Endotracheal intubation (ETI) is a complex clinical skill complicated by the inherent challenge of providing care in the prehospital setting. Literature reports a low success rate of prehospital ETI attempts, partly due to the care environment and partly to the lack of consistent standardized training opportunities of prehospital providers in ETI.

The availability of a mobile simulation laboratory (MSL) to study clinically critical interventions is needed in the prehospital setting to enhance instruction and maintain proficiency. This report is on the development and validation of a prehospital airway simulator and MSL that mimics in situ care provided in an ambulance.

The MSL was a Type 3 ambulance with four cameras allowing audio-video recordings of observable behaviors. The prehospital airway simulator is a modified airway mannequin with increased static tongue pressure and a rigid cervical collar. Airway experts validated the model in a static setting through ETI at varying tongue pressures with a goal of a Grade 3 Cormack-Lehane (CL) laryngeal view. Following completion of this development, the MSL was launched with the prehospital airway simulator to distant communities utilizing a single facilitator/driver. Paramedics were recruited to perform ETI in the MSL, and the detailed airway management observations were stored for further analysis.

Nineteen airway experts performed 57 ETI attempts at varying tongue pressures demonstrating increased CL views at higher tongue pressures. Tongue pressure of 60 mm Hg generated 31% Grade 3/4 CL view and was chosen for the prehospital trials. The MSL was launched and tested by 18 paramedics. First pass success was 33% with another 33% failing to intubate within three attempts.

The MSL created was configured to deliver, record, and assess intubator behaviors with a difficult airway simulation. The MSL created a reproducible, high fidelity, mobile learning environment for assessment of simulated ETI performance by prehospital providers.

BischofJJ, PanchalAR, FinneganGI, TerndrupTE. Creation and Validation of a Novel Mobile Simulation Laboratory for High Fidelity, Prehospital, Difficult Airway Simulation. Prehosp Disaster Med. 2016;31(5):465–470.

Obesity is a growing epidemic in the United States with increasing burden to the health care system. Management and transport of the morbidly obese (MO) pose challenges for Emergency Medical Services (EMS) providers. Though equipment and resources are being directed to the transport of the obese, little research exists to guide these efforts. To address this, the author of this study sought to assess EMS providers’ perspectives on the challenges of caring for MO patients.

An anonymous, web-based survey was distributed to all active providers of prehospital transport of a large, urban, fire-based EMS system to evaluate the challenges of MO patients. The definition of MO was left up to the provider. This survey looked at various components of transport: lifting, transport time, airway management, establishing intravenous access, drug administration, as well as demographics, equipment, and education needs. The survey contained yes/no, rank-order, and Likert scale questions. Data were analyzed using descriptive statistics. The study was approved by the University of Miami (Miami, Florida USA) Institutional Review Board.

Of survey participants, 71.9% felt the average weight of their patients had increased, and 100% reported to have transported a MO patient. Of calls made to EMS, 25% were only for assistance in the house and another 25% were for non-emergent transport to a health care facility; shortness of breath was the most common emergent complaint. Of specific challenges to properly care for MO patients, 94.4 % ranked lifting and/or moving the patient highest, followed by airway management, intravenous access, and measuring vital signs. A total of 43.8% of respondents felt that MO patients require at least six to eight EMS personnel to transport patients while 31.8% felt more than eight providers were necessary. Greater than 81.3% felt it would be beneficial to receive more training and 90.4% felt more equipment was needed. Of participants, 68.8 % felt that MO patients did not receive the same standard of care.

Surveyed participants reported that patient’s weights are increasing with all having transported a MO patient. Despite the majority of transports being for non-emergent problems, providers felt more training would be beneficial, that equipment available does not meet needs, and that the MO pose challenges to appropriate patient care.

CienkiJJ. Emergency Medical Service Providers’ Perspectives towards Management of the Morbidly Obese. Prehosp Disaster Med. 2016;31(5):471–474.

Hospitals play a critical role in providing health care in the aftermath of disasters and emergencies. Nonetheless, while multiple tools exist to assess hospital disaster preparedness, existing instruments have not been tested adequately for validity.

This study reports on the development of a preparedness assessment tool for hospitals that are part of the US Department of Veterans Affairs (VA; Washington, DC USA).

The authors evaluated hospital preparedness in six “Mission Areas” (MAs: Program Management; Incident Management; Safety and Security; Resiliency and Continuity; Medical Surge; and Support to External Requirements), each composed of various observable hospital preparedness capabilities, among 140 VA Medical Centers (VAMCs). This paper reports on two successive assessments (Phase I and Phase II) to assess the MAs’ construct validity, or the degree to which component capabilities relate to one another to represent the associated domain successfully. This report describes a two-stage confirmatory factor analysis (CFA) of candidate items for a comprehensive survey implemented to assess emergency preparedness in a hospital setting.

The individual CFAs by MA received acceptable fit statistics with some exceptions. Some individual items did not have adequate factor loadings within their hypothesized factor (or MA) and were dropped from the analyses in order to obtain acceptable fit statistics. The Phase II modified tool was better able to assess the pre-determined MAs. For each MA, except for Resiliency and Continuity (MA 4), the CFA confirmed one latent variable. In Phase I, two sub-scales (seven and nine items in each respective sub-scale) and in Phase II, three sub-scales (eight, four, and eight items in each respective sub-scale) were confirmed for MA 4. The MA 4 capabilities comprise multiple sub-domains, and future assessment protocols should consider re-classifying MA 4 into three distinct MAs.

The assessments provide a comprehensive and consistent, but flexible, approach for ascertaining health system preparedness. This approach can provide an organization with a clear understanding of areas for improvement and could be adapted into a standard for hospital readiness.

DobalianA, SteinJA, RadcliffTA, RiopelleD, BrewsterP, HagigiF, Der-MartirosianC. Developing Valid Measures of Emergency Management Capabilities within US Department of Veterans Affairs Hospitals. Prehosp Disaster Med. 2016;31(5):475–484.

The 2010 floods submerged more than one-fifth of Pakistan’s land area and affected more than 20 million people. Over 1.6 million homes were damaged or destroyed and 2,946 direct injuries and 1,985 deaths were reported. Infrastructure damage was widespread, including critical disruptions to the power and transportation networks.

Damage and loss of critical infrastructure will affect the population’s ability to seek and access adequate health care for years to come. This study sought to evaluate factors associated with access to health care in the aftermath of the 2010 Pakistan floods.

A population-proportional, randomized cluster-sampling survey method with 80 clusters of 20 (1,600) households of the flood-affected population was used. Heads of households were surveyed approximately six months after flood onset. Multivariate analysis was used to determine significance.

A total of 77.8% of households reported needing health services within the first month after the floods. Household characteristics, including rural residence location, large household size, and lower pre- and post-flood income, were significantly associated (P<.05) with inadequate access to health care after the disaster. Households with inadequate access to health care were more likely to have a death or injury in the household. Significantly higher odds of inadequate access to health care were observed in rural populations (adjusted OR 4.26; 95% CI, 1.89-9.61).

Adequate health care access after the 2010 Pakistani floods was associated with urban residence location, suggesting that locating health care providers in rural areas may be difficult. Access to health services also was associated with post-flood income level, suggesting health resources are not readily available to households suffering great income losses.

JacquetGA, KirschT, DurraniA, SauerL, DoocyS. Health Care Access and Utilization after the 2010 Pakistan Floods. Prehosp Disaster Med. 2016;31(5):485–491.

Trauma patients in the extremes of age may require a specialized approach during a multiple-casualty incident (MCI).

The aim of this study was to examine the type of injuries encountered in children and elderly patients and the implications of these injuries for treatment and organization.

A review of medical record files of patients admitted in MCIs in one Level II trauma center was conducted. Patients were classified according to age: children (≤12 years), adults (between 12-65 years), and elders (≥65 years).

The files of 534 were screened: 31 (5.8%) children and 54 (10.1%) elderly patients. One-third of the elderly patients were either moderately or severely injured, compared to only 6.5% of the children and 11.1% of the adults (P<.001). Elderly patients required more blood transfusions (P=.0001), more computed tomography imaging (P=.0001), and underwent more surgery (P=.0004). Elders were hospitalized longer (P=.0003). There was no mortality among injured children, compared to nine (2.0%) of the adults and seven (13.0%) of the elderly patients (P<.0001). All the adult deaths occurred early and directly related to their injuries, whereas most of the deaths among the elderly patients (four out of seven) occurred late and were due to complications and multiple organ failure.

Injury at an older age confers an increased risk of complications and death in victims of MCIs.

AshkenaziI, EinavS, OlshaO, Turegano-FuentesF, KrauszMM, AlficiR. The Impact of Age upon Contingency Planning for Multiple-casualty Incidents Based on a Single Center’s Experience. Prehosp Disaster Med. 2016;31(5):492–497.

Primary triage in a mass-casualty event setting using low-visibility tags may lead to informational confusion and difficulty in judging triage attribution of patients. In this simulation study, informational confusion during primary triage was investigated using a method described in a prior study that applied Shannon’s Information Theory to triage.

Primary triage using a low-visibility tag leads to a risk of informational confusion in prioritizing care, owing to the intermingling of pre- and post-triage patients. It is possible that Shannon’s entropy evaluates the degree of informational confusion quantitatively and improves primary triage.

The Simple Triage and Rapid Treatment (START) triage method was employed. In Setting 1, entropy of a triage area with 32 patients was calculated for the following situations: Case 1 – all 32 patients in the triage area at commencement of triage; Case 2 – 16 randomly imported patients to join 16 post-triage patients; Case 3 – eight patients imported randomly and another eight grouped separately; Case 4 – 16 patients grouped separately; Case 5 – random placement of all 32 post-triage patients; Case 6 – isolation of eight patients of minor priority level; Case 7 – division of all patients into two groups of 16; and Case 8 – separation of all patients into four categories of eight each. In Setting 2, entropies in the triage area with 32 patients were calculated continuously with each increase of four post-triage patients in Systems A and B (System A – triage conducted in random manner; and System B – triage arranged into four categories).

In Setting 1, entropies in Cases 1-8 were 2.00, 3.00, 2.69, 2.00, 2.00, 1.19, 1.00, and 0.00 bits/symbol, respectively. Entropy increased with random triage. In Setting 2, entropies of System A maintained values the same as, or higher than, those before initiation of triage: 2.00 bits/symbol throughout the triage. The graphic waveform showed a concave shape and took 3.00 bits/symbol as maximal value when the probability of each category was 1/8, whereas the values in System B showed a linear decrease from 2.00 to 0.00 bits/symbol.

Informational confusion in a primary triage area measured using Shannon’s entropy revealed that random triage using a low-visibility tag might increase the degree of confusion. Methods for reducing entropy, such as enhancement of triage colors, may contribute to minimizing informational confusion.

AjimiY, SasakiM, UchidaY, KanekoI, NakaharaS, SakamotoT. Primary Triage in a Mass-casualty Event Possesses a Risk of Increasing Informational Confusion: A Simulation Study Using Shannon’s Entropy. Prehosp Disaster Med. 2016;31(5):498–504.

Emergency medical technicians (EMTs) and paramedics are at serious risk for work-related injuries (WRIs) during work hours. Both EMTs and paramedics have higher WRI rates, according to the literature data. This study was designed to investigate causes and characteristics of WRIs involving EMTs and paramedics staffed in Western Turkey.

All health care personnel staffed in Emergency Medical Services (EMS) in the city were interviewed face-to-face in their off-duty hours to inform them about the study. Excluded from the study were those who declined to participate in the study, those who were not on duty during the two-month study period, and those who had been working in the EMS for less than one year. The subjects were asked to answer multiple-choice questions.

A total of 163 personnel (117 EMTs and 46 paramedics) comprised the study sample. Eighty-three personnel (50.9%) were female and mean age was 29.7 years (SD=8.4 years). The most common mechanisms of WRI, as reported by the personnel, were motor vehicle accidents (MVAs; 31.9%), needlestick injuries (16.0%), ocular exposure to bodily fluids (15.4%), and sharp injuries (9.8%), respectively. Needlestick injuries commonly occurred during intravenous line procedures (59.4%) and inside the cruising ambulance (n=20; 62.5%). Working inside the cruising ambulance was the most commonly accused cause of the WRI (41.3%).

Paramedic personnel and EMTs are under high risk of WRI. Motor vehicle accidents and needlestick injuries were the most common causes of WRI. Strict measures need to be taken to restructure the interior design to protect personnel from all kinds of WRIs.

YilmazA, SerinkenM, DalO, YaylacıS, KarciogluO. Work-related Injuries Among Emergency Medical Technicians in Western Turkey. Prehosp Disaster Med. 2016;31(5):505–508.

Bystander cardiopulmonary resuscitation (CPR) improves survival after prehospital cardiac arrest. While community CPR training programs have been implemented across the US, little is known about their acceptability in non-US Latino populations.

The purpose of this study was to identify barriers to enrolling in CPR training classes and performing CPR in San José, Costa Rica.

After consulting 10 San José residents, a survey was created, pilot-tested, and distributed to a convenience sample of community members in public gathering places in San José. Questions included demographics, CPR knowledge and beliefs, prior CPR training, having a family member with heart disease, and prior witnessing of a cardiac arrest. Questions also addressed barriers to enrolling in CPR classes (cost/competing priorities). The analysis focused on two main outcomes: likelihood of registering for a CPR class and willingness to perform CPR on an adult stranger. Odds ratios and 95% CIs were calculated to test for associations between patient characteristics and these outcomes.

Among 371 participants, most were male (60%) and <40 years old (77%); 31% had a college degree. Many had family members with heart disease (36%), had witnessed a cardiac arrest (18%), were trained in CPR (36%), and knew the correct CPR steps (70%). Overall, 55% (95% CI, 50-60%) indicated they would “likely” enroll in a CPR class; 74% (95% CI, 70-78%) would perform CPR on an adult stranger. Cardiopulmonary resuscitation class enrollment was associated with prior CPR training (OR: 2.6; 95% CI, 1.6-4.3) and a prior witnessed cardiac arrest (OR: 2.0; 95% CI, 1.1-3.5). Willingness to perform CPR on a stranger was associated with a prior witnessed cardiac arrest (OR: 2.5; 95% CI, 1.2-5.4) and higher education (OR: 1.9; 95% CI, 1.1-3.2). Believing that CPR does not work was associated with a higher likelihood of not attending a CPR class (OR: 2.4; 95% CI, 1.7-7.9). Fear of performing mouth-mouth, believing CPR is against God’s will, and fear of legal risk were associated with a likelihood of not attending a CPR class and not performing CPR on a stranger (range of ORs: 2.4-3.9).

Most San José residents are willing to take CPR classes and perform CPR on a stranger. To implement a community CPR program, barriers must be considered, including misgivings about CPR efficacy and legal risk. Hands-only CPR programs may alleviate hesitancy to perform mouth-to-mouth.

SchmidKM, Mould-MillmanNK, HammesA, KroehlM, Quiros GarcíaR, Umaña McDermottM, LowensteinSR. Barriers and Facilitators to Community CPR Education in San José, Costa Rica. Prehosp Disaster Med. 2016;31(5):509–515.

In resource-constrained environments, appropriately employing triage in disaster situations is crucial. Although both case-based learning (CBL) and simulation exercises (SEs) commonly are utilized in teaching disaster preparedness to adult learners, there is no substantial evidence supporting one as a more efficacious methodology. This randomized controlled trial (RCT) evaluated the effectiveness of CBL versus SEs in addition to standard didactic instruction in knowledge attainment pertaining to disaster triage preparedness.

This RCT was performed during a one-day disaster preparedness course in Lucknow, India during October 2014. Following provision of informed consent, nursing trainees were randomized to knowledge assessment after didactic teaching (control group); didactic plus CBL (Intervention Group 1); or didactic plus SE (Intervention Group 2). The educational curriculum used the topical focus of triage processes during disaster situations. Cases for the educational intervention sessions were scripted, identical between modalities, and employed structured debriefing. Trained live actors were used for SEs. After primary assessment, the groups underwent crossover to take part in the alternative educational modality and were re-assessed. Two standardized multiple-choice question batteries, encompassing key core content, were used for assessments. A sample size of 48 participants was calculated to detect a ≥20% change in mean knowledge score (α=0.05; power=80%). Robustness of randomization was evaluated using X2, anova, and t-tests. Mean knowledge attainment scores were compared using one- and two-sample t-tests for intergroup and intragroup analyses, respectively.

Among 60 enrolled participants, 88.3% completed follow-up. No significant differences in participant characteristics existed between randomization arms. Mean baseline knowledge score in the control group was 43.8% (standard deviation=11.0%). Case-based learning training resulted in a significant increase in relative knowledge scores at 20.8% (P=0.003) and 10.3% (P=.033) in intergroup and intragroup analyses, respectively. As compared to control, SEs did not significantly alter knowledge attainment scores with an average score increase of 6.6% (P=.396). In crossover intra-arm analysis, SEs were found to result in a 26.0% decrement in mean assessment score (P < .001).

Among nursing trainees assessed in this RCT, the CBL modality was superior to SEs in short-term disaster preparedness educational translation. Simulation exercises resulted in no detectable improvement in knowledge attainment in this population, suggesting that CBL may be utilized preferentially for adult learners in similar disaster training settings.

AluisioAR, DanielP, GrockA, FreedmanJ, SinghA, PapanagnouD, ArquillaB. Case-based Learning Outperformed Simulation Exercises in Disaster Preparedness Education Among Nursing Trainees in India: A Randomized Controlled Trial. Prehosp Disaster Med. 2016;31(5):516–523.

There were 5,385 deceased and 710 missing in the Ishinomaki medical zone following the Great East Japan Earthquake that occurred in Japan on March 11, 2011. The Ishinomaki Zone Joint Relief Team (IZJRT) was formed to unify the relief teams of all organizations joining in support of the Ishinomaki area. The IZJRT expanded relief activity as they continued to manually collect and analyze assessments of essential information for maintaining health in all 328 shelters using a paper-type survey. However, the IZJRT spent an enormous amount of time and effort entering and analyzing these data because the work was vastly complex. Therefore, an assessment system must be developed that can tabulate shelter assessment data correctly and efficiently. The objective of this report was to describe the development and verification of a system to rapidly assess evacuation centers in preparation for the next major disaster.

Based on experiences with the complex work during the disaster, software called the “Rapid Assessment System of Evacuation Center Condition featuring Gonryo and Miyagi” (RASECC-GM) was developed to enter, tabulate, and manage the shelter assessment data. Further, a verification test was conducted during a large-scale Self-Defense Force (SDF) training exercise to confirm its feasibility, usability, and accuracy. The RASECC-GM comprises three screens: (1) the “Data Entry screen,” allowing for quick entry on tablet devices of 19 assessment items, including shelter administrator, living and sanitary conditions, and a tally of the injured and sick; (2) the “Relief Team/Shelter Management screen,” for registering information on relief teams and shelters; and (3) the “Data Tabulation screen,” which allows tabulation of the data entered for each shelter, as well as viewing and sorting from a disaster headquarters’ computer. During the verification test, data of mock shelters entered online were tabulated quickly and accurately on a mock disaster headquarters’ computer. Likewise, data entered offline also were tabulated quickly on the mock disaster headquarters’ computer when the tablet device was moved into an online environment.

The RASECC-GM, a system for rapidly assessing the condition of evacuation centers, was developed. Tests verify that users of the system would be able to easily, quickly, and accurately assess vast quantities of data from multiple shelters in a major disaster and immediately manage the inputted data at the disaster headquarters.

IshiiT, NakayamaM, AbeM, TakayamaS, KameiT, AbeY, YamaderaJ, AmitoK, MorinoK. Development and Verification of a Mobile Shelter Assessment System “Rapid Assessment System of Evacuation Center Condition Featuring Gonryo and Miyagi (RASECC-GM)” for Major Disasters. Prehosp Disaster Med. 2016;31(5):539–546.

Pediatric hospital disaster responders must be well-trained and prepared to manage children in a mass-casualty incident. Simulations of various types have been the traditional way of testing hospital disaster plans and training hospital staff in skills that are used in rare circumstances. The objective of this longitudinal, survey-based, observational study was to assess the effect of disaster response and management-based experiential learning on the knowledge and confidence of advanced learners.

A simulation-based workshop was created for practicing Pediatric Emergency Medicine (PEM) physicians, senior PEM physicians, and critical care and pediatric surgery residents to learn how to manage a disaster response. Given that this particular group of learners had never been exposed to such a disaster simulation, its educational value was assessed with the goal of improving the quality of the hospital pediatric medical response to a disaster by increasing the responders’ knowledge and confidence. Objective and subjective measures were analyzed using both a retrospective, pre-post survey, as well as case-based evaluation grids.

The simulation workshop improved the learners’ perceived ability to manage patients in a disaster context and identified strengths and areas needing improvement for patient care within the disaster context.

Advanced learners exposed to an experiential learning activity believed that it improved their ability to manage patients in a disaster situation and felt that it was valuable to their learning. Their confidence was preserved six months later.

BankI, KhalilE. Are Pediatric Emergency Physicians More Knowledgeable and Confident to Respond to a Pediatric Disaster after an Experiential Learning Experience?Prehosp Disaster Med. 2016;31(5):551–556.