Paramedics are a vital component of the Emergency Medical Services (EMS) workforce and the United States health care system. The continued provision of high-quality care demands constantly improving education at accredited institutions. To date, only limited characteristics of paramedic education in the United States have been documented and studied in the literature. The objective of this study was to describe the educational infrastructure of accredited paramedic programs in the United States in 2018.

This is a retrospective, cross-sectional evaluation of the 2018 paramedic program annual report from The Committee on Accreditation of Educational Programs for the EMS Professions (CoAEMSP; Rowlett, Texas USA). The dataset includes detailed program metrics. Additionally, questions concerning program characteristics, demographics, and resources were asked as part of the evaluation. Resource availability was assessed via the Resource Assessment Matrix (RAM) with a benchmark of 80%. Included in the analysis are all paramedic programs with students enrolled. Descriptive statistics were calculated (median, [interquartile range/IQR]).

A total of 677 programs submitted data (100% response rate). Of these, 626 met inclusion criteria, totaling 17,422 students. Program annual enrollment varied greatly from one to 362 with most programs having small sizes (18 students [IQR 12-30]). Program duration was 12 months [IQR 12-16] with total hours of instruction being approximately 1,174 [IQR 1069-1304], 19% of which were dedicated to clinical experience. Full-time faculty sizes were small (two faculty members [IQR 1-3]) with most programs (80%) having annual operating budgets below USD$500,000. For programs with an annual budget below USD$100,000 (34% of programs), annual enrollment was approximately 14 students [IQR 9-21]. Degrees conferred by programs included certificates (90%), associate degrees (55%), and bachelor’s degree (2%). Simulation access was assessed with nearly all (100%) programs reporting simple task trainers and 84% of programs investing in advanced simulation manikins. Seventy-eight percent of programs met the RAM benchmark.

Most paramedic educational programs in the United States have small annual enrollments with low numbers of dedicated faculty and confer certificates and associate degrees. Nearly one-quarter of paramedic educational programs are not adequately resourced. This study is limited by self-reported data to the national accreditation agency. Future work is needed to identify program characteristics that are associated with high performance.

The Glasgow Coma Scale (GCS) was devised in 1974 as a way of tracking the progress of neurosurgical coma patients. It is comprised of three components: eye movement, response to verbal commands, and motor function. Since then, it has become the primary tool in Emergency Medical Services (EMS) and emergency departments for assessing cognitive function and triaging patients in the setting of acute trauma. However, the GCS was never intended to be used in such a way. It has been demonstrated that there is a high degree of inter-rater variability when assigning GCS scores for trauma patients. Potential differences in GCS score assignments between different countries were examined. It was hypothesized there would be differences in mean total and component scores.

Using de-identified data from the Pan-Asian Trauma Outcomes Study (PATOS), the distributions of GCS scores from six countries were assessed: Japan, Korea, Malaysia, Taiwan, Thailand, and Vietnam. Using SPSS data analysis, a one-way ANOVA and Bonferroni post-hoc tests were performed to compare the means of the three GCS components and the total GCS scores reported by EMS personnel caring for trauma patients.

Data from 15,173 cases showed significant differences in mean total GCS score between countries (P <.001) as well as in mean component GCS scores (P <.001 for each of eye, verbal, and motor). Post-hoc tests showed that EMS personnel in Korea assigned significantly lower scores compared to all other countries in both component and total GCS scores. Field personnel in Japan, Malaysia, and Vietnam assigned the highest scores and significantly differed from the other three countries on component and total scores; Thailand and Taiwan had similar scores but significantly differed from the other four countries on component and total scores. Visual inspection of mean component and total GCS score histograms revealed differences in score assignment patterns among countries.

There are a number of significant differences in the mean total and component GCS scores assigned by EMS personnel in the six Asian countries studied. More investigation is necessary to determine if there is clinical significance to these differences in GCS score assignments, as well as the reasons for the differences.

Research in cardiac care has identified significant gender-based differences across many outcomes. Women with heart disease are less likely both to be diagnosed and to receive standard care. Gender-based disparities in the prehospital setting are under-researched, but they were found to exist within rates of 12-lead electrocardiogram (ECG) acquisition within one urban Emergency Medical Services (EMS) agency.

This study evaluates the quality improvement (QI) initiative that was implemented in that agency to raise overall rates of 12-lead ECG acquisition and reduce the gap in acquisition rates between men and women.

This QI project included two interventions: revised indications for 12-lead acquisition, and training that highlighted sex- and gender-based differences relevant to patient care. To evaluate this project, a retrospective database review identified all patient contacts that potentially involved cardiac assessment over 18 months. The primary outcome was the rate of 12-lead acquisition among patients with qualifying complaints. This was assessed by mean rates of acquisition in before and after periods, as well as segmented regression in an interrupted time series. Secondary outcomes included differences in rates of 12-lead acquisition, both overall and in individual complaint categories, each compared between men/women and before/after the interventions.

Among patients with qualifying complaints, the mean rate of 12-lead acquisition in the lead-in period was 22.5% (95% CI, 21.8% - 23.2%) with no discernible trend. The protocol change and training were each associated with a significant absolute level increase in the acquisition rate: 2.09% (95% CI, 0.21% - 4.0%; P = .03) and 3.2% (95% CI, 1.18% - 5.22%; P = .003), respectively. When compared by gender and time period, women received fewer 12-leads than men overall, and more 12-leads were acquired after the interventions than before. There were also significant interactions between gender and period, both overall (2.8%; 95% CI, 1.9% - 3.6%; P < .0001) and in all complaint categories except falls and heart problems.

This QI project resulted in an increase in 12-leads acquired. Pre-existing gaps in rates of acquisition between men and women were reduced but did not disappear. On-going research is examining the reasons behind these differences from the perspective of prehospital providers.

Police transport (PT) of penetrating trauma patients has the potential to improve survival rates. There are no well-established guidelines for PT of penetrating trauma patients.

This study examines the association between survival rate to hospital discharge of adult penetrating trauma patients and mode of transport (PT versus ground ambulance [GA]).

A retrospective, matched cohort study was conducted using the United States (US) National Trauma Data Bank (NTDB). All adult penetrating injury patients transported by police to trauma centers were identified and matched (one-to-four) to patients transported by GA for analysis. Descriptive analysis was carried out. The patients’ demographic and clinical characteristics were tabulated and stratified by the transport mode.

Out of the 733 patients with penetrating injuries, ground Emergency Medical Services (EMS) transported 513 patients and police transported 220 patients. Most patients were 16-64 years of age with a male (95.6%) and Black/African American race (79.0%) predominance. Firearm-related injuries (68.8%) were the most common mechanism of injury with the majority of injuries involving the body extremities (62.9%). Open wounds were the most common nature of injury (75.7%). The overall survival rate to hospital discharge was similar for patients transported by GA and by police (94.5% versus 92.7%; P = .343).

In this study, patients with penetrating trauma transported by police had similar outcomes to those transported by GA. As such, PT in penetrating trauma appears to be effective. Detailed protocols should be developed to further improve resource utilization and outcomes.

Mass gatherings (MGs) often bring together professionals and organizations that collaborate irregularly or have never engaged in joint working. They involve interaction and communication among multiple and diverse services, which can often prove challenging. Planning such an event is of paramount importance for its success, and interorganizational communication ranks among its most important aspects. Nonetheless, there is limited empirical evidence to support interagency communication in MGs.

This study used the 2017 Athens Marathon (Athens, Greece) as the empirical setting to examine how interorganizational communication was perceived among the multiple public health and safety professionals during the planning and implementation phase of the event.

Data comprised 15 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 three key components of interorganizational communication in such an event: (1) shared situational awareness; (2) interorganizational understanding; and (3) implementing liaison officers.

This study outlined the factors that influenced interorganizational communication before and during a MG. Practical implications arising from this study may inform the way organizers of marathons and other mass sporting events can engage in effective interorganizational communication.

Terrorists increasingly aim at so-called soft targets, such as hospitals. However, little is known about terrorist attacks against Emergency Medical Services (EMS).

This study aims to review all documented terrorist attacks against EMS that occurred world-wide from 1970-2019 using the Global Terrorism Database (GTD).

Reports of terrorist attacks against EMS were extracted from the GTD from 1970-2019. Data collection included temporal factors, attack and weapon type, number of casualties, and if it was a primary or secondary attack (secondary attack: deliberate attack against the first responders of an initial terrorist attack). Reports were excluded if EMS were not a target or if it was unclear whether they were a target. Chi-square tests were performed to evaluate trends over time.

There were 184 terrorist attacks against EMS, resulting in 748 deaths and 1,239 people injured. Terrorist attacks against EMS significantly increased over the past two decades. The “Middle East & North Africa” was the most frequently affected region with 81 attacks (44.0%) followed by “South Asia” with 41 attacks (22.3%). Bombings and explosions were the most common attack type (85 incidents; 46.2%) followed by armed assaults (68 incidents; 35.3%). Combined prehospital and hospital attacks were first reported in 2005 and occurred seven times. The first secondary attack against EMS dates from 1997, after which an increase was observed from 10 to 39 incidents in the periods 2000-2009 and 2010-2019, respectively.

This analysis of the GTD, which identified 184 terrorist attacks against EMS over a 50-year period, demonstrates that terrorist attacks against EMS have significantly increased during the years and that secondary attacks are an emerging risk. Bombings and explosions are the most common attack type. Terrorist attacks against EMS are most prevalent in countries with high level of internal conflicts, however, they have also occurred in western countries. These incidents may hold valuable information to prevent future attacks.

The rapid popularization of unmanned aerial vehicles (UAVs; also referred to as drones), in both the recreational and industrial sectors, has paved the way for rapid developments in drone capabilities. Although the threat of UAVs used by terrorists has been recognized by specialists in both Counter-Terrorism and Counter-Terrorism Medicine (CTM), there are limited data on the extent and characteristics of drone use by terrorist organizations.

Data collection was performed using a retrospective database search through the Global Terrorism Database (GTD). The GTD was searched using the internal database search functions for all terrorist attacks using UAVs from January 1, 1970 - December 31, 2019. Years 2020 and 2021 were not yet available at the time of the study. Primary weapon type, number and type of UAVs used, related attacks, location (country, world region), and number of deaths and injuries were collated. Results were exported into an Excel spreadsheet (Microsoft Corp.; Redmond, Washington USA) for analysis.

There were 76 terrorist attacks using UAVs. The first attack occurred in 2016, and the number of attacks per year varied considerably (range: 4-36). Forty-seven of the 76 attacks (70%) were successful. Twenty-seven individually listed events (36%) were related and part of nine coordinated, multi-part incidents. A total of 50 deaths and 132 injuries were recorded, which equated to 1.09 deaths (range: 0-6) and 2.89 injuries (range: 0-20) per successful attack. The mean number of UAVs used in an attack was 1.28 (range: 1-5) and multiple UAVs were used in 22% of attacks.

The use of UAVs to carry out terrorist attacks is on the rise. Seventy-six terrorist attacks using this novel method were recorded since 2016, killing 50 and injuring 132 people. While the use of UAV-related explosives appears less lethal than traditional explosive attacks, advancing technologies and swarming capabilities, increasing ability to carry larger payloads, and the possibility of UAVs to disperse chemical, biological, radiological, and nuclear (CBRN) weapons will likely increase UAV lethality in the future, requiring CTM specialists be more proactive.

Mass-casualty incidents (MCIs) and disasters are characterized by a high heterogeneity of effects and may pose important logistic challenges that could hamper the emergency rescue operations.

The main objective of this study was to establish the most frequent logistic challenges (red flags) observed in a series of Italian disasters with a problem-based approach and to verify if the 80-20 rule of the Pareto principle is respected.

A series of 138 major events from 1944 through 2020 with a Disaster Severity Score (DSS) ≥ four and five or more victims were analyzed for the presence of twelve pre-determined red flags.

A Pareto graph was built considering the most frequently observed red flags, and eventual correlations between the number of red flags and the components of the DSS were investigated.

Eight out of twelve red flags covered 80% of the events, therefore not respecting the 80-20 rule; the number of red flags showed a low positive correlation with most of the components of the DSS score. The Pareto analysis showed that potential hazards, casualty nest area > 2.5km2, number of victims over 50, evacuation noria over 20km, number of nests > five, need for extrication, complex access to victims, and complex nest development were the most frequently observed red flags.

Logistic problems observed in MCIs and disaster scenarios do not follow the 80-20 Pareto rule; this demands for careful and early evaluation of different logistic red flags to appropriately tailor the rescue response.

Rainfall-induced floods and landslides accounted for 20.7% of all disaster events in Japan from 1985 through 2018 and caused a variety of health problems, both directly and indirectly, including injuries, infectious diseases, exacerbation of pre-existing medical conditions, and psychological issues. More evidence of health problems caused by floods or heavy rain is needed to improve preparedness and preventive measures; however, collecting health data surrounding disaster events is a major challenge due to environmental hazards, logistical constraints, political and economic issues, difficulties in communication among stakeholders, and cultural barriers. In response to the West Japan Heavy Rain in July 2018, Emergency Medical Teams (EMTs) used Japan - Surveillance in Post-Extreme Emergencies and Disasters (J-SPEED) as a daily reporting template, collecting data on the number and type of patients they treated and sending it to an EMT coordination cell (EMTCC) during the response.

The aim of the study was to conduct a descriptive epidemiology study using J-SPEED data to better understand the health problems during floods and heavy rain disasters.

The number and types of health problems treated by EMTs in accordance with the J-SPEED (Ver 1.0) form were reported daily by 85 EMTs to an EMTCC, where data were compiled during the West Japan Heavy Rain from July 8 through September 11, 2018. Reported items in the J-SPEED form were analyzed by age, gender, area (prefecture), and time period.

The analysis of J-SPEED data from the West Japan Heavy Rain 2018 revealed the characteristics of a total of 3,617 consultations with the highest number of consultations (2,579; 71.3%) occurring between Day 5 and Day 12 of the 65-day EMT response. During the response period, skin disease was the most frequently reported health event (17.3%), followed by wounds (14.3%), disaster stress-related symptoms (10.0%), conjunctivitis (6.3%), and acute respiratory infections (ARI; 5.4%).

During the response period, skin disease was the most frequently reported health event, followed by wounds, stress, conjunctivitis, and ARIs. The health impacts of a natural disaster are determined by a variety of factors, and the current study’s findings are highly context dependent; however, it is expected that as more data are gathered, the consistency of finding will increase.

The Middle East and North Africa (MENA) region has been, like many parts of the world, a hotbed for terrorist activities. Terrorist attacks can affect both demand for and provision of health care services and often places a unique burden on first responders, hospitals, and health systems. This study aims to provide an epidemiological description of all terrorism-related attacks in the Middle East sustained from 1970-2019.

Data collection was performed using a retrospective database search through the Global Terrorism Database (GTD). The GTD was searched using the internal database search functions for all events which occurred in Iraq, Yemen, Turkey, Egypt, Syria, West Bank and Gaza Strip, Israel, Lebanon, Iran, Saudi Arabia, Bahrain, Jordan, Kuwait, United Arab Emirates, North Yemen, Qatar, and South Yemen from January 1, 1970 - December 31, 2019. Primary weapon type, primary target type, country where the incident occurred, and number of deaths and injuries were collated and the results analyzed.

A total of 41,837 attacks occurred in the Middle East from 1970-2019 accounting for 24.9% of all terrorist attacks around the world. A total of 100,446 deaths were recorded with 187,447 non-fatal injuries. Fifty-six percent of all attacks in the region occurred in Iraq (23,426), 9.4% in Yemen (3,929), and 8.2% in Turkey (3,428). “Private Citizens and Properties” were targeted in 37.6% (15,735) of attacks, 15.4% (6,423) targeted “Police,” 9.6% targeted “Businesses” (4,012), and 9.6% targeted “Governments” (4,001). Explosives were used in 68.4% of attacks (28,607), followed by firearms in 20.4% of attacks (8,525).

Despite a decline in terrorist attacks from a peak in 2014, terrorist events remain an important cause of death and injuries around the world, particularly in the Middle East where 24.9% of historic attacks took place. While MENA countries are often clustered together by economic and academic organizations based on geographical, political, and cultural similarities, there are significant differences in terrorist events between countries within the region. This is likely a reflection of the complexities of the intricate interplay between politics, culture, security, and intelligence services unique to each country.

Many capital cities around the world have been subjected to terrorist attacks on their transport systems with devastating consequences. Large crowds in small enclosed spaces, disruption to people movement, and the psychosocial and financial repercussions of attacks are some of the many soft target vulnerabilities of mass-transit systems.

This study is an epidemiological examination of all terrorism-related events targeting air, sea, and ground transport modalities sustained from 1970-2019, comparing the rates of fatal injuries (FI) and non-fatal injuries (NFI).

The Global Terrorism Database (GTD) was downloaded and searched using the internal database search functions for all events that occurred from January 1, 1970 - December 31, 2019. Years 2020 and 2021 were not yet available at the time of the study. “Transportation,” “Airport and Aircraft,” and “Maritime” as primary target types were selected for the purpose of this study, and events were further sub-classified by region, weapon type used, and by suicide attack (SA). “Airport personnel” were excluded. All classifications and sub-classifications were pre-determined by the GTD.

There were 8,729 transportation-related (air, sea, and ground) attacks documented during the study period with 19,020 fatalities and 45,218 NFI. This accounted for 5.2% of all terrorist attacks (168,003 total events), 5.6% of all FI (total 339,435), and 9.1% of all NFI (total 496,225). The mean FI was 2.2 per event and the mean NFI was 5.2 per attack.

South Asia (28.4%), Middle East and North Africa (18.2%), and South America (14.9%) accounted for 61.5% of all transport related attacks. Attacks on subways inflicted a disproportionately high 51.5 NFI per attack. Suicide attacks recorded the highest ratios for both FI (13.71 per attack) and NFI (139.00 per attack).

Transport modalities are vulnerable terrorist soft targets. The repercussions of attacks on public transport modalities represent a significant and unique psychosocial and economical risk to the affected communities. Suicide attacks on subways represent a unique and significantly higher casualty risk than other transport modalities. Risk mitigation strategies should be regularly revisited by Counter-Terrorism Medicine (CTM) specialists.

Hospitals are vulnerable to terrorist attacks, as they must remain easily accessible to the general public. Hospitals are also occupied with both staff and patients 24 hours a day, 365 days a year, meaning that any attack is almost guaranteed to inflict a multitude of casualties. In addition to the immediate effects of attacking a hospital, there are also uniquely devastating second- and third-order effects when hospitals are attacked.

A focused search of the Global Terrorism Database (GTD) was performed to identify terrorist attacks against hospitals throughout the world. Data between the years 1970-2018 were selected, which included 191,465 entries in total. These entries were then searched for incidents containing the term “hospital” and the results were manually searched to identify trends in the number of incidents occurring per year, as well as the armament that was employed, and the regions of the world where the attacks occurred.

A total of 430 terrorist attacks on hospitals were identified in the GTD, resulting in 1,291 deaths and an additional 1,921 wounded. The frequency of terrorist attacks against hospitals has been steadily increasing over the last two decades and is disproportionate to the overall increase in terrorist attacks against all target types. Attacks have been carried out against hospitals in 61 different countries. The most common method used in these attacks was “bombing/explosion,” which accounted for 299 attacks. Of the known terrorist groups identified in the GTD, “Houthi extremists (Anshar Allah)” and “Islamic State of Iraq and the Levant (ISIL)” carried out the greatest number of attacks on hospitals.

There has been a disproportionate rise in the frequency of terrorist attacks on hospitals when compared to other target types, highlighting the vulnerability of these key structures. Unsurprisingly, these attacks have inflicted large casualty counts in addition to disrupting community health care and disaster response. Attacks against hospitals have been reported on every inhabited continent except Australia, making their protection a matter of international security. The rate of terrorist attacks on hospitals has increased dramatically over the last two decades, creating an urgent need to develop improved defense strategies that will better ensure their protection.

The survivability of mass casualties exposed to a chemical attack is dependent on clinical knowledge, evidence-based practice, as well as protection and decontamination capabilities. The aim of this systematic review was to identify the knowledge gaps that relate to an efficient extraction and care of mass casualties caused by exposure to chemicals.

This systematic review was conducted from November 2018 through September 2020 in compliance with Cochrane guidelines. Five databases were used (MEDLINE, Web of Science Core Collection, Embase, Cochrane, and CINAHL) to retrieve studies describing interventions performed to treat victims of chemical attacks (protection, decontamination, and treatment). The outcomes were patient’s health condition leading to his/her stabilization (primary) and death (secondary) due to interventions applied (medical, protection, and decontamination).

Of the 2,301 papers found through the search strategy, only four publications met the eligibility criteria. According to these studies, the confirmed chemical poisoning cases in acute settings resulting from the attacks in Matsumoto (1994), Tokyo (1995), and Damascus (2014) accounted for 1,333 casualties including 11 deaths. No study reported comprehensive prehospital clinical data in acute settings. No mention was made of the integration of specialized capabilities in medical interventions such as personal protective equipment (PPE) and decontamination to prevent a secondary exposure. Unfortunately, it was not possible to perform the planned meta-analysis.

This study demonstrated gaps in clinical knowledge application regarding the medical extraction of casualties exposed during a chemical attack. Further research is required to optimize clinical practice integrating mixed capabilities (protection and decontamination) for the patient and medical staff.

In a mass-casualty incident (MCI) involving children, there is a need to apply accurate triage tools in order to help those who require important care, and at the same time, to avoid unnecessary use of resources. Thus, it is discussed which would be the best triage device to use in these situations. One of the most used is a modification of Simple Triage and Rapid Treatment, JumpSTART, whose performative quality this review focuses on.

This review sought to compare the performance parameters of JumpSTART with other triage algorithms used in pediatric disaster victims.

This systematic review was performed according to the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and registered with the PROSPERO database of systematic reviews with the number CRD42021258415. The last update of the search in the databases was on August 12, 2021 and resulted in six documents to be analyzed. The inclusion criteria included the peer-reviewed academic papers in English, Portuguese, Spanish, and Italian languages, and the databases used were PubMed, Scopus, MEDLINE/Bireme (Virtual Library of Health), Web of Science, and CINAHL, which executes the query on the topic, keywords, or abstracts. Also to be included, documents that were available with full-text access through CAPES, Google, or Google Scholar. Books, non-academic research, and content in languages other than the presented ones were represented as exclusion criteria. The Joanna Briggs Institute (JBI) checklists were used to evaluate the methodological quality of the retrieved studies. The results were presented through narrative synthesis. This review was not funded.

Of the collected publications, five articles were used to carry out this review, with the addition of an extra article captured by citation tracking. The findings from the obtained results were that JumpSTART was the preferred tool and presented the fastest speed of use. Only one of the five studies that dealt with accuracy showed JumpSTART as the most accurate algorithm, while three of the other four showed its inferiority in most aspects. In one study, no significant difference was observed amongst the chosen protocols.

There is insufficient evidence to validate JumpSTART as a universal triage tool, given the disparities in the results obtained from the comparisons. No tool performed satisfactorily well, therefore there is an urgent need to create a reliable algorithm.

Portable oxygen concentrators (POCs) are medical devices that use physical means to separate oxygen from the atmosphere to produce concentrated, medical-grade gas. Providing oxygen to low-resources environments, such as austere locations, military combat zones, rural Emergency Medical Services (EMS), and during disasters, becomes expensive and logistically intensive. Recent advances in separation technology have promoted the development of POC systems ruggedized for austere use. This review provides a comprehensive summary of the available data regarding POCs in these challenge environments.

PubMed, Google Scholar, and the Defense Technical Information Center were searched from inception to November 2021. Articles addressing the use of POCs in low-resource settings were selected. Three authors were independently involved in the search, review, and synthesis of the articles. Evidence was graded using Oxford Centre for Evidence-Based Medicine guidelines.

The initial search identified 349 articles, of which 40 articles were included in the review. A total of 724 study subjects were associated with the included articles. There were no Level I systematic reviews or randomized controlled trials.

Generally, POCs are a low-cost, light-weight tool that may fill gaps in austere, military, veterinary, EMS, and disaster medicine. They are cost-effective in low-resource areas, such as rural and high-altitude hospitals in developing nations, despite relatively high capital costs associated with initial equipment purchase. Implementation of POC in low-resource locations is limited primarily on access to electricity but can otherwise operate for thousands of hours without maintenance. They provide a unique advantage in combat operations as there is no risk of explosive if oxygen tanks are struck by high-velocity projectiles. Despite their deployment throughout the battlespace, there were no manuscripts identified during the review involving the efficacy of POCs for combat casualties or clinical outcomes in combat. Veterinary medicine and animal studies have provided the most robust data on the physiological effectiveness of POCs. The success of POCs during the coronavirus disease 2019 (COVID-19) pandemic highlights the potential for POCs during future mass-casualty events. There is emerging technology available that combines a larger oxygen concentrator with a compressor system capable of refilling small oxygen cylinders, which could transform the delivery of oxygen in austere environments if ruggedized and miniaturized. Future clinical research is needed to quantify the clinical efficacy of POCs in low-resource settings.

The Howard Springs Quarantine Facility (HSQF) is located in tropical Northern Australia and has 875 blocks of four rooms (3,500 rooms in total) spread over 67 hectares. The HSQF requires a large outdoor workforce walking outdoor pathways to provide individual care in the ambient climate. The personal protective equipment (PPE) required for the safety of quarantine workers varies between workgroups and limits body heat dissipation that anecdotally contributes to excessive sweating, which combined with heat stress symptoms of fatigue, headache, and irritability, likely increases the risk of workplace injuries including infection control breaches.

The purpose of this study was the description of qualitative and quantitative assessment for HSQF workers exposed to tropical environmental conditions and provision of evidenced-based strategies to mitigate the risk of heat stress in an outdoor quarantine and isolation workforce.

The study comprised two components - a cross-sectional physiological monitoring study of 18 workers (eight males/ten females; means: 41.4 years; 1.69m; 80.6kg) during a single shift in November 2020 and a subjective heat health survey completed by participants on a minimum of four occasions across the wet season/summer period from November 2020 through February 2021. The physiological monitoring included continuous core temperature monitoring and assessment of fluid balance.

The mean apparent temperature across first-half and second-half of the shift was 34.7°C (SD = 0.8) and 35.6°C (SD = 1.9), respectively. Across the work shift (mean duration 10.1 hours), the mean core temperature of participants was 37.3°C (SD = 0.2) with a range of 37.0°C - 37.7°C. The mean maximal core temperature of participants was 37.7°C (SD = 0.3). In the survey, for the workforce in full PPE, 57% reported feeling moderately, severely, or unbearably hot compared to 49% of those in non-contact PPE, and the level of fatigue was reported as moderate to severe in just over 25% of the workforce in both groups.

Heat stress is a significant risk in outdoor workers in the tropics and is amplified in the coronavirus disease 2019 (COVID-19) frontline workforce required to wear PPE in outdoor settings. A heat health program aimed at mitigating risk, including workplace education, limiting exposure times, encouraging hydration, buddy system, active cooling, and monitoring, is recommended to limit PPE breaches and other workplace injuries in this workforce.

Coronavirus disease 2019 (COVID-19), caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2), has killed nearly 800,000 Americans since early 2020. The disease has disproportionately affected older Americans, men, persons of color, and those living in congregate living facilities. Sacramento County (California USA) has used a novel Mobile Integrated Health Unit (MIH) to test hundreds of patients who dwell in congregate living facilities, including skilled nursing facilities (SNF), residential care facilities (ie, assisted living facilities [ALF] and board and care facilities [BCF]), and inpatient psychiatric facilities (PSY), for SARS-CoV-2.

The MIH was authorized and rapidly created at the beginning of the COVID-19 pandemic as a joint venture between the Sacramento County Department of Public Health (SCDPH) and several fire-based Emergency Medical Services (EMS) agencies within the county to perform SARS-CoV-2 testing and surveillance in a prehospital setting at a number of congregate living facilities. All adult patients (≥18 years) who were tested for SARS-CoV-2 infection by the MIH from March 31, 2020 through April 30, 2020 and lived in congregate living facilities were included in this retrospective descriptive cohort. Demographic and laboratory data were collected to describe the cohort of patients tested by the MIH.

During the study period, the MIH tested a total of 323 patients from 15 facilities in Sacramento County. The median age of patients tested was 66 years and the majority were female (72%). Overall, 72 patients (22%) tested positive for SARS-CoV-2 in congregate living settings, a higher rate of positivity than was measured across the county during the same time period.

The MIH was a novel method of epidemic surveillance that succeeded in delivering effective and efficient testing to patients who reside in congregate living facilities and was able to accurately identify pockets of infection within otherwise low prevalence areas. Cooperative prehospital models are an effective model to deliver out-of-hospital testing and disease surveillance that may serve as a blueprint for community-based care delivery for a number of disease states and future epidemics or pandemics.