On November 21 and 22 of 2016, Victoria witnessed an unprecedented epidemic thunderstorm asthma emergency event in size acuity and impact. This scenario was never exercised nor contemplated. The event resulted in a 73% increase in calls to the Emergency Services Telecommunications Authority and 814 ambulance cases in the six hours from 6 pm on November 21, 2016. A 58% increase in people presented to public hospital emergency departments in Melbourne and Geelong on November 21 and 22, 2016 (based on the three-year average). 313 calls were made to the nurse on call from people with breathing, respiratory, and allergy problems (compared to an average of 63 calls for the previous month). Tragically, ten deaths are linked to this event.

A substantial amount of work has been completed, much of which goes towards addressing the Inspector-General for Emergency Management recommendations following a review of the event, including:

• Release of an epidemic thunderstorm asthma campaign and education programs which were rolled out across Victoria for the community and health professionals from September through November 2017;

• Development of a new epidemic thunderstorm asthma forecasting system on 1 October 2017 and updated warning protocols during the 2017 grass pollen season;

• Implementation of a Real-time Health Emergency Monitoring System to alert the department of demands on public hospital emergency departments on the system; and

• Introduction of a new State Health Emergency Response Plan in October 2017 to improve coordination and communications before and during a health emergency.

The presentation will concentrate on the lessons learned more than two years down the track from the event in November 2016.

Large-scale mass-sporting events are increasingly requiring greater prehospital event planning and preparation to address inherent event-associated medical conditions in addition to incidents that may be unexpected. The Bank of America Chicago Marathon (Chicago, Illinois USA) is one of the largest marathons in the world, and with the improvement of technology, the use of historical patient and event data, in conjunction with environmental conditions, can provide organizers and public safety officials a way to plan based on injury patterns and patient demands for care by predicting the placement and timing of needed medical support and resources.

During large-scale events, disaster planning and preparedness between event organizers, Emergency Medical Services (EMS), and local, state, and federal agencies is critical to ensure participant and public safety.

This study looked at the Bank of America Chicago Marathon, a significant endurance event, and took a unique approach of reviewing digital runner data retrospectively over a five-year period to establish patterns of medical demand geographically, temporally, and by the presenting diagnoses. Most medical complaints were musculoskeletal in nature; however, there were life-threatening conditions such as hyperthermia and cardiac incidents that highlight the need for detailed planning, coordination, and communication to ensure a safe and secure event.

The Chicago Marathon is one of the largest marathons in the world, and this study identified an equal number of participants requiring care on-course and at the finish line. Most medical complaints were musculoskeletal in nature; however, there were life-threatening conditions such as hyperthermia and cardiac incidents that highlight the need for detailed planning, multi-disciplined coordination, and communication to ensure a safe and secure event. As technology has evolved, the use, analysis, and implementation of historical digital data with various environmental conditions can provide organizers and public safety officials a map to plan injury patterns and patient demands by predicting the placement and timing of needed medical support, personnel, and resources.

Disaster medical team response by governmental and non-governmental responders is highly variable and poorly characterized. Each response is unique in terms of caseload, patient demographics, and medical needs encountered. This variability increases the difficulty of determining team member composition as well as supply and equipment needs. In an effort to demonstrate this issue, we have reviewed the National Disaster Medical Response to Hurricane Sandy.

This project was a retrospective chart review of Hurricane Sandy data abstracted from the National Disaster Medical System (NDMS) Health Information Repository (HIR) medical records from the NDMS system response, and were abstracted for data including vital signs, ages, sex, chief complaint, and final impressions. In addition, length of stay among other parameters was abstracted. The data was analyzed using Microsoft Excel and Access with descriptive statistics. In addition, the results were compared to similar indices in a community emergency department and prior NDMS responses.

The results indicate a wide range of patient ages, chief complaints, and final impressions. The vast majority of patients seen by Disaster Medical Assistance Teams (DMAT) were stable with relatively low acuity issues. The total number of charts reviewed were 7,905. Respiratory complaints were the most frequent at 845 patients followed by toxicology/injuries at 706 patients and mental health issues at 452 patients. In approximately 3,400 patients, no diagnosis was present in the chart. Length of stay averaged below 1 hour and peak patient ages were between 50-60 with a significant number of infants less than 2 years.

Characterization of NDMS responses by DMATs and comparison with prior events and community emergency department caseloads can provide an insight into the needs of DMATs and other response organizations in future responses.

This paper discusses the need for consistency in mass-gathering research and evaluation from an environmental reporting perspective.

Mass gatherings occur frequently throughout the world. Having an understanding of the complexities of mass gatherings is important to inform health services about the possible required health resources. Factors within the environmental, psychosocial, and biomedical domains influence the usage of health services at mass gatherings. A minimum data set (MDS) has been proposed to standardize collection of biomedical data across various mass gatherings, and there is a need for an environmental component. The environmental domain includes factors such as the nature of the event, availability of drugs or alcohol, venue characteristics, and meteorological factors.

This research used an integrative literature review design. Manuscripts were collected using keyword searches from databases and journal content pages from 2003 through 2018. Data were analyzed and categorized using the existing MDS as a framework.

In total, 39 manuscripts were identified that met the inclusion criteria.

In collecting environmental data from mass gatherings, there must be an agreed-upon MDS. A set of variables can be used to collect de-identified environmental variables for the purpose of making comparisons across societies for mass-gathering events (MGEs).

Prehospital physicians balance the need to stabilize patients prior to transport, minimizing the delay to transport patients to the appropriate level of care. Literature has focused on which interventions should be performed in the prehospital environment, with airway management, specifically prehospital intubation (PHI), being a commonly discussed topic. However, few studies have sought additional factors which influence scene time or quantify the impact of mission characteristics or therapeutic interventions on scene time.

The goal of this study was to identify specific interventions, patient demographics, or mission characteristics that increase scene time and quantify their impact on scene time.

A retrospective, database model-building study was performed using the prehospital mission database of South Australian Ambulance Service (SAAS; Adelaide, South Australia) MedSTAR retrieval service from January 1, 2015 through August 31, 2016. Mission variables, including patient age, weight, gender, retrieval platform, physician type, PHI, arterial line placement, central line placement, and finger thoracostomy, were assessed for predictors of scene time.

A total of 506 missions were included in this study. Average prehospital scene time was 34 (SD = 21) minutes. Four mission variables significantly increased scene time: patient age, rotary wing transport, PHI, and arterial line placement increased scene time by 0.09 (SD = 0.08) minutes, 13.6 (SD = 3.2) minutes, 11.6 (SD = 3.8) minutes, and 34.4 (SD = 8.4) minutes, respectively.

This study identifies two mission characteristics, patient age and rotary wing transport, and two interventions, PHI and arterial line placement, which significantly increase scene time. Elderly patients are medically complex and more severely injured than younger patients, thus, may require more time to stabilize on-scene. Inherent in rotary wing operations is the time to prepare for the flight, which is shorter during ground transport. The time required to safely execute a PHI is similar to that in the literature and has remained constant over the past two years; arterial line placement took longer than envisioned. The SAAS MedSTAR has changed its clinical practice guidelines for prehospital interventions based on this study’s results. Retrieval services should similarly assess the necessity and efficiency of interventions to optimize scene time, knowing that the time required to safely execute an intervention may reach a minimum duration. Defining the scene time enables mission planning, team training, and audit review with the aim of improved patient care.

The recent increase in natural disasters and mass shootings highlights the need for medical providers to be prepared to provide care in extreme environments. However, while physicians of all specialties may respond in emergencies, disaster medicine training is minimal or absent from most medical school curricula in the United States. A voluntary Disaster Medicine Certificate Series (DMCS) was piloted to fill this gap in undergraduate medical education.

Beginning in August of 2017, second- and third-year medical students voluntarily enrolled in DMCS. Students earned points toward the certificate through participation in activities and membership in community organizations in a flexible format that caters to variable schedules and interests. Topics covered included active shooter training, decontamination procedures, mass-casualty triage, Incident Command System (ICS) training, and more. At the conclusion of the pilot year, demographic information was collected and a survey was conducted to evaluate student opinions regarding the program.

Sixty-eight second- and third-year medical students participated in the pilot year, with five multi-hour skills trainings and five didactic lectures made available to students. Forty-eight of those 68 enrolled in DMCS completed the retrospective survey. Student responses indicated that community partners serve as effective means for providing lectures (overall mean rating 4.50/5.0) and skills sessions (rating 4.58/5.0), and that the program created avenues for real-world disaster response in their local communities (rating 4.40/5.0).

The DMCS voluntary certificate series model served as an innovative method for providing disaster medicine education to medical students.

Kommor MB, Hodge B, Ciottone G. Development and implementation of a Disaster Medicine Certificate Series (DMCS) for medical students. Prehosp Disaster Med. 2019;34(2):197–202

On January 13, 2018, a false ballistic missile alert that lasted 38 minutes was issued across Oahu, Hawaii, United States. As a result of a system failure, an erroneous text message was sent that stated, “Ballistic missile threat inbound to Hawaii. Seek immediate shelter.”

The research team wanted to know the degree of reported anxiety triggered by the event and if knowledge, attitudes, or behaviors for individual/family emergency preparedness (EP) changed post-event.

A 50-question survey that asked about individual and family EP pre- and post-event, and the level of anxiety triggered by the event, was administered to a convenience sample of full-time adult residents of Oahu. The study was conducted over a 6-8 week period post-event. Statistical analysis was used to identify factors associated with an increasing level of EP post-event and reported event-triggered anxiety.

209 participants completed the survey (29% male, 71% female) with about one half living with children. One third were essential workers. Key factors that correlate with increasing various areas of EP post-event include higher educational, receipt of electronic emergency alerts, prior emergency training, and higher reported connectedness to community. Those with higher event anxiety were more likely to develop and practice an EP plan post-event, encourage EP with friends, and report a higher level of community connectedness. The elderly were more likely to have higher levels of EP before and after the event but were less likely to receive emergency alert notifications or have EP training.

While the event was very unfortunate, it did seem to stimulate citizen disaster EP among some groups. Additional research should explore the utility of increasing EP education for communities immediately after disasters, tailoring this education for groups, and targeting the elderly for participation in the emergency alert system.

The aim of this study was to examine the extent to which an exposure to disaster is associated with change in health behaviors.

Federal disaster declarations were matched at the county-level to self-reported behaviors for participants in the Health and Retirement Study (HRS), 2000-2014. Multivariable logistic regression was used to evaluate the relationship between disaster and change in physical activity, body mass index (BMI), and cigarette smoking.

The sample included 20,671 individuals and 59,450 interviews; 1,451 unique disasters were declared in counties in which HRS respondents lived during the study period. Exposure to disaster was significantly associated with weight gain (unadjusted RRR=1.19; 95% CI, 1.11-1.27; adjusted RRR=1.21; 95% CI, 1.13-1.30). Vigorous physical activity was significantly lower among those who had experienced a disaster compared to those who had not (unadjusted OR=0.89; 95% CI, 0.84-0.95; adjusted OR=0.84; 95% CI, 0.79-0.89). No significant difference in cigarette smoking was found.

This study found an increase in weight gain and decrease in physical activity among older adults after disaster exposure. Adverse health behaviors such as these can contribute to functional decline among older adults.

BellSA, ChoiH, LangaKM, IwashynaTJ. Health Risk Behaviors after Disaster Exposure Among Older Adults. Prehosp Disaster Med. 2019;34(1):95–97.

In July 2016, a mass-casualty stabbing attack took place at a facility for disabled persons located in Sagamihara City (Kanagawa Prefecture, Japan). The attack resulted in 45 casualties, including 19 deaths. The study hospital dispatched physicians to the field and admitted multiple casualties. This report aimed to review the physicians’ experiences and to provide insights for the formulation of response measures for similar incidents in the future.

This incident involved 30 emergency teams and 12 fire department teams, including those from neighboring fire departments. Five physicians from three medical institutions, including the study hospital, entered the field. The Simple Triage and Rapid Treatment (START) method was used on the field. The final field triage category count was: 20 red, four yellow, two green, and 19 black tags. All the casualties (n = 26) except for the 19 black tag casualties were transported to one of six neighboring medical institutions.

The median age of the transported casualties was 41 years (interquartile range [IQR] = 35.5 – 42.0). Three casualties (21.4%) were in hemorrhagic shock on arrival at the hospital. Twelve patients had multiple cervical stab wounds (median four wounds; IQR = 3.75 – 6.0). A total of 91.7% of these stab wounds were in mid-neck Zone II region. Of the 12 patients with cervical stab wounds, four (33.3%) required emergency surgery, and the rest were sutured on an out-patient basis. One patient had already been sutured on the field. All patients requiring emergency surgery had deep wounds, including those of the carotid vein, thyroid gland, nerves, and the trachea. Eight of the casualties were hospitalized at the study institution. Five of them were admitted to the intensive care unit. There were no deaths among the casualties transported to the hospitals.

Regional core disaster medical hospitals must take on a central role, particularly in the case of local disasters. Horizontal communication and interactions should be reinforced by devising protocols and conducting joint training for effective inter-department collaborations on the field.

Maruhashi, T, Takeuchi, I, Hattori, J, Kataoka, Y, Asari, Y. The Tsukui (Japan) Yamayuri-en facility stabbing mass-casualty incident. Prehosp Disaster Med. 2019;34(2):203–208

Paramedics are tasked with providing 24/7 prehospital emergency care to the community. As part of this role, they are also responsible for providing emergency care in the event of a major incident or disaster. They play a major role in the response stage of such events, both domestic and international. Despite this, specific standardized training in disaster management appears to be variable and inconsistent throughout the profession. A suggested method of building disaster response capacities is through competency-based education (CBE). Core competencies can provide the fundamental basis of collective learning and help ensure consistent application and translation of knowledge into practice. These competencies are often organized into domains, or categories of learning outcomes, as defined by Blooms taxonomy of learning domains. It is these domains of competency, as they relate to paramedic disaster response, that are the subject of this review.

The methodology for this paper to identify existing paramedic disaster response competency domains was adapted from the guidance for the development of systematic scoping reviews, using a methodology developed by members of the Joanna Briggs Institute (JBI; Adelaide, South Australia) and members of five Joanna Briggs Collaborating Centres.

The literature search identified six articles for review that reported on paramedic disaster response competency domains. The results were divided into two groups: (1) General Core Competency Domains, which are suitable for all paramedics (both Advanced Life Support [ALS] and Basic Life Support [BLS]) who respond to any disaster or major incident; and (2) Specialist Core Competencies, which are deemed necessary competencies to enable a response to certain types of disaster. Further review then showed that three separate and discrete types of competency domains exits in the literature: (1) Core Competencies, (2) Technical/Clinical Competencies, and (3) Specialist Technical/Clinical Competencies.

The most common domains of core competencies for paramedic first responders to manage major incidents and disasters described in the literature were identified. If it’s accepted that training paramedics in disaster response is an essential part of preparedness within the disaster management cycle, then by including these competency domains into the curriculum development of localized disaster training programs, it will better prepare the paramedic workforce’s competence and ability to effectively respond to disasters and major incidents.

Disasters cause severe disruption to socio-economic, infrastructural, and environmental aspects of community and nation. While the impact of disasters is strongly felt by those directly affected, they also have significant impacts on the mental and physical health of relief/recovery workers and volunteers. Variations in the nature and scale of disasters necessitate different approaches to risk management and hazard reduction during the response and recovery phases.

Published articles (2010-2017) on the quantitative and quantitative relationship between disasters and the physical and mental health of relief/recovery workers and volunteers were systematically collected and reviewed. A total of 162 relevant studies were identified. Physical injuries and mental health impacts were categorized into immediate, short-term, and chronic conditions. A systematic review of the literature was undertaken to explore the health risks and injuries encountered by disaster relief workers and volunteers, and to identify the factors contributing to these and relating mitigation strategies.

There were relatively few studies into this issue. However, the majority of the scrutinized articles highlighted the dependence of nature and scope of injuries with the disaster type and the types of responders, while the living and working environment and socio-economic standing also had significant influence on health outcomes.

A conceptual framework derived from the literature review clearly illustrated several critical elements that directly or indirectly cause damage to physical and mental health of disaster responders. Pre-disaster and post-disaster risk mitigation approaches may be employed to reduce the vulnerability of both volunteers and workers while understanding the identified stressors and their relationships.

Khatri KC J, Fitzgerald G, Poudyal Chhetri MB. Health risks in disaster responders: a conceptual framework. Prehosp Disaster Med. 2019;34(2):209–216