Norway is a country with many road tunnels and therefore also has experience with rescue operations in tunnel environments. Major incidents always challenge involved emergency services’ management skills. Oslo, Norway has a specially trained medical on-scene commander, a function already existing in police and rescue service. Intra-agency communication and management of personnel are essential factors for a successful rescue effort.

To investigate the medical management provided by the specially trained Norwegian medical on-scene commander in relation to tunnel incidents.

Interviews were conducted with six of the seven medical on-scene commanders in Oslo. The collected data were analyzed using qualitative content analysis.

An overarching theme emerged: A need for mutual understanding of the tunnel incident. The medical on-scene commanders established guidelines for response in collaboration with the other emergency services. By creating a sense of trust, the collaboration between the emergency services became more fluent. Socializing outside of work resulted in improved reliance on their counterparts in the other services. The management also included that the medical on-scene commander supervised his personnel on site by providing support using knowledge of the risk object and surrounding area.

A forum for the emergency services on-scene commanders where they share ideas and knowledge, improve the on-scene intra-agency communication, and trust is desirable. A culture of trust between the organizations is needed for a mutual understanding. Further research on this subject is needed in other contexts and countries.

Emergency service workers perform physical work while being subjected to multiple stressors and adverse, volatile working environments for extended periods. Recent research has highlighted sleep as a significant and potentially modifiable factor impacting operational performance.

This presentation would (a) examine the existing literature on emergency service workers’ sleep quantity and quality during operations, (b) synthesize the operational and environmental factors that impact sleep (e.g., shift start times, shift length, sleeping location, smoke, noise, heat), and (c) assess how sleep impacts aspects of emergency service workers’ health and safety, including mental and physical health and performance.

This presentation would be based on a narrative review conducted by the authors which used a systematic search strategy of health-related databases. Articles that were not relevant, duplicate or from non-peer-reviewed sources were excluded.

Sleep is restricted during emergency service deployments, particularly when shifts have early start times, are long duration, and/or when sleeping in temporary accommodation (e.g., tents, vehicles). Shortened sleep impairs cognitive but not physical performance under simulated emergency services conditions.

Depending on the organization and jurisdiction, these findings warrant re-evaluation of existing policies, formalization of beneficial but currently ad-hoc practice, or provide support for current procedures. Work shifts should be structured, wherever possible, to provide regular and sufficient recovery opportunities (rest during and sleep between shifts), especially in dangerous working environments where fatigue-related errors have more severe consequences. For agencies to continue to defend local communities against natural hazards, strategies should be implemented to improve and manage emergency service workers sleep and reduce any adverse impacts on work.

Individuals may not receive messages via usual sources. Social media such as Facebook, LinkedIn, Twitter and social networking groups have been useful in the notification, information dissemination, safe notices, and reunification.

A survey of the literature and of social media sites to determine what possibilities of notification, information exchange, marked safe, and reunification information that can be helpful in disasters.

Social media is useful during all phases of a disaster: pre-disaster notification, information dissemination during disasters, and safe notices/reunification post-disaster

Social media is internet-based and requires a device that needs power. There is widespread internet access to various forms of social media, such as email, various broadcast sources, and social networking sites. Social media may provide pre-disaster warnings (weather alert app, reverse 911), evacuation/sheltering information, blocked routes, open gas stations, stores with supplies, hotels/motels with rooms, and shelter locations. Social networking groups were full of messages informing others they could shelter someone fleeing the California wildfires and recent hurricanes. Volunteers can be alerted and responses collected via social media groups. Social media may reach individuals earlier than official announcements, although sometimes accuracy may be in question. Rumor and malignant information source as well as inaccurate information are possible and may need to be managed. Separation is common during disasters. Knowing if their loved ones are safe and well, then reunifying is critical, especially for the vulnerable: children/infants, elderly, and disabled. Reunification systems need safeguards for vulnerable individuals who may be exploited or abused during disasters. In previous disasters (Hurricanes Maria, Mark, and others; California wildfires), when usual communication was nonfunctional due to downed power lines or damaged/destroyed substations; social media was deluged with individuals giving names and identifying information for family and others and asking whether anyone has seen or heard from them.

In a patient going into shock, blood is redistributed from the periphery to the central circulation, making an assessment of skin perfusion useful in a prehospital setting. Capillary refill time (CRT) is the time required for a pressure blanched skin site to reperfuse. Currently, CRT is tested by manually applying pressure for 5s to the skin and observing the time before reperfusion. Guidelines state that CRT should be 2-3s in a healthy patient. Shortcomings in this procedure include lack of standardization of pressure, subjective assessment of the time for reperfusion, and not accounting for the patient’s skin temperature.

To develop a standardized objective procedure for testing CRT in the prehospital setting.

The study protocol was approved by the Ethics Committee at Linköping University (M200-07, 2015-99-31). An electro-pneumatic device exerting constant force (9N) over 5s was developed. CRT was measured using the Tissue Viability Imager (Wheelsbridge AB, Sweden) which relies on polarization spectroscopy. To simulate hypothermic conditions, healthy volunteers were subjected to low ambient temperature (8°C). Blood loss was simulated using a custom-built lower body negative pressure (LBNP) chamber. In both scenarios, the CRT test was carried out on three test sites (finger pulp, forehead, and sternum).

CRT on the finger pulp and sternum was shown to be increased following the hypothermic conditions, but not on the forehead. Skin temperature on the three sites followed the same pattern, with the forehead being virtually unchanged. Tests performed during LBNP revealed an apparent effect on CRT following the simulated blood loss, with prolonged CRT for all sites tested.

A successful methodology for objective assessment of CRT was developed, which was validated on healthy volunteers following hypothermia or simulated blood loss. Ongoing work will investigate a combination of hypothermia and blood loss to more accurately simulate the prehospital setting.

National Disaster Medical System (NDMS) Disaster Medical Assistance Teams (DMATs) are used to provide medical care when local and state resources are overwhelmed in response to natural and human-made disasters. The stress these professionals experience during these events requires intentional and therapeutic interventions to support emotional and mental resilience. Evidence-based interventions will be presented.

DMATs were deployed after Hurricane Maria to work in a Federal Medical Station (FMS), at the Coliseum Bencito, Manati, Puerto Rico. The FMS was operated through a collaboration of federal agencies and non-government agencies. Community infrastructure was impacted, including two damaged area hospitals, overwhelming available resources with increased patient care demands. The facility provided acute care and short-term services around the clock for a 10-day period, serving several hundred clients, in and around the municipality of Manati.

Several strategies were utilized to decrease stress levels while nurses worked at the FMS included having a safe and secure environment, sharing stories with peers, taking scheduled breaks, utilizing physical activities (Zumba), and having designated sleeping areas. Additional strategies used for clients were relief supply choices, allowing one person to stay with special needs client, and bereaved care.

Nurses were able to decrease stress levels to themselves and clients while working with community partners providing acute and chronic health care needs at the area where health care services were impacted. Verbal and written feedback was provided during formal and informal meetings as well as receiving client comments on the services given at the facility.

Contribution to practice-heightened emotional responses in a disaster setting are expected and should be a focus of intervention even with health care providers. Nurses were able to employ disaster nursing knowledge, including mental health strategies in this setting and be able to better address the needs of others.

In Japan, after an earthquake, or when there is a heavy downpour, transportation is affected and guardians of children may not be able to reach home in time from the office. In elementary schools, because the guardian is unable to come and pick up the child, the teacher needs to ensure that the children are protected, and therefore, bears enormous responsibility. Since commuting times to work are long, guardians need to instate measures for the safety of their children.

This study aims to clarify guardians’ recognition of children’s safety in the event of a disaster, and examine the corresponding challenge they face in terms of commuting distance.

The subjects are 2,181 guardians of children in four elementary schools near places where landslides had occurred in Hiroshima city in 2014. The questionnaires distributed throughout the school produced 1,027 valid responses. Guardians were divided based on commuting distance into two groups; one of whom were within 3-km commuting distance and the other of more than 3 km. The two groups were compared for their recognition of children’s safety using a chi-square test.

Children’s safety in school was a concern for 73.9% of guardians. The safety of school buildings in case of a disaster was a cause of concern for 80% of guardians who are close commuters, and 73.9% of guardians whose commute distance is longer (P = 0.015). The fact that children cannot return home was a cause of worry for 33.9% of guardians whose workplace is nearby, and for 29.9% whose workplace was distant (P=0.044).

Most parents, especially guardians going to work far away, do not recognize that they cannot reach home, and therefore, need to think about providing safety measures for their children in the disaster.

Proper use of personal protective equipment (PPE) is essential when facing emerging infectious diseases. Proper training methods can promote the use of the PPE correctly.

To explore the effect of the training method of sequential operation training on medical staff to master PPE penetration and removal skills, and to study the memory attenuation after training.

Fifteen medical staff with no experience of PPE operation in a hospital were trained to wear PPE in accordance with WHO standards by illustration and sequential operation method. The training included 30 minutes of theoretical teaching and 60 minutes of practical exercises. At the end of the training and 1 week after the training, the training objects were evaluated for PPE operation. A 2.5 x 2.5 cm fluorescent agent was applied on 6 parts, such as hands, chest, abdomen, and knees, to simulate contamination. After taking the PPE off, the parts of the whole body and the inner layer of clothing that were fluorescently contaminated were recorded. The whole operation process was recorded by video to evaluate whether the operation was correct. The error rates of two operations and the contamination position and frequency were compared.

The error rate of the operating PPE after training was 18.6%, rising to 31.9% after 1 week (Z=16.0, P<0.05). After the training, the average number of contaminated PPE removal was 1.96±1.56, which rose to 2.96±2.03 one month later. The difference was statistically significant (Z=8.92, P<0.05). The main vulnerable sites are the wrist, chest, abdomen, and left calf.

Illustrative sequential operation training is an important means to improve the way for medical staff to wear PPE, but it must be completed more than once to ensure that medical staff can firmly master the skills of wearing and removing PPE.

Personal protective equipment (PPE) is a necessary item in the period of unknown and high risk emerging infectious disease. It is not only the necessary requirement of strict isolation but also the last line of defense to protect medical staff.

To determine the frequency and sites of contamination of personnel during the process of using Chinese PPE.

Recruit 56 health care workers (HCWs) who worked in front-line clinical to test PPE issued by the Chinese Center for Disease Control for preventing Ebola virus. Eight batches of HCWs were divided to conduct simulations of contaminated PPE removal using fluorescent lotion. Then the frequency and sites of contamination of personnel were recorded after removal of contaminated PPE. The method of visual observation was used to determine contamination.

The frequency of easily contaminated parts included: left hand and wrist (7 times), left calf (7 times), front chest center, left and right chest (6 times each), and left abdomen (5 times). Mistakes in the process of wearing PPE included: clothing touching the ground (20.00%), N95 air mask tightness not checked (13.33%), glove air-tightness not checked (4.44%), protective clothing zipper not checked (4.44%). Mistakes in doffing PPE included: clothes touching the ground or the inner surface is polluted (20.00%), the wrong method of removing N95 mask (14.44%), touching the pollution goggles mirror with hands (12.22%), incomplete washing steps, insufficient time and frequency of hand hygiene (11.11%).

It is necessary to carry out training on PPE donning and doffing for Chinese medical workers.

In 2010, an estimated 1.3 million road traffic injury (RTI) deaths occurred worldwide, accounting for about 2.5% of all deaths. Mortality in serious injuries is 6 times worse in a developing country such as India compared to a developed country. Strengthening and undertaking research on the public health burden and impact and understanding the risk factors of trauma is the need of the hour.

To identify the nature of injury in terms of causes and severity of injury.

Using a quantitative approach, a retrospective cross-sectional survey was conducted at the emergency and trauma center in Ram Manohar Lohia (RML) Hospital, New Delhi. The information of all the injured patients seeking health care during the past one year from October 2015 - September 2016 at Emergency and trauma center was collected from the trauma registry forms filled at the time of registration.

A total of 1952 cases of road traffic injury sought health care during the study period. The average number of cases reported per day was five. Maximum of the cases (40%) were reported between 12-6PM. Among the injured, 82% were males and the majority of victims were between 20-30 years age group followed by 30-40 years.

Trauma services need to be coordinated in infrastructure and human resources so that the right patient is taken to the right hospital at the right time. This calls for a lead agency at the district, state, and finally national level. Safety education regarding road safety should be imparted, especially to all victims, relatives, and the general public to make the care comprehensive. Students in schools and colleges should also be the target for intense safety education.

An expert government committee in Japan decided to revise the chance of a Nankai Trough earthquake in the next 30 years from 70% to between 70 and 80% in 2017. If a mega-earthquake occurs, medical institutions in disaster regions are required to perform self-contained activities during the super-acute phase. Human damage varies depending on whether medical functions can be sustained, particularly in rural areas and isolated islands. Here we examined actual situations.

To identify the issues of a disaster medical system in rural areas and isolated islands that need solving.

Regarding disaster preparedness planning, we conducted a survey on 10 hospitals undesignated as disaster key hospitals of remote area medical care bases (survey group), and 69 hospitals designated as disaster key hospitals (control group) in three prefectures in the Tokai region (Aichi, Mie, and Shizuoka).

We received responses from four hospitals in the survey group and 52 hospitals in the control group. The hospitals in the survey group responded that they could accept 74 severe casualties and 85 moderate casualties. We identified problems such as insufficient stockpiling of fuel, water, and oxygen, and lack of a prioritized lifeline supply contract.

It was predicted that human damage would be relatively minor given smaller populations in rural areas and isolated islands in the Tokai region. However, the number of patients would exceed their acceptance capacity. Moreover, the system for sustaining infrastructure is not adequate for providing medical services. Thus, it was indicated that these regions would be isolated in terms of disaster measures. It is imperative to establish a disaster medical system in rural areas and isolated islands that lack adequate disaster medical systems to manage Nankai Trough earthquakes.

The principles of Disaster and Emergency Medicine are applicable beyond the confines of planet Earth. With the accelerating rate of climate change, natural disasters, and overpopulation, as well as the innate human appetite for knowledge and technological advancement, there has recently been an increased interest in the prospect of long-duration spaceflight with a view to colonize extra-terrestrial bodies, such as Mars. However, there is a need to understand the risk of adverse medical events in the hostile environment of space. For example, previous incidences of infectious disease and immune dysregulation during a short-term mission have threatened to jeopardize the crew dynamic and the mission objectives. The risk of infectious diseases to the astronaut is one of the many knowledge gaps that must be addressed before long-duration flight is considered.

To review how spaceflight impacts an astronaut’s in-flight susceptibility to infectious diseases.

Research was guided by the Microbiology section of the NASA Human Research Roadmap Program. Search terms in the University of Adelaide Library Search database collection included: “infectious diseases + spaceflight,” “astronaut + immunity,” “analog,” and “inflammatory marker.”

Studies that have been conducted in-flight and on Earth demonstrate that both the astronaut and the microbe are affected by spaceflight. Stress, microgravity, and the isolated nature of the spacecraft have been found to compromise the immunity of the astronaut, as shown by reduced T cell counts and increased viral shedding of dormant viruses. Microbes have demonstrated rapid adaptation mechanisms, including genetic mutation and increased virulence.

This paper identifies a significant need for further research into host immunity during spaceflight to mitigate infectious disease risk. It is recommended that in-situ studies and terrestrial space analogs are most effective and that current knowledge on the principles of wilderness and expedition medicine be applied where possible.

After accidents of Fukushima Daiichi power plant, the Japanese Government distinguished some medical institutions corresponding to the nuclear disaster by roles and functions. Nuclear Regulation Authority is managing these medical institutions. The Nagasaki University was designated as two centers for “the advanced radiation emergency medical support” and “nuclear emergency medical support”. We established “Headquarters for Nuclear Disaster Response and Preparedness in Nagasaki University” (NDRP) and prepared for emergency ordinarily. The staff of headquarters are mainly concentrating their power on the network construction and joint training with each facility. We are improving the dispatch system of nuclear emergency medical assistance team, but some problems were found through the experiences of some trainings.

To stimulate discussion and listen to opinions from several facilities.

The dispatch system of nuclear emergency medical assistance team imitated the system of Japan Disaster Medical Assistance Team (DMAT). Specifically, activity days of all teams are limited, and all teams should come under the command of the head of support acceptance medical institution of a disaster area. Particularly the main duties of the dispatch team, which is sent from the nuclear emergency medical support center, are unification and adjustment of the team activities from other facilities. Some other duties include offering appropriate medical care to patients at the disaster area and support of patients’ transportation from the hospital at the disaster area to “advanced radiation emergency medical support center” or “nuclear emergency medical support center.”

In training the many facilities that participated, we realized that we couldn’t proceed with each activity quickly and smoothly without support from the nuclear emergency medical assistance teams from outside the boundaries of disaster areas. We need to clarify the problems that are obtained from trainings and improve the current system corresponding to a nuclear disaster with efficiency.

Earthquakes have killed around 800,000 people globally in the past 20 years, with head injury being the main cause of mortality and morbidity.

To conduct a systematic review to determine the characteristics of head injuries after earthquakes for better disaster preparedness and management.

All publications related to head injuries and earthquakes were searched using Pubmed, Web of Science, the Cochrane Library, and Ichushi.

Thirty-six articles were included in the analysis. Head injury was the third most common cause of injury among survivors of earthquakes. The most common injury after an earthquake occurred was in the lower extremities (36.2%), followed by the upper extremities (19.9%), head (16.6%), spine (13.3%), chest (11.3%), and abdomen (3.8%). Earthquake-related head injuries were predominantly caused by a blunt strike (79%), and were more frequently associated with soft tissue injury compared to non-earthquake-related head injuries and less frequently with intracranial hemorrhage. The mean age of patients with earthquake-related head injuries was 32.6 years, and 55.1% of sufferers were male. The most common earthquake-related head injury was laceration or contusion (59.2%) while epidural hematoma was most common among inpatients with intracranial hemorrhage after an earthquake (9.5%). Early wound irrigation and debridement and antibiotics administration are needed to decrease the risk of infection. Mortality due to earthquake-related head injuries was 5.6%.

Head injury was the main cause of mortality and morbidity after an earthquake. The characteristics of earthquake-related head injuries differed from those of non-earthquake-related head injuries, including the frequency of multiple injuries, and occurrence of contaminated soft tissue injury and epidural hematoma. This knowledge is important for determining demands for neurosurgery and for adequate management of patients, especially in resource-limited conditions.

Recent hospital fire incidents in South Korea have heightened the importance of patient evacuation. Moving patients from an intensive care unit (ICU) or emergency department (ED) setting is a challenge due to the complexity of moving acutely unwell patients who are reliant on invasive monitoring and organ support. Despite the importance of patient evacuation, the readiness of ICU and ED for urgent evacuation has not been assessed.

To enhance the readiness and competencies of workers from ICU and ED in the evacuation of patients during a simulated tabletop fire exercise.

A tabletop simulation exercise was developed by the Center for Disaster Relief, Training, and Research referencing the fire evacuation manual developed by the hospital’s ICU and ED. The scenario consisted of evacuating patients horizontally and vertically from each department. The participants’ actions were assessed using a checklist. A debriefing was completed after the exercise to discuss the gaps observed. A post-survey questionnaire was used to evaluate the exercise and assess the perception changes of the participants. All pre-to-post differences within subjects were analyzed with paired t-tests.

A total of 22 and 29 people participated in the exercise from ICU and ED, respectively. Knowledge and confidence improved post-exercise for both ICU and ED scenarios (p<0.05). Course satisfaction was 7.9 and 8.7, respectively for ICU and ED exercise. Correct performance rates for ICU and ED were 59% and 58%, respectively. Common gaps noted for both ICU and ED were wearing protective masks, patient hand-over communication, and preparation for resources.

There need to be exercises to recognize system gaps in place for hospital fire evacuation preparedness. Tabletop simulation exercises are ideal tools for this purpose. Although this was a short 90-minute exercise, this increased familiarity with the evacuation plan, tested the plan, and allowed for identification of gaps.

The G7 Summit was held in Charlevoix, Quebec (Canada) on June 8 and 9, 2018. The Urgences-santé Corporation (USC), in charge of prehospital emergency services in Montreal and Laval, was asked to intervene outside of its usual territory during the Summit, mainly because it has the only tactical medical team in the province of Quebec to be equipped and trained for high-risk situations.

Part of USC’s tactical medical team was deployed to the Charlevoix region from May 29 to June 10, 2018. The team had two responsibilities: act in the event of a chemical, biological, radiological, nuclear or explosive (CBRNE) attack, and in the event of social disturbance or violence, provide care for protestors and the police officers tasked with maintaining and restoring order.

The mission required rigorous preparation to ensure the team’s safety outside its usual area of activity while maintaining full coverage of metropolitan Montreal, where the impacts of the G7 Summit were also felt. Emphasis was placed on intensive coaching of the tactical medics, on joint training, and on the coordination of intervention protocols across EMS, fire and law enforcement.

A total of 14 tactical medics and two managers were sent to Charlevoix for the Summit. Before their departure, three joint training days were held, and our training center provided six days of training to our partners.

While no CBRNE incident or major social disorder occurred during the Summit, USC was able to gain more visibility and therefore reach out to different organizations on site. Close ties were developed with the Sûreté du Québec (provincial police), with whom USC now regularly collaborates during training and interventions. The lessons learned also helped consolidate our extra-territorial deployment procedures.

To develop a simulation-based pediatric procedural sedation curriculum for acute care attending physicians to achieve and maintain privileges in this important skill.

Neonatal and pediatric intensive care physicians participated in simulation-based sedation training to achieve and maintain sedation privileges. Participants were required to review pediatric sedation materials prior to participation. Demographic data were collected prior to the simulations, and all participants completed a pre-test to assess their baseline knowledge. Sessions were held in the simulation center or neonatal intensive care unit (depending on group), and the attending physicians, in pairs, participated in two high-fidelity mannequin scenarios (sedation for a painful procedure; hypoxia during sedation). Simulations were followed by a facilitated debriefing session while utilizing a standard performance checklist. All participants completed a program evaluation at the conclusion of their training.

Neonatal (n=11) and pediatric (n=9) intensive care attending physicians participated in the sedation simulation training. The program was well received and 100% rated it as “excellent” or “very good”. All participants strongly agreed the instructors allotted time for questions/answers, 100% strongly agreed the debriefing/feedback was effective, 95% strongly agreed instructors had a thorough knowledge and understanding of the program, were supportive, and facilitated learning, and 95% strongly agreed the equipment and physical environment were conducive to learning. Participants reported that simulation-based training and the use of a standardized checklist during facilitated debriefing were very helpful and effective for sedation training. Additionally, many participants indicated the desire for more simulation-based training.

Simulation-based sedation training is a feasible, easy to implement, and viable learning technique for acute care physicians.

Indian railway systems are fourth largest in the world, and cause on average 15 deaths daily due to various intentional and unintentional reasons. This study presents a 5-year retrospective data analysis of polytrauma patients with train-related injuries.

To highlight key lessons learned from data analysis to inform better safety measures and laws.

Trauma registry data between 2012 and 2016 were analyzed for patients with train-related injuries. Data from 726 patients were analyzed for demographics, event, injuries, management, and final outcome. ISS was used to quantify the extent of injury.

Mean patient age was 33 years with an 86% to 14% male to female ratio. 62% of patients were in the 20- to 40-year age group. Average time of arrival at health facility post-injury was 3.3 hours. Half of the patients were trespassers. Mean ISS was 11.65. Chest injuries were present in 24.6% of patients, with half requiring interventions like ICD insertion or surgery. 20% of patients underwent amputations of extremities. 40% of patients needed admission to the ICU. 3.5% died in the Emergency Department (ED). Mean hospital stay was 17 days with an in-hospital mortality of 17.4%.

This analysis is the largest to date showing comprehensive injury patterns and outcomes of train-related injuries from a developing country. Patients injured on the platform and off the platform had the same severity of injuries. This analysis shows the need for safety measures and strict law enforcement both at the station and at the track.

Sudden onset disasters exceed the capabilities of local health services. Emergency Medical Teams (EMTs), including the Australian Medical Assistance Team (AUSMAT), are a vital element of the Australian Governments capacity to respond to regional and international sudden-onset disasters. AUSMAT has the capacity to deploy an EMT Type 2 surgical field hospital and has been successfully verified by the World Health Organisation (WHO). All AUSMAT members must complete AUSMAT Team Member training. The National Critical Care and Trauma Response Centre, Darwin, Australia is responsible for all AUSMAT training.

To educate and train the Surgical Team (perioperative nurses, surgeons, and anesthetists) in preparation for AUSMAT deployments in the austere environment.

Prior to 2015, the surgical AUSMAT training was conducted via two courses: one for perioperative nurses and a separate course for surgeons and anesthetists. In 2015, the course was redesigned with the aim of collaborative training with all the Surgical Team Members. The new Surgical Team Course (STC) engages all three professions to learn alongside each other and discuss potential difficulties in techniques, the daily running of the operating room, and ethical discussions.

Since the rejuvenation of the STC, 15 surgeons, 17 anesthetists, and 18 perioperative nurses have completed the course. The attendees are familiarized with operational and clinical guidelines, the surgical field hospital, and operating room equipment including CSSD. A pivotal component of the course focuses on the essentials of medical records and Minimum Data Set reporting for EMTs as defined by WHO.

Since 2015, the NCCTRC has successfully run two courses. The revised collaborative model for AUSMAT STC has enhanced the quality of the program and subsequent learning experiences for participants.

At various accidents or disaster sites, rescue, first aid, and transport to hospitals has been provided by ambulance crews (paramedics). In the case of mass casualties, they also need to operate triage for injured people.

To consider and reveal challenges in triage by ambulance crews (paramedics) on-site.

Interviews of seven ambulance crews (paramedics) and their instructors were conducted and their answers were analyzed.

(1.) Triage black tags: declaring “deceased: not able to survive” might give a heavy mental burden and psychological responsibility. Legal protection and an interstitial rule will be necessary in the future. (2.) Missed triage: the ambulance crew cannot perform a triage that may develop a legal problem. It is always important to prevent ambulance crews from being charged. (3.) Triage education and training: there are few triage trainings at fire departments although the number of emergency medical responses is increasing compared to fire response. It will be necessary to increase time of the triage education and training in near future. (4.) Command system (characteristic rank system in the fire department): There is a problem with the rank system in fire departments since confusion occurs when a commander of the First Aid Station is not a licensed paramedic. The ambulance crew (paramedic) usually consists of the three different ranked people. Individual operations are difficult during operation. Education for the paramedic executive is necessary for the fire organization.

For the triage by ambulance crew (paramedic), legal protection by medical control operation is required, and it may lead to a reduction of heavy mental burden. Triage training is needed to improve the training of triage. The ambulance crew (paramedic) operates under the fire department command system. However, at the time of disaster, the ambulance crew (paramedic) should also work under the medical command system.

The SALT Triage system has been advocated as an easy-to-use sorting and treatment system for mass casualty incidents (MCI). Minimally injured (GREEN) patients tend to be in the majority and may cause impediments to access and treatment of the most critically injured (RED). By identifying flaws in MCI communications that impair effective patient care, responders can be more effective.

To discover strategies that effectively manage the minimally injured and leverage their help, increasing triage efficiency and treatment of the immediate casualties.

Direct observation, after-action debriefing, and literature search.

The literature was vague regarding recommendations on a bystander and trained provider communication best practices. Feedback from standardized patients (actors) and participants during a structured debriefing following a 2018 American Society of Anesthesiology MCI exercise suggested that triaging providers under stress may communicate poorly, contributing to increased patient anxiety, disruptive behavior, and less effective team dynamics during a disaster. Strategies suggested include: eye contact; therapeutic touch (culturally appropriate); using slow, clear, reassuring speech; clearly explaining what is happening and why (sickest (RED and YELLOW) first priority, minimal (GREEN) next, expectant (BLACK) last); acknowledging their emotional state and their grief (not ignoring them); assigning nontechnical tasks to those capable of helping (putting pressure on a wound, moving casualties, or comforting the injured, dying, and the emotionally distraught).

Bystander engagement has been repeatedly identified as a means to increase the capacity of first responders to provide care to patients during an MCI. Utilization and management of the minimally injured and any uninjured bystanders and responders can become a force multiplier for the triage/treating responders. Developing a best practice dialogue to be used in training first responders could help improve many of these issues and augment current MCI training programs.