The aim of this study was to assist organizations seeking to develop or improve their medical disaster relief effort by identifying fundamental elements and processes that permeate high-quality, international, medical disaster relief organizations and the teams they deploy.

A qualitative descriptive design was used. Data were gathered from interviews with key personnel at five international medical response organizations, as well as during field observations conducted at multiple sites in Jordan and Greece, including three refugee camps. Data were then reviewed by the research team and coded to identify patterns, categories, and themes.

The results from this qualitative, descriptive design identified three themes which were key characteristics of success found in effective, well-established, international medical disaster relief organizations. These characteristics were first, ensuring an official invitation had been extended and the need for assistance had been identified. Second, the response to that need was done in an effective and sustainable manner. Third, effective organizations strived to obtain high-quality volunteers.

By following the three key characteristics outlined in this research, organizations are more likely to improve the efficiency and quality of their work. In addition, they will be less likely to impede the overall recovery process.

BrobyN, LassetterJH, WilliamsM, WintersBA. Effective International Medical Disaster Relief: A Qualitative Descriptive Study. Prehosp Disaster Med. 2018;33(2):119–126.

The “Stop the Bleed” campaign advocates for non-medical personnel to be trained in basic hemorrhage control. However, it is not clear what type of education or the duration of instruction needed to meet that requirement. The objective of this study was to determine the impact of a brief hemorrhage control educational curriculum on the willingness of laypersons to respond during a traumatic emergency.

This “Stop the Bleed” education initiative was conducted by the University of Texas Health San Antonio Office of the Medical Director (San Antonio, Texas USA) between September 2016 and March 2017. Individuals with formal medical certification were excluded from this analysis. Trainers used a pre-event questionnaire to assess participants knowledge and attitudes about tourniquets and responding to traumatic emergencies. Each training course included an individual evaluation of tourniquet placement, 20 minutes of didactic instruction on hemorrhage control techniques, and hands-on instruction with tourniquet application on both adult and child mannequins. The primary outcome in this study was the willingness to use a tourniquet in response to a traumatic medical emergency.

Of 236 participants, 218 met the eligibility criteria. When initially asked if they would use a tourniquet in real life, 64.2% (140/218) responded “Yes.” Following training, 95.6% (194/203) of participants responded that they would use a tourniquet in real life. When participants were asked about their comfort level with using a tourniquet in real life, there was a statistically significant improvement between their initial response and their response post training (2.5 versus 4.0, based on 5-point Likert scale; P<.001).

In this hemorrhage control education study, it was found that a short educational intervention can improve laypersons’ self-efficacy and reported willingness to use a tourniquet in an emergency. Identified barriers to act should be addressed when designing future hemorrhage control public health education campaigns. Community education should continue to be a priority of the “Stop the Bleed” campaign.

RossEM, RedmanTT, MappJG, BrownDJ, TanakaK, CooleyCW, KharodCU, WamplerDA. Stop the Bleed: The Effect of Hemorrhage Control Education on Laypersons’ Willingness to Respond During a Traumatic Medical Emergency. Prehosp Disaster Med. 2018;33(2):127–132.

Despite emphasis by disaster experts on the importance of disaster preparedness, disaster management in Yemen has attracted only a little attention. Most of the efforts have focused on post-disaster relief activities rather than the pre-disaster preparedness and risk reduction. Hospitals have a crucial role in emergency response and should be prepared. Thus, the aim of this study was intended to assess the hospital preparedness of Aden Capital, South Yemen against disasters.

A cross-sectional study was conducted in June 2016. The sample was all Aden City facilities with a total number of 10 hospitals: five public and five private hospitals. A survey was done by using the World Health Organization (WHO; Geneva, Switzerland) standards checklist 2011.

The overall preparedness of Aden City hospitals to disasters fell at the unacceptable level of readiness, with an average mean of 46.6 (SD = 38.31; range 24-82). Of 10 hospitals, two ranked insufficient while eight hospitals were at unacceptable levels of preparedness.

All hospitals were noted grossly unprepared for potential disasters. Therefore, it is recommended that greater efforts be invested in creating a comprehensive strategy and national or local guidelines to establish an emergency management system based on the anticipated hazard and the needed resources.

NaserWN, IngrassiaPL, AladhraeS, AbdulraheemWA. A Study of Hospital Disaster Preparedness in South Yemen. Prehosp Disaster Med. 2018;33(2):133–138.

The incidence of natural disasters is increasing worldwide, with countries the least well-equipped to mitigate or manage them suffering the greatest losses. Following natural disasters, ill-prepared foreign responders may become a burden to the affected population, or cause harm to those needing help.

The study was performed to determine if international guidelines for foreign workers in the health sector exist, and evidence of their implementation.

A structured literature search was used to identify guidelines for foreign health workers (FHWs) responding to natural disasters. Analysis of semi-structured interviews of health sector responders to the 2015 Nepal earthquake was then performed, looking at preparation and field activities.

No guidelines were identified to address the appropriate qualifications of, and preparations for, international individuals participating in disaster response in the health sector. Interviews indicated individuals choosing to work with experienced organizations received training prior to disaster deployment and described activities in the field consistent with general humanitarian principles. Participants in an ad hoc team (AHT) did not.

In spite of need, there is a lack of published guidelines for potential international health sector responders to natural disasters. Learning about disaster response may occur only after joining a team.

Dunin-BellO. What do They Know? Guidelines and Knowledge Translation for Foreign Health Sector Workers Following Natural Disasters. Prehosp Disaster Med. 2018;33(2):139–146.

Triage has an important role in providing suitable care to the largest number of casualties in a disaster setting, but there are no secondary triage methods suitable for children. This study developed a new secondary triage method named the Pediatric Physiological and Anatomical Triage Score (PPATS) and compared its accuracy with current triage methods.

A retrospective chart review of pediatric patients under 16 years old transferred to an emergency center from 2014 to 2016 was performed. The PPATS categorized the patients, defined the intensive care unit (ICU)-indicated patients if the category was highest, and compared the accuracy of prediction of ICU-indicated patients among PPATS, Physiological and Anatomical Triage (PAT), and Triage Revised Trauma Score (TRTS).

Among 137 patients, 24 (17.5%) were admitted to ICU. The median PPATS score of these patients was significantly higher than that of patients not admitted to ICU (11 [IQR: 9-13] versus three [IQR: 2-4]; P<.001). The optimal cut-off value of the PPTAS was six, yielding a sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of 95.8%, 86.7%, 60.5%, and 99.0%. The area under the receiver-operating characteristic curve (AUC) was larger for PPTAS than for PAT or TRTS (0.95 [95% CI, 0.87-1.00] versus 0.65 [95% CI, 0.58-0.72]; P<.001 and 0.79 [95% CI, 0.69-0.89]; P=.003, respectively). Regression analysis showed a significant association between the PPATS and the predicted mortality rate (r2=0.139; P<.001), ventilation time (r2=0.320; P<.001), ICU stay (r2=0.362; P<.001), and hospital stay (r2=0.308; P<.001).

The accuracy of PPATS was superior to other methods for secondary triage of children.

ToidaC, MugurumaT, AbeT, ShinoharaM, GakumazawaM, YogoN, ShirasawaA, MorimuraN. Introduction of Pediatric Physiological and Anatomical Triage Score in Mass-Casualty Incident. Prehosp Disaster Med. 2018;33(2):147–152.

Rapid access to defibrillation is a key element in the management of out-of-hospital cardiac arrests (OHCAs). Public automated external defibrillators (PAEDs) are becoming increasingly available, but little information exists regarding the relation between the proximity to the arrest and their usage in urban areas.

This study is a retrospective, observational, cross-sectional analysis of non-traumatic OHCA during a 24-month period in the greater Montreal area (Quebec, Canada). Using logistic regression, bystander shock odds are described with regards to distance from the OHCA scene to the nearest PAED, adjusted for prehospital care arrival delay and time of day, and stratifying for type of location.

Out of a total of 2,443 OHCA victims identified, 77 (3%) received bystander PAED shock, 622 (26%) occurred out-of-home, and 743 (30%) occurred during business hours. When controlling for time (business hours versus other hours) and minimum response delay for prehospital care arrival, a marginal negative association was found between bystander shock and distance to the nearest PAED in logged meters (aOR=0.80; CI, 0.64-0.99) for out-of-home cardiac arrests. No significant association was found between distance and bystander shock for at-home arrests. Out-of-home victims had significantly higher odds of receiving bystander shock up to 175 meters of distance to a PAED inclusively (aOR=2.52; CI, 1.07-5.89).

For out-of-home cardiac arrests, proximity to a PAED was associated with bystander shock in the greater Montreal area. Strategies aiming to increase accessibility and use of these life-saving devices could further expand this advantage by assisting bystanders in rapidly locating nearby PAEDs.

Neves BriardJ, de MontignyL, RossD, de ChamplainF, SegalE. Is Distance to the Nearest Registered Public Automated Defibrillator Associated with the Probability of Bystander Shock for Victims of Out-of-Hospital Cardiac Arrest?Prehosp Disaster Med. 2018;33(2):153–159.

Many Syrians have left their country and migrated to other countries since March 2011, due to the civil war. As of March 2016, a total of 2,747,946 Syrian refugees had immigrated to Turkey. Some Syrian refugees have been living in camps, while 2,475,134 have been living in metropolitan areas, such as Ankara.

This study investigated Emergency Medical Service (EMS) utilization among Syrian refugees residing in Ankara.

This study was a descriptive, cross-sectional database analysis using data obtained from the Department of EMS of the Ankara Provincial Health Directorate.

Five stations in the Altındağ region of Ankara responded to 42% of all calls from Syrian refugees. Prehospital EMS in Ankara have been used mostly by Syrian refugees younger than 18-years-old. Study findings also suggest that medical staff in regions where Syrian refugees are likely to be treated should be supported and provided with the ability to overcome language barriers and cultural differences.

AltınerAO, Tekeli YeşilS. Emergency Medical Service (EMS) Utilization by Syrian Refugees Residing in Ankara, Turkey. Prehosp Disaster Med. 2018;33(2):160–164.

Law enforcement is increasingly viewed as a key component in the out-of-hospital chain of survival, with expanded roles in cardiac arrest, narcotic overdose, and traumatic bleeding. Little is known about the nature of care provided by law enforcement prior to the arrival of Emergency Medical Services (EMS) assets. The purpose of the current study was to perform a descriptive analysis of events reported to a national EMS database.

This study was a descriptive analysis of the 2014 National Emergency Medical Services Information System (NEMSIS) public release research data set, containing EMS emergency response data from 41 states. Code E09_02 1200 specifically identifies care provided by law enforcement prior to EMS arrival.

A total of 25,835,729 unique events were reported. Of events in which pre-arrival care was documented, 2.0% received prior aid by law enforcement. Patients receiving law enforcement care prior to EMS arrival were more likely to be younger (52.8 [SD=23.3] years versus 58.7 [SD=23.3] years), male (54.8% versus 46.7%), and white (80.3% versus 77.5%). Basic Life Support (BLS) EMS response was twice as likely in patients receiving prior aid by law enforcement. Multiple-casualty incidents were five times more likely with prior aid by law enforcement. Compared with prior aid by other services, law enforcement pre-arrival care was more likely with motor vehicle accidents, firearm assaults, knife assaults, blunt assaults, and drug overdoses, and less likely at falls and childbirths. Cardiac arrest was significantly more common in patients receiving prior aid by law enforcement (16.5% versus 2.6%). Tourniquet application and naloxone administration were more common in the law enforcement prior aid group.

Where noted, law enforcement pre-arrival care occurs in 2.0% of EMS patient encounters. The majority of cases involve cardiac arrest, motor vehicle accidents, and assaults. Better understanding of the nature of law enforcement care is required in order to identify potential barriers to care and to develop appropriate training and policy recommendations.

KlassenAB, CoreSB, LohseCM, SztajnkrycerMD. A Descriptive Analysis of Care Provided by Law Enforcement Prior to EMS Arrival in the United States. Prehosp Disaster Med. 2018;33(2):165–170.

The aim of this study was to assess the risk of cardiopulmonary resuscitation (CPR) performed in out-of-hospital settings for chest injuries in patients with out-of-hospital cardiac arrest (OHCA).

This retrospective, observational study was conducted in an emergency critical care medical center in Japan. Non-traumatic OHCA patients transferred to the hospital from April 2013 through August 2016 were analyzed. The outcome was defined by chest injuries related to CPR, which is composite of rib fractures, sternal fractures, and pneumothoraces. A multivariate logistic regression analysis was performed to assess the independent risk factors for chest injuries related to CPR. The threshold of out-of-hospital CPR duration that increased risk of chest injuries was also assessed.

A total of 472 patients were identified, of whom 233 patients sustained chest injuries. The multivariate logistic regression model showed that the independent risk factors for chest injuries were age and out-of-hospital CPR duration (age: AOR=1.06 [95% CI, 1.04 to 1.07]; out-of-hospital CPR duration: AOR=1.03 [95% CI, 1.01 to 1.05]). In-hospital CPR duration was not an independent risk factor for chest injuries. When the duration of out-of-hospital CPR extended over 15 minutes, the likelihood of chest injuries increased; however, this association was not statistically significant.

Long duration of out-of-hospital CPR was an independent risk factor for chest injuries, possibly due to the difficulty of maintaining adequate quality of CPR. Further investigations to assess the efficacy of alternative CPR devices are expected in cases requiring long transportation times.

TakayamaW, KoguchiH, EndoA, OtomoY. The Association between Cardiopulmonary Resuscitation in Out-of-Hospital Settings and Chest Injuries: A Retrospective Observational Study. Prehosp Disaster Med. 2018;33(2):171–175.

This review was conducted to explore the literature to determine the availability, content, and evaluation of existing chemical, biological, radiological, and nuclear (CBRN) education programs for health professionals.

An integrative review of the international literature describing disaster education for CBRN (2004-2016) was conducted. The following relevant databases were searched: Proquest, Pubmed, Science Direct, Scopus, Journals @ OVID, Google Scholar, Medline, and Ichuschi ver. 5 (Japanese database for health professionals). The search terms used were: “disaster,” “chemical,” “biological,” “radiological,” “nuclear,” “CBRN,” “health professional education,” and “method.” The following Medical Subject Headings (MeSH) terms, “education,” “nursing,” “continuing,” “disasters,” “disaster planning,” and “bioterrorism,” were used wherever possible and appropriate. The retrieved articles were narratively analyzed according to availability, content, and method. The content was thematically analyzed to provide an overview of the core content of the training.

The literature search identified 619 potentially relevant articles for this study. Duplicates (n=104) were removed and 87 articles were identified for title review. In total, 67 articles were discarded, yielding 20 articles for all-text review, following 11 studies were retained for analysis, including one Japanese study. All articles published in English were from the USA, apart from the two studies located in Japan and Sweden. The most typical content in the selected literature was CBRN theory (n=11), followed by studies based on incident command (n=8), decontamination (n=7), disaster management (n=7), triage (n=7), personal protective equipment (PPE) use (n = 5), and post-training briefing (n=3).

While the CBRN training course requires the participants to gain specific skills and knowledge, proposed training courses should be effectively constructed to include approaches such as scenario-based simulations, depending on the participants’ needs.

KakoM, HammadK, MitaniS, ArbonP. Existing Approaches to Chemical, Biological, Radiological, and Nuclear (CBRN) Education and Training for Health Professionals: Findings from an Integrative Literature Review. Prehosp Disaster Med. 2018;33(2):182–190.

This study was aimed to analyze post-disaster birth outcomes in coastal and inland regions of Miyagi Prefecture, Japan.

Primary data sets were compiled from birth records of obstetric facilities and 12,808 patients were analyzed for baseline birth outcomes by region. Regional risk analysis of the low-birth-weight rate and premature birth rate were conducted using multi-level logistic regression analysis.

From overall baseline birth outcomes, a preterm birth rate was 4.6% and low-birth-weight rate was 8.8%. Regional analysis revealed that a preterm birth rate was 3.2% (coastal) and 5.0% (inland), respectively, and the rate of low birth weight was 6.5% in the coastal and 8.5% in the inland region. In the risk analysis of low-birth-weight rate and preterm birth rate, the risk in the coastal region could not be considered any higher than in the inland region (adjusted odds ratio 0.91 [0.73-1.14] and 0.85 [0.46-1.59], respectively).

The incidence of preterm birth and low birth weight were not adversely affected by the disaster. Early transfer and intensive medical intervention may have led to those findings. Further survey will be necessary to determine the long-term effects in both mothers and children.

SugawaraJ, IwamaN, HoshiaiT, TokunagaH, NishigoriH, MetokiH, OkamuraK, YaegashiN. Regional Birth Outcomes after the 2011 Great East Japan Earthquake and Tsunami in Miyagi Prefecture. Prehosp Disaster Med. 2018;33(2):215–219.

Young adult patrons are vulnerable to risk-taking behavior, including drug taking, at outdoor music festivals. Therefore, the aim of this field report is to discuss the on-site medical response during a music festival, and subsequently highlight observed strategies aimed at minimizing substance abuse harm.

The observed outdoor music festival was held in Canberra (Australian Capital Territory [ACT], Australia) during the early summer of 2016, with an attendance of 23,008 patrons. First aid and on-site medical treatment data were gained from the relevant treatment area and service.

The integrated first aid service provided support to 292 patients. Final analysis consisted of 286 patients’ records, with 119 (41.6%) males and 167 (58.4%) females. Results from this report indicated that drug intoxication was an observed event issue, with 15 (5.1%) treated on site and 13 emergency department (ED) presentations, primarily related to trauma or medical conditions requiring further diagnostics.

This report details an important public health need, which could be met by providing a coordinated approach, including a robust on-site medical service, accepting intrinsic risk-taking behavior. This may include on-site drug-checking, providing reliable information on drug content with associated education.

LutherM, GardinerF, LensonS, CaldicottD, HarrisR, SabetR, MalloyM, PerkinsJ. An Effective Risk Minimization Strategy Applied to an Outdoor Music Festival: A Multi-Agency Approach. Prehosp Disaster Med. 2018;33(2):220–224.