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.

Individuals with chronic conditions often experience exacerbation of those conditions and have specialized medical needs after a disaster. Less is known about the level of disaster preparedness of this particular population and the extent to which being prepared might have an impact on the risk of disease exacerbation. The purpose of this study was to examine the association between self-reported asthma, cardiovascular disease, and diabetes and levels of household disaster preparedness.

Data were analyzed from 14 US states participating in the 2006-2010 Behavioral Risk Factor Surveillance System (BRFSS), a large state-based telephone survey. Chi-square statistics and adjusted prevalence ratios were calculated.

After adjusting for sociodemographic characteristics, as compared to those without each condition, persons with cardiovascular disease (aPR = 1.09; 95% CI, 1.01-1.17) and diabetes (aPR = 1.13; 95% CI, 1.05-1.22) were slightly more likely to have an evacuation plan and individuals with diabetes (aPR = 1.04; 95% CI, 1.02-1.05) and asthma (aPR = 1.02; 95% CI, 1.01-1.04) were slightly more likely to have a 3-day supply of prescription medication. There were no statistically significant differences in the prevalence for all other preparedness measures (3-day supply of food and water, working radio and flashlight, willingness to leave during a mandatory evacuation) between those with and those without each chronic condition.

Despite the increased morbidity and mortality associated with chronic conditions, persons with diabetes, cardiovascular disease, and asthma were generally not more prepared for natural or man-made disasters than those without each chronic condition.

KoJY , StrineTW , AllweissP . Chronic Conditions and Household Preparedness for Public Health Emergencies: Behavioral Risk Factor Surveillance System, 2006-2010. Prehosp Disaster Med. 2014;29(1):1-8.

Following Hurricane Katrina and the 2009 H1N1 epidemic, pediatric critical care clinicians recognized the urgent need for a standardized pediatric triage/allocation system. This study collected regional provider opinion on issues of care allocation and pediatric triage in a disaster/pandemic setting.

This study was a cross-sectional survey of United States (US) health care providers and public health workers who demonstrated interest in critical care and/or disaster care medicine by attending a Northwest regional pediatric critical care symposium on disaster preparation, held in 2012 at Seattle Children's Hospital in Seattle, Washington (USA). The survey employed an electronic audience response system and included demographic, ethical, and logistical questions. Differences in opinions between respondents grouped by professions and work locations were evaluated using a chi-square test.

One hundred and twelve (97%) of 116 total attendees responded to at least one question; however, four of these responders failed to answer every question. Sixty-two (55%) responders were nurses, 29 (26%) physicians, and 21 (19%) other occupations. Fifty-five (51%) responders worked in pediatric hospitals vs 53 (49%) in other locations. Sixty-three (58%) of 108 successful responses prioritized children predicted to have a good neuro-cognitive outcome. Seventy-one (68%) agreed that no pediatric age group should be prioritized. Twenty-two (43%) of providers working in non-pediatric hospital locations preferred a triage system based on an objective score alone vs 14 (26%) of those in pediatric hospitals (P = .038).

JohnsonEM, DiekemaDS, Lewis-NewbyM, KingMA. Pediatric Triage and Allocation of Critical Care Resources During Disaster: Northwest Provider Opinion. Prehosp Disaster Med. 2014;29(5):1-6.

Despite federal and local efforts to educate the public to prepare for major emergencies, many US households remain unprepared for such occurrences. United States Armed Forces veterans are at particular risk during public health emergencies as they are more likely than the general population to have multiple health conditions.

This study compares general levels of household emergency preparedness between veterans and nonveterans by focusing on seven surrogate measures of household emergency preparedness (a 3-day supply of food, water, and prescription medications, a battery-operated radio and flashlight, a written evacuation plan, and an expressed willingness to leave the community during a mandatory evacuation). This study used data from the 2006 through 2010 Behavioral Risk Factor Surveillance System (BRFSS), a state representative, random sample of adults aged 18 and older living in 14 states.

The majority of veteran and nonveteran households had a 3-day supply of food (88% vs 82%, respectively) and prescription medications (95% vs 89%, respectively), access to a working, battery-operated radio (82% vs 77%, respectively) and flashlight (97% vs 95%, respectively), and were willing to leave the community during a mandatory evacuation (91% vs 96%, respectively). These populations were far less likely to have a 3-day supply of water (61% vs 52%, respectively) and a written evacuation plan (24% vs 21%, respectively). After adjusting for various sociodemographic covariates, general health status, and disability status, households with veterans were significantly more likely than households without veterans to have 3-day supplies of food, water, and prescription medications, and a written evacuation plan; less likely to indicate that they would leave their community during a mandatory evacuation; and equally likely to have a working, battery-operated radio and flashlight.

These findings suggest that veteran households appear to be better prepared for emergencies than do nonveteran households, although the lower expressed likelihood of veterans households to evacuate when ordered to do so may place them at a somewhat greater risk of harm during such events. Further research should examine household preparedness among other vulnerable groups including subgroups of veteran populations and the reasons why their preparedness may differ from the general population.

Der-MartirosianC , StrineT , AtiaM , ChuK , MitchellMN , DobalianA . General Household Emergency Preparedness: A Comparison Between Veterans and Nonveterans. Prehosp Disaster Med. 2014;29(2):1-7.

In catastrophic events, a key to reducing health risks is to maintain functioning of local health facilities. However, little research has been conducted on what types and levels of care are the most likely to be affected by catastrophic events.

The Great East Japan Earthquake Disaster (GEJED) was one of a few “megadisasters” that have occurred in an industrialized society. This research aimed to develop an analytical framework for the holistic understanding of hospital damage due to the disaster.

Hospital damage data in Miyagi Prefecture at the time of the GEJED were collected retrospectively. Due to the low response rate of questionnaire-based surveillance (7.7%), publications of the national and local governments, medical associations, other nonprofit organizations, and home web pages of hospitals were used, as well as literature and news sources. The data included information on building damage, electricity and water supply, and functional status after the earthquake. Geographical data for hospitals, coastline, local boundaries, and the inundated areas, as well as population size and seismic intensity were collected from public databases. Logistic regression was conducted to identify the risk factors for hospitals ceasing inpatient and outpatient services. The impact was displayed on maps to show the geographical distribution of damage.

Data for 143 out of 147 hospitals in Miyagi Prefecture (97%) were obtained. Building damage was significantly associated with closure of both inpatient and outpatient wards. Hospitals offering tertiary care were more resistant to damage than those offering primary care, while those with a higher proportion of psychiatric care beds were more likely to cease functioning, even after controlling for hospital size, seismic intensity, and distance from the coastline.

Implementation of building regulations is vital for all health care facilities, irrespective of function. Additionally, securing electricity and water supplies is vital for hospitals at risk for similar events in the future. Improved data sharing on hospital viability in a future event is essential for disaster preparedness.

OchiS, NakagawaA, LewisJ, HodgsonS, MurrayV. The Great East Japan Earthquake Disaster: Distribution of Hospital Damage in Miyagi Prefecture. Prehosp Disaster Med. 2014;29(3):1-8.

During January 2010, a 7.0 magnitude earthquake struck Haiti, resulting in death and destruction for hundreds of thousands of people. This study describes the types of orthopedic procedures performed, the options for patient follow-up, and limitations in obtaining outcomes data in an emergency setting.

There is not a large body of data that describes larger orthopedic cohorts, especially those focusing on internal fixation surgeries in resource-poor settings in postdisaster regions. This article describes 248 injuries and over 300 procedures carried out in the Médecins Sans Frontières-Orthopedic Centre Paris orthopedic program.

Surgeries described in this report were limited to orthopedic procedures carried out under general anesthesia for all surgical patients. Exclusion factors included simple fracture reduction, debridement, dressing changes, and removal of hardware. This data was collected using both prospective and retrospective methods; prospective inpatient data were collected using a data collection form designed promptly after the earthquake and retrospective data collection was performed in October 2010.

Of the 264 fractures, 204 were fractures of the major long bones (humerus, radius, femur, tibia). Of these 204 fractures of the major long bones, 34 (16.7%) were upper limb fractures and 170 (83.3%) were lower limb fractures. This cohort demonstrated a large number of open fractures of the lower limb and closed fractures of the upper limb. Fractures were treated according to their location and type. Of the 194 long bone fractures, the most common intervention was external fixation (36.5%) followed by traction (16.7%), nailing (15.1%), amputation (14.6%), and plating (9.9%).

The number of fractures described in this report represents one of the larger orthopedic cohorts of patients treated in a single center in the aftermath of the 2010 earthquake in Haiti. The emergent surgical care described was carried out in difficult conditions, both in the hospital and the greater community. While outcome and complication data were limited, the proportion of patients attending follow-up most likely exceeded expectations and may reflect the importance of the rehabilitation center. This data demonstrates the ability of surgical teams to perform highly-specialized surgeries in a disaster zone, and also reiterates the need for access to essential and emergency surgical programs, which are an essential part of public health in low- and medium-resource settings.

TeicherCL , AlbertiK , PortenK , ElderG , BaronE , HerardP . Médecins Sans Frontières Experience in Orthopedic Surgery in Postearthquake Haiti in 2010. Prehosp Disaster Med. 2014;29(1):1-6.

No standard exists for provision of care following catastrophic natural disasters. Host nations, funders, and overseeing agencies need a method to identify the most effective interventions when allocating finite resources. Measures of effectiveness are real-time indicators that can be used to link early action with downstream impact.

Group consensus methods can be used to develop measures of effectiveness detailing the major functions of post natural disaster acute phase medical response.

A review of peer-reviewed disaster response publications (2001-2011) identified potential measures describing domestic and international medical response. A steering committee comprised of six persons with publications pertaining to disaster response, and those serving in leadership capacity for a disaster response organization, was assembled. The committee determined which measures identified in the literature review had the best potential to gauge effectiveness during post-disaster acute-phase medical response. Using a modified Delphi technique, a second, larger group (Expert Panel) evaluated these measures and novel measures suggested (or “free-texted”) by participants for importance, validity, usability, and feasibility. After three iterations, the highest rated measures were selected.

The literature review identified 397 measures. The steering committee approved 116 (29.2%) of these measures for advancement to the Delphi process. In Round 1, 25 (22%) measures attained >75% approval and, accompanied by 77 free-text measures, graduated to Round 2. There, 56 (50%) measures achieved >75% approval. In Round 3, 37 (66%) measures achieved median scores of 4 or higher (on a 5-point ordinal scale). These selected measures describe major aspects of disaster response, including: Evaluation, Treatment, Disposition, Public Health, and Team Logistics. Of participants from the Expert Panel, 24/39 (63%) completed all rounds. Thirty-three percent of these experts represented international agencies; 42% represented US government agencies.

Experts identified response measures that reflect major functions of an acute medical response. Measures of effectiveness facilitate real-time assessment of performance and can signal where practices should be improved to better aid community preparedness and response. These measures can promote unification of medical assistance, allow for comparison of responses, and bring accountability to post-disaster acute-phase medical care. This is the first consensus-developed reporting tool constructed using objective measures to describe the functions of acute phase disaster medical response. It should be evaluated by agencies providing medical response during the next major natural disaster.

DaftaryRK, CruzAT, ReavesEJ, BurkleFMJr, ChristianMD, FagbuyiDB, GarrettAL, KapurGB, SirbaughPE. Making Disaster Care Count: Consensus Formulation of Measures of Effectiveness for Natural Disaster Acute Phase Medical Response. Prehosp Disaster Med. 2014;29(5):1-7.

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.

When the world is faced with a new potential pandemic outbreak, the media report heavily about it. Media are an important disseminator of health threat information. This study examined potential media effects during the 2009 outbreak of A/H1N1 influenza.

To examine the relationship between media reports of the swine flu and self-registrations in an emergency department (ED) of a tertiary hospital in Flanders, Belgium.

All articles concerning swine flu published in seven Flemish newspapers were selected during the biggest flu peak in Belgium. This number was compared with the number of patients who presented themselves with a self-diagnosis of swine flu symptoms during the same time frame. The Pearson's correlation coefficient was selected to determine the relationship. The cross-correlation function determined the direction of this relationship.

A strong correlation was found between the number of potential patients (n = 308) and the number of articles in the Flemish press (n = 1657). The number of patients was the leading indicator; increases in the volume of written press followed increases in the number of patients.

Media reporting is extensive when a new infectious disease breaks out and intensifies when it is feared that pandemic levels are reached. This was also the case with the swine flu outbreak in Flanders. These findings suggest that a rise in the number of media reports follows a rise in the number of cases, rather than the reverse.

NelissenS , BeullensK , SabbeM , Van den BulckJ . The Swine Flu Emergency Department: The Relationship Between Media Attention for the Swine Flu and Registrations in an Emergency Medicine Unit. Prehosp Disaster Med. 2014;29(2):1-5.

The Focused Abdominal Sonography in Trauma (FAST) scan is used to detect free fluid in the peritoneal cavity, or pericardium, to quickly assess for injuries needing immediate surgical intervention. Mass-casualty incidents (MCIs) are settings where paramedics must make triage decisions in minutes. The Simple Triage and Rapid Transport (START) system is used to prioritize transport. The FAST scan can be added to the triage of critical patients, and may aid in triage.

This was a single-blinded, randomized control trial. Ten paramedics with field experience were trained with an ultrasound machine in the performance of the FAST scan. Two weeks were allowed to pass before testing to simulate the time between training of standard procedures and their implementation. On test day, five peritoneal dialysis patients with instilled dialysis fluid and five matched control patients were placed in a room in a random order where the paramedics performed FAST scans on each patient. The paramedics were assessed by declaring positive or negative for each evaluation, as well as being timed for the total exercise.

Of the ninety tests (one paramedic dropped out due to family emergency), the paramedics had a mean accuracy of 60% and median of 62% (range 40%-80%). There was a statistically significant higher false-positive rate of 59% than false-negative rate of 41% (P < .01). Sensitivity was 67% with a specificity of 56%. Average time taken was 1,218 seconds (121.8 seconds per patient) with a range of 735-1,701 seconds and a median of 1,108 seconds.

In this simulation study, paramedics had difficulty performing FAST scans with a high degree of accuracy. However, they were more apt to call a patient positive, limiting the likelihood for false-negative triage.

WestB , CusserJA , EtengoffS , LandsgaardH , LaBondV . The Use of FAST Scan by Paramedics in Mass-casualty Incidents: A Simulation Study. Prehosp Disaster Med. 2014;29(6):1-4.

While several reports discuss controversies regarding ambulance diversion from acute care hospitals and the mortality, financial, and resource effects, there is scant literature related to the effect of hospital characteristics.

The objective of this study was to describe specific paramedic receiving center characteristics that are associated with ambulance diversion rates in an Emergency Medical Services system.

A retrospective observational study design was used. The study was performed in a suburban EMS system with 27 paramedic receiving centers studied; one additional hospital present at the beginning of the study period (2000-2008) was excluded due to lack of recent data. Hospital-level and population-level characteristics were gathered, including diversion rate (hours on diversion/total hours open), for-profit status, number of specialty services (including trauma, burn, cardiovascular surgery, renal transplant services, cardiac catheterization capability [both interventional and diagnostic], and burn surgery), average inpatient bed occupancy rate (total patient days/licensed bed days), annual emergency department (ED) volume (patients per year), ED admission rate (percent of ED patients admitted), and percent of patients leaving without being seen. Demographic characteristics included percent of persons in each hospital's immediate census tract below the 100% and 200% poverty lines (each considered separately), and population density within the census tract. Bivariate and regression analyses were performed.

Diversion rates for the 27 centers ranged from 0.3%-14.5% (median 4.5%). Average inpatient bed occupancy rate and presence of specialty services were correlated with an increase in diversion rate; occupancy rate showed a 0.08% increase in diversion hours per 1% increase in occupancy rate (95% CI, 0.01%-0.16%), and hospitals with specialty services had, on average, a 4.1% higher diversion rate than other hospitals (95% CI, 1.6%-6.7%). Other characteristics did not show a statistically significant effect. When a regression was performed, only the presence of specialty services was related to the ambulance diversion rate.

Hospitals in this study providing specialty services were more likely to have higher diversion rates. This may result in increased difficulty getting patients requiring specialty care to centers able to provide the needed level of service. Major limitations include the retrospective nature of the study, as well as reliance on multiple data systems.

KahnC , StrattonS , AndersonC . Characteristics of Hospitals Diverting Ambulances in a California EMS System. Prehosp Disaster Med. 2014;29(1):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.

Substance use in young adults is a significant and growing problem. Emergency Medical Services (EMS) personnel often encounter this problem, yet the use of prehospital data to evaluate the prevalence and magnitude of substance abuse has been limited.

This study evaluated drug and alcohol use through the use of prehospital and EMS data in one suburban county in Maryland (USA). The primary hypothesis was that the type of drug being abused is associated with age. The secondary hypothesis was substance abuse incidence is associated with location. The tertiary hypothesis was that substance abuse is associated with a history of mental illness.

Deidentified patient care reports (PCRs) were obtained during a 24-month period from October 2010 through September 2012 for patients 0 through 25 years of age. Inclusion criteria included chief complaint of alcohol overdose, drug overdose, or the use of naloxone.

The primary hypothesis was supported that age was associated with drug category (P < .001). Younger adolescents were more likely to use household items, prescription drugs, or over-the-counter drugs, whereas older adolescents were more likely to use illicit drugs. The secondary hypothesis was supported that both alcohol (P < .001) and drugs (P < .001) were associated with location of call. Calls involving alcohol were more likely to be at a home or business, whereas calls involving drugs were more likely to be at home or at a public venue. The tertiary hypothesis was supported that both alcohol (P = .001) and drug use (P < .001) were associated with history of mental illness. Older adolescents were more likely to report a history of mental illness. Chi-squared tests indicated there were significant differences between genders and drug category (P = .002) and gender and current suicide attempt (P = .004). Females were more likely to use prescription drugs, whereas males were more likely to use illicit drugs. Calls involving younger adolescents under 18 were more likely to be at school or the mall, whereas calls involving older adolescents were likely to be at a prison, public venue, or a business.

All three hypotheses were supported: the type of substance being abused was associated with both age and location, and substance abuse was associated with a history of mental illness. This research has important implications for understanding how EMS resources are utilized for substance use. This information is valuable in not only the education and training of prehospital care providers, but also for the targeting of future public health interventions.

SeamanEL, LevyMJ, JenkinsJL, GodarCC, SeamanKG. Assessing Pediatric and Young Adult Substance Use Through Analysis of Prehospital Data. Prehosp Disaster Med. 2014;29(4):1-6.

Geographically isolated islands are vulnerable during natural or technological disasters. During disasters, island health facilities should be able to secure power and water in order to continue operations.

This study sought to determine the existence of Greek island health facility backup systems for water and power. When such systems existed, reserve capacity was quantified and compared to the Pan American Health Organization (PAHO) Hospital Safety Index standards.

A standardized, self-administered questionnaire was sent to major health care facilities belonging to the national health system in all Greek islands. The biggest facility available in each island was included (hospital, health center, or health post). For Crete and Euboea, all hospitals were included.

Fifty-four of 85 facilities queried (27 hospitals, 17 health centers and 41 health posts) responded, for a response rate of 64%. Responding to the survey were 16 hospitals, 12 health centers and 26 health posts. In 70% of responding facilities (all 16 hospitals, 10 health centers, and 12 health posts) a backup water tank was available, while 72% (all 16 hospitals, 11 health centers, and 12 health posts) had a backup power supply system. Twenty-seven facilities provided data on water reserve, with 15 (56%) reporting a reserve for three or more days. Twenty facilities provided data on fuel stock and power consumption; six (30%) had energy reserves for more than 72 hours, and eight (40%) had reserves for 24-72 hours.

Greek state-supported island health facilities responding to the questionnaire had water and power reserves for use in an emergency. Health centers and health posts were less prepared than hospitals. Of the responding health facilities, half had a water backup system and approximately one-third had power backup systems with reserves that would last for at least 72 hours.

AlexakisLC, CodreanuTA, StrattonSJ. Water and Power Reserve Capacity of Health Facilities in the Greek Islands. Prehosp Disaster Med. 2014;29(1):1-5.

Prehospital maritime transportation in northern areas sets high demands on hypothermia prevention. To prevent body cooling and hypothermia of seriously-ill or injured casualties during transportation, casualty coverings must provide adequate thermal insulation and protection against cold, wind, moisture, and water splashes.

The aim of this study was to determine the thermal protective properties of different types of casualty coverings and to evaluate which would be adequate for use under difficult maritime conditions (cold, high wind speed, and water splashes). In addition, the study evaluated the need for thermal protection of a casualty and verified the optimum system for maritime casualty transportation.

The study consisted of two parts: (1) the definition and comparison of the thermal protective properties of different casualty coverings in a laboratory; and (2) the evaluation of the chosen optimum protective covering for maritime prehospital transportation. The thermal insulations of ten different casualty coverings were measured according to the European standard for sleeping bags (EN 13537) using a thermal manikin in a climate chamber (-5°C) with wind speeds of 0.3 m/s and 4.0 m/s, and during moisture simulations. The second phase consisted of measurements of skin and core temperatures, air temperature, and relative humidity inside the clothing of four male test subjects during authentic maritime prehospital transportation in a partially-covered motor boat.

Wind (4 m/s) decreased the total thermal insulation of coverings by 11%-45%. The decrement of thermal insulation due to the added moisture inside the coverings was the lowest (approximately 22%-29%) when a waterproof reflective sheet inside blankets or bubble wrap was used, whereas vapor-tight rescue bags and bubble wrap provide the most protection against external water splashes. During authentic maritime transportation lasting 30 minutes, mean skin temperature decreased on average by 0.5°C when a windproof and water-resistant rescue bag was used over layered winter clothing.

The selected optimum rescue bag consisted of insulating and water-resistant layers providing sufficient protection against cold, wind, and water splashes during prehospital transportation lasting 30 minutes in the uncovered portion of a motor boat. The minimum thermal insulation for safe maritime transportation (30 minutes) is 0.46 m2K/W at a temperature of -5°C and a wind speed of 10 m/s.

JussilaK , RissanenS , ParkkolaK , AnttonenH . Evaluating Cold, Wind, and Moisture Protection of Different Coverings for Prehospital Maritime Transportation–A Thermal Manikin and Human Study. Prehosp Disaster Med. 2014;29(6):1-9.

Prehospital postresuscitation induced hypothermia (IH) has been shown to reduce neurological complications in comatose cardiac-arrest survivors. Retrofitting ambulances to include equipment appropriate to initiate hypothermia, such as refrigeration units for cooled saline, is expensive. The objective of this nonhuman subject research study was to determine if inexpensive, commercially available coolers could, in conjunction with five reusable ice packs, keep two 1 L bags of precooled 0.9% normal saline solution (NSS) at or below 4°C for an average shift of eight to 12 hours in a real-world environment, on board in-service Emergency Medical Service (EMS) units, over varying weather conditions in all seasons.

The coolers were chosen based on availability and affordability from two nationally available brands: The Igloo MaxxCold (Igloo Products Corp., Katy, Texas USA) and Coleman (The Coleman Company, Wichita, Kansas USA). Both are 8.5 liter (nine-quart) coolers that were chosen because they adequately held two 1 L bags of saline solution, along with the reusable ice packs designated in the study design, and were small enough for ease of placement on ambulances. Initial testing of the coolers was conducted in a controlled environment. Thereafter, each EMS unit was responsible to cool the saline to less than 4°C prior to shift. Data were collected by emergency medical technicians, paramedics, and resident physicians working in seven different ambulance squads. Data analysis was performed using repeated measurements recorded over a 12-hour period from 19 individual coolers and were summarized by individual time points using descriptive statistics.

Initial testing determined that the coolers maintained temperatures of 4°C for 12 hours in a controlled environment. On the ambulances, results based on the repeated measurements over time revealed that the saline solution samples as defined in the protocol, remained consistently below 4°C for 12 hours. Utilizing the lower bound of the 2-sided 95% exact binomial confidence intervals, there was less than a five percent chance that saline samples could not be maintained below 4°C for 12 hours, even during the summer months.

Simple, commercially available coolers can maintain two 1 L bags of 0.9% NSS at 4°C for 12 hours in ambulances in varying environmental conditions. This suggests that EMS agencies could inexpensively initiate prehospital IH in appropriate cases.

KaneKE , TomshoRJ , PheasantK , StaufferT , SchoenfeldtB , HamiltonS , KainT , KaneBG . The “ICE” Study: Feasibility of Inexpensive Commercial Coolers on Mobile EMS Units. Prehosp Disaster Med. 2014;29(3):1-8.

Situational awareness (SA), or being aware of what is going on and what might happen next, is essential for the successful management of prehospital emergency care. However, far too little attention has been paid to the flow of information. Having the right information is important when formulating plans and actions.

The aim of this study was to analyze and describe the type of information that is meaningful for SA in the work of paramedic field supervisors, and to create an information profile for them in the context of prehospital emergency care.

Data were collected from January through March 2012 from semi-structured interviews with ten paramedic field supervisors representing four rescue departments in Finland. The interviews were based on three different types of real-life scenarios in the context of prehospital emergency care, and deductive content analysis was employed according to the information exchange meta-model. Data management and analysis were performed using Atlas.ti 7.

A paramedic field supervisor information interest profile was formulated. The most important information categories were Events, Means, Action Patterns, and Decisions. The profile showed that paramedic field supervisors had four roles – situation follower, analyzer, planner and decision maker – and they acted in all four roles at the same time in the planning and execution phases.

Paramedic field supervisors are multitasking persons, building SA by using the available data, combining it with extensive know-how from their working methods and competencies, and their tacit knowledge. The results can be used in developing work processes, training programs, and information systems.

Norri-SederholmT, KuusistoR, KurolaJ, SarantoK, PaakkonenH. A Paramedic Field Supervisor's Situational Awareness in Prehospital Emergency Care. Prehosp Disaster Med. 2014;29(2):1-9.

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.

Ambulance staff face complex and sometimes stressful or potentially traumatic situations, not only in disasters but also in their routine daily work. The aim of this study was to survey ambulance managers’ descriptions of crisis support interventions for ambulance staff after potential traumatic events (PTEs).

Semistructured interviews with a qualitative descriptive design were conducted with six ambulance managers in a health care region in central Sweden. The data was analyzed using content analysis.

Five categories were found in the result: (1) description of a PTE; (2) description and performance of crisis support interventions; (3) impact of working in potentially traumatic situations; (4) the ambulance managers’ role in crisis support interventions; and (5) the ambulance managers’ suggestions for improvement. Ambulance managers described crisis support interventions after a PTE as a single, mandatory group meeting with a structure reminiscent of debriefing. The ambulance managers also expressed doubts about the present structures for crisis support and mentioned an alternative approach which is more in line with present evidence-based recommendations.

The results indicated a need for increased understanding of the importance of the managers’ attitudes for ambulance staff; a need for further implementation of evidence-based recommendations for crisis support interventions was also highlighted.

HugeliusK , BergS , WesterbergE , GiffordM , AdolfssonA . Swedish Ambulance Managers’ Descriptions of Crisis Support for Ambulance Staff After Potentially Traumatic Events. Prehosp Disaster Med. 2014;29(6):1-4.

The aim of this study was to determine the effect of prehospital time and advanced trauma life support interventions for trauma patients transported to an Iranian Trauma Center.

This study was a retrospective study of trauma victims presenting to a trauma center in central Iran by Emergency Medical Services (EMS) and hospitalized more than 24 hours. Demographic and injury characteristics were obtained, including accident location, damaged organs, injury mechanism, injury severity score, prehospital times (response, scene, and transport), interventions and in-hospital outcome.

Two thousand patients were studied with an average age of 36.3 (SD = 20.8) years; 83.1% were male. One hundred twenty patients (6.1%) died during hospitalization. The mean response time, at scene time and transport time were 6.6 (SD = 3), 11.1 (SD = 5.2) and 12.8 (SD = 9.4), respectively. There was a significant association of longer transport time to worse outcome (P = .02). There was a trend for patients with transport times >10 minutes to die (OR: 0.8; 95% CI, 0.1-6.59). Advanced Life Support (ALS) interventions were applied for patients with severe injuries (Revised Trauma Score ⩽7) and ALS intervention was associated with more time on scene. There was a positive association of survival with ALS interventions applied in suburban areas (P = .001).

In-hospital trauma mortality was more common for patients with severe injuries and long prehospital transport times. While more severely injured patients received ALS interventions and died, these interventions were associated with positive survival trends when conducted in suburban and out-of-city road locations with long transport times.

HosseinpourM, ParavarM, MohammadzadehM, MirzadehAS. Prehospital Care and In-hospital Mortality of Trauma Patients in Iran. Prehosp Disaster Med. 2014;29(5):1-5.