Social and political instability have become common situations in many parts of the world. Exposure to different types of traumatic circumstances may differentially affect psychological status.

The aim of this study was to compare the relationship between personal perceptions of control over the events happening in one's life and psychological distress in two groups who experienced physical trauma but differed as to whether the trauma was a result of political upheaval and violence. Views on the extent to which the state was interested in the individual were also assessed.

The sample consisted of 120 patients who were injured in the Cairo epicenter and 120 matched controls from the greater Cairo area whose injuries were from other causes. The Brown Locus of Control Scale and the Symptom Checklist-90-Revised (SCL 90-R) were administered approximately three months after the January 2011 start of the demonstrations and subsequent overthrow of the government.

The groups did not differ on locus of control. For both groups, externality was associated with greater distress, suggesting a relationship between perceived helplessness in controlling one's life and distress. The Cairo group scored significantly higher than the control group on the SCL 90-R Global Severity Index (GSI) and Positive Symptom Total (PST). Perceptions of state interest in the population were low; overall, 78% viewed the state as having little or no interest in them.

The relationship between exposure intensity and psychological distress is examined. In addition, differences in findings in populations experiencing political chaos compared with other types of disasters are considered.

Beliefs regarding personal control over one's life circumstances are more closely associated with psychological distress than the circumstances in which the trauma occurred.

PapanikolaouV, GadallahM, LeonG, MassouE, ProdromitisG, SkembrisA, LevettJ. Relationship of Locus of Control, Psychological Distress, and Trauma Exposure in Groups Impacted by Intense Political Conflict in Egypt. Prehosp Disaster Med. 2013;28(4):1-5.

During the night of February 27 and the early morning of February 28, 2010, 15 coastal municipalities situated in two French departments, Vendée and Charente-Maritime, were violently stricken by a severe windstorm named “Xynthia.” This storm caused the death of 12 individuals in Charente-Maritime and 29 people in Vendée. Houses, agricultural fields, and shellfish companies were severely flooded with seawater. Several thousand people temporarily had to leave their homes. The objective of this study was to estimate the short-term mental health impact of Xynthia, in terms of psychotropic drug delivery, on the resident population of the 15 coastal municipalities severely hit by the flooding.

The French national health insurance database was used to calculate a daily number of new psychotropic treatments from September 1, 2008 through December 24, 2010. New treatments were calculated for each of the following European Pharmaceutical Marketing Research Association (EphMRA) classes: tranquilizers (N05C), hypnotics (N05B), and antidepressants (N06A). A period of three weeks following the storm was defined as the exposure period. A generalized additive model with a Poisson distribution that allows for over-dispersion was used to analyze the correlation between the Xynthia variable and the number of new psychotropic treatments.

With a relative risk (RR) of 1.54 (95% CI, 1.39-1.62) corresponding to an estimate of 409 new deliveries of psychotropic drugs during the three weeks following the storm, this study confirms the importance of the psychological impact of Xynthia. This impact is seen on all three classes of psychotropic drugs studied. The impact is greater for tranquilizers (RR of 1.78; 95% CI, 1.59-1.89) than for hypnotics (RR of 1.53; 95% CI, 1.31-1.67) and antidepressants (RR of 1.26; 95% CI, 1.06-1.40). The RR was higher for females than for males.

This study shows the importance of the psychological impact of the storm as observed clinically by health workers who intervened in the field during the aftermath of Xynthia. It confirms that administrative databases can be used to show a health impact of a disaster even at a local level. This is one more step in the direction of a comprehensive strategy of collecting information to allow the assessment of the health impact of an extreme event, the detection of vulnerable populations, and the orientation of the short-, mid- and long-term public health response.

MotreffY, PirardP, GoriaS, LabradorB, Gourier-FréryC, NicolauJ, Le TertreA, Chan-CheeC. Increase in Psychotropic Drug Deliveries after the Xynthia Storm, France, 2010. Prehosp Disaster Med. 2013;28(5):1-6.

Social networks play an important role in disaster situations as they have become a new form of social convergence that provides collective information. The effect of social media on people who experienced disaster should be assessed.

In this study, Twitter communication during the Great East Japan Earthquake of March 11, 2011 was assessed. The hypothesis of this study was that usage of Twitter had psychological effects on victims of the disaster.

A cross-sectional questionnaire survey was carried out in cooperation with a major Japanese newspaper three months after the disaster, and 1,144 volunteer participants responded. They were asked about their health, area of residence, property damage they had experienced, information sources they used at the time of the disaster, and their usage of Twitter. Further, the Twitter users were divided into two groups—with and without disaster experience. Their psychological effects relating to feelings of relief, stress or anxiety that they experienced in using Twitter were compared between two groups, and Twitter's psychological risk of disaster experience was estimated as an odds ratio.

Twitter users in this study tended to reside in disaster-affected areas and thought Twitter was a credible information source during the time of the disaster. The psychological effect of Twitter differed based on participants’ disaster experience and gender. Females with disaster experience reported more feelings of relief and stress as a result of using Twitter compared to females who did not experience the disaster. On the other hand, males with disaster experience only reported more stress experiences as a result of using Twitter compared to those without disaster experience.

Twitter users with disaster experience had a higher usage of Twitter than those without disaster experience. Social media might have had a material psychological influence on people who experienced disaster, and the effect differed by gender. Regardless of gender, negative feelings were transmitted easily among people who experienced the disaster. It was anticipated that the application of Twitter in a disaster situation will be expanded further by taking these findings into consideration.

UmiharaJ, NishikitaniM. Emergent Use of Twitter in the 2011 Tohoku Earthquake. Prehosp Disaster Med.2013;28(5):1-7.

Methods of defining hospital disaster preparedness are poorly defined in the literature, leaving wide discrepancies between a hospital's self-reported preparedness and that assessed by an objective reviewer.

This study compared self-reported surge capacity data from individual hospitals, obtained from a previously reported long-distance tabletop drill (LDTT) prior to the 2010 FIFA World Cup tournament in Cape Town, South Africa, with surge capacity data assessed by an on-site survey inspection team.

In this prospective, observational study, contact persons used in the prior LDTT assessing hospital disaster preparedness in the lead-up to the 2010 FIFA World Cup made surge capacity assessments (licensed bed capacity plus surge capacity beds) for the respiratory intensive care unit (RICU), neonatal intensive care unit (NICU), medical intensive care unit (MICU), and general medical/surgical beds in each hospital. Following the 2010 World Cup, this data was then re-evaluated by an on-site survey team consisting of two of the authors.

The contact persons for the individual hospitals from the LDTT underreported their individual hospital's surge capacity in 86% (95% CI, 46%-99%) of RICU beds; 100% (95% CI, 63%-100%) of MICU beds; 75% (95% CI, 40%-94%) of NICU beds; and 71% (95% CI, 35%-92%) of medical/surgical beds compared with the on-site inspection team.

The contact persons for the LDTT overwhelmingly underreported surge capacity beds compared with the surge capacity determined by the on-site inspection team.

ValeskyW, RoblinP, PatelB, AdelaineJ, ZehtabchiS, ArquillaB. Assessing Hospital Preparedness: Comparison of an On-site Survey with a Self-reported, Internet-based, Long-distance Tabletop Drill. Prehosp Disaster Med. 2013;28(4):1-4.

Dealing with major incidents requires an immediate and coordinated response by multiple organizations. Communicating and coordinating over multiple geographical locations and organizations is a complex process. One of the greatest challenges is patient tracking and tracing. Often, data about the number of victims, their condition, location and transport is lacking. This hinders an effective response and causes public distress. To address this problem, a Victim Tracing and Tracking system (ViTTS) was developed.

An online ViTTS was developed based on a wireless network with routers on ambulances, and direct online registration of victims and their triage data through barcode injury cards. The system was tested for feasibility and usability during disaster drills.

The formation of a local radio network of hotspots with mobile routers and connection over General Packet Radio Service (GPRS) to the central database worked well. ViTTS produced accurately stored data, real-time availability, and a real-time overview of the patients (number, seriousness of injury, and location).

The ViTTS provides a system for early, unique registration of victims close to the impact site. Online application and connection of the various systems used by the different chains in disaster relief promotes interoperability and enables patient tracking and tracing. It offers a real-time overview of victims to all involved disaster relief partners, which is necessary to generate an adequate disaster response.

MarresGMH, TaalL, BemelmanM, BoumanJ, LeenenLPH. Online Victim Tracking and Tracing System (ViTTS) for Major Incident Casualties. Prehosp Disaster Med. 2013;28(4):1-9.

Hospitals are expected to continue to provide medical care during disasters. However, they often fail to function under these circumstances. Vulnerability to disasters has been shown to be related to the socioeconomic level of a country. This study compares hospital preparedness, as measured by functional capacity, between Iran and Sweden.

Hospital affiliation and size, and type of hazards, were compared between Iran and Sweden. The functional capacity was evaluated and calculated using the Hospital Safety Index (HSI) from the World Health Organization. The level and value of each element was determined, in consensus, by a group of evaluators. The sum of the elements for each sub-module led to a total sum, in turn, categorizing the functional capacity into one of three categories: A) functional; B) at risk; or C) inadequate.

The Swedish hospitals (n = 4) were all level A, while the Iranian hospitals (n = 5) were all categorized as level B, with respect to functional capacity. A lack of contingency plans and the availability of resources were weaknesses of hospital preparedness. There was no association between the level of hospital preparedness and hospital affiliation or size for either country.

The results suggest that the level of hospital preparedness, as measured by functional capacity, is related to the socioeconomic level of the country. The challenge is therefore to enhance hospital preparedness in countries with a weaker economy, since all hospitals need to be prepared for a disaster. There is also room for improvement in more affluent countries.

DjalaliA, CastrenM, KhankehH, GrythD, RadestadM, OhlenG, KurlandL. Hospital Disaster Preparedness as Measured by Functional Capacity: a Comparison between Iran and Sweden. Prehosp Disaster Med.2013;28(5):1-8.

Patients with possible spinal injury must be immobilized properly during transport to medical facilities. The aim of this research was comparing spinal immobilization using a long backboard (LBB) with using a vacuum mattress splint (VMS) in trauma victims transported by an Emergency Medical Services (EMS) system.

In this randomized clinical trial, 60 trauma victims with possible spinal trauma were divided to two groups, each group immobilized with one of the two instruments. Speed and ease of application, immobilization rate, and the patients’ comfort were recorded.

In this survey, LBB was faster to apply: 211.66 (SD = 28.53) seconds vs 654.00 (SD = 16.61) seconds. Various measures of immobilization were better by LBB. Also, LBB offered a significant improvement in comfort over a VMS for the patient with possible spinal injury. All of the results were statistically significant.

The results of this study showed that immobilization using LBB was easier, faster, and more comfortable for the patient, and provided additional decrease in spinal movement when compared with a VMS.

MahshidfarB, MofidiM, YariA, MehrsoroshS. Long Backboard versus Vacuum Mattress Splint to Immobilize Whole Spine in Trauma Victims in the Field: a Randomized Clinical Trial. Prehosp Disaster Med. 2013;28(5):1-4.

According to US military data, airway obstruction is the third leading cause of possibly preventable death in combat. In the absence of law enforcement-specific medical training, military experience has been translated to the law enforcement sector. The purpose of this study was to determine whether airway obstruction represents a significant cause of possibly preventable death in police officers, and whether current military combat lifesaver training programs might have prevented these fatalities.

De-identified, open-source US Federal Bureau of Investigation (FBI) Uniform Crime Report Law Enforcement Officers Killed and Assaulted (LEOKA) data for the years 1998-2007 were reviewed. Cases were included if officers were on duty at the time of fatal injury and died within one hour from time of wounding from penetrating face or neck trauma. After case identification, letters requesting autopsy reports were sent to the departments of victim officers. Reports were abstracted into a Microsoft Excel database.

During the study period, 42 of 533 victim officers met inclusion criteria. Departmental response rate was 85.7%. Autopsy reports were provided for 29 officers; 23 (54.8%) cases remained in the final analysis. All officers died from gunshot wounds. No coroner specifically identified airway obstruction as either a direct cause of death or contributing factor. Based upon autopsy findings, three of 341 officers possibly succumbed to airway trauma (0.9%; 95% CI, 0.0%-1.9%). Endotracheal intubation was the most common advanced airway management technique utilized during attempted resuscitation.

The limited LEOKA data suggests that acute airway obstruction secondary to penetrating trauma appears to be a rare cause of possibly preventable death in police officers. Based upon the nature of airway trauma, nasopharyngeal airways would not be expected to be an effective lifesaving intervention. This study highlights the requirement for a comprehensive mortality and “near miss” database for law enforcement officers.

FisherL, CallawayD, SztajnkrycerM. Incidence of Fatal Airway Obstruction in Police Officers Feloniously Killed in the Line of Duty: A 10-Year Retrospective Analysis. Prehosp Disaster Med.2013;28(5):1-5.

Police officers often serve as first responders during out-of-hospital cardiac arrests (OHCA). Current knowledge and attitudes about resuscitation techniques among police officers are unknown.

This study evaluated knowledge and attitudes about cardiopulmonary resuscitation (CPR) and automated external defibrillators (AEDs) among urban police officers and quantified the effect of video self-instruction (VSI) on these outcomes.

Urban police officers were enrolled in this online, prospective, educational study conducted over one month. Demographics, prior CPR-AED experience, and baseline attitudes were queried. Subjects were randomized into two groups. Each group received a slightly different multiple-choice test of knowledge and crossed to the alternate test after the intervention, a 10-minute VSI on CPR and AEDs. Knowledge and attitudes were assessed immediately before and after the intervention. The primary attitude outcome was entering “very likely” (5-point Likert) to do chest compressions (CC) and use an AED on a stranger. The primary knowledge outcomes were identification of the correct rate of CC, depth of CC, and action in an OHCA scenario.

A total of 1616 subjects responded with complete data (63.6% of all electronic entries). Randomization produced 819 participants in group 1, and 797 in group 2. Groups 1 and 2 did not differ significantly in any background variable. After the intervention, subjects “very likely” to do CC on a stranger increased by 17.2% (95% CI, 12.5%-21.8%) in group 1 and 21.2% (95% CI, 16.4%-25.9%) in group 2. Subjects “very likely” to use an AED on a stranger increased by 20.0% (95% CI, 15.3%-24.7%) in group 1 and 25.0% (95% CI, 20.2%-29.6%) in group 2. Knowledge of correct CC rate increased by 59.0% (95% CI, 55.0%-62.8%) in group 1 and 64.8% (95% CI, 60.8%-68.3%) in group 2. Knowledge of correct CC depth increased by 44.8% (95% CI, 40.5%-48.8%) in group 1 and 54.4% (95% CI, 50.3%-58.3%) in group 2. Knowledge of correct action in an OHCA scenario increased by 27.4% (95% CI, 23.4%-31.4%) in group 1 and 27.2% (95% CI, 23.3%-31.1%) in group 2.

Video self-instruction can significantly improve attitudes toward and knowledge of CPR and AEDs among police officers. Future studies can assess the impact of VSI on actual rates of CPR and AED use during real out-of-hospital cardiac arrests.

AldeenAZ, HartmanND, SequraA, PhullA, ShawDM, ChiampasGT, CourtneyDM. Video Self-instruction for Police Officers in Cardiopulmonary Resuscitation and Automated External Defibrillators. Prehosp Disaster Med. 2013;28(5):1-6.

High-dose intravenous nitroglycerin is a common in-hospital treatment for respiratory distress due to congestive heart failure (CHF) with hypertension. Intravenous (IV) nitroglycerin administration is impractical in the prehospital setting. In 2011, a new regional Emergency Medical Services (EMS) protocol was introduced allowing advanced providers to treat CHF with high-dose oral nitroglycerin. The protocol calls for patients to be treated with two sublingual tabs (0.8 mg) when systolic blood pressure (SBP) was >160 mm Hg, or three sublingual tabs (1.2 mg) when SBP was >200 mm Hg, every five minutes as needed.

To assess the protocol's safety, the incidence of hypotension following prehospital administration of multiple simultaneous nitroglycerin (MSN) tabs by EMS providers was studied.

This study was a retrospective cohort study of patients from a single commercial EMS agency over a 6-month period. Records from patients with at least one administration of MSN were reviewed. For each administration, the first documented vital signs pre- and post-administration were compared. Administrations were excluded if pre- or post-administration vital signs were missing.

One hundred case-patients had at least one MSN administration by an advanced provider during the study period. Twenty-five case-patients were excluded due to incomplete vital signs. Seventy-five case-patients with 95 individual MSN administrations were included for analysis. There were 65 administrations of two tabs, 29 administrations of three tabs, and one administration of four tabs. The mean change in SBP following MSN was -14.7 mm Hg (SD = 30.7; range, +59 to -132). Three administrations had documented systolic hypotension in the post-administration vital signs (97/71, 78/50 and 66/47). All three patients were over 65 years old, were administered two tabs, had documented improved respiratory status, and had repeat SBP of at least 100. The incidence of hypotension following MSN administration was 3.2%.

High-dose oral nitroglycerin administration is a practical alternative to IV nitroglycerin in the prehospital setting when administered by advanced providers. The prehospital protocol for high dose oral nitroglycerin was demonstrated to be safe in the cohort of patients studied. Limitations of the study include the relatively small sample size and the inability to identify hypotension that may have occurred following the cessation of data collection in the field.

Hypotension was rare and self-limited in prehospital patients receiving MSN.

ClemencyB, ThompsonJ, TundoG, LindstromH. Prehospital High-dose Sublingual Nitroglycerin Rarely Causes Hypotension. Prehosp Disaster Med. 2013;28(5):1-4.

Heat waves have significant impacts on mortality and morbidity. However, little is known regarding effects on pre-admission health outcomes such as ambulance attendances, particularly in subtropical regions.

This study investigated both main temperature effects and the added effects of heat waves on ambulance attendances in Brisbane, a subtropical city in Australia.

Daily data relating to 783,935 ambulance attendances, along with data on meteorological variables and air pollutants, were collected for the period 2000-2007. Ambient temperature (main) effects were assessed using a distributed lag nonlinear approach that accounted for delayed effects of temperature, while added heat wave effects were incorporated separately using a local heat wave definition. Effect estimates were obtained for total, cardiovascular and respiratory attendances, and different age groups.

Main effects of temperature were found for total attendances, which increased by 50.6% (95% CI, 32.3%-71.4%) for a 9.5°C increase above a reference temperature of 29°C. An added heat wave effect on total attendances was observed (18.8%; 95% CI, 6.5%-32.5%). Significant effects were found for both respiratory and cardiovascular attendances, particularly for those aged 65 and above.

Ambulance attendances can be significantly impacted by sustained periods of high temperatures, and are a valid source of early detection of the effects of extreme temperatures on the population. The planning of ambulance services may need to be adapted as a consequence of increasing numbers of heat waves in the future. Ambulance attendance data also should be utilized in the development of heat warning systems and climate change adaptation strategies.

TurnerLR, ConnellD, TongS. The Effect of Heat Waves on Ambulance Attendances in Brisbane, Australia. Prehosp Disaster Med. 2013;28(5):1-6.

Electronic medical records (EMRs) are considered superior in documentation of care for medical practice. Current disaster medical response involves paper tracking systems and radio communication for mass-casualty incidents (MCIs). These systems are prone to errors, may be compromised by local conditions, and are labor intensive. Communication infrastructure may be impacted, overwhelmed by call volume, or destroyed by the disaster, making self-contained and secure EMR response a critical capability.

As the prehospital disaster EMR allows for more robust content including protected health information (PHI), security measures must be instituted to safeguard these data. The Wireless Internet Information System for medicAl Response in Disasters (WIISARD) Research Group developed a handheld, linked, wireless EMR system utilizing current technology platforms. Smart phones connected to radio frequency identification (RFID) readers may be utilized to efficiently track casualties resulting from the incident. Medical information may be transmitted on an encrypted network to fellow prehospital team members, medical dispatch, and receiving medical centers. This system has been field tested in a number of exercises with excellent results, and future iterations will incorporate robust security measures.

A secure prehospital triage EMR improves documentation quality during disaster drills.

DeMersG, KahnC, JohanssonP, BuonoC, ChiparaO, GriswoldW, ChanT. Secure Scalable Disaster Electronic Medical Record and Tracking System. Prehosp Disaster Med. 2013;28(5):1-4.

The building of prehospital emergency medical care systems in developing and lower middle-income countries (as defined by the World Bank) is a critical step in those countries’ efforts to reduce unnecessary morbidity and mortality. This case report presents the development of a prehospital care system in Jaffna District, Sri Lanka and provides the results of the system's first year of operations, the likely reasons for the results, and the prospects for sustained operations of the system. The goal of this report is to add to the literature surrounding Emergency Medical Services (EMS) in developing countries by providing insight into the implementation of a prehospital emergency care system in developing and lower middle-income settings.

The level of utilization and the financial performance of the system during its first year of operation were analyzed using data from the Jaffna Regional Director of Health Services (RDHS) Call Center database and information from the implementing organization, Medical Teams International.

The system responded to >2000 emergency calls in its first 11 months of operation. The most utilized ambulance of the system experienced only a US $13.50 loss during the first 12 months of operation. Factors such as up-front support, a systematic approach, and appropriateness contributed to the successful implementation of the Jaffna prehospital EMS system.

The implementation of a prehospital EMS system and its functioning were successful in terms of utility and, in many regards, financial stability. The system's success in development may serve as a potential model for implementing prehospital emergency medical care in other developing and lower middle-income country settings, keeping in mind factors outside of the system that were integral to its developmental success.

ZimmermanJR, BertermannKM, BollingerPJ, WoodyardDR. Prehospital System Development in Jaffna, Sri Lanka. Prehosp Disaster Med. 2013;28(5):1-8.

Pain associated with pediatric trauma is often under-assessed and under-treated in the out-of-hospital setting. Administering an opioid such as fentanyl via the intranasal route is a safe and efficacious alternative to traditional routes of analgesic delivery and could potentially improve pain management in pediatric trauma patients.

The study sought to examine the effect of introducing the mucosal atomization device (MAD) on analgesia administration as an alternative to intravenous fentanyl delivery in pediatric trauma patients. The hypothesis for the study is that the introduction of the MAD would increase the administration of fentanyl in pediatric trauma patients.

The research utilized a 2-group design (pre-MAD and post-MAD) to study 946 pediatric trauma patients (age <16) transported by a large, urban EMS agency to one of eight hospitals in Marion County, which is located in Indianapolis Indiana. Two emergency medicine physicians independently determined whether the patient met criteria for pain medication receipt and a third reviewer resolved any disagreements. A comparison of the rates of fentanyl administration in both groups was then conducted.

There was no statistically significant difference in the rate of fentanyl administration between the pre-MAD (30.4%) and post-MAD groups (37.8%) (P = .238). A subgroup analysis showed that age and mechanism of injury were stronger predictors of fentanyl administration.

Contrary to the hypothesis, the addition of the MAD device did not increase fentanyl administration rates in pediatric trauma patients. Future research is needed to address the barriers to analgesia administration in pediatric trauma patients.

O'DonnellDP, SchaferLC, StevensAC, WeinsteinE, MiramontiCM, KozakMA. Effect of Introducing the Mucosal Atomization Device for Fentanyl Use in Out-of-Hospital Pediatric Trauma Patients. Prehosp Disaster Med. 2013;28(4):1-3.

In Italy, administration of medications or advanced procedures dictates the prehospital presence of a physician to initiate treatment. Nursing staff is often used as dispatchers in Italian emergency medical ambulance services. There is little data about nursing dispatch performance in detecting high-acuity patients who need prehospital medications and procedures.

To determine the ability of a dispatch center staffed by emergency ambulance nurses to detect prehospital need for physician interventions in the context of a semi-rural area Emergency Medical Services system.

A retrospective analysis of 53,606 calls from the Rovigo Emergency Ambulance Services’ database was undertaken. Physician prehospital interventions were defined as the administration of medications or procedures (advanced airway management and ventilation, pneumothorax decompression, fluid replacement therapy, external defibrillation, cardioversion and pacing). The dispatch codes (assigned by a subjective decision-making process as Red, Yellow, or Green) of all transported prehospital patient calls were matched with an out-of-hospital triage system staffed by clinicians to determine the number of correctly identified prehospital need of physician interventions. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated.

The sensitivity of subjective experience-based nursing dispatch in detecting the need for physician interventions was 78.0% (95% CI, 76.9%-79.1%), with a PPV of 36.6% (95% CI, 35.8%-37.5%). Specificity was 83.8% (95% CI: 83.4%-84.1%), with an NPV of 96.9% (95% CI, 96.8%-97.1%).

A dispatch center staffed by nurses with six years of experience and three months of training correctly identified when not to send a doctor to the scene in the absence of need for physician interventions, using a subjective decision-making process. The nurses staffing the dispatch center also worked in the field. Dispatch center staff were not able to predict when there was no need for physician interventions in high-acuity dispatch code patients, resulting in an over-triage and use of emergency physicians on scene.

LeopardiM, SommacampagnaM.Emergency Nursing Staff Dispatch: Sensitivity and Specificity in Detecting Prehospital Need for Physician Interventions During Ambulance Transport in Rovigo Emergency Ambulance Service, Italy. Prehosp Disaster Med. 2013;28(5):1-6.