The Telemedicine Spacebridge, a satellite-mediated, audio-video-fax link between four United States and two Armenian and Russian medical centers, permitted remote American consultants to assist Armenian and Russian physicians in the management of medical problems following the December 1988 earthquake in Armenia and the June 1989 gas explosion near Ufa.

During 12 weeks of operations, 247 Armenian and Russian and 175 American medical professionals participated in 34 half-day clinical conferences. A total of 209 patients were discussed, requiring expertise in 20 specialty areas.

Telemedicine consultations resulted in altered diagnoses for 54, new diagnostic studies for 70, altered diagnostic processes for 47 and modified treatment plans for 47 of 185 Armenian patients presented. Simultaneous participation of several US medical centers was judged beneficial; quality of data transmission was judged excellent.

These results suggest that interactive consultation by remote specialists can provide valuable assistance to on-site physicians and favorably influence clinical decisions in the aftermath of major disasters.

Profound agitation in the prehospital setting confers substantial risk to patients and providers. Optimal chemical sedation in this setting remains unclear.

The goal of this study was to describe intubation rates among profoundly agitated patients treated with prehospital ketamine and to characterize clinically significant outcomes of a prehospital ketamine protocol.

This was a retrospective cohort study of all patients who received prehospital ketamine, per a predefined protocol, for control of profound agitation and who subsequently were transported to an urban Level 1 trauma center from May 1, 2010 through August 31, 2013. Identified records were reviewed for basic ambulance run information, subject characteristics, ketamine dosing, and rate of intubation. Emergency Medical Services (EMS) ambulance run data were matched to hospital-based electronic medical records. Clinically significant outcomes are characterized, including unadjusted and adjusted rates of intubation.

Overall, ketamine was administered 227 times in the prehospital setting with 135 cases meeting study criteria of use of ketamine for treatment of agitation. Endotracheal intubation was undertaken for 63% (85/135) of patients, including attempted prehospital intubation in four cases. Male gender and late night arrival were associated with intubation in univariate analyses (χ2=12.02; P=.001 and χ2=5.34; P=.021, respectively). Neither ketamine dose, co-administration of additional sedating medications, nor evidence of ethanol (ETOH) or sympathomimetic ingestion was associated with intubation. The association between intubation and both male gender and late night emergency department (ED) arrival persisted in multivariate analysis. Neither higher dose (>5mg/kg) ketamine nor co-administration of midazolam or haloperidol was associated with intubation in logistic regression modeling of the 120 subjects with weights recorded. Two deaths were observed. Post-hoc analysis of intubation rates suggested a high degree of provider-dependent variability.

Prehospital ketamine is associated with a high rate of endotracheal intubation in profoundly agitated patients; however, ketamine dosing is not associated with intubation rate when adjusted for potential confounders. It is likely that factors not included in this analysis, including both provider comfort with post-ketamine patients and anticipated clinical course, play a role in the decision to intubate patients who receive prehospital ketamine.

OlivesTD, NystromPC, ColeJB, DoddKW, HoJD. Intubation of Profoundly Agitated Patients Treated with Prehospital Ketamine. Prehosp Disaster Med. 2016;31(6):593–602.

The objective was to test, in this trauma system, the North American hypothesis that exceeding the 60-minute limit for the entire prehospital time (“golden hour of shock”) increases mortality of blunt polytrauma patients.

In a prospective, observational, cohort study conducted between 1990 and 1996, a severity characterization of trauma (ASCOT) score was used to compare the actual mortality with the predicted mortality in 107 blunt polytrauma patients (Group 1) with prehospital rescue periods ≤60 minutes (time from accident until arrival at the emergency department). The same comparison was performed for 147 blunt polytrauma patients (Group 2) with rescue periods >60 minutes. Inclusion criteria were blunt trauma of at least two body sites, an Injury Severity Score (ISS) of ≥8, and direct admission to the trauma centre. Multivariate regression analysis was performed to test for bias and confounding, and to identify factors that might influence mortality. Odd ratio (OR) and 95% confidence interval (CI) were calculated.

The mortality in Group 1 was 14%, and was not statisticvally significantly higher than the 10.2% observed for Group 2. 4.8 patients, or 47% more than predicted, died in Group 1 (p = 0.057). The corresponding figures in Group 2 were 4.2 patients or 22% fewer than predicted (p = 0.19). Multivariate logistic regression confirmed this trend with a significant mortality odds ratio of 8 (95% CI 1.7 to 38.5) for Group 1 compared to Group 2. Significantly more patients in Group 2 were treated by emergency physicians.

It appears in this trauma system, in which emergency physicians often are deployed, that the ‘golden hour of shock’ can be extended safely in many blunt polytrauma patients, since this was associated with better survival figures than in those patients for whom the time was <1 hour.

The large number casualties caused by the 1995 Great Hanshin and Awaji Earthquake created a massive demand for medical care. However, as area hospitals also were damaged by the earthquake, they were unable to perform their usual functions. Therefore, the care capacity was reduced greatly. Thus, the needs to: (1) transport a large number of injured and ill people out of the disaster-affected area; and (2) dispatch medical teams to perform such wide-area transfers were clear. The need for trained medical teams to provide medical assistance also was made clear after the Niigata-ken Chuetsu Earthquake in 2004. Therefore, the Japanese government decided to establish Disaster Medical Assistance Teams (DMATs), as “mobile, trained medical teams that rapidly can be deployed during the acute phase of a sudden-onset disaster”. Disaster Medical Assistance Teams have been established in much of Japan. The provision of emergency relief and medical care and the enhancement and promotion of DMATs for wide-area deployments during disasters were incorporated formally in the Basic Plan for Disaster Prevention in its July 2005 amendment.

The essential points pertaining to DMATs were summarized as a set of guidelines for DMAT deployment. These were based on the results of research funded by a Health and Labour Sciences research grant from the, Labour and Welfare (MHLW) of the Ministry of Health. The guidelines define the basic procedures for DMAT activities—for example: (1) the activities are to be based on agreements concluded between prefectures and medical institutions during non-emergency times; and (2) deployment is based on requests from disaster-affected prefectures and the basic roles of prefectures and the MHLW. The guidelines also detail DMAT activities at the disaster scene of the, support from medical institutions, and transportation assistance including “wide-area” medical transport activities, such as medical treatment in staging care units and the implementation of medical treatment onboard aircraft.

Japan's DMATs are small-scale units that are designed to be suitable for responding to the demands of acute emergencies. Further issues to be examined in relation to DMATs include expanding their application to all prefectures, and systems to facilitate continuous education and training.

Survivors of natural disasters in the United States experience significant health ramifications. Women particularly are vulnerable to both post-disaster posttraumatic stress disorder (PTSD) and depression, and research has documented that these psychopathological sequelae often are correlated with increased incidence of intimate partner violence (IPV). Understanding the link between these health concerns is crucial to informing adequate disaster response and relief efforts for victims of natural disaster.

The purpose of this review was to report the results of a scoping review on the specific mental health effects that commonly impact women following natural disasters, and to develop a conceptual framework with which to guide future research.

A scoping review of mental and physical health effects experienced by women following natural disasters in the United States was conducted. Articles from 2000-2015 were included. Databases examined were PubMed, PsycInfo, Cochrane, JSTOR, Web of Science, and databases available through ProQuest, including ProQuest Research Library.

A total of 58 articles were selected for inclusion, out of an original 149 that were selected for full-text review. Forty-eight articles, or 82.8%, focused on mental health outcomes. Ten articles, or 17.2%, focused on IPV.

Certain mental health outcomes, including PTSD, depression, and other significant mental health concerns, were recurrent issues for women post-disaster. Despite the strong correlation between experience of mental health consequences after disaster and increased risk of domestic violence, studies on the risk and mediating factors are rare. The specific challenges faced by women and the interrelation between negative mental health outcomes and heightened exposure to IPV following disasters require a solid evidence base in order to facilitate the development of effective interventions. Additional research informed by theory on probable health impacts is necessary to improve development/implementation of emergency relief policy.

BellSA, FolkerthLA. Women’s Mental Health and Intimate Partner Violence Following Natural Disaster: A Scoping Review. Prehosp Disaster Med. 2016;31(6):648–657.

The ongoing threat of a terrorist attack places public agencies under increasing pressure to ensure readiness in the event of a disaster. Yet, little published information exists regarding the current state of readiness, which would allow local and regional organizations to develop disaster preparedness plans that would function seamlessly across service areas. The objective of this study is to characterize state-level disaster readiness soon after September 2001 and correlate readiness with existing programs providing an organized response to medical emergencies.

During the first quarter of 2002, a cross-sectional survey assessing five components of disaster readiness was administered in all 50 states. The five components of disaster readiness included: (1) statewide disaster planning; (2) coordination; (3) training; (4) resource capacity; and (5) preparedness for biological/chemical terrorism.

Most states reported the presence of a statewide disaster plan (94%), but few are tested by activation, (48%) and still fewer contain a bioterrorism component (38%). All states have designated disaster operations centers (100%), but few states have an operating communications system linking health and medical resources (36%). Approximately half of states offer disaster training to medical professionals; about 10% of states require the training. Between 22–48% of states have various contingency plans to treat victims when service capacity is exceeded. Biochemical protective equipment for health professionals is lacking in all but one state, and only 10% of states indicate that all hospitals have decontamination capabilities. States with a functioning statewide trauma system were significantly more likely to possess key attributes of a functioning disaster readiness plan.

These findings suggest that disaster plans are prevalent among states. However, key programs and policies were noticeably absent. Communication systems remain fragmented and adequate training programs and protective equipment for health personnel are markedly lacking. Statewide trauma systems may provide a framework upon which to build future medical disaster readiness capacity.

To study the natural outcome of patients refusing prehospital transportation (PT).

A total of 188 consecutive patients who refused PT in an urban, advanced life support (ALS), emergency medical services (EMS) system were studied. Of these, 77 (41 %) were male, and the average age was 51 years. Patients were entered into the study group only once.

Only 94 (50%) patients could be reached by telephone follow-up. Seven (7%) of these 94 patients had abnormal vital signs, 33 (35%) had cardiopulmonary complaints, 16 (17%) had an altered level of consciousness, nine (10%) were involved in accidents, and eight (8%) had abdominal pain. Six (6%) patients were admitted to the hospital, two (2 %) received ALS-level treatment by the paramedics and then refused conveyance, and 31 (33 %) either saw or contacted a physician. Consultation with an EMS physician was initiated for nine (5%) refusals. Of all the patients contacted, six (6%) needed PT for hospitalization.

As only 50% of the patients refusing prehospital transportation could be reached using follow-up telephone calls, the 6% figure probably underestimates the true number of patients requiring PT. Telephone follow-up is an inadequate means of determining the natural outcome for this patient population. The ALS nature of many of the complaints combined with the lack of consistent physician consultation, exposes the EMS system to an undefined medico-legal liability risk.

Emergency medical vehicle collisions (EMVCs) occurring during initia response and with patient transport have been a long-standing problem for emergency medical services (EMS) systems. Experience suggests “wake-effect” collision occur as a result of an EMS vehicle's transit, but do not involve the emergency medical vehicle (EMV). Substantiating the existence and magnitude of wake-effect collisions may have major implications regarding the manner of EMV response.

Paramedics will report that wake-effect collisions do occur and that the occur more frequently than do EMVCs.

Design: Survey analysis. Participants: Thirty paramedics employed by the Salt Lake City (Utah) Fire Department and 45 paramedics employed by Salt Lake County Fire Department. Geographic Area: Service area has population of 650,000 and is urban, suburban, and rural. Measurements: The survey consisted of three openended questions concerning years on the job, EMVCs, and wake-effect collisions. Analysis: The mean value for the number of EMVCs and wake-effect EMVCs, along with the 0.95 confidence intervals (0.95 CI) were determined.

Seventy-three surveys were analyzed. Sixty EMVCs and 255 wake-effect collisions were reported. Overall, the mea value for the number EMVCs per respondent was 0.82 (0.60–1.05) and for wake-effect collisions 3.49 (2.42–4.55). The mean values for EMVC's for each service were 0.86 (0.50–1.38); 0.80 (0.50–11.0). For wake-effect collisions the mean values were 4.59 (2.83–6.35); and 2.76 (1.46–4.06) respectively.

This study suggests that the wake-effect collision is real and may occur with greater frequency than do EMVCs. Significant limitations of this study are recall bias and misclassiftcation bias. Future studies are needed to define more precisely wake-effect collision prevalence and the resulting “cost” in regards to injury and vehicle/property damage.

An understanding of disaster medicine and the health care system during mass-casualty events is vital to a successful disaster response, and has been recommended as an integral part of the medical curriculum by the Association of American Medical Colleges (AAMC). It has been documented that medical students do not believe that they have received adequate training for responding to disasters. The purpose of this pilot study was to determine the inclusion of disaster medicine in the required course work of medical students at AAMC schools in the United States, and to identify the content areas addressed.

An electronic on-line survey was developed based upon published core competencies for health care workers, and distributed via e-mail to the education liaison for each medical school in the United States that was accredited by the AAMC. The survey included questions regarding the inclusion of disaster medicine in the medical school curricula, the type of instruction, and the content of instruction.

Of the 29 (25.2%) medical schools that completed the survey, 31% incorporated disaster medicine into their medical school curricula. Of those schools that included disaster medicine in their curricula, 20.7% offered disaster material as required course work, and 17.2% offered it as elective course work. Disaster medicine topics provided at the highest frequency included pandemic influenza/severe acute respiratory syndrome (SARS, 27.5%), and principles of triage (10.3%). The disaster health competency included most frequently was the ability to recognize a potential critical event and implement actions at eight (27.5%) of the responding schools.

Only a small percentage of US medical schools currently include disaster medicine in their core curriculum, and even fewer medical schools have incorporated or adopted competency-based training within their disaster medicine lecture topics and curricula.

> SmithJ , LevyMJ , HsuEB , LevyJL . Disaster Curricula in Medical Education: Pilot Survey. Prehosp Disaster Med.2012;27(5):1-3.

This study sought to determine the lifesaving potentials of modern resuscitation medicine as applied to a catastrophic disaster situation. Previous articles reported the preliminary results (I), and methodology (II) of a structured, retrospective interview study of the 1988 earthquake in Armenia. The present article (III) reports and discusses the definitive findings, formulates conclusions, and puts forth recommendations for future responses to catastrophic disasters anywhere in the world.

Observations include: 1) The lack of adequate construction materials and procedures in the Armenian region contributed significantly to injury and loss of life; 2) The uninjured, lay population together with medical teams including physicians in Armenia were capable of rapid response (within two hours); 3) Due to a lack of Advanced Trauma Life Support (ATLS) training for medical teams and of basic first-aid training of the lay public, and scarcity of supplies and equipment for extrication of casualties, they were unable to do much at the scene. As a result, an undetermined number of severely injured earthquake victims in Armenia died slowly without the benefit of appropriate and feasible resuscitation attempts.

1) Widespread adoption of seismic-resistant building codes for regions of high seismic risk; 2) The lay public living in these regions should be trained in life-supporting first-aid (LSFA) and basic rescue techniques; 3) Community-wide emergency medical services (EMS) systems should be developed world-wide (tai-lored to the emergency needs of each region) with ATLS capability for field resuscitation; 4) Such systems be prepared to extend coverage to mass casualties; 5) National disaster medical system (NDMS) plans should provide integration of existing trauma-EMS systems into regional systems linked with advanced (heavy) rescue (public works, fire, police); and 6) New techniques and devices for victim extrication should be developed to enable rapid extrication of earthquake casualties within 24 hours.

To characterize the prevalence and morbidity of injuries to emergency medical technicians EMTs) in New England [United States].

A survey was mailed to a 2% random sample of all registered EMTs in the six New England States. The identity of the EMTs remained anonymous, and a second mailing was used to improve return rate. The EMTs were requested to recall events that occurred during the previous six months.

A total of 439 of the 786 (56%) surveys were returned representing 13,875 hours of duty time in the six-month period. Seventy one percent of the EMTs were male with a mean age of 35 years. Sixty-six percent were basic-EMTs. Injury attack rates (number of injuries/100 EMTs/6 months) were: stress, 11.2; back, 10.5; extremity, 9.8; assault, 8.4; ambulance collision, 4.1; hearing loss, 2.5; and eye injury, 1.4. Twelve percent of the EMTs were injured more than once in the six-month period. The paramedics more frequently were involved in ambulance collisions, suffered from stress, and were less likely to injure their back. There were minor interstate differences. Disability due to back injury affected 2.5% of those surveyed, four EMTs lost duty time secondary to an assault, and 0.5% of the EMTs were out of work due to stress.

This survey begins to characterize the occupational risks of EMTs. The prevalence of back injuries, assault, stress, and extremity injuries seems to be too high. Educational programs and preventive interventions should be designed to minimize back injuries, stress, and assault. There is a need for more research nationwide in order to better characterize these injuries.