Mass gatherings pose unique challenges for interorganizational collaboration. The “Athens Marathon, The Authentic” is a 42,195m (26.2mile) race with approximately 18,000 runners that increases annually. On the same day, additional races take place and a grand total of more than 50,000 runners fill the city center of Athens, Greece. Responding effectively to unexpected incidents requires comprehensive planning, clear decision-making structure, and effective collaboration. Nonetheless, there is limited empirical evidence to support interagency collaboration in mass gatherings.

This study used the 2017 Athens Marathon and related races as the empirical setting to examine how interagency collaboration was perceived among the multiple public health and safety professionals involved in the marathon command center.

Data comprised 10 semi-structured, in-depth interviews with key informants, direct observations of meetings and the event itself, and documentary analysis. Open coding and thematic analysis were used to analyze the data.

Findings indicated four key components of interagency collaboration in such an event: organizational culture, team synthesis, on-site spatial planning, and the usage of radio-amateurs.

This study outlined the factors that shaped interagency collaboration in the context of a mass event. Practical implications arising from this study may inform the ways organizers of marathons and other mass sporting events can engage in effective partnerships and joint working.

Disaster Medicine (DM) education for Emergency Medicine (EM) residents is highly variable due to time constraints, competing priorities, and program expertise. The investigators’ aim was to define and prioritize DM core competencies for EM residency programs through consensus opinion of experts and EM professional organization representatives.

Investigators utilized a modified Delphi methodology to generate a recommended, prioritized core curriculum of 40 DM educational topics for EM residencies.

The DM topics recommended and outlined for inclusion in EM residency training included: patient triage in disasters, surge capacity, introduction to disaster nomenclature, blast injuries, hospital disaster mitigation, preparedness, planning and response, hospital response to chemical mass-casualty incident (MCI), decontamination indications and issues, trauma MCI, disaster exercises and training, biological agents, personal protective equipment, and hospital response to radiation MCI.

This expert-consensus-driven, prioritized ranking of DM topics may serve as the core curriculum for US EM residency programs.

Herd immunity, a concept normally applied in vaccinated populations, is a preventative measure to determine if a significant portion of a population can protect vulnerable individuals against a certain disease. Like vaccines, tourniquet education can be a form of herd immunity to protect vulnerable individuals in a population and prevent the loss of life from a peripheral hemorrhage. The authors have identified a deficiency in simple, quick, and effective hemorrhage control education. Therefore, to maximize herd immunity, the novel educational platform evaluates the efficacy of “Just-in-Time” (JiT) tourniquet application training.

The authors hypothesize that the utilization of JiT training will be effective in promoting both competence and confidence for individuals to utilize tourniquets in response to a disaster environment.

This Institutional Review Board-approved study recruited medical students who were trained in hemorrhage control measures at a Level 1 Trauma Center. Tourniquet training sessions were held, and naïve civilians received tourniquet education. The subjects received a five- to ten-minute lesson on indications, contraindications, and application techniques of commercial and improvisational tourniquets. Participants subsequently applied a tourniquet to an instructor’s arm to demonstrate proper tourniquet application for a brachial artery hemorrhage. Pre- and post-educational surveys were completed to test participant competency and confidence.

Of the 104 subjects who completed the course, 97 had no prior training in hemorrhage control techniques, including commercial and improvisational tourniquet application. The mean pre-test score was 2.27/5.00 and the mean post-test score was 4.38/5.00, P <.001 (n = 97). When queried “How competent would you feel applying a tourniquet (commercial or improvisational) on an individual with a bleeding wound?” 92/97 felt confident (95%), one felt less confident, and four felt no difference in confidence levels (P <.001).

Just-in-Time training is an effective method in teaching naïve civilians proper tourniquet application. This platform could serve as an alternative to more extensive training programs and requires less time, costs, and resources. If a significant number of individuals in a local community can effectively apply a tourniquet in a disaster scenario, a “herd immunity” effect could be achieved to control peripheral hemorrhages.

Cultural awareness can be defined as an understanding of the differences that exist between cultures. This understanding is a crucial first step towards the development of cultural sensitivity, a willingness to accept those differences as having equal merit, and becoming operationally effective when working within different cultures. The benefits of cultural awareness have become apparent in recent decades, including within governments, militaries, and corporations. Many organizations have developed cultural awareness training for their staffs to improve cross-cultural cooperation. However, there has not been a large movement toward cultural sensitivity training among non-governmental organizations (NGOs) who provide aid globally, across a number of countries and cultures. Cultural awareness can be a useful tool which enables an NGO to better serve the populations with which they engage.

The goal of this study was to evaluate the presence of cultural awareness training for employees and volunteers working within international NGOs.

Ten of the largest international NGOs were identified. Their websites were evaluated for any mention of training in cultural awareness available to their employees and volunteers. All ten were then contacted via their public email addresses to find out if they provide any form of cultural awareness training.

Of the ten NGOs identified, none had any publicly available cultural awareness training on their websites. One NGO dealt with cultural awareness by only hiring local staff, who were already a part of the prevalent culture of the area. None of the others who responded provided any cultural awareness training.

Cultural awareness is a vital tool when working internationally. Large NGOs, which operate in a wide-range of cultures, have an obligation to act in a culturally aware and accepting manner. Most large NGOs currently lack a systematic, robust cultural awareness training for their employees and volunteers.

ST-segment elevation myocardial infarction (STEMI) is a time-sensitive entity that has been shown to benefit from prehospital diagnosis by electrocardiogram (ECG). Current computer algorithms with binary decision making are not accurate enough to be relied on for cardiac catheterization lab (CCL) activation.

An algorithmic approach is proposed to stratify binary STEMI computerized ECG interpretations into low, intermediate, and high STEMI probability tiers.

Based on previous literature, a four-criteria algorithm was developed to rule out/in common causes of prehospital STEMI false-positive computer interpretations: heart rate, QRS width, ST elevation criteria, and artifact. Prehospital STEMI cases were prospectively collected at a single academic center in Salt Lake City, Utah (USA) from May 2012 through October 2013. The prehospital ECGs were applied to the algorithm and compared against activation of the CCL by an emergency department (ED) physician as the outcome of interest. In addition to calculating test characteristics, linear regression was used to look for an association between number of criteria used and accuracy, and logistic regression was used to test if any single criterion performed better than another.

There were 63 ECGs available for review, 39 high probability and 24 intermediate probability. The high probability STEMI tier had excellent test characteristics for ruling in STEMI when all four criteria were used, specificity 1.00 (95% CI, 0.59-1.00), positive predictive value 1.00 (0.91-1.00). Linear regression showed a strong correlation demonstrating that false-positives increased as fewer criteria were used (adjusted r-square 0.51; P <.01). Logistic regression showed no significant predictive value for any one criterion over another (P = .80). Limiting physician overread to the intermediate tier only would reduce the number of ECGs requiring physician overread by a factor of 0.62 (95% CI, 0.48-0.75; P <.01).

Prehospital STEMI ECGs can be accurately stratified to high, intermediate, and low probabilities for STEMI using the four criteria. While additional study is required, using this tiered algorithmic approach in prehospital ECGs could lead to changes in CCL activation and decreased requirements for physician overread. This may have significant clinical and quality implications.

In January of 2010, North Carolina (NC) USA implemented state-wide Trauma Triage Destination Plans (TTDPs) to provide standardized guidelines for Emergency Medical Services (EMS) decision making. No study exists to evaluate whether triage behavior has changed for geriatric trauma patients.

The impact of the NC TTDPs was investigated on EMS triage of geriatric trauma patients meeting physiologic criteria of serious injury, primarily based on whether these patients were transported to a trauma center.

This is a retrospective cohort study of geriatric trauma patients transported by EMS from March 1, 2009 through September 30, 2009 (pre-TTDP) and March 1, 2010 through September 30, 2010 (post-TTDP) meeting the following inclusion criteria: (1) age 50 years or older; (2) transported to a hospital by NC EMS; (3) experienced an injury; and (4) meeting one or more of the NC TTDP’s physiologic criteria for trauma (n = 5,345). Data were obtained from the Prehospital Medical Information System (PreMIS). Data collected included proportions of patients transported to a trauma center categorized by specific physiologic criteria, age category, and distance from a trauma center.

The proportion of patients transported to a trauma center pre-TTDP (24.4% [95% CI 22.7%-26.1%]; n = 604) was similar to the proportion post-TTDP (24.4% [95% CI 22.9%-26.0%]; n = 700). For patients meeting specific physiologic triage criteria, the proportions of patients transported to a trauma center were also similar pre- and post-TTDP: systolic blood pressure <90 mmHg (22.5% versus 23.5%); respiratory rate <10 or >29 (23.2% versus 22.6%); and Glascow Coma Scale (GCS) score <13 (26.0% versus 26.4%). Patients aged 80 years or older were less likely to be transported to a trauma center than younger patients in both the pre- and post-TTDP periods.

State-wide implementation of a TTDP had no discernible effect on the proportion of patients 50 years and older transported to a trauma center. Under-triage remained common and became increasingly prevalent among the oldest adults. Research to understand the uptake of guidelines and protocols into EMS practice is critical to improving care for older adults in the prehospital environment.

Blood glucose level (BGL) is routinely assessed by paramedics in the out-of-hospital setting. Most commonly, BGL is measured using a blood sample of capillary origin analyzed by a hand-held, point-of-care glucometer. In some clinical circumstances, the capillary sample may be replaced by blood of venous origin. Given most point-of-care glucometers are engineered to analyze capillary blood samples, the use of venous blood instead of capillary may lead to inaccurate or misleading measurements.

The aim of this prospective study was to compare mean difference in BGL between venous and capillary blood from healthy volunteers when measured using a capillary-based, hand-held, point-of-care glucometer.

Using a prospective observational comparison design, 36 healthy participants provided paired samples of blood, one venous and the other capillary, taken near simultaneously. The BGL values were similar between the two groups. The capillary group had a range of 4.3mmol/l, with the lowest value being 4.4mmol/l and 8.7mmol/l the highest. The venous group had a range of 2.7mmol/l, with the lowest value being 4.1mmol/l and 7.0mmol/l the highest.

For the primary research question, the mean BGL for the venous sample group was 5.3mmol/l (SD = 0.6), compared to 5.6mmol/l (SD = 0.8) for the capillary group. This represented a statistically significant difference of 0.3mmol/l (P = .04), but it did not reach the a priori established point of clinical significance (1.0mmol/l). Pearson’s correlation coefficient for capillary versus venous indicated moderate correlation (r = 0.42).

In healthy, non-fasted people in a non-clinical setting, a statistically significant, but not clinically significant, difference was found between venous- and capillary-derived BGL when measured using a point-of-care, capillary-based glucometer. Correlation between the two was moderate. In this context, using venous samples in a capillary-based glucometer is reasonable providing the venous sample can be gathered without exposure of the clinician to risk of needle-stick injury. In clinical settings where physiological derangement or acute illness is present, capillary sampling would remain the optimal approach.

Prehospital emergency care is cost-effective for improving morbidity and mortality of emergency conditions. However, such care has been discounted in the public health system of many lower middle-income countries (LMICs). Where it exists, the Emergency Medical Service (EMS) system is grossly inadequate, unpopular, and misrepresented. Many EMS reviews in developing countries have identified systemic problems with infrastructure and human resources, but they neglected impacts of sociocultural factors. This study examines the sociocultural dimensions of LMICs’ prehospital emergency systems in order to improve the quality and impact of emergency care in those countries.

Qualitative studies on EMS systems in LMICs were systematically reviewed and analyzed using Kleinman’s health system theory of folk, popular, and professional health sectors. Also, the three-delay model of emergency care – seeking, reaching, and receiving – provided a guiding framework.

The search yielded over 3,000 papers and the inclusion criteria eventually selected 14, with duplicates and irrelevant papers as the most frequent exclusion. Both user and provider experiences with emergency conditions and the processes of prehospital care were described. Sociocultural factors such as trust and beliefs underlay the way emergency care was experienced. Attitudes of family and community shaped service-seeking behaviors. Traditional medicine was often the first point of care. Private vehicles were the main transportation for accessing care due to distrust and misunderstanding of ambulance services.

The findings led to the discussion on how culture is woven into the patients’ pathway to care, and the recommendation for any future development to place a far greater emphasis on this aspect. Instead of relying purely on the biomedical sector, the health system should acknowledge and show respect for popular knowledge and folk belief. Such strategies will improve trust, facilitate information exchange, and enable stronger healer-patient relationships.

Provision of critical care and resuscitation was not practical during early missions into space. Given likely advancements in commercial spaceflight and increased human presence in low Earth orbit (LEO) in the coming decades, development of these capabilities should be considered as the likelihood of emergent medical evacuation increases.

PubMed, Web of Science, Google Scholar, National Aeronautics and Space Administration (NASA) Technical Server, and Defense Technical Information Center were searched from inception to December 2018. Articles specifically addressing critical care and resuscitation during emergency medical evacuation from LEO were selected. Evidence was graded using Oxford Centre for Evidence-Based Medicine guidelines.

The search resulted in 109 articles included in the review with a total of 2,177 subjects. There were two Level I systematic reviews, 33 Level II prospective studies with 647 subjects, seven Level III retrospective studies with 1,455 subjects, and two Level IV case series with four subjects. There were two Level V case reports and 63 pertinent review articles.

The development of a medical evacuation capability is an important consideration for future missions. This review revealed potential hurdles in the design of a dedicated LEO evacuation spacecraft. The ability to provide critical care and resuscitation during transport is likely to be limited by mass, volume, cost, and re-entry forces. Stabilization and treatment of the patient should be performed prior to departure, if possible, and emphasis should be on a rapid and safe return to Earth for definitive care.

Epinephrine has been recommended for out-of-hospital cardiac arrest (OHCA) resuscitation for nearly one century, but its efficacy and safety remain unclear in the literature. The primary aim of this review was to determine whether epinephrine increases the return of spontaneous circulation in OHCA patients.

A systematic review and meta-analysis were conducted using the following databases: MEDLINE, EMBASE, and CENTRAL, from their inception until October 2018. All the randomized controlled trials (RCTs) were included. Observational studies, case reports, case series, and non-systematic reviews were excluded.

Two trials including 8,548 patients were eligible for inclusion in the data synthesis. In patients who received epinephrine during OHCA, the incidence of return of spontaneous circulation was increased, with an odds ratio (95%CI) of 4.25 (3.79-4.75), P <.001, high-quality of evidence. The number of patients transported to hospital was increased in patients who had prehospital epinephrine, with an odds ratio (95%CI) of 2.31 (2.11-2.53), P <.001, high-quality of evidence. The prehospital use of epinephrine was associated with an increased survival to hospital discharge, the odds ratio (95%CI) being 1.43 (1.10-1.87), P = .008, moderate-quality of evidence. No significant effect was noted on the favorable neurologic state of patient at hospital discharge, with an odds ratio (95%CI) of 1.21 (0.90-1.64), P = .21, moderate-quality of evidence.

This meta-analysis suggests that the prehospital use of epinephrine increases return of spontaneous circulation, transport of patients to hospital, and survival to hospital discharge for OHCA. However, no significant effects on favorable neurologic function at hospital discharge were demonstrated. The general quality of evidence ranged from moderate to high.

This paper discusses the need for consistency in mass-gathering research and evaluation from an environmental reporting perspective.

Mass gatherings occur frequently throughout the world. Having an understanding of the complexities of mass gatherings is important to inform health services about the possible required health resources. Factors within the environmental, psychosocial, and biomedical domains influence the usage of health services at mass gatherings. A minimum data set (MDS) has been proposed to standardize collection of biomedical data across various mass gatherings, and there is a need for an environmental component. The environmental domain includes factors such as the nature of the event, availability of drugs or alcohol, venue characteristics, and meteorological factors.

This research used an integrative literature review design. Manuscripts were collected using keyword searches from databases and journal content pages from 2003 through 2018. Data were analyzed and categorized using the existing MDS as a framework.

In total, 39 manuscripts were identified that met the inclusion criteria.

In collecting environmental data from mass gatherings, there must be an agreed-upon MDS. A set of variables can be used to collect de-identified environmental variables for the purpose of making comparisons across societies for mass-gathering events (MGEs).