Traumatic brain injuries (TBIs) are an important cause of mortality and disability around the world. Early intervention and stabilization are necessary to obtain optimal outcomes, yet little is written on the topic in low- and middle-income countries (LMICs). The aim is to provide a descriptive analysis of patients with TBI treated by Service d’Aide Medicale Urgente (SAMU), the prehospital ambulance service in Kigali, Rwanda.

What is the incidence and nature of TBI seen on the ambulance in Kigali, Rwanda?

A retrospective descriptive analysis was performed using SAMU records captured on an electronic database from December 2012 through May 2016. Variables included demographic information, injury characteristics, and interventional data.

Patients with TBIs accounted for 18.0% (n = 2,012) of all SAMU cases. The incidence of TBIs in Kigali was 234 crashes per 100,000 people. The mean age was 30.5 (SD = 11.5) years and 81.5% (n = 1,615) were men. The most common mechanisms were road traffic incidents (RTIs; 78.5%, n = 1,535), assault (10.7%, n=216), and falls (7.8%, n=156). Most patients experienced mild TBI (Glasgow Coma Score [GCS] ≥ 13; 83.5%, n = 1,625). The most common interventions were provision of pain medications (71.0%, n = 1,429), placement of a cervical collar (53.6%, n = 1,079), and administration of intravenous fluids (48.7%, n = 979). In total, TBIs were involved in 67.0% of all mortalities seen by SAMU.

Currently, TBIs represent a large burden of disease managed in the prehospital setting of Kigali, Rwanda. These injuries are most often caused by RTIs and were observed in 67% of mortalities seen by SAMU. Rwanda has implemented several initiatives to reduce the incidence of TBIs with a specific emphasis on road safety. Further efforts are needed to better prevent these injuries. Countries seeking to develop prehospital care capacity should train providers to manage patients with TBIs.

An earthquake is a hazard that may cause urgent needs requiring international assistance. To ensure rapid funding for such needs-based humanitarian assistance, swift decisions are needed. However, data to guide needs-based funding decisions are often missing in the acute phase, causing delays. Instead, it may be feasible to use data building on existing indexes that capture hazard and vulnerability information to serve as a rapid tool to prioritize funding according to the scale of needs: needs-based funding. However, to date, it is not known to what extent the indicators in the indexes can predict the scale of disaster needs. The aim of this study was to identify predictors for the scale of disaster needs after earthquakes.

The predictive performance of vulnerability indicators and outcome indicators of four commonly used disaster risk and severity indexes were assessed, both individually and in different combinations, using linear regression. The number of people who reportedly died or who were affected was used as an outcome variable for the scale of needs, using data from the Emergency Events Database (EM-DAT) provided by the Centre for Research on the Epidemiology of Disasters at the Université Catholique de Louvain (CRED; Brussels, Belgium) from 2007 through 2016. Root mean square error (RMSE) was used as the performance measure.

The assessed indicators did not predict the scale of needs. This attempt to create a multivariable model that included the indicators with the lowest RMSE did not result in any substantially improved performance.

None of the indicators, nor any combination of the indicators, used in the four assessed indexes were able to predict the scale of needs in the assessed earthquakes with any precision.

The effect and subjective perception of audiovisual consults (AVCs) by paramedics with a distant physician in prehospital emergency care (PHEC) remain unexplained, especially in low-urgency calls.

The primary objective of the study was to evaluate the effect of AVCs by paramedics with a base physician on the rate of patients treated on site without the need of hospital transfer. The co-primary safety outcome was the frequency of repeated ambulance trips within 48 hours to the same patient. Secondary objective was the qualitative analysis of perception of the AVCs.

During a six-week period, the dispatching center of Karlovy Vary Emergency Medical Service (EMS) randomized low-urgency events from a rural area (n = 791) to receive either a mandatory phone-call consult (PHONE), AVC (VIDEO), or performed by the paramedic crew in a routine manner, when phone-call consultation is for paramedic crew optional (CONTROL). Secondarily, the qualitative analysis of subjective perception of AVCs compared to consultation over the phone by the paramedic and consulting physician was performed.

Per-protocol analysis (PPA) was performed (CONTROL, n = 258; PHONE, n = 193; and VIDEO, n = 192) in addition to the intention-to-treat (ITT) analysis. Patients (PPA) in both mandatory consulted groups were twice as likely to be treated and left on site compared to the CONTROL (PHONE: OR = 2.07; 95% CI, 1.19 to 3.58; P = 0.01 or VIDEO: OR = 2.01; 95% CI, 1.15 to 3.49; P = .01). Repeated trips to patients treated and left on site in 48 hours occurred in three (8.6%) of 35 cases in the PHONE group and in eight (23.5%) of 34 cases in the VIDEO group.

The AVCs of the emergency physician by paramedics was not superior to the mandatory conventional phone call in increasing the proportion of patients treated and left at home after a low-urgency call. The AVC improved the subjective feelings of safety by physicians, but not the satisfaction of patients or paramedics, and may lead to an increased need of repeated trips.

The Richter Scale measures the magnitude of the seismic activity for an earthquake; however, it does not quantify the humanitarian need at the point of impact. This poses a challenge for humanitarian stakeholders in decision and policy making, especially in risk reduction, response, recovery, and reconstruction. The new disaster metrics tool titled “The YEW Disaster Severity Index” (DSI) was developed and presented at the 2017 World Congress of Disaster and Emergency Medicine, May 2017, Toronto, Canada. It uses a median score of three for vulnerability and exposure indicators, a median score percentage of 100%, and medium YEW DSI scoring of four to five as baseline, indicating the ability to cope within local capacity. Therefore, scoring more than baseline coping capacity indicates that external assistance is needed. This special real-time report was presented at the 2nd National Pre-Hospital Care Conference and Championship, October 2018, Malaysia.

The aim of this analysis is to present the real-time humanitarian impact and response to the 2018 earthquake and tsunami at Donggala and Palu, Sulawesi in Indonesia using the new disaster metrics YEW DSI. Based on the earthquake (measuring 7.7 on the Richter Scale) and tsunami at Donggala, the humanitarian impact calculated on September 29, 2018 scored 7.4 High in the YEW DSI with 11 of the total 17 indicators scoring more than the baseline coping capacity. The same YEW DSI score of 7.4 was scored on the earthquake and tsunami at Palu, with 13 of the total 17 indicators scoring more than baseline ability to cope within local capacity. Impact analysis reports were sent to relevant authorities on September 30, 2018.

A State of Emergency was declared for a national response, which indicated an inability to cope within the local capacity, shown by the YEW DSI. The strong correlation between the earthquake magnitude, intensities, and the humanitarian impact at Donggala and Palu reported could be added into the science of knowledge in prehospital care and disaster medicine research and practice. As a conclusion, the real-time disaster response was found to be almost an exact fit with the YEW DSI indicators, demonstrating the inability to cope within the local capacity.

Drug and alcohol consumption at sporting mass-gathering events (MGEs) has become part of the spectator culture in some countries. The direct and indirect effects of drug and alcohol intoxication at such MGEs has proven problematic to in-event health services as well as local emergency departments (EDs). With EDs already under significant strain from increasing patient presentations, resulting in access block, it is important to understand the impact of sporting and other MGEs on local health services to better inform future planning and provision of health care delivery.

The aim of this review was to explore the impact of sporting MGEs on local health services with a particular focus on drug and alcohol related presentations.

A well-established integrative literature review methodology was undertaken. Six electronic databases and the Prehospital and Disaster Medicine (PDM) journal were searched to identify primary articles related to the aim of the review. Articles were included if published in English, from January 2008 through July 2019, and focused on a sporting MGE, mass-gathering health, EDs, as well as drug and alcohol related presentations.

Seven papers met the criteria for inclusion with eight individual sporting MGEs reported. The patient presentation rate (PPR) to in-event health services ranged from 0.18/1,000 at a rugby game to 41.9/1,000 at a recreational bicycle ride. The transport to hospital rate (TTHR) ranged from 0.02/1,000 to 19/1,000 at the same events. Drug and alcohol related presentations from sporting MGEs contributed up to 10% of ED presentations. Alcohol was a contributing factor in up to 25% of cases of ambulance transfers.

Drug and alcohol intoxication has varying levels of impact on PPR, TTHR, and ED presentation numbers depending on the type of sporting MGE. More research is needed to understand if drug and alcohol intoxication alone influences PPR, TTHR, and ED presentations or if it is multifactorial. Inconsistent data collection and reporting methods make it challenging to compare different sporting MGEs and propose generalizations. It is imperative that future studies adopt more consistent methods and report drug and alcohol data to better inform resource allocation and care provision.

Low-resource environments, such as those found in humanitarian crises, pose significant challenges to the provision of proper medical treatment. While the lack of training of health providers to such settings has been well-acknowledged in literature, there has yet to be any scientific evidence for this phenomenon.

This pilot study utilized a randomized crossover experimental design to examine the effects of high- versus low-resource simulated scenarios of a resuscitation of a critically ill obstetric patient on a medical doctors’ performance and inter-personal skills. Ten senior residents (fifth-year post-graduate) of the Maggiore Hospital School of Medicine (Novara, NO, Italy) were included in the study.

Overall performance score for the high-resource setting was 5.2, as opposed to only 2.3 for the low-resource setting. The mean effect size for the overall score was 2.9 (95% CI, 1.7–4.0; P <.001). The results suggest a significant decrease in both technical (medical) and non-technical skills, such as leadership, problem solving, situation awareness, resource utilization, and communication in the low-resource environment setting. The latter finding is of special important since it was yet to be reported.

This pilot study suggests that untrained physicians in low-resource environments may experience a considerable setback not only to their professional performance, but also to their interpersonal skills, when deployed ill-prepared to humanitarian missions. Consequently, this may endanger the health of local populations.

The use of triage systems is one of the most important measures in response to mass-casualty incidents (MCIs) caused by emergencies and disasters. In these systems, certain principles and criteria must be considered that can be achieved with a lack of resources. Accordingly, the present study was conducted as a systematic review to explore the principles of triage systems in emergencies and disasters world-wide.

The present study was conducted as a systematic review of the principles of triage in emergencies and disasters. All papers published from 2000 through 2019 were extracted from the Web of Science, PubMed, Scopus, Cochrane Library, and Google Scholar databases. The search for the articles was conducted by two trained researchers independently.

The classification and prioritization of the injured people, the speed, and the accuracy of the performance were considered as the main principles of triage. In certain circumstances, including chemical, biological, radiation, and nuclear (CBRN) incidents, certain principles must be considered in addition to the principles of the triage based on traumatic events. Usually in triage systems, the classification of the injured people is done using color labeling. The short duration of the triage and its accuracy are important for the survival of the injured individuals. The optimal use of available resources to protect the lives of more casualties is one of the important principles of triage systems and does not conflict with equity in health.

The design of the principles of triage in triage systems is based on scientific studies and theories in which attempts have been made to correctly classify the injured people with the maximum correctness and in the least amount of time to maintain the survival of the injured people and to achieve the most desirable level of health. It is suggested that all countries adopt a suitable and context-bond model of triage in accordance with all these principles, or to propose a new model for the triage of injured patients, particularly for hospitals in emergencies and disasters.

The study describes the implementation of a prehospital treatment algorithm that included intravenous (IV) bolus (IVB) nitroglycerin (NTG) followed by maintenance infusion for the treatment of acute pulmonary edema (APE) in a single, high-volume Emergency Medical Services (EMS) system.

This is a retrospective chart review of patients who received IVB NTG for APE in a large EMS system in Minnesota and Wisconsin (USA). Inclusion criteria for treatment included a diagnosis of APE, systolic blood pressure ≥120mmHg, and oxygen saturation (SpO2) ≤93% following 800mcg of sublingual NTG. Patients received a 400mcg IVB of NTG, repeated every two minutes as needed, and subsequent infusion at 80mcg/min for transport times ≥10 minutes.

Forty-four patients were treated with IVB NTG. The median total bolus dose was 400mcg. Twenty patients were treated with NTG infusion following IVB NTG. The median infusion rate was 80mcg/min. For all patients, the initial median blood pressure was 191/113mmHg. Five minutes following IVB NTG, it was 160/94mmHg, and on arrival to the emergency department (ED) it was 152/90mmHg. Five minutes after the initial dose of IVB NTG, median SpO2 increased to 92% from an initial reading of 88% and was 94% at hospital arrival. One episode of transient hypotension occurred during EMS transport.

Patients treated with IVB NTG for APE had reduction in blood pressure and improvement in SpO2 compared to their original presentation. Prehospital treatment of APE with IVB appears to be feasible and safe. A randomized trial is needed to confirm these findings.

Emerging evidence is guiding changes in prehospital management of potential spinal injuries. The majority of settings related to current recommendations are in resource-rich environments (RREs), whereas there is a lack of guidance on the provision of spinal motion restriction (SMR) in resource-scarce environments (RSEs), such as: mass-casualty incidents (MCIs); low-middle income countries; complex humanitarian emergencies; conflict zones; and prolonged transport times. The application of Translational Science (TS) in the Disaster Medicine (DM) context was used to develop this study, leading to statements that can be used in the creation of evidence-based clinical guidelines (CGs).

What is appropriate SMR in RSEs?

The first round of this modified Delphi (mD) study was a structured focus group conducted at the World Association for Disaster and Emergency Medicine (WADEM) Congress in Brisbane Australia on May 9, 2019. The result of the focus group discussion of open-ended questions produced ten statements that were added to ten statements derived from Fischer (2018) to create the second mD round questionnaire.

Academic researchers and educators, operational first responders, or first receivers of patients with suspected spinal injuries were identified to be mD experts. Experts rated their agreement with each statement on a seven-point linear numeric scale. Consensus amongst experts was defined as a standard deviation ≤1.0. Statements that were in agreement reaching consensus were included in the final report; those that were not in agreement but reached consensus were removed from further consideration. Those not reaching consensus advanced to the third mD round.

For subsequent rounds, experts were shown the mean response and their own response for each of the remaining statements and asked to reconsider their rating. As above, those that did not reach consensus advanced to the next round until consensus was reached for each statement.

Twenty-two experts agreed to participate with 19 completing the second mD round and 16 completing the third mD round. Eleven statements reached consensus. Nine statements did not reach consensus.

Experts reached consensus offering 11 statements to be incorporated into the creation of SMR CGs in RSEs. The nine statements that did not reach consensus can be further studied and potentially modified to determine if these can be considered in SMR CGs in RSEs.

Triage at mass gatherings in Australia is commonly performed by staff members with first aid training. There have been no evaluations of the performance of first aid staff with respect to diagnostic accuracy or identification of presentations requiring ambulance transport to hospital.

It was hypothesized that triage decisions by first aid staff would be considered correct in at least 61% of presentations.

A retrospective audit of 1,048 presentations to a single supplier of event health care services in Australia was conducted. The presentations were assessed based on the first measured set of physiological parameters, and the primary triage decision was classified as “expected” if the primary and secondary triage classifications were the same or “not expected” if they differed. The performance of the two triage systems was compared using area under the receiver operating characteristic curve (AUROC) analysis.

The expected decision was made by first aid staff in 674 (71%) of presentations. Under-triage occurred in 131 (14%) presentations and over-triage in 142 (15%) presentations. The primary triage strategy had an AUROC of 0.7644, while the secondary triage strategy had an AUROC of 0.6280, which was significantly different (P = .0199).

The results support the continued use of first aid trained staff members in triage roles at Australian mass gatherings. Triage tools should be simple, and the addition of physiological variables to improve the sensitivity of triage tools is not recommended because such an approach does not improve the discriminatory capacity of the tools.

Analgesia in the prehospital setting is an extremely important, yet controversial topic. Ketamine, a N-methyl D-aspartate (NMDA) receptor antagonist, has been commonly used in the prehospital setting, including recommendations by the US Department of Defense and by the Royal Australian College of Pain Medicine, despite the paucity of high-level evidence.

Accordingly, a review of the literature was conducted using several electronic medical literature databases from the earliest available records to the time at which the search was conducted (October 2018).

The search strategy yielded a total of 707 unique papers, of which 43 were short-listed for full review, and ultimately, ten papers were identified as meeting all the relevant inclusion criteria. The included studies varied significantly in the prehospital context and in the means of administering ketamine. There was only low-grade evidence that ketamine offered a safe and effective analgesia when used as the only analgesic, and only low-grade evidence that it was as effective as alternative opioid options. However, there was moderate evidence that co-administration of ketamine with morphine may improve analgesic efficacy and reduce morphine requirement.

Overall, ketamine as a prehospital analgesic may be best used in combination with opioids to reduce opioid requirement. It is suggested that future studies should use a standardized approach to measuring pain reduction. Future studies should also investigate short-term side effects and long-term complications or benefits of prehospital ketamine.

Shopping centers (SCs) are social areas with a group of commercial establishments which attract customers of numerous people every day. However, analysis of urgent health conditions and provided health care in SCs has not been performed so far.

The aim of the study was to perform a comparative analysis of clients visiting SCs and demographics, complaints, and health care of patients admitted to Emergency Medical Intervention Units (EMIU) located in grand SCs in Ankara, Turkey.

Customer and health care records of nine grand SCs in Ankara from January 1, 2018 through December 31, 2018 were evaluated retrospectively. Health care services in EMIUs of SCs were provided by employed medical staff. Data including demographic characteristics, complaints, treatment protocols, discharge, and referral to hospital of the patients were retrospectively analyzed from medical registration forms.

Medical records of nine grand SCs were analyzed. Number of customers could not be obtained in three SCs due to privacy issues and were not included in patient presentation rate (PPR) and transport-to-hospital rate (TTHR) calculation. Total number of customers in the remaining six SCs were 53,277,239. The total number of patients seeking medical care was 6,749. The number of patients seeking health care in six SCs with known number of customers was 4,498 and PPR ranged from 0.018 to 0.381 patients per 1,000 attendants. The median age of the recorded 4,065 patients (60.2%) was 28 (interquartile range [IQR]: 38-21), and 3,611 (53.5%) of the patients admitted to EMIUs were female. The number of patients treated in the SC was 4,634 (68.6%) and 189 patients (2.8%) were transferred-to-hospital by ambulance for further evaluation and treatment. Transportation to hospital was required in 125 patients who sought medical care in six SCs which provided total number of customers, and TTHR ranged from 0.000 to 0.005 patients per 1,000 attendants. No sudden cardiac death was seen. Medical conditions were the primary reasons for seeking health care. The most frequent causes of presentation were laceration and abrasions (639 patients, 9.4%).

The PPR and TTHR in SCs are low. The most common causes of presentation are minor conditions and injuries. Majority of urgent medical conditions in SCs can be managed by health care providers in EMIUs.

The Sydney City-2-Surf (Australia) fun run is the world’s largest annual run entered by around 80,000 people. First aid planning at mass-participation running events such as the City-2-Surf is an area in the medical literature that has received little attention. Consequently, first aid planning for these events is based on experience rather than evidence. The models for predicting casualties that currently exist in the literature are either dated or not statistically significant.

The aim of this study was to characterize patterns of injuries linked to geographic location across the course of the City-2-Surf, and to explore relationships of injury types with location and meteorological conditions.

Records for formally treated casualties and meteorological conditions were obtained for the race years 2010-2016 and statistically analyzed to find associations between meteorological conditions, geographic conditions, casualty types, and location.

The most common casualties encountered were heat exhaustion or hyperthermia (39.2%), musculoskeletal (25.4%), and physical exhaustion (10.2%). Associations were found between gradient and the location. Type of casualty incidence with the individual distribution trends of casualty types were quite clear. Clusters of musculoskeletal casualties emerged in the parts of the course with the steepest negative gradients, while a cluster of cardiovascular events was found to occur at the top of the “heartbreak hill,” the longest climb of the race. Regression analysis highlighted the linear relationship between the number of heat and physical exhaustion casualties and the apparent temperature (AT) at 12:00pm (R2 = 0.59; P = .044). This linear equation was used to formulate a model to predict these casualties.

The findings of this study demonstrate the relationship between meteorological conditions, geographic conditions, and casualties. This will assist planners of other similar events to determine optimum allocation of resources to anticipated injury and illness burden.

The World Health Organization (WHO; Geneva, Switzerland) recommends lay first responder (LFR) programs as a first step toward establishing formal Emergency Medical Services (EMS) in low- and middle-income countries (LMICs) to address injury. There is a scarcity of research investigating LFR program development in predominantly rural settings of LMICs.

A pilot LFR program was launched and assessed over 12 months to investigate the feasibility of leveraging pre-existing transportation providers to scale up prehospital emergency care in rural, low-resource settings of LMICs.

An LFR program was established in rural Chad to evaluate curriculum efficacy, using a validated 15-question pre-/post-test to measure participant knowledge improvement. Pre-/post-test score distributions were compared using a Wilcoxon Signed-Rank test. For test evaluation, each pre-test question was mapped to its corresponding post-test analog and compared using McNemar’s Chi-Squared Test to examine knowledge acquisition on a by-question basis. Longitudinal prehospital care was evaluated with incident reports, while program cost was tracked using a one-way sensitivity analysis. Qualitative follow-up surveys and semi-interviews were conducted at 12 months, with initial participants and randomly sampled motorcycle taxi drivers, and used a constructivist grounded theory approach to understand the factors motivating continued voluntary participation to inform future program continuity. The consolidated criteria for reporting qualitative research (COREQ) checklist was used to guide design, analysis, and reporting the qualitative results.

A total of 108 motorcycle taxi participants demonstrated significant knowledge improvement (P <.001) across three of four curricular categories: scene safety, airway and breathing, and bleeding control. Lay first responders treated 71 patients over six months, encountering five deaths, and provided patient transport in 82% of encounters. Lay first responders reported an average confidence score of 8.53/10 (n = 38). In qualitative follow-up surveys and semi-structured interviews, the ability to care for the injured, new knowledge/skills, and the resultant gain in social status and customer acquisition motivated continued involvement as LFRs. Ninety-six percent of untrained, randomly sampled motorcycle taxi drivers reported they would be willing to pay to participate in future training courses.

Lay first responder programs appear feasible and cost-effective in rural LMIC settings. Participants demonstrate significant knowledge acquisition, and after 12 months of providing emergency care, report sustained voluntary participation due to social and financial benefits, suggesting sustainability and scalability of LFR programs in low-resource settings.

Having experienced the Tokyo subway sarin attack in 1995, Japan has established extremely strict rules on handling injured victims before they are sent to a hospital. As a result, it takes a long time before rescue actions are taken. This report aims to propose a reform to change the system that focuses on saving lives.

First, the issues in firefighting on sites that currently present problems in Japan were identified. Then, Japanese guidelines were compared with those that were considered in other countries. Based on this, an ideal way of running rescue operations was examined, and a proposal to save many lives was made. This research was conducted with funding from the Ministry of Health, Labour, and Welfare of Japan (MHLW; Chiyoda, Tokyo, Japan).

In addition to preventing secondary injuries, the temporal aspect of rescuing people early with the clear goal of saving many lives was emphasized. Priority was given to measures against nerve agents to prevent secondary injuries, which put the rescuers’ lives at risk. Possible decontamination methods were pursued before choosing the one that was most appropriate. A linear algorithm was used to determine which decontamination method could be started immediately, and then the gradual use of equipment was recommended. Even if Level A personal protective equipment (PPE) and other dedicated equipment and materials cannot be procured, the possibility of starting rescue activities under certain condition using regular equipment was pointed out. The need for a system for possible victims who would require support, such as foreigners, the handicapped, and elderly people, was also identified. Japan limits the scope of activities that can be undertaken by emergency medical technicians (EMTs) on-site. The way in which on-site medical care can be provided with future legal revisions in mind was also discussed.

There is an urgent need to build a framework in which rescue activities can take place so that the number of deaths would not rise, even if sarin and other poisons are scattered.