Emergency Medical Service (EMS) systems are vital in the identification, assessment, and treatment of trauma, stroke, myocardial infarction, and sepsis patients, improving early recognition, resuscitation, and transport. Emergency Medical Service personnel provide similar care for patients with syncope. The role of EMS in the management of patients with syncope has not been reported.

The objective of this study was to describe the management of out-of-hospital syncope by prehospital providers in an urban EMS system.

This was a retrospective cohort study of consecutively enrolled patients over 18 years of age, over a two-year period, who presented by EMS with syncope, or near-syncope, to a tertiary care emergency department (ED). Demographics included comorbidities, history, and physical exam findings documented by prehospital providers, as well as the interventions provided. Data were collected from standardized patient care records for descriptive analysis.

Of the 723 patients presenting with syncope to the ED, 284 (39.3%) were transported by EMS. Compared to non-EMS patients, those who arrived by ambulance were older (mean age 65 [SD = 18.5] years versus 61 [SD = 19.2] years; P = .019). There were no statistically significant differences in cardiovascular comorbidities (hypertension, coronary artery disease, diabetes mellitus, stroke, or congestive heart failure) between EMS and non-EMS patients. The most common chief complaints were fainting (50.0%) and dizziness (44.7%). The most common intervention provided was cardiac monitoring (55.6%), followed by administration of normal saline infusion (50.5%), oxygen (41.9%), blood glucose check (41.5%), and electrocardiogram (EKG; 40.5%).

Emergency Medical Service personnel transport more than one-third of patients presenting to the ED with syncope. Documentation of key elements of the history (witnesses, prodrome, predisposing factors, and post-event symptoms) and physical examination were not recorded consistently.

LongBJ , SerranoLA , CabanasJG , BellolioMF . Opportunities for Emergency Medical Services (EMS) Care of Syncope. Prehosp Disaster Med. 2016;31(4):349–352.

The goal of this study was to test the hypothesis that the prehospital time between injury and arrival at a trauma center for critically injured children is associated with patient injury severity and mode of transport.

Secondary analysis of prospectively collected data on children 0-17 years of age admitted with traumatic injuries to a designated Level I pediatric trauma center from January 1, 2006 through September 30, 2007 was conducted. Multivariate regression methods were used to assess for factors independently associated with prehospital time.

Of 1,175 admissions during the study period, only 355 (30%) had a prehospital time within 60 minutes of injury. Prehospital time within 60 minutes of injury was associated with higher frequency of coma, higher mean injury severity scores (ISS), and greater frequency of admission to the intensive care unit when compared with prehospital time beyond 60 minutes of injury. Children who arrived at the trauma center within 60 minutes versus beyond 60 minutes were 13-fold (odds ratio [OR]: 12.9; 95% Confidence Interval [CI], 7.6-22.0) more likely to be transported via air ambulance than a private vehicle, and had 4.8-fold greater odds (95% CI, 2.2-10.3) of transport via ground ambulance than private vehicle. For each kilometer of distance between the injury zip code and the trauma center, the odds of arrival within 60 minutes versus beyond 60 minutes decreased by 15% (OR: 0.85; 95% CI, 0.79-0.91).

Field triage and decision making appeared to correlate with severity of patient injury with expeditious transport of the most severely injured children to definitive trauma care. This finding serves as important groundwork that might enable further study into factors that influence triage and overall prehospital care for critically injured children.

OdetolaFO , MannNC , HansenKW , BrattonSL . Factors Associated with Time to Arrival at a Regional Pediatric Trauma Center. Prehosp Disaster Med. 2016;31(1):4–9.

The objective of this study is to describe the Longitudinal Emergency Medical Technician (EMT) Attributes and Demographic Study (LEADS) design, instrument development, pilot testing, sampling procedures, and data collection methodology. Response rates are provided, along with results of follow-up surveys of non-responders (NRs) and a special survey of Emergency Medical Services (EMS) professionals who were not nationally certified.

Annual surveys from 1999 to 2008 were mailed out to a random, stratified sample of nationally registered EMT-Basics and Paramedics. Survey weights were developed to reflect each respondent’s probability of selection. A special survey of NRs was mailed out to individuals who did not respond to the annual survey to estimate the probable extent and direction of response bias. Individuals who indicated they were no longer in the profession were mailed a special exit survey to determine their reasons for leaving EMS.

Given the large number of comparisons between NR and regular (annual) survey respondents, it is not surprising that some statistically significant differences were found. In general, there were few differences. However, NRs tended to report higher annual EMS incomes, were younger, healthier, more physically fit, and were more likely to report that they were not practicing EMS. Comparisons of the nationally certified EMS professionals with EMS professionals who were not nationally certified indicated that nationally certified EMS providers were younger, had less EMS experiences, earned less, were more likely to be female and work for private EMS services, and less likely to work for fire-based services. These differences may reflect state and local policy and practice, since many states and local agencies do not require maintenance of national certification as a requirement to practice. When these differences were controlled for statistically, there were few systematic differences between non-nationally certified and nationally certified EMS professionals.

The LEADS study is the only national, randomized, and longitudinal data source for studying EMS professionals in the United States. Although not without flaws, this study remains an excellent source of information about EMS provider demographics, attributes, attitudes, workplace issues and concerns, and how the profession has changed from 1999 to 2008.

LevineR. Longitudinal Emergency Medical Technician Attributes and Demographic Study (LEADS) Design and Methodology. Prehosp Disaster Med. 2016;31(Suppl. 1):s7–s17.

The aim of this study was to describe an educational method teaching Disaster Medicine to American Emergency Medicine (EM) physicians and to evaluate knowledge attainment using this method.

This was an observational study using a pre-test and a post-test. A full-scale disaster exercise (FSE) was conducted at a large academic center with two hospitals in Brooklyn, New York (USA). Eighty-two EM residents (physicians in training, post medical school) participated in the study. Inclusion criteria for study participation was all EM residents training at the State University of New York (SUNY) Downstate at the time of the study. There were no exclusion criteria. The exercise was a disaster drill designed as “Olympic Games.” Participants in the exercise took a pre-test and a post-test. The primary outcome of the study was the mean difference between pre-test and post-test scores of the study participants using independent sample t-tests. Secondary outcomes of the study were percent of critical actions met by the residents and the hospitals as measured by direct observation of trained study personnel during the exercise.

Mean resident post-test scores were higher than pre-test scores to a degree that was statistically significant (62% versus 53%; P =.002). The residents’ performances ranged from 48% to 63% of objectives met. The hospitals’ performances met 50% to 100% of their objectives.

The use of an Olympic Games format was an effective model for disaster education for physicians. The model allowed for evaluation of performance and protocols of participants and hospital systems, respectively, and may be used objectively to evaluate for areas of improvement. The Disaster Olympics drill was found to improve emergency preparedness knowledge in the population studied and may constitute a novel and efficacious methodology in disaster training.

DanielP, GistR, GrockA, KohlhoffS, RoblinP, ArquillaB. Disaster Olympics: A Model for Resident Education. Prehosp Disaster Med. 2016;31(3):237–241.

Endotracheal intubation (ETI) is a complex clinical skill complicated by the inherent challenge of providing care in the prehospital setting. Literature reports a low success rate of prehospital ETI attempts, partly due to the care environment and partly to the lack of consistent standardized training opportunities of prehospital providers in ETI.

The availability of a mobile simulation laboratory (MSL) to study clinically critical interventions is needed in the prehospital setting to enhance instruction and maintain proficiency. This report is on the development and validation of a prehospital airway simulator and MSL that mimics in situ care provided in an ambulance.

The MSL was a Type 3 ambulance with four cameras allowing audio-video recordings of observable behaviors. The prehospital airway simulator is a modified airway mannequin with increased static tongue pressure and a rigid cervical collar. Airway experts validated the model in a static setting through ETI at varying tongue pressures with a goal of a Grade 3 Cormack-Lehane (CL) laryngeal view. Following completion of this development, the MSL was launched with the prehospital airway simulator to distant communities utilizing a single facilitator/driver. Paramedics were recruited to perform ETI in the MSL, and the detailed airway management observations were stored for further analysis.

Nineteen airway experts performed 57 ETI attempts at varying tongue pressures demonstrating increased CL views at higher tongue pressures. Tongue pressure of 60 mm Hg generated 31% Grade 3/4 CL view and was chosen for the prehospital trials. The MSL was launched and tested by 18 paramedics. First pass success was 33% with another 33% failing to intubate within three attempts.

The MSL created was configured to deliver, record, and assess intubator behaviors with a difficult airway simulation. The MSL created a reproducible, high fidelity, mobile learning environment for assessment of simulated ETI performance by prehospital providers.

BischofJJ, PanchalAR, FinneganGI, TerndrupTE. Creation and Validation of a Novel Mobile Simulation Laboratory for High Fidelity, Prehospital, Difficult Airway Simulation. Prehosp Disaster Med. 2016;31(5):465–470.

There is no standard guidance for strategies for hospitals to use to coordinate with other agencies during a disaster.

This study analyzes successful strategies and barriers encountered by hospitals across the nation in coordinating and collaborating with other response agencies.

Quantitative and qualitative data were collected from a web-based study from 577 acute care hospitals sampled from the 2013 American Hospital Association (AHA) database. The results were analyzed using descriptive statistics.

The most common barriers to collaboration are related to finances, ability to communicate, and personnel.

AdelaineSA , ShoafK , HarveyC . An Assessment of Collaboration and Disasters: A Hospital Perspective. Prehosp Disaster Med. 2016;31(2):121–125.

This report explores nurses’ perspectives following the Canterbury (New Zealand) 2010-2011 earthquake sequence and the subsequent recovery process.

Little is known about the experiences of health care professionals during a disaster recovery process, and this research generates insights about the challenges faced.

Qualitative semi-structured interviews were undertaken with 11 nurses from the Christchurch (New Zealand) area to explore the challenges faced by the nurses during and following the earthquakes. The interviews took place three years after the start of the earthquake experience to enable exploration of longer term aspects of the recovery process. The interview transcripts were analyzed and coded using a grounded theory approach.

The data analysis identified that the nurses had faced a number of challenges and these were characterized as practical, emotional, and professional. While some of the challenges were short-lived in the aftermath of the earthquakes, some were long-lasting due to the extended nature of the recovery process. Dealing with house damage, insurance negotiations, and working in damaged environments had a negative impact on the nurses. The nurses experienced a range of emotions, both negative and positive, after the disaster, though many had needed time to elapse before feeling able to reflect on their experiences.

The findings suggest that secondary stressors have a negative impact on the psychosocial recovery process. The nurses recognized that they received support from others and were also required to focus on others. Keeping busy appeared to be the most common coping strategy. This lack of reflection on their experiences may have resulted in delayed emotional responses. Some of the nurses changed their work role, hours, and responsibilities suggesting that working in this environment was having a detrimental impact.

The research indicates the challenges faced by nurses in the initial impact of the earthquakes and during the longer term recovery process. There is a need to consider the psychosocial impact of working and living in a post-disaster context and to develop support packages to ensure the health and well-being of nurses in this environment.

JohalSS , MounseyZ , BrannellyP , JohnstonDM . Nurse Perspectives on the Practical, Emotional, and Professional Impacts of Living and Working in Post-earthquake Canterbury, New Zealand. Prehosp Disaster Med. 2016;31(1):10–16.

In the foothills of the Cumberland Mountains, in central Appalachia (a region that spans 13 states in the US), sits an economically distressed and rural community of the United States. Once a thriving coal-mining area, this region now is reported as one of the hardest places to live in the US. Southeastern Kentucky, located in a remote, rocky, mountainous area surrounded by rivers and valleys and prone to flooding, experienced a major flood in Spring 2013 causing significant damage to homes and critical infrastructure.

Aims of the study were to: (1) identify and better understand the contextual variables compounding the impact of a disaster event that occurred in Spring 2013; (2) identify ways participants managed antecedent circumstances, risk, and protective factors to cope with disaster up to 12 months post-event; and (3) further determine implications for community-focused interventions that may enhance recovery for vulnerable populations to promote greater outcomes of adaptation, wellness, and readiness.

Using an ethnographic mixed-methods approach, an inter-collaborative team conducted face-to-face interviews with (N=12) Appalachian residents about their disaster experience, documented observations and visual assessment of need on an observation tool, and used photography depicting structural and environmental conditions. A Health and Emergency Preparedness Assessment Survey Tool was used to collect demographic, health, housing, environment, and disaster readiness assessment data. Community stakeholders facilitated purposeful sampling through coordination of scheduled home visits.

Triangulation of all data sources provided evidence that the community had unique coping strategies related to faith and spirituality, cultural values and heritage, and social support to manage antecedent circumstances, risk, and protective factors during times of adversity that, in turn, enhanced resilience up to 12 months post-disaster. The community was found to have an innate capacity to persevere and utilize resources to manage and transcend adversity and restore equilibrium, which reflected components of resilience that deserve greater recognition and appreciation.

Resilience is a foundational concept for disaster science. A model of resilience for the rural Appalachia community was developed to visually depict the encompassing element of community-based interventions that may enhance coping strategies, mitigate risk factors, integrate protective factors, and strengthen access. Community-based interventions are recommended to strengthen resilience, yielding improved outcomes of adaptation, health and wellness, and disaster readiness.

BanksLH, DavenportLA, HayesMH, McArthurMA, ToroSN, KingCE, VaziraniHM. Disaster Impact on Impoverished Area of US: An Inter-Professional Mixed Method Study. Prehosp Disaster Med. 2016;31(6):583–592.

Children, with their specific vulnerabilities and needs, make up to more than 20% of society, so they are at risk of getting involved in disasters. Are the specialists treating them for medical problems in daily life also capable to deal with them in disaster situations?

The goals of this study were to evaluate perceived knowledge and capability of tertiary pediatricians to deal with disasters, to identify promoting factors, and to evaluate education need and willingness to work.

A survey looking for demographics, hospital disaster planning, estimated risk and capability for disasters, training, and willingness to work, and a set of six content assessment questions to evaluate knowledge, were presented to emergency pediatricians and pediatric emergency physicians in specialized tertiary centers.

The response rate was 51%. Thirty-five percent had disaster training and 53% felt that disaster education should be obligatory in their curriculum. Risk for disasters was estimated from 2.4/10 for nuclear incidents to 7.6/10 for major trauma. Self-estimated capability for these situations ranged from 1.8/10 in nuclear incidents to 7.6/10 in major trauma. Unconditional willingness to work ranged from 37% in nuclear situations to 68% in pandemics. Mean score on the questions was 2.06/6. Training, knowledge of antidote and personal protective equipment (PPE) use, self-estimated capability, and exposure were significant predictors for higher scores. Willingness to work correlated significantly with age, self-estimated capability, and risk estimation. In case of chemical and nuclear incidents, there was correlation with knowledge on the use of decontamination, PPE, and radio-detection devices.

Despite a clear perception of the risks and a high willingness to work, preparedness is limited. The major conclusion is that basics of disaster management should be included in pediatric training.

MortelmansLJM , MaebeS , DieltiensG , AnseeuwK , SabbeMB , Van de VoordeP . Are Tertiary Care Paediatricians Prepared for Disaster Situations?Prehosp Disaster Med. 2016;31(2):126–131.

The aim of this study was to evaluate whether bystanders with no training in triage can correctly prioritize three injured patients by using a triage instrument.

An observational study was conducted. Participants performed a primary triage on three paper-based patient cases and answered 11 questions during a public event in the center of Stockholm, Sweden.

A total of 69 persons participated in the study. The success rate among all the participants for correct triage of the three patient cases was 52 percent. The female participants and younger participants (<55 years of age) performed correct triage to a greater extent. The over-triage was 12.5 percent and under-triage was 6.3 percent.

Participants with no prior knowledge of triage instruments may be capable of triaging injured patients with the help of an easy triage instrument. The over- and under-triage percentages were low, and this may indicate that the developed triage instrument is relatively easy to use. It may also indicate that bystanders can identify a severely injured patient.

NordbergM , CastrénM , LindströmV . Primary Trauma Triage Performed by Bystanders: An Observation Study. Prehosp Disaster Med.2016;31(4):353–357.

The aim of disaster reduction education (DRE) is to achieve behavioral change. Over the past two decades, many efforts have been directed towards this goal, but educational activities have been developed based on unverified assumptions. Further, the literature has not identified any significant change towards disaster preparedness at the individual level. In addition, previous research suggests that change is dependent on multiple independent predictors. It is difficult to determine what specific actions DRE might result in; therefore, the preamble of such an action, which is to have discussions about it, has been chosen as the surrogate outcome measure for DRE success. This study describes the relationship of the perceived entity responsible for disaster education, disaster education per se, sex, and country-specific characteristics, with students discussing disasters with friends and family as a measure of proactive behavioral change in disaster preparedness.

A total of 3,829 final year high school students participated in an international, multi-center prospective, cross-sectional study using a validated questionnaire. Nine countries with different levels of disaster exposure risk and economic development were surveyed. Regression analyses examined the relationship between the likelihood of discussing disasters with friends and family (dependent variable) and a series of independent variables.

There was no statistically significant relationship between a single entity responsible for disaster education and discussions about potential hazards and risks with friends and/or family. While several independent predictors showed a significant main effect, DRE through school lessons in interaction with Family & Charity Organizations had the highest predictive value.

Disaster reduction education might require different delivery channels and methods and should engage with the entities with which the teenagers are more likely to collaborate.

CodreanuTA, CelenzaA, NgoH. Disaster Risk Education of Final Year High School Students Requires a Partnership with Families and Charity Organizations: An International Cross-sectional Survey. Prehosp Disaster Med. 2016;31(3):242–254.

Obesity is a growing epidemic in the United States with increasing burden to the health care system. Management and transport of the morbidly obese (MO) pose challenges for Emergency Medical Services (EMS) providers. Though equipment and resources are being directed to the transport of the obese, little research exists to guide these efforts. To address this, the author of this study sought to assess EMS providers’ perspectives on the challenges of caring for MO patients.

An anonymous, web-based survey was distributed to all active providers of prehospital transport of a large, urban, fire-based EMS system to evaluate the challenges of MO patients. The definition of MO was left up to the provider. This survey looked at various components of transport: lifting, transport time, airway management, establishing intravenous access, drug administration, as well as demographics, equipment, and education needs. The survey contained yes/no, rank-order, and Likert scale questions. Data were analyzed using descriptive statistics. The study was approved by the University of Miami (Miami, Florida USA) Institutional Review Board.

Of survey participants, 71.9% felt the average weight of their patients had increased, and 100% reported to have transported a MO patient. Of calls made to EMS, 25% were only for assistance in the house and another 25% were for non-emergent transport to a health care facility; shortness of breath was the most common emergent complaint. Of specific challenges to properly care for MO patients, 94.4 % ranked lifting and/or moving the patient highest, followed by airway management, intravenous access, and measuring vital signs. A total of 43.8% of respondents felt that MO patients require at least six to eight EMS personnel to transport patients while 31.8% felt more than eight providers were necessary. Greater than 81.3% felt it would be beneficial to receive more training and 90.4% felt more equipment was needed. Of participants, 68.8 % felt that MO patients did not receive the same standard of care.

Surveyed participants reported that patient’s weights are increasing with all having transported a MO patient. Despite the majority of transports being for non-emergent problems, providers felt more training would be beneficial, that equipment available does not meet needs, and that the MO pose challenges to appropriate patient care.

CienkiJJ. Emergency Medical Service Providers’ Perspectives towards Management of the Morbidly Obese. Prehosp Disaster Med. 2016;31(5):471–474.