This study intended to create symptom-based triage algorithms for the initial encounter with terror-attack victims. The goals of the triage algorithms include: (1) early recognition; (2) avoiding contamination; (3) early use of antidotes; (4) appropriate handling of unstable, contaminated victims; and (5) provisions of force protection. The algorithms also address industrial accidents and emerging infections, which have similar clinical presentations and risks for contamination as weapons of mass destruction (WMD).

The algorithms were developed using references from military and civilian sources. They were tested and adjusted using a series of theoretical patients from a CD-ROM chemical, biological, radiological/nuclear, and explosive victim simulator. Then, the algorithms were placed into a card format and sent to experts in relevant fields for academic review.

Six inter-connected algorithms were created, described, and presented in figure form. The “attack” algorithm, for example, begins by differentiating between overt and covert attack victims (A covert attack is defined by epidemiological criteria adapted from the Centers for Disease Control and Prevention (CDC) recommendations). The attack algorithm then categorizes patients either as stable or unstable. Unstable patients flow to the “Dirty Resuscitation” algorithm, whereas, stable patients flow to the “Chemical Agent” and “Biological Agent” algorithms. The two remaining algorithms include the “Suicide Bomb/Blast/Explosion” and the “Radiation Dispersal Device” algorithms, which are inter-connected through the overt pathway in the “Attack” algorithm.

A civilian, symptom-based, algorithmic approach to the initial encounter with victims of terrorist attacks, industrial accidents, or emerging infections was created. Future studies will address the usability of the algorithms with theoretical cases and utility in prospective, announced and unannounced, field drills. Additionally, future studies will assess the effectiveness of teaching modalities used to reinforce the algorithmic approach.

On 28 November 2002, three suicide bombers crashed their car into a hotel in Mombassa, Kenya; 12 people were killed, including three Israelis, and 80 were wounded (22 of whom were Israeli). The Israeli Defense Force Airborne Medical Evacuation Flight Teams participated in a repatriation mission to bring the wounded home.

The objectives of this study are to outline the distinctive aspects of this mission, as well as to share the experiences and lessons learned.

Israeli Army debriefing reports were used to study the composition of the crew, medical equipment taken, injury distribution, mode of operation, and mission schedule.

A total of six fixed-wing aircraft were used—two Boeing 707s and four Hercules C-130s—with a total of 54 medical team members on board. A total of 260 Israelis were repatriated, 22 of whom were wounded, and three were dead. Of the casualties, 14 were conveyed sitting, and eight supine. The time from the first landing in Kenya to the evacuation of the last supine patient was 5.5 hours. Nurses, as well as social workers, played a central role in the mission. A forward team, including five doctors, was used for the initial organization and for gathering information on the medical status of the casualties.

There was redundancy in the medical crew and medical equipment sent. The need for improved infrastructure on the medical aircraft was stressed. Based on this experience, a new mode for operation for similar missions in the future was formulated.

Evidence suggests that regular disaster exercises have beneficial effects on subsequent mock and actual disaster responses. The purpose of this report is to describe a multiple hospital, bioterrorism exercise, evaluated by independent observers who used an evaluation template.

The overall tabletop exercise design included participation from 23 Joint Commission Accreditation of Healthcare Organizations hospitals, four health departments, and a representative from one federal agency. The exercise was evaluated by trained exercise observers utilizing an independently prepared, evaluation protocol.

All exercise sites successfully identified the bio-agent involved and answered after-exercise debriefing questions without much difficulty. Evaluations, in the form of an after-action report by the independent observers, commented upon the many limitations to the construct of the exercise.

Having an independent observer group at the exercise appeared to provide a value-added benefitfor capturing subjective information and data. However, these data were not in a form conducive to statisticalanalysis. Further work is needed to create an evaluation tool that would allow for statistical analysis so that exercises can be compared and improvements can be objective.

This study was undertaken to identify prehospital system and management deficiencies and preventable deaths between 01 January 1997 and 31 December 1998 in 243 consecutive Victorian road crash victims with fatal outcomes.

The complete prehospital and hospital records, the deposition to the coroner, and autopsy findings were evaluated by computer analysis and peer group review with multidisciplinary discussion.

One-hundred eighty-seven (77%) patients had prehospital errors or inadequacies, of which 135 (67%) contributed to death. Three-hundred ninety-four (67%) related to management and 130 (22%) to system deficiencies. Technique errors, diagnosis delays, and errors relatively were infrequent. One of 24 deaths at the crash scene or en route to hospital was considered to be preventable and two potentially preventable.

The high prevalence of prehospital deficiencies has been addressed by a Ministerial Task Force on Trauma and Emergency Services and followed by the introduction of a new trauma care system in Victoria.

Responses to disasters involve many factors beyond personnel, such as medical andnon-medical equipment and supplies. When disaster teams respond, they must do so with sufficient amounts of medicine and supplies to manage all of the patients expected for several days before re-supply. In order for this process to be efficient and expedient, accurate and advanced planning for supplies needed by disaster workers is necessary. These supplies must provide for general medical care and for hazard-specific problems.

To develop a model that provides the framework for determining supply requirements for the National Disaster Medical System, Disaster Medical Assistance Teams, or other responding disaster teams in a civilian environment.

A community hospital was modeled to determine patient characteristics when presenting to an emergency department (ED), including patient demographics and chief complaint, medications administered during the emergency department visit and prescribed at discharge, and laboratory tests ordered to assess disaster team supply requirements. Data were downloaded from a patient tracking software package and abstracted from various hospital data information systems. Data from the community hospital were compared with data published from two hurricane disasters by members of the National Disaster Medical System.

To the extent possible, the model predicted the proportion of patient complaints and, therefore, the medicine and supplies needed for the management of these patients.

This model offers a first step in preparing disaster medical teams for deployment.

Mass-gathering events are dynamic and challenge traditional medical management systems. To improve the system for the provision of first aid at mass-gathering events, an evaluation of two models that assist in forecasting the number of patients presenting for first-aid services was conducted.

A prospective evaluation of a recurrent, mass-gathering event was undertaken comparing predicted patient presentations and ambulance transfers generated by a predictive model developed by Arbon et al and a retrospective review of seven years of historical, event data as described by Zeitz et al.

Patient presentation rate (per 1,000 patrons) for this event was 1.6 and the transport to hospital rate (per 1,000 patrons) was 0.07. The retrospective review closely predicted the actual overall attendance.Both methods forecast the number of patients presenting on a daily basis. The prediction proved to be more accurate, on a day-by-day basis, using the Zeitz method.

The Arbon method is particularly useful for events where there is no or limited information about previous medical work. Retrospective review of data generated from specific events (Zeitz method) considers the unique and individual variability that can occur from event to event and is more accurate at predicting patient presentations when the data are available. Both methods have the potential to be used more frequently to adequately and efficiently plan for the resources required for specific events.

A consensus panel of Emergency Physicians with experience in international health has published a recommended curriculum for a formal fellowship in International Emergency Medicine. This article reviews the current International Emergency Medicine (IEM) fellowships available to residency-trained Emergency Physicians in the United States.

Every allopathic Emergency Medicine (EM) residency program in the United States was contacted via e-mail or telephone. Programs that reported having an IEM fellowship were asked detailed information about their program, including: (1) the number of years the program has been offered; (2) the duration of the program; (3) the number of fellows taken each year; (4) the number of fellowship graduates from each program and their current practice patterns; (5) how the fellowship is funded; and (6) whether a Masters Degree in Public Health (MPH) is offered.

All 127 allopathic EM residency programs responded. Eight (6.8%) of these programs offered IEM fellowships. Of a total of 29 graduates identified, 23 (79.3%) were employed in academic medicine. All of the fellowships offered formal public health training and were funded by a combination of clinical billing and project-specific grants and scholarships. All IEM fellowships described a curriculum that reflected the previously published recommendations.

Opportunities in formal training in international health are increasing for graduates of EM residencies in the United States. The proposed curriculum for IEM fellowships seems to have been implemented and graduates of IEM fellowships seem to be applying their training in international projects.

Few previous studies have been conducted on the prehospital management of hypotensive trauma patients in Stockholm County. The aim of this study was to describe the prehospital management of hypotensive trauma patients admitted to the largest trauma center in Sweden, and to assess whether prehospital trauma life support (PHTLS) guidelines have been implemented regarding prehospital time intervals and fluid therapy. In addition, the effects of the age, type of injury, injury severity, prehospital time interval, blood pressure, and fluid therapy on outcome were investigated.

This is a retrospective, descriptive study on consecutive, hypotensivetrauma patients (systolic blood pressure ≤90 mmHg on the scene of injury) admitted to Karolinska University Hospital in Stockholm, Sweden, during 2001–2003. The reported values are medians with interquartile ranges. Basic demographics, prehospital time intervals and interventions, injury severity scores (ISS), type and volumes of prehospital fluid resuscitation, and 30-day mortality were abstracted. The effects of the patient's age, gender, prehospital time interval, type of injury, injury severity, on-scene and emergency department blood pressure, and resuscitation fluid volumes on mortality were analyzed using the exact logistic regression model.

In 102 (71 male) adult patients (age ≥15 years) recruited, the median age was 35.5 years (range: 27–55 years) and 77 patients (75%) had suffered blunt injury. The predominant trauma mechanisms were falls between levels (24%) and motor vehicle crashes (22%) with an ISS of 28.5 (range: 16–50). The on-scene time interval was 19 minutes (range: 12–24 minutes). Fluid therapy was initiated at the scene of injury in the majority of patients (73%) regardless of the type of injury (77 blunt [75%] / 25 penetrating [25%]) or injury severity (ISS: 0–20; 21–40; 41–75). Age (odds ratio (OR) = 1.04), male gender (OR = 3.2), ISS 21–40 (OR = 13.6), and ISS >40 (OR = 43.6) were the significant factors affecting outcome in the exact logistic regression analysis.

The time interval at the scene of injury exceeded PHTLS guidelines. The vast majority of the hypotensive trauma patients were fluid-resuscitated on-scene regardless of the type, mechanism, or severity of injury. A predefined fluid resuscitation regimen is not employed in hypotensive trauma victims with different types of injuries. The outcome was worsened by male gender, progressive age, and ISS >20 in the exact multiple regression analysis.

Epidemiological research about disasters is difficult to perform. Most often, it must be completed retrospectively, since data collection may not be feasible or possible during the disaster.Now, there is a recognized need for a standard method to assess the severity of a disaster.

The aim of this paper is to assess the severity of the disasters that occurred in Italy during the 20th century, using a Disaster Severity Scale (DSS). Another goal is to find a standard method for the classification of previous disasters, test the feasibility and reliability of the use of the Disaster Severity Scale, and improvedisaster management and planning.

Data were obtained from formal reports of the Civil Defence Unit (Italy) and were used to calculate the Disaster Severity Scale score. Disasters were classified into major and minor disasters, according tothe numbers of deaths and severity of the damage. The number of deaths was compared with the obtained Disaster Severity Scale score. A seasonal trend for different types of events was obtained to assess if there is a relationship between the type of event and the time of the year in which it occurred, as related to the weather conditions existing at that time.

There were enough data to calculate a Disaster Severity Scale score for 26 major events that caused death and economic damage, and occurred in Italy between 18 March 1944 and 11 November 1999, and for 82 minor events, that occurred between October 1982 and December 1999. There were some significant peaks varying from different types of events during particular seasons, but the cause for those with the highest incidence is not clear. Events related to natural hazards were the only type of event that reached the highest Disaster Severity Scale when considering the number of deaths, while no events associated with man-made hazards had a Disaster Severity Scale score >8.

The Disaster Severity Scale score could be a reliable index for the assessment of events related to either natural or man-made disasters. Use of the Disaster Severity Scale allows researchers to classify previous hazards by scoring each disaster's severity. Further studies in other countries could be useful to further validate the Disaster Severity Scale.

Professional behavior is one of the cornerstones of effective emergency medical services (EMS) practice and is a required part of the National Standard Curricula for advanced levels of EMS education. However, peer rating of emergency medical technicians with respect to the 11 categories of professional behavior never has been quantified. This study uses a peer evaluation methodology to assess the affective competencies of practicing EMS providers.

A professional behavior evaluation form was included as part of a survey that was sent to 2,443 randomly selected, nationally registered emergency medical technicians (EMTs). Participants were asked to rate the EMT partner with whom they worked most closely in the past year using 11 different categories of professional behavior using a Likert scale.

One thousand, five hundred, ten (61.8%) surveys were returned and analyzed. Both nationally registered EMTs at the Basic and Paramedic levels rated their partners with respect to 11 categories of professional behavior. The overall average score was 0.68 on a 0–1 scale, with one being the highest. The rating of each of the categories was: (1) integrity (0.77); (2) appearance/personal hygiene (0.74); (3) patient advocacy (0.73); (4) empathy (0.72); (5) self-confidence (0.70); (6) careful delivery of service (0.70); (7) respect (0.65); (8) communication skills (0.64); (9) time management skills (0.63); (10) teamwork/diplomacy skills (0.62); and (11) self-motivation (0.61). Overall, the NREMT-Paramedics rated their partners significantly lower than did the NREMT-Basics (p = 0.0156) and experienced EMT-Basics rated their partners significantly lower than did the newer EMT-Basics (p = 0.0002). Those EMTs who indicated high satisfaction with their current EMS assignment rated their partner more highly on professional behaviors than did those EMTs who were not as satisfied.

Overall, EMTs peer evaluation of professional behavior was “good.” The behaviors most highly rated were integrity and appearance/personal hygiene. The behaviors rated lowest were self-motivation and team work/diplomacy. It appears that paramedics are more critical of their colleagues than are EMT-Basics, that experienced EMT-Basics are harsher critics than are newer EMT-Basics, and that there is a relationship between job satisfaction and peer evaluation.