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Bousigues M, Pretalli JB, Vivien B, Lambert C, Outrey J, Khoury A. Damage Control Training: A Cross-sectional Survey of Health care Personnel of French Emergency Medicine Structures. Mil Med 2024; 189:e2257-e2263. [PMID: 39028221 DOI: 10.1093/milmed/usae258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 02/29/2024] [Accepted: 05/16/2024] [Indexed: 07/20/2024] Open
Abstract
INTRODUCTION Terrorist threats are a worldwide phenomenon. The injuries caused with military weapons or explosives are multiple and unusual for civilian care services. Damage control (DC) training has then become a critical need. In response to the November 2015 attacks, the French authorities launched a national DC training campaign for emergency care personnel. The aim was to describe the implementation of DC training campaign and its perception according to the respondent's profession, DC teaching levels, and the history of terrorist attacks in the last decade of the hospital center's activities. MATERIALS AND METHODS A survey was distributed to all Casualty Department staff in France. The answers were collected between June 9, 2020 and July 22, 2020. The project was qualified as not involving humans and participation was on voluntary basis. The study is out of the French Jardé law. RESULTS Two-thirds of the 1,525 respondents considered themselves trained in DC (emergency physicians [76.8%], nurse anesthetists [68.1%], and ambulance drivers [65.3%]). Less than half considered their theoretical (41.1%) and practical (44.7%) knowledge excellent or good. More than 95% of the untrained personnel wanted to receive this type of training. Trained personnel were in favor of annual refresher training (95.7%) and training for practical applications (95.1%). Personnel at teaching centers were more frequently trained than personnel at nonteaching centers (respectively 75.3% and 64.3%, P < .0001) and had applied their knowledge significantly more often (50.1% vs. 43.4%, P = .038). They often considered their knowledge to be excellent (respectively 50.8% vs. 42.4%, P = .064). CONCLUSION The training of emergency personnel in DC is far from being generalized in France. Among the trained personnel, it was often deemed insufficient, in theory and in practice. There was an inequity of training in favor of those in teaching centers. It is therefore essential that training in DC techniques in France be continued, generalized, improved, and standardized throughout the country in order to guarantee an optimal response from the health care systems in the event of new terrorist attacks.
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Affiliation(s)
- Maud Bousigues
- Department of Emergency Medicine and Critical Care, Besançon University Hospital, Besançon 25030, France
| | - Jean-Baptiste Pretalli
- Department of Emergency Medicine and Critical Care, Besançon University Hospital, Besançon 25030, France
- INSERM CIC 1431, Besançon University Hospital, Besançon 25030, France
| | - Benoit Vivien
- Intensive Care Unit, Anesthesiology, SAMU, Necker Enfants Malades Hospital, Assistance Publique-Hôpitaux de Paris, Paris 75015, France
| | - Christophe Lambert
- Department of Emergency Medicine and Critical Care, Besançon University Hospital, Besançon 25030, France
| | - Justin Outrey
- Department of Emergency Medicine and Critical Care, Besançon University Hospital, Besançon 25030, France
| | - Abdo Khoury
- Department of Emergency Medicine and Critical Care, Besançon University Hospital, Besançon 25030, France
- INSERM CIC 1431, Besançon University Hospital, Besançon 25030, France
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Ugelvik KS, Thomassen Ø, Braut GS, Geisner T, Sjøvold JE, Agri J, Montan C. Evaluation of prehospital preparedness for major incidents on a national level, with focus on mass casualty incidents. Eur J Trauma Emerg Surg 2024; 50:945-957. [PMID: 38117294 PMCID: PMC11249512 DOI: 10.1007/s00068-023-02386-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 10/21/2023] [Indexed: 12/21/2023]
Abstract
PURPOSE To investigate prehospital preparedness work for Mass Casualty Incidents (MCI) and Major Incidents (MI) in Norway. METHOD A national cross-sectional descriptive study of Norway's prehospital MI preparedness through a web-based survey. A representative selection of Rescue and Emergency Services were included, excluding Non-Governmental Organisations and military. The survey consisted of 59 questions focused on organisation, planning, education/training, exercises and evaluation. RESULTS Totally, 151/157 (96%) respondents answered the survey. The results showed variance regarding contingency planning for MCI/MI, revisions of the plans, use of national triage guidelines, knowledge requirements, as well as haemostatic and tactical first aid skills training. Participation in interdisciplinary on-going life-threatening violence (PLIVO) exercises was high among Ambulance, Police and Fire/Rescue Emergency Services. Simulations of terrorist attacks or disasters with multiple injured the last five years were reported by 21/151 (14%) on a regional level and 74/151 (48%) on a local level. Evaluation routines after MCI/MI events were reported by half of the respondents (75/151) and 70/149 (47%) described a dedicated function to perform such evaluation. CONCLUSION The study indicates considerable variance and gaps among Prehospital Rescue and Emergency Services in Norway regarding MCI/MI preparedness work, calling for national benchmarks, minimum requirements, follow-up routines of the organisations and future reassessments. Implementation of mandatory PLIVO exercises seems to have contributed to interdisciplinary exercises between Fire/Rescue, Police and Ambulance Emergency Service. Repeated standardised surveys can be a useful tool to assess and follow-up the MI preparedness work among Prehospital Rescue and Emergency Services at a national, regional and local level.
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Affiliation(s)
- Kristina Stølen Ugelvik
- University of Bergen, Bergen, Norway.
- Regional Trauma Centre, Haukeland University Hospital, Bergen, Norway.
| | - Øyvind Thomassen
- University of Bergen, Bergen, Norway
- HEMS, Haukeland University Hospital, Bergen, Norway
- Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Geir Sverre Braut
- Stavanger University Hospital, Stavanger, Norway
- Western Norway University of Applied Sciences, Stavanger, Norway
| | - Thomas Geisner
- Gastrosurgical Department, Haukeland University Hospital, Bergen, Norway
| | | | - Joakim Agri
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Carl Montan
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
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Xu Y, Malik N, Chernbumroong S, Vassallo J, Keene D, Foster M, Lord J, Belli A, Hodgetts T, Bowley D, Gkoutos G. Triage in major incidents: development and external validation of novel machine learning-derived primary and secondary triage tools. Emerg Med J 2024; 41:176-183. [PMID: 37751994 PMCID: PMC10894820 DOI: 10.1136/emermed-2022-212440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 08/12/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Major incidents (MIs) are an important cause of death and disability. Triage tools are crucial to identifying priority 1 (P1) patients-those needing time-critical, life-saving interventions. Existing expert opinion-derived tools have limited evidence supporting their use. This study employs machine learning (ML) to develop and validate models for novel primary and secondary triage tools. METHODS Adults (16+ years) from the UK Trauma Audit and Research Network (TARN) registry (January 2008-December 2017) served as surrogates for MI victims, with P1 patients identified using predefined criteria. The TARN database was split chronologically into model training and testing (70:30) datasets. Input variables included physiological parameters, age, mechanism and anatomical location of injury. Random forest, extreme gradient boosted tree, logistic regression and decision tree models were trained to predict P1 status, and compared with existing tools (Battlefield Casualty Drills (BCD) Triage Sieve, CareFlight, Modified Physiological Triage Tool, MPTT-24, MSTART, National Ambulance Resilience Unit Triage Sieve and RAMP). Primary and secondary candidate models were selected; the latter was externally validated on patients from the UK military's Joint Theatre Trauma Registry (JTTR). RESULTS Models were internally tested in 57 979 TARN patients. The best existing tool was the BCD Triage Sieve (sensitivity 68.2%, area under the receiver operating curve (AUC) 0.688). Inability to breathe spontaneously, presence of chest injury and mental status were most predictive of P1 status. A decision tree model including these three variables exhibited the best test characteristics (sensitivity 73.0%, AUC 0.782), forming the candidate primary tool. The proposed secondary tool (sensitivity 77.9%, AUC 0.817), applicable via a portable device, includes a fourth variable (injury mechanism). This performed favourably on external validation (sensitivity of 97.6%, AUC 0.778) in 5956 JTTR patients. CONCLUSION Novel triage tools developed using ML outperform existing tools in a nationally representative trauma population. The proposed primary tool requires external validation prior to consideration for practical use. The secondary tool demonstrates good external validity and may be used to support decision-making by healthcare workers responding to MIs.
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Affiliation(s)
- Yuanwei Xu
- Centre for Computational Biology, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
- Health Data Science Centre, University of Birmingham, Birmingham B15 2TT, UK
| | - Nabeela Malik
- NIHR Surgical Reconstruction Microbiology Research Centre, Edgbaston, UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Mindelsohn Way, Edgbaston, Birmingham B152WB, UK
| | - Saisakul Chernbumroong
- Centre for Computational Biology, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
- NIHR Surgical Reconstruction Microbiology Research Centre, Edgbaston, UK
| | - James Vassallo
- Emergency Department, Derriford Hospital, Plymouth, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK
| | - Damian Keene
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Mindelsohn Way, Edgbaston, Birmingham B152WB, UK
| | - Mark Foster
- NIHR Surgical Reconstruction Microbiology Research Centre, Edgbaston, UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Mindelsohn Way, Edgbaston, Birmingham B152WB, UK
| | - Janet Lord
- NIHR Surgical Reconstruction Microbiology Research Centre, Edgbaston, UK
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Antonio Belli
- NIHR Surgical Reconstruction Microbiology Research Centre, Edgbaston, UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Douglas Bowley
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Mindelsohn Way, Edgbaston, Birmingham B152WB, UK
| | - George Gkoutos
- Centre for Computational Biology, Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
- Health Data Science Centre, University of Birmingham, Birmingham B15 2TT, UK
- NIHR Surgical Reconstruction Microbiology Research Centre, Edgbaston, UK
- Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
- MRC Health Data Research UK (HDR UK), Birmingham, UK
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Giaume L, Le Roy B, Daniel Y, Lauga Cami H, Jost D, Travers S, Trousselard M. Psychological, cognitive, and physiological impact of hazards casualties' trainings on first responders: the example of a chemical and radiological training. An exploratory study. Front Psychol 2024; 15:1336701. [PMID: 38352026 PMCID: PMC10861781 DOI: 10.3389/fpsyg.2024.1336701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 01/15/2024] [Indexed: 02/16/2024] Open
Abstract
Background First responders are among the first to respond to hazards casualties. They might operate in volatile, uncertain, complex, and ambiguous (VUCA) environments. While they have underlined the need to improve their knowledge and training to face these environments, there are few data regarding the stress induced by these trainings. Chemical, biological, radiological, and nuclear (CBRN) hazards casualties' trainings seem to be a good model of "in vivo" stress. First responders must operate in a hostile and encountered environment with a CBRN protective equipment that places demand on their psychological, cognitive, and physiological capacities. Current research recognizes that the activity of the parasympathetic system (PSS) can be used as an objective marker of stress adaptation, measured as heart rate variability (HRV). Objectives To compare between baseline and simulation the evolution of the parasympathetic activity (primary outcome), anxiety, emotions, cognitive load, and body posture awareness (secondary outcomes). Methods A total of 28 first responders attended to three simulated scenarios requiring CBRN management of casualties. One day before simulation, we collected HRV data (baseline). The simulations' day (pre-, post-simulation) we collected anxiety score (STAI-Y B), emotions (SPANE), cognitive load (NASA TLX), body posture awareness (PAS) and HRV. The morning after we collected the PAS score (recovery). We compare data' evolution between different times of the simulation. Results (i) A high level of anxiety at baseline [Median 51 (46; 56)] which decreased between pre- and post-simulation (p = 0.04; F = 2.93); (ii) a post-simulation decrease in negative feelings (p = 0.03); (iii) a decrease in body awareness after simulation which returned to the initial level at recovery (p = 0.03; F = 3.48); (iv) a decrease in mean RR between baseline, pre- and post-simulation (p = 0.009; F = 5.11). There were no significant difference between times on others analysis of HRV. Conclusion Prior to simulation, participants experienced anticipatory anxiety. Simulations training practiced regularly could be one way to combat anticipatory anxiety.
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Affiliation(s)
- Louise Giaume
- Emergency Medical Department, Paris Fire Brigade, Paris, France
- French Military Biomedical Research, Brétigny-sur-Orge, France
| | | | - Yann Daniel
- Emergency Medical Department, Paris Fire Brigade, Paris, France
| | | | - Daniel Jost
- Emergency Medical Department, Paris Fire Brigade, Paris, France
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Perry O, Jaffe E, Goldberg A, Bitan Y. Incident commander decision making: Quantitative evaluation of instantaneous and considered decisions. APPLIED ERGONOMICS 2024; 114:104139. [PMID: 37748355 DOI: 10.1016/j.apergo.2023.104139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 08/14/2023] [Accepted: 09/11/2023] [Indexed: 09/27/2023]
Abstract
The Incident Commander (IC) decision-making process has previously been modeled primarily by qualitative evaluation methods, which has made it difficult to generalize an objective model. In this study, we took a quantitative approach to elucidate a decision-making model based on the "dual-process" model that consists of instantaneous decisions ("System 1") and considered decisions ("System 2") to gain new insights regarding the IC decision-making process. High-fidelity simulation data from eight mass-casualty incidents (MCIs) were analyzed in two categories. The first category represents cues of new information and the IC's actions, divided into three main subcategories: actions following the MCI protocol, responses following cues, and actions without a cue. The second category divides the simulation into three MCI management phases: (1) evaluation and triage, (2) treatment and preparedness for evacuation, and (3) evacuation. Actions that followed the MCI protocol were significantly higher in the first phase compared to the other two phases (p<0.01 for both phases). Responses following cues were significantly higher in the second phase compared to the first (p<0.01). Actions without a cue were significantly higher in both the second and third phases compared to the first (p<0.01 for both phases). The results reveal that the IC followed MCI protocol guidance in the simulation initiation and immediately responded to cues, which fits "System 1". As the simulation evolved, the IC made more planned tasks and initiated actions without leading cues, which fits "System 2". The study found that ICs can change their decision-making mode, and this understanding can serve to improve their decision-making process and increase casualty survival rates.
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Affiliation(s)
- Omer Perry
- Department of Health Policy & Management, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
| | - Eli Jaffe
- Magen-David-Adom, Israeli National Emergency Medical Services, Israel.
| | - Avishay Goldberg
- Department of Health Policy & Management, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
| | - Yuval Bitan
- Department of Health Policy & Management, Ben-Gurion University of the Negev, Beer-Sheva, Israel.
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Alruqi F, Aglago EK, Cole E, Brohi K. Factors Associated With Delayed Pre-Hospital Times During Trauma-Related Mass Casualty Incidents: A Systematic Review. Disaster Med Public Health Prep 2023; 17:e525. [PMID: 37947290 DOI: 10.1017/dmp.2023.187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
OBJECTIVE Critically injured patients have experienced delays in being transported to hospitals during Mass Casualty Incidents (MCIs). Extended pre-hospital times (PHTs) are associated with increased mortality. It is not clear which factors affect overall PHT during an MCI. This systematic review aimed to investigate PHTs in trauma-related MCIs and identify factors associated with delays for triaged patients at incident scenes. METHODS This systematic review was performed in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Web of Science, CINAHL, MEDLINE, and EMBASE were searched between January and February 2022 for evidence. Research studies of any methodology, and grey literature in English, were eligible for inclusion. Studies were narratively synthesized according to Cochrane guidance. RESULTS Of the 2025 publications identified from the initial search, 12 papers met the inclusion criteria. 6 observational cohort studies and 6 case reports described a diverse range of MCIs. PHTs were reported variably across incidents, from a median of 35 minutes to 8 hours, 8 minutes. Factors associated with prolonged PHT included: challenging incident locations, concerns about scene safety, and adverse decision-making in MCI triage responses. Casualty numbers did not consistently influence PHTs. Study quality was rated moderate to high. CONCLUSION PHT delays of more than 2 hours were common. Future MCI planning should consider responses within challenging environments and enhanced timely triage decision-making.
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Affiliation(s)
- Fayez Alruqi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
- Emergency Medical Services Department, Faculty of Applied Medical Sciences, Jazan University, Jazan, Saudi Arabia
| | - Elom K Aglago
- Department of Epidemiology and Biostatistics, School of Public Health, Imperial College London, London, UK
| | - Elaine Cole
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
| | - Karim Brohi
- Centre for Trauma Sciences, Blizard Institute, Queen Mary University of London, London, UK
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Weinstein ES, Cuthbertson JL, Herbert TL, Voicescu GT, Bortolin M, Magalini S, Gui D, Helou M, Lennquist Montan K, Montan C, Rafalowsky C, Ratto G, Damele S, Bazurro S, Laist I, Marzi F, Borrello A, Fransvea P, Fidanzio A, Benitez CY, Faccincani R, Ragazzoni L, Caviglia M. Advancing the scientific study of prehospital mass casualty response through a Translational Science process: the T1 scoping literature review stage. Eur J Trauma Emerg Surg 2023; 49:1647-1660. [PMID: 37060443 PMCID: PMC10449715 DOI: 10.1007/s00068-023-02266-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 03/26/2023] [Indexed: 04/16/2023]
Abstract
PURPOSE The European Union Horizon 2020 research and innovation funding program awarded the NIGHTINGALE grant to develop a toolkit to support first responders engaged in prehospital (PH) mass casualty incident (MCI) response. To reach the projects' objectives, the NIGHTINGALE consortium used a Translational Science (TS) process. The present work is the first TS stage (T1) aimed to extract data relevant for the subsequent modified Delphi study (T2) statements. METHODS The authors were divided into three work groups (WGs) MCI Triage, PH Life Support and Damage Control (PHLSDC), and PH Processes (PHP). Each WG conducted simultaneous literature searches following the PRISMA extension for scoping reviews. Relevant data were extracted from the included articles and indexed using pre-identified PH MCI response themes and subthemes. RESULTS The initial search yielded 925 total references to be considered for title and abstract review (MCI Triage 311, PHLSDC 329, PHP 285), then 483 articles for full reference review (MCI Triage 111, PHLSDC 216, PHP 156), and finally 152 articles for the database extraction process (MCI Triage 27, PHLSDC 37, PHP 88). Most frequent subthemes and novel concepts have been identified as a basis for the elaboration of draft statements for the T2 modified Delphi study. CONCLUSION The three simultaneous scoping reviews allowed the extraction of relevant PH MCI subthemes and novel concepts that will enable the NIGHTINGALE consortium to create scientifically anchored statements in the T2 modified Delphi study.
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Affiliation(s)
- Eric S Weinstein
- CRIMEDIM-Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health, Università del Piemonte Orientale, Novara, Italy.
| | - Joseph L Cuthbertson
- CRIMEDIM-Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health, Università del Piemonte Orientale, Novara, Italy
| | - Teri Lynn Herbert
- Research and Education Services, Medical University of South Carolina Library, Charleston, SC, USA
| | - George T Voicescu
- CRIMEDIM-Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health, Università del Piemonte Orientale, Novara, Italy
| | - Michelangelo Bortolin
- CRIMEDIM-Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health, Università del Piemonte Orientale, Novara, Italy
| | - Sabina Magalini
- Department of Surgery, Policlinico Gemelli, Catholic University of the Sacred Heart, Rome, Italy
| | - Daniele Gui
- Department of Surgery, Policlinico Gemelli, Catholic University of the Sacred Heart, Rome, Italy
| | - Mariana Helou
- School of Medicine, Department of Emergency Medicine, Lebanese American University, Beirut, Lebanon
| | - Kristina Lennquist Montan
- MRMID-International Association for Medical Response to Major Incidents and Disasters, and Vascular Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Carl Montan
- MRMID-International Association for Medical Response to Major Incidents and Disasters, and Vascular Surgery, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Chaim Rafalowsky
- Magen David Adom, National Emergency Medical, Disaster, Ambulance and Blood Bank Service, Ashkelon, Israel
| | - Giuseppe Ratto
- Emergency Department, Azienda Sociosanitaria Ligure 2, Liguria, Italy
| | - Stefano Damele
- Emergency Department, Azienda Sociosanitaria Ligure 2, Liguria, Italy
| | - Simone Bazurro
- Emergency Department, Azienda Sociosanitaria Ligure 2, Liguria, Italy
| | - Itamar Laist
- ESTES-European Society for Trauma and Emergency Surgery, Disaster and Military Surgery Section, Milan, Italy
| | - Federica Marzi
- Department of Surgery, Policlinico Gemelli, Catholic University of the Sacred Heart, Rome, Italy
| | - Alessandro Borrello
- Department of Surgery, Policlinico Gemelli, Catholic University of the Sacred Heart, Rome, Italy
| | - Pietro Fransvea
- Department of Surgery, Policlinico Gemelli, Catholic University of the Sacred Heart, Rome, Italy
| | - Andrea Fidanzio
- Department of Surgery, Policlinico Gemelli, Catholic University of the Sacred Heart, Rome, Italy
| | - Carlos Yanez Benitez
- ESTES-European Society for Trauma and Emergency Surgery, Disaster and Military Surgery Section, Milan, Italy
| | - Roberto Faccincani
- ESTES-European Society for Trauma and Emergency Surgery, Disaster and Military Surgery Section, Milan, Italy
| | - Luca Ragazzoni
- CRIMEDIM-Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health, Università del Piemonte Orientale, Novara, Italy
- Department of Sustainable Development and Ecological Transition, Università del Piemonte Orientale, Vercelli, Italy
| | - Marta Caviglia
- CRIMEDIM-Center for Research and Training in Disaster Medicine, Humanitarian Aid, and Global Health, Università del Piemonte Orientale, Novara, Italy
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
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Nyberger K, Caragounis EC, Djerf P, Wahlgren CM. Management and outcomes of firearm-related vascular injuries. Scand J Trauma Resusc Emerg Med 2023; 31:35. [PMID: 37420263 DOI: 10.1186/s13049-023-01098-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 06/29/2023] [Indexed: 07/09/2023] Open
Abstract
BACKGROUND Violence due to firearms is a major global public health issue and vascular injuries from firearms are particularly lethal. The aim of this study was to analyse population-based epidemiology of firearm-related vascular injuries. METHODS This was a retrospective nationwide epidemiological study including all patients with firearm injuries from the national Swedish Trauma Registry (SweTrau) from January 1, 2011 to December 31, 2019. There were 71,879 trauma patients registered during the study period, of which 1010 patients were identified with firearm injuries (1.4%), and 162 (16.0%) patients with at least one firearm-related vascular injury. RESULTS There were 162 patients admitted with 238 firearm-related vascular injuries, 96.9% men (n = 157), median age 26.0 years [IQR 22-33]. There was an increase in vascular firearm injuries over time (P < 0.005). The most common anatomical vascular injury location was lower extremity (41.7%) followed by abdomen (18.9%) and chest (18.9%). The dominating vascular injuries were common femoral artery (17.6%, 42/238), superficial femoral artery (7.1%, 17/238), and iliac artery (7.1%, 17/238). Systolic blood pressure (SBP) < 90 mmHg or no palpable radial pulse in the emergency department was seen in 37.7% (58/154) of patients. The most common vascular injuries in this cohort with hemodynamic instability were thoracic aorta 16.5% (16/97), femoral artery 10.3% (10/97), inferior vena cava 7.2% (7/97), lung vessels 6.2% (6/97) and iliac vessels 5.2% (5/97). There were 156 registered vascular surgery procedures including vascular suturing (22%, 34/156) and bypass/interposition graft (21%, 32/156). Endovascular stent was placed in five patients (3.2%). The 30-day and 90-day mortality was 29.9% (50/162) and 33.3% (54/162), respectively. Most deaths (79.6%; 43/54) were within 24-h of injury. In the multivariate regression analysis, vascular injury to chest (P < 0.001) or abdomen (P = 0.002) and injury specifically to thoracic aorta (P < 0.001) or femoral artery (P = 0.022) were associated with 24-h mortality. CONCLUSIONS Firearm-related vascular injuries caused significant morbidity and mortality. The lower extremity was the most common injury location but vascular injuries to chest and abdomen were most lethal. Improved early hemorrhage control strategies seem critical for better outcome.
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Affiliation(s)
- Karolina Nyberger
- Department of Molecular Medicine and Surgery, Karolinska Institute, 171 76, Stockholm, Sweden.
- Department of Trauma, Emergency Surgery and Orthopedics, Karolinska University Hospital, Stockholm, Sweden.
- Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden.
| | - Eva-Corina Caragounis
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska University Hospital, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Pauline Djerf
- Department of Surgery, Lund University, Skåne University Hospital, Malmö, Sweden
| | - Carl-Magnus Wahlgren
- Department of Molecular Medicine and Surgery, Karolinska Institute, 171 76, Stockholm, Sweden
- Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
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Nyberger K, Strömmer L, Wahlgren CM. A systematic review of hemorrhage and vascular injuries in civilian public mass shootings. Scand J Trauma Resusc Emerg Med 2023; 31:30. [PMID: 37337265 DOI: 10.1186/s13049-023-01093-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 06/07/2023] [Indexed: 06/21/2023] Open
Abstract
BACKGROUND Civilian public mass shootings (CPMSs) are a major public health issue and in recent years several events have occurred worldwide. The aim of this systematic review was to characterize injuries and mortality after CPMSs focusing on in-hospital management of hemorrhage and vascular injuries. METHOD A systematic review of all published literature was undertaken in Medline, Embase and Web of Science January 1st, 1968, to February 22nd, 2021, according to the PRISMA guidelines. Literature was eligible for inclusion if the CPMS included three or more people shot, injured or killed, had vascular injuries or hemorrhage. RESULTS The search identified 2884 studies; 34 were eligible for inclusion in the analysis. There were 2039 wounded in 45 CPMS events. The dominating anatomic injury location per event was the extremity followed by abdomen and chest. The median number of operations and operated patients per event was 22 (5-101) and 10.5 (4-138), respectively. A total of 899 deaths were reported with a median mortality rate of 36.1% per event (15.9-71.4%) Thirty-eight percent (13/34) of all studies reported on vascular injuries. Vascular injuries ranged from 8 to 29%; extremity vascular injury the most frequent. Specific vascular injuries included thoracic aorta 18% (42/232), carotid arteries 6% (14/232), and abdominal aorta 5% (12/232). Vascular injuries were involved in 8.3%-10% of all deaths. CONCLUSION This systematic review showed an overall high mortality after CPMS with injuries mainly located to the extremities, thorax and abdomen. About one quarter of deaths was related to hemorrhage involving central large vessel injuries. Further understanding of these injuries, and structured and uniform reporting of injuries and treatment protocols may help improve evaluation and management in the future. Level of Evidence Systematic review and meta-analysis, level III.
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Affiliation(s)
- Karolina Nyberger
- Department of Molecular Medicine and Surgery, Karolinska Institute, 171 76, Stockholm, Sweden.
- Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden.
| | - Lovisa Strömmer
- Division of Surgery, Department of Clinical Science Intervention and Technology (CLINTEC), Karolinska Institute, Stockholm, Sweden
| | - Carl-Magnus Wahlgren
- Department of Molecular Medicine and Surgery, Karolinska Institute, 171 76, Stockholm, Sweden
- Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
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10
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Stendahl S, Rollgard L, Behm L, Rantala A. "You have to live with some risk, it's part of the profession". Specialist ambulance nurses' perceptions of assignments involving ongoing lethal violence. Scand J Trauma Resusc Emerg Med 2023; 31:17. [PMID: 37020308 PMCID: PMC10077736 DOI: 10.1186/s13049-023-01082-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Accepted: 03/28/2023] [Indexed: 04/07/2023] Open
Abstract
BACKGROUND As a result of several violent terrorist incidents, authorities in Sweden have shifted from previous approaches of being certain that it is safe for the ambulance service to enter the scene, to a one where "safe enough" is sufficient, potentially making it possible to save more lives. The aim was therefore to describe specialist ambulance nurses' perceptions of the new approach to assignments involving incidents with ongoing lethal violence. METHODS This interview study employed a descriptive qualitative design with a phenomenographic approach in accordance with Dahlgren and Fallsberg. RESULTS Five categories containing conceptual descriptions were developed from the analysis: Collaboration, Unsafe environments, Resources, Unequipped and Risk taking and self-protection. CONCLUSIONS The findings highlight the need to ensure that the ambulance service is a learning organisation, where clinicians with experience of an ongoing lethal violence event can pass on and share their knowledge with colleagues to prepare mentally for such an event. Potentially compromised security in the ambulance service when dispatched to ongoing lethal violence incidents needs to be addressed.
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Affiliation(s)
| | - Linda Rollgard
- Ambulance Service Department, Region Skåne, Helsingborg, Sweden
| | - Lina Behm
- Faculty of Health Science, Kristianstad University, Kristianstad, Sweden
| | - Andreas Rantala
- Ambulance Service Department, Region Skåne, Helsingborg, Sweden.
- Department of Health Sciences, Lund University, P.O. Box 157, 221 00, Lund, Sweden.
- Centre of Interprofessional Cooperation Within Emergency Care (CICE), Linnaeus University, Växjö, Sweden.
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11
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Kman NE, Price A, Berezina‐Blackburn V, Patterson J, Maicher K, Way DP, McGrath J, Panchal AR, Luu K, Oliszewski A, Swearingen S, Danforth D. First Responder Virtual Reality Simulator to train and assess emergency personnel for mass casualty response. J Am Coll Emerg Physicians Open 2023; 4:e12903. [PMID: 36817080 PMCID: PMC9933861 DOI: 10.1002/emp2.12903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 12/27/2022] [Accepted: 01/19/2023] [Indexed: 02/18/2023] Open
Abstract
As mass casualty incidents continue to escalate in the United States, we must improve frontline responder performance to increase the odds of victim survival. In this article, we describe the First Responder Virtual Reality Simulator, a high-fidelity, fully immersive, automated, programmable virtual reality (VR) simulation designed to train frontline responders to treat and triage victims of mass casualty incidents. First responder trainees don a wireless VR head-mounted display linked to a compatible desktop computer. Trainees see and hear autonomous, interactive victims who are programmed to simulate individuals with injuries consistent with an explosion in an underground space. Armed with a virtual medical kit, responders are tasked with triaging and treating the victims on the scene. The VR environment can be made more challenging by increasing the environmental chaos, adding patients, or increasing the acuity of patient injuries. The VR platform tracks and records their performance as they navigate the disaster scene. Output from the system provides feedback to participants on their performance. Eventually, we hope that the First Responder system will serve both as an effective replacement for expensive conventional training methods as well as a safe and efficient platform for research on current triage protocols.
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Affiliation(s)
- Nicholas E. Kman
- Department of Emergency MedicineThe Ohio State University College of MedicineColumbusOhioUSA
| | - Alan Price
- Center for Immersive MediaUniversity of the ArtsPhiladelphiaPennsylvaniaUSA
| | | | - Jeremy Patterson
- Advanced Computing Center for the Arts and Design, The Ohio State UniversityColumbusOhioUSA
| | - Kellen Maicher
- Wexner Medical Center, James Cancer Hospital, Operations ImprovementThe Ohio State UniversityColumbusOhioUSA
| | - David P. Way
- Department of Emergency MedicineThe Ohio State University College of MedicineColumbusOhioUSA
| | - Jillian McGrath
- Department of Emergency MedicineThe Ohio State University College of MedicineColumbusOhioUSA
| | - Ashish R. Panchal
- Department of Emergency MedicineThe Ohio State University College of MedicineColumbusOhioUSA
| | - Katherine Luu
- Department of Emergency MedicineThe Ohio State University College of MedicineColumbusOhioUSA
| | - Alex Oliszewski
- Advanced Computing Center for the Arts and Design, The Ohio State UniversityColumbusOhioUSA
| | - Scott Swearingen
- Advanced Computing Center for the Arts and Design, The Ohio State UniversityColumbusOhioUSA
| | - Douglas Danforth
- Department of Obstetrics & GynecologyThe Ohio State University College of MedicineColumbusOhioUSA
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12
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Adebayo O, Bhuiyan ZA, Ahmed Z. Exploring the effectiveness of artificial intelligence, machine learning and deep learning in trauma triage: A systematic review and meta-analysis. Digit Health 2023; 9:20552076231205736. [PMID: 37822960 PMCID: PMC10563501 DOI: 10.1177/20552076231205736] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 09/18/2023] [Indexed: 10/13/2023] Open
Abstract
Background The development of artificial intelligence (AI), machine learning (ML) and deep learning (DL) has advanced rapidly in the medical field, notably in trauma medicine. We aimed to systematically appraise the efficacy of AI, ML and DL models for predicting outcomes in trauma triage compared to conventional triage tools. Methods We searched PubMed, MEDLINE, ProQuest, Embase and reference lists for studies published from 1 January 2010 to 9 June 2022. We included studies which analysed the use of AI, ML and DL models for trauma triage in human subjects. Reviews and AI/ML/DL models used for other purposes such as teaching, or diagnosis were excluded. Data was extracted on AI/ML/DL model type, comparison tools, primary outcomes and secondary outcomes. We performed meta-analysis on studies reporting our main outcomes of mortality, hospitalisation and critical care admission. Results One hundred and fourteen studies were identified in our search, of which 14 studies were included in the systematic review and 10 were included in the meta-analysis. All studies performed external validation. The best-performing AI/ML/DL models outperformed conventional trauma triage tools for all outcomes in all studies except two. For mortality, the mean area under the receiver operating characteristic (AUROC) score difference between AI/ML/DL models and conventional trauma triage was 0.09, 95% CI (0.02, 0.15), favouring AI/ML/DL models (p = 0.008). The mean AUROC score difference for hospitalisation was 0.11, 95% CI (0.10, 0.13), favouring AI/ML/DL models (p = 0.0001). For critical care admission, the mean AUROC score difference was 0.09, 95% CI (0.08, 0.10) favouring AI/ML/DL models (p = 0.00001). Conclusions This review demonstrates that the predictive ability of AI/ML/DL models is significantly better than conventional trauma triage tools for outcomes of mortality, hospitalisation and critical care admission. However, further research and in particular randomised controlled trials are required to evaluate the clinical and economic impacts of using AI/ML/DL models in trauma medicine.
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Affiliation(s)
- Oluwasemilore Adebayo
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, UK
| | - Zunira Areeba Bhuiyan
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, UK
| | - Zubair Ahmed
- Institute of Inflammation and Ageing, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, Birmingham, UK
- Centre for Trauma Sciences Research, University of Birmingham, Edgbaston, Birmingham, UK
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Agri J, Montán C, Söderin L, Lennquist-Montán K, Hammarberg E. Prehospital Preparedness for Major Incidents in Sweden: A National Survey with Focus on Mass-Casualty Incidents. Prehosp Disaster Med 2022; 38:1-8. [PMID: 36440661 DOI: 10.1017/s1049023x22002229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Major incidents (MIs) put great demands on the medical response to effectively organize and redistribute resources and personnel, in prehospital care as well as hospital care, and coordinating functions. Studies indicate that regular training and well-established contingency plans are vital for the medical response to MIs. Previous assessments have concluded that Swedish disaster preparedness requires improved organization and coordination. There is currently no method to easily follow-up the preparedness work of the prehospital medical response organizations for MIs in Sweden. PROBLEM The aim of the study was to assess qualifications and training requirements for central individual roles, to examine frequency and focus of training and simulation, as well as to examine current regional routines for MIs in Sweden. The aim was also to identify, to evaluate, and to investigate areas for improvement in prehospital health care preparedness for MIs in Sweden. METHODS Descriptive comparative study of Sweden's prehospital organization, planning, education, and training for MIs through a web-based survey sent to all 21 regions in Sweden. The survey included 64 questions and was based on national legislation and guidelines for preparedness and previous investigations of real MIs. RESULTS A total of 37 answers to the survey were collected representing 17/21 regions (80.9%) from which Regional Management Individuals (RMIs) were selected from 15 regions and used as representative primary responses. The initial routines regarding alarm and establishment of management functions were mainly in-line with national guidelines. Staffing and qualification requirements for certain leadership roles differed substantially between regions. The requirements for the health care staff's knowledge of the contingency plan were generally low and routines for follow-up were often lacking. The frequency of exercises in certain areas were deficient. CONCLUSIONS The results of the study showed several potential areas for improvement within the prehospital emergency medical preparedness for MIs in Sweden. Methodology and adherence of national guidelines for medical response preparedness differ between regions in Sweden, which motivates recurring assessments. It is possible to use a well-prepared questionnaire study to follow-up and to examine parts of the regional prehospital preparedness work and organization for MIs.
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Affiliation(s)
- Joakim Agri
- Department of Molecular Medicine and Surgery (MMK), Karolinska Institutet, Stockholm, Sweden
| | - Carl Montán
- Department of Molecular Medicine and Surgery (MMK), Karolinska Institutet, Stockholm, Sweden
| | - Louise Söderin
- Department of Molecular Medicine and Surgery (MMK), Karolinska Institutet, Stockholm, Sweden
| | | | - Elsa Hammarberg
- Department of Molecular Medicine and Surgery (MMK), Karolinska Institutet, Stockholm, Sweden
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Making Space to Save Lives: A Critical Role for the Hospitalist During Mass Casualty Incidents. Disaster Med Public Health Prep 2022; 17:e213. [PMID: 35929349 DOI: 10.1017/dmp.2022.175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE An effective hospital response to mass casualty incidents (MCIs) requires rapid mobilization of personnel capable of caring for critically ill trauma patients and availability of resuscitation resources. METHODS Hospitals facing an MCI wrestle with the challenge of immediately adjusting their overextended clinical operations to resuscitate a large number of rapidly arriving patients without compromising the care of existing patients. RESULTS Hospitalists are well positioned to add significant value by off-loading the emergency department (ED) given their broad clinical expertise. We describe our institution's protocol to generate immediate and sustained surge capacity by integrating our hospitalist service into MCI response. CONCLUSIONS Our protocol details the safe and rapid transfer of care of existing ED patients to hospitalist teams to make ED staff and space available to care for incoming MCI patients.
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15
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Perry O, Jaffe E, Bitan Y. Dynamic Communication Quantification Model for Measuring Information Management During Mass-Casualty Incident Simulations. HUMAN FACTORS 2022; 64:228-249. [PMID: 34275344 PMCID: PMC8873974 DOI: 10.1177/00187208211018880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Revised: 02/25/2021] [Accepted: 04/22/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To develop a new model to quantify information management dynamically and to identify factors that lead to information gaps. BACKGROUND Information management is a core task for emergency medical service (EMS) team leaders during the prehospital phase of a mass-casualty incident (MCI). Lessons learned from past MCIs indicate that poor information management can lead to increased mortality. Various instruments are used to evaluate information management during MCI training simulations, but the challenge of measuring and improving team leaders' abilities to manage information remains. METHOD The Dynamic Communication Quantification (DCQ) model was developed based on the knowledge representation typology. Using multi point-of-view synchronized video, the model quantifies and visualizes information management. It was applied to six MCI simulations between 2014 and 2019, to identify factors that led to information gaps, and compared with other evaluation methods. RESULTS Out of the three methods applied, only the DCQ model revealed two factors that led to information gaps: first, consolidation of numerous casualties from different areas, and second, tracking of casualty arrivals to the medical treatment area and departures from the MCI site. CONCLUSION The DCQ model allows information management to be objectively quantified. Thus, it reveals a new layer of knowledge, presenting information gaps during an MCI. Because the model is applicable to all MCI team leaders, it can make MCI simulations more effective. APPLICATION This DCQ model quantifies information management dynamically during MCI training simulations.
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Affiliation(s)
- Omer Perry
- 26732 Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Eli Jaffe
- 26732 Ben-Gurion University of the Negev, Beer-Sheva, Israel
- Magen David Adom (MDA), Israel
| | - Yuval Bitan
- 26732 Ben-Gurion University of the Negev, Beer-Sheva, Israel
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16
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Lessons learned from terror attacks: thematic priorities and development since 2001-results from a systematic review. Eur J Trauma Emerg Surg 2022; 48:2613-2638. [PMID: 35024874 PMCID: PMC8757406 DOI: 10.1007/s00068-021-01858-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 11/29/2021] [Indexed: 11/03/2022]
Abstract
Purpose The threat of national and international terrorism remains high. Preparation is the key requirement for the resilience of hospitals and out-of-hospital rescue forces. The scientific evidence for defining medical and tactical strategies often feeds on the analysis of real incidents and the lessons learned derived from them. This systematic review of the literature aims to identify and systematically report lessons learned from terrorist attacks since 2001. Methods PubMed was used as a database using predefined search strategies and eligibility criteria. All countries that are part of the Organization for Economic Cooperation and Development (OECD) were included. The time frame was set between 2001 and 2018. Results Finally 68 articles were included in the review. From these, 616 lessons learned were extracted and summarized into 15 categories. The data shows that despite the difference in attacks, countries, and casualties involved, many of the lessons learned are similar. We also found that the pattern of lessons learned is repeated continuously over the time period studied. Conclusions The lessons from terrorist attacks since 2001 follow a certain pattern and remained constant over time. Therefore, it seems to be more accurate to talk about lessons identified rather than lessons learned. To save as many victims as possible, protect rescue forces from harm, and to prepare hospitals at the best possible level it is important to implement the lessons identified in training and preparation.
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17
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Atia A, Halligan L, Brezina L, Levites H, Hollins A, Blau J, Hernandez JA, Lohmeier S, Suresh V, Powers DB. Distribution of wounding patterns in casualties from mass shooting events. TRAUMA-ENGLAND 2021. [DOI: 10.1177/14604086211049636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction The incidence and severity of public mass shootings, and mass casualty incidents (MCI), continues to rise. Understanding the wounding pattern and incidence of potentially preventable death after these incidents is key not only to Health System and Trauma Center emergency response planning but also to community outreach and initial emergency interventions. Methods A retrospective study of autopsy reports after events with at least 10 fatalities exclusive of the assailants identified via the Federal Bureau of Investigation database from 1 January 1999 to 31 December 2020 was performed. Sites of injury, identification of weaponry, and identification of potentially survivable wounds were compiled. Results Nine events including 203 victims were reviewed. Overall, 56% of gunshots were to the head/neck/face; 37% were to the chest; 43% were to the abdomen/torso/back; 31% were to the lower extremity; and 36% were to the upper extremity. On average, there were 29 fatalities per event. Conclusion Emergency response disaster care strategy should focus on immediate point of care at the site of wounding by both the civilian population and medical personnel, as well as rapid extrication of victims for definitive medical care. Review of these autopsy results indicates exsanguination, often treatable, is the primary cause of death—supporting community education efforts in hemorrhage control. The location of the wounding patterns seen in this study warrants primary integration of craniomaxillofacial, orthopedic trauma, neurotrauma, and surgical critical care/trauma surgical specialists into the initial response team for MCI.
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Affiliation(s)
- Andrew Atia
- Division of Plastic, Maxillofacial & Oral Surgery, Duke University Hospital, Durham, NC, USA
| | - Lauren Halligan
- Department of Surgery, Duke University Medical Center, Durham, NC, USA
| | - Libor Brezina
- Duke University School of Medicine, Durham, NC, USA
- Medical Student Researcher, Barts Health NHS Trust, London, England, UK
| | - Heather Levites
- Division of Plastic, Maxillofacial & Oral Surgery, Duke University Hospital, Durham, NC, USA
| | - Andrew Hollins
- Division of Plastic, Maxillofacial & Oral Surgery, Duke University Hospital, Durham, NC, USA
| | - Jared Blau
- Division of Plastic, Maxillofacial & Oral Surgery, Duke University Hospital, Durham, NC, USA
| | - J Andres Hernandez
- Division of Plastic, Maxillofacial & Oral Surgery, Duke University Hospital, Durham, NC, USA
| | - Steven Lohmeier
- Division of Plastic, Maxillofacial & Oral Surgery, Duke University Hospital, Durham, NC, USA
| | - Visakha Suresh
- Department of Plastic Surgery, Johns Hopkins Hospital, Baltimore, MD; Duke University School of Medicine, Durham, NC, USA
| | - David B Powers
- Division of Plastic, Maxillofacial & Oral Surgery, Duke University Hospital, Durham, NC, USA
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Malik NS, Chernbumroong S, Xu Y, Vassallo J, Lee J, Moran CG, Newton T, Arul GS, Lord JM, Belli A, Keene D, Foster M, Hodgetts T, Bowley DM, Gkoutos GV. Paediatric major incident triage: UK military tool offers best performance in predicting the need for time-critical major surgical and resuscitative intervention. EClinicalMedicine 2021; 40:101100. [PMID: 34746717 PMCID: PMC8548919 DOI: 10.1016/j.eclinm.2021.101100] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 08/06/2021] [Accepted: 08/06/2021] [Indexed: 12/05/2022] Open
Abstract
BACKGROUND Children are frequently injured during major incidents (MI), including terrorist attacks, conflict and natural disasters. Triage facilitates healthcare resource allocation in order to maximise overall survival. A critical function of MI triage tools is to identify patients needing time-critical major resuscitative and surgical intervention (Priority 1 (P1) status). This study compares the performance of 11 MI triage tools in predicting P1 status in children from the UK Trauma Audit and Research Network (TARN) registry. METHODS Patients aged <16 years within TARN (January 2008-December 2017) were included. 11 triage tools were applied to patients' first recorded pre-hospital physiology. Patients were retrospectively assigned triage categories (P1, P2, P3, Expectant or Dead) using predefined intervention-based criteria. Tools' performance in <16s were evaluated within four-yearly age subgroups, comparing tool-predicted and intervention-based priority status. FINDINGS Amongst 4962 patients, mortality was 1.1% (n = 53); median Injury Severity Score (ISS) was 9 (IQR 9-16). Blunt injuries predominated (94.4%). 1343 (27.1%) met intervention-based criteria for P1, exhibiting greater intensive care requirement (60.2% vs. 8.5%, p < 0.01) and ISS (median 17 vs 9, p < 0.01) compared with P2 patients. The Battlefield Casualty Drills (BCD) Triage Sieve had greatest sensitivity (75.7%) in predicting P1 status in children <16 years, demonstrating a 38.4-49.8% improvement across all subgroups of children <12 years compared with the UK's current Paediatric Triage Tape (PTT). JumpSTART demonstrated low sensitivity in predicting P1 status in 4 to 8 year olds (35.5%) and 0 to 4 year olds (28.5%), and was outperformed by its adult counterpart START (60.6% and 59.6%). INTERPRETATION The BCD Triage Sieve had greatest sensitivity in predicting P1 status in this paediatric trauma registry population: we recommend it replaces the PTT in UK practice. Users of JumpSTART may consider alternative tools. We recommend Lerner's triage category definitions when conducting MI evaluations.
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Affiliation(s)
- Nabeela S. Malik
- NIHR Surgical Reconstruction and Microbiological Research Centre (SRMRC), Heritage Building, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, United Kingdom
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham B15 2TT, United Kingdom
- 212 (Yorkshire) Field Hospital, Endcliffe Hall, Endcliffe Vale Road, Sheffield S10 3EU, United Kingdom
- Corresponding author at: NIHR Surgical Reconstruction and Microbiological Research Centre (SRMRC), Heritage Building, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, United Kingdom.
| | - Saisakul Chernbumroong
- NIHR Surgical Reconstruction and Microbiological Research Centre (SRMRC), Heritage Building, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, United Kingdom
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom
| | - Yuanwei Xu
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom
| | - James Vassallo
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, United Kingdom
| | - Justine Lee
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham B15 2TT, United Kingdom
- University Hospitals Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, United Kingdom
- NHS England London, Skipton House, 80 London Road, London SE1 6LH, United Kingdom
| | - Christopher G. Moran
- NHS England London, Skipton House, 80 London Road, London SE1 6LH, United Kingdom
- Nottingham University Hospitals NHS Trust, Derby Road, Nottingham NG7 2UH, United Kingdom
| | - Tina Newton
- Birmingham Children's Hospital, Steelhouse Lane, Birmingham B4 6NH, United Kingdom
| | - G. Suren Arul
- 212 (Yorkshire) Field Hospital, Endcliffe Hall, Endcliffe Vale Road, Sheffield S10 3EU, United Kingdom
- Birmingham Children's Hospital, Steelhouse Lane, Birmingham B4 6NH, United Kingdom
| | - Janet M. Lord
- NIHR Surgical Reconstruction and Microbiological Research Centre (SRMRC), Heritage Building, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, United Kingdom
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham B15 2TT, United Kingdom
| | - Antonio Belli
- NIHR Surgical Reconstruction and Microbiological Research Centre (SRMRC), Heritage Building, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, United Kingdom
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham B15 2TT, United Kingdom
- University Hospitals Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, United Kingdom
| | - Damian Keene
- University Hospitals Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, United Kingdom
- Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, United Kingdom
| | - Mark Foster
- NIHR Surgical Reconstruction and Microbiological Research Centre (SRMRC), Heritage Building, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, United Kingdom
- University Hospitals Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, United Kingdom
- Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, United Kingdom
| | - Timothy Hodgetts
- Headquarters Defence Medical Services, Coltman House, Lichfield WS14 9PY, United Kingdom
| | - Douglas M. Bowley
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham B15 2TT, United Kingdom
- University Hospitals Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, United Kingdom
- Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, United Kingdom
| | - Georgios V. Gkoutos
- NIHR Surgical Reconstruction and Microbiological Research Centre (SRMRC), Heritage Building, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, United Kingdom
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2TT, United Kingdom
- Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, United Kingdom
- MRC Health Data Research UK (HDR UK), Midlands Site, Birmingham B15 2TT, United Kingdom
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Borgers F, Van Boxstael S, Sabbe M. Is tactical combat casualty care in terrorist attacks suitable for civilian first responders? J Trauma Acute Care Surg 2021; 91:e86-e92. [PMID: 34238863 DOI: 10.1097/ta.0000000000003337] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
INTRODUCTION Prehospital management of intentional mass casualty incidents is a unique challenge to Emergency Medical Services. Tactical Combat Casualty Care (TCCC) and the use of tourniquets for extremity hemorrhage have already proven to reduce mortality on the battlefield. This literature review aims to determine the place of these military concepts in a civilian high-threat prehospital setting. METHODS The PubMed database was searched for articles published between January 1, 2000, and December 1, 2019, containing descriptions, discussions, or experiences of the application of tourniquets or other TCCC-based interventions in the civilian prehospital setting. Data extraction focused on identifying important common themes in the articles. RESULTS Of the 286 identified articles, 30 were selected for inclusion. According to the Oxford Centre for Evidence-based Medicine Levels of Evidence, overall level of evidence was low. Most articles were observational, retrospective cohort studies without a nontourniquet control group. Outcome measures and variables were variably reported. Two articles specifically analyzed tourniquet use during high-threat situations, and three described their application by law enforcement personnel. Overall, tourniquets were found to be effective in stopping major limb bleeding. Reported mortality was low and related complications appeared to be infrequent. Only four articles mentioned the application of other TCCC-based maneuvers, such as airway and respiratory management. CONCLUSION This literature review shows that tourniquets appear to be safe tools associated with few complications and might be effective in controlling major bleeding in civilian limb trauma. For example, during mass casualty incidents, their use could be justified. Training and equipping ambulance and police services to deal with massive bleeding could likewise improve interoperability and victim survival in a civilian high-threat prehospital setting. More qualitative research is needed to further evaluate the effects of hemorrhage control training for first responders on patient outcomes. Literature describing the application of other TCCC-based principles is limited, which makes it difficult to draw conclusions regarding their use in a civilian setting. LEVEL OF EVIDENCE Systematic review, level III.
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Affiliation(s)
- Felix Borgers
- From the Department of Anesthesiology (F.B.), University Hospitals Leuven, Leuven, Belgium; Emergency Department (V.B.), ZOL Hospital Genk, Genk, Belgium; and Emergency Department (M.S.), University Hospitals Leuven, Leuven, Belgium
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Lott C, Truhlář A, Alfonzo A, Barelli A, González-Salvado V, Hinkelbein J, Nolan JP, Paal P, Perkins GD, Thies KC, Yeung J, Zideman DA, Soar J. [Cardiac arrest under special circumstances]. Notf Rett Med 2021; 24:447-523. [PMID: 34127910 PMCID: PMC8190767 DOI: 10.1007/s10049-021-00891-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/19/2021] [Indexed: 01/10/2023]
Abstract
These guidelines of the European Resuscitation Council (ERC) Cardiac Arrest under Special Circumstances are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required for basic and advanced life support for the prevention and treatment of cardiac arrest under special circumstances; in particular, specific causes (hypoxia, trauma, anaphylaxis, sepsis, hypo-/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), specific settings (operating room, cardiac surgery, cardiac catheterization laboratory, dialysis unit, dental clinics, transportation [in-flight, cruise ships], sport, drowning, mass casualty incidents), and specific patient groups (asthma and chronic obstructive pulmonary disease, neurological disease, morbid obesity, pregnancy).
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Affiliation(s)
- Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Mainz, Deutschland
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Tschechien
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Hradec Králové, Charles University in Prague, Hradec Králové, Tschechien
| | - Anette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife Großbritannien
| | - Alessandro Barelli
- Anaesthesiology and Intensive Care, Teaching and research Unit, Emergency Territorial Agency ARES 118, Catholic University School of Medicine, Rom, Italien
| | - Violeta González-Salvado
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Institute of Health Research of Santiago de Compostela (IDIS), Biomedical Research Networking Centres on Cardiovascular Disease (CIBER-CV), A Coruña, Spanien
| | - Jochen Hinkelbein
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Köln, Deutschland
| | - Jerry P. Nolan
- Resuscitation Medicine, Warwick Medical School, University of Warwick, CV4 7AL Coventry, Großbritannien
- Anaesthesia and Intensive Care Medicine, Royal United Hospital, BA1 3NG Bath, Großbritannien
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Österreich
| | - Gavin D. Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, Großbritannien
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, Großbritannien
| | - Karl-Christian Thies
- Dep. of Anesthesiology and Critical Care, Bethel Evangelical Hospital, University Medical Center OLW, Bielefeld University, Bielefeld, Deutschland
| | - Joyce Yeung
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, Großbritannien
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, Großbritannien
| | | | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, Großbritannien
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21
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Malik NS, Chernbumroong S, Xu Y, Vassallo J, Lee J, Bowley DM, Hodgetts T, Moran CG, Lord JM, Belli A, Keene D, Foster M, Gkoutos GV. The BCD Triage Sieve outperforms all existing major incident triage tools: Comparative analysis using the UK national trauma registry population. EClinicalMedicine 2021; 36:100888. [PMID: 34308306 PMCID: PMC8257989 DOI: 10.1016/j.eclinm.2021.100888] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Natural disasters, conflict, and terrorism are major global causes of death and disability. Central to the healthcare response is triage, vital to ensure the right care is provided to the right patient at the right time. The ideal triage tool has high sensitivity for the highest priority (P1) patients with acceptably low over-triage. This study compared the performance of major incident triage tools in predicting P1 casualty status in adults in the prospective UK Trauma Audit and Research Network (TARN) registry. METHODS TARN patients aged 16+ years (January 2008-December 2017) were included. Ten existing triage tools were applied using patients' first recorded pre-hospital physiology. Patients were subsequently assigned triage categories (P1, P2, P3, Expectant or Dead) based on pre-defined, intervention-based criteria. Tool performance was assessed by comparing tool-predicted and intervention-based priority status. FINDINGS 195,709 patients were included; mortality was 7·0% (n=13,601); median Injury Severity Score (ISS) was 9 (IQR 9-17); 97·1% sustained blunt injuries. 22,144 (11·3%) patients fulfilled intervention-based criteria for P1 status, exhibiting higher mortality (12·8% vs. 5·0%, p<0.001), increased intensive care requirement (52·4% vs 5·0%, p<0.001), and more severe injuries (median ISS 21 vs 9, p<0.001) compared with P2 patients.In 16-64 year olds, the highest performing tool was the Battlefield Casualty Drills (BCD) Triage Sieve (Prediction of P1 status: 70·4% sensitivity, over-triage 70·9%, area under the receiver operating curve (AUC) 0·068 [95%CI 0·676-0·684]). The UK National Ambulance Resilience Unit (NARU) Triage Sieve had sensitivity of 44·9%; over-triage 56·4%; AUC 0·666 (95%CI 0·662-0·670). All tools performed poorly amongst the elderly (65+ years). INTERPRETATION The BCD Triage Sieve performed best in this nationally representative population; we recommend it supersede the NARU Triage Sieve as the UK primary major incident triage tool. Validated triage category definitions are recommended for appraising future major incidents. FUNDING This study is funded by the National Institute for Health Research (NIHR) Surgical Reconstruction and Microbiology Research Centre. GVG also acknowledges support from the MRC Heath Data Research UK (HDRUK/CFC/01). The views expressed are those of the authors and not necessarily those of the NIHR, the Department of Health and Social Care, or the Ministry of Defence.
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Affiliation(s)
- Nabeela S. Malik
- NIHR Surgical Reconstruction and Microbiological Research Centre (SRMRC), Heritage Building, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, UK
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham B15 2TT, UK
- 212 (Yorkshire) Field Hospital, Endcliffe Hall, Endcliffe Vale Road, Sheffield S10 3EU, UK
- Corresponding author at: NIHR Surgical Reconstruction and Microbiological Research Centre (SRMRC), Heritage Building, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham, B15 2TH, UK.
| | - Saisakul Chernbumroong
- NIHR Surgical Reconstruction and Microbiological Research Centre (SRMRC), Heritage Building, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, UK
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - Yuanwei Xu
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2TT, UK
| | - James Vassallo
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK
| | - Justine Lee
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham B15 2TT, UK
- University Hospitals Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK
- NHS England London, Skipton House, 80 London Road, London SE1 6LH, UK
| | - Douglas M. Bowley
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham B15 2TT, UK
- Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK
- University Hospitals Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK
| | - Timothy Hodgetts
- Army Health, Army Headquarters, Monxton Road, Andover SP11 8HT, UK
| | - Christopher G Moran
- NHS England London, Skipton House, 80 London Road, London SE1 6LH, UK
- Nottingham University Hospitals NHS Trust, Derby Road, Nottingham NG7 2UH, UK
| | - Janet M Lord
- NIHR Surgical Reconstruction and Microbiological Research Centre (SRMRC), Heritage Building, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, UK
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham B15 2TT, UK
| | - Antonio Belli
- NIHR Surgical Reconstruction and Microbiological Research Centre (SRMRC), Heritage Building, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, UK
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham B15 2TT, UK
- University Hospitals Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK
| | - Damian Keene
- Academic Department of Military Surgery & Trauma, Royal Centre for Defence Medicine, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK
- University Hospitals Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK
| | - Mark Foster
- NIHR Surgical Reconstruction and Microbiological Research Centre (SRMRC), Heritage Building, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, UK
- Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK
- University Hospitals Birmingham, Mindelsohn Way, Edgbaston, Birmingham B15 2WB, UK
| | - Georgios V Gkoutos
- NIHR Surgical Reconstruction and Microbiological Research Centre (SRMRC), Heritage Building, Queen Elizabeth Hospital, Mindelsohn Way, Edgbaston, Birmingham B15 2TH, UK
- Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham B15 2TT, UK
- Institute of Translational Medicine, University Hospitals Birmingham NHS Foundation Trust, Birmingham B15 2TT, UK
- MRC Health Data Research UK (HDR UK), Midlands Site, B15 2TT UK
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Dark P, Smith M, Ziman H, Carley S, Lecky F. Healthcare system impacts of the 2017 Manchester Arena bombing: evidence from a national trauma registry patient case series and hospital performance data. Emerg Med J 2021; 38:746-755. [PMID: 33888513 PMCID: PMC8461451 DOI: 10.1136/emermed-2019-208575] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Revised: 04/04/2021] [Accepted: 04/08/2021] [Indexed: 11/14/2022]
Abstract
Introduction In response to detonation of an improvised explosive device at the Manchester Arena on 22 May 2017, we aimed to use detailed information about injured patients flowing through hospital healthcare to objectively evaluate the preplanned responses of a regional trauma care system and to show how routinely collected hospital performance data can be used to assess impact on regional healthcare. Methods Data about injury severity, management and outcome for patients presenting to hospitals were collated using England’s major trauma registry for 30 days following hospital attendance. System-wide data about hospital performance were collated by National Health Service England’s North West Utilisation Management Unit and presented as Shewhart charts from 15 April 2017 to 25 June 2017. Results Detailed information was obtained on 153 patients (109 adults and 44 children) who attended hospital emergency departments after the incident. Within 6 hours, a network of 11 regional trauma care hospitals received a total of 138 patients (90%). For the whole patient cohort, median Injury Severity Score (ISS) was 1 (IQR 1–10) and median New ISS (NISS) was 2 (IQR 1–14). For the 75 patients (49%) attending a major trauma centre, median ISS was 7.5 (IQR 1–14) and NISS was 10 (IQR 3–22). Limb and torso body regions predominated when injuries were classified as major life threatening (Abbreviated Injury Scale>3). Ninety-three patients (61%) required hospital admission following emergency department management, with 21 (14%) requiring emergency damage control surgery and 24 (16%) requiring critical care. Three fatalities occurred during early resuscitative treatment and 150 (98%) survived to day 30. The increased system-wide hospital admissions and care activity was linked to increases in regional hospital care capacity through cancellations of elective surgery and increased community care. Consequently, there were sustained system-wide hospital service improvements over the following weeks. Conclusions The systematic collation of injured patient and healthcare system data has provided an objective evaluation of a regional major incident plan and provided insight into healthcare system resilience. Hospital patient care data indicated that a prerehearsed patient dispersal plan at incident scene was implemented effectively.
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Affiliation(s)
- Paul Dark
- Humanitarian and Conflict Response Institute, University of Manchester, Manchester, UK
| | - Martin Smith
- Emergency Department, Salford Royal Hospitals NHS Trust, Salford, UK
| | | | - Simon Carley
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research, The University of Sheffield, Sheffield, UK
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James A, Yordanov Y, Ausset S, Langlois M, Tourtier JP, Carli P, Riou B, Raux M. Assessment of the mass casualty triage during the November 2015 Paris area terrorist attacks: towards a simple triage rule. Eur J Emerg Med 2021; 28:136-143. [PMID: 33252375 DOI: 10.1097/mej.0000000000000771] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKROUND Triage is key in the management of mass casualty incidents. OBJECTIVE The objective of this study was to assess the prehospital triage performed during the 2015 Paris area terrorist attack. DESIGN SETTING AND PARTICIPANT This was a retrospective cohort study that included all casualties of the attacks on 13 November 2015 in Paris area, France, that were admitted alive at the hospital within the first 24 h after the events. Patients were triaged as absolute emergency or relative emergency by a prehospital physician or nurse. This triage was then compared to the one of an expert panel that had retrospectively access to all prehospital and hospital files. OUTCOMES MEASURES AND ANALYSIS The primary endpoints were the rate of overtriage and undertriage, defined as number of patients misclassified in one triage category, divided by the total number of patients in this triage category. MAIN RESULT Among 337 casualties admitted to the hospital, 262 (78%) were triaged during prehospital care, with, respectively, 74 (28%) and 188 (72%) as absolute and relative emergencies. Among these casualties, the expert panel classified 96 (37%) patients as absolute emergencies and 166 (63%) as relative emergency. The rate of undertriage and overtriage was 36% [95% confidence interval (CI), 27-47%] and 8% (95% CI, 4-13%), respectively. Among undertriaged casualties, 8 (23%) were considered as being severely undertriaged. Among overtriaged casualties, 10 (77%) were considered as being severely overtriaged. CONCLUSION A simple prehospital triage for trauma casualties during the 13 November terrorist attack in Paris could have been performed triaged in 78% of casualties that were admitted to the hospital, with a 36% rate of undertriage and 8% of overtriage. Qualitative analysis of undertriage and overtriage indicate some possibilities for further improvement.
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Affiliation(s)
- Arthur James
- Sorbonne Université
- Department of Anaesthesiology and Critical Care Paris, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP)
| | - Youri Yordanov
- Sorbonne Université
- UMRS Inserm 1136
- Department of Emergency Medicine and Surgery, Hôpital Saint-Antoine
- Department of Emergency, APHP
| | - Sylvain Ausset
- Department of Anesthesiology and Critical Care, Hôpital d'Instruction des armées (HIA), Clamart
| | - Matthieu Langlois
- Department of Anaesthesiology and Critical Care Paris, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP)
- Service Médical du RAID, Bièvres
| | | | - Pierre Carli
- Service d'Aide Médicale Urgente 75, Hôpital Necker-Enfants Malades, APHP
- Université de Paris
| | - Bruno Riou
- Sorbonne Université
- Department of Emergency Medicine and Surgery, Hôpital Saint-Antoine
- UMRS Inserm 1166, IHU ICAN
- Department of Emergency Medicine and Surgery, Hôpital Pitié-Salpêtrière
| | - Mathieu Raux
- Sorbonne Université
- Department of Anaesthesiology and Critical Care Paris, Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (APHP)
- UMRS Inserm 1158, Paris, France
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Teuben MPJ, Mand C, Moosdorf L, Sprengel K, Shehu A, Pfeifer R, Ruchholtz S, Lefering R, Pape HC, Jensen KO. Simultaneous Casualty Admissions-Do they Affect Treatment in the Receiving Trauma Center? World J Surg 2021; 45:2037-2045. [PMID: 33782732 PMCID: PMC8154817 DOI: 10.1007/s00268-021-06074-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2021] [Indexed: 11/27/2022]
Abstract
Background Simultaneous trauma admissions expose medical professionals to increased workload. The impact of simultaneous trauma admissions on hospital allocation, therapy, and outcome is currently unclear. We hypothesized that multiple admission-scenarios impact the diagnostic pathway and outcome. Methods The TraumaRegister DGU® was utilized. Patients admitted between 2002–2015 with an ISS ≥ 9, treated with ATLS®- algorithms were included. Group ´IND´ included individual admissions, two individuals that were admitted within 60 min of each other were selected for group ´MULT´. Patients admitted within 10 min were considered as simultaneous (´SIM´) admissions. We compared patient and trauma characteristics, treatment, and outcomes between both groups. Results 132,382 admissions were included, and 4,462/3.4% MULTiple admissions were found. The SIM-group contained 1,686/1.3% patients. The overall median injury severity score was 17 and a mean age of 48 years was found. MULT patients were more frequently admitted to level-one trauma centers (68%) than individual trauma admissions were (58%, p < 0.001). Mean time to CT-scanning (24 vs. 26/28 min) was longer in MULT / SIM patients compared to individual admissions. No differences in utilization of damage control principles were seen. Moreover, mortality rates did not differ between the groups (13.1% in regular admissions and 11.4%/10,6% in MULT/SIM patients). Conclusion This study demonstrates that simultaneous treatment of injured patients is rare. Individuals treated in parallel with other patients were more often admitted to level-one trauma centers compared with individual patients. Although diagnostics take longer, treatment principles and mortality are equal in individual admissions and simultaneously admitted patients. More studies are required to optimize health care under these conditions.
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Affiliation(s)
- Michel Paul Johan Teuben
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8090 Zurich, Switzerland
- Department of Surgery, Thurgau Cantonal Hospital, Frauenfeld, Switzerland
| | - Carsten Mand
- Department of Trauma-,Hand-, and Reconstructive Surgery, University Clinic Giessen and Marburg, Marburg, Germany
| | - Laura Moosdorf
- Department of Trauma-,Hand-, and Reconstructive Surgery, University Clinic Giessen and Marburg, Marburg, Germany
| | - Kai Sprengel
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8090 Zurich, Switzerland
| | - Alba Shehu
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8090 Zurich, Switzerland
| | - Roman Pfeifer
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8090 Zurich, Switzerland
| | - Steffen Ruchholtz
- Department of Trauma-,Hand-, and Reconstructive Surgery, University Clinic Giessen and Marburg, Marburg, Germany
| | - Rolf Lefering
- Institute for Research in Operative Medicine (IFOM), University Witten/Herdecke, Cologne, Germany
| | - Hans-Christoph Pape
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8090 Zurich, Switzerland
| | - Kai Oliver Jensen
- Department of Trauma, University Hospital Zurich, Raemistrasse 100, 8090 Zurich, Switzerland
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Lott C, Truhlář A, Alfonzo A, Barelli A, González-Salvado V, Hinkelbein J, Nolan JP, Paal P, Perkins GD, Thies KC, Yeung J, Zideman DA, Soar J. European Resuscitation Council Guidelines 2021: Cardiac arrest in special circumstances. Resuscitation 2021; 161:152-219. [PMID: 33773826 DOI: 10.1016/j.resuscitation.2021.02.011] [Citation(s) in RCA: 314] [Impact Index Per Article: 104.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
These European Resuscitation Council (ERC) Cardiac Arrest in Special Circumstances guidelines are based on the 2020 International Consensus on Cardiopulmonary Resuscitation Science with Treatment Recommendations. This section provides guidelines on the modifications required to basic and advanced life support for the prevention and treatment of cardiac arrest in special circumstances; specifically special causes (hypoxia, trauma, anaphylaxis, sepsis, hypo/hyperkalaemia and other electrolyte disorders, hypothermia, avalanche, hyperthermia and malignant hyperthermia, pulmonary embolism, coronary thrombosis, cardiac tamponade, tension pneumothorax, toxic agents), special settings (operating room, cardiac surgery, catheter laboratory, dialysis unit, dental clinics, transportation (in-flight, cruise ships), sport, drowning, mass casualty incidents), and special patient groups (asthma and COPD, neurological disease, obesity, pregnancy).
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Affiliation(s)
- Carsten Lott
- Department of Anesthesiology, University Medical Center, Johannes Gutenberg-University Mainz, Germany.
| | - Anatolij Truhlář
- Emergency Medical Services of the Hradec Králové Region, Hradec Králové, Czech Republic; Department of Anaesthesiology and Intensive Care Medicine, Charles University in Prague, University Hospital Hradec Králové, Hradec Králové, Czech Republic
| | - Annette Alfonzo
- Departments of Renal and Internal Medicine, Victoria Hospital, Kirkcaldy, Fife, UK
| | - Alessandro Barelli
- Anaesthesiology and Intensive Care, Catholic University School of Medicine, Teaching and Research Unit, Emergency Territorial Agency ARES 118, Rome, Italy
| | - Violeta González-Salvado
- Cardiology Department, University Clinical Hospital of Santiago de Compostela, Institute of Health Research of Santiago de Compostela (IDIS), Biomedical Research Networking Centres on Cardiovascular Disease (CIBER-CV), A Coruña, Spain
| | - Jochen Hinkelbein
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Cologne, Germany
| | - Jerry P Nolan
- Resuscitation Medicine, University of Warwick, Warwick Medical School, Coventry, CV4 7AL, UK; Anaesthesia and Intensive Care Medicine, Royal United Hospital, Bath, BA1 3NG, UK
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospitallers Brothers Hospital, Paracelsus Medical University, Salzburg, Austria
| | - Gavin D Perkins
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Karl-Christian Thies
- Department of Anesthesiology, Critical Care and Emergency Medicine, Bethel Medical Centre, OWL University Hospitals, Bielefeld University, Germany
| | - Joyce Yeung
- Warwick Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK; University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Jasmeet Soar
- Southmead Hospital, North Bristol NHS Trust, Bristol, UK
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Blood product needs and transfusion timelines for the multisite massive Paris 2015 terrorist attack: A retrospective analysis. J Trauma Acute Care Surg 2021; 89:496-504. [PMID: 32301884 DOI: 10.1097/ta.0000000000002729] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Hemorrhage is the leading cause of death after terrorist attack, and the immediacy of labile blood product (LBP) administration has a decisive impact on patients' outcome. The main objective of this study was to evaluate the transfusion patterns of the Paris terrorist attack victims, November 13, 2015. METHODS We performed a retrospective analysis including all casualties admitted to hospital, aiming to describe the transfusion patterns from admission to the first week after the attack. RESULTS Sixty-eight of 337 admitted patients were transfused. More than three quarters of blood products were consumed in the initial phase (until November 14, 11:59 PM), where 282 packed red blood cell (pRBC) units were transfused along with 201 plasma and 25 platelet units, to 55 patients (16% of casualties). Almost 40% of these LBPs (134 pRBC, 73 plasma, 8 platelet units) were transfused within the first 6 hours after the attack. These early transfusions were massive transfusion (MT) for 20 (6%) of 337 patients, and the average plasma/red blood cell ratio was 0.8 for MT patients who received 366 (72%) of 508 LBPs.The median time from admission to pRBC transfusion was 57 (25-108) minutes and 208 (52-430) minutes for MT and non-MT patients, respectively. These same time intervals were 119 (66-202) minutes and 222 (87-381) minutes for plasma and 225 (131-289) minutes and 198 (167-230) minutes for platelets. CONCLUSION Our data suggest that improving transfusion procedures in mass casualty setting should rely more on shortening the time to bring LBP to the bedside than in increasing the stockpile. LEVEL OF EVIDENCE Epidemiological study, Therapeutic IV.
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Khorram-Manesh A, Plegas P, Högstedt Å, Peyravi M, Carlström E. Immediate response to major incidents: defining an immediate responder! Eur J Trauma Emerg Surg 2020; 46:1309-1320. [PMID: 30953109 PMCID: PMC7691304 DOI: 10.1007/s00068-019-01133-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Accepted: 04/01/2019] [Indexed: 12/02/2022]
Abstract
PURPOSE There is a gap in time between the occurrence of a mass casualty incident (MCI) and the arrival of the first responders to the scene, which offers an opportunity for the public (immediate responders) to perform life-saving measures. The purpose of this study was to identify these measures and the public's willingness to conduct them. METHOD An extensive literature review was performed to identify the possible measures that can be undertaken by the public. A group of experts were asked to prioritize and rank the feasibility of performing the measures by the public. Finally, the public was asked whether they were willing to do the chosen measures before and after an appropriate education. RESULTS Twenty different measures were identified and presented in a questionnaire as statements, which were prioritized and ranked by the expert group into four categories: what (1) should be done, (2) is good to know how, (3) is not necessary to know, and (4) should not be done. All statements were converted into understandable statements and were sent to the public. There were some differences and some agreements between the experts and the public regarding what an immediate responder should do. However, the willingness of the public to perform most of the measures was high and increased after being offered an appropriate education. CONCLUSION The use of immediate responders is a life-saving approach in MCIs and in situations when every minute counts and every human resource is an invaluable asset. Multiple steps, such as education, empowerment, and access, should be taken into consideration to enable bystanders to effectively help struggling survivors.
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Affiliation(s)
- Amir Khorram-Manesh
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Patricia Plegas
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Åsa Högstedt
- Emergency and Disaster Medicine, Faculty of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Mahmoudreza Peyravi
- Unit of Prehospital Dispatching Center, Region Västra Götaland, Gothenburg, Sweden
| | - Eric Carlström
- Health and Crisis Management and Policy, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- USN School of Business, University of South-Eastern Norway, Vestfold, Norway
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O'Neill KM, Shultz BN, Lye CT, Ranney ML, D'Onofrio G, Coupet E. Physicians on the Frontlines: Understanding the Lived Experience of Physicians Working in Communities That Experienced a Mass Casualty Shooting. THE JOURNAL OF LAW, MEDICINE & ETHICS : A JOURNAL OF THE AMERICAN SOCIETY OF LAW, MEDICINE & ETHICS 2020; 48:55-66. [PMID: 33404322 PMCID: PMC8147517 DOI: 10.1177/1073110520979402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
This qualitative study describes the lived experience of physicians who work in communities that have experienced a public mass shooting. Semi-structured interviews were conducted with seventeen physicians involved in eight separate mass casualty shooting incidents in the United States. Four major themes emerged from constant comparative analysis: (1) The psychological toll on physicians: "I wonder if I'm broken"; (2) the importance of and need for mass casualty shooting preparedness: "[We need to] recognize this as a public health concern and train physicians to manage it"; (3) massive media attention: "The media onslaught was unbelievable"; and (4) commitment to advocacy for a public health approach to firearm violence: "I want to do whatever I can to prevent some of these terrible events."
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Affiliation(s)
- Kathleen M O'Neill
- Kathleen M. O'Neill, M.D., is a general surgery resident at Yale New Haven Hospital. She is currently completing a Ph.D. at the Yale Graduate School of Arts and Sciences in New Haven, CT through the Investigative Medicine Program. She received her BA from Columbia University (2008) in New York City, NY and her M.D. from University of Pennsylvania (2015) in Philadelphia, PA. Blake N. Shultz is a fifth-year medical student at Yale School of Medicine and a second-year law student at Yale Law School, in New Haven, CT. He is also a fellow at the Solomon Center for Health Law and Policy at Yale Law School. He received his B.A. from Cornell University (2015) in Ithaca, NY. Carolyn T. Lye is a fourth-year medical student at Yale School of Medicine and a first-year law student at Yale Law School in New Haven, CT. She received her B.A. from University of Pennsylvania (2016) in Philadelphia, PA. Megan L. Ranney, M.D., M.P.H., is an Associate Professor Emergency Medicine at Alpert Medical School and Directof of the Center for Digital Health at Brown University. She is also Chief Research Officer for the American Foundation for Firearm Injury Reduction in Medicine (AFFIRM Research). Gail D'Onofrio, M.D., M.S., is Professor and Chair of Emergency Medicine at Yale School of Medicine and Professor in the School of Public Health. She is also the Chief of Emergency Services for Yale New Haven Hospital. Edouard Coupet, Jr., M.D., M.S., is a National Institute of Drug Abuse (NIDA)-sponsored Yale Drug Use, Addiction, and HIV Scholar (DARHS) and Assistant Professor in Emergency Medicine at Yale New Haven Hospital. He received his M.D. from the University of Chicago Pritzker School of Medicine (2012). He received his Master's in Health Policy Research at the University of Pennsylvania Perelman School of Medicine (2018)
| | - Blake N Shultz
- Kathleen M. O'Neill, M.D., is a general surgery resident at Yale New Haven Hospital. She is currently completing a Ph.D. at the Yale Graduate School of Arts and Sciences in New Haven, CT through the Investigative Medicine Program. She received her BA from Columbia University (2008) in New York City, NY and her M.D. from University of Pennsylvania (2015) in Philadelphia, PA. Blake N. Shultz is a fifth-year medical student at Yale School of Medicine and a second-year law student at Yale Law School, in New Haven, CT. He is also a fellow at the Solomon Center for Health Law and Policy at Yale Law School. He received his B.A. from Cornell University (2015) in Ithaca, NY. Carolyn T. Lye is a fourth-year medical student at Yale School of Medicine and a first-year law student at Yale Law School in New Haven, CT. She received her B.A. from University of Pennsylvania (2016) in Philadelphia, PA. Megan L. Ranney, M.D., M.P.H., is an Associate Professor Emergency Medicine at Alpert Medical School and Directof of the Center for Digital Health at Brown University. She is also Chief Research Officer for the American Foundation for Firearm Injury Reduction in Medicine (AFFIRM Research). Gail D'Onofrio, M.D., M.S., is Professor and Chair of Emergency Medicine at Yale School of Medicine and Professor in the School of Public Health. She is also the Chief of Emergency Services for Yale New Haven Hospital. Edouard Coupet, Jr., M.D., M.S., is a National Institute of Drug Abuse (NIDA)-sponsored Yale Drug Use, Addiction, and HIV Scholar (DARHS) and Assistant Professor in Emergency Medicine at Yale New Haven Hospital. He received his M.D. from the University of Chicago Pritzker School of Medicine (2012). He received his Master's in Health Policy Research at the University of Pennsylvania Perelman School of Medicine (2018)
| | - Carolyn T Lye
- Kathleen M. O'Neill, M.D., is a general surgery resident at Yale New Haven Hospital. She is currently completing a Ph.D. at the Yale Graduate School of Arts and Sciences in New Haven, CT through the Investigative Medicine Program. She received her BA from Columbia University (2008) in New York City, NY and her M.D. from University of Pennsylvania (2015) in Philadelphia, PA. Blake N. Shultz is a fifth-year medical student at Yale School of Medicine and a second-year law student at Yale Law School, in New Haven, CT. He is also a fellow at the Solomon Center for Health Law and Policy at Yale Law School. He received his B.A. from Cornell University (2015) in Ithaca, NY. Carolyn T. Lye is a fourth-year medical student at Yale School of Medicine and a first-year law student at Yale Law School in New Haven, CT. She received her B.A. from University of Pennsylvania (2016) in Philadelphia, PA. Megan L. Ranney, M.D., M.P.H., is an Associate Professor Emergency Medicine at Alpert Medical School and Directof of the Center for Digital Health at Brown University. She is also Chief Research Officer for the American Foundation for Firearm Injury Reduction in Medicine (AFFIRM Research). Gail D'Onofrio, M.D., M.S., is Professor and Chair of Emergency Medicine at Yale School of Medicine and Professor in the School of Public Health. She is also the Chief of Emergency Services for Yale New Haven Hospital. Edouard Coupet, Jr., M.D., M.S., is a National Institute of Drug Abuse (NIDA)-sponsored Yale Drug Use, Addiction, and HIV Scholar (DARHS) and Assistant Professor in Emergency Medicine at Yale New Haven Hospital. He received his M.D. from the University of Chicago Pritzker School of Medicine (2012). He received his Master's in Health Policy Research at the University of Pennsylvania Perelman School of Medicine (2018)
| | - Megan L Ranney
- Kathleen M. O'Neill, M.D., is a general surgery resident at Yale New Haven Hospital. She is currently completing a Ph.D. at the Yale Graduate School of Arts and Sciences in New Haven, CT through the Investigative Medicine Program. She received her BA from Columbia University (2008) in New York City, NY and her M.D. from University of Pennsylvania (2015) in Philadelphia, PA. Blake N. Shultz is a fifth-year medical student at Yale School of Medicine and a second-year law student at Yale Law School, in New Haven, CT. He is also a fellow at the Solomon Center for Health Law and Policy at Yale Law School. He received his B.A. from Cornell University (2015) in Ithaca, NY. Carolyn T. Lye is a fourth-year medical student at Yale School of Medicine and a first-year law student at Yale Law School in New Haven, CT. She received her B.A. from University of Pennsylvania (2016) in Philadelphia, PA. Megan L. Ranney, M.D., M.P.H., is an Associate Professor Emergency Medicine at Alpert Medical School and Directof of the Center for Digital Health at Brown University. She is also Chief Research Officer for the American Foundation for Firearm Injury Reduction in Medicine (AFFIRM Research). Gail D'Onofrio, M.D., M.S., is Professor and Chair of Emergency Medicine at Yale School of Medicine and Professor in the School of Public Health. She is also the Chief of Emergency Services for Yale New Haven Hospital. Edouard Coupet, Jr., M.D., M.S., is a National Institute of Drug Abuse (NIDA)-sponsored Yale Drug Use, Addiction, and HIV Scholar (DARHS) and Assistant Professor in Emergency Medicine at Yale New Haven Hospital. He received his M.D. from the University of Chicago Pritzker School of Medicine (2012). He received his Master's in Health Policy Research at the University of Pennsylvania Perelman School of Medicine (2018)
| | - Gail D'Onofrio
- Kathleen M. O'Neill, M.D., is a general surgery resident at Yale New Haven Hospital. She is currently completing a Ph.D. at the Yale Graduate School of Arts and Sciences in New Haven, CT through the Investigative Medicine Program. She received her BA from Columbia University (2008) in New York City, NY and her M.D. from University of Pennsylvania (2015) in Philadelphia, PA. Blake N. Shultz is a fifth-year medical student at Yale School of Medicine and a second-year law student at Yale Law School, in New Haven, CT. He is also a fellow at the Solomon Center for Health Law and Policy at Yale Law School. He received his B.A. from Cornell University (2015) in Ithaca, NY. Carolyn T. Lye is a fourth-year medical student at Yale School of Medicine and a first-year law student at Yale Law School in New Haven, CT. She received her B.A. from University of Pennsylvania (2016) in Philadelphia, PA. Megan L. Ranney, M.D., M.P.H., is an Associate Professor Emergency Medicine at Alpert Medical School and Directof of the Center for Digital Health at Brown University. She is also Chief Research Officer for the American Foundation for Firearm Injury Reduction in Medicine (AFFIRM Research). Gail D'Onofrio, M.D., M.S., is Professor and Chair of Emergency Medicine at Yale School of Medicine and Professor in the School of Public Health. She is also the Chief of Emergency Services for Yale New Haven Hospital. Edouard Coupet, Jr., M.D., M.S., is a National Institute of Drug Abuse (NIDA)-sponsored Yale Drug Use, Addiction, and HIV Scholar (DARHS) and Assistant Professor in Emergency Medicine at Yale New Haven Hospital. He received his M.D. from the University of Chicago Pritzker School of Medicine (2012). He received his Master's in Health Policy Research at the University of Pennsylvania Perelman School of Medicine (2018)
| | - Edouard Coupet
- Kathleen M. O'Neill, M.D., is a general surgery resident at Yale New Haven Hospital. She is currently completing a Ph.D. at the Yale Graduate School of Arts and Sciences in New Haven, CT through the Investigative Medicine Program. She received her BA from Columbia University (2008) in New York City, NY and her M.D. from University of Pennsylvania (2015) in Philadelphia, PA. Blake N. Shultz is a fifth-year medical student at Yale School of Medicine and a second-year law student at Yale Law School, in New Haven, CT. He is also a fellow at the Solomon Center for Health Law and Policy at Yale Law School. He received his B.A. from Cornell University (2015) in Ithaca, NY. Carolyn T. Lye is a fourth-year medical student at Yale School of Medicine and a first-year law student at Yale Law School in New Haven, CT. She received her B.A. from University of Pennsylvania (2016) in Philadelphia, PA. Megan L. Ranney, M.D., M.P.H., is an Associate Professor Emergency Medicine at Alpert Medical School and Directof of the Center for Digital Health at Brown University. She is also Chief Research Officer for the American Foundation for Firearm Injury Reduction in Medicine (AFFIRM Research). Gail D'Onofrio, M.D., M.S., is Professor and Chair of Emergency Medicine at Yale School of Medicine and Professor in the School of Public Health. She is also the Chief of Emergency Services for Yale New Haven Hospital. Edouard Coupet, Jr., M.D., M.S., is a National Institute of Drug Abuse (NIDA)-sponsored Yale Drug Use, Addiction, and HIV Scholar (DARHS) and Assistant Professor in Emergency Medicine at Yale New Haven Hospital. He received his M.D. from the University of Chicago Pritzker School of Medicine (2012). He received his Master's in Health Policy Research at the University of Pennsylvania Perelman School of Medicine (2018)
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Chen CH, Wong TY, Chen HC, Huang JF, Wang CJ. Telemedicine communication using instant messaging technology improves pre-hospital triage in high mountain train disasters. HONG KONG J EMERG ME 2020. [DOI: 10.1177/1024907920966530] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background:Differences between pre-hospital triage by an emergency medical technician and Simple Triage and Rapid Treatment triage (START) by emergency staffs often affect manpower management and aggravate the chaos condition of emergency room.Objectives:Under the assistance of instant messaging, the authors aimed to identify ways of improving triage differences between emergency medical technician triage grading and Simple Triage and Rapid Treatment triage grading by emergency staffs.Methods:Recorded photographs of all patients were reviewed by a smartphone. We categorized patients according to three triage conditions: group 1, accident scene on-site or instantaneous Simple Triage and Rapid Treatment triage by the emergency medical technician; group 2, triage under Simple Triage and Rapid Treatment grading by emergency staffs; group 3, re-triage with START grading using recorded photographs, Glasgow Coma Scale, and vital signs when these patients were arrived in emergency room. The Wilcoxon Signed-Rank test, Spearman rank correlations, and Kruskal–Wallis test are employed to test differences among the groups. We used risk estimates with odds ratios and the chi-square test to statistically analyze the differences in triage grading.Results:Statistical analysis found conflicting results among Wilcoxon Signed-Rank test, Spearman rank correlations, and Kruskal–Wallis test. The difference in triage grading between groups 2 and 1 was greater than that between groups 2 and 3 (odds ratio, 6.473; 95% confidence interval, 1.693–24.470; p-value < 0.05).Conclusion:Transferred photographs combined with Glasgow Coma Scale and vital signs can help us to understand the real situations of patients. With instant messaging applications, it is possible to make more precise pre-hospital or instantaneous triage.
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Affiliation(s)
- Chia-Hsi Chen
- Department of Emergency Medicine, St. Martin De Porres Hospital, Chiayi
| | - Tak-Yee Wong
- Department of Radiology, St. Martin De Porres Hospital, Chiayi
| | - Hsiu-Chun Chen
- Department of Nursing, St. Martin De Porres Hospital, Chiayi
| | - Jui-Fang Huang
- Department of Education and Research, St. Martin De Porres Hospital, Chiayi
| | - Chung-Jing Wang
- Medical Education and Research Committee, St. Martin De Porres Hospital, Chiayi
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Ozguler A, Gauthier K, Titreville R, Groizard C, Baer M, Fleischel C, Grohens M, Loeb T. What are the psychological consequences of playing the role of victim in terrorist attack exercise? Am J Emerg Med 2020; 46:757-759. [PMID: 32988695 DOI: 10.1016/j.ajem.2020.09.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2020] [Revised: 09/11/2020] [Accepted: 09/11/2020] [Indexed: 10/23/2022] Open
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Terrorist attacks: common injuries and initial surgical management. Eur J Trauma Emerg Surg 2020; 46:683-694. [PMID: 32342113 DOI: 10.1007/s00068-020-01342-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2019] [Accepted: 03/02/2020] [Indexed: 01/22/2023]
Abstract
Terrorism-related incidents and shootings that involve the use of war weapons and explosives are associated with gunshot and blast injuries. Despite the perceived threat of terrorism, these incidents and injuries are rare in Germany. For this reason, healthcare providers are unlikely to have a full understanding of the special aspects of managing these types of injuries. Until a clear and complete picture of the situation is available after a terrorist or shooter incident, tactical and strategic approaches to the clinical management of the injured must be tailored to circumstances that have the potential to overwhelm resources temporarily. Hospitals providing initial care must be aware that the first patients who are taken to medical facilities will present with uncontrollable bleeding from injuries to the trunk and body cavities. To improve the outcome of these patients in extremis, the aim of the index surgery is to stop the bleeding and control the contamination. Unlike damage control surgery, which is tailored to the patient's condition, tactical abbreviated surgical care (TASC) is first and foremost adapted to the overall situation. Once the patients are stabilised and all information on the situation is available, the surgical management and reconstruction of gunshot and blast injuries can follow the principles of damage control (DC) and definitive early total care (ETC). The purpose of this article is to provide an overview of the pathophysiology of gunshot and blast injuries, wound ballistics, and the approach and procedures of successful surgical management.
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Usero-Pérez MDC, Jiménez-Rodríguez ML, González-Aguña A, González-Alonso V, Orbañanos-Peiro L, Santamaría-García JM, Gómez-González JL. Validation of an evaluation instrument for responders in tactical casualty care simulations. Rev Lat Am Enfermagem 2020; 28:e3251. [PMID: 32321042 PMCID: PMC7164920 DOI: 10.1590/1518-8345.3052.3251] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 10/23/2019] [Indexed: 11/28/2022] Open
Abstract
OBJECTIVE to construct and validate a tool for the evaluation of responders in tactical casualty care simulations. METHOD three rubrics for the application of a tourniquet, an emergency bandage and haemostatic agents recommended by the Hartford Consensus were developed and validated. Validity and reliability were studied. Validation was performed by 4 experts in the field and 36 nursing participants who were selected through convenience sampling. Three rubrics with 8 items were evaluated (except for the application of an emergency bandage, for which 7 items were evaluated). Each simulation was evaluated by 3 experts. RESULTS an excellent score was obtained for the correlation index for the 3 simulations and 2 levels that were evaluated (competent and expert). The mean score for the application of a tourniquet was 0.897, the mean score for the application of an emergency bandage was 0.982, and the mean score for the application of topical haemostats was 0.805. CONCLUSION this instrument for the evaluation of nurses in tactical casualty care simulations is considered useful, valid and reliable for training in a prehospital setting for both professionals who lack experience in tactical casualty care and those who are considered to be experts.
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Affiliation(s)
| | | | - Alexandra González-Aguña
- Universidad de Alcalá de Henares, Facultad de Ciencias de la
Computación, Alcalá de Henares, Madrid, Madrid, Spain
| | | | | | - Jose María Santamaría-García
- Universidad de Alcalá de Henares, Facultad de Ciencias de la
Computación, Alcalá de Henares, Madrid, Madrid, Spain
| | - Jorge Luís Gómez-González
- Universidad de Alcalá de Henares, Facultad de Ciencias de la
Computación, Alcalá de Henares, Madrid, Madrid, Spain
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Emergency response to terrorist attacks: results of the federal-conducted evaluation process in Germany. Eur J Trauma Emerg Surg 2020; 46:725-730. [PMID: 32206880 PMCID: PMC7429537 DOI: 10.1007/s00068-020-01347-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 03/10/2020] [Indexed: 11/04/2022]
Abstract
Purpose Rescue missions during terrorist attacks are extremely challenging for all rescue forces (police as well as non-police forces) involved. To improve the quality and safety of the rescue missions during an active killing event, it is obligatory to adapt common rescue mission goals and strategies. Methods After the recent attacks in Europe, the Federal Office of Civil Protection and Disaster Assistance started an evaluation process on behalf of the Federal Ministry of the Interior and the Federal Ministry of Health. This was done to identify weaknesses, lessons learned and to formulate new adapted guidelines. Results The presented bullet point recommendations summarise the basic and most important results of the ongoing evaluation process for the Federal Republic of Germany. The safety of all the rescue forces and survival of the greatest possible number of casualties are the priority goals. Furthermore, the preservation and re-establishment of the socio-political integrity are the overarching goals of the management of active killing events. Strategic incident priorities are to stop the killing and to save as much lives as possible. The early identification and prioritised transportation of casualties with life-threatening non-controllable bleeding are major tasks and the shortest possible on-scene time is an important requirement with respect to safety issues. Conclusion With respect to hazard prevention tactics within Germany, we attributed the highest priority impact to the bullet points. The focus of the process has now shifted to intense work about possible solutions for the identified deficits and implementation strategies of such solutions during mass killing incidents.
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Smith D, Walters EL, Reibling E, Brockie D, Lee C, Neeki M, Ochoa H, Henson T, Fisgus J, Thomas T. UNIFIED: Understanding New Information from Emergency Departments Involved in the San Bernardino Terrorist Attack. West J Emerg Med 2020; 21:382-390. [PMID: 32191197 PMCID: PMC7081877 DOI: 10.5811/westjem.2019.11.43437] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 11/18/2019] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Emergency departments (ED) are on the front line for treating victims of multi-casualty incidents. The primary objective of this study was to gather and detail the common experiences from those hospital-based health professionals directly involved in the response to the San Bernardino terrorism attack on December 2, 2015. Secondary objectives included gathering information on experiences participants found were best practices. METHODS We undertook a qualitative study using Consolidated Criteria for Reporting Qualitative Research (COREQ) guidelines by performing semi-structured interviews with physicians, nurses, and incident management staff from multiple institutions responding to the San Bernardino terrorist attack. We coded transcripts using qualitative analysis techniques and we delineated and agreed upon a refined list with code definitions using a negotiated group process. Final themes were developed and analyzed. RESULTS A total of 26 interviews were completed; 1172 excerpts were coded and categorized into 66 initial themes. Six final categories of communication, training, unexpected help, process bypassed, personal impact/emotions, and practical advice resulted. CONCLUSION Our study provides context regarding the response of healthcare personnel from multiple institutions to a singular terrorist attack in the United States. It elucidates several themes to help other institutions prepare for similar events. Understanding these common experiences provides opportunity to prepare for future incidents and develop questions to study in future events.
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Affiliation(s)
- Dustin Smith
- Loma Linda University Health, Department of Emergency Medicine, Loma Linda, California
| | - Elizabeth L Walters
- Loma Linda University Health, Department of Emergency Medicine, Loma Linda, California
| | - Ellen Reibling
- Loma Linda University Health, Department of Emergency Medicine, Loma Linda, California
| | - Darren Brockie
- Loma Linda University Health, Department of Emergency Medicine, Loma Linda, California
| | - Carol Lee
- Arrowhead Regional Medical Center, Department of Emergency Medicine, Colton, California
| | - Michael Neeki
- Arrowhead Regional Medical Center, Department of Emergency Medicine, Colton, California
| | - Humberto Ochoa
- Riverside University Health System, Department of Emergency Medicine, Moreno Valley, California
| | - Travis Henson
- St. Bernardine's Medical Center, Department of Emergency Medicine, San Bernardino, California
| | - James Fisgus
- San Antonio Regional Hospital, Department of Emergency Medicine, Upland, California
| | - Tammi Thomas
- Loma Linda University Health, Department of Emergency Medicine, Loma Linda, California
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Analysis of the medical response to November 2015 Paris terrorist attacks: resource utilization according to the cause of injury. Intensive Care Med 2019; 45:1231-1240. [PMID: 31418059 DOI: 10.1007/s00134-019-05724-9] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 07/30/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE The majority of terrorist acts are carried out by explosion or shooting. The objective of this study was first, to describe the management implemented to treat a large number of casualties and their flow together with the injuries observed, and second, to compare these resources according to the mechanism of trauma. METHODS This retrospective cohort study collected medical data from all casualties of the attacks on November 13th 2015 in Paris, France, with physical injuries, who arrived alive at any hospital within the first 24 h after the events. Casualties were divided into two groups: explosion injuries and gunshot wounds. RESULTS 337 casualties were admitted to hospital, 286 (85%) from gunshot wounds and 51 (15%) from explosions. Gunshot casualties had more severe injuries and required more in-hospital resources than explosion casualties. Emergency surgery was required in 181 (54%) casualties and was more frequent for gunshot wounds than explosion injuries (57% vs. 35%, p < 0·01). The types of main surgery needed and their delay following hospital admission were as follows: orthopedic [n = 107 (57%); median 744 min]; general [n = 27 (15%); 90 min]; vascular [n = 19 (10%); median 53 min]; thoracic [n = 19 (10%); 646 min]; and neurosurgery [n = 4 (2%); 198 min]. CONCLUSION The resources required to deal with a terrorist attack vary according to the mechanism of trauma. Our study provides a template to estimate the proportion of various types of surgical resources needed overall, as well as their time frame in a terrorist multisite and multitype attack. FUNDING Assistance Publique-Hôpitaux de Paris.
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Franke A, Bieler D, Friemert B, Kollig E, Flohe S. [Preclinical and intrahospital management of mass casualties and terrorist incidents]. Chirurg 2019; 88:830-840. [PMID: 29149359 DOI: 10.1007/s00104-017-0489-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Due to the recent terrorist attacks in Paris, Brussels, Ansbach, Munich, Berlin and more recently Manchester and London, terrorism is realized as a present threat to our society and social life, as well as a challenge for the health care system. Without fueling anxiety, there is a need for sensitization to this subject and to familiarize all concerned with the special kind of terrorist attack-related injuries, the operational priorities and tactics and the individual basic principles of preclinical and hospital care. There is a need to adapt the known established medical structure for a conventional mass casualty situation to the special requirements that are raised by this new kind of terrorist threat to our social life. It is the aim of this article, from a surgical point of view, to depict the tactics and challenges of preclinical care of the special kind of terrorist attack-related injuries from the site of the incident, via the advanced medical post or casualty collecting point, to the triage point at the hospital. The special needs of medical care and organizational aspects of the primary treatment in the hospital are highlighted and possible decisional options and different approaches are discussed.
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Affiliation(s)
- A Franke
- Klinik für Unfallchirurgie, Orthopädie, Rekonstruktive- und Handchirurgie, Verbrennungsmedizin, Bundeswehrzentralkrankenhaus Koblenz, Rübenacherstrasse 170, 56072, Koblenz, Deutschland
| | - D Bieler
- Klinik für Unfallchirurgie, Orthopädie, Rekonstruktive- und Handchirurgie, Verbrennungsmedizin, Bundeswehrzentralkrankenhaus Koblenz, Rübenacherstrasse 170, 56072, Koblenz, Deutschland.
| | - B Friemert
- Klinik Unfallchirurgie und Orthopädie, Septische und Rekonstruktive Chirurgie, Sporttraumatologie, Bundeswehrkrankenhaus Ulm, Ulm, Deutschland
| | - E Kollig
- Klinik für Unfallchirurgie, Orthopädie, Rekonstruktive- und Handchirurgie, Verbrennungsmedizin, Bundeswehrzentralkrankenhaus Koblenz, Rübenacherstrasse 170, 56072, Koblenz, Deutschland
| | - S Flohe
- Klinik für Unfallchirurgie, Orthopädie und Handchirurgie, Städt. Klinikum Solingen, Solingen, Deutschland
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Service Medical du Raid, Reuter PG, Baker C, Loeb T. Specific stretchers enhance rapid extraction by tactical medical support teams in mass casualty incidents. Injury 2019; 50:358-364. [PMID: 30594314 DOI: 10.1016/j.injury.2018.12.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 11/14/2018] [Accepted: 12/05/2018] [Indexed: 02/02/2023]
Abstract
OBJECTIVE In mass casualty incidents where the threat is on-going, victim evacuation remains a challenge: fast extraction while respecting spinal immobilisation and haemorrhage control. Different devices can be used but their suitability has not been compared. METHODS We conducted a simulation study comparing eight extraction devices with a randomisation of the order of testing. Five teams, consisting of four officers, evacuated a single victim in five steps: device's deployment, loading the victim, carrying the victim along a corridor, negotiating a corner passage and a descent by staircase. Primary outcome was the emergency extraction time, from deployment to the first obstacle. Secondary outcomes included ease of transport and victim's stability, rated from 1 (worst) to 10 (best). RESULTS One hundred and sixty simulations were carried out. The median emergency extraction time was 16.7 [IQR: 11.6-24.9] seconds. The three speediest devices were the "firefighters' worn", "snogg" and "flexible tarp", taking 9.7 [8.1-11.0], 11.7 [10.9-15.4] and 12.2 [11.2-17.9] seconds respectively (p < 0.0001). Regarding the ease of transport, the three best-evaluated devices were the "firefighters' worn", "strap" and "flexible tarp" with 10 [9-10], 9 [8-9] and 8 [8-9] respectively (p < 0.0001). Considering stability reported by simulated victims, the three best-evaluated devices were the "inflated stretcher", "flexible tarp" and "firefighters' worn" with 8.0 [7.8-9.0], 8.0[7.0-8.0] and 6.5 [6.0-7.0] respectively. CONCLUSION Devices were not equivalent in terms of extraction time and suitability criteria. For rapid extraction of victims from danger zones, the "firefighter's worn" and "flexible tarp", as very simple stretchers, seem to be the most appropriate devices.
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Affiliation(s)
- Service Medical du Raid
- RAID (Recherche, Assistance, Intervention, Dissuasion), Force d'Intervention de la Police Nationale, France.
| | | | - Chloe Baker
- Royal London Hospital, Whitechapel Road, E1 1BB, London, UK
| | - Thomas Loeb
- SAMU 92, hôpital Raymond Poincaré, AP-HP, 92380, Garches, France
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Slevin JP, Harrison C, Da Silva E, White NJ. Martial arts technique for control of severe external bleeding. Emerg Med J 2019; 36:154-158. [PMID: 30612092 DOI: 10.1136/emermed-2018-207966] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Revised: 11/27/2018] [Accepted: 12/10/2018] [Indexed: 11/04/2022]
Abstract
OBJECTIVES Haemorrhage control is a critical component of preventing traumatic death. Other than the battlefield, haemostatic devices, such as tourniquets or bandages, may not be available, allowing for significant avoidable blood loss. We hypothesised that compression of vascular pressure points using a position adapted from the martial art of Brazilian Jiu-Jitsu could be adapted to decrease blood flow velocity in major extremity arteries. METHODS Knee mount compression was applied to the shoulder, groin and abdomen of healthy adult volunteer research subjects from Seattle, Washington, USA, from March through May 2018. Mean arterial blood flow velocity (MAV) was measured using ultrasound in the brachial and femoral arteries before and after compression. A MAV decrease greater than 20% with compression was deemed clinically relevant. RESULTS For 11 subjects, median (IQR) MAV combining all anatomical locations tested was 29.2 (34.1, 24.1) cm/s at baseline and decreased to 3.3 (0, 19.1) cm/s during compression (Wilcoxon p<0.001). MAV was significantly decreased during compression for each individual anatomical position tested (Wilcoxon p≤0.004). Per cent (95% CI) MAV reduction was significantly greater than 20% for shoulder compression at 97.5%(94% to 100%) and groin compression at 78%(56% to 100%), but was not statistically greater for abdominal compression at 35%(12% to 57%). Complete vessel occlusion was most common with compression at the shoulder (73%), followed by groin (55%) and abdomen (9%) (χ² LR, p=0.018). CONCLUSION The Brazilian Jiu-Jitsu knee mount position can significantly decrease blood flow in major arteries of the extremities. This technique may be useful for bleeding control after injury.
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Affiliation(s)
- John P Slevin
- Department of Bioengineering, University of Washington, Seattle, Washington, USA
| | - Cierra Harrison
- Department of Arts and Sciences, University of Washington, Seattle, Washington, USA
| | - Eric Da Silva
- Eric Da Silva Steel Blanket Brazilian Jiu-Jitsu, Woodinville, Washington, USA
| | - Nathan J White
- Department of Bioengineering, University of Washington, Seattle, Washington, USA.,Department of Emergency Medicine, University of Washington, Seattle, Washington, USA
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Cesareo E, Raux M, Soulat L, Huot-Marchand F, Voiglio E, Puidupin A, Claret PG, Desclef JP, Douay B, Duchenne J, Gloaguen A, Lefort H, Rerbal D, Zanker C, Cook F, Pelée de Saint Maurice G, Lachenaud L, Gabilly L, Prieto N, Levraut J, Gueugniaud PY. Recommandations de bonne pratique clinique concernant la prise en charge médicale des victimes d’une « tuerie de masse ». ANNALES FRANCAISES DE MEDECINE D URGENCE 2018. [DOI: 10.3166/afmu-2018-0103] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Wurmb T, Schorscher N, Justice P, Dietz S, Schua R, Jarausch T, Kinstle U, Greiner J, Möldner G, Müller J, Kraus M, Simon S, Wagenhäuser U, Hemm J, Roewer N, Helm M. Structured analysis, evaluation and report of the emergency response to a terrorist attack in Wuerzburg, Germany using a new template of standardised quality indicators. Scand J Trauma Resusc Emerg Med 2018; 26:87. [PMID: 30340516 PMCID: PMC6194622 DOI: 10.1186/s13049-018-0555-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 10/02/2018] [Indexed: 11/20/2022] Open
Abstract
Background Until now there has been a reported lack of systematic reports and scientific evaluations of rescue missions during terror attacks. This however is urgently required in order to improve the performance of emergency medical services and to be able to compare different missions with each other. Aim of the presented work was to report the systematic evaluation and the lessons learned from the response to a terror attack that happened in Wuerzburg, Germany in 2016. Methods A team of 14 experts developed a template of quality indicators and operational characteristics, which allow for the description, assessment and comparison of civil emergency rescue missions during mass killing incidents. The entire systematic evaluation process consisted of three main steps. The first step was the systematic data collection according to the quality indicators and operational characteristics. Second was the systematic stratification and assessment of the data. The last step was the prioritisation of the identified weaknesses and the definition of the lessons learned. Results Five important “lessons learned” have been defined. First of all, a comprehensive concept for rescue missions during terror attacks is essential. Furthermore, the establishment of a defined high priority communication infrastructure between the different dispatch centres (“red phone”) is vital. The goal is to secure the continuity of information between a few well-defined individuals. Thirdly, the organization of the incident scene needs to be commonly decided and communicated between police, medical services and fire services during the mission. A successful mission tactic requires continuous flux of reports to the on-site command post. Therefore, a predefined and common communication infrastructure for all operational forces is a crucial point. Finally, all strategies need to be extensively trained before the real life scenario hits. Conclusion According to a systematic evaluation, we defined the lessons learned from a terror attack in 2016. Further systematic reports and academic work surrounding life threatening rescue missions and mass killing incidents are needed in order to ultimately improve such mission outcomes. In the future, a close international collaboration might help to find the best database to report and evaluate major incidents but also mass killing events.
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Affiliation(s)
- T Wurmb
- Subsection Emergency and Disaster Relief Medicine, Department of Anaesthesia and Critical Care, University Hospital of Wuerzburg, Oberdürrbacherstrasse 6, 97080, Würzburg, Germany.
| | - N Schorscher
- Department of Anaesthesia and Critical Care, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - P Justice
- Emergency Medical Services and firebrigade alerting for the counties of Kitzingen, Main-Spessart and the city of Wuerzburg, Wuerzburg, Germany
| | - S Dietz
- Emergency Medical Service of the Bavarian Red Cross, Würzburg, Germany
| | - R Schua
- Medical Department, Government of Lower Franconia, Wuerzburg, Germany
| | - T Jarausch
- Emergency Medical Service of the Maltese Cross, Wuerzburg, Germany
| | - U Kinstle
- The Johanniter Rescue Emergency Services, Wuerzburg, Germany
| | - J Greiner
- Emergency Medical Service of the Bavarian Red Cross, Würzburg, Germany
| | - G Möldner
- Fire and Rescue Integrated Control Centre Wuerzburg, Wuerzburg, Germany
| | - J Müller
- Fire and Rescue Integrated Control Centre Wuerzburg, Wuerzburg, Germany
| | - M Kraus
- Medical Head of the Emergency Medical Services of Lower Fraconia, Wuerzburg, Germany
| | - S Simon
- Emergency Medical Service of the Maltese Cross, Wuerzburg, Germany
| | - U Wagenhäuser
- Head of emergency pastoral care in the diocese of Würzburg, Wuerzburg, Germany
| | - J Hemm
- Department of danger prevention and police operation by the police department of Lower Franconia (Chief Police Officer i.R.), Würzburg, Wuerzburg, Germany
| | - N Roewer
- Department of Anaesthesia and Critical Care, University Hospital of Wuerzburg, Wuerzburg, Germany
| | - M Helm
- Department of Anaesthesiology and Intensive Care Medicine, Section Emergency Medicine, Federal Armed Forces Medical Hospital, Ulm, Germany
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Hugenschmitt D, Cesareo É, Claret PG, Lefort H. [Not Available]. SOINS; LA REVUE DE REFERENCE INFIRMIERE 2018; 63:59-61. [PMID: 30366707 DOI: 10.1016/j.soin.2018.07.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- Delphine Hugenschmitt
- Samu-Smur 69, CHU Édouard-Herriot, Hospices Civils de Lyon, 5, place d'Arsonval, 69003 Lyon, France
| | - Éric Cesareo
- Pôle anesthésie-réanimation douleur urgences, CHU de Nîmes, F-30000 Nîmes, France
| | - Pierre-Géraud Claret
- Structure des urgences, Hôpital d'instruction des armées Legouest, 27, avenue de Plantières, 57000 Metz, France
| | - Hugues Lefort
- Structure des urgences, Hôpital d'instruction des armées Legouest, 27, avenue de Plantières, 57000 Metz, France.
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Lapostolle F, Loeb T, Lecarpentier E, Vivien B, Pasquier P, Raux M. Comment appréhender une tuerie de masse pour les équipes Smur primo-intervenantes ? ANNALES FRANCAISES DE MEDECINE D URGENCE 2018. [DOI: 10.3166/afmu-2018-0084] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Le risque terroriste présent sur l’ensemble de notre territoire depuis plusieurs années conduit les équipes de Samu–Smur à intervenir sur les lieux d’une tuerie de masse aux côtés de forces de sécurité, voire en tant que primointervenants. De telles circonstances exposent les équipes à un environnement de travail inhabituel et hostile. Cette mise au point, proposée en complément de la recommandation formalisée d’experts sur la prise en charge de tuerie de masse, répond aux interrogations qui naissent sur le terrain en pareilles circonstances. Elle facilite une juste appréciation des événements, aide à réguler ses émotions, dans le but d’augmenter la capacité des soignants à agir, tout en réduisant la phase de sidération initiale, elle-même responsable d’une inertie à même d’impacter le pronostic des blessés en choc hémorragique. Des procédures anticipées, sous forme de check-lists, guident les actions à mener de manière sereine. Les équipes médicales préhospitalières doivent apporter sur le terrain non seulement une compétence médicale, mais également une compétence tactique et décisionnelle pour accélérer les flux d’évacuation. Le premier médecin engagé doit aider à la décision aux côtés du commandant des opérations de secours, du commandant des opérations de police et de gendarmerie et des médecins intégrés aux forces de sécurité intérieure en attendant le directeur des secours médicaux. Il doit donc également faire preuve d’une compétence de chef d’équipe.
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Klassen AB, Marshall M, Dai M, Mann NC, Sztajnkrycer MD. Emergency Medical Services Response to Mass Shooting and Active Shooter Incidents, United States, 2014-2015. PREHOSP EMERG CARE 2018; 23:159-166. [PMID: 30118358 DOI: 10.1080/10903127.2018.1484970] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND The purpose of the current study was to describe the injury patterns, EMS response and interventions to mass shooting (MS) and active shooter (AS) incidents. METHODS Retrospective analysis of 2014-2015 National Emergency Medical Services Information System (NEMSIS) data sets. Date, time, and location for MS incidents were obtained from the Gun Violence Archive and then correlated with NEMSIS data set records. AS incidents were identified through Federal Bureau of Investigation (FBI) data. A de-identified database was generated for final analysis. RESULTS A total of 608 MS incidents were identified, of which 19 were also classified as AS incidents. NEMSIS patient care data was available for 652 EMS activations representing 226 unique MS incidents. Thirty-four EMS responses to 5 unique AS incidents were similarly identified: 76% of victims were male and 80% of victims were African American. Dispatch complaint did not suggest shooting (potentially dangerous scene environment) in 15.9% of records. The most commonly reported incident locations for MS were Street/Highway (38.2%) and Home/Residence (32.4%). Location of wounds included extremities (49%), chest (12%), and head/neck (13%). Tourniquet use was documented in 6 victims. 35.9% of victims were transported to the closest facility. CONCLUSIONS MS and AS incidents are prevalent in the United States. Despite the fact that extremity wounds were common, documented EMS tourniquet use was uncommon. While MS events are high risk for responders, dispatch information was lacking in almost 15% of records. Responding EMS agencies were diverse, emphasizing the need to ensure all EMS providers are prepared to respond to MS incidents.
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Thompson J, Rehn M, Sollid SJM. EHAC medical working group best practice advice on the role of air rescue and pre hospital critical care at major incidents. Scand J Trauma Resusc Emerg Med 2018; 26:65. [PMID: 30111347 PMCID: PMC6094568 DOI: 10.1186/s13049-018-0522-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 11/28/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Helicopter EMS (HEMS) teams may perform a variety of clinical, managerial and transport functions during major incident management. Despite national and international variations in HEMS systems, the rapid delivery of HEMS personnel with advanced skills in major incident management and clinical scene leadership has been crucial to the delivery of an effective medical response at previous incidents. This document outlines the Best Practice Advice of the European HEMS and Air Ambulance Committee (EHAC) Medical Working Group on how HEMS and Pre Hospital Critical Care teams may maximise the positive impact of their resources in the event of Major Incidents. METHODS Narrative literature review and expert consensus. RESULTS To ensure a safe, coordinated and effective response, HEMS teams require suitable, proportionate and up to date major incident plans that are integrated into the major incident plans of other regional emergency and healthcare services. Role specific protocols, training and equipment should be adapted to the expected HEMS role in the major incident plan and likely regional threats. System and incident factors will influence HEMS utilisation during the major incident response and can include patient and staff transfer, equipment resupply, aerial assessment, search and rescue, clinical leadership and advanced care. During the recovery phase of a major incident there is a need to ensure restoration of conventional service and address the welfare of involved HEMS personnel. Standardised reporting of major incidents is strongly recommended for clinical governance, legal and research reasons. CONCLUSIONS The rapid delivery of HEMS personnel with advanced skills in Major Incident management and clinical scene leadership is crucial to the delivery of an effective medical response at Major Incidents.
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Affiliation(s)
- Julian Thompson
- Adult Intensive Care Unit, North Bristol NHS Trust, Bristol, UK. .,Great Western Air Ambulance, Bristol, UK. .,Severn Major Trauma Network, North Bristol NHS Trust, Bristol, UK. .,Department of Health Studies, University of Stavanger, Stavanger, Norway.
| | - Marius Rehn
- Department of Research, Norwegian Air Ambulance Foundation, Drøbak, Norway.,Pre-hospital Division, Air Ambulance Department, Oslo University Hospital, Oslo, Norway.,Department of Health Studies, University of Stavanger, Stavanger, Norway
| | - Stephen J M Sollid
- Department of Research, Norwegian Air Ambulance Foundation, Drøbak, Norway.,Department of Health Studies, University of Stavanger, Stavanger, Norway.,Air Ambulance Department, Oslo University Hospital, Oslo, Norway
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Typische Verletzungen durch terrorassoziierte Ereignisse und ihre Implikationen für die Erstversorgung. ACTA ACUST UNITED AC 2018. [DOI: 10.1007/s10039-018-0393-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Chauhan R, Conti BM, Keene D. Marauding terrorist attack (MTA): prehospital considerations. Emerg Med J 2018; 35:389-395. [PMID: 29572386 DOI: 10.1136/emermed-2017-206959] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 02/26/2018] [Accepted: 03/07/2018] [Indexed: 11/04/2022]
Abstract
Terrorist attacks are increasing each year as are the number of deaths associated with them. Recent incidents have seen a shift in tactics with the use of multiple terrorists across multiple locations with firearms or knives, referred to as the marauding terrorist attack. These methods are becoming more prevalent alongside the use of vehicles deliberately aimed at pedestrians. Management of these incidents can be challenging. Not only it involves a large number of casualties but also the management of a dynamic scene in terms of both location and threat from attack. In order to improve response, and potentially outcomes, a system or response needs to have preplanned and practised procedures in place. This article reviews major incident management for those unfamiliar with current prehospital practice and details some of the findings from recent marauding terrorist firearm attacks, in particular the evolution of newer scene management tools such as 3 Echo and THREAT. It highlights the importance of haemorrhage control and the public initiatives focusing on actions during a terrorist incident.
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Affiliation(s)
- Ravi Chauhan
- Defence Medical Services, Lichfield, UK.,R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | - Bianca M Conti
- R Adams Cowley Shock Trauma Center, Baltimore, Maryland, USA
| | - Damian Keene
- Royal Centre for Defence Medicine, Birmingham, UK
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Hardy S, Fattah S, Wisborg T, Raatiniemi L, Staff T, Rehn M. Systematic reporting to improve the emergency medical response to major incidents: a pilot study. BMC Emerg Med 2018; 18:4. [PMID: 29368642 PMCID: PMC5784690 DOI: 10.1186/s12873-018-0153-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Accepted: 01/07/2018] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Major incidents affect us globally, and are occurring with increasing frequency. There is still no evidence-based standard regarding the best medical emergency response to major incidents. Currently, reports on major incidents are non-standardised and variable in quality. This pilot study examines the first systematic reports from a consensus-based, freely accessible database, aiming to identify how descriptive analysis of reports submitted to this database can be used to improve the major incident response. METHODS Majorincidentreporting.net is a website collecting reports on major incidents using a standardised template. Data from these reports were analysed to compare the emergency response to each incident. RESULTS Data from eight reports showed that effective triage by experienced individuals and the use of volunteers for transport were notable successes of the major incident response. Inadequate resources, lack of a common triage system, confusion over command and control and failure of communication were reported failures. The following trends were identified: Fires had the slowest times for several aspects of the response and the only three countries to have a single dialling number for all three emergency services had faster response times. Helicopter Emergency Medical services (HEMS) were used for transport and treatment in rural locations and for triage and treatment in urban locations. In two incidents, a major incident was declared before the arrival of the first Emergency Medical Services (EMS) personnel. CONCLUSION This study shows that we can obtain relevant data from major incidents by using systematic reporting. Though the sample size from this pilot study is not large enough to draw any specific conclusions it illustrates the potential for future analyses. Identified lessons could be used to improve the emergency medical response to major incidents.
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Affiliation(s)
- Sophie Hardy
- Emergency Department, St George's Hospital, Tooting, London, UK.
| | - Sabina Fattah
- The Norwegian Air Ambulance Foundation, Drøbak, Norway
- Anaesthesia and Critical Care Research Group, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway
| | - Torben Wisborg
- Anaesthesia and Critical Care Research Group, Faculty of Health Sciences, University of Tromsø, Tromsø, Norway
- Hammerfest Hospital, Department of Anaesthesiology and Intensive Care, Finnmark Health Trust, Hammerfest, Norway
- Norwegian National Advisory Unit on Trauma, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Lasse Raatiniemi
- Hammerfest Hospital, Department of Anaesthesiology and Intensive Care, Finnmark Health Trust, Hammerfest, Norway
- Centre for Pre-Hospital Emergency Care/ FinnHEMS 50, Oulu University Hospital, Oulu, Finland
- Anaesthesia Research Group, MRC, University of Oulu, Oulu, Finland
| | - Trine Staff
- Paramedic Sciences, Oslo and Akershus University College, Oslo, Norway
| | - Marius Rehn
- The Norwegian Air Ambulance Foundation, Drøbak, Norway
- Department of Health Studies, University of Stavanger, Stavanger, Norway
- Division of Emergencies and Critical Care. Department of Anaesthesia, Oslo University Hospital, Oslo, Norway
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Blix SW, Melau J, Lund-Kordahl I. Performance of Norwegian civilian EMTs and army medics in penetrating trauma: a controlled simulation-based assessment. Acta Anaesthesiol Scand 2017; 61:848-853. [PMID: 28547840 PMCID: PMC5518435 DOI: 10.1111/aas.12910] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2017] [Revised: 04/26/2017] [Accepted: 04/27/2017] [Indexed: 01/04/2023]
Abstract
Background Penetrating trauma kills rapidly. Thorough and efficient examination and aggressive hemorrhage control is important to save lives. The aim of this study was to assess the skills of civilian Emergency Medical Technicians (EMTs) in bleeding examination and control compared to Army Medics. Our hypothesis was that civilian pre‐hospital systems perform at a lower level compared to an expert group, and did not have sufficient focus on education and training in examination and treatment of penetrating injuries. Material and methods We included 60 volunteer Certified EMTs and Army Medics. First, the participants examined a wounded patient. Second, the participants were presented a patient with a penetrating injury on a pork side fixated to the thigh with an artificial arterial bleeding. Results The EMTs took significantly shorter time examining, median 1 min 5 s vs. 3 min 58 s (P < 0.001). 5/30 (17%) of EMTs and 28/30 (93%) of army medics did an approved gauze wound packing of the penetrating injury (P < 0.001). EMTs took (median) 18 s and army medics 8 s to hemostasis regardless of approved packing or not (P < 0.001). Time spent on the packing was (median) 1 min 50 s vs. 5 min 47 s respectively (P < 0.001). Increasing time spent on the procedure showed significantly better chance of a successful procedure. Conclusion The EMTs had lower accuracy in examination but used significantly shorter time than the Army Medics. The treatment part of the study showed poor EMT performance compared to the Army Medics. This study indicates that more wound packing training needs to be incorporated into initial and ongoing civilian EMT training.
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Affiliation(s)
- S. W. Blix
- The Arctic University of Norway; Tromsø N-9037 Norway
| | - J. Melau
- Division of Pre-hospital Services; Vestfold Hospital Trust; Tønsberg 3103 Norway
| | - I. Lund-Kordahl
- Anaesthesia and critical care research group; Department of Clinical Medicine; UiT - The Arctic University of Norway; Tromsø N-9037 Norway
- Norwegian National Advisory Unit on Trauma; Division of Emergencies and Critical Care; Oslo University Hospital; Oslo N-0424 Norway
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Turner CDA, Lockey DJ, Rehn M. Erratum to: Pre-hospital management of mass casualty civilian shootings: a systematic literature review. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:94. [PMID: 28403866 PMCID: PMC5390449 DOI: 10.1186/s13054-017-1663-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 03/06/2017] [Indexed: 11/10/2022]
Affiliation(s)
- Conor D A Turner
- Barts and The London School of Medicine and Dentistry, Queen Mary University London, Garrod Building, Turner Street, Whitechapel, London, E1 2AD, UK.
| | - David J Lockey
- Barts and The London School of Medicine and Dentistry, Queen Mary University London, Garrod Building, Turner Street, Whitechapel, London, E1 2AD, UK.,London's Air Ambulance, Barts Health Trust, London, UK.,The Norwegian Air Ambulance Foundation, Drøbak, Norway
| | - Marius Rehn
- London's Air Ambulance, Barts Health Trust, London, UK.,The Norwegian Air Ambulance Foundation, Drøbak, Norway.,Department of Health Studies, University of Stavanger, Stavanger, Norway
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