Outdoor activities have accelerated in the past several years. The authors were tasked with providing medical care for the Union Cycliste International (UCI) mountain biking World Cup in Snowshoe, West Virginia (USA) in September 2021. The Hartman and Arbon models were designed to predict patient presentation and hospital transport rates as well as needed medical resources at urban mass-gathering events. However, there is a lack of standardized methods to predict injury, illness, and insult severity at rural mass gatherings.

This study aimed to determine whether the Arbon model would predict, within 10%, the number of patient presentations to be expected and to determine if the event classification provided by the Hartman model would adequately predict resources needed during the event.

Race data were collected from UCI event officials and injury data were collected from participants at time of presentation for medical care. Predicted presentation and transport rates were calculated using the Arbon model, which was then compared to the actual observed presentation rates. Furthermore, the event classification provided by the Hartman model was compared to the resources utilized during the event.

During the event, 34 patients presented for medical care and eight patients required some level of transport to a medical facility. The Arbon predictive model for the 2021 event yielded 30.3 expected patient presentations. There were 34 total patient presentations during the 2021 race, approximately 11% more than predicted. The Hartman model yielded a score of four. Based on this score, this race would be classified as an “intermediate” event, requiring multiple Advanced Life Support (ALS) and Basic Life Support (BLS) personnel and transport units.

The Arbon model provided a predicted patient presentation rate within reasonable error to allow for effective pre-event planning and resource allocation with only a four patient presentation difference from the actual data. While the Arbon model under-predicted patient presentations, the Hartman model under-estimated resources needed due to the high-risk nature of downhill cycling. The events staffed required physician skills and air medical services to safely care for patients. Further evaluation of rural events will be needed to determine if there is a generalized need for physician presence at smaller events with inherently risky activities, or if this recurring cycling event is an outlier.

Many capital cities around the world have been subjected to terrorist attacks on their transport systems with devastating consequences. Large crowds in small enclosed spaces, disruption to people movement, and the psychosocial and financial repercussions of attacks are some of the many soft target vulnerabilities of mass-transit systems.

This study is an epidemiological examination of all terrorism-related events targeting air, sea, and ground transport modalities sustained from 1970-2019, comparing the rates of fatal injuries (FI) and non-fatal injuries (NFI).

The Global Terrorism Database (GTD) was downloaded and searched using the internal database search functions for all events that occurred from January 1, 1970 - December 31, 2019. Years 2020 and 2021 were not yet available at the time of the study. “Transportation,” “Airport and Aircraft,” and “Maritime” as primary target types were selected for the purpose of this study, and events were further sub-classified by region, weapon type used, and by suicide attack (SA). “Airport personnel” were excluded. All classifications and sub-classifications were pre-determined by the GTD.

There were 8,729 transportation-related (air, sea, and ground) attacks documented during the study period with 19,020 fatalities and 45,218 NFI. This accounted for 5.2% of all terrorist attacks (168,003 total events), 5.6% of all FI (total 339,435), and 9.1% of all NFI (total 496,225). The mean FI was 2.2 per event and the mean NFI was 5.2 per attack.

South Asia (28.4%), Middle East and North Africa (18.2%), and South America (14.9%) accounted for 61.5% of all transport related attacks. Attacks on subways inflicted a disproportionately high 51.5 NFI per attack. Suicide attacks recorded the highest ratios for both FI (13.71 per attack) and NFI (139.00 per attack).

Transport modalities are vulnerable terrorist soft targets. The repercussions of attacks on public transport modalities represent a significant and unique psychosocial and economical risk to the affected communities. Suicide attacks on subways represent a unique and significantly higher casualty risk than other transport modalities. Risk mitigation strategies should be regularly revisited by Counter-Terrorism Medicine (CTM) specialists.

The Middle East and North Africa (MENA) region has been, like many parts of the world, a hotbed for terrorist activities. Terrorist attacks can affect both demand for and provision of health care services and often places a unique burden on first responders, hospitals, and health systems. This study aims to provide an epidemiological description of all terrorism-related attacks in the Middle East sustained from 1970-2019.

Data collection was performed using a retrospective database search through the Global Terrorism Database (GTD). The GTD was searched using the internal database search functions for all events which occurred in Iraq, Yemen, Turkey, Egypt, Syria, West Bank and Gaza Strip, Israel, Lebanon, Iran, Saudi Arabia, Bahrain, Jordan, Kuwait, United Arab Emirates, North Yemen, Qatar, and South Yemen from January 1, 1970 - December 31, 2019. Primary weapon type, primary target type, country where the incident occurred, and number of deaths and injuries were collated and the results analyzed.

A total of 41,837 attacks occurred in the Middle East from 1970-2019 accounting for 24.9% of all terrorist attacks around the world. A total of 100,446 deaths were recorded with 187,447 non-fatal injuries. Fifty-six percent of all attacks in the region occurred in Iraq (23,426), 9.4% in Yemen (3,929), and 8.2% in Turkey (3,428). “Private Citizens and Properties” were targeted in 37.6% (15,735) of attacks, 15.4% (6,423) targeted “Police,” 9.6% targeted “Businesses” (4,012), and 9.6% targeted “Governments” (4,001). Explosives were used in 68.4% of attacks (28,607), followed by firearms in 20.4% of attacks (8,525).

Despite a decline in terrorist attacks from a peak in 2014, terrorist events remain an important cause of death and injuries around the world, particularly in the Middle East where 24.9% of historic attacks took place. While MENA countries are often clustered together by economic and academic organizations based on geographical, political, and cultural similarities, there are significant differences in terrorist events between countries within the region. This is likely a reflection of the complexities of the intricate interplay between politics, culture, security, and intelligence services unique to each country.

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.

Comprehensive studies on the relationship between patient demographics and subsequent treatment and disposition at a single mass-gathering event are lacking. The Sydney Royal Easter Show (SRES; Sydney Olympic Park, New South Wales, Australia) is an annual, 14-day, agricultural mass-gathering event occurring around the Easter weekend, attracting more than 800,000 patrons per year. In this study, patient records from the SRES were analyzed to examine relationships between weather, crowd size, day of week, and demographics on treatment and disposition. This information would help to predict factors affecting patient treatment and disposition to guide ongoing training of first responders and to evaluate the appropriateness of staffing skills mix at future events.

Patient demographics, environmental factors, and attendance would influence the nature and severity of presentations at the SRES, which would influence staffing requirements.

A retrospective analysis of 4,141 patient record forms was performed for patients who presented to St John Ambulance (Australian Capital Territory, Australia) at the SRES between 2012 and 2014 inclusive. Presentation type was classified using a previously published minimum data set. Data on weather and crowd size were obtained from the Australian Bureau of Meteorology (Melbourne, Victoria, Australia) and the SRES, respectively. Statistical analyses were performed using SPSS v22 (IBM; Armonk, New York USA).

Between 2012 to 2014, over 2.5 million people attended the SRES with 4,141 patients treated onsite. As expected, the majority of presentations were injuries (49%) and illnesses (46%). Although patient demographics and presentation types did not change over time, the duration of treatment increased. A higher proportion of patients were discharged to hospital or home compared to the proportion of patients discharged back to the event. Patients from rural/regional locations (accounting for 15% of all patients) were more likely to require advanced treatment, health professional review, and were more likely to be discharged to hospital or home rather than discharged back to the event. Extremes of temperature were associated with a lower crowd size and higher patient presentation rate (PPR), but had no impact on transfer or referral rates to hospital.

This study demonstrated that analyses of patient presentations at an agricultural show provide unique insights on weather, attendance, and demographic features that correlated with treatment and disposition. These data can help guide organizers with information on how to better staff and train health care providers at future mass-gathering events of this type.

CrabtreeN, MoS, OngL, JegatheesT, WeiD, FaheyD, LiuJ. Retrospective Analysis of Patient Presentations at the Sydney (Australia) Royal Easter Show from 2012 to 2014. Prehosp Disaster Med. 2017;32(2)187–194.

Triage is fundamental to emergency patient assessment. Effective triage systems accurately prioritize patients and help predict resource utilization. CTAS is a validated five-level triage score utilized in Emergency Departments (EDs) across Canada and internationally. Historically CTAS has been applied by triage nurses in EDs. Observational evidence suggests that the CTAS might be implemented reliably by paramedics in the prehospital setting. This is the first system-wide assessment of CTAS interrater reliability between paramedics and triage nurses during clinical practice.

Variables were extracted from hospital and EMS databases. EMS providers determined CTAS on-scene, CTAS pre-transport, and CTAS on-arrival at hospital for each patient (N=14,378). The hospital arrival EMS CTAS (CTAS arrival) score was compared to the initial nursing CTAS score (CTAS initial) and the final nursing CTAS score (CTAS final) incuding nursing overrides. Interrater reliability between ED CTAS initial and EMS CTAS arrival scores was assessed. Interrater reliability between ED CTAS final and EMS CTAS arrival scores, as well as proportion of patient encounters with perfect or near-perfect agreement, were evaluated.

Our primary outcome, interrater reliability [kappa=0.437 (p<0.001, 95% CI 0.421-0.452)], indicated moderate agreement. EMS CTAS arrival and ED CTAS initial scores had an exact or within one point match 84.3% of the time. The secondary interrater reliability outcome between hospital arrival EMS CTAS (CTAS arrival) score and the final ED triage CTAS score (CTAS final) showed moderate agreement with kappa =0.452 (p<0.001, 95% CI 0.437-0.466).

Interrater reliability of CTAS scoring between triage nurses and paramedics was moderate in this system-wide implementation study.

To study the diagnoses of patients presenting to a medical facility within a mass-gathering public event, “The Great New York State Fair” (NYSF) based on chief complaints, diagnoses, and time of arrival. The goal of the study was to assess the need for increased staffing, services, or supplies during certain times of day for an event that gathers approximately 1 million patrons over a 12-day span. Patrons occupy the grounds between the hours of 10 am and 11 pm, while workers and staff are on the grounds around the clock.

Triage data gathered by trained medical students was collected from all of the patients seen during the 2009 NYSF from 12 am to 11:59 pm. Triage information was categorized based on the nature of complaint, physician impression, and time of arrival to assess for trends in the distribution of common chief complaints and diagnoses at a mass-gathering medical care facility.

The early hours of the NYSF were occupied mostly with treatment of minor first aid complaints, while later hours were occupied more commonly by orthopedic complaints. Insect stings were the most frequent complaint throughout the day.

Daytime and evening hours at the fair have a significant number of orthopedic diagnoses and may benefit from specific staff and equipment sufficient to handle these complaints. Stings and minor first aid injuries are also significant and may benefit from adequate stocking of the infirmary for such events. Major medical complaints, including cardiac and neurological complaints, did occur but were a minor part of the total patient population.

NaccaK , ScottJ , GrantW . Diagnosis According to Time of Arrival at “The Great New York State Fair”Prehosp Disaster Med. 2014;29(1):1-3.

Despite their popularity and unique characteristics, county shows, also known as agricultural fairs, are amongst the least-studied mass-gathering events. Suffolk Show is one of the biggest such events in the UK, attracting tens of thousands of people annually over a 2-day period. In addition to trade stands and livestock displays, the 2011 show included top international show jumping and other sport activities.

Due to the range of activities and large number of attendees of different ages and medical backgrounds, combined with a lack of objective data about medical contacts made during these events, medical officers and local emergency services find planning an appropriate level of medical coverage for county shows particularly challenging. This study involved analyzing the characteristics of medical contacts during a major county show and assessing the level of medical coverage provided.

Data collected from St John Ambulance (SJA) and British Red Cross standard medical records of all contacts on the show ground over the two days were analyzed in terms of demographics, presenting complaints, medical history, and discharge destination. The Event Safety Guide by the Health and Safety Executive (HSE) was the agreed standard for the level of medical coverage.

More than 90,000 people visited the show, with a total of 180 medical contacts recorded. Patient presentation rate (per 1,000 attendees) was 2.0 and the transport to hospital rate (per 1,000 attendees) was 0.1.

Of the 112 cases handled by SJA, 74 (66%) were women and 49 (44%) were 18-64 years of age. Wounds, lacerations and abrasions made up 26 (23.2%) of all presentations to SJA, followed by foot and lower limb blisters at 20 (17.8%). Hypertension was the most common medical history in presentations to SJA (11 cases, 10%), followed by asthma in 7 (6%).

The majority of presentations were due to minor injuries or ailments. An understanding of the event characteristics, demographics, and nature of medical contacts will provide organizers, medical officers, and local emergency services with information about the level of coverage and resources required. This data can further help advance knowledge of mass-gathering medicine across the various types of events.

PakravanAH, WestRJ, HodgkinsonDW. Suffolk Show 2011: Prehospital Medical Coverage in a Mass-gathering Event. Prehosp Disaster Med. 2013;28(5):1-4.

We sought to assess the knowledge of, use of and barriers to the use of personal protective equipment for airway management among emergency medical technicians (EMTs) during and since the 2003 Canadian outbreak of Severe Acute Respiratory Syndrome (SARS).

Using a cross-sectional survey, EMTs in Toronto, Ont., were surveyed 1 year after the SARS outbreak during mandatory training on the use of personal protective equipment in airway management during the outbreak and just before taking the survey. Practices that were addressed reflected government directives on the use of this equipment. Main outcome measures included the frequency of personal protective equipment use and, as applicable, why particular items were not always used.

The response rate was 67.3% (n = 230). During the SARS outbreak, an N95-type particulate respirator was reported to be always used by 91.5% of respondents. Conversely, 72.9% of the respondents reported that they never used the open face hood. Equipment availability and vision impairment were often cited as impediments to personal protective equipment use. In nonoutbreak conditions, only the antimicrobial airway filter was most often reported to be always used (52.0%), while other items were used at an intermediate frequency. The most common reason for not always donning equipment was that paramedics deemed it unnecessary for the situation.

Personal protective equipment is not consistently employed as per medical directives. Reasons given for nonuse included nonavailability, judgment of nonnecessity or technical difficulties. There are important public health implications of noncompliance.

Morbidity and mortality due to acute but treatable conditions remain high in the developing world, as many significant barriers exist to providing emergency medical care.This study investigates these barriers in a rural region of Ethiopia.

The limited capacity of frontline healthcare workers to diagnose and treat acute medical and surgical conditions represents a major barrier to the provision of emergency care in rural Ethiopia.

Health providers at a convenience sample of 16 rural health centers in the state of Tigray, Ethiopia completed a questionnaire designed to assess the availability of diagnostic and treatment modalities, the proximity and methods of transportation to referral facilities, and health providers' level of comfort in diagnosing and treating a variety of representative emergency medical conditions.

Thirteen (81%) providers had only a very basic level of medical training, and seven (44%) lacked access to any diagnostic equipment.While most providers could offer oral rehydration solution (ORS), anti-pyretic medications, and antibiotics, none of the providers could offer blood transfusions or any form of surgery. Ten (63%) respondents stated that their patients had to travel >10 km from the health center to a referral hospital, with only a minority of patients having access to motorized transport. For the seven emergency conditions assessed, a majority of providers felt comfortable diagnosing these conditions, though fewer felt comfortable treating them.

There is a significant need for both health worker training and improvements in transportation infrastructure in order to increase access to emergency medical care in rural areas of the developing world.Low-cost interventions that improve human capacity in a context-appropriate manner are warranted as transportation and hospital network capacity expansions are considered.

Exsanguination from a femoral artery wound can occur in sec-onds and may be encountered more often due to increased use of body armor. Some military physicians teach compression of the distal abdominal aorta (Abdominal Aorta) with a knee or a fist as a temporizing measure.

The objective of this study was to evaluate if complete collapse of the Abdominal Aorta was feasible and with what weight it occurs.

This was a prospective, interventional study at a Level-I, academ-ic, urban, emergency department with an annual census of 80,000 patients. Written, informed consent was obtained from nine male volunteers after Institutional Research Board approval. Any patient who presented with abdominal pain or had undergone previous abdominal surgery was excluded from the study. Subjects were placed supine on the floor to simulate an injured soldier. Various dumbbells of increasing weight were placed over the distal Abdominal Aorta, and pulsed-wave Doppler measurements were taken at the right common femoral artery (CFA). Dumbbells were placed on top of a tightly bundled towel roughly the surface area of an adult knee. Flow measurements at the CFA were taken at increments of 20 pounds. This was repeated with weight over the proximal right artery iliac and distal right iliac artery to eval- uate alternate sites. Descriptive statistics were utilized to evaluate the data.

The mean velocity through the CFA was 75.8 cm/ sec at 0 pounds. Compression of the Abdominal Aorta ranging 80 to 140 pounds resulted in no flow in the CFA. A steady decrease in mean flow velocity was seen starting with 20 pounds. Flow velocity decreased more rapidly with compression of the prox- imal right iliac artery, and stopped in all nine volunteers by 120 pounds of pressure. For all nine volunteers, up to 80 pounds of pressure over the distal iliac artery failed to decrease CFA flow velocity, and no subject was able to tolerate more weight at that location.

Flow to the CFA can be stopped completely with pressure over the distal Abdominal Aorta or proximal iliac artery in catastrophic wounds. Compression over the proximal iliac artery worked best, but a first responder still may need to apply upward of 120 pounds of pressure to stop exsanguination.