The Comprehensive Framework for Disaster Evaluation Typologies, developed in 2017 (CFDET 2017), aims to unify and facilitate agreement regarding the identification, structure, and relationships between various evaluation typologies found in the disaster setting. A peer-reviewed validation process sought input from international experts in the fields of disaster medicine, disaster/emergency management, humanitarian/development, and evaluation. This paper discusses the validation process, its results, and outcomes.

Previous frameworks, identified in the literature, lack validation and consistent terminology. To gain credibility and utility, this unique framework needed to be validated by international experts in the disaster setting.

A mixed methods approach was designed to validate the framework. An initial iterative process informed an online survey which used a combination of a five-point Likert scale and open-ended questions. Pre-determined consensus thresholds, informed by a targeted literature review, provided the validation criteria.

A sample of 33 experts from 11 countries responded to the validation process. Quantitative measures largely supported the elements and relationships of the framework, and strongly supported its value and usefulness for supporting, promoting, and undertaking evaluations, as well as its usefulness for teaching evaluation in the disaster setting. Qualitative input suggested opportunities to strengthen and enhance the framework. There were limited responses to better understand the barriers and enablers of undertaking disaster evaluations. A potential for self-selection bias of respondents may be a limitation of this study. The attainment of high consensus thresholds, however, provides confidence in the validity of the results.

For the first time, a framework of this nature has undergone a rigorous validation process by experts in three related disciplines at an international level. The modified framework, CFDET 2018, provides a unifying framework within which existing evaluation typologies can be structured. It gives evaluators confidence to choose an appropriate strategy for their particular evaluation in the disaster setting and facilitates consistency in reporting across the different phases of a disaster to better understand the process, outcomes, and impacts of the efficacy and efficiency of interventions. Future research could create a series of toolkits to support improved disaster evaluation processes and to evaluate the utility of the framework in the real-world setting.

Natural disasters often damage or destroy the protective public health service infrastructure (PHI) required to maintain the health and well-being of people with noncommunicable diseases (NCDs). This interruption increases the risk of an acute exacerbation or complication, potentially leading to a worse long-term prognosis or even death. Disaster-related exacerbations of NCDs will continue, if not increase, due to an increasing prevalence and sustained rise in the frequency and intensity of disasters, along with rapid unsustainable urbanization in flood plains and storm-prone coastal zones. Despite this, the focus of disaster and health systems preparedness and response remains on communicable diseases, even when the actual risk of disease outbreaks post-disaster is low, particularly in developed countries. There is now an urgent need to expand preparedness and response beyond communicable diseases to include people with NCDs.

The developing evidence-base describing the risk of disaster-related exacerbation of NCDs does not incorporate the perspectives, concerns, and challenges of people actually living with the conditions. To help address this gap, this research explored the key influences on patient ability to successfully manage their NCD after a natural disaster.

A survey of people with NCDs in Queensland, Australia collected data on demographics, disease, disaster experience, and primary concern post-disaster. Descriptive statistics and chi-square tests with a Bonferroni-adjustment were used to analyze data.

There were 118 responses to the survey. Key influences on the ability to self-manage post-disaster were access to medication, medical services, water, treatment and care, power, and food. Managing disease-specific symptoms associated with cardiovascular disease, diabetes, mental health, and respiratory diseases were primary concerns following a disaster. Stress and anxiety, loss of sleep, weakness or fatigue, and shortness of breath were common concerns for all patients with NCDs. Those dependent on care from others were most worried about shortness of breath and slow healing sores. Accessing medication and medical services were priorities for all patients post-disaster.

The key influences on successful self-management post-disaster for people with NCDs must be reflected in disaster plans and strategies. Achieving this will reduce exacerbations or complications of disease and decrease demand for emergency health care post-disaster.

In July 2013, a train carrying 72 cars of crude oil derailed in the town of Lac-Mégantic (Eastern Townships, Quebec, Canada). This disaster provoked a major conflagration, explosions, 47 deaths, the destruction of 44 buildings, the evacuation of one-third of the local population, and an unparalleled oil spill. Notwithstanding the environmental impact, many citizens of this town and in surrounding areas have suffered and continue to suffer substantial losses as a direct consequence of this catastrophe.

To tailor public health interventions and to meet the psychosocial needs of the community, the Public Health Department of Eastern Townships has undertaken repeated surveys to monitor health and well-being over time. This study focuses on negative psychosocial outcomes one and two years after the tragedy.

Two cross-sectional surveys (2014 and 2015) were conducted among large random samples of adults in Lac-Mégantic and surrounding areas (2014: n = 811; 2015: n = 800), and elsewhere in the region (2014: n = 7,926; 2015: n = 800). A wide range of psychosocial outcomes was assessed (ie, daily stress, main source of stress, sense of insecurity, psychological distress, excessive drinking, anxiety or mood disorders, psychosocial services use, anxiolytic drug use, gambling habits, and posttraumatic stress symptoms [PSS]). Exposure to the tragedy was assessed using residential location (ie, six-digit postal code) and intensity of exposure (ie, intense, moderate, or low exposure; from nine items capturing human, material, or subjective losses). Relationships between such exposures and adverse psychosocial outcomes were examined using chi-squares and t-tests. Distribution of outcomes was also examined over time.

One year after the disaster, an important proportion of participants reported human, material, and subjective losses (64%, 23%, and 54%, respectively), whereas 17% of people experienced intense exposure. Participants from Lac-Mégantic, particularly those intensely exposed, were much more likely to report psychological distress, depressive episode, anxiety disorders, and anxiolytic drug use, relative to less-exposed ones. In 2015, 67% of the Lac-Mégantic participants (76% of intensely exposed) reported moderate to severe PSS. Surprisingly, the use of psychosocial services in Lac-Mégantic declined by 41% from 2014 to 2015.

The psychosocial burden in the aftermath of the Lac-Mégantic tragedy is substantial and persistent. Public health organizations responding to large-scaling disasters should monitor long-term psychosocial consequences and advocate for community-based psychosocial support in order to help citizens in their recovery process.

International Emergency Medical Teams’ (I-EMTs) response to disasters has been characterized by a late arrival, an over-focus on trauma care, and a lack of coordination and accountability mechanisms. Analysis of I-EMT performance in past and upcoming disasters is deemed necessary to improve future response.

This study aimed to describe the characteristics, timing, and activities of I-EMTs deployed to the 2015 Nepal earthquake, and to assess their registration and adherence to the World Health Organization Emergency Medical Teams’ (WHO-EMT; Geneva, Switzerland) minimum standards compared to past disasters.

An online literature search was performed and key web sites related to I-EMT deployments were purposively examined. The methodology used is reported following the STARLITE principles. All articles and documents in English containing information about characteristics, timing, and activities of I-EMTs during Nepal 2015 were included in the study. Data were retrieved from selected sources to compile the results following a systematic approach. The findings were validated by the Nepalese focal point for the coordination of I-EMTs after the earthquake.

Overall, 137 I-EMTs deployed from 36 countries. They were classified as Type I (65%), Type II (15%), Type III (1%), and specialized cells (19%). Although national teams remained the first responders, two regional I-EMTs arrived within the first 24 hours post-earthquake. According to daily reporting, the activities performed by I-EMTs included 28,372 out-patient consultations (comprising 6,073 trauma cases); 1,499 in-patient admissions; and 440 major surgeries. The activities reported by I-EMTs during their deployment were significantly lower than the capacities they offered at arrival. Over 80% of I-EMTs registered through WHO or national registration mechanisms, but daily reporting of activities by I-EMTs was low. The adherence of I-EMTs to WHO-EMT standards could not be assessed due to lack of data.

The I-EMT response to the Nepal earthquake was quicker than in previous disasters, and registration and follow-up of I-EMTs was better. Still, there is need to improve I-EMT coordination, reporting, and quality assurance while strengthening national EMT capacity.

Amat Camacho N, Karki K, Subedi S, von Schreeb J. International Emergency Medical Teams in the aftermath of the 2015 Nepal earthquake. Prehosp Disaster Med. 2019;34(3):260–264.

In recent years, several high-profile attacks on hospitals providing medical aid in conflict settings have raised international concern. The International Humanitarian Law prohibits the deliberate targeting of health care settings. Violation of this law is considered a war crime and impacts both those delivering and receiving medical aid.

While it has been demonstrated that both aid workers and health care settings are increasingly being targeted, little is known about the trends and characteristics of security incidents involving aid workers in health care compared to non-health care settings.

Data from the publicly available Aid Worker Security Database (AWSD) containing security incidents involving humanitarian aid workers world-wide were used in this study. The security incidents occurring from January 1, 1997 through December 31, 2016 were classified by two independent reviewers as having occurred in health care and non-health care settings, and those in health care settings were further classified into five categories (hospital, health clinic, mobile clinic, ambulance, and vaccination visit) for the analysis. A stratified descriptive analysis, χ2 Goodness of Fit test, and Cochran-Armitage test for trend were used to examine and compare security incidents occurring in health care and non-health care settings.

Among the 2,139 security incidents involving 4,112 aid workers listed in the AWSD during the study period, 74 and 2,065 incidents were in health care settings and non-health care settings, respectively. There was a nine-fold increase from five to 45 incidents in health care settings (χ2 = 56.27; P < .001), and a five-fold increase from 159 to 852 incidents in non-health care settings (χ2 = 591.55; P < .001), from Period 1 (1997-2001) to Period 4 (2012-2016). Of the 74 incidents in health care settings, 23 (31.1%) occurred in ambulances, 15 (20.3%) in hospitals, 13 (17.6%) in health clinics, 13 (17.6%) during vaccination visits, and six (8.1%) in mobile clinics. Bombings were the most common means of attack in hospitals (N = 9; 60.0%), followed by gun attacks (N = 3; 20.0%). In health care settings, 184 (95.3%) were national staff and nine (4.7%) were international staff.

Security threats are a growing occupational health hazard for aid workers, especially those working in health care settings. There is a need for high-quality data from the field to better monitor the rapidly changing security situation and improve counter-strategies so aid workers can serve those in need without having to sacrifice their lives.

While the impact of disasters is strongly felt by those directly affected, they also have significant impact on the mental and physical health of rescue/relief workers and volunteers during the response phase of disaster management.

Semi-structured interviews were conducted with 11 experts in the field of disaster management from Nepal, inquiring specifically about the impact of the 2015 mega-earthquake on the mental and physical health of rescue/relief workers and volunteers. A thematic approach was used to analyze the results. These were used to assess the applicability of a previously developed conceptual framework which illustrates the hazards and risk factors affecting disaster response workers and the related hazard mitigation approaches.

The findings suggested a relationship between the type of injuries to responders and the type of disaster, type of responder, and vulnerability of location. The conceptual framework derived from literature was verified for its applicability with a slight revision on analysis of experts’ opinion based on particular context and disaster setting. Technical skills of responders, social stigma, governance, and the socio-economic status of the affected nation were identified as critical influencing factors to heath injuries and could be minimized utilizing some specific or collective measures targeted at the aforementioned variables. Some geographic and weather-specific risks may be challenging to overcome.

To prevent or minimize the hazards for disaster relief workers, it is vital to understand the variables that contribute to injuries. Risk minimization strategies should address these critical factors.

The rate of failing to apply a tourniquet remains high.

The study objective was to examine whether early advanced training under conditions that approximate combat conditions and provide stress inoculation improve competency, compared to the current educational program of non-medical personnel.

This was a randomized controlled trial. Male recruits of the armored corps were included in the study. During Combat Lifesaver training, recruits apply The Tourniquet 12 times. This educational program was used as the control group. The combat stress inoculation (CSI) group also included 12 tourniquet applications, albeit some of them in combat conditions such as low light and physical exertion. Three parameters defined success, and these parameters were measured by The Simulator: (1) applied pressure ≥ 200mmHg; (2) time to stop bleeding ≤ 60 seconds; and (3) placement up to 7.5cm above the amputation.

Out of the participants, 138 were assigned to the control group and 167 were assigned to the CSI group. The overall failure rate was 80.33% (81.90% in the control group versus 79.00% in the CSI group; P value = .565; 95% confidence interval, 0.677 to 2.122). Differences in pressure, time to stop bleeding, or placement were not significant (95% confidence intervals, −17.283 to 23.404, −1.792 to 6.105, and 0.932 to 2.387, respectively). Tourniquet placement was incorrect in most of the applications (62.30%).

This study found high rates of failure in tourniquet application immediately after successful completion of tourniquet training. These rates did not improve with tourniquet training, including CSI. The results may indicate that better tourniquet training methods should be pursued.

Tsur, AM, Binyamin, Y, Koren, L, Ohayon, S, Thompson; P, Glassberg, E. High tourniquet failure rates among non-medical personnel do not improve with tourniquet training, including combat stress inoculation: a randomized controlled trial. Prehosp Disaster Med. 2019;34(3):282–287.

Emergency Medical Services (EMS) professionals face high physical demands in high-stress settings; however, the prevalence of cardiovascular health (CVH) risk factors in this health care workforce has not been explored. The primary objective of this study was to compare the distribution of CVH and its individual components between a sample of emergency medical technicians (EMTs) and paramedics. The secondary objective was to identify associations between demographic and employment characteristics with ideal CVH in EMS professionals.

A cross-sectional survey based on the American Heart Association’s (AHA; Dallas, Texas USA) Life’s Simple 7 (LS7) was administered to nationally-certified EMTs and paramedics. The LS7 components were scored according to previously described cut points (ideal = 2; intermediate = 1; poor = 0). A composite CVH score (0-10) was calculated from the component scores, excluding cholesterol and blood glucose due to missing data. Multivariable logistic regression was used to estimate odds ratios (OR; 95% CI) for demographic and employment characteristics associated with optimal CVH (≥7 points).

There were 24,708 respondents that were currently practicing and included. More EMTs achieved optimal CVH (n = 4,889; 48.8%) compared to paramedics (n = 4,338; 40.6%). Factors associated with higher odds of optimal CVH included: higher education level (eg, college graduate or more: OR = 2.26; 95% CI, 1.97-2.59); higher personal income (OR = 1.26; 95% CI, 1.17-1.37); and working in an urban versus rural area (OR = 1.31; 95% CI, 1.23-1.40). Paramedic certification level (OR = 0.84; 95% CI, 0.78-0.91), older age (eg, 50 years or older: OR = 0.65; 95% CI, 0.58-0.73), male sex (OR = 0.54; 95% CI, 0.50-0.56), working for a non-fire-based agency (eg, private service: OR = 0.68; 95% CI, 0.62-0.74), and providing medical transport service (OR = 0.81; 95% CI, 0.69-0.94) were associated with lower odds of optimal CVH.

Several EMS-related characteristics were associated with lower odds of optimal CVH. Future studies should focus on better understanding the CVH and metabolic risk profiles for EMS professionals and their association with incident cardiovascular disease (CVD), major cardiac events, and occupational mortality.

Cash RE, Crowe RP, Bower JK, Foraker RE, Panchal AR. Differences in cardiovascular health metrics in emergency medical technicians compared to paramedics: a crosssectional study of Emergency Medical Services professionals. Prehosp Disaster Med. 2019;34(3):288–296.

Atrial fibrillation (AFIB) with rapid ventricular response (RVR) is a common tachydysrhythmia encountered by Emergency Medical Services (EMS). Current guidelines suggest rate control in stable, symptomatic patients.

Little is known about the safety or efficacy of rate-controlling medications given by prehospital providers. This study assessed a protocol for prehospital administration of diltiazem in the setting of AFIB with RVR for provider protocol compliance, patient clinical improvement, and associated adverse events.

This was a retrospective, cohort study of patients who were administered diltiazem by providers in the Orange County EMS System (Florida USA) over a two-year period. The protocol directed a 0.25mg/kg dose of diltiazem (maximum of 20mg) for stable, symptomatic patients in AFIB with RVR at a rate of >150 beats per minute (bpm) with a narrow complex. Data collected included patient characteristics, vital signs, electrocardiogram (ECG) rhythm before and after diltiazem, and need for rescue or additional medications. Adverse events were defined as systolic blood pressure <90mmHg or administration of intravenous fluid after diltiazem administration. Clinical improvement was defined as a heart rate decreased by 20% or less than 100bmp. Original prehospital ECG rhythm interpretations were compared to physician interpretations performed retrospectively.

Over the study period, 197 patients received diltiazem, with 131 adhering to the protocol. The initial rhythm was AFIB with RVR in 93% of the patients (five percent atrial flutter, two percent supraventricular tachycardia, and one percent sinus tachycardia). The agreement between prehospital and physician rhythm interpretation was 92%, with a Kappa value of 0.454 (P <.001). Overall, there were 22 (11%) adverse events, and 112 (57%) patients showed clinical improvement. When diltiazem was given outside of the existing protocol, the patients had higher rates of adverse events (18% versus eight percent; P = .033). Patients who received diltiazem in adherence with protocols were more likely to show clinical improvement (63% versus 46%; P = .031).

This study suggests that prehospital diltiazem administration for AFIB with RVR is safe and effective when strict protocols are followed.

Rodriguez A, Hunter CL, Premuroso C, Silvestri S, Stone A, Miller S, Zuver C, Papa L. Safety and efficacy of prehospital diltiazem for atrial fibrillation with rapid ventricular response. Prehosp Disaster Med. 2019;34(3):297–302.

Hemorrhage is the leading cause of preventable death in combat, although early recognition of hemorrhage is still challenging on the battlefield.

The objective of this study was to describe the shock index (SI) in a healthy military population, and to measure its variation during a controlled blood loss, simulated by blood donation.

A prospective observational study that enrolled military subjects, volunteers for blood donation, was conducted. Demographic and clinical information, concerning both the patient and the blood collection, were recorded. Baseline vital signs were measured, before and after donation, in a 45° supine position. Statistical analysis was performed after calculation of SI.

A total of 483 participants were included in the study. The mean blood donation volume was 473mL (SD = 44mL). The median pre- and post-blood donation SI were significantly different: 0.54 (IQR = 0.48-0.63) and 0.57 (IQR = 0.49-0.66), respectively (P = .002). Changes in pre-/post-donation blood pressure (BP) and heart rate (HR) also reached statistical difference but represented a clinically poor relevance. The multivariate analysis showed no significant associations between SI variations and age, sex, body mass index (BMI), sport activities, blood donation volume, and enteral volume replacement (EVR).

In this model of mild hemorrhage, SI exhibited significant variations but failed to reach clinical relevance. Further studies are needed to prove the benefit of SI calculation as a possible parameter for early recognition of hemorrhage in combat casualties at the point of injury.

Pasquier P, Duron S, Pouget T, Carbonnel AC, Boutonnet M, Malgras B, Barbier O, de Saint Maurice G, Sailliol A, Ausset S, Martinaud C. Use of shock index to identify mild hemorrhage: an observational study in military blood donors. Prehosp Disaster Med. 2019;34(3):303–307.

Large-scale mass-sporting events are increasingly requiring greater prehospital event planning and preparation to address inherent event-associated medical conditions in addition to incidents that may be unexpected. The Bank of America Chicago Marathon (Chicago, Illinois USA) is one of the largest marathons in the world, and with the improvement of technology, the use of historical patient and event data, in conjunction with environmental conditions, can provide organizers and public safety officials a way to plan based on injury patterns and patient demands for care by predicting the placement and timing of needed medical support and resources.

During large-scale events, disaster planning and preparedness between event organizers, Emergency Medical Services (EMS), and local, state, and federal agencies is critical to ensure participant and public safety.

This study looked at the Bank of America Chicago Marathon, a significant endurance event, and took a unique approach of reviewing digital runner data retrospectively over a five-year period to establish patterns of medical demand geographically, temporally, and by the presenting diagnoses. Most medical complaints were musculoskeletal in nature; however, there were life-threatening conditions such as hyperthermia and cardiac incidents that highlight the need for detailed planning, coordination, and communication to ensure a safe and secure event.

The Chicago Marathon is one of the largest marathons in the world, and this study identified an equal number of participants requiring care on-course and at the finish line. Most medical complaints were musculoskeletal in nature; however, there were life-threatening conditions such as hyperthermia and cardiac incidents that highlight the need for detailed planning, multi-disciplined coordination, and communication to ensure a safe and secure event. As technology has evolved, the use, analysis, and implementation of historical digital data with various environmental conditions can provide organizers and public safety officials a map to plan injury patterns and patient demands by predicting the placement and timing of needed medical support, personnel, and resources.

Prehospital physicians balance the need to stabilize patients prior to transport, minimizing the delay to transport patients to the appropriate level of care. Literature has focused on which interventions should be performed in the prehospital environment, with airway management, specifically prehospital intubation (PHI), being a commonly discussed topic. However, few studies have sought additional factors which influence scene time or quantify the impact of mission characteristics or therapeutic interventions on scene time.

The goal of this study was to identify specific interventions, patient demographics, or mission characteristics that increase scene time and quantify their impact on scene time.

A retrospective, database model-building study was performed using the prehospital mission database of South Australian Ambulance Service (SAAS; Adelaide, South Australia) MedSTAR retrieval service from January 1, 2015 through August 31, 2016. Mission variables, including patient age, weight, gender, retrieval platform, physician type, PHI, arterial line placement, central line placement, and finger thoracostomy, were assessed for predictors of scene time.

A total of 506 missions were included in this study. Average prehospital scene time was 34 (SD = 21) minutes. Four mission variables significantly increased scene time: patient age, rotary wing transport, PHI, and arterial line placement increased scene time by 0.09 (SD = 0.08) minutes, 13.6 (SD = 3.2) minutes, 11.6 (SD = 3.8) minutes, and 34.4 (SD = 8.4) minutes, respectively.

This study identifies two mission characteristics, patient age and rotary wing transport, and two interventions, PHI and arterial line placement, which significantly increase scene time. Elderly patients are medically complex and more severely injured than younger patients, thus, may require more time to stabilize on-scene. Inherent in rotary wing operations is the time to prepare for the flight, which is shorter during ground transport. The time required to safely execute a PHI is similar to that in the literature and has remained constant over the past two years; arterial line placement took longer than envisioned. The SAAS MedSTAR has changed its clinical practice guidelines for prehospital interventions based on this study’s results. Retrieval services should similarly assess the necessity and efficiency of interventions to optimize scene time, knowing that the time required to safely execute an intervention may reach a minimum duration. Defining the scene time enables mission planning, team training, and audit review with the aim of improved patient care.

Paramedics are tasked with providing 24/7 prehospital emergency care to the community. As part of this role, they are also responsible for providing emergency care in the event of a major incident or disaster. They play a major role in the response stage of such events, both domestic and international. Despite this, specific standardized training in disaster management appears to be variable and inconsistent throughout the profession. A suggested method of building disaster response capacities is through competency-based education (CBE). Core competencies can provide the fundamental basis of collective learning and help ensure consistent application and translation of knowledge into practice. These competencies are often organized into domains, or categories of learning outcomes, as defined by Blooms taxonomy of learning domains. It is these domains of competency, as they relate to paramedic disaster response, that are the subject of this review.

The methodology for this paper to identify existing paramedic disaster response competency domains was adapted from the guidance for the development of systematic scoping reviews, using a methodology developed by members of the Joanna Briggs Institute (JBI; Adelaide, South Australia) and members of five Joanna Briggs Collaborating Centres.

The literature search identified six articles for review that reported on paramedic disaster response competency domains. The results were divided into two groups: (1) General Core Competency Domains, which are suitable for all paramedics (both Advanced Life Support [ALS] and Basic Life Support [BLS]) who respond to any disaster or major incident; and (2) Specialist Core Competencies, which are deemed necessary competencies to enable a response to certain types of disaster. Further review then showed that three separate and discrete types of competency domains exits in the literature: (1) Core Competencies, (2) Technical/Clinical Competencies, and (3) Specialist Technical/Clinical Competencies.

The most common domains of core competencies for paramedic first responders to manage major incidents and disasters described in the literature were identified. If it’s accepted that training paramedics in disaster response is an essential part of preparedness within the disaster management cycle, then by including these competency domains into the curriculum development of localized disaster training programs, it will better prepare the paramedic workforce’s competence and ability to effectively respond to disasters and major incidents.

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.

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.