The pivotal role of anesthesiologists in the implementation of disaster plans is not widely appreciated.

To describe the role of anesthesiologists as managers in the operating room (OR) especially during hospital disaster management.

On 25 February 1991, King Fahd Hospital of the University in Eastern Saudi Arabia, was alerted, received, triaged, and treated the victims of a Scud missile attack on a United States military barracks which killed 28 and injured more than 100 service personnel.

There were 47 males and 15 females admitted to the hospital. Their initial triage categories of injuries were: 1) red, 23; 2) yellow, 27; and 3) green, 7. The flow of patients through the main operating rooms occurred in two peaks: 1) treated within nine hours (60%); and 2) during the next 11 hours (40%). A total 101 units of blood and blood products were consumed.

The role of the Chief of Anesthesiology was vital in the dynamics of the situation regarding appropriate deployment of staff and ensuring an orderly throughput of victims in the operating room. He also was required to keep track of resources and supply levels in the operating room, so that he could advise the hospital administration appropriately.

The successful management of a large multi-casualty incident, which involved use of the operating rooms, depended upon the efficient coordination of clearly defined functions with the Chief of Anesthesiology Service as the team leader.

Tenecteplase is a thrombolytic protein drug used by paramedics, emergency responders, and critical care medical personnel for the prehospital treatment of blood clotting diseases. Minimizing the time between symptom onset and the initiation of thrombolytic treatment is important for reducing mortality and improving patient outcomes. However, the structure of protein drug molecules makes them susceptible to physical and chemical degradation that could potentially result in considerable adverse effects. In locations that experience extreme temperatures, lyophilized tenecteplase transported in emergency service vehicles (ESVs) may be subjected to conditions that exceed the manufacturer’s recommendations, particularly when access to the ambulance station is limited.

This study evaluated the impact of heat exposure (based on temperatures experienced in an emergency vehicle during summer in a regional Australian city) on the stability and efficacy of lyophilized tenecteplase.

Vials containing 50mg lyophilized tenecteplase were stored at 4.0°C (39.2°F), 35.5°C (95.9°F), or 44.9°C (112.8°F) for a continuous period of eight hours prior to reconstitution. Stability and efficacy were determined through assessment of: optical clarity and pH; analyte concentration using UV spectrometry; percent protein monomer and single chain protein using size-exclusion chromatography; and in vitro bioactivity using whole blood clot weight and fibrin degradation product (D-dimer) development.

Heat treatment, particularly at 44.9°C, was found to have the greatest impact on tenecteplase solubility; the amount of protein monomer and single chain protein lost (suggesting structural vulnerability); and the capacity for clot lysis in the form of decreased D-dimer production. Meanwhile, storage at 4.0°C preserved tenecteplase stability and in vitro bioactivity.

The findings indicate that, in its lyophilized form, even relatively short exposure to high temperature can negatively affect tenecteplase stability and pharmacological efficacy. It is therefore important that measures are implemented to ensure the storage temperature is kept below 30.0°C (86.0°F), as recommended by manufacturers, and that repeated refrigeration-heat cycling is avoided. This will ensure drug administration provides more replicable thrombolysis upon reaching critical care facilities.

Triage - the sorting of patients according to urgency of need for clinical care - is an essential part of delivering effective and efficient emergency care. But when frequent over- or under-triaging occurs, finite time and resources are diverted away from those in greatest need of care and the entire Emergency Medical Services (EMS) system is strained. In resource-constrained settings, such as South Africa, poor triage in EMS only serves to compound other contextual challenges. This study examined the accuracy of dispatcher triage over a one-year period in the Western Cape Government (WCG) EMS system in South Africa.

A retrospective analysis of existing dispatch and EMS data to assess the accuracy of dispatch-assigned priorities was conducted. The mismatch between dispatcher-assigned call priority and triage levels determined by EMS personnel was analyzed via over- and under-triage rates, sensitivity and specificity, and positive and negative predictive values (PPVs and NPVs, respectively).

A total of 185,166 records from December 2016 through November 2017 were analyzed. Across all dispatch complaints, the over-triage rate was 67.6% (95% CI, 66.34-68.76) and the under-triage rate was 16.2% (95% CI, 15.44-16.90). Dispatch triage sensitivity for all included records was 49.2% (95% CI, 48.10-50.38), specificity 71.9% (95% CI, 71.00-72.92), PPV 32.5% (95% CI, 30.02-34.88), and NPV 83.8% (95% CI, 81.93-85.73).

This study provides the first evaluation of dispatch triage accuracy in the WCG EMS system, identifying that the system is suffering from both under- and over-triage. Despite variance across dispatch complaints, both under- and over-triage remained higher than widely accepted norms, and all rates were significantly above acceptable target metrics described in similar studies. Results of this study will be used to motivate the development of more rigorous training programs and resources for WCG EMS dispatchers, including improved dispatch protocols for conditions suffering from high over- and under-triage.

Cadaveric and older radiographic studies suggest that concurrent cervical spine fractures are rare in gunshot wounds (GSWs) to the head. Despite this knowledge, patients with craniofacial GSWs often arrive with spinal motion restriction (SMR) in place. This study quantifies the incidence of cervical spine injuries in GSWs to the head, identified using computerized tomography (CT). Fracture frequency is hypothesized to be lower in self-inflicted (SI) injuries.

Isolated craniofacial GSWs were queried from this Level I trauma center registry from 2013-2017 and the US National Trauma Data Bank (NTDB) from 2012–2016 (head or face abbreviated injury scale [AIS] >2). Datasets included age, gender, SI versus not, cervical spine injury, spinal surgery, and mortality. For this hospital’s data, prehospital factors, SMR, and CTs performed were assessed. Statistical evaluation was done with Stata software, with P <.05 significant.

Two-hundred forty-one patients from this hospital (mean age 39; 85% male; 66% SI) and 5,849 from the NTDB (mean age 38; 84% male; 53% SI) were included. For both cohorts, SI patients were older (P < .01) and had increased mortality (P < .01). Overall, cervical spine fractures occurred in 3.7%, with 5.4% requiring spinal surgery (0.2% of all patients). The frequency of fracture was five-fold greater in non-SI (P < .05). Locally, SMR was present in 121 (50.2%) prior to arrival with six collars (2.5%) placed in the trauma bay. Frequency of SMR was similar regardless of SI status (49.0% versus 51.0%; P = not significant) but less frequent in hypotensive patients and those receiving cardiopulmonary resuscitation (CPR). The presence of SMR was associated with an increased use of CT of the cervical spine (80.0% versus 33.0%; P < .01).

Cervical spine fractures were identified in less than four percent of isolated GSWs to the head and face, more frequently in non-SI cases. Prehospital SMR should be avoided in cases consistent with SI injury, and for all others, SMR should be discontinued once CT imaging is completed with negative results.

All first responders must be prepared to respond to suicide attacks. Staging safe and effective responses to these incidents requires knowledge of a number of unique considerations.

The research presented in this presentation used reviews of open source information along with site visits to multiple suicide bombing sites in Israel and the United Kingdom to determine the important considerations for first responders responding to suicide attacks. What is presented is not a specific standard operating procedure but rather a common framework that can help to facilitate a coordinated and effective response from all agencies involved.

Civilians and private security guards can play an important role in detecting the planning and execution of suicide attacks and sometimes even in their interdiction in the imminent attack phase. The suspicions of civilians must be taken seriously and citizens should be encouraged to report these suspicions immediately. The first responding emergency services personnel must be able to effectively begin their agency's response to the attack while maintaining a strong situational awareness. Also on scene, strong frontline commanders are needed to work together to lead a coordinated response. Interagency communication and using a scaled response is of increased importance at these incidents when first responders could be targeted by the secondary attacks or an initial threat that has not yet been neutralized. First responders can take the initial steps to promote the return to normalcy that is important after terrorist attacks. In the aftermath of attacks, efforts should be made to establish a collective knowledge within the emergency services community to share lessons learned in the response.

The results of this research can help local agencies plan for suicide attack response and also provides a strong foundation for future research to further investigate responses to the varying types of suicide attacks around the world.

To provide a descriptive analysis of the prehospital emergency medical transportation system operating in and around a major Bosnian city, and to discuss the effect of the war on that transportation system.

A prospective, consecutive sample study.

The largest tertiary-care referral hospital currently operating in central Bosnia.

158 consecutive patients who sought care in the trauma and medical receiving rooms at Zenica Hospital.

Patients were surveyed as to time of transportation to the site of first medical care and to Zenica Hospital, and modes of transportation used.

Time to transport to first care within the city of Zenica is 30±21 minutes. Time to transport to Zenica Hospital from within Zenica is 51±39 minutes. Time to transport to first care outside of Zenica is 77±56 minutes. Time to transport to Zenica Hospital from outside the city of Zenica is 178±94 minutes. The prehospital emergency medical service was used in 11.7% of cases reviewed.

The majority of patients with major injury and illness are unable to obtain prehospital transportation and medical care through informal modes of transportation. The existing prehospital emergency medical services system is inadequate for the numbers of patients requiring such services, and transportation time from outside the city of study is especially prolonged.