1) To determine if paramedics could select appropriate patients for use of the saline lock; 2) to evaluate saline-lock patency upon arrival at the emergency department (ED); and 3) to define any cost-savings associated with the use of the saline lock.

Patients in the prehospital setting who required intravenous (IV) access, but did not require fluid resuscitation. Patients with hypotension or multiple traumatic injuries were excluded.

Paramedics were given the option for the use of either the saline lock or a routine IV set-up. Initially, the reservoir was flushed with 1 ml 0.9 N saline solution and the flush was repeated only if medications subsequently were completed for each patient. Information collected included: 1) demographics; 2) reason for selection; 3) need for fluid infusion; 4) conversion of the lock to a routine IV set-up; and 5) administration of medications through the lock. Failures included inability to flush after arrival to the ED, or local infiltration detected on flush while in the ED. Costs associated with the use of the saline locks were compared with those associated with the use of traditional IV set-ups. Cost-savings were calculated as the cost of a traditional IV set-up minus costs of the lock set-up.

A total of 58 male and 42 female patients was enrolled. All patients were assigned appropriately. The most commonly used indications included chest pain, possible stroke, and shortness of breath. Two locks were occluded, and two had infiltrated when flushed following arrival of the patient to the ED. Five patients had IV fluid bads initiated through the locks. Cumulative cost-saving were [U.S.]$130 to the hospitals and $1,710 to the patients or their carriers. Most paramedics were pleased with the performance and utility of the locks.

The use of saline locks is an alternative to the use of traditional IVs in certain patients in the prehospital setting.

Supplying an adequate amount of drinking water to a population is a complex problem that becomes an extremely difficult task in war conditions. In this paper, several simple methods for obtaining individual supplies of drinking water by filtration of atmospheric water with common household items are reported.

Samples of atmospheric water (rain and snow) were collected, filtered, and analyzed for bacteriological and chemical content. The ability of commonly available household materials (newspaper, filter paper, gauze, cotton, and white cotton cloth) to filter water from the environmental sources was compared.

According to chemical and biological analysis, the best results were obtained by filtering melted snow from the ground through white cotton cloth.

Atmospheric water collected during war or in extreme shortage conditions can be purified with simple improvised filtering techniques and, if chlorinated, used as an emergency potable water source.

Anthrax is a potential biological weapon and can be used in an air-borne or mail attack, such as in the attack in the United States in 2001. Planning for such an event requires the best available science. Since large-scale experiments are not feasible, mathematical modelling is a crucial tool to inform planning. The aim of this study is to systematically review and evaluate the approaches to mathematical modelling of inhalational anthrax attack to support public health decision making and response.

A systematic review of inhalational anthrax attack models was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) criteria. The models were reviewed based on a set of defined criteria, including the inclusion of atmospheric dispersion component and capacity for real-time decision support.

Of 13 mathematical modelling studies of human inhalational anthrax attacks, there were six studies that took atmospheric dispersion of anthrax spores into account. Further, only two modelling studies had potential utility for real-time decision support, and only one model was validated using real data.

The limited modelling studies available use widely varying methods, assumptions, and data. Estimation of attack size using different models may be quite different, and is likely to be under-estimated by models which do not consider weather conditions. Validation with available data is crucial and may improve models. Further, there is a need for both complex models that can provide accurate atmospheric dispersion modelling, as well as for simpler modelling tools that provide real-time decision support for epidemic response.

Housing has always been a source of stress for people in Hong Kong (HK), especially to those living in sub-optimal settings. About 210,000 people are forced to live in subdivided flats in HK. Most of these flats cannot meet health standards set by the UN even for prisoners, in terms of the floor space, climatic conditions, lighting, air quality, and ventilation. Fire and public safety equipment are lacking. Most believed that the substandard environment has a negative impact on one’s mental health.

To investigate how the living condition in a subdivided flat affects a person’s mental health.

104 households living in the subdivided flats in Kwai Tsing, one of the 18 Districts of HK, were surveyed by HKJCDPRI’s Collaborating Partner, HKSKH Lady MacLehose Centre in February 2017; while a follow-up study with purposive sampling was conducted in October 2017 to interview 10 households on their mental health status. A mixed Methods was used combining the quantitative Results of the WHO Quality of Life-BREF scale and Depression Anxiety Stress Scale 21, and qualitative Results of face-to-face interviews.

80% of 104 households surveyed suffered from mental distress. The follow-up study revealed that seven of them displayed signs of depression and/or anxiety, while two were diagnosed with a mental disorder. Distress is proven to associate with the environmental and health risks, including fire and disease outbreak, as well as chronic issues resulting from poor indoor air quality and extreme weather.

Low level of perception and preparedness among HK people is making these public health risks more apparent. The already desperate housing and land policy don’t seem to offer any help in the near future. Public educations efforts need tremendous enhancement, to engage, mobilize and empower individuals and communities, to actively plan and prepare for future shocks.

The majority of pediatric medications are dosed according to weight and therefore accurate weight assessment is essential. However, this can be difficult in the unpredictable and peripatetic prehospital care setting, and medication errors are common. The Handtevy method and the Broselow tape are two systems designed to guide Emergency Medical Services (EMS) providers in both pediatric patient weight estimation and medication dosing. The accuracy of the Handtevy method of weight estimation as practiced in the field by EMS has not been previously examined.

The primary objective of this study was to examine the field performance of the Handtevy method and the Broselow tape with respect to prehospital patient weight estimation.

This was a retrospective chart review of trauma and non-trauma patients transported by EMS to the emergency department (ED) of a quaternary care children’s hospital from January 1, 2021 through June 30, 2021. Demographic data, ED visit information, prehospital weight estimation, and medication dosing were collected and analyzed. Scale-based weight from the ED was used as the standard for comparison.

A total of 509 patients <13 years of age were included in this study. The EMS providers using the Broselow method estimated patient weight to within +/-10% of ED scale weight in 51.3% of patients. When using the Handtevy method, the EMS providers estimated patient weight to within +/-10% of ED scale weight in 43.7% of patients. When comparing the Handtevy versus Broselow method of prehospital weight estimation, there was no significant association between method and categorized weight discrepancy (over, under, or accurate estimates – defined as within 10% of ED scale weight; P = .25) or percent weight discrepancy (P = .75). On average, prehospital weight estimation was 6.33% lower than ED weight with use of the Handtevy method and 6.94% lower with use of the Broselow method.

This study demonstrated no statistically significant difference between the use of the Handtevy or Broselow methods with respect to prehospital weight estimation. While further research is necessary, these results suggest similar field performance of the Broselow and Handtevy methods.

Terrorist attacks against hospitals and health care providers have disproportionally increased during the last decades. A significant proportion of these attacks targeted abortion clinics and abortion providers. In the light of the overturning of Roe v. Wade in 2022, an increase of anti-abortion terrorist attacks is anticipated. Therefore, it becomes imperative to gain further insight into the risk and characteristics of past terrorist attacks. This study aimed to review terrorist attacks against health care targets providing abortion services from 1970 through 2020.

Data collection was performed using a retrospective database search through the Global Terrorism Database (GTD). The GTD was searched using the internal database functions for all terrorist attacks against abortion health care providers from January 1, 1970 - December 31, 2020. Temporal factors, location, attack and weapon type, and number of casualties or hostages were analyzed using descriptive statistics.

In total, 262 terrorist attacks were identified in five different countries. The majority (96.6%) occurred in the United States, with the highest counts during the last 20 years of the 20th century. Facility and infrastructure attacks were the most common attack types, followed by bombings and explosions. The attacks resulted in 34 injuries and nine fatalities. Kidnapping took place in three incidents. Of all successful attacks, 96.9% resulted in property damage.

Abortion-related health care facilities and providers have repeatedly been the target of terrorists over the past decades. Nearly all of these attacks took place in the United States, with the highest counts during the last 20 years of the 20th century.

Major incidents (MIs) put great demands on the medical response to effectively organize and redistribute resources and personnel, in prehospital care as well as hospital care, and coordinating functions. Studies indicate that regular training and well-established contingency plans are vital for the medical response to MIs. Previous assessments have concluded that Swedish disaster preparedness requires improved organization and coordination. There is currently no method to easily follow-up the preparedness work of the prehospital medical response organizations for MIs in Sweden.

The aim of the study was to assess qualifications and training requirements for central individual roles, to examine frequency and focus of training and simulation, as well as to examine current regional routines for MIs in Sweden. The aim was also to identify, to evaluate, and to investigate areas for improvement in prehospital health care preparedness for MIs in Sweden.

Descriptive comparative study of Sweden’s prehospital organization, planning, education, and training for MIs through a web-based survey sent to all 21 regions in Sweden. The survey included 64 questions and was based on national legislation and guidelines for preparedness and previous investigations of real MIs.

A total of 37 answers to the survey were collected representing 17/21 regions (80.9%) from which Regional Management Individuals (RMIs) were selected from 15 regions and used as representative primary responses. The initial routines regarding alarm and establishment of management functions were mainly in-line with national guidelines. Staffing and qualification requirements for certain leadership roles differed substantially between regions. The requirements for the health care staff’s knowledge of the contingency plan were generally low and routines for follow-up were often lacking. The frequency of exercises in certain areas were deficient.

The results of the study showed several potential areas for improvement within the prehospital emergency medical preparedness for MIs in Sweden. Methodology and adherence of national guidelines for medical response preparedness differ between regions in Sweden, which motivates recurring assessments. It is possible to use a well-prepared questionnaire study to follow-up and to examine parts of the regional prehospital preparedness work and organization for MIs.

On August 4, 2020, a massive explosion struck the Beirut Harbor in Lebanon. Approximately 220 people were killed and around 7,000 were injured, of which 12% were hospitalized. Despite being weakened by economic crisis and increasing numbers of coronavirus disease 2019 (COVID-19) cases, the national health care system responded promptly. Within a day, international health care assistance in the form of International Emergency Medical Teams (I-EMTs) started arriving. Previous studies have found that I-EMTs have arrived late and have not been adapted to the context and dominating health care needs. The aim of this study was to document the organization, type, activity, and timing of I-EMTs deployed to Beirut and to discuss their relevance in relation to medical needs.

Data on all deployed I-EMTs were retrieved from all available sources, including internet searches, I-EMT contacts, and from the World Health Organization (WHO) EMT coordination cell (EMT CC) in Lebanon. The WHO EMT classification was used to categorize deployed teams. Information on characteristics, timing, and activities was retrieved and systematically assessed.

Nine I-EMTs were deployed to Beirut following the explosion. Five were equivalent to EMT Type 2 (field hospitals), out of which three were military. The first EMT Type 2 arrived within 24 hours, while the last EMT set up one month after the explosion. Four civilian I-EMTs provided non-clinical support as EMT Specialized Care Teams. A majority of the I-EMTs were focused on trauma care. Three of the four I-EMT Specialized Care Teams were rapidly re-tasked to support COVID-19 care in public hospitals.

A majority of the deployed I-EMT Type 2 were military and focused on trauma care rather than the normal burden of disease including COVID-19. Re-tasking of EMTs requires flexible EMTs. To be better adapted, the I-EMT response should be guided by a systematic assessment of both health care capacities in the affected country as well as the varying health effects of hazards before deployment.

The 2019 coronavirus disease (COVID-19) pandemic created overwhelming demand for critical care services within Maryland’s (USA) hospital systems. As intensive care units (ICUs) became full, critically ill patients were boarded in hospital emergency departments (EDs), a practice associated with increased mortality and costs. Allocation of critical care resources during the pandemic requires thoughtful and proactive management strategies. While various methodologies exist for addressing the issue of ED overcrowding, few systems have implemented a state-wide response using a public safety-based platform. The objective of this report is to describe the implementation of a state-wide Emergency Medical Services (EMS)-based coordination center designed to ensure timely and equitable access to critical care.

The state of Maryland designed and implemented a novel, state-wide Critical Care Coordination Center (C4) staffed with intensivist physicians and paramedics purposed to ensure appropriate critical care resource management and patient transfer assistance. A narrative description of the C4 is provided. A retrospective cohort study design was used to present requests to the C4 as a case series report to describe the results of implementation.

Providing a centralized asset with regional situational awareness of hospital capability and bed status played an integral role for directing the triage process of critically ill patients to appropriate facilities during and after the COVID-19 pandemic. A total of 2,790 requests were received by the C4. The pairing of a paramedic with an intensivist physician resulted in the successful transfer of 67.4% of requests, while 27.8% were managed in place with medical direction. Overall, COVID-19 patients comprised 29.5% of the cohort. Data suggested increased C4 usage was predictive of state-wide ICU surges. The C4 usage volume resulted in the expansion to pediatric services to serve a broader age range. The C4 concept, which leverages the complimentary skills of EMS clinicians and intensivist physicians, is presented as a proposed public safety-based model for other regions to consider world-wide.

The C4 has played an integral role in the State of Maryland’s pledge to its citizens to deliver the right care to the right patient at the right time and can be considered as a model for adoption by other regions world-wide.

World events continue to compel hospitals to have agile and scalable response arrangements for managing natural and instigated disasters. While many hospitals have disaster plans, few exercise these plans or test their staff under realistic scenarios.

This study explores changes in perceived preparedness of multidisciplinary hospital-wide teams to manage mass casualty incidents.

Two Emergo Train System (ETS) mass casualty exercises involving 80 and 86 “victims,” respectively, were run at two southeast Queensland hospitals: one large teaching hospital and one smaller regional hospital. Pre- and post-exercise surveys were administered, capturing participants’ confidence, skills, and process knowledge anonymously on 5-point Likert scales. A waiver of ethics review was obtained. Changes in individuals’ pre- and post-scores were analyzed using paired t-tests. Open-ended questions and a “hot debrief” occurring immediately post-exercise allowed for capture of improvement ideas.

Nearly 200 unique healthcare staff (n=193) participated in one exercise. At least one survey was returned by 159 staff (82.4%). Pre- and post- surveys were available for 89 staff; two-thirds (n=59) were nurses or doctors, and 46% overall were emergency department clinicians. Ninety-seven percent reported the exercise was valuable, also recommending additional simulations. Analysis of the 89 matched-pairs showed significant (p<.001) increases in self-confidence, skills, and knowledge (point increases on a five-point Likert scale (95% confidence intervals): 0.8 (0.6-0.9) for confidence and 0.4 (0.2-0.5) for both skills and knowledge. The exercise was critically appraised and a summary of operational learnings was developed. The most common criticism of ETS was its lack of real patients.

Involvement in simulated exercises (e.g. ETS) can increase confidence, knowledge, and skills of staff to manage disasters, with the biggest improvement in confidence. Whilst validating and testing plans, simulations can also uncover opportunities to improve processes and systems.

Select units in the military have improved combat medic training by integrating their functions into routine clinical care activities with measurable improvements in battlefield care. This level of integration is currently limited to special operations units. It is unknown if regular Army units and combat medics can emulate these successes. The goal of this project was to determine whether US Army combat medics can be integrated into routine emergency department (ED) clinical care, specifically medication administration.

This was a quality assurance project that monitored training of combat medics to administer parenteral medications and to ensure patient safety. Combat medics were provided training that included direct supervision during medication administration. Once proficiency was demonstrated, combat medics would prepare the medications under direct supervision, followed by indirect supervision during administration. As part of the quality assurance and safety processes, combat medics were required to document all medication administrations, supervising provider, and unexpected adverse events. Additional quality assurance follow-up occurred via complete chart review by the project lead.

During the project period, the combat medics administered the following medications: ketamine (n=13), morphine (n=8), ketorolac (n=7), fentanyl (n=5), ondansetron (n=4), and other (n=6). No adverse events or patient safety events were reported by the combat medics or discovered during the quality assurance process.

In this limited case series, combat medics safely administered parenteral medications under indirect provider supervision. Future research is needed to further develop this training model for both the military and civilian setting.

SchauerSG, CunninghamCW, FisherAD, DeLorenzoRA. A Pilot Project Demonstrating that Combat Medics Can Safely Administer Parenteral Medications in the Emergency Department. Prehosp Disaster Med. 2017;32(6):679–681.