Real-time video communication between ambulance paramedic and scene - a simulation-based study.

INTRODUCTION: Telemedicine has been widely used in various medical settings including in Emergency Medical Services (EMS). The goal of this study was to assess the possible roles of real-time video communication between paramedics and bystanders at scenes of emergency, in the analysis and treatment of patients. METHODS: 44 experienced paramedics participated in a simulation. Participants communicated with the experimenter presenting video clips showing patients that simulated three emergency scenarios: trauma, an unresponsive patient with cardiac arrest, and an opiate overdose. The simulation sessions were conducted through Zoom™, recorded, and then analyzed to document participants' questions, requests, instructions, and their timings during each scenario. RESULTS: The trauma scenario was assessed most promptly, with instructions to handle the bleeding provided by all paramedics. In the unresponsive patient with cardiac arrest scenario, most of the participants achieved a correct initial diagnosis, and in the opiate overdose scenario over half of paramedics sought visual clinical clues for the differential diagnoses of loss of consciousness and their causes. Additional results show the type of assessment, treatment and diagnosis participants provided in each scenario, and their confidence about situation. CONCLUSIONS: The findings show that direct video communication between paramedic and scene may facilitate correct diagnosis, provision of instructions for treatment, and early preparation of medications or equipment. These may decrease time to correct diagnosis and lifesaving treatment and impact patient morbidity and mortality. Moreover, the findings highlight the difference between incidents with higher visual clarity, such as trauma, and conditions that require an extended diagnosis to reveal, such as unresponsive patients. This may also increase the paramedics' mental preparedness for what is expected at the scene.

The rapid development of AmboVent: a simple yet sustainable ventilation solution for use in a pandemic.

INTRODUCTION: COVID-19 (SARS-CoV-2) emerged at the end of 2019, generating a rapidly evolving pandemic, raising serious global health implications. Among them was the fear of a mechanical ventilator shortage due to COVID-19's high contagion rate and pathophysiology. Fears of a ventilator shortage unleashed a wave of innovations. MATERIAL AND METHOD: This manuscript describes the AmboVent, a ventilator, rapidly developed with a sense of urgency, by a group of Israeli volunteers. RESULTS: Using a decentralized approach, we worked extensively and managed within ten days to create a working ventilator. It utilizes a 64-year-old technological concept, the bag valve mask (BVM), sometimes known by the proprietary name Ambu bag, which we transformed into an automatic, controlled, and feature-rich ventilator by endowing it with contemporary computing technology. CONCLUSIONS: Applying a functional rather than a commercial-oriented approach can result in the ad hoc development of lifesaving solutions during a rapidly spreading pandemic.

Evolution of emergency medical calls during a pandemic - An emergency medical service during the COVID-19 outbreak.

INTRODUCTION: Emergency Medical Services (EMS) are expected to be affected by a pandemic outbreak. However, the available data about trends and extents of these effects is limited. METHODS: We analyzed numbers of ambulance calls for all 136 diagnosis codes used by Magen David Adom (MDA), Israel's national EMS during 121 days between January 01 and April 30, 2020. RESULTS: There was an increase in calls for COVID-19 symptoms (cough, fever, throat pain). This trend followed the same shape as the curve for confirmed COVID-19 patients. Trends were found to increase for calls not followed by transport to the hospital as well as in calls for mental or psychiatric causes. Simultaneously, there was a decrease in calls for cardiovascular issues, pneumonia, and all injuries. CONCLUSION: Understanding these correlations may allow better preparedness of the EMS and a better response towards the public needs in the period of an epidemic or a pandemic.

Flattening the COVID-19 Curve: The Unique Role of Emergency Medical Services in Containing a Global Pandemic.

BACKGROUND: The potential excess flow of patients into emergency departments and community clinics for testing and examination during a pandemic poses a major issue. These additional patients may lead to the risk of viral transmission to other patients and medical teams. To contain the spread of coronavirus disease-2019 (COVID-19), the Israeli Ministry of Health initiated a plan spearheaded by Magen David Adom (MDA), Israel's national emergency medical services (EMS) organization. OBJECTIVES: To describe outbreak containment actions initiated by MDA, including a COVID-19 tele-triage center and home testing by paramedics. METHODS: Retrospective analysis was conducted of de-identified data from the call management and command and control systems during the first period of the COVID-19 outbreak in Israel (23 February 2020-15 March 2020). RESULTS: During the study period, the total number of calls to the dispatch centers was 477,321 with a daily average of 21,696, compared to 6000-6500 during routine times. The total number of COVID-19 related calls was 334,230 (daily average 15,194). There were 28,454 calls (8.51% of all COVID-19 related calls, average 1293/day) transferred to the COVID-19 call center. Of the COVID-19 call center inquiries, 8390 resulted in the dispatch of a dedicated vehicle, including a paramedic wearing personal protective equipment, to collect samples for testing (daily average 381). CONCLUSIONS: Maximizing EMS during a pandemic using phone triage, in addition to dispatching paramedics to perform home testing, may significantly distance infected patients from the public and health care system. These steps can further minimize the spread of disease.

The Association Between Heat Waves and Other Meteorological Parameters and Snakebites: Israel National Study.

BACKGROUND: Published annual estimates report a global burden of 2.5 million snakebite cases and >100,000 deaths. In Israel, envenomations are the third most frequent cause of poisonings that are of moderate to major clinical severity. Most studies focus on the clinical descriptions of snakebites in tropical climates, and we sought to investigate the association between snakebite frequency and meteorological parameters. OBJECTIVE: We sought to investigate the seasonality of snakebites and evaluate the association between increasingly common heat waves and other meteorological parameters and snakebite frequency in a semiarid nontropical climate. METHODS: We obtained data for all medical evacuations (2008-2015) because of snakebites in Israel. Climate data included daily 24-hour average temperature (°C) and relative humidity (%). We used a time-stratified case crossover method, in which a conditional logistic regression was applied to estimate the association, and we also stratified our analysis by season and by region. RESULTS: We identified 1234 snakebite cases over 8 years, of which most (74.2%) occurred in hot seasons and between 6 pm and 9 pm. The risk of snakebite was positively associated with temperature >23°C (odds ratio [OR] 1.24, 95% confidence interval [CI] 1.01-1.53) and inversely with humidity >40% (OR 0.74, 95% CI 0.57-0.97). We also found an association with heat waves both in cold (OR 1.62, 95% CI 1.01-2.60) and hot seasons (OR 1.50, 95% CI 1.18-1.92). CONCLUSIONS: In a semiarid nontropical climate, we observed an association between an increase in the number of snakebite cases and higher temperatures and lower humidity. Moreover, heat waves increased the frequency of snakebites in both cold and hot seasons.

Terrorist Stabbings-Distinctive Characteristics and How to Prepare for Them.

BACKGROUND: The number of terror attack incidents is on the increase worldwide. The knife is one of the weapons most commonly used among terrorists. Appropriate preparation in trauma units for coping with the increasing numbers of terrorist-inflicted stabbings is different from the preparation suitable for civilian stabbings. Therapeutic and logistic guidelines need to be adjusted to accommodate those differences. OBJECTIVES: Characterize the unique injuries related to terrorist stabbing, and suggest preparedness actions. METHODS: Retrospective data on all terrorist-inflicted stabbing incidents between September 2015 and May 2016 were retrieved from the database of the national Israeli emergency medical services and from the Israeli Defense Forces Medical Corps records. RESULTS: There were a total of 414 civilian victims (34 fatalities) of terror incidents. Of these, 161 involved stabbings during 106 separate incidents. There was more than 1 stab wound per patient in approximately 60% of cases, and more than 1 victim in approximately 40% of cases. Unlike civilian stabbings, terrorist stabbings were characterized by more commonly occurring to the upper part of the body, being executed by large knives with high force, and involving multiple and more severe injuries. CONCLUSION: There is a clear distinction between the characteristics of wounds resulting from civilian stabbings and those incurred by acts of terror. Terrorists intend to injure as many random victims as possible, and trauma units need to be prepared to cope with the simultaneous admission of multiple patients with penetrating and often life-threatening knife wounds.

Impact of repeated military conflicts on civilian patterns of emergency medical services utilization: A retrospective cohort study.

OBJECTIVE: To assess the impact of repeated rocket attacks on a civilian population during successive military conflicts on the patterns of emergency medical services (EMS) utilization. DESIGN: This retrospective cohort study (2008-2021) analyzed EMS data from one region of Israel characterized by intensive rocket attacks on a civilian population during four successive military conflicts. EMS activity for the periods prior to, during, and after the conflicts was compared. Data included call volume, type of calls ("medical illness," "motor vehicle collision (MVC)," and "other-injuries"), and level of response (advanced life support (ALS) or basic life support (BLS)). RESULTS: Compared to the Pre-Conflict period, there were statistically significant decreased volumes of calls during the 2008 (-20 percent), 2012 (-13 percent), and 2021 (-11 percent) military conflicts for "medical illness" and during the 2008 (-23 percent), 2012 (-30 percent), and 2021 (-31 percent) for "MVC." Decreases in calls for "medical illness" were accompanied by decreased ALS dispatches (-28, -33, and -18 percent for 2008, 2012, and 2021, respectively). The number of calls returned to preconflict values during the Post-Conflict periods. No change was evidenced in numbers of calls during the 2014 military conflict. CONCLUSION: Military conflicts involving a civilian population were usually found to be associated with lower numbers of calls for the categories of "medical illness" and "MVC." Less calls for "medical illness" were associated with fewer ALS dispatches. There was a rapid return of call volumes to preconflict levels shortly after a ceasefire was reached. The absence of change in calls during the 2014 conflict suggests involvement of habituation processes.

Responses of a Pre-hospital Emergency Medical Service During Military Conflict Versus COVID-19: A Retrospective Comparative Cohort Study.

BACKGROUND: Decreases in routine healthcare practices have been shown to occur during disasters. However, research regarding the impacts of natural disasters, pandemics, or military conflicts on emergency medical services (EMS) is scarce. OBJECTIVES: This study assessed the impact of a military conflict versus the coronavirus disease 2019 (COVID-19) pandemic on a national EMS organization in terms of responses to overall daily emergencies, medical illnesses, motor vehicle collisions, and other injuries. METHODS: This retrospective comparative cohort study assessed daily routine emergency ambulance calls to Magen David Adom (MDA), Israel's national EMS organization. This included overall emergency calls as well as those related to medical illnesses, motor vehicle collisions (MVCs), and other injuries. All data were obtained from the MDA command and control database. During the military conflict Operation Protective Edge (2014), the civilian population was subjected to intensive rocket attacks for 24 days, followed by 26 days of a progressive withdrawal of operations and then to a post-conflict period. During the first wave of the COVID-19 pandemic (March-April 2020), the population was subjected to 32 days of total lockdown, followed by 27 days of progressive relief of confinement, and then to a post-lockdown period. RESULTS: The total number of emergency calls in this study was 330,430. During the conflict, the mean number of daily calls decreased, followed by an increase during Relief and Post-Conflict with higher values in Post-Conflict than in Pre-Conflict. During the COVID-19 pandemic, there was a decrease in the mean daily number of calls during Lockdown. It remained low during Relief and increased during Post-Lockdown. However, it remained lower in Post-Lockdown than during Pre-Lockdown. Calls related to medical illnesses decreased during the conflict and during the lockdown. The post-conflict period was characterized by a similar baseline call magnitude but not during the post-lockdown period. Decreases in calls for MVC and other injuries were significant during the lockdown but not during the military conflict. Post-lockdown was accompanied by return to baseline call volumes for MVC, whereas calls for other injuries increased above baseline both after the lockdown and military conflict. CONCLUSION: This study shows decreasing trends in routine daily calls for EMS during both Operation Protective Edge and COVID-19. However, different patterns of needs for EMS were evidenced for medical illnesses, MVC, or calls concerning other injuries. These results are instrumental for managing the operational demands of EMS during military conflicts and pandemics.

Traumatic Injuries Following Mechanical versus Manual Chest Compression.

Objective: Survival after out-of-hospital cardiac arrest (OHCA) depends on multiple factors, mostly quality of chest compressions. Studies comparing manual compression with a mechanical active compression-depression device (ACD) have yielded controversial results in terms of outcomes and injury. The aim of the present study was to determine whether out-of-hospital ACD cardiopulmonary resuscitation (CPR) use is associated with more skeletal fractures and/or internal injuries than manual compression, with similar duration of cardiopulmonary resuscitation (CPR) between the groups. Methods: The cohort included all patients diagnosed with out-of-hospital cardiac arrest (OHCA) at a tertiary medical center between January 2018 and June 2019 who achieved return of spontaneous circulation (ROSC). The primary outcome measure was the incidence of skeletal fractures and/or internal injuries in the two groups. Secondary outcome measures were clinical factors contributing to skeletal fracture/internal injuries and to achievement of ROSC during CPR. Results: Of 107 patients enrolled, 45 (42%) were resuscitated with manual chest compression and 62 (58%) with a piston-based ACD device (LUCAS). The duration of chest compression was 46.0 minutes vs. 48.5 minutes, respectively (p=0.82). There were no differences in rates of ROSC (53.2% vs.50.8%, p=0.84), cardiac etiology of OHCA (48.9% vs.43.5%, p=0.3), major complications (ribs/sternum fracture, pneumothorax, hemothorax, lung parenchymal damage, major bleeding), or any complication (20.5% vs.12.1%, p=0.28). On multivariate logistic regression analysis, factors with the highest predictive value for ROSC were cardiac etiology (OR 1.94;CI 2.00-12.94) and female sex (OR 1.94;CI 2.00-12.94). Type of arrhythmia had no significant effect. Use of the LUCAS was not associated with ROSC (OR 0.73;CI 0.34-2.1). Conclusion: This is the first study to compare mechanical and manual out-of-hospital chest compression of similar duration to ROSC. The LUCAS did not show added benefit in terms of ROSC rate, and its use did not lead to a higher risk of traumatic injury. ACD devices may be more useful in cases of delayed ambulance response times, or events in remote locations.

The Role of Israel's Emergency Medical Services During a Pandemic in the Pre-Exposure Period.

OBJECTIVE: The scientific literature on coronavirus disease (COVID-19) is extensive, but little is written about the role of emergency medical services (EMS). The objective of this study is to describe the role of Magen David Adom (MDA), Israel's national emergency prehospital medical organization, in the pre-exposure period, before widespread governmental action. These efforts were based on (1) phone diagnosis, dispatch, and transport; and (2) border management checkpoints. METHODS: This is a descriptive study of MDA's role in pandemic response during the pre-exposure period. Medical emergency telephone calls from either individuals or medical sources were identified by a dispatcher as "suspected COVID-19" based on symptoms and travel exposure. Data were also collected for travelers approaching the MDA border checkpoint at Ben-Gurion International Airport. RESULTS: The total number of protected transports during this time was 121. Of these, 44 (36.3%) were referred by medical sources, and 77 (63.7%) were identified as "suspected COVID-19" by dispatchers. The checkpoint was accessed by 156 travelers: 87 were sent to home-quarantine; 12 were transported to the hospital; 18 were refused entry; and 39 required no further action. CONCLUSION: EMS can work effectively in the pre-exposure period through instructing home quarantine, providing protected transport, and staffing border control checkpoints.

Maximizing the Role of Emergency Medical Services in COVID-19 Response.

The Centers for Disease Control and Prevention define 6 intervals of a pandemic: (1) investigation of cases, (2) recognition of the increased potential for ongoing transmission, (3) initiation of a pandemic wave, (4) acceleration of a pandemic wave, (5) deceleration of a pandemic wave, and (6) preparation for future pandemic waves. Each of these stages has 8 domains. Following China's coronavirus disease 2019 (COVID-19) outbreak announcement, Israel's National Emergency Medical Services (EMS) Organization immediately began working in conjunction with the Ministry of Health (MOH) to address the threat of the COVID-19 outbreak. This article will describe how a national EMS organization acted according to these pandemic intervals and domains. In the initial stages, EMS managed a checkpoint in the international airport voluntarily testing people for febrile symptoms. Calls to the dispatch centers that aroused the suspicion of COVID-19 resulted in EMS transport to the hospital with protective gear. During the period of first exposure, the scope of the medical emergency number was increased to include questions concerning coronavirus, telemedicine, and home sampling by protected EMS workers. In the contagion stages, epidemiological tests were conducted by the MOH, and EMS began operating dedicated telephone triage, mass drive-through sampling, and finally, administration of vaccinations.

Epidemic investigations within an arm's reach - role of google maps during an epidemic outbreak.

Epidemics such as novel Coronavirus 2019 (COVID-19) can be contained and the rate of infection reduced by public health measures such as epidemiologic inquiries and social distancing. Epidemiologic inquiry requires resources and time which may not be available or reduced when the outbreak is excessive. We evaluated the use of Google Maps Timeline (GMTL) for creating spatial epidemiologic timelines. The study compares locations, routes, and means of transport between GMTL and user recall for 17 suitable users who were recruited during March 2020. They were interviewed about their timeline using the Timeline Follow-Back (TLFB) method which was then compared to their GMTL and discrepancies between both methods were addressed. Interviewer conclusions were divided into categories: (1) participant recalled, (2) no recall (until shown). Categories were subdivided by GMTL accuracy: [a] GMTL accurate, [b] GMTL inaccurate, [c] GMTL data missing. A total of 362 locations were compared. Participants recalled 322 (88.95% SD = 8.55) locations compared with 40 (11.05%, SD = 2.05) locations not recalled. There were 304 locations found accurate on GMTL (83.98%, SD = 9.49), 29 (8.01%, SD = 1.11) inaccurate locations, and 29 (8.01%, SD = 0.54) missing locations. The total discrepancy between GMTL and TLFB recall was 95 cases (26.24%, SD = 3.25). Despite variations between users, Google Maps with GMTL technology may be useful in identifying potentially exposed individuals in a pandemic. It is especially useful when resources are limited. Further research is required with a larger number of users who are undergoing a real epidemiologic investigation to corroborate findings and establish further recommendations.