Following an air ambulance crash with five fatalities, critical incident stress debriefing (CISD) was provided for involved paramedics, physicians, and nurses. A study was conducted to evaluate the long-term effects of a critical incident with critical incident stress debriefing according to the Mitchell model.

Six months following the incident, empirically designed questionnaires were mailed to all transport paramedics and directly involved medical staff, and a random sample of both nurses from the dispatch/receiving institution and paramedics from around the province. Twenty-four months post-incident, all members of the transport paramedics completed the Impact of Events Scale and the General Health Questionnaires.

There were no differences between groups on any scores, except for disturbed sleep patterns, bad dreams, and the need for personal counseling being greater among transport paramedics at one day. There was no correlation between how well the deceased individuals were known, amount of debriefing, and symptom severity. A trend was seen for those with pre-existing stress management routines to have less severe symptoms at six months (p = 0.07). At two years, 16% of transport paramedics still had significant abnormal behavior.

CISD did not appear to affect the severity of stress symptoms, whereas having pre-existing stress management strategies may. These findings give justification for proceeding to a randomized, controlled trial of different levels of critical incident stress intervention.

— Define the mortality associated with extremely hot weather during the 04 July through 14 July, 1993 heat wave that struck the northeastern United States.

Design — A rapid field assessment was used to compare mortality occurring during the heat wave to mortality occurring during a period in which there was no heat wave using copies of death certificates. The findings of the rapid field assessment were validated, and it was determined whether increases in mortality occurred in other metropolitan east-coast counties also affected by the heat wave, by reviewing computerized mortality files. Setting —Information was collected on all deaths occurring in Baltimore City, Maryland; Baltimore County, Maryland; Essex County, New Jersey; Newcastle County, Delaware; and Philadelphia County, Pennsylvania; during these specified study periods: 08–18 June (comparison period) and 06–16 July (heat wave study period), 1993.

Main Outcome Measures — Ratios for total mortality, cause-specific mortality, and variables such as age, sex, race, residence, and day and place of death, that were available from death certificates were calculated.

From the rapid field assessment, the following were observed: a 26% increase in total mortality and a 98% increase in cardiovascular mortality associated with the heat wave in Philadelphia. Data from the computerized mortality files showed an increase in total mortality in four of five counties examined and an increase in cardiovascular mortality in all five counties. The risk for death for those dying from cardiovascular disease increased significantly for people older than 64 years, for both sexes, and all races.

Conclusion: As initially indicated by the Philadelphia Medical Examiner, there was excess mortality associated with a heat wave in Philadelphia. All other nearby counties examined also experienced excess mortality associated with the heat wave, although this excess was not recognized by the local health officials. The true impact of a heat wave that causes excess preventable mortality must be appropriately and rapidly ascertained. Using a national standard to certify a death as heat-related will provide the needed information rapidly so that public health resources can be more effectively allocated and mobilized to prevent further heat-related illnesses and death.

To study the effects of early, advanced prehospital life support on the survival rate of war casualties during the battle of Jalalabad, Afghanistan from 1989–1992.

The outcomes of simple trauma care administered from 1989–1990 were compared to the outcomes of advanced trauma care administered from 1991–1992 in the combat zone. The outcomes were measured by the number of deaths at admission to the referral surgical hospitals in Pakistan.

A total of 3,890 war casualties were treated in the combat zone by paramedics, and were evacuated through light, forward, field clinics to surgical hospitals in Pakistan. Advanced trauma care that was administered in the combat zone reduced the prehospital mortality rate from 26.1% to 13.6% (95% confidence interval for difference = 9.7–15.4%).

In scenarios with protracted evacuation, early and advanced trauma care should be included in the chain of survival. Local paramedics can provide such trauma care with a minimum of resources.

This descriptive research used a large, urban population-based data set for prehospital emergency medical transports to examine racial/ethnic patterns of access and utilization for several broad categories of emergency medical transport services.

Fire department files of approximately 39,000 reports on service provision were used to establish rates of transport utilization per 1,000 population in 1990, the most recent year for which reliable citylevel census data were available. Data were categorized by three age groups (< 25 years 25–64years,≥ 65years), three racial/ethnic groups (non-Hispanic whites, African-Americans, Hispanics), and gender. Transport rates were computed for total utilization, trauma incidents, and incidents due to medical conditions. Racial/ethnic rates were analyzed for each age and gender group and age- and gender-standardized rates were analyzed and presented in a graphical comparison. Statistical analyses of racial/ethnic differences were conducted using Tukey-type tests of multiple comparisons of proportions, with significant differences evaluated at the p = 0.001 level of significance.

Significant differences between racial/ethnic groups in the utilization of emergency transport services existed for all pair-wise comparisons including comparisons by each of the three age groups and gender. For total utilization, unadjusted rates are highest for African-Americans (65.9/1,000) and lowest for Hispanics (25.8/1.000). Likewise, African-American rates were substantially higher for both gender groups and across all age groups. Categorized by gender and age group under age ≥ 65 years, non-Hispanic whites are observed to have the lowest rates for both males and females under the age 65 years, while Hispanics have the lowest rates in the group 65 years old However, when rates are age- and gender- standardized, compared to African-Americans and Hispanics, rates for non-Hispanic whites are significantly lower for total transports and for trauma and medically related transports (p = 0.001).

Age- and gender- standardized rates for emergency medical transport were found to be lowest for non-Hispanic whites, moderately higher for Hispanics, and subsantially higher for African-Americans, who experienced transport rates nearly three times higher than were the rates for non-Hispanic whites. Further research is required to establish the extent to which racial/ethnic differences observed in this geographically restricted study reflect variations between racial/ethnic groups in the underlying need for services.

The past decade has been a period of evolution for the Federal disaster response system within the United States. Two domestic hurricanes were pivotal events that influenced the methods used for organizing Federal disaster assistance. The lessons of Hurricane Hugo (1989) and Hurricane Andrew (1992) were incorporated into the successful response to Hurricane Marilyn in the U.S. Virgin Islands in 1995. Following each of these storms, the Department of Defense was a major component of the response by the health sector. Despite progress in many areas, lack of clear communication between military and civilian managers and confusion among those requesting Department of Defense health resources may remain as obstacles to rapid response.

This discussion is based on an unpublished case report utilizing interviews with military and civilian managers involved in the Hurricane Marilyn response.

The findings suggest that out-of-channel pathways normally utilized in the warning and emergency phase of the response remained operational after more formal civilian-military communication pathways and local assessment capability had been established.

It is concluded that delays may be avoided if the system in place was to make all active pathways for the request and validation of military resources visible to the designated Federal managers located within the area of operations.

Behavioral and social science research suggests that job satisfaction and job performance are positively correlated. It is important that Emergency Medical Services managers identify predictors of job satisfaction in order to maximize job performance among prehospital personnel.

Identify job stressors that predict the level of job satisfaction among prehospital personnel.

The study was conducted with in a large, urban Emergency Medical Services (Emergency Medical Services) service performing approximately 60,000 Advanced Life Support (Advanced Life Support) responses annually. Using focus groups and informal interviews, potential predictors of global job satisfaction were identified. These factors included: interactions with hospital nurses and physicians; on-line communications; dispatching; training provided by the ambulance service; relationship with supervisors and; standing orders as presently employed by the ambulance service. These factors were incorporated into a 21 item questionnaire including one item measuring global job satisfaction, 14 items measuring potential predictors of satisfaction, and seven questions exploring demographic information such as age, gender, race, years of experience, and years with the company. The survey was administered to all paramedics and Emergency Medical Technicians (Emergency Medical Technicians s) Results of the survey were analyzed using univariate and multivariate techniques to identify predictors of global job satisfaction.

Ninety paramedics and Emergency Medical Technicians participated in the study, a response rate of 57.3%. Job satisfaction was cited as extremely satisfying by 11%, very satisfying by 29%, satisfying by 45%, and not satisfying by 15% of respondents. On univariate analysis, only the quality of training, quality of physician interaction, and career choice were associated with global job satisfaction. On multivariate analysis, only career choice (p = 0.005) and quality of physician interaction (p = 0.05) were predictive of global job satisfaction

Quality of career choice and interactions with physicians are predictive of global job satisfaction within this urban emergency medical service (Emergency Medical Technicians). Future studies should examine specific characteristics of the physician-paramedic interface that influence job satisfaction and attempt to generalize these results to other settings.