The 2019 Core Content of Emergency Medical Services Medicine.

On March 13, 2019 the EMS Examination Committee of the American Board of Emergency Medicine (ABEM) approved modifications to the Core Content of EMS Medicine. The Core Content is used to define the subspecialty of EMS Medicine, provides the basis for questions to be used during written examinations, and leads to development of a certification examination blueprint. The Core Content defines the universe of knowledge for the treatment of prehospital patients that is necessary to practice EMS Medicine. It informs fellowship directors and candidates for certification of the full range of content that might appear on certification examinations.

Formation of raiding parties for intergroup violence is mediated by social network structure.

Intergroup violence is common among humans worldwide. To assess how within-group social dynamics contribute to risky, between-group conflict, we conducted a 3-y longitudinal study of the formation of raiding parties among the Nyangatom, a group of East African nomadic pastoralists currently engaged in small-scale warfare. We also mapped the social network structure of potential male raiders. Here, we show that the initiation of raids depends on the presence of specific leaders who tend to participate in many raids, to have more friends, and to occupy more central positions in the network. However, despite the different structural position of raid leaders, raid participants are recruited from the whole population, not just from the direct friends of leaders. An individual's decision to participate in a raid is strongly associated with the individual's social network position in relation to other participants. Moreover, nonleaders have a larger total impact on raid participation than leaders, despite leaders' greater connectivity. Thus, we find that leaders matter more for raid initiation than participant mobilization. Social networks may play a role in supporting risky collective action, amplify the emergence of raiding parties, and hence facilitate intergroup violence in small-scale societies.

Recovery of locomotion after injury in Drosophila melanogaster depends on proprioception.

Locomotion is necessary for survival in most animal species. However, injuries to the appendages mediating locomotion are common. We assess the recovery of walking in Drosophila melanogaster following leg amputation. Whereas flies pre-amputation explore open arenas in a symmetric fashion on average, foreleg amputation induces a strong turning bias away from the side of the amputation. However, we find that unbiased walking behavior returns over time in wild-type flies, while recovery is significantly impaired in proprioceptive mutants. To identify the biomechanical basis of this locomotor impairment and recovery, we then examine individual leg motion (gait) at a fine scale. A minimal mathematical model that links neurodynamics to body mechanics during walking shows that redistributing leg forces between the right and left side enables the observed recovery. Altogether, our study suggests that proprioceptive input from the intact limbs plays a crucial role in the behavioral plasticity associated with locomotor recovery after injury.

Facilitators and Barriers for Effective Academic-Community Collaboration for Disaster Preparedness and Response.

CONTEXT: For academic institutions to meaningfully contribute to community-disaster preparedness and response, they must effectively collaborate with governmental public health and emergency management agencies. OBJECTIVE: To explore the opinions of leaders of public health and emergency management agencies and academic institutions regarding the facilitators for and barriers to effective collaboration for disaster preparedness and response. DESIGN, SETTING, AND PARTICIPANTS: We convened focus groups of leaders of state and local public health and emergency management agencies and academic institutions in conjunction with the 2010 Public Health Preparedness Summit and the 2010 Southeastern Center for Emerging Biological Threats Meeting. We employed a semistructured interview guide to elicit information about resources leveraged for community preparedness and response and perceived facilitators and barriers to engagement and on-going collaboration. Focus groups were transcribed verbatim. We performed thematic analysis of the transcripts employing a data-coding scheme based on emergent themes. RESULTS: Academic institutions engaged with public health and emergency management agencies in the provision of an array of resources for community-disaster preparedness and response, ranging from technical expertise to the conduct of training activities, workforce surge capacity, and facility sharing. Recognized barriers to engagement included unfamiliarity of organizational personnel, concerns about ownership of outputs resulting from the collaboration, and differences in organizational culture and modus operandi. On-going relationships through shared training of students and staff and participation in community-level partner meetings facilitated collaboration in disaster response as does having a recognizable point of contact that can comprehensively represent academic institutional resources. Legal issues were identified as both facilitators (eg, contracts) and barriers (eg, liability concerns) to engagement. CONCLUSIONS: There are both recognized facilitators and barriers to effective and sustainable academic-community collaboration for disaster preparedness and response from the perspectives of leaders of public health and emergency management agencies and academic institutions.

Development of a Core Clinical Dataset to Characterize Serious Illness, Injuries, and Resource Requirements for Acute Medical Responses to Public Health Emergencies.

OBJECTIVES: In developed countries, public health systems have become adept at rapidly identifying the etiology and impact of public health emergencies. However, within the time course of clinical responses, shortfalls in readily analyzable patient-level data limit capabilities to understand clinical course, predict outcomes, ensure resource availability, and evaluate the effectiveness of diagnostic and therapeutic strategies for seriously ill and injured patients. To be useful in the timeline of a public health emergency, multi-institutional clinical investigation systems must be in place to rapidly collect, analyze, and disseminate detailed clinical information regarding patients across prehospital, emergency department, and acute care hospital settings, including ICUs. As an initial step to near real-time clinical learning during public health emergencies, we sought to develop an "all-hazards" core dataset to characterize serious illness and injuries and the resource requirements for acute medical response across the care continuum. SUBJECTS: A multidisciplinary panel of clinicians, public health professionals, and researchers with expertise in public health emergencies. DESIGN: Group consensus process. INTERVENTIONS: The consensus process included regularly scheduled conference calls, electronic communications, and an in-person meeting to generate candidate variables. Candidate variables were then reviewed by the group to meet the competing criteria of utility and feasibility resulting in the core dataset. MEASUREMENTS AND MAIN RESULTS: The 40-member panel generated 215 candidate variables for potential dataset inclusion. The final dataset includes 140 patient-level variables in the domains of demographics and anthropometrics (7), prehospital (11), emergency department (13), diagnosis (8), severity of illness (54), medications and interventions (38), and outcomes (9). CONCLUSIONS: The resulting all-hazard core dataset for seriously ill and injured persons provides a foundation to facilitate rapid collection, analyses, and dissemination of information necessary for clinicians, public health officials, and policymakers to optimize public health emergency response. Further work is needed to validate the effectiveness of the dataset in a variety of emergency settings.

Transport and Management of Patients With Confirmed or Suspected Ebola Virus Disease.

The foundation of safe care for patients with confirmed or suspected Ebola virus disease is effective infection control practice, which requires implementation of appropriate administrative policies, work practices, and environmental controls, accompanied by focused education, training, and supervision. In 2002, Emory University partnered with the Centers for Disease Control and Prevention to develop a capability for the evaluation and management of individuals with serious communicable disease. In 2005, the University of Nebraska developed a similar isolation capability. In each case, the hospitals partnered with emergency medical services (EMS) professionals to ensure safe out-of-hospital transport and management of their patients. The objectives of these hospital and out-of-hospital collaborations were to close education, training, and practice gaps to best facilitate the care for patients with serious communicable disease while ensuring the safety of the medics and the general public through meticulous implementation of infection control practices as recommended by Centers for Disease Control and Prevention. The description of practices implemented by EMS teams in these communities for the transport of patients with confirmed Ebola virus disease is shared so that others might more readily implement these practices, policies, and procedures as applicable to their mission requirements and system design. Transport of patients with relevant travel history and development of illness (persons under investigation) is also included.

"Picture to puncture": a novel time metric to enhance outcomes in patients transferred for endovascular reperfusion in acute ischemic stroke.

BACKGROUND: Comprehensive stroke centers allow for regionalization of subspecialty stroke care. Efficacy of endovascular treatments, however, may be limited by delays in patient transfer. Our goal was to identify where these delays occurred and to assess the impact of such delays on patient outcome. METHODS AND RESULTS: This was a retrospective study evaluating patients treated with endovascular therapy from November 2010 to July 2012 at our institution. We compared patients transferred from outside hospitals with locally treated patients with respect to demographics, imaging, and treatment times. Good outcomes, as defined by 90-day modified Rankin Scale scores of 0 to 2, were analyzed by transfer status as well as time from initial computed tomography to groin puncture ("picture-to-puncture" time). A total of 193 patients were analyzed, with a mean age of 65.8 ± 14.5 years and median National Institutes of Health Stroke Scale score of 19 (interquartile range, 15-23). More than two thirds of the patients (132 [68%]) were treated from referring facilities. Outside transfers were noted to have longer picture-to-puncture times (205 minutes [interquartile range, 162-274] versus 89 minutes [interquartile range, 70-119]; P<0.001), which was attributable to the delays in transfer. This corresponded to fewer patients with favorable Alberta Stroke Program Early CT Scores on preprocedural computed tomographic imaging (Alberta Stroke Program Early CT Scores >7: 50% versus 76%; P<0.001) and significantly worse clinical outcomes (29% versus 51%; P=0.003). In a logistic regression model, picture-to-puncture times were independently associated with good outcomes (odds ratio, 0.994; 95% confidence interval, 0.990-0.999; P=0.009). CONCLUSIONS: Delays in picture-to-puncture times for interhospital transfers reduce the probability of good outcomes among treated patients. Strategies to reduce such delays herald an opportunity for hospitals to improve patient outcomes.

Air Quality Monitoring During High-Level Biocontainment Ground Transport: Observations From Two Operational Exercises.

OBJECTIVE: Stretcher transport isolators provide mobile, high-level biocontainment outside the hospital for patients with highly infectious diseases, such as Ebola virus disease. Air quality within this confined space may pose human health risks. METHODS: Ambient air temperature, relative humidity, and CO2 concentration were monitored within an isolator during 2 operational exercises with healthy volunteers, including a ground transport exercise of approximately 257 miles. In addition, failure of the blower unit providing ambient air to the isolator was simulated. A simple compartmental model was developed to predict CO2 and H2O concentrations within the isolator. RESULTS: In both exercises, CO2 and H2O concentrations were elevated inside the isolator, reaching steady-state values of 4434 ± 1013 ppm CO2 and 22 ± 2 mbar H2O in the first exercise and 3038 ± 269 ppm CO2 and 20 ± 1 mbar H2O in the second exercise. When blower failure was simulated, CO2 concentration exceeded 10 000 ppm within 8 minutes. A simple compartmental model predicted CO2 and H2O concentrations by accounting for human emissions and blower air exchange. CONCLUSIONS: Attention to air quality within stretcher transport isolators (including adequate ventilation to prevent accumulation of CO2 and other bioeffluents) is needed to optimize patient safety.

A University-Led Contact Tracing Program Response to a COVID-19 Outbreak Among Students in Georgia, February-March 2021.

Few reports have described how university programs have controlled COVID-19 outbreaks. Emory University established a case investigation and contact tracing program in June 2020 to identify and mitigate transmission of SARS-CoV-2 in the Emory community. In February 2021, this program identified a surge in COVID-19 cases. In this case study, we present details of outbreak investigation, construction of transmission networks to assess clustering and identify groups for targeted testing, and program quality metrics demonstrating the efficiency of case investigation and contact tracing, which helped bring the surge under control. During February 10-March 5, 2021, Emory University identified 265 COVID-19 cases confirmed by nucleic acid testing in saliva or nasopharyngeal samples. Most students with COVID-19 were undergraduates (95%) and were affiliated with Greek life organizations (70%); 41% lived on campus. Network analysis identified 1 epidemiologically linked cluster of 198 people. Nearly all students diagnosed with COVID-19 (96%) were interviewed the same day as their positive test result. Of 340 close contacts, 90% were traced and 89% were tested. The median time from contact interview to first test was 2 days (interquartile range, 0-6 days); 43% received a positive test result during their quarantine. The surge was considered under control within 17 days, after which new cases were no longer epidemiologically linked. Early detection through systematic testing protocols and rapid and near-complete contact tracing, paired with isolation and quarantine measures, helped to contain the surge. Our approach emphasizes the importance of early preparation of adequate outbreak response infrastructure and staff to implement interventions appropriately and consistently during a pandemic.

A survey of emergency department 2009 pandemic influenza A (H1N1) surge preparedness--Atlanta, Georgia, July-October 2009.

During August through September 2009, a surge in emergency department (ED) visits for 2009 pandemic influenza A (pH1N1) illness occurred in Georgia, particularly among children. To understand surge preparedness and capacity, we obtained influenza-like illness (ILI) ED visit data from the Georgia State Electronic Notifiable Disease Surveillance System (SendSS) and conducted a retrospective, Internet-based survey among all 26 metro Atlanta ED managers with reference to the period 1 July-1 October 2009. SendSS detected a marked and progressive increase in mean monthly ILI visits from 1 July-1 October 2009, which more than tripled (from 399 to 2196) for the 2 participating EDs that cared for pediatric patients during this time. ED managers reported patient volume surges, resulting in space and supply limitations, especially at pediatric EDs. Most (92%) of the facilities had current pandemic influenza plans. Pandemic planning can help to ensure preparedness for natural and man-made disasters and for future influenza pandemics.

A modeling study to inform screening and testing interventions for the control of SARS-CoV-2 on university campuses.

University administrators face decisions about how to safely return and maintain students, staff and faculty on campus throughout the 2020-21 school year. We developed a susceptible-exposed-infectious-recovered (SEIR) deterministic compartmental transmission model of SARS-CoV-2 among university students, staff, and faculty. Our goals were to inform planning at our own university, Emory University, a medium-sized university with around 15,000 students and 15,000 faculty and staff, and to provide a flexible modeling framework to inform the planning efforts at similar academic institutions. Control strategies of isolation and quarantine are initiated by screening (regardless of symptoms) or testing (of symptomatic individuals). We explored a range of screening and testing frequencies and performed a probabilistic sensitivity analysis. We found that among students, monthly and weekly screening can reduce cumulative incidence by 59% and 87%, respectively, while testing with a 2-, 4- and 7-day delay between onset of infectiousness and testing results in an 84%, 74% and 55% reduction in cumulative incidence. Smaller reductions were observed among staff and faculty. Community-introduction of SARS-CoV-2 onto campus may be controlled with testing, isolation, contract tracing and quarantine. Screening would need to be performed at least weekly to have substantial reductions beyond disease surveillance. This model can also inform resource requirements of diagnostic capacity and isolation/quarantine facilities associated with different strategies.

Web-based self-triage of influenza-like illness during the 2009 H1N1 influenza pandemic.

The sudden emergence of 2009 H1N1 influenza in the spring of that year sparked a surge in visits to emergency departments in New York City and other communities. A larger, second wave of cases was anticipated the following autumn. To reduce a potential surge of health system utilization without denying needed care, we enlisted the input of experts from medicine, public health, nursing, information technology, and other disciplines to design, test, and deploy clinical algorithms to help minimally trained health care workers and laypeople make informed decisions about care-seeking for influenza-like illness. The product of this collaboration, named Strategy for Off-Site Rapid Triage (SORT) was disseminated in 2 forms. Static algorithms, posted on the Centers for Disease Control and Prevention's Web site, offered guidance to clinicians and telephone call centers on how to manage adults and children with influenza-like illness. In addition, 2 interactive Web sites, http://www.Flu.gov and http://www.H1N1ResponseCenter.com, were created to help adults self-assess their condition and make an informed decision about their need for treatment. Although SORT was anchored in a previously validated clinical decision rule, incorporated the input of expert clinicians, and was subject to small-scale formative evaluations during rapid standup, prospective evaluation is lacking. If its utility and safety are confirmed, SORT may prove to be a useful tool to blunt health system surge and rapidly collect epidemiologic data on future disease outbreaks.

Development and Usability Testing of a Web-based COVID-19 Self-triage Platform.

INTRODUCTION: The development and deployment of a web-based, self-triage tool for severe respiratory syndrome coronavirus 2 (COVID-19 disease) aimed at preventing surges in healthcare utilization could provide easily understandable health guidance with the goal of mitigating unnecessary emergency department (ED) and healthcare visits. We describe the iterative development and usability testing of such a tool. We hypothesized that adult users could understand and recall the recommendations provided by a COVID-19 web-based, self-triage tool. METHODS: We convened a multidisciplinary panel of medical experts at two academic medical schools in an iterative redesign process of a previously validated web-based, epidemic screening tool for the current COVID-19 pandemic. We then conducted a cross-sectional usability study over a 24-hour period among faculty, staff, and students at the two participating universities. Participants were randomly assigned a pre-written health script to enter into the self-triage website for testing. The primary outcome was immediate recall of website recommendations. Secondary outcomes included usability measures. We stratified outcomes by demographic characteristics. RESULTS: A final sample of 877 participants (mean age, 32 years [range, 19-84 years]; 65.3% female) was used in the analysis. We found that 79.4% of the participants accurately recalled the recommendations provided by the website. Almost all participants (96.9%) found the website easy to use and navigate. CONCLUSION: Adult users of a COVID-19 self-triage website, recruited from an academic setting, were able to successfully recall self-care instructions from the website and found it user-friendly. This website appears to be a feasible way to provide evidence-based health guidance to adult patients during a pandemic. Website guidance could be used to reduce unnecessary ED and healthcare visits.

The Structure of Negative Social Ties in Rural Village Networks.

Negative (antagonistic) connections have been of longstanding theoretical importance for social structure. In a population of 24,696 adults interacting face to face within 176 isolated villages in western Honduras, we measured all connections that were present, amounting to 105,175 positive and 16,448 negative ties. Here, we show that negative and positive ties exhibit many of the same structural characteristics. We then develop a complete taxonomy of all 138 possible triads of two-type relationships. Consistent with balance theory, we find that antagonists of friends and friends of antagonists tend to be antagonists; but, in an important empirical refutation of balance theory, we find that antagonists of antagonists also tend to be antagonists, not friends. Finally, villages with comparable levels of animosity tend to be geographically proximate. Similar processes, involving social contact, give rise to both positive and negative social ties in rural villages, and negative ties play an important role in social structure.