Morbidity and mortality due to acute but treatable conditions remain high in the developing world, as many significant barriers exist to providing emergency medical care.This study investigates these barriers in a rural region of Ethiopia.

The limited capacity of frontline healthcare workers to diagnose and treat acute medical and surgical conditions represents a major barrier to the provision of emergency care in rural Ethiopia.

Health providers at a convenience sample of 16 rural health centers in the state of Tigray, Ethiopia completed a questionnaire designed to assess the availability of diagnostic and treatment modalities, the proximity and methods of transportation to referral facilities, and health providers' level of comfort in diagnosing and treating a variety of representative emergency medical conditions.

Thirteen (81%) providers had only a very basic level of medical training, and seven (44%) lacked access to any diagnostic equipment.While most providers could offer oral rehydration solution (ORS), anti-pyretic medications, and antibiotics, none of the providers could offer blood transfusions or any form of surgery. Ten (63%) respondents stated that their patients had to travel >10 km from the health center to a referral hospital, with only a minority of patients having access to motorized transport. For the seven emergency conditions assessed, a majority of providers felt comfortable diagnosing these conditions, though fewer felt comfortable treating them.

There is a significant need for both health worker training and improvements in transportation infrastructure in order to increase access to emergency medical care in rural areas of the developing world.Low-cost interventions that improve human capacity in a context-appropriate manner are warranted as transportation and hospital network capacity expansions are considered.

Road traffic collisions are a common cause of injuries and injury-related deaths in sub-Saharan Africa (SSA). Basic prehospital care can be the difference between life and death for injured drivers, passengers, and pedestrians.

This study examined the challenges associated with current first response practices in Malawi.

In April 2014, focus groups were conducted in two areas of Malawi: Karonga (in the Northern Region) and Blantyre (in the Southern Region; both are along the M1 highway), and a qualitative synthesis approach was used to identify themes. All governmental and nongovernmental first response organizations identified by key informants were contacted, and a checklist was used to identify the services they offer.

Access to professional prehospital care in Malawi is almost nonexistent, aside from a few city fire departments and private ambulance services. Rapid transportation to a hospital is usually the primary goal of roadside care because of limited first aid knowledge and a lack of access to basic safety equipment. The key informants recommended: expanding community-based first aid training; emphasizing umunthu (shared humanity) to inspire bystander involvement in roadside care; empowering local leaders to coordinate on-site responses; improving emergency communication systems; equipping traffic police with road safety gear; and expanding access to ambulance services.

Prehospital care in Malawi would be improved by the creation of a formal network of community leaders, police, commercial drivers, and other lay volunteers who are trained in basic first aid and are equipped to respond to crash sites to provide roadside care to trauma patients and prepare them for safe transport to hospitals.

ChokothoL, MulwafuW, SinginiI, NjalaleY, Maliwichi-SenganimalunjeL, JacobsenKH. First Responders and Prehospital Care for Road Traffic Injuries in Malawi. Prehosp Disaster Med. 2017;32(1):14–19.

Paramedics often are asked to care for patients at the end of life. To do this, they must communicate effectively with family and caregivers, understand their legal obligations, and know when to withhold unwanted interventions. The objectives of this study were to ascertain paramedics' attitudes toward end-of-life (EOL) situations and the frequency with which they encounter them; and to compare paramedics' preparation during training for a variety of EOL care skills.

A written survey was administered to a convenience sample of paramedics in two cities: Denver, Colorado and Los Angeles, California. Questions addressed: (1) attitudes toward EOL decision-making in prehospital settings; (2) experience (number of EOL situations experienced in the past two years); (3) importance of various EOL tasks in clinical practice (pronouncing and communicating death, ending resuscitation, honoring advance directives (ADs)); and (4) self-assessed preparation for these EOL tasks. For each task, importance and preparation were measured using a four-point Likert scale. Proportions were compared using McNemar chi-square statistics to identify areas of under or over-preparation.

Two hundred thirty-six paramedics completed the survey. The mean age was 39 years (range 22–59 years), and 222 (94%) were male. Twenty percent had >20 years of experience. Almost all participants (95%; 95% CI = 91–97%) agreed that prehospital providers should honor field ADs, and more than half (59%; 95% CI = 52–65%) felt that providers should honor verbal wishes to limit resuscitation at the scene. Ninety-eight percent of the participants (95% CI = 96–100%) had questioned whether specific life support interventions were appropriate for patients who appeared to have a terminal disease. Twenty-six percent (95% CI = 20–32%) reported to have used their own judgment during the past two years to withhold or end resuscitation in a patient who appeared to have a terminal disease. Significant discrepancies between the importance in practice and the level of preparation during training for the four EOL situations included: (1) understanding ADs (75% very important vs. 40% well prepared; difference 35%: 95% CI = 26–43%); (2) knowing when to honor written ADs (90% very important vs. 59% well-prepared; difference 31%: 95% CI = 23–38%); and (3) verbal ADs (75% very important vs. 54% well-prepared, difference 21%: 95% CI = 12–29%); and (4) communicating death to family or friends (79% very important vs. 48% well prepared, difference 31%: 95% CI = 23–39%). Paramedics' preparation in EOL skills was significantly lower than that for clinical skills such as endotracheal intubation or defibrillation.

There is a need to include more training in EOL care into prehospital training curricula, including how to verify and apply ADs, when to withhold treatments, and how to discuss death with victims' family or friends.

The disruption of routine treatment, including the interruption of medication, exacerbates chronic conditions during disasters. However, the health consequences of the interruption of medication have not been fully examined. On 22 July 2006, a flash flood affected more than 3,000 households in five cities and four towns in the northern part of Kagoshima Prefecture in southwest Japan. The aims of this study are to describe the prevalence of the interruption of medication among the outpatients in the flood-affected area and to determine the risk and preventive factors for the interruption of medication.

This was a cross-sectional study using a self-administered questionnaire. The study subjects were the outpatients who visited nine of 15 medical facilities in the flood-affected area from 23 January and 31 January 2007. Of 810 valid respondents, 309 who received medication treatment before the event were eligible for the study. Information on socio-demographic factors, chronic health conditions, preparedness-related factors before the event and damage-related factors were collected. Overall and evacuation status-specific prevalence of interruption of medication were presented. For those evacuated, the associations between interruption of medication and relevant patient characteristics, as well as deterioration of health status after the event, were examined.

The prevalence of interruption of medication was 9% in total, but it increased up to 23% among the evacuated subjects. Interruption of medication was more likely among those aged ≥75 years (odds ratio [OR] = 3.6; 95% confidence interval [CI] = 1.0−12.6) and those receiving long-term care services (OR = 4.6; 95% CI = 1.1−19.1), while it was less likely among those with hypertension (OR = 0.2; 95% CI = 0.1−0.8) and those prepared to go out with medication (OR = 0.2; 95% CI = 0.03−0.8). Those who experienced interruption of medication were more likely to have deteriorated health status one month after the event (OR = 4.5; 95% CI = 1.2−17.6).

Interruption of medication occurred more commonly among the evacuated subjects. Among the evacuated, the elderly and those receiving longterm care services were at high risk for interruption of medication, while the preparedness behavior of “preparing to go out with medication” had preventive effect. Special attention must be paid to the high-risk subgroups, and some preventive behaviors should be recommended.

Traffic crashes constitute a major, worldwide public-health problem that cause disabilities, life-long suffering, and huge economic losses. When a person is injured in a traffic crash, actions taken by bystanders often are of crucial importance. To perform first-aid actions in a correct manner, bystanders, often lay persons, need both the courage and the knowledge to do so. For preventive purposes, society spends large resources to inform and educate the public in order to enhance people's ability to take correct actions. However, there only is little information on the rate in a population of persons who have had first-aid training, have been bystanders at a traffic crash, on the actions taken by such persons, and on effects of first-aid training on patient care.

The aim of this study was to acquire knowledge about: (1) the prevalence of first-aid training; (2) the incidence of being a bystander and of the first aid provided at traffic crashes and other emergencies; and (3) the impact of first-aid training on the risks people take in road traffic.

A questionnaire was administered to 2,800 randomly selected persons aged 18–74 years.

The response rate was 67.5%. During the previous five years, 39% of the population had received first-aid training, with a higher rate among younger individuals and those with a higher education. After training, 30% of the respondents had used their skills, and 41% took fewer risks in traffic, particularly those who were older or had a lower level of education. Fourteen percent of those with training (significantly more men) had been bystanders at a traffic crash. At 20% of the crashes, a bystander had administered first aid, and one-third of those who provided such assistance had had use of their training. Conclusion: Intensified first-aid training of the general public could lead to citizens who are more cautious in traffic and to bystanders who provide more immediate and adequate first aid at traffic crashes and other emergencies.

The objective of this study was to compare the psychiatric morbidity between the displaced and non-displaced populations of the Andaman and Nicobar Islands during the first three months following the 2004 earthquake and tsunami.

The study was conducted at the 74 relief camps in the Andaman and Nicobar Islands. Port Blair had 12 camps, which provided shelter to 4,684 displaced survivors. There were 62 camps on Car-Nicobar Island, which provided shelter to approximately 8,100 survivors who continued to stay in their habitat (non-displaced population). The study sample included all of the survivors who sought mental health assistance inside the camp. A psychiatrist diagnosed the patients using the ICD-10 criteria.

Psychiatric morbidity was 5.2% in the displaced population and 2.8% in the non-displaced population. The overall psychiatric morbidity was 3.7%. The displaced survivors had significantly higher psychiatric morbidity than did the non-displaced population.The disorders included panic disorder, anxiety disorders not otherwise specified, and somatic complaints. The existence of an adjustment disorder was significantly higher in the non-displaced survivors. Depression and post-traumatic stress disorder (PTSD) were distributed equally in both groups.

Psychiatric morbidity was found to be highest in the displaced population. However, the incidence of depression and PTSD were distributed equally in both groups. Involvement of community leaders and survivors in shared decision-making processes and culturally acceptable interventions improved the community participation. Cohesive community, family systems, social support, altruistic behavior of the community leaders, and religious faith and spirituality were factors that helped survivors cope during the early phase of the disaster.

The importance of accessing care within the first hour after injury has been a fundamental tenet of trauma system planning for 30 years. However, the scientific basis for this belief either has been missing or largely derived from case series from trauma centers. This study sought to determine the correlation between prehospital times and outcomes among severely injured elderly patients.

This is a cross-sectional, observational study. All adults (<18 years of age) with acute trauma as defined by The International Classification of Diseases Ninth Edition, Clinical Modification diagnostic codes and E-codes were included. Poisonings, single system burns, and late effects of injury were excluded. Chi-square and Student's ttest were used for significance testing. To assess the predictive effects of prehospital time and outcomes, three inde-pendent logistic regression models were constructed for both young and elderly groups, with hospital length of stay, mortality, and complications as individual dependent variables. Statistical significance was set at the 0.05 level.

Of 41,041 cases, 37,276 were >_18 years of age. Of the 1,866 with an Injury Severity Score (ISS) >15, 1,205 were young and 661 elderly. Logistic regression results showed that prehospital time correlated significantly with hospital length of stay (p = 0.001) and complications (p = 0.016), but not with mortality (p = 0.264) among young patients, whereas in the elderly group prehospital time had no significant predictive effect for length of stay, complica- tions, or mortality (p = 0.512, p = 0.512, and p = 0.954 respectively).

This population-based study has demonstrated that prehospital time correlates with length of stay and complications in young patients. In elderly patients, prehospital time failed to show correlation with any outcomes measured.

Hospital disaster manuals and response plans often lack formal command structure; instead, they rely on the presence of key individuals who are familiar with hospital operations, or who are in leadership positions during routine, day-to-day operations. Although this structure occasionally may prove to be successful, it is unreliable, as this leadership may be unavailable at the time of the crisis, and may not be sustainable during a prolonged event. The Hospital Emergency Incident Command System (HEICS) provides a command structure that does not rely on specific individuals, is flexible and expandable, and is ubiquitous in the fire service, emergency medical services, military, and police agencies, thus allowing for ease of communication during event management.

A descriptive report of the implementation of the HEICS throughout a large healthcare network is reviewed. Results and Conclusions: Implementation of the HEICS provides a consistent command structure for hospitals that enables consistency and commonality with other hospitals and disaster response entities.

Expatriate healthcare professionals frequently participate in international relief operations that are initiated in response to disasters due to natural hazards or humanitarian emergencies in low resource settings. This practice environment is significantly different from the healthcare delivery environment in the home countries of expatriate healthcare professionals. Human rights, public health, medicine, and ethics intersect in distinct ways as healthcare professionals provide care and services in communities affected by crisis.

The purpose of this study was to explore the moral experience of Canadian healthcare professionals during humanitarian relief work.

This is a qualitative study with 18 semi-structured individual interviews based on Interpretive Description methodology. There are two groups of participants: (1) 15 healthcare professionals (nine doctors, five nurses, and one midwife) with more than three months experience in humanitarian work; and (2) three individuals who have experience as human resource or field coordination officers for humanitarian, non-governmental organizations. Participants were recruited by contacting non-governmental organizations, advertisement at the global health interest group of a national medical society, word of mouth, and a snowball sampling approach in which participants identified healthcare professionals with experience practicing in humanitarian settings who might be interested in the research.

Five central themes were identified during the analysis: (1) examination of motivations and expectations; (2) the relational nature of humanitarian work; (3) attending to steep power imbalances; (4) acknowledging and confronting the limits of what is possible in a particular setting; and (5) recognition of how organizational forms and structures shape everyday moral experience.

Humanitarian relief work is a morally complex activity. Healthcare professionals who participate in humanitarian relief activities, or who are contemplating embarking on a humanitarian project, will benefit from carefully considering the moral dimensions of this work. Humanitarian organizations should address the moral experiences of healthcare professionals in staff recruitment, as they implement training prior to departure, and in supporting healthcare professionals in the field.

In December 2003, the residents of Bam, Iran experienced an earthquake that measured 6.6 on the Richter scale and destroyed >90% of the city. After the assessment and initial treatment of injuries at national and international field hospitals, a considerable number of victims (approximately 12,000) were transferred to tertiary referral hospitals around the country. Objective: This report evaluated the injuries of 854 victims transferred to 12 referral hospitals in Tehran.

The demographic data, injury patterns, injury severity score (ISS), diagnosis, treatment, and outcome data of 854 Bam earthquake victims were assessed.

There were 467 (54.7%) males and 387 (45.3%) females. The mean age of the patients was 29.0 years. Transportation by aircraft was the most common method used for evacuation, which was used to evacuate 555 patients (65%). Fifty-four percent of the victims required initial medical aid at field hospitals before transportation to Tehran. There were 1,322 patients with injuries, of which, fractures of the lower extremities were the most common (331; 25%). Limb fixation was the most commonly performed primary procedure in emergency wards (389 cases, 39.9%). The mean value ±SD for ISS was 6.7 ±5.2. Orthopedic operations were the most frequent surgical procedures performed (195/260 operations, 75%) and the overall mortality rate was 1.6% (n = 14).

Along with the crucial importance of aid provided by national and international field hospitals in disasters, suitable triage of casualties and preparedness of tertiary referral centers in unaffected regions also play an important role in providing medical care to disaster victims. During these situations, the number of victims cannot be predicted accurately, and sufficient medical care, particularly for orthopedic problems, can be provided by referral centers.

Emergency medical services (EMS) responses to mass gatherings have been described frequently, but there are few reports describing the response to a single-day gathering of large magnitude.

This report describes the EMS response to the largest single-day, ticketed concert held in North America: the 2003 “Toronto Rocks!” Rolling Stones Concert.

Medical care was provided by paramedics, physicians, and nurses. Care sites included ambulances, medically equipped, all-terrain vehicles, bicycle paramedic units, first-aid tents, and a 124-bed medical facility that included a field hospital and a rehydration unit. Records from the first-aid tents, ambulances, paramedic teams, and rehydration unit were obtained. Data abstracted included patient demographics, chief complaint, time of incident, treatment, and disposition.

More than 450,000 people attended the concert and 1,870 sought medical care (42/10,000 attendees). No record was kept for the 665 attendees simply requesting water, sunscreen, or bandages. Of the remaining 1,205 patients, the average of the ages was 28 ±11 years, and 61% were female. Seven-hundred, ninety-five patients (66%) were cared for at one of the first-aid tents. Physicians at the tents assisted in patient management and disposition when crowds restricted ambulance movement. Common complaints included headache (321 patients; 27%), heat-related complaints (148; 12%), nausea or vomiting (91; 7.6%), musculoskeletal complaints (83; 6.9%), and breathing problems (79; 6.6%). Peak activity occurred between 14:00 and 19:00 hours, when 102 patients per hour sought medical attention. Twenty-four patients (0.5/10,000) were transferred to off-site hospitals.

This report on the EMS response, outcomes, and role of the physicians at a large single-day mass gathering may assist EMS planners at future events.

Post-earthquake engineering and epidemiologic assessments are important for the development of injury prevention strategies. This paper describes mortality and its relationship to building collapse patterns and initial medical responses following the 1992 earthquake in Erzincan, Turkey.

The study consisted of: 1) background data collection and review; 2) design and implementation of a field survey; and 3) site inspection of building collapse patterns. The survey included: 1) national (n = 11) and local (n = 17) officials; 2) medical and search and rescue (SAR) workers (n = 38); and 3) a geographically stratified random sample of lay survivors (n = 105). The survey instruments were designed to gather information regarding location, injuries, initial actions and prior training of survivors and responders, and the location, injuries, and management of dead and dying victims. A case-control design was constructed to assess the relationship between mortality, location, and building collapse pattern.

There was extensive structural damage throughout the region, especially in the city where mid-rise, unreinforced masonry buildings (MUMBs) incorporating a “soft” first floor design (large store windows for commercial use) and one story adobe structures were most vulnerable to collapse. Of 526 people who died in the city, 87% (n = 456) were indoors at the time of the earthquake. Of these, 92% (n = 418) died in MUMBs. Of 54 witnessed deaths, 55% (n = 28) of victims died slowly, the majority of whom (n = 26) were pinned or trapped (p <0.05). Of 42 MUMB occupants identified through the survey, those who died (n = 25) were more likely to have been occupying the ground floor when compared with survivors (n = 28) (p <0.01). Official medical and search and rescue responders arrived after most deaths had occurred. Prior first-aid or rescue training of lay, uninjured survivors was associated with a higher likelihood of rescuing and resuscitating others (p <0.001).

During an earthquake, MUMBs with soft ground floor construction are highly lethal, especially for occupants on the ground floor, suggesting that this building type is inappropriate for areas of seismic risk. The vulnerability of MUMBs appears due to a lack of lateral force resistance as a result of the use of glass store fiont windows and the absence of shear walls. The prevalence of this building type in earthquake-prone regions needs to be investigated further. A large portion of victims dying in an earthquake die slowly at the scene of injury. Prior public first-aid and rescue training programs increase participation in rescue efforts in major earthquakes and may improve survival.

Emergency medical services collisions (EMVCs) are a largely unexplored area of emergency medical services (EMS) research. Factors that might contribute to an EMVC are numerous and include use of warning lights and siren (WL&S). Few of these factors have been evaluated scientifically. Similarly, the incidence and severity of EMVCs is poorly documented in the literature. This study sought to define the incidence and severity of, and where possible, identify any contributing factors to EMVCs in a large urban system.

Retrospective study of all collisions involving vehicles assigned to the EMS Division of the Houston Fire Department in calendar year 1993. Fifty-one ambulances were operational 24 hours per day during calendar year 1993. Houston EMS received 150,000 requests for assistance, made 180,000 vehicular responses, and accrued 2,651,760 miles in 1993.

Eighty-six EMVCs were identified during the study period. The gross incidence rate was therefore 3.2 EMVC/100,000 miles driven or 4.8 collisions/10,000 responses. Of the 86 EMVCs, 74 (86%) files were complete and available for evaluation. Major collisions, determined according to injuries or vehicular damage, accounted for 10.8% of all EMVCs. There were 17 persons transported to hospitals from EMS collisions, yielding an injury incidence of 0.64 injuries/100,000 miles driven or 0.94 injuries/10,000 responses. There were no fatalities. The majority of collisions (85.1%) occurred at some site other than an intersection. There was no statistical association between occurrence at an intersection and severity, day versus night, weekend versus weekday, presence or absence of precipitation, or use of WL&S versus severity of collision. Drivers with a history of previous EMVCs were involved in 33% of all collisions. The presence of prior EMVCs was associated (p < 0.001) with the number of persons transported from the collision to a local hospital. Five drivers, all with previous EMVCs, accounted for 88.2% (15/17) of all injuries.

A few drivers with previous EMVCs account for a disproportionate number of EMVCs and nearly 90% of all injuries. This risk factor—history of previous EMVC—has not been reported in the EMS literature. It is postulated that this factor ultimately will prove to be the major determinant of EMVCs. Data collection of EMS collisions needs to be standardized and a proposed collection tool is provided.

An appreciation of the experience of Ebola survivors is critical for community engagement and an effective outbreak response. Few qualitative, descriptive studies have been conducted to date that concentrate on the voices of Ebola survivors.

This study aimed to explore the experiences of Ebola survivors following the West African epidemic of 2014.

An interpretive, qualitative design was selected using semi-structured interviews as the method of data collection. Data were collected in August 2015 by Médecins Sans Frontières (MSF) Belgium, for the purposes of internal evaluation. Data collection occurred at three sites in Liberia and Sierra Leone and involved 25 participants who had recovered from Ebola. Verbal consent was obtained, audio recordings were de-identified, and ethics approval was provided by Monash University (Melbourne, Australia).

Two major themes emerged from the study: “causes of distress” and “sources of resilience.” Two further sub-themes were identified from each major theme: the “multiplicity of death,” “abandonment,” “self and community protection and care,” and “coping resources and activities.” The two major themes were dominant across all three sample groups, though each survivor experienced infection, treatment, and recovery differently.

By identifying and mobilizing the inherent capacity of communities and acknowledging the importance of incorporating the social model of health into culturally competent outbreak responses, there is an opportunity to transcend the victimization effect of Ebola and empower communities, ultimately strengthening the response.

SchwerdtlePM, De ClerckV, PlummerV. Experiences of Ebola Survivors: Causes of Distress and Sources of Resilience. Prehosp Disaster Med. 2017;32(3):234–239.