There is insufficient research on medical care at mass-gathering events (MGEs) on college and university campuses. Fun Day is an annual celebratory day held at Skidmore College (Saratoga Springs, New York USA), a small liberal arts college in the Northeastern United States. Fun Day is focused around an outdoor music festival; students also congregate and celebrate throughout the surrounding campus. To improve care and alleviate strain on local resources, a model was developed for the provision of emergency care by a collegiate-based, volunteer first-response service – Skidmore College Emergency Medical Services (EMS) – in coordination with a contracted, private ambulance service.

The aims of this study were to: (1) analyze medical usage rates and case mixes at Fun Day over a four-year period, and to (2) describe the collegiate-based first response model for MGEs.

Data were collected retrospectively from event staff, college administrators, and Skidmore College EMS on event-related variables, patient encounters, and medical operations at Fun Day over a four-year period (2014-2017).

Annual attendance at the music festival was estimated at 2,000 individuals. Over four years, 54 patients received emergency medical care on campus on Fun Day, and 18 (33.3%) were transported to the emergency department. On-site contracted ambulances transported 77.8% of patients who were transported to the emergency department; mutual aid was requested for the other 22.2% of transports. The mean (SD) patient presentation rate (PPR) was 7.0 (SD = 1.0) per 1,000 attendees. The mean (SD) transport-to-hospital rate (TTHR) was 2.0 (SD = 1.0) per 1,000 attendees. Thirty (55.6%) patients presented with intoxication, seven (13.0%) with laceration(s), and five (9.3%) with head trauma as the primary concern. Medical command was established by volunteer undergraduate students. Up to 16 volunteer student first responders (including emergency medical technicians [EMTs]) were stationed on campus, in addition to two contracted ambulances at the Basic Life Support (BLS) and Advanced Life Support (ALS) levels. Operational strategies included: mobile first response crews, redundant communication systems, preventative education, and harm reduction.

High medical usage rates were observed, primarily due to alcohol/illicit substance use and traumatic injuries. The provision of emergency care by a collegiate-based first response service in coordination with a contracted, private ambulance agency serves as an innovative model for mass-gathering medical care on college and university campuses.

FriedmanNMG, O’ConnorEK, MunroT, GoroffD.Mass-Gathering Medical Care Provided by a Collegiate-Based First Response Service at an Annual College Music Festival and Campus-Wide Celebration. Prehosp Disaster Med. 2019;34(1):98–103.

Terror attacks have increased in frequency, and tactics utilized have evolved. This creates significant challenges for first responders providing life-saving medical care in their immediate aftermath. The use of coordinated and multi-site attack modalities exacerbates these challenges. The use of triage is not well-validated in mass-casualty settings, and in the setting of intentional mass violence, new and innovative approaches are needed.

Literature sourced from gray and peer-reviewed sources was used to perform a comparative analysis on the application of triage during the 2011 Oslo/Utoya Island (Norway), 2015 Paris (France), and 2015 San Bernardino (California USA) terrorist attacks. A thematic narrative identifies strengths and weaknesses of current triage systems in the setting of complex, coordinated terrorist attacks (CCTAs).

Triage systems were either not utilized, not available, or adapted and improvised to the tactical setting. The complexity of working with large numbers of patients, sensory deprived environments, high physiological stress, and dynamic threat profiles created significant barriers to the implementation of triage systems designed around flow charts, physiological variables, and the use of tags. Issues were identified around patient movement and “tactical triage.”

Current triage tools are inadequate for use in insecure environments, such as the response to CCTAs. Further research and validation are required for novel approaches that simplify tactical triage and support its effective application. Simple solutions exist in tactical triage, patient movement, and tag use, and should be considered as part of an overall triage system.

Despite the influential Hyogo and Sendai Frameworks, risk remains poorly understood in the emergency preparedness sector. Hazard assessment and risk management are usually considered before events. An alternative view considers risk as a cascade of potential consequences throughout an event. The 2014 fire in the Victorian rural community of Morwell included a three-phased event: a small bush fire, from which embers ignited a persistent fire in a disused open cut brown coal mine fire. The consequent air pollution precipitated a public health emergency in the nearby community of 15,000 people.

To examine this event as a case study to investigate concordance with accepted definitions and key elements of a cascading event.

Selected literature informed a risk cascade definition and model as a framework to examine the key post-event public inquiries available in the public domain.

Informed by a Conceptual Framework for a Hazard Evolving into a Disaster (Birnbaum et al., 2015), Wong and colleagues promote a Core Structure of a Comprehensive Framework for Disaster Evaluation Typologies (Wong, 2017). This Core Structure provided an adequate model to examine the sequence of events in the Morwell event. Definitions of cascading effects is more complex (Zuccaro et al., 2018). Our analysis of the Morwell event used the authoritative definition of cascading disasters published by Pescaroli and Alexander (2015). Using this definition, the Morwell event increased in progression over time and generated unexpected secondary events of strong impact. The secondary events could be distinguished from the original source of disaster, and demonstrated failures of physical structures as well as inadequacy of disaster mitigation strategies, while highlighting unresolved vulnerabilities in human society.

The Morwell coal mine fire of 2014 reflects the key criteria of a cascading disaster and provides understandings to mitigate the consequences of similar events in the future.

In the prehospital setting, many providers advocate for video laryngoscopy as the initial method of intubation to improve the likelihood of a successful first attempt. However, bright ambient light can worsen visualization of the video laryngoscope liquid crystal display (LCD).

A patient involved in a motor vehicle accident was evaluated by an Emergency Medical Services (EMS) crew. Initial endotracheal intubation attempt using video laryngoscopy was aborted after the patient desaturated. The primary reason for the failure was poor visualization of the video laryngoscope LCD, despite attempts to block direct sunlight. Debriefing revealed that the intubating provider was wearing polarized sunglasses.

Because LCDs emit polarized light, use of polarized sunglasses may cause the display to appear dark. Thus, the purpose of this Case Report is to raise awareness of a potential safety issue that is likely under-recognized by prehospital providers but can be easily avoided.

SmithAJ, JackimczykK, HorwoodB, ChristensonD. Use of Polarized Sunglasses During Video Laryngoscopy: A Cause of Difficult Prehospital IntubationPrehosp Disaster Med. 2019;34(1):104–107.

Interest in tactical medicine, the provision of medical support to law enforcement and military special operations teams, continues to grow. The majority of tactical physicians are emergency physicians with additional training and experience in tactical operations. A 2005 survey found that 18% of responding Emergency Medicine (EM) residencies offered their resident physicians structured exposure to tactical medicine at that time.

This study sought to assess interval changes in tactical medicine exposure during EM residency and Emergency Medical Services (EMS) fellowship training. A secure online survey was distributed electronically to all 212 EM residency programs and 44 EMS fellowship programs in the United States.

Responses were received from 99 (46%) EM residency and 40 (91%) EMS fellowship programs. Results showed that 52 (53%) of the responding residencies offered physician trainees formal exposure to tactical medicine as part of their training (P < .0001 compared to 18% in 2005). In addition, 32 (72%) of the 40 responding EMS fellowships (newly established since the initial survey) offered this opportunity. Experiences ranged from observation to active participation during tactical training and call-outs. The EM residents and EMS fellows provide support to local, state, and federal law enforcement agencies. A small number of programs (six residencies and four fellowships) allowed a subset of qualified trainees to be armed during tactical operations.

Overall, training opportunities in tactical medicine have grown significantly over the last decade from 18% to 53% of responding EM residencies. In addition, 72% of responding EMS fellowships incorporate tactical medicine in their training program.

Petit NP, Stopyra JP, Padilla RA, Bozeman WP. Resident involvement in tactical medicine: 12 years later. Prehosp Disaster Med. 2019;34(2):217–219

The management of chemical and explosive events is critical to reducing morbidity and mortality. However, initial patient care considerations and protective actions for staff are unfamiliar to most frontline clinicians.

This study evaluated an Incident report.

On December 1, 2017, a factory of chemical industries in Japan exploded. Dust forming as a byproduct from the crushing and packing process of the resin for ink exploded at the facility. A local fire department requested the dispatch of two physician-staffed helicopters (known as a doctor helicopter [DH] in Japan). The first party of emergency services established a headquarters and first-aid station. However, this area was feared to be at risk of a second explosion. Physicians performed re-triage for all 11 burned patients. Three severely injured patients were transported to emergency medical service centers either by ground ambulance or the DH without undergoing any decontamination. The physician who escorted the patient by ground ambulance complained of a headache. One of the severely injured patients was treated at a local hospital and then transported to an emergency medical service center after undergoing decontamination and intubation. Fortunately, all patients who were transported to medical facilities obtained a survival outcome.

Chemical, biological, radiological, nuclear, and explosive incidents are rare, but can be fatal for responders to this kind disaster. As such, all who work at such scenes should be prepared and train adequately to ensure they have the knowledge and skill to both manage patients and protect themselves from harm.

Despite United States national learning objectives referencing research fundamentals and the critical appraisal of medical literature, many paramedic programs are not meeting these objectives with substantive content.

The objective was to develop and implement a journal club educational module for paramedic training programs, which is all-inclusive and could be distributed to Emergency Medical Services (EMS) educators and EMS medical directors to use as a framework to adapt to their program.

Four two-hour long journal club sessions were designed. First, the educator provided students with four types of articles on a student-chosen topic and discussed differences in methodology and structures. Next, after a lecture about peer-review, students used search engines to verify references of a trade magazine article. Third, the educator gave a statistics lecture and critiqued the results section of several articles found by students on a topic. Finally, students found an article on a topic of personal interest and presented it to their classmates, as if telling their paramedic partner about it at work. Before and after the series, students from two cohorts (2017, 2018) completed a survey with questions about demographics and perceptions of research. Students from one cohort (2017) received a follow-up survey one year later.

For the 2016 cohort, 13 students participated and provided qualitative feedback. For the 2017 and 2018 cohorts, 33 students participated. After the series, there was an increased self-reported ability to find, evaluate, and apply medical research articles, as well as overall positive trending opinions of participating in and the importance of prehospital research. This ability was demonstrated by every student during the final journal club session. McNemar’s and Related-Samples Cochran’s Q testing of questionnaire responses suggested a statistically significant improvement in student approval of exceptions from informed consent.

The framework for this paramedic journal club series could be adapted by EMS educators and medical directors to enable paramedics to search for, critically appraise, and discuss the findings of medical literature.

The objective of this study was to explore preferred self-care practices among paramedics and emergency medical technicians (EMTs) who responded to the September 11, 2001 terrorist attack (9/11) in New York City (New York USA).

Qualitative research methodology with convenience and subsequent snowball sampling was utilized. Participants were adult (at least 18 years of age) paramedics or EMTs who self-reported as responding to the 9/11 terrorist attack in New York City.

Preferred self-care practices; participant characteristics; indications and patterns of self-care use; perceived benefits and harms; and views on appropriate availability of support and self-care services were the main outcome measures.

The 9/11 paramedic and EMT participants reported a delay in recognizing the need for self-care. Preferred physical self-care practices included exercise, good nutrition, getting enough sleep, and sticking to routine. Preferred psychosocial self-care practices included spending time with family and friends, participating in peer-support programs and online support forums, and routinely seeing a mental health professional. Self-care was important for younger paramedics and EMTs who reported having less-developed supportive infrastructure around them, as well as for retiring paramedics and EMTs who often felt left behind by a system they had dedicated their lives to. Access to cooking classes and subsidized gym memberships were viewed as favorable, as was the ability to include family members in self-care practices.

A range of physical and psychosocial self-care practices should be encouraged among paramedic students and implemented by Australian ambulance services to ensure the health and well-being of paramedics throughout their career and into retirement.

Clinicians working in emergency departments (ED) play a vital role in the healthcare response to chemical, biological, radiological, nuclear, and explosive (CBRNe) events. However, ED clinicians’ individual and workplace preparedness for CBRNe events is largely unknown.

The aim of this research was to explore Australian ED nurses and doctors’ perceptions of individual and workplace preparedness related to CBRNe events.

The study populations were Australian nurses and doctors who work in EDs. Data was collected via a survey with 43 questions requiring binary responses or a rating on a Likert scale. The survey consisted of questions relating to the participant’s previous disaster training, perceived likelihood of a CBRNe event impacting their ED, perceived level of knowledge, perceived personal preparedness, perception of ED preparedness, and willingness to attend their workplace. Data were analyzed using descriptive and inferential statistics.

There were 244 complete responses, 92 (37.7%) doctors and 152 (62.3%) nurses. When comparing doctors and nurses, there was a statistical difference between gender (p = < 0.001), length of employment (p = < 0.001), and role in the ED (p = < 0.001). Doctors and nurses had a similar level of previous training except for practical training in mask fitting (p = 0.033). CBRNe events were considered separately. Perceived level of knowledge, perceived personal preparedness, and perception of ED preparedness were significant predictors of willingness to work in all CBRNe event. Perceived likelihood of a CBRNe event impacting their ED was not a predictor of willingness.

This research contributes to an overview of the current status of Australian ED clinicians’ preparedness for CBRNe response. To increase the willingness of ED doctors and nurses attending their workplace for a CBRNe event, strategies should focus on enhancing individuals perceived level of knowledge, perceived personal preparedness, and perception of ED preparedness.

Tranexamic acid (TXA) is an antifibrinolytic agent shown to reduce morbidity and mortality in hemorrhagic shock. It has potential use in prehospital and wilderness medicine; however, in these environments, TXA is likely to be exposed to fluctuating and extreme temperatures. If TXA degrades under these conditions, this may reduce antifibrinolytic effects.

This study sought to determine if repetitive temperature derangement causes degradation of TXA.

Experimental samples underwent either seven days of freeze/thaw or heating cycles and then were analyzed via mass spectrometry for degradation of TXA. An internal standard was used for comparison between experimental samples and controls. These samples were compared to room temperature controls to determine if fluctuating extreme temperatures cause degradation of TXA.

The coefficient of variability of ratios of TXA to internal standard within each group (room temperature, freeze, and heated) was less than five percent. An independent t-test was performed on freeze/thaw versus control samples (t = 2.77; P = .17) and heated versus control samples (t = 2.77; P = .722) demonstrating no difference between the groups.

These results suggest that TXA remains stable despite repeated exposure to extreme temperatures and does not significantly degrade. These findings support the stability of TXA and its use in extreme environments.

Hyperventilation during cardiopulmonary resuscitation (CPR) negatively affects cardiopulmonary physiology. Compression-adjusted ventilations (CAVs) may allow providers to deliver ventilation rates more consistently than conventional ventilations (CVs). This study sought to compare ventilation rates between these two methods during simulated cardiac arrest.

That CAV will not result in different rates than CV in simulated CPR with metronome-guided compressions.

Volunteer Basic Life Support (BLS)-trained providers delivered bag-valve-mask (BVM) ventilations during simulated CPR with metronome-guided compressions at 100 beats/minute. For the first 4-minute interval, volunteers delivered CV. Volunteers were then instructed on how to perform CAV by delivering one breath, counting 12 compressions, and then delivering a subsequent breath. They then performed CAV for the second 4-minute interval. Ventilation rates were manually recorded. Minute-by-minute ventilation rates were compared between the techniques.

A total of 23 volunteers were enrolled with a median age of 36 years old and with a median of 14 years of experience. Median ventilation rates were consistently higher in the CV group versus the CAV group across all 1-minute segments: 13 vs 9, 12 vs 8, 12 vs 8, and 12 vs 8 for minutes one through four, respectively (P <.01, all). Hyperventilation (>10 breaths per minute) occurred 64% of the time intervals with CV versus one percent with CAV (P <.01). The proportion of time which hyperventilation occurred was also consistently higher in the CV group versus the CAV group across all 1-minute segments: 78% vs 4%, 61% vs 0%, 57% vs 0%, and 61% vs 0% for minutes one through four, respectively (P <.01, all).

In this simulated model of cardiac arrest, CAV had more accurate ventilation rates and fewer episodes of hyperventilation compared with CV.

Nikolla DA, Kramer BJ, Carlson JN. A cross-over trial comparing conventional to compression-adjusted ventilations with metronome-guided compressions. Prehosp Disaster Med. 2019;34(2):220–223