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

This report describes the EMS response to thelargest single-day, ticketed concert held in NorthAmerica: the 2003 “Toronto Rocks!” Rolling StonesConcert.

Medical care was provided by paramedics,physicians, and nurses. Care sites includedambulances, medically equipped, all-terrainvehicles, bicycle paramedic units, first-aidtents, and a 124-bed medical facility thatincluded a field hospital and a rehydration unit.Records from the first-aid tents, ambulances,paramedic teams, and rehydration unit wereobtained. Data abstracted included patientdemographics, chief complaint, time of incident,treatment, and disposition.

More than 450,000 people attended the concert and1,870 sought medical care (42/10,000 attendees).No record was kept for the 665 attendees simplyrequesting water, sunscreen, or bandages. Of theremaining 1,205 patients, the average of the ageswas 28 ±11 years, and 61% were female.Seven-hundred, ninety-five patients (66%) werecared for at one of the first-aid tents.Physicians at the tents assisted in patientmanagement and disposition when crowds restrictedambulance movement. Common complaints includedheadache (321 patients; 27%), heat-relatedcomplaints (148; 12%), nausea or vomiting (91;7.6%), musculoskeletal complaints (83; 6.9%), andbreathing problems (79; 6.6%). Peak activityoccurred between 14:00 and 19:00 hours, when 102patients per hour sought medical attention.Twenty-four patients (0.5/10,000) were transferredto off-site hospitals.

This report on the EMS response, outcomes, androle of the physicians at a large single-day massgathering may assist EMS planners at futureevents.

Recently, there has been speculation that suiciderates increase after a disaster. Yet, in spite ofanecdotal reports, it is difficult to demonstratea systematic relationship between suicide anddisaster. Suicides are fairly rare events, andsingle disasters rarely have covered geographicareas with large enough populations to be able tofind statistically significant differences in suchrelatively rare events (annual suicide rates inthe United States average 12/100,000population).

Suicide rates increased in the three calendaryears (1994–1996) following the Northridgeearthquake as compared to the three calendar years(1991–1993) prior to the earthquake. Likewise thesuicide rates for 1993 are compared with the ratesin 1994. By looking at the suicide rates in athree-year period after the earthquake, theadditional disasters that befell SouthernCalifornia in 1995 and 1996 may have had anadditive effect on psychological disorders andsuicide rates that can be measured.

Data on suicide mortality were compiled for theyears from 1989 through 1996. Differences in ratesfor 1993 compared with 1994 and for three-yearperiods before and after the earthquake (1991–1993vs. 1994 –1996) were analyzed using az-statistic.

There is a statistically significant differencein the rates for the years prior to the earthquake(1991–1993) when pooled and compared to thesuicide rates for the years after the earthquake(1994–1996). The rates of suicide are lower in thethree years following the earthquake (11.85 vs.13.12/100,000 population) than they are in thethree years prior to the earthquake(z = -3.85, p<0.05). Likewise, there is a similar differencewhen comparing 1993 to 1994 (11.77 vs. 13.84,z = -3.57, p<0.05). The patterns of suicide remain similarover time, with males and non-Hispanic Whiteshaving the highest rates of suicide.

It does not appear that suicide rates increase asa result of earthquakes in this setting. Thisstudy demonstrates that the psychological impactsof the Northridge earthquake did not culminate inan increase in the rates of suicide.

Hospital disaster manuals and response plansoften lack formal command structure; instead, theyrely on the presence of key individuals who arefamiliar with hospital operations, or who are inleadership positions during routine, day-to-dayoperations. Although this structure occasionallymay prove to be successful, it is unreliable, asthis leadership may be unavailable at the time ofthe crisis, and may not be sustainable during aprolonged event. The Hospital Emergency IncidentCommand System (HEICS) provides a commandstructure that does not rely on specificindividuals, is flexible and expandable, and isubiquitous in the fire service, emergency medicalservices, military, and police agencies, thusallowing for ease of communication during eventmanagement.

A descriptive report of the implementation of theHEICS throughout a large healthcare network isreviewed. Results and Conclusions: Implementationof the HEICS provides a consistent commandstructure for hospitals that enables consistencyand commonality with other hospitals and disasterresponse entities.

In Latin America, there is a preponderance ofprehospital trauma deaths. However, scarceresources mandate that any improvements inprehospital medical care must be cost-effective.This study sought to evaluate thecosteffectiveness of several approaches toimproving training for personnel in threeambulance services in Mexico.

In Monterrey, training was augmented withPreHospital Trauma Life Support (PHTLS) at a costof [US]$150 per medic trained. In San Pedro,training was augmented with Basic Trauma LifeSupport (BTLS), Advanced Cardiac Life Support(ACLS), and a locally designed airway managementcourse, at a cost of $400 per medic. Process andoutcome of trauma care were assessed before andafter the training of these medics and at acontrol site.

The training was effective for both interventionservices, with increases in basic airway maneuversfor patients in respiratory distress in Monterrey(16% before versus 39% after) and San Pedro (14%versus 64%). The role of endotrachal intubationfor patients with respiratory distress increasedonly in San Pedro (5% versus 46%), in which themost intensive Advanced Life Support (ALS)training had been provided. However, mortalitydecreased only in Monterrey, where it had been thehighest (8.2% before versus 4.7% after) and wherethe simplest and lowest cost interventions wereimplemented. There was no change in process oroutcome in the control site.

This study highlights the importance of assuringuniform, basic training for all prehospitalproviders. This is a more cost-effective approachthan is higher-cost ALS training for improvingprehospital trauma care in environments such asLatin America.

To assess the religious spirituality of EMSpersonnel and their perception of the spiritualneeds of ambulance patients.

Emergency medical technicians (EMTs) andparamedics presenting to an urban, academicemergency department (ED) were asked to complete athree-part survey relating to demographics,personal practices, and perceived patient needs.Their responses were compared to those ofambulance patients presenting to an ED during aprevious study period and administered a similarsurvey.

A total of 143 EMTs and 89 paramedics returnedthe surveys. There were 161 (69.4%) male and 71(30.6%) female respondents with a median age rangeof 26–35 years old. Eighty-seven percent believedin God, 82% practiced prayer or meditation, 62%attended religious services occasionally, 55%belonged to a religious organization, 39% feltthat their beliefs affected their job, and 18%regularly read religious material. This wassimilar to the characteristics of ambulancepatients.

However, only 43% felt that occasionallyambulance patients presented with spiritualconcerns and 78% reported never or rarelydiscussing spiritual issues with patients.Contrastingly, >40% of ambulance patientsreported spiritual needs or concerns at the timeof ED presentation, and >50% wanted theirproviders to discuss their beliefs. Twenty-sixpercent of respondents reported praying ormeditating with patients, while 50% reportedpraying or meditating for patients.

Females were no more religious or spiritual thanmales, but were more likely to engage in prayerwith (OR = 2.38, p = 0.0049) orfor (OR = 6.45, p <0.0001)patients than their male counterparts.

EMTs and paramedics did not perceive spiritualconcerns as often as reported by ambulancepatients, nor did they commonly inquire about thereligious/spiritual needs of patients.

Aspirin is commonly administered for acutecoronary syndromes in the prehospital setting. Fewstudies have addressed the incidence of adverseeffects associated with prehospital administrationof aspirin. Objective: To determine the incidenceof adverse events following the administration ofaspirin by prehospital personnel.

Multi-center, retrospective, case series thatinvolved all patients who received aspirin in theprehospital setting from (01 August 1999–31January 2000). Patient encounter forms of theemergency medical services (EMS) of a metropolitanfire department were reviewed. All patients whohad a potential cardiac syndrome (i.e., chestpain, dyspnea) as documented on the EMS forms wereincluded in the review. Exclusion criteriaincluded failure to meet inclusion criteria, andchest pain secondary to apparent noncardiac causes(i.e., trauma). Hospital charts were reviewed froma subset of patients at the participatinghospitals. The major outcome was an adverse eventfollowing prehospital administration of aspirin.This outcome was evaluated during the EMSencounter, at emergency department discharge, orat six and 24-hours post-aspirin ingestion. Anadverse event secondary to aspirin ingestion wasdefined as anaphylaxis or allergic reactions, suchas rash or respiratory changes.

A total of 25,600 EMS encounter forms werereviewed, yielding 2,399 patients with a potentialcardiac syndrome. Prior to EMS arrival, 585patients had received aspirin, and 893 wereadministered aspirin by EMS personnel. No patientshad an adverse event during the EMS encounter. Ofthese patients, 229 were transported toparticipating hospitals and 219 medical recordswere available for review with no adversereactions recorded during their hospitalcourse.

Aspirin is rarely associated with adverse eventswhen administered by prehospital personnel forpresumed coronary syndromes.

The diagnosis of endotracheal tube (ETT)mal-position may be delayed in extremeenvironments. Several methods are utilized toconfirm proper ETT placement, but these methodscan be unreliable or unavailable in certainsettings. Thoracic sonography, previously utilizedto detect pneumothoraces, has not been tested toassess ETT placement.

Thoracic sonography could correlate withpulmonary ventilation, and thereby, help toconfirm proper ETT placement.

Thirteen patients requiring elective intubationunder general anesthesia, and data from two traumapatients were evaluated. Using a portable,hand-held, ultrasound (PHHU) machine, sonographicrecordings of the chest wall visceral-parietalpleural interface (VPPI) were recorded bilaterallyin each patient during all phases of airwaymanagement: (1) preoxygenation; (2) induction; (3)paralysis; (4) intubation; and (5) ventilation.Results: The VPPI could be well-imaged for all ofthe patients. In the two trauma patients, rightmainstem intubations were noted in which specificpleural signals were not seen in the left chestwall VPPI after tube placement. These signsreturned after correct repositioning of the ETTtube. In all of the elective surgery patients,signs correlating with bilateral ventilation ineach patient were imaged and correlated withconfirmation of ETT placement byanesthesiology.

This report raises the possibility that thoracicsonography may be another tool that could be usedto confirm proper ETT placement. This techniquemay have merit in extreme environments, such as inremote, prehospital settings or during aerospacemedical transports, in which auscultation isimpossible due to noise, or capnography is notavailable, and thus, requires further scientificevaluation.

Revisar la evidencia existente sobre laefectividad de los simulacros de desastres,intervenciones basadas en la tecnología yejercicios de gabinete para el entrenamiento delpersonal hospitalario en la respuesta a incidentescon víctimas múltiples.