The implication of a translational triage tool in mass casualty incidents: part three: a multinational study, using validated patient cards.

BACKGROUND: Mass casualty incidents (MCI) pose significant challenges to existing resources, entailing multiagency collaboration. Triage is a critical component in the management of MCIs, but the lack of a universally accepted triage system can hinder collaboration and lead to preventable loss of life. This multinational study uses validated patient cards (cases) based on real MCIs to evaluate the feasibility and effectiveness of a novel Translational Triage Tool (TTT) in primary triage assessment of mass casualty victims. METHODS: Using established triage systems versus TTT, 163 participants (1575 times) triaged five patient cases. The outcomes were statistically compared. RESULTS: TTT demonstrated similar sensitivity to the Sieve primary triage method and higher sensitivity than the START primary triage system. However, the TTT algorithm had a lower specificity compared to Sieve and higher over-triage rates. Nevertheless, the TTT algorithm demonstrated several advantages due to its straightforward design, such as rapid assessment, without the need for additional instrumental interventions, enabling the engagement of non-medical personnel. CONCLUSIONS: The TTT algorithm is a promising and feasible primary triage tool for MCIs. The high number of over-triages potentially impacts resource allocation, but the absence of under-triages eliminates preventable deaths and enables the use of other personal resources. Further research involving larger participant samples, time efficiency assessments, and real-world scenarios is needed to fully assess the TTT algorithm's practicality and effectiveness in diverse multiagency and multinational contexts.

Hybrid warfare and counter-terrorism medicine.

INTRODUCTION: March 9, 2022. An airstrike by Russian forces destroying a maternity hospital in Mariupol, Ukraine. The image of a severely injured pregnant woman covered in blood being stretchered away against the backdrop of destroyed buildings. Mutterings of the use of chemical weapons. This paper is a primer for healthcare personnel and health systems on hybrid warfare and counter-terrorism medicine. DISCUSSION: While recent events and images arising from conflicts around the world represent a cruel hallmark in today's history, attacks against healthcare facilities and innocent civilians are not new and continue to be perpetrated around the world. In war, the Geneva Convention protects civilians and healthcare institutions from harm but when war crimes are being committed and civilians knowingly targeted, parallels from a healthcare perspective can be drawn with terrorism events. Increasingly, civilian institutions and in particular the healthcare sector, are drawn into such conflicts and understanding the health system impact of hybrid warfare and other asymmetrical attack methods is of great importance. CONCLUSION: The field of Counter-Terrorism Medicine (CTM) explores the healthcare impacts of intentional, man-made attacks and much recent research and discussions around this topic are extremely relevant and applicable not just to the ongoing hybrid war in Ukraine, but to today's threat climate all around us.

Delayed-Onset Neuropathological Complications From a Foramen Magnum and Occipital Crest Focused Traumatic Brain Injury of the Vietnam War and Other Conflicts: Part I, Case Report.

INTRODUCTION: The diagnosis of traumatic brain injuries is typically based on hemispheric blasts resulting in degrees of unconsciousness and associated cerebral injuries. This case report describes a Vietnam War era setting in which a traumatic blast wave struck the posterior cranium in the region of the foramen magnum, occipital crest, and other skull openings (orbit, oronasal, and ear) and the unique secondary clinical signs and symptoms experienced over time. MATERIALS AND METHODS: This case report describes secondary delayed-onset clinical signs and symptoms consistent with progressive decades-long physical and functional complications. The traumatic blast resulted in brief unconsciousness, decreased vision in left eye, confusion, right sided hemotympanum, deafness, severe tinnitus, severe nasopharynx pain and difficulty swallowing, pain in right posterior and occipital area of the head, and loss of dental amalgams. Subsequent exams revealed progressive hyperacusis, sea sickness, dysdiadochokinesis, diagnosis of 9th and 10th cranial nerve traumatic schwannomas, hyperdense changes to the frontal lobe white matter, progressive tinnitus, chronic vertigo, right-sided high-frequency hearing loss, progressive oculo-gyric crisis of Tumarkin-like seizures, left-sided chronic vitreous hemorrhage, and diminished right hemisphere performance of the brain based on neurophysiological assessment. No post-traumatic stress, depression, or other emotional or psychiatric difficulties were claimed. CONCLUSION: This case report, unique to the English language scientific literature, discusses in detail the secondary signs and symptoms of a foramen magnum and occipital crest focused-associated blast injury.

A Consensus Framework for the Humanitarian Surgical Response to Armed Conflict in 21st Century Warfare.

Importance: Armed conflict in the 21st century poses new challenges to a humanitarian surgical response, including changing security requirements, access to patients, and communities in need, limited deployable surgical assets, resource constraints, and the requirement to address both traumatic injuries as well as emergency surgical needs of the population. At the same time, recent improvements in trauma care and systems have reduced injury-related mortality. This combination of new challenges and medical capabilities warrants reconsideration of long-standing humanitarian surgery protocols. Objective: To describe a consensus framework for surgical care designed to respond to this emerging need. Design, Setting, and Participants: An international group of 35 representatives from humanitarian agencies, US military, and academic trauma programs was invited to the Stanford Humanitarian Surgical Response in Conflict Working Group to engage in a structured process to review extant trauma protocols and make recommendations for revision. Main Outcomes and Measures: The working group's method adapted core elements of a modified Delphi process combined with consensus development conference from August 3 to August 5, 2018. Results: Lessons from civilian and military trauma systems as well as recent battlefield experiences in humanitarian settings were integrated into a tiered continuum of response from point of injury through rehabilitation. The framework addresses the security and medical requirements as well as ethical and legal principles that guide humanitarian action. The consensus framework includes trained, lay first responders; far-forward resuscitation/stabilization centers; rapid damage control surgical access; and definitive care facilities. The system also includes nontrauma surgical care, injury prevention, quality improvement, data collection, and predeployment training requirements. Conclusions and Relevance: Evidence suggests that modern trauma systems save lives. However, the requirements of providing this standard of care in insecure conflict settings places new burdens on humanitarian systems that must provide both emergency and trauma surgical care. This consensus framework integrates advances in trauma care and surgical systems in response to a changing security environment. It is possible to reduce disparities and improve the standard of care in these settings.

Paramedic and Emergency Medical Technician Reflections on the Ongoing Impact of the 9/11 Terrorist Attacks.

IntroductionIn the years following the September 11, 2001 terrorist attacks in New York City (New York USA), otherwise known as 9/11, first responders began experiencing a range of health and psychosocial impacts. Publications documenting these largely focus on firefighters. This research explores paramedic and emergency medical technician (EMT) reflections on the long-term impact of responding to the 9/11 terrorist attacks. METHODS: Qualitative methods were used to conduct interviews with 54 paramedics and EMTs on the 15-year anniversary of 9/11. RESULTS: Research participants reported a range of long-term psychosocial issues including posttraumatic stress disorder (PTSD), anxiety, depression, insomnia, relationship breakdowns and impact on family support systems, and addictive and risk-taking behaviors. Ongoing physical health issues included respiratory disorders, eye problems, and cancers.DiscussionThese findings will go some way to filling the current gap in the 9/11 evidence-base regarding the understanding of the long-term impact on paramedics and EMTs. The testimony of this qualitative research is to ensure that an important voice is not lost, and that the deeply personal and richly descriptive experiences of the 9/11 paramedics and EMTs are not forgotten. SmithEC, BurkleFMJr. Paramedic and emergency medical technician reflections on the ongoing impact of the 9/11 terrorist attacks. Prehosp Disaster Med. 2019;34(1):56-61.

Developing a Nuclear Global Health Workforce Amid the Increasing Threat of a Nuclear Crisis.

This study argues that any nuclear weapon exchange or major nuclear plant meltdown, in the categories of human systems failure and conflict-based crises, will immediately provoke an unprecedented public health emergency of international concern. Notwithstanding nuclear triage and management plans and technical monitoring standards within the International Atomic Energy Agency and the World Health Organization (WHO), the capacity to rapidly deploy a robust professional workforce with the internal coordination and collaboration capabilities required for large-scale nuclear crises is profoundly lacking. A similar dilemma, evident in the early stages of the Ebola epidemic, was eventually managed by using worldwide infectious disease experts from the Global Outbreak Alert and Response Network and multiple multidisciplinary WHO-supported foreign medical teams. This success has led the WHO to propose the development of a Global Health Workforce. A strategic format is proposed for nuclear preparedness and response that builds and expands on the current model for infectious disease outbreak currently under consideration. This study proposes the inclusion of a nuclear global health workforce under the technical expertise of the International Atomic Energy Agency and WHO's Radiation Emergency Medical Preparedness and Assistance Network leadership and supported by the International Health Regulations Treaty. Rationales are set forth for the development, structure, and function of a nuclear workforce based on health outcomes research that define the unique health, health systems, and public health challenges of a nuclear crisis. Recent research supports that life-saving opportunities are possible, but only if a rapidly deployed and robust multidisciplinary response component exists.

Identifying and Describing the Impact of Cyclone, Storm and Flood Related Disasters on Treatment Management, Care and Exacerbations of Non-communicable Diseases and the Implications for Public Health.

INTRODUCTION: Over the last quarter of a century the frequency of natural disasters and the burden of non-communicable diseases (NCD) across the globe have been increasing. For individuals susceptible to, or chronically experiencing, NCDs this has become a significant risk. Disasters jeopardize access to essential treatment, care, equipment, water and food, which can result in an exacerbation of existing conditions or even preventable death. Consequently, there is a need to expand the public health focus of disaster management to include NCDs. To provide a platform for this to occur, this article presents the results from a systematic review that identifies and describes the impact of cyclone, flood and storm related disasters on those susceptible to, or experiencing, NCDs. The NCDs researched were: cardiovascular diseases; cancers; chronic respiratory diseases; and diabetes.   METHODS: Four electronic publication databases were searched with a date limit of 31 December 2014. The data was analyzed through an aggregation of individual papers to create an overall data description. The data was then grouped by disease to describe the impact of a disaster on treatment management, exacerbation, and health care of people with NCDs. The PRISMA checklist was used to guide presentation of the research. RESULTS:   The review identified 48 relevant articles. All studies represented developed country data. Disasters interrupt treatment management and overall care for people with NCDs, which results in an increased risk of exacerbation of their illness or even death. The interruption may be caused by a range of factors, such as damaged transport routes, reduced health services, loss of power and evacuations. The health impact varied according to the NCD. For people with chronic respiratory diseases, a disaster increases the risk of acute exacerbation. Meanwhile, for people with cancer, cardiovascular diseases and diabetes there is an increased risk of their illness exacerbating, which can result in death.    CONCLUSION:   Cyclone, flood and storm related disasters impact on treatment management and care for people with NCDs. Possible consequences include exacerbation of illness, complications or even death. There is now a need to expand traditional disaster approaches by public health to incorporate NCDs. This must be guided by the major NCDs identified by the World Health Organization and implemented in-line with the Sendai Framework for Disaster Risk Reduction: 2015-2030. This includes understanding all the factors that influence both direct and indirect (preventable) morbidity and mortality related to NCDs during and after disasters. Once achieved, disaster planners and public health professionals will be in a position to develop and implement effective mitigation strategies.

Academic affiliated training centers in humanitarian health, Part I: program characteristics and professionalization preferences of centers in North America.

The collaborative London based non-governmental organization network ELRHA (Enhancing Learning and Research for Humanitarian Assistance) supports partnerships between higher education institutions and humanitarian organizations worldwide with the objective to enhance the professionalization of the humanitarian sector. While coordination and control of the humanitarian sector has plagued the response to every major crisis, concerns highlighted by the 2010 Haitian earthquake response further catalyzed and accelerated the need to ensure competency-based professionalization of the humanitarian health care work force. The Harvard Humanitarian Initiative sponsored an independent survey of established academically affiliated training centers in North America that train humanitarian health care workers to determine their individual training center characteristics and preferences in the potential professionalization process. The survey revealed that a common thread of profession-specific skills and core humanitarian competencies were being offered in both residential and online programs with additional programs offering opportunities for field simulation experiences and more advanced degree programs. This study supports the potential for the development of like-minded academic affiliated and competency-based humanitarian health programs to organize themselves under ELRHA's regional "consultation hubs" worldwide that can assist and advocate for improved education and training opportunities in less served developing countries.

Emergency surgery data and documentation reporting forms for sudden-onset humanitarian crises, natural disasters and the existing burden of surgical disease.

Following large-scale disasters and major complex emergencies, especially in resource-poor settings, emergency surgery is practiced by Foreign Medical Teams (FMTs) sent by governmental and non-governmental organizations (NGOs). These surgical experiences have not yielded an appropriate standardized collection of data and reporting to meet standards required by national authorities, the World Health Organization, and the Inter-Agency Standing Committee's Global Health Cluster. Utilizing the 2011 International Data Collection guidelines for surgery initiated by Médecins Sans Frontières, the authors of this paper developed an individual patient-centric form and an International Standard Reporting Template for Surgical Care to record data for victims of a disaster as well as the co-existing burden of surgical disease within the affected community. The data includes surgical patient outcomes and perioperative mortality, along with referrals for rehabilitation, mental health and psychosocial care. The purpose of the standard data format is fourfold: (1) to ensure that all surgical providers, especially from indigenous first responder teams and others performing emergency surgery, from national and international (Foreign) medical teams, contribute relevant and purposeful reporting; (2) to provide universally acceptable forms that meet the minimal needs of both national authorities and the Health Cluster; (3) to increase transparency and accountability, contributing to improved humanitarian coordination; and (4) to facilitate a comprehensive review of services provided to those affected by the crisis.

Surgical care during humanitarian crises: a systematic review of published surgical caseload data from foreign medical teams.

OBJECTIVE: Humanitarian surgery is often organized and delivered with short notice and limited time for developing unique strategies for providing care. While some surgical pathologies can be anticipated by the nature of the crisis, the role of foreign medical teams in treating the existing and unmet burden of surgical disease during crises is unclear. The purpose of this study was to examine published data from crises during the years 1990 through 2011 to understand the role of foreign medical teams in providing surgical care in these settings. METHODS: A literature search was completed using PubMed, MEDLINE, and EMBASE databases to locate relevant manuscripts published in peer-reviewed journals. A qualitative review of the surgical activities reported in the studies was performed. RESULTS: Of 185 papers where humanitarian surgical care was provided by a foreign medical team, only 11 articles met inclusion criteria. The reporting of surgical activities varied significantly, and pooled statistical analysis was not possible. The quality of reporting was notably poor, and produced neither reliable estimates of the pattern of surgical consultations nor data on the epidemiology of the burden of surgical diseases. The qualitative trend analysis revealed that the most frequent procedures were related to soft tissue or orthopedic surgery. Procedures such as caesarean sections, hernia repairs, and appendectomies also were common. As length of deployment increased, the surgical caseload became more reflective of the existing, unmet burden of surgical disease. CONCLUSIONS: This review suggests that where foreign medical teams are indicated and requested, multidisciplinary surgical teams capable of providing a range of emergency and essential surgical, and rehabilitation services are required. Standardization of data collection and reporting tools for surgical care are needed to improve the reporting of surgical epidemiology in crisis-affected populations.

Best practice guidelines on surgical response in disasters and humanitarian emergencies: report of the 2011 Humanitarian Action Summit Working Group on Surgical Issues within the Humanitarian Space.

The provision of surgery within humanitarian crises is complex, requiring coordination and cooperation among all stakeholders. During the 2011 Humanitarian Action Summit best practice guidelines were proposed to provide greater accountability and standardization in surgical humanitarian relief efforts. Surgical humanitarian relief planning should occur early and include team selection and preparation, appropriate disaster-specific anticipatory planning, needs assessment, and an awareness of local resources and limitations of cross-cultural project management. Accurate medical record keeping and timely follow-up is important for a transient surgical population. Integration with local health systems is essential and will help facilitate longer term surgical health system strengthening.

Childhood physical abnormalities following paternal exposure to sulfur mustard gas in Iran: a case-control study.

BACKGROUND: Mustard gas, a known chemical weapon, was used during the Iran-Iraq war of 1980-1988. We aimed to determine if exposure to mustard gas among men was significantly associated with abnormalities and disorders among progenies. METHODS: Using a case-control design, we identified all progenies of Sardasht men (exposed group, n = 498), who were born at least nine months after the exposure, compared to age-matched controls in Rabat, a nearby city (non-exposed group, n = 689). We conducted a thorough medical history, physical examination, and appropriate paraclinical studies to detect any physical abnormality and/or disorder. Given the presence of correlated data, we applied Generalized Estimating Equation (GEE) multivariable models to determine associations. RESULTS: The overall frequency of detected physical abnormalities and disorders was significantly higher in the exposed group (19% vs. 11%, Odds Ratio [OR] 1.93, 95% Confidence Interval [CI], 1.37-2.72, P = 0.0002). This was consistent across sexes. Congenital anomalies (OR 3.54, 95% CI, 1.58-7.93, P = 0.002) and asthma (OR, 3.12, 95% CI, 1.43-6.80, P = 0.004) were most commonly associated with exposure. No single abnormality was associated with paternal exposure to mustard gas. CONCLUSION: Our study demonstrates a generational effect of exposure to mustard gas. The lasting effects of mustard gas exposure in parents effects fertility and may impact child health and development in the long-term.

The provision of surgical care by international organizations in developing countries: a preliminary report.

OBJECTIVE: Emerging data demonstrate that a large fraction of the global burden of disease is amenable to surgical intervention. There is a paucity of data related to delivery of surgical care in low- and middle-income countries, and no aggregate data describe the efforts of international organizations to provide surgical care in these settings. This study was designed to describe the roles and practices of international organizations delivering surgical care in developing nations with regard to surgical types and volume, outcomes tracking, and degree of integration with local health systems. METHODS: Between October 2008 and December 2008, an Internet-based confidential questionnaire was distributed to 99 international organizations providing humanitarian surgical care to determine their size, scope, involvement in surgical data collection, and integration into local systems. RESULTS: Forty-six international organizations responded (response rate 46%). Findings reveal that a majority of organizations that provide surgery track numbers of cases performed and immediate outcomes, such as mortality. In general, these groups have mechanisms in place to track volume and outcomes, provide for postintervention follow-up, are committed to providing education, and work in conjunction with local health organizations and providers. Whereas most organizations surveyed provided fewer than 500 surgical procedures annually, more than half had the capacity to provide emergency services. In addition, a great diversity of specialized surgical care was provided, including obstetrics, orthopedic, plastic, and ophthalmologic surgery. CONCLUSIONS: International organizations providing surgical services are diverse in size and breadth of surgical services provided yet, with consistency, provide rudimentary analysis, postoperative follow-up care, and both education and integration of health services at the local level. The role of international organizations in the delivery of surgery is an important index, worthy of further evaluation.

Burden of surgical disease: strategies to manage an existing public health emergency.

The World Health Organization estimates that the burden of surgical disease due to war, self-inflicted injuries, and road traffic incidents will rise dramatically by 2020. During the 2009 Harvard Humanitarian Initiative's Humanitarian Action Summit (HHI/HAS),members of the Burden of Surgical Disease Working Group met to review the state of surgical epidemiology, the unmet global surgical need, and the role international organizations play in filling the surgical gap during humanitarian crises, conflict, and war. An outline of the group's findings and recommendations is provided.

Potential roles of military-specific response to natural disasters -- analysis of the rapid deployment of a mobile surgical team to the 2007 Peruvian earthquake.

The August 2007 earthquake in Peru resulted in the loss of critical health infrastructure and resource capacity. A regionally located United States Military Mobile Surgical Team was deployed and operational within 48 hours. However, a post-mission analysis confirmed a low yield from the military surgical resource. The experience of the team suggests that non-surgical medical, transportation, and logistical resources filled essential gaps in health assessment, evacuation, and essential primary care in an otherwise resource-poor surge response capability. Due to an absence of outcomes data, the true effect of the mission on population health remains unknown. Militaries should focus their disaster response efforts on employment of logistics, primary medical care, and transportation/evacuation. Future response strategies should be evidence-based and incorporate a means of quantifying outcomes.

Application of outcome measures in international humanitarian aid: comparing indices through retrospective analysis of corrective surgical care cases.

It is common for international organizations to provide surgical corrective care to vulnerable populations in developing countries. However, a current worsening of the overall surgical burden of disease in developing countries reflects an increasing lack of sufficient numbers of trained healthcare personnel, and renders outside volunteer assistance more desirable and crucial than ever. Unfortunately, program evaluation and monitoring, including outcome indices and measures of effectiveness, is not measured commonly. In 2005, Operation Smile International implemented an electronic medical record system that helps monitor a number of critical indices during surgical missions that are essential for quality assurance reviews. This record system also provided an opportunity to retrospectively evaluate cases from previous missions. Review of data sets from >8,000 cases in 2005 and 2006 has provided crucial information regarding the priority of surgery, perioperative and operative complications, and surgical program development. The most common procedure provided was unilateral cleft lip repair, followed closely by cleft palate. A majority of these interventions occurred for patients who were older than routinely provided for in the western world. The average child treated had an age:weight ratio at or below the [US] Centers for Disease Control and Prevention (CDC) 50th percentile, with a small percentage falling below the CDC 20th percentile. A majority of children had acceptable levels of hemoglobin, but the relative decreased age:weight ratio nonetheless can reflect mild malnutrition. Complications requiring medical intervention were seen in 1.2% of cases in 2005 and 1.0% in 2006. Thirty percent were reported as anesthesia complications, and 61% reported as surgical complications. One death was reported, but occurred after discharge outside the perioperative period. Complication rates are similar to rates reported in the US and UK and emphasizes the importance of standardization with uniform indices to compare quality performance and equity of care. This study offers an important example of the importance of collecting, analyzing, and reporting measures of effectiveness in all surgical settings.

Burden of surgical disease: does the literature reflect the scope of the international crisis?

BACKGROUND: Little is factually known about the burden of surgical disease and less is known about global surgical provision of care for diseases that may be treated, cured, or palliated by a surgical intervention. Despite the lack of information, surgical interventions are provided by a variety of agencies every day in the developing world. This literature review represents the first published comprehensive review of the global surgical literature. The primary goal was to collect and summarize what has been published on the current global burden of surgical disease and thereby encourage and promote the allocation of further research and resources. METHODS: A systematic review of English language publications on Pubmed or Medline was performed. RESULTS AND CONCLUSIONS: This report summarizes what little is known in terms of numeric estimates for the global burden of surgical disease. Globally, access and availability of surgical care in developing countries remains scarce, but the problem is receiving more attention for the first time in surgical circles. Much work remains in the effort to obtain reliable estimates of the global burden of surgical disease.