The Emergency Medical Team (EMT) Strategic Advisory Group of the World Health Organization has endorsed the EMT Minimum Data Set (MDS) as the standard methodology for EMT daily report. The MDS had been developed on a similar methodology called J-SPEED which developed in Japan. Thus, lessons learned from the J-SPEED can be applied to the MDS.

To review previous J-SPEED activations and to extract lessons learned.

Cases of the J-SPEED activation at the Kumamoto earthquake in 2016, West Japan Heavy Rain in 2018, and Hokkaido Earthquake in 2018 were reviewed.

The first large-scale activation of the J-SPEED at the Kumamoto earthquake revealed a significant burden in aggregations of submitted paper forms at the EMT Coordination Cell (EMTCC). To strengthen this function of the EMTCC, electronic system and human capacity development have been identified as key issues. To fulfill this gap, a smartphone app so-called J-SPEED+ has been developed. Also, the J-SPEED offsite analysis support team, which is a team to support analysis of data from outside of an affected area has been established. These two functions contributed to significant improvement of J-SPEED data flow at the West Japan Heavy Rain and Hokkaido Earthquake. These two responses reinforced the necessity of strengthening the capacity of J-SPEED onsite coordinator working at the ETMCC, and national education and training for all EMTs.

In order to strengthen the mechanism to run the J-SPEED, nationwide training for all EMTs, onsite coordinators, and the off-site analysis support team have been established. The authors regard this structural approach as a requirement for other countries to run the MDS.

The early recognition of patients with sepsis is difficult and the initial assessment outside of hospitals is challenging for ambulance clinicians (ACs). Indicators that ACs can use to recognize sepsis early are beneficial for patient outcomes. Research suggests that elevated point-of-care (POC) plasma glucose and serum lactate levels may help to predict sepsis in the ambulance service (AS) setting.

The aim of this study was to test the hypothesis that the elevation of POC plasma glucose and serum lactate levels may help to predict Sepsis-3 in the AS.

A prospective observational study was performed in the AS setting of Gothenburg in Sweden from the beginning of March 2018 through the end of September 2019. The criteria for sampling POC plasma glucose and serum lactate levels in the AS setting were high or intermediate risk according to the Rapid Emergency Triage and Treatment System (RETTS), as red, orange, yellow, and green if the respiratory rate was >22 breaths/minutes. Sepsis-3 were identified retrospectively. A primary and secondary analyses were carried out. The primary analysis included patients cared for in the AS and emergency department (ED) and were hospitalized. In the secondary analysis, patients who were only cared for in the AS and ED without being hospitalized were also included. To evaluate the predictive ability of these biomarkers, the area under the curve (AUC), sensitivity, specificity, and predictive values were used.

A total of 1,057 patients were included in the primary analysis and 1,841 patients were included in the secondary analysis. In total, 253 patients met the Sepsis-3 criteria (in both analyses). The AUC for POC plasma glucose and serum lactate levels showed low accuracy in predicting Sepsis-3 in both the primary and secondary analyses. Among all hospitalized patients, regardless of Sepsis-3, more than two-thirds had elevated plasma glucose and nearly one-half had elevated serum lactate when measured in the AS.

As individual biomarkers, an elevated POC plasma glucose and serum lactate were not associated with an increased likelihood of Sepsis-3 when measured in the AS in this study. However, the high rate of elevation of these biomarkers before arrival in hospital highlights that their role in clinical decision making at this early stage needs further evaluation, including other endpoints than Sepsis-3.

The initial assessment of critical patients includes prompt identification of life-threatening conditions. Any device or technique that can aid in this process may ultimately save lives. This study examined whether clothing could be removed faster with the use of a hooked cutting device as compared with the commonly-used heavy-duty, blunt-tipped, serrated scissors.

This study took place in an urban academic emergency department of a Level-1 trauma center. Human patient simulator mannequins were clothed in identical shirts and pants. The time required for clinical personnel to expose the patient using each device was measured. Each of the 50 participants was queried regarding their tactile comfort using each device.

The mean time for shirt removal using scissors was 83 seconds (SD = 55 seconds; 95% CI, 68-99). The mean time for shirt removal using the hook device was 28 seconds (SD = 21 seconds; 95% CI, 22-34). The mean time for pants removal using scissors was 69 seconds (SD = 40 seconds; 95% CI, 56-73). The mean time for pants removal using the hook device was 19 seconds (SD=15 seconds; 95% CI, 15-23).

The hooked device was 69% faster at removing clothing than traditionally-used scissors. Though simple in concept, these implications can be life saving, particularly in conditions of uncontrolled, life-threatening external hemorrhage.

TangN , LevyM , HarrowJ , BinghamN . Use of a Hooked Cutting Device Compared With Scissors for the Emergency Exposure of Critically Ill and Injured Patients. Prehosp Disaster Med. 2013;28(6):1-4.

Osborne and Gaebler's Reinventing Government has sparked discussion amongst elected officials, civil servants, the media, and the general public regarding advantages of privatizing government services. Its support stems from an effort to provide services to municipalities while reducing taxpayer expenditure. Many echo the sentiment of former New York Governor Mario Cuomo, who said, “It is not government's obligation to provide services, but to see that they're provided.” Even in the area of public safety, privatization has found a “market.”

In many localities, privatizing Emergency Medical Services (EMS) is a popular and successful method for providing ambulance services. Privately owned ambulance services staff and respond to medical emergencies in a given community as part of the 9–1–1 emergency response system. Regulations for acceptable response times, equipment, and other essential components of EMS systems are specified by contract. This allows the municipality oversight of the service provided, but it does not provide the service directly. As will be discussed, this “contracting-out” model has many benefits.

Privatizing EMS services is a decision based not only on cost-savings, but on accountability. A thorough evaluation must be utilized in the selection process. Issues of efficiency, effectiveness, quality, customer service, responsiveness, and equity must be considered by the government, in addition to cost of service.

The uncertain future of health care in the United States has led those in EMS to look beyond the field's internal market to explore additional opportunities for expanding and redefining its roles beyond emergency care. It is important, however, to consider how emergency medical care, the original role of EMS, can be best delivered. Responding to emergencies is not just one of the functions involved in this field, it is the principal function from which public perception of EMS is formed, and from which support for entering other markets can be fostered.

The purpose of this paper is to present several important concepts and considerations that public officials, medical directors, and the public must be aware of when contemplating the possibility of privatizing their Emergency Medical Services. A review of the general concepts of privatization and issues of accountability will be presented, referencing policy experts, followed by an examination of how advocates of privatization might see these issues as they relate to providing EMS. The conclusion will present prescriptions for both municipal and commercial ambulance providers.

Expired air resuscitation is an essential part of first-aid and cannot be replaced by other measures. Because of the risk of transmitting infectious diseases, the use of devices is recommended. Three types are available—masks, tubes, and foils.

Six masks (Air-Vita Bi-Protect, Laerdal Pocket-mask, Dräger Hivita Mask E, Rescue-Med De-vice, Resuscitator, SealEasy Resuscitation Kit), five tube instruments (Dr. Brook Airway, Dual-Aid, Goettinger Tubus, Lifeway, Sussex Valve Airway), and two foils (Ambu Life-Key, Laerdal ResusdFace Shield) were studied.

Inspiratory and expiratory resistance, valve leakage, ability to protect against infection transmission, and practicability (e.g., possibility of training on standard mannequins, seal) were measured and tested in the laboratory.

Only a few of the mask and tube devices had low inspiratory and expiratory resistances. Some of the one-way valves failed. There were definite risks of provoking complications (vomiting, lacerations) when using tube instruments.

Devices consisting of a foil have definite advantages, and seem to be more appropriate for the use by first-aiders [first responders].

In Part I of the study, the collar and a short spine board were applied to 25 adult volunteers in a sitting position, using standard methods. Each subject then exerted maximal force inflexion, extension, rotation, and abduction. Degrees of head motion from neutral position were measured in each direction. Mean values were compared using Student's t-test. For Part II, 10 EMS personnel were asked to apply the collar to volunteers. Each rated the performance of the collar on a scale of 1 (poor) to 4 (excellent) regarding: ease of application (sitting and supine), ease of extrication (lifting, logrolling, transfer), access to patient (chest auscultation, CPR, airway management), storage, and overall utility.

The collar was significantly better than the short spine board in both lateral and rotational immobilization (p<0.001). There was no significant difference for flexion or extension (p>0.05). The Red E.M. limited motion to a mean of 15° or less in any direction. Ratings by EMS personnel for the device (meant±standard error) were: ease of application (sitting) 3.5±0.2, (supine) 2.7±0.2; ease of extrication 3.1±0.2; access to patient 3.4±0.2; storage 3.1±0.3; and overall utility 3.1±0.2.

This study indicates that the Philadelphia Red E.M. Collar with Head Immobilizer/Stabilizer is an effective and practical adjunct to stabilization and extrication of potentially neck-injured patients.

Portable suction units used by EMS personnel are utilized infrequently and often are powered by batteries. Lack of use and inspection often results in failure of the device when it is needed. The purpose of this study was to examine the incidence of portable suction unit failure in a rural EMS system and to identify the reasons for failures.

A convenience sample was obtained through both random inspections by the staff of a regional EMS council and data from twice monthly checks reported by respective EMS agencies following a standard protocol for each unit. A standard protocol was used, including checking the vacuum level on each suction unit and inspecting the tubing, canister, and battery. Each inspector assessed whether the unit was capable of achieving 300 mmHg of suction within four seconds. Also, the unit was inspected for any signs of misalignment or dry rot of the gasket, kinking of suction hose, damage to the suction canister, weak/dead battery, or defective pump. Findings were recorded.

Over a two-year period, 9,631 suction unit inspections were completed. There were 233 failures (2.4%) noted. The majority (126, 54.1%) were due to battery failure. Seventy-three units failed due to other reasons (not recorded, switch failure, battery not seated). Ten inspections failed due to incorrect assembly. Nineteen inspections failed due to defects with the suction canister. Five inspections failed due to kinked/disconnected suction tubing.

Only a relatively small percentage of inspections of suction units revealed failures (4.6% Advanced Life Support, 8.6% Basic Life Support) using the above-stated criteria. However, given the importance of airway management and potential complications associated with airway compromise, including aspiration pneumonia, hypoxia, and hemodynamic instability, this is of concern relative to the morbidity and mortality that could be related to airway failure. Due to the relative infrequency of use and the nature of portable suction units, the potential for lack of maintenance and deficiencies in routine inspection may impact the functional status of these devices in EMS agencies. Clearly, improved documentation of battery installation date, charging in accordance with manufacturer recommendations, and thorough inspection of the portable suction unit in its entirety will ensure readiness of these devices. Additionally, more rigorous documentation and analysis of inspections should be a focus of EMS agencies.

RisaviBL, SabotchickKJ, HeileCJ. Portable Suction Unit Failure in a Rural EMS System. Prehosp Disaster Med. 2013;28(4):1-3.

The role of explosions and patient transport vehicles as sources and vectors of Gram-negative, multidrug-resistant organisms (MDROs) that predominate infections following lengthy evacuations after disasters due to natural hazards and in current war-trauma patients is unknown.

Damaged or heavily-used vehicles could be sources of the MDROs subsequently linked to nosocomial infections.

From January through May 2008 in Iraq, inside surfaces of heavily-used, tactical vehicles (Experimental Group) were sampled with sterile, pre-moistened swabs. Swabs, along with positive and negative controls, were shipped to the reference laboratory in Washington, DC, where they underwent culture, identification and susceptibility testing, and pulsed-field gel electrophoresis. Multidrug-resistant organisms were defined according to the standard Centers for Disease Control and Prevention definitions. High risk organisms (HROs) were defined as susceptible E. coli, A. baumannii, P. aeruginosa, Enterobacter spp, or Klebsiella spp. Concurrently, new counterparts (Control Group) were similarly surveyed in a storage lot in Georgia, USA. Groups were compared using the Chi-squared test.

One hundred thirty-nine consecutive vehicles including all available ambulances were sampled, yielding 153 swabs. Nineteen were lost or damaged during shipping. Seventy-nine swabs yielded growth of one or more Gram-negative bacteria. The amount and genotype of MDROs in heavily-used vehicles, including those involved in roadside bombings, were compared to control vehicles and to strains isolated from wounds and environmental surfaces at the base hospital. Predominant organisms included P. agglomerans (34%), S. flexneri (8%), E. vulneris (6%), Pseudomonas sp. (6%), and K. pneumonia (6%). No MDROs were isolated. Thirteen vehicles (eight of 94 experimental and five of 45 control) yielded HRO. There was no difference in contamination rates (P = .63). No HROs were isolated from ambulances. No clonal association existed between vehicle and hospital strains.

Given the implications that this knowledge gap has on military and civilian prehospital reservoirs of infection, further study is warranted to confirm these findings and identify targets for preventive intervention throughout civilian disaster and military casualty evacuation chains.

LeshoE, AkeJ, HuangX, CashDM, NikolichM, BarberM, RobensK, GarnettE, LindlerL, ScottP. Amount of Usage and Involvement in Explosions Not Associated with Increased Contamination of Prehospital Vehicles with Multi-drug-resistant Organisms. Prehosp Disaster Med. 2013;28(2):1-3..

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.

Violence against primary care providers (PCPs) has increased during the current pandemic. While some of these violent acts are not defined as terrorist events, they are intentional events with an aim to disrupt, kill, or injure. Despite their pivotal role in health care, little is known about the risk for PCPs as targets of terrorism.

Data collection was performed using a retrospective database search through the Global Terrorism Database (GTD). The GTD was searched using the internal database search functions for all terrorist attacks against PCPs and their offices from January 1, 1970 - December 31, 2019. Years 2020 and 2021 were not yet available at the time of the study. Primary attack and weapon type, location (country, world region), and number of deaths and injuries were collated. Results were exported into an Excel spreadsheet (Microsoft Corp.; Redmond, Washington USA) for analysis.

There were 29 terrorist attacks against PCPs and their offices from 1970-2019. The majority of attacks occurred during or after 2010. There were 58 fatalities, 52 injured, and 13 hostages. Most documented attacks took place in Pakistan, the United States, and Sri Lanka. Bombings concerned 55% of cases and 21% were hostage-takings.

Although less common than attacks on other health care related targets, terrorist attacks against PCPs have occurred. The majority of attacks occurred during the last decade. Future studies are warranted to further assess the risk of terrorist attacks against PCPs: before, during, and beyond the current pandemic.

Recreational drug use has become more and more accepted in society. Availability and purity are rising and new psychoactive substances (NPS) are popping up.

The aim of this study was to provide objective data on illicit drug use at a Belgian festival in order to report on arising trends. This may provide additional information to help develop preventive strategies.

A cross-sectional study took place during a music festival in the summer of 2019, where 43 samples of pooled urine were collected at four different locations and at different moments of the day. Analysis was performed using gas chromatography with a flame ionization detector (GC-FID) to determine ethanol concentrations. Drugs of abuse were quantified using liquid chromatography-tandem mass spectrometry. A qualitative analysis was performed using high-resolution mass spectrometry.

Median ethanol concentration was 0.88g/L. Cocaine, 3,4-methylenedioxymethamphetamine (MDMA), amphetamines, ketamine, and cannabis were detected in almost every sample and often in high concentrations. Furthermore, two NPS were detected and a variety of over-the-counter medication and adulterants were also found.

The findings were largely in-line with trends outlined in the European Drug Report. Striking were the relatively high concentrations of MDMA and ketamine and detection of two synthetic cathinones. Two possible adulterants of cocaine were detected, namely flecainide and amlodipine.

Music festivals are considered a high-risk setting for alcohol consumption and illicit drug use. Analysis of pooled urine samples at a festival therefore provides a valuable method to evaluate trends and to screen for new substances. Wide-spread use of classical drugs and identification of two NPS were observed during a major international music festival in Belgium. Results need to be interpreted carefully, taking into account the possibilities and limitations of the used techniques and a standardized sampling is required.

Incorporating emerging knowledge into Emergency Medical Service (EMS) competency assessments is critical to reflect current evidence-based out-of-hospital care. However, a standardized approach is needed to incorporate new evidence into EMS competency assessments because of the rapid pace of knowledge generation.

The objective was to develop a framework to evaluate and integrate new source material into EMS competency assessments.

The National Registry of Emergency Medical Technicians (National Registry) and the Prehospital Guidelines Consortium (PGC) convened a panel of experts. A Delphi method, consisting of virtual meetings and electronic surveys, was used to develop a Table of Evidence matrix that defines sources of EMS evidence. In Round One, participants listed all potential sources of evidence available to inform EMS education. In Round Two, participants categorized these sources into: (a) levels of evidence quality; and (b) type of source material. In Round Three, the panel revised a proposed Table of Evidence. Finally, in Round Four, participants provided recommendations on how each source should be incorporated into competency assessments depending on type and quality. Descriptive statistics were calculated with qualitative analyses conducted by two independent reviewers and a third arbitrator.

In Round One, 24 sources of evidence were identified. In Round Two, these were classified into high- (n = 4), medium- (n = 15), and low-quality (n = 5) of evidence, followed by categorization by purpose into providing recommendations (n = 10), primary research (n = 7), and educational content (n = 7). In Round Three, the Table of Evidence was revised based on participant feedback. In Round Four, the panel developed a tiered system of evidence integration from immediate incorporation of high-quality sources to more stringent requirements for lower-quality sources.

The Table of Evidence provides a framework for the rapid and standardized incorporation of new source material into EMS competency assessments. Future goals are to evaluate the application of the Table of Evidence framework in initial and continued competency assessments.