Emergency medical services (EMS) responses to mass gatherings have been described frequently, but there are few reports describing the response to a single-day gathering of large magnitude.

This report describes the EMS response to the largest single-day, ticketed concert held in North America: the 2003 “Toronto Rocks!” Rolling Stones Concert.

Medical care was provided by paramedics, physicians, and nurses. Care sites included ambulances, medically equipped, all-terrain vehicles, bicycle paramedic units, first-aid tents, and a 124-bed medical facility that included a field hospital and a rehydration unit. Records from the first-aid tents, ambulances, paramedic teams, and rehydration unit were obtained. Data abstracted included patient demographics, chief complaint, time of incident, treatment, and disposition.

More than 450,000 people attended the concert and 1,870 sought medical care (42/10,000 attendees). No record was kept for the 665 attendees simply requesting water, sunscreen, or bandages. Of the remaining 1,205 patients, the average of the ages was 28 ±11 years, and 61% were female. Seven-hundred, ninety-five patients (66%) were cared for at one of the first-aid tents. Physicians at the tents assisted in patient management and disposition when crowds restricted ambulance movement. Common complaints included headache (321 patients; 27%), heat-related complaints (148; 12%), nausea or vomiting (91; 7.6%), musculoskeletal complaints (83; 6.9%), and breathing problems (79; 6.6%). Peak activity occurred between 14:00 and 19:00 hours, when 102 patients per hour sought medical attention. Twenty-four patients (0.5/10,000) were transferred to off-site hospitals.

This report on the EMS response, outcomes, and role of the physicians at a large single-day mass gathering may assist EMS planners at future events.

Recently, there has been speculation that suicide rates increase after a disaster. Yet, in spite of anecdotal reports, it is difficult to demonstrate a systematic relationship between suicide and disaster. Suicides are fairly rare events, and single disasters rarely have covered geographic areas with large enough populations to be able to find statistically significant differences in such relatively rare events (annual suicide rates in the United States average 12/100,000 population).

Suicide rates increased in the three calendar years (1994–1996) following the Northridge earthquake as compared to the three calendar years (1991–1993) prior to the earthquake. Likewise the suicide rates for 1993 are compared with the rates in 1994. By looking at the suicide rates in a three-year period after the earthquake, the additional disasters that befell Southern California in 1995 and 1996 may have had an additive effect on psychological disorders and suicide rates that can be measured.

Data on suicide mortality were compiled for the years from 1989 through 1996. Differences in rates for 1993 compared with 1994 and for three-year periods before and after the earthquake (1991–1993 vs. 1994 –1996) were analyzed using a z-statistic.

There is a statistically significant difference in the rates for the years prior to the earthquake (1991–1993) when pooled and compared to the suicide rates for the years after the earthquake (1994–1996). The rates of suicide are lower in the three years following the earthquake (11.85 vs. 13.12/100,000 population) than they are in the three years prior to the earthquake (z = -3.85, p <0.05). Likewise, there is a similar difference when comparing 1993 to 1994 (11.77 vs. 13.84, z = -3.57, p <0.05). The patterns of suicide remain similar over time, with males and non-Hispanic Whites having the highest rates of suicide.

It does not appear that suicide rates increase as a result of earthquakes in this setting. This study demonstrates that the psychological impacts of the Northridge earthquake did not culminate in an increase in the rates of suicide.

Hospital disaster manuals and response plans often lack formal command structure; instead, they rely on the presence of key individuals who are familiar with hospital operations, or who are in leadership positions during routine, day-to-day operations. Although this structure occasionally may prove to be successful, it is unreliable, as this leadership may be unavailable at the time of the crisis, and may not be sustainable during a prolonged event. The Hospital Emergency Incident Command System (HEICS) provides a command structure that does not rely on specific individuals, is flexible and expandable, and is ubiquitous in the fire service, emergency medical services, military, and police agencies, thus allowing for ease of communication during event management.

A descriptive report of the implementation of the HEICS throughout a large healthcare network is reviewed. Results and Conclusions: Implementation of the HEICS provides a consistent command structure for hospitals that enables consistency and commonality with other hospitals and disaster response entities.

In Latin America, there is a preponderance of prehospital trauma deaths. However, scarce resources mandate that any improvements in prehospital medical care must be cost-effective. This study sought to evaluate the costeffectiveness of several approaches to improving training for personnel in three ambulance services in Mexico.

In Monterrey, training was augmented with PreHospital Trauma Life Support (PHTLS) at a cost of [US]$150 per medic trained. In San Pedro, training was augmented with Basic Trauma Life Support (BTLS), Advanced Cardiac Life Support (ACLS), and a locally designed airway management course, at a cost of $400 per medic. Process and outcome of trauma care were assessed before and after the training of these medics and at a control site.

The training was effective for both intervention services, with increases in basic airway maneuvers for patients in respiratory distress in Monterrey (16% before versus 39% after) and San Pedro (14% versus 64%). The role of endotrachal intubation for patients with respiratory distress increased only in San Pedro (5% versus 46%), in which the most intensive Advanced Life Support (ALS) training had been provided. However, mortality decreased only in Monterrey, where it had been the highest (8.2% before versus 4.7% after) and where the simplest and lowest cost interventions were implemented. There was no change in process or outcome in the control site.

This study highlights the importance of assuring uniform, basic training for all prehospital providers. This is a more cost-effective approach than is higher-cost ALS training for improving prehospital trauma care in environments such as Latin America.

To assess the religious spirituality of EMS personnel and their perception of the spiritual needs of ambulance patients.

Emergency medical technicians (EMTs) and paramedics presenting to an urban, academic emergency department (ED) were asked to complete a three-part survey relating to demographics, personal practices, and perceived patient needs. Their responses were compared to those of ambulance patients presenting to an ED during a previous study period and administered a similar survey.

A total of 143 EMTs and 89 paramedics returned the surveys. There were 161 (69.4%) male and 71 (30.6%) female respondents with a median age range of 26–35 years old. Eighty-seven percent believed in God, 82% practiced prayer or meditation, 62% attended religious services occasionally, 55% belonged to a religious organization, 39% felt that their beliefs affected their job, and 18% regularly read religious material. This was similar to the characteristics of ambulance patients.

However, only 43% felt that occasionally ambulance patients presented with spiritual concerns and 78% reported never or rarely discussing spiritual issues with patients. Contrastingly, >40% of ambulance patients reported spiritual needs or concerns at the time of ED presentation, and >50% wanted their providers to discuss their beliefs. Twenty-six percent of respondents reported praying or meditating with patients, while 50% reported praying or meditating for patients.

Females were no more religious or spiritual than males, but were more likely to engage in prayer with (OR = 2.38, p = 0.0049) or for (OR = 6.45, p <0.0001) patients than their male counterparts.

EMTs and paramedics did not perceive spiritual concerns as often as reported by ambulance patients, nor did they commonly inquire about the religious/spiritual needs of patients.

Aspirin is commonly administered for acute coronary syndromes in the prehospital setting. Few studies have addressed the incidence of adverse effects associated with prehospital administration of aspirin. Objective: To determine the incidence of adverse events following the administration of aspirin by prehospital personnel.

Multi-center, retrospective, case series that involved all patients who received aspirin in the prehospital setting from (01 August 1999–31 January 2000). Patient encounter forms of the emergency medical services (EMS) of a metropolitan fire department were reviewed. All patients who had a potential cardiac syndrome (i.e., chest pain, dyspnea) as documented on the EMS forms were included in the review. Exclusion criteria included failure to meet inclusion criteria, and chest pain secondary to apparent noncardiac causes (i.e., trauma). Hospital charts were reviewed from a subset of patients at the participating hospitals. The major outcome was an adverse event following prehospital administration of aspirin. This outcome was evaluated during the EMS encounter, at emergency department discharge, or at six and 24-hours post-aspirin ingestion. An adverse event secondary to aspirin ingestion was defined as anaphylaxis or allergic reactions, such as rash or respiratory changes.

A total of 25,600 EMS encounter forms were reviewed, yielding 2,399 patients with a potential cardiac syndrome. Prior to EMS arrival, 585 patients had received aspirin, and 893 were administered aspirin by EMS personnel. No patients had an adverse event during the EMS encounter. Of these patients, 229 were transported to participating hospitals and 219 medical records were available for review with no adverse reactions recorded during their hospital course.

Aspirin is rarely associated with adverse events when administered by prehospital personnel for presumed coronary syndromes.

The diagnosis of endotracheal tube (ETT) mal-position may be delayed in extreme environments. Several methods are utilized to confirm proper ETT placement, but these methods can be unreliable or unavailable in certain settings. Thoracic sonography, previously utilized to detect pneumothoraces, has not been tested to assess ETT placement.

Thoracic sonography could correlate with pulmonary ventilation, and thereby, help to confirm proper ETT placement.

Thirteen patients requiring elective intubation under general anesthesia, and data from two trauma patients were evaluated. Using a portable, hand-held, ultrasound (PHHU) machine, sonographic recordings of the chest wall visceral-parietal pleural interface (VPPI) were recorded bilaterally in each patient during all phases of airway management: (1) preoxygenation; (2) induction; (3) paralysis; (4) intubation; and (5) ventilation. Results: The VPPI could be well-imaged for all of the patients. In the two trauma patients, right mainstem intubations were noted in which specific pleural signals were not seen in the left chest wall VPPI after tube placement. These signs returned after correct repositioning of the ETT tube. In all of the elective surgery patients, signs correlating with bilateral ventilation in each patient were imaged and correlated with confirmation of ETT placement by anesthesiology.

This report raises the possibility that thoracic sonography may be another tool that could be used to confirm proper ETT placement. This technique may have merit in extreme environments, such as in remote, prehospital settings or during aerospace medical transports, in which auscultation is impossible due to noise, or capnography is not available, and thus, requires further scientific evaluation.

Revisar la evidencia existente sobre la efectividad de los simulacros de desastres, intervenciones basadas en la tecnología y ejercicios de gabinete para el entrenamiento del personal hospitalario en la respuesta a incidentes con víctimas múltiples.