<.001).

In this hemorrhage control education study, it was found that a short educational intervention can improve laypersons’ self-efficacy and reported willingness to use a tourniquet in an emergency. Identified barriers to act should be addressed when designing future hemorrhage control public health education campaigns. Community education should continue to be a priority of the “Stop the Bleed” campaign.

RossEM, RedmanTT, MappJG, BrownDJ, TanakaK, CooleyCW, KharodCU, WamplerDA. Stop the Bleed: The Effect of Hemorrhage Control Education on Laypersons’ Willingness to Respond During a Traumatic Medical Emergency. Prehosp Disaster Med. 2018;33(2):127–132.

The first decade of the 21st century has witnessed three major influenza public health emergencies: (1) the severe acute respiratory syndrome of 2002-2003; (2) the avian flu of 2006; and (3) the 2009 H1N1 pandemic influenza. An effective public health response to an influenza public health emergency depends on the majority of uninfected health care personnel (HCP) continuing to report to work. The purposes of this study were to determine the state of the evidence concerning the willingness of HCP to work during an influenza public health emergency, to identify the gaps for future investigation, and to facilitate evidence-based influenza public health emergency planning.

A systemic literature review of relevant, peer-reviewed, quantitative, English language studies published from January 1, 2001 through June 30, 2010 was conducted. Search strategies included the Cochrane Library, PubMed, PubMed Central, EBSCO Psychological and Behavioral Sciences Collection, Google Scholar, ancestry searching of citations in relevant publications, and information from individuals with a known interest in the topic.

Thirty-two studies met the inclusion criteria. Factors associated with a willingness to work during an influenza public health emergency include: being male, being a doctor or nurse, working in a clinical or emergency department, working full-time, prior influenza education and training, prior experience working during an influenza emergency, the perception of value in response, the belief in duty, the availability of personal protective equipment (PPE), and confidence in one's employer. Factors found to be associated with less willingness were: being female, being in a supportive staff position, working part-time, the peak phase of the influenza emergency, concern for family and loved ones, and personal obligations. Interventions that resulted in the greatest increase in the HCP's willingness to work were preferential access to Tamiflu for the HCP and his/her family, and the provision of a vaccine for the individual and his/her family.

Understanding the factors that contribute to the willingness of HCP to report to work during an influenza public health emergency is critical to emergency planning and preparedness. Information from this review can guide emergency policy makers, planners, and implementers in both understanding and influencing the willingness of HCP to work during an influenza public health emergency.

DevnaniM. Factors Associated with the Willingness of Health Care Personnel to Work During an Influenza Public Health Emergency: An Integrative Review. Prehosp Disaster Med. 2012;27(6):1-16.

Emergency preparedness can be defined by the preparedness pyramid, which identifies planning, infrastructure, knowledge and capabilities, and training as the major components of maintaining a high level of preparedness.The aim of this article is to review the characteristics of contingency plans for mass-casualty incidents (MCIs) and models for assessing the emergency preparedness of hospitals.

Emergency preparedness should focus on community preparedness, a personnel augmentation plan, and communications and public policies for funding the emergency preparedness. The capability to cope with a MCI serves as a basis for preparedness for non-conventional events. Coping with chemical casualties necessitates decontamination of casualties, treating victims with acute stress reactions, expanding surge capacities of hospitals, and integrating knowledge through drills. Risk communication also is important.

An annual assessment of the emergency plan is required in order to assure emergency preparedness. Preparedness assessments should include: (1) elements of disaster planning; (2) emergency coordination; (3) communication; (4) training; (5) expansion of hospital surge capacity; (6) personnel; (7) availability of equipment; (8) stockpiles of medical supplies; and (9) expansion of laboratory capacities. The assessment program must be based on valid criteria that are measurable, reliable, and enable conclusions to be drawn. There are several assessment tools that can be used, including surveys, parameters, capabilities evaluation, and self-assessment tools.

Healthcare systems are required to prepare an effective response model to cope with MCIs. Planning should be envisioned as a process rather than a production of a tangible product. Assuring emergency preparedness requires a structured methodology that will enable an objective assessment of the level of readiness.

The Working Group on Mental Health and Psychosocial Support was convened as part of the 2009 Harvard Humanitarian Action Summit. The Working Group chose to focus on ethical issues in mental health and psychosocial research and programming in humanitarian settings. The Working Group built on previous work and recommendations, such as the Inter-Agency Standing Committee's Guidelines on Mental Health and Psychosocial Support in Emergency Settings.

The objective of this working group was to address one of the factors contributing to the deficiency of research and the need to develop the evidence base on mental health and psychosocial support interventions during complex emergencies by proposing ethical research guidelines. Outcomes research is vital for effective program development in emergency settings, but to date, no comprehensive ethical guidelines exist for guiding such research efforts.

Working Group members conducted literature reviews which included peer-reviewed publications, agency reports, and relevant guidelines on the following topics: general ethical principles in research, cross-cultural issues, research in resource-poor countries, and specific populations such as trauma and torture survivors, refugees, minorities, children and youth, and the mentally ill. Working Group members also shared key points regarding ethical issues encountered in their own research and fieldwork.

The group adapted a broad definition of the term “research”, which encompasses needs assessments and data gathering, as well as monitoring and evaluation. The guidelines are conceptualized as applying to formal and informal processes of assessment and evaluation in which researchers as well as most service providers engage. The group reached consensus that it would be unethical not to conduct research and evaluate outcomes of mental health and psychosocial interventions in emergency settings, given that there currently is very little good evidence base for such interventions. Overarching themes and issues generated by the group for further study and articulation included: purpose and benefits of research, issues of validity, neutrality, risk, subject selection and participation, confidentiality, consent, and dissemination of results.

The group outlined several key topics and recommendations that address ethical issues in conducting mental health and psychosocial research in humanitarian settings. The group views this set of recommendations as a living document to be further developed and refined based on input from colleagues representing different regions of the globe with an emphasis on input from colleagues from low-resource countries.

During a medical emergency, the American public often relies on the expertise of emergency medical technicians (EMTs). These professionals face a number of occupational hazards, and the literature suggests that EMTs are at a greater risk of developing physical and mental stress-related disorders. The purpose of this paper is to systematically examine gaps in the extant literature and to present a theoretically driven conceptual model to serve as a basis for future intervention and research efforts.

A systematic review of the literature was conducted utilizing rele-vant databases (e.g., PsychInfo, Medline). All empirical articles regarding emergency medical responders were reviewed, but given the limited research available, relevant theoretical and conceptual literature on the constructs of interest in other, related populations also were included. Based on this extensive review, a modification of the stress process model is suggested to explain the relationships among occupational stress exposure, post-traumatic stress disorder (PTSD), and high-risk alcohol and other drug use.

Exposure to traumatic events was reported to be between 80% and 100% among EMTs, and rates of PTSD are >20%. High-risk alcohol and drug use rates among other emergency response professionals were reported to be as high as 40%. The proposed model suggests direct linkages between occupationally related stress exposure, including chronic and critical incident stress, PTSD, and high-risk alcohol and other drug use. Social support and personal resources (e.g., coping, locus of control) are proposed to have mediating and moderating influences on the three main constructs, and cohesion is introduced as an important, idiosyncratic influence in this population. The moderating influences of gender, age, ethnicity, marital status, and socioeconomic status, level of training, and years of service are included in the proposed model.

High-risk alcohol and other drug use and post-traumatic symptomatology pose substantial risks for EMTs, and consequently, for the patients they serve. It is imperative that researchers develop and test a theoretically grounded model of risk and protective factors that will guide intervention development and future study. The model suggested in this paper, based on a comprehensive literature review and development of theory, represents a critical first step in the intervention research process.

St John Ambulance Operations Branch Volunteers have been providing first-aid services at the Royal Adelaide Show for 90 years. The project arose from a need to more accurately predict the workload for first-aid providers at mass gathering events. A formal analysis of workload patterns and the determinants of workload had not been performed.

Casualty presentation workload would be predicted by factors including day of the week, weather, and crowd size.

Collated and analyzed casualty reports over a seven-year period representing >7,000 patients who presented for first-aid assistance for that period (63 show days) were reviewed retrospectively.

Casualty presentations correlated significantly with crowd size, maximum daily temperature, humidity, and day of the week. Patient presentation rate had heterogeneous determinants. The most frequent presentation was minor medical problems with Wednesdays attracting higher casualty presentations and more major medical categories.

Individual event analysis is a useful mechanism to assist in determining resource allocation at mass gathering events providing an evidence base upon which to make decisions about future needs. Subsequent analysis of other events will assist in supporting accurate predictor models.

Recent studies demonstrate that early, in-field, basic life support by paramedics improves trauma survival where prehospital transport times are long. So far, no case-control studies of the effect of layperson trauma first responders have been reported. It was hypothesized that trained layperson first responders improve trauma outcomes where prehospital transit times are long.

A rural prehospital trauma system was established in the mine and war zones in Iraq, consisting of 135 paramedics and 7,000 layperson trauma first responders in the villages. In a non-randomized clinical study, the outcomes of patients initially managed in-field by first-responders were compared to patients not receiving first-responder support.

The mortality rate was significantly lower among patients initially managed in-field by first responders (n = 325) compared to patients without first-responder support (n = 1,016), 9.8% versus 15.6%, 95% CI = 1.3−10.0%.

Trained layperson first responders improve trauma outcomes where prehospital evacuation times are long. This finding demonstrates that simple interventions done early—by any type of trained care provider—are crucial for trauma survival. Where the prevalence of severe trauma is high, trauma first-responders should be an integral element of the trauma system.

Traditional strategies to determine hospital bed surge capacity have relied on cross-sectional hospital census data, which underestimate the true surge capacity in the event of a mass-casualtyincident.

To determine hospital bed surge capacity for the County more accurately using physician and nurse manager assessments for the disposition of all in-patients at multiple facilities.

Overnight- and day-shift nurse managers from each in-patient unit at four different hospitals were approached to make assessments for each patient as to their predicted disposition at 2, 24, and 72 hours post-event in the case of a mass-casualty incident, including transfer to a hypothetical, onsite nursing facility. Physicians at the two academic institutions also were approached for comparison. Age, gender, and admission diagnosis also were recorded for each patient.

A total of 1,741 assessments of 788 patients by 82 nurse managers aabnd 25 physicians from the four institutions were included. Nurse managers assessed approximately one-third of all patients as dischargeable at 24 hours and approximately one-half at 72 hours; one-quarter of the patients were assessed as being transferable to a hypothetical, on-site nursing facility at both time points. Physicians were more likely than werenurse managers to send patients to such a facility or discharge them, but less likely to transfer patients outof the intensive care unit (ICU). Inter-facility variability was explained by differences in the distribution of patient diagnoses.

A large proportion of in-patients can be discharged within 24 and 72 hours in the event of a mass-casualty incident (MCI). Additional beds can be made available if an on-site nursing facility is made available. Both physicians and nurse managers should be included on the team that makes patient dispositions in the event of a MCI.

In Australia, cardiac arrest kills 142 out of every 100,000 people each year; with only 3–4% of out-of-hospital patients with cardiac arrest in Melbourne surviving to hospital discharge. Prompt initiation of cardiopulmonary resuscitation (CPR), defibrillation, and advanced cardiac care greatly improves the chances of survival from cardiac arrest. A critical step in survival is identifying by the emergency ambulance dispatcher potential of the probability that the person is in cardiac arrest. The Melbourne Metropolitan Ambulance Service (MAS) uses the computerized call-taking system, Medical Priority Dispatch System (MPDS), to triage incoming, emergency, requests for ambulance responses. The MPDS is used in many emergency medical systems around the world, however, there is little published evidence of the system's efficacy.

This study attempts to undertake a sensitivity/specificity analysis to determine the ability of MPDS to detect cardiac arrest.

Emergency ambulance dispatch records of all cases identified as suspected cardiac arrest by MPDS were matched with ambulance, patient-care records and records from the Victorian Ambulance Cardiac Arrest Registry to determine the number of correctly identified cardiac arrests. Additionally, cases that had cardiac arrests, but were not identified correctly at the point of call-taking, were examined. All data were collected retrospectively for a three-month period (01 January through 31 March 2003).

The sensitivity of MPDS in detecting cardiac arrest was 76.7% (95% confidence interval (CI): 73.6%–79.8%) and specificity was 99.2% (95% CI: 99.1–99.3%). These results indicate that cardiac arrests are correctly identified in 76.7% of cases.

Although the system correctly identified 76.7% of cardiac arrest cases, the number of false negatives suggests that there is room for improvement in recognition by MPDS to maximize chances for survival in out-of-hospital cardiac arrest. This study provides an objective and comprehensive measurement of the accuracy of MPDS cardiac-arrest detection in Melbourne, as well as providing a baseline for comparison with subsequent changes to the MPDS.

In early 2015, a patient from a cluster of cases of Ebola Virus Disease (EVD) in Monrovia, Liberia traveled to a rural village in Margibi County, potentially exposing numerous persons. The patient died in the village and post-mortem testing confirmed Ebola Virus infection.

The Margibi County Health Team (CHT; Kakata, Margibi, Liberia) needed to prevent further transmission of EVD within and outside of the affected villages, and they needed to better understand the factors that support or impede compliance with measures to stop the spread of EVD.

In February-March 2015, the Margibi CHT instituted a 21-day quarantine and active monitoring for two villages where the patient had contact with numerous residents, and a 21-day active monitoring for five other villages where the patient had possible contact with an unknown number of persons. One contact developed EVD and quarantine was extended an additional 12 days in one village. In April 2015, the Margibi CHT conducted a household-based EVD knowledge, attitudes, and practices (KAP) survey of the seven villages. From April 24-29, 2015, interview teams approached every household in the seven villages and collected information on demographics, knowledge of EVD, attitudes about quarantine to prevent the spread of EVD, and their quarantine experiences and practices. Descriptive statistics were calculated.

One hundred fifteen interviews were conducted, representing the majority of the households in the seven villages. Most (99%) correctly identified touching an infected person’s body fluids and contact with the body of someone who has died from EVD as transmission routes. However, interviewees sometimes incorrectly identified mosquito bites (58%) and airborne spread (32%) as routes of EVD transmission, and 72% incorrectly identified the longest EVD incubation period as ≤seven days. Eight of 16 households in the two quarantined villages (50%) reported times when there was not enough water or food during quarantine. Nine of 16 (56%) reported that a household member had illnesses or injuries during quarantine; of these, all (100%) obtained care from a clinic, hospital, or Ebola treatment unit (ETU).

Residents’ knowledge of EVD transmission routes and incubation period were suboptimal. Public health authorities should consider assessing residents’ understanding of Ebola transmission routes and effectively educate them to ensure correct understanding. Quarantined residents should be provided with sufficient food, water, and access to medical care.

WilkenJA, PordellP, GoodeB, JartehR, MillerZ, SaygarBGSr., MaximoreL, BorborWM, CarmueM, WalkerGW, YeiahA. Knowledge, Attitudes, and Practices among Members of Households Actively Monitored or Quarantined to Prevent Transmission of Ebola Virus Disease — Margibi County, Liberia: February-March 2015. Prehosp Disaster Med. 2017;32(6):673–678.

During the last decades, several humanitarian emergencies have occurred, with an increasing number of humanitarian organizations taking part in providing assistance. However, need assessments, medical intelligence, and coordination of the aid often are sparse, resulting in the provision of ineffective and expensive assistance. When an earthquake with the strength of 7.7 on the Richter scale struck the state of Gujarat, India, during the early morning on 26 January 2001, nearly 20,000 persons were killed, nearly 170,000 were injured, and 600,000 were rendered homeless. This study identifies how assigned indicators to measure the level of health care may improve disaster preparedness and management, thus, reducing human suffering.

During a two-week mission in the disaster area, the disaster relief provided to the disaster-affected population of Gujarat was evaluated. Vulnerability due to climate, geography, culture, religion, gender, politics, and economy, as each affected the outcome, was studied. By assigning indicators to the eight ELEMENTS of the Primary Health Care System as advocated by the World Health Organization (WHO), the level of public health and healthcare services were estimated, an evaluation of the impact of the disaster was conducted, and possible methods for improving disaster management are suggested. Representatives of the major relief organizations involved were interviewed on their relief policies. Strategies to improve disaster relief, such as policy development in the different aspects of public health/primary health care, were sought.

Evaluation of the pre-event status of the affected society revealed a complex situation in a vulnerable society with substantial deficiencies in the existing health system that added to the severity of the disaster. Most of the civilian hospitals had collapsed, and army field hospitals provided medical care to most of the patients under primitive conditions using tents. When the foreign field hospitals arrived 5 to 7 days after the earthquake, most of the casualties requiring surgical intervention already had been operated on. Relief provided to the disaster victims had reduced quality for the following reasons: (1) proper public health indicators had not yet been developed; (2) efficient coordination was lacking; (3) insufficient, overestimated, or partly irrelevant relief was provided; (4) relief was delayed because of bureaucracy; and (5) policies on the delivery of disaster relief had not been developed.

To optimize the effectiveness of limited resources, disaster preparedness and the provision of feasible and necessary aid is of utmost importance. An appropriate, rapid, crisis intervention could be achieved by continual surveillance of the world's situation by a Relief Coordination Center. A panel of experts could evaluate and coordinate the international disaster responses and make use of stored emergency material and emergency teams. A successful disaster response will depend on accurate and relevant medical intelligence and socio-geographical mapping in advance of, during, and after the event(s) causing the disaster. More effective and feasible equipment coordinated with the relief provided by the rest of the world is necessary. If policies and agreements are developed as part of disaster preparedness, on international, bilateral, and national levels, disaster relief may be more relevant, less chaotic, and easier to estimate, thus, bringing improved relief to the disaster victims.