Prompt prehospital care is essential for improving outcomes of road crash victims; however, this service is sub-optimal in developing countries because Emergency Medical Services (EMS) are not readily available. Training of lay responders in first aid has been suggested as a means of filling this gap in settings with inadequate EMS. This study was conducted to determine the effect of first aid training on the first aid knowledge and skills of commercial drivers.

A before-and-after study was conducted among 128 commercial drivers (62 intervention and 66 controls) selected by multi-stage sampling. Drivers’ first aid knowledge and skills were assessed at baseline, immediate, and three months post-intervention. The intervention involved a 2-day training session in first aid. Repeated measures ANOVA was used to test for differences in respondents’ pre- and post-intervention scores over the three assessment points.

Mean first aid knowledge scores for intervention drivers were 48.9% (SD=12.0), 57.8% (SD=11.2), and 59.2% (SD=9.0) at baseline, immediate, and three months post-intervention. Corresponding scores for the controls were 48.3% (SD=12.8), 39.2% (SD=15.3), and 46.8% (SD=15.3). Mean first aid skill scores for intervention drivers were 17.5% (SD=3.8), 80.7% (SD=8.3), and 72.3% (SD=16.8). Scores for control drivers were 16.5% (SD=4.5), 16.3% (SD=4.7), and 20.4% (SD=9.1), respectively. Repeated measures ANOVA showed significant differences in first aid knowledge and skills scores over the three phases. Independent t-test revealed significant differences in scores between the intervention and control groups post-intervention.

The training led to significant improvement in first aid knowledge and skills of intervention drivers. This confirms that lay responders can be trained in provision of first aid. The slight drop in skills scores, which occurred three months post-intervention, highlights the need for periodic refresher trainings to be conducted for the drivers in order to maintain the knowledge and skills acquired.

OlumideAO, AsuzuMC, KaleOO. Effect of First Aid Education on First Aid Knowledge and Skills of Commercial Drivers in South West Nigeria. Prehosp Disaster Med. 2015;30(6):579–585.

In cases of mass-casualty incidents (MCIs), triage represents a fundamental tool for the management of and assistance to the wounded, which helps discriminate not only the priority of attention, but also the priority of referral to the most suitable center.

The objective of this study was to evaluate the capacity of different prehospital triage systems based on physiological parameters (Shock Index [SI], Glasgow-Age-Pressure Score [GAP], Revised Trauma Score [RTS], and National Early Warning Score 2 [NEWS2]) to predict early mortality (within 48 hours) from the index event for use in MCIs.

This was a longitudinal prospective observational multi-center study on patients who were attended by Advanced Life Support (ALS) units and transferred to the emergency department (ED) of their reference hospital. Collected were: demographic, physiological, and clinical variables; main diagnosis; and data on early mortality. The main outcome variable was mortality from any cause within 48 hours.

From April 1, 2018 through February 28, 2019, a total of 1,288 patients were included in this study. Of these, 262 (20.3%) participants required assistance for trauma and injuries by external agents. Early mortality within the first 48 hours due to any cause affected 69 patients (5.4%). The system with the best predictive capacity was the NEWS2 with an area under the curve (AUC) of 0.891 (95% CI, 0.84-0.94); a sensitivity of 79.7% (95% CI, 68.8-87.5); and a specificity of 84.5% (95% CI, 82.4-86.4) for a cut-off point of nine points, with a positive likelihood ratio of 5.14 (95% CI, 4.31-6.14) and a negative predictive value of 98.7% (95% CI, 97.8-99.2).

Prehospital scores of the NEWS2 are easy to obtain and represent a reliable test, which make it an ideal system to help in the initial assessment of high-risk patients, and to determine their level of triage effectively and efficiently. The Prehospital Emergency Medical System (PhEMS) should evaluate the inclusion of the NEWS2 as a triage system, which is especially useful for the second triage (evacuation priority).

Prehospital providers regularly encounter patients with obstetrical emergencies. This study determined the frequency and outcome of out-of-hospital deliveries in an urban, all advanced life support (ALS) emergency medical services (EMS) system.

Retrospective review of all out-of-hospital records that involved women delivering babies in the care of prehospital providers from 1984–1988. The EMS system answered an average of 62,000 calls during the study period. The records of these patients were identified through a computer database.

A total of 81 out-of-hospital deliveries (1.4/month) occurred during the study years. The average age of the mothers was 24 years, and the average gestation period was 30 weeks. The women had an average of three previous pregnancies and two previous deliveries, and 10 were primagravida. Seventy-two (89%) of the deliveries occurred in the home. The paramedia encountered a variety of obstetrical and neonatal complications in 34% of the patient encounters. Nine neonates were delivered prior to the arrival of the paramedic team. Twenty-four neonates had Apgar scores calculated, and the one- and five-minute scores averaged eight and nine respectively. Five of the mothers had no prenatal care. Maternal complications included four patients noted to be hypertensive with the delivery, nine patients had some degree of vaginal bleeding, and in 33 patients, the prehospital providers did not deliver the placenta in the field. An EMS physician was in attendance for only two of the out-of-hospital deliveries.

In this urban EMS system, out-of-hospital deliveries, especially pre-term deliveries, are a common event. There appears to be a significant number of neonatal complications that confront paramedics. Generally, the paramedics were deficient in their documentation of the neonatal assessment. Continuing educational programs for paramedics should include reviewing normal and complicated vaginal deliveries as well as ALS measures for neonates. Protocols for obstetrical emergencies need to be developed and subjected to quality improvement measures.

Paramedics, especially those in urban settings, are likely to encounter obstetrical and neonatal emergencies and a significant number of associated complications. Emergency medical services systems and medical directors should have in place continuing educational programs, patient-care protocols, and continuous quality improvement measures to evaluate the care rendered to patients having out-of-hospital deliveries.

Despite emphasis by disaster experts on the importance of disaster preparedness, disaster management in Yemen has attracted only a little attention. Most of the efforts have focused on post-disaster relief activities rather than the pre-disaster preparedness and risk reduction. Hospitals have a crucial role in emergency response and should be prepared. Thus, the aim of this study was intended to assess the hospital preparedness of Aden Capital, South Yemen against disasters.

A cross-sectional study was conducted in June 2016. The sample was all Aden City facilities with a total number of 10 hospitals: five public and five private hospitals. A survey was done by using the World Health Organization (WHO; Geneva, Switzerland) standards checklist 2011.

The overall preparedness of Aden City hospitals to disasters fell at the unacceptable level of readiness, with an average mean of 46.6 (SD = 38.31; range 24-82). Of 10 hospitals, two ranked insufficient while eight hospitals were at unacceptable levels of preparedness.

All hospitals were noted grossly unprepared for potential disasters. Therefore, it is recommended that greater efforts be invested in creating a comprehensive strategy and national or local guidelines to establish an emergency management system based on the anticipated hazard and the needed resources.

NaserWN, IngrassiaPL, AladhraeS, AbdulraheemWA. A Study of Hospital Disaster Preparedness in South Yemen. Prehosp Disaster Med. 2018;33(2):133–138.

Mass-gathering music events, such as outdoor music festivals (OMFs), increase the risk of injuries and illnesses among attendees. This increased risk is associated with access to alcohol and other drugs by young people and an environment that places many people in close contact with each other.

The purpose of this report was to demonstrate how Haddon’s matrix was used to examine the factors that contributed to injuries and illnesses that occurred at 26 OMFs using data from the Ranse and Hutton’s minimum data set.

To help understand the kinds of injuries and illnesses experienced, Hutton et al identified previous patterns of patient presentations at 26 OMFs in Australia. To develop effective prevention strategies, the next logical step was to examine the risk factors associated with each illness/injury event. The Haddon matrix allows event practitioners to formulate anticipatory planning for celebratory-type events.

What was evident from this work was that the host, the agent, and the physical and social environments contributed to the development of injuries and illness at an event. The physical environment could be controlled, to a certain extent, through event design, safety guidelines, and legislation. However, balancing cultural norms, such as the importance placed on celebratory events, with the social environment is more difficult.

The use of the Haddon matrix demonstrates that interventions need to be targeted at all stages of the event, particularly both pre-event and during the event. The opportunity to promote health is lost by the time of post event. The matrix provided vital information on what factors may contribute to injury at OMFs; form this information, event planners can strategize possible interventions.

HuttonA , SavageC , RanseJ , FinnellD , KubJ . The Use of Haddon’s Matrix to Plan for Injury and Illness Prevention at Outdoor Music Festivals. Prehosp Disaster Med2015; 30(2):1-9

Awareness of the risk of spinal-cord damage in moving an unconscious person with a suspected neck injury into the “lateral recovery position,” coupled with the even greater risk of inadequate airway management if the person is not moved, has resulted in a suggested modification to the lateral recovery position for use in this circumstance.

It is proposed that the modification to the lateral recovery position reduces movement of the neck. In this modification, one of the patient's arms is raised above the head (in full abduction) to support the head and neck. The position is called the “HAINES modified recovery position.” HAINES is an acronym for High Arm IN Endangered Spine.

Neck movements in two healthy volunteers were measured by the use of video-image analysis and radiographic studies when the volunteers were rolled from the supine position to both the lateral recovery position and the HAINES modified recovery position.

For both subjects, the total degree of lateral flexion of the cervical spine in the HAINES modified recovery position was less than half of that measured during use of the lateral recovery position (while an open airway was maintained in each).

An unconscious person with a suspected neck injury should be positioned in the HAINES modified recovery position. There is less neck movement (and less degree of lateral angulation) than when the lateral recovery position is used, and, therefore, HAINES use carries less risk of spinal-cord damage.

A comprehensive state wide emergency medical services and helicopter transport system has been developed in the State of Maryland on the principle that early definitive care improves patient out comes. The purpose of this study was to determine if empirical data exist to support the theory that air medical transportation services provided by the Maryland State Police (Maryland State Police) Aviation Division contribute to an improved trauma patient survival rate in Maryland.

A retrospective study was conducted on the records of all patients transported by helicopter or ground ambulance and admitted to the R Adams Cowley Shock Trauma Center (R Adams Cowley Shock Trauma Center of the University of Maryland Medical System) of the University of Maryland Medical System. Data were obtained from the Maryland Institute of Emergency Medical Services Systems (Maryland Institute for Emergency Medical Services Systems) Shock Trauma Clinical Registry for the period January 1988 through July 1995, covering 23,002 patients. Patients included those transported directly from the scene of injury to the Maryland Institute for Emergency Medical Services Systems as well as those from interfacility transfers. All patients were stratified by injury severity and compared by outcome (mortality) using Mantel-Haenszel statistics.

During the study period, 11,379 patients were transported by ground and 11,623 were transported by Maryland State Police helicopter. The mean Injury Severity Score (Maryland State Police) for patients transported by ground was 12.7 (standard deviation = 12.52) and the mean Injury Severity Score for patients transported by air was 14.6 (Injury Severity Score = 13.42), p <0.001. Among patients classified as having a high index of injury severity, the mortality rate was lower among those transported by Maryland State Police helicopter than among those transported by ambulance. The mortality rate was significantly lower for air transported patient with an Injury Severity Score higher than 31.

The State of Maryland has demonstrated a commitment to its citizenry and invested heavily in its public safety air medical service. This study suggests the rapid air transport of victims of traumatic events by specialized personnel in Maryland has a positive effect on the outcome of severely injured patients. Further research is necessary to clarify the causal relationships in order to more fully elucidate the value of this resource.

Use of ketamine in the prehospital setting may be advantageous due to its potent analgesic and sedative properties and favorable risk profile. Use in the military setting has demonstrated both efficacy and safety for pain relief. The purpose of this study was to assess ketamine training, use, and perceptions in the civilian setting among nationally certified paramedics (NRPs) in the United States.

A cross-sectional survey of NRPs was performed. The electronic questionnaire assessed paramedic training, authorization, use, and perceptions of ketamine. Included in the analysis were completed surveys of paramedics who held one or more state paramedic credentials, indicated “patient care provider” as their primary role, and worked in non-military settings. Descriptive statistics were calculated.

A total of 14,739 responses were obtained (response rate=23%), of which 10,737 (73%) met inclusion criteria and constituted the study cohort. Over one-half (53%) of paramedics reported learning about ketamine during their initial paramedic training. Meanwhile, 42% reported seeking ketamine-related education on their own. Of all respondents, only 33% (3,421/10,737) were authorized by protocol to use ketamine. Most commonly authorized uses included pain management (55%), rapid sequence intubation (RSI; 72%), and chemical restraint/sedation (72%). One-third of authorized providers (1,107/3,350) had never administered ketamine, with another 32% (1,070/3,350) having administered ketamine less than five times in their career. Ketamine was perceived to be safe and effective as the vast majority reported that they were comfortable with the use of ketamine (94%) and would, in similar situations (95%), use it again.

This was the first large, national survey to assess ketamine training, use, and perceptions among paramedics in the civilian prehospital setting. While training related to ketamine use was commonly reported among paramedics, few were authorized to administer the drug by their agency’s protocols. Of those authorized to use ketamine, most paramedics had limited experience administering the drug. Future research is needed to determine why the prevalence of ketamine use is low and to assess the safety and efficacy of ketamine use in the prehospital setting.

BucklandDM, CroweRP, CashRE, GondekS, MalusoP, SirajuddinS, SmithER, DangerfieldP, ShapiroG, WankaC, PanchalAR, SaraniB. Ketamine in the Prehospital Environment: A National Survey of Paramedics in the United States. Prehosp Disaster Med. 2018;33(1):23–28.

Knowledge of injuries of earthquake victims is important to plan relief efforts. This cross-sectional study was conducted following the 08 October 2005 earthquake in Northern Pakistan to determine the pattern of injuries sustained and their relationship with age and gender in order to identify the medical needs in an earthquake-affected zone.

The study was conducted between 13 October and 23 October 2005 at the Emergency Relief Hospital, Doraha, Mansehra. From the 1,700 patients registered in the hospital, 310 were sampled randomly for the study. Demography and details of the patients' injuries were noted by history and physical examination. Twelve cases were omitted due to incomplete data.

Of the cases, 54% were female. Children ≤10 years old formed the largest age group. Isolated bone injuries were present in 41%, soft tissue injuries in 36%, and mixed injuries in 23% of the patients.The most common bone injury was lower limb fracture (52%), while the most common non-bone injury was non-infected, soft tissue wounds on the limbs (33%). Among patients with soft tissue injuries, gangrenous wounds were present in 9%, and grossly infected wounds in 30% (20% on limbs and 10% on rest of the body).

The population injured during the earthquake showed a higher proportion of females and children ≤10 years old, and lower limb bone injuries. The data highlight the need to address orthopedic, pediatric, and women's health issues, and for logistic arrangement of relevant diagnostic and therapeutic facilities at the initial stages of relief activities after earthquakes.

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.

The Flint Community Resilience Group (Flint, Michigan USA) and the Centers for Disease Control and Prevention (CDC; Atlanta, Georgia USA) assessed behavioral health concerns among community members to determine the impact of lead contamination of the Flint, Michigan water supply.

A Community Assessment for Public Health Emergency Response (CASPER) was conducted from May 17 through May 19, 2016 using a multi-stage cluster sampling design to select households and individuals to interview.

One-half of households felt overlooked by decision makers. The majority of households self-reported that at least one member experienced more behavioral health concerns than usual. The prevalence of negative quality of life indicators and financial concerns in Flint was higher than previously reported in the Michigan 2012 and 2014 Behavioral Risk Factor Surveillance System (BRFSS) survey.

The following can be considered to guide recovery efforts in Flint: identifying additional resources for behavioral health interventions and conducting follow-up behavioral health assessments to evaluate changes in behavioral health concerns over time; considering the impact of household economic factors when implementing behavioral health interventions; and ensuring community involvement and engagement in recovery efforts to ease community stress and anxiety.

FortenberryGZ, ReynoldsP, BurrerSL, Johnson-LawrenceV, WangA, SchnallA, PullinsP, KieszakS, BayleyegnT, WolkinA. Assessment of Behavioral Health Concerns in the Community Affected by the Flint Water Crisis — Michigan (USA) 2016. Prehosp Disaster Med. 2018;33(3):256–265.

The purpose of this study was to describe the regional locations of cardiac arrest, and to identify public locations and the annual incidence of arrests within the identified locations, in order to help to determine optimal placement of Automatic External Defibrillators (AEDs) under the regional Public Access Defibrillation (PAD) Program. This is a retrospective study.

The locations of cardiac arrest were abstracted from Ambulance Call Reports (ACRs) collected by the Essex-Kent Base Hospital Centre from regional ambulance services throughout the City of Windsor, and the Counties of Essex and Kent, Ontario, Canada, from 01 January 1994 through 31 December 2000. Arrest locations were grouped into five categories, and then the number of public venues was determined. Public sites were grouped into 28 Public Locations. Also included in the Public Sites were both General Industry and Outdoors categories. Categories identified but excluded from Public Sites were Institutions and Private Residences.

During the study, 2,295 arrests occurred, 152 cases were excluded, 2,142 arrests were categorized, (average annual incidence of 306 ±50.4 cardiac arrests), 329 (15.4%) of which were in Public Sites. Nineteen public venues had an average of >1 arrest/year, and nine public venues had an average of ≤1 arrest/year during the study, period. Calculations of the annual incidence of arrests for each public location were completed.

These findings have significant prehospital emergency cardiac care implications for communities that wish to strengthen/improve their responses to out-of-hospital cardiac arrests. Public Access Defibrillation Programs should identify the site-specific incidence of arrest within their communities in order to provide legitimacy for funding and planning of programs. Training and availability of AEDs will reduce the time to first shock, thus strengthening the chain-of-survival and will save more lives.

The undertreatment of pediatric pain is a significant concern among families, clinicians, and researchers. Although some have examined prehospital pain management, the deterrents to pediatric analgesia administration by Emergency Medical Services (EMS) have not yet been examined in Canada.

This study describes EMS pain-management practices and prehospital provider comfort treating pediatric pain. It highlights differences in pain management between adults and children and assesses the potential barriers, misconceptions, difficulties, and needs related to provision of pediatric analgesia.

A study-specific survey tool was created and distributed to all Primary Care Paramedics (PCPs) and Advanced Care Paramedics (ACPs) over four mandatory educational seminars in the city of Edmonton (Alberta, Canada) from September through December 2008.

Ninety-four percent (191/202) of EMS personnel for the city of Edmonton completed the survey. The majority of respondents were male (73%, 139/191), aged 26-35 (42%, 80/191), and had been in practice less than 10 years (53%, 101/191). Seventy-four percent (141/191) of those surveyed were ACPs, while 26% (50/191) were PCPs. Although the majority of respondents reported using both pain scales and clinical judgement to assess pain for adults (85%, 162/191) and adolescents (86%, 165/191), children were six times more likely than adults (31%, 59/191 vs 5%, 10/191) to be assessed by clinical judgement alone. Emergency Medical Services personnel felt more comfortable treating adults than children (P < .001), and they were less likely to treat children even if they were experiencing identical types and intensities of pain as adults (all P values <.05) and adolescents (all P values < .05). Twenty-five percent of providers (37/147) assumed pediatric patients required less analgesia due to immature nervous systems. Three major barriers to treating children's pain included limited clinical experience (34%, 37/110), difficulty in communication (24%, 26/110) and inability to assess children's pain accurately (21%, 23/110).

Emergency Medical Services personnel self-report that children's pain is less rigorously measured and treated than adults’ pain. Educational initiatives aimed at increasing clinical exposure to children, as well as further education regarding simple pain measurement tools for use in the field, may help to address identified barriers and discomfort with assessing and treating children.

RahmanA, CurtisS, DeBruyneB, SookramS, ThomsonD, LutzS, AliS. Emergency Medical Services Provider Comfort with Prehospital Analgesia Administration to Children. Prehosp Disaster Med. 2015;30(1):1-6.