The employment of resuscitative endovascular balloon occlusion of the aorta in deployed settings.

BACKGROUND: Resuscitative endovascular balloon occlusion of the aorta (REBOA) has been often used in place of open aortic occlusion for management of hemorrhagic shock in trauma. There is a paucity of data evaluating REBOA usage in military settings. STUDY DESIGN AND METHODS: We queried the Department of Defense Trauma Registry (DODTR) for all cases with at least one intervention or assessment available within the first 72 h after injury between 2007 and 2023. We used relevant procedural codes to identify the use of REBOA within the DODTR, and we used descriptive statistics to characterize its use. RESULTS: We identified 17 cases of REBOA placed in combat settings from 2017 to 2019. The majority of these were placed in the operating room (76%) and in civilian patients (70%). A penetrating mechanism caused the injury in 94% of cases with predominantly the abdomen and extremities having serious injuries. All patients subsequently underwent an exploratory laparotomy after REBOA placement, with moderate numbers of patients having spleen, liver, and small bowel injuries. The majority (82%) of included patients survived to hospital discharge. DISCUSSION: We describe 17 cases of REBOA within the DODTR from 2007 to 2023, adding to the limited documentation of patients undergoing REBOA in military settings. We identified patterns of injury in line with previous studies of patients undergoing REBOA in military settings. In this small sample of military casualties, we observed a high survival rate.

Association of Prehospital Neck Wound Survivability and Battlefield Medical Evacuation Time in Afghanistan.

INTRODUCTION: The U.S. Military's Golden Hour policy led to improved warfighter survivability during the Global War on Terror. The policy's success is well-documented, but a categorical evaluation and stratification of medical evacuation (MEDEVAC) times based on combat injury is lacking. METHODS: We queried the Department of Defense Joint Trauma System Prehospital Trauma Registry for casualties with documented penetrating neck trauma in Afghanistan requiring battlefield MEDEVAC from June 15, 2009, through February 1, 2021. Casualties were excluded if the time from the point of injury to reach higher level medical care was not documented, listed as zero, or exceeded 4 hours. They were also excluded if demographic data were incomplete or deemed unreliable or if their injuries occurred outside of Afghanistan.We designed a logistic regression model to test for associations in survivability, adjusting for composite injury severity score, patient age group, and type of next higher level of care reached. We then used our model to interpolate MEDEVAC times associated with 0.1%, 1%, and 10% increased risk of death for an incapacitated casualty with penetrating neck trauma. RESULTS: Of 1,147 encounters, 444 casualties met inclusion criteria. Of these casualties, 430 (96.9%) survived to discharge. Interpolative analysis of our multivariable logistic regression model showed that MEDEVAC times ≥8 minutes, ≥53 minutes, and ≥196 minutes are associated with a 0.1%, 1%, and 10% increased risk of mortality from baseline, respectively. CONCLUSIONS: Our data characterize the maximum MEDEVAC times associated with 0.1%, 1%, and 10% increased risk of death from baseline survivability for penetrating battlefield neck trauma in Afghanistan.

Content Validation of an Emergency Department Skin Risk Assessment Instrument.

Pressure injuries (PIs) are an important quality and patient safety metric for health care organizations. PI monitoring and treatment are often overlooked in the emergency department (ED). Emergency care professionals must be proactive about PI early identification and prevention strategies. A team at a Level 1 trauma center recognized the need for ED-friendly documentation and a validated ED skin risk assessment instrument. The Bjorklund 25-item ED Skin/Risk Assessment Tool was selected. However, because the tool was not fully validated, permission to validate/use was obtained from the author. The purpose of this research study was to determine the content validity of the Bjorklund Tool. Using a prospective survey design, content experts were recruited from wound, quality, and ED and participated in two rounds of content validation. The experts reviewed the Tool for relevance, clarity, and appropriateness for the ED population. Item-level content validity index (I-CVI) and scale-level CVI (S-CVI) were calculated, with 0.78 and 0.90 as the lower limits of acceptability for individual items and the overall scale, respectively. Of the first round I-CVI ratings, 24 of 75 were below 0.78, including 14 for relevance, four for clarity, and six for appropriateness. S-CVI was 0.7574 for relevance, 0.8809 for clarity, 0.8592 for appropriateness, and 0.8325 overall. The Bjorklund Tool was determined to be invalid in its current form. A novel tool was thus created in the second round per content experts' recommendations. After redesign and simplifying items and images, all I-CVIs rated above 0.78. S-CVI was 0.923 for relevance, 0.9743 for clarity, 0.9615 for appropriateness, and 0.9529 overall. These CVIs indicate excellent content validity of the new UCHealth ED Skin Risk Assessment Instrument. This research contributes to establishment of content validity of a skin risk assessment instrument which can be used in the unique ED setting.

Market Analysis of Video Laryngoscopy Equipment for the Role 1 Setting.

INTRODUCTION: Airway compromise is the second leading cause of potentially preventable prehospital combat death. Endotracheal intubation (ETI) remains the most common role 1 airway intervention. Video laryngoscopy (VL) is superior to direct laryngoscopy (DL) for first-attempt intubation, especially in less-experienced providers and for trauma patients. The cost has been a major challenge in pushing VL technology far-forward; however, the cost of equipment continues to become more affordable. We conducted a market analysis of VL devices under $10,000 for possible options for role 1. MATERIALS AND METHODS: We searched Google, PubMed, and the Food and Drug Administration database from August 2022 to January 2023 with a combination of several keywords to identify current VL market options under $10,000. After identifying relevant manufacturers, we then reviewed individual manufacturer or distributor websites for pricing data and system specifications. We noted several characteristics regarding VL device design for comparison. These include monitor features, size, modularity, system durability, battery life, and reusability. When necessary, we requested formal price quotes from respective companies. RESULTS: We identified 17 VL options under $10,000 available for purchase, 14 of which were priced below $5,000 for individual units. Infium (n = 3) and Vimed Medical (n = 4) provided the largest number of unique models. VL options under $10,000 exist in both reusable and disposable modalities. These modalities included separate monitors as well as monitors attached to the VL handle. Disposable options, on a per-unit basis, cost less than reusable options. CONCLUSIONS: Several VL options exist within our goal price point in both reusable and disposable options. Clinical studies assessing the technology performance of ETI and deliberate downselection are needed to identify the most cost-effective solution for role 1 dispersion.

Suicide Ideation, Plans, and Attempts Attributed to the COVID-19 Pandemic Among US Veterans.

This cross-sectional study analyzes data from the 2021 National Survey on Drug Use and Health to assess whether suicidal experiences among US veterans are associated with the COVID-19 pandemic.

Prehospital Pharmacotherapy in Moderate and Severe Traumatic Brain Injury: A Systematic Review.

BACKGROUND: Traumatic brain injury (TBI) affects civilian and military populations with high morbidity and mortality rates and devastating sequelae. As the US military shifts its operational paradigm to prepare for future large-scale combat operations, the need for prolonged casualty care is expected to intensify. Identifying efficacious prehospital TBI management strategies is therefore vital. Numerous pharmacotherapies are beneficial in the inpatient management of TBI, including beta blockers, calcium channel blockers, statins, and other agents. However, their utility in prehospital management of moderate or severe TBI is not well understood. We performed a systematic review to elucidate agents of potential prehospital benefit in moderate and severe TBI. METHODS: We searched 6 databases from January 2000 through December 2021 without limitations in outcome metrics using a variety of search terms designed to encapsulate all studies pertaining to prehospital TBI management. We identified 2,142 unique articles, which netted 114 studies for full review. Seven studies met stringent inclusion criteria for our aims. RESULTS: Studies meeting inclusion criteria assessed tranexamic acid (TXA) (n=6) and ethanol (n=1). Of the TXA studies, 3 were randomized controlled trials, 2 were retrospective cohort studies, 1 was a prospective cohort study, and 1 was a meta-analysis. Notably absent were papers investigating therapeutics shown to be beneficial in inpatient hospital treatment of TBI. Overall, data suggest TXA administration is potentially beneficial in moderate or severe TBI with or without intracranial hemorrhage. Severe TBI with or without penetrating trauma was associated with worse overall outcomes, regardless of TXA use. CONCLUSION: Effective interventions for treating moderate or severe TBI are lacking. TXA is the most widely studied pharmacologic intervention and appears to offer some benefit without adverse effects in moderate TBI (with or without intracranial hemorrhage) in the pre-hospital setting despite heterogeneous results. Limitations of these studies include heterogeneity in outcome metrics, patient populations, and circumstances of TXA use. We identified a gap in the literature in translating agents with demonstrated inpatient benefit to the prehospital setting. Further investigation into these and other novel therapeutic options in the prehospital arena is crucial to improving clinical outcomes in TBI.

Military Medical Role in Civilian Disaster.

US military medical units have responded to natural disasters (eg, hurricanes, earthquakes), relieved overwhelmed civilian health care systems (eg, during the COVID-19 pandemic), and provided support to stabilization efforts after civil unrest. The military will continue to assist civilian agencies with future medical response to similar disasters, contagious outbreaks, or even terrorist attacks. The keys to an effective disaster response are unity of effort, prior coordination, and iterative practice during military-civilian exercises to identify strengths and areas of improvement. Critical care advanced practice nurses are likely to work concurrently with military medical colleagues in multiple scenarios in the future; therefore, it is important for these nurses to understand the capacities and limitations of military medical assets. This article describes the capabilities and collaboration needed between civilian and military medical assets during a variety of disaster scenarios.

An Assessment of Nursing Skills Required for Sustaining a Casualty during Prolonged Casualty Care: Implications for Training and Preparing for the Next Major War.

BACKGROUND: The US military is transitioning rapidly from the Global War on Terrorism in preparation for near-peer combat in a multidomain operations (MDO) and/or large scale combat operations (LSCO) setting. Due to potentially contested freedom of movement in this setting, casualty evacuation may be significantly delayed, resulting in medics and other prehospital medical personnel taking on patient care duties normally performed by nurses in a hospital-based setting. However, the frequency of nursing-type care remains unclear. We seek to determine the nursing interventions typically performed in a facility with patient holding capability during the first 72 hours of care in the deployed setting. MATERIALS AND METHODS: This is a sub-analysis of previously described data from the Department of Defense Trauma Registry of US and North Atlantic Treaty Organization (NATO) military personnel from January 2007 to March 2020 with a focus on relevant nursing procedures identified in current Individual Critical Task Lists (ICTL) for critical care, emergency, medical-surgical nurses, and combat medics. RESULTS: Among all casualties, the most common nursing-related skills performed in the prehospital setting were wound dressing application (33%), administration of parenteral opioids (35%), and administration of ketamine (7%); in the hospital setting were preparation for transfer (60%), managing a post-operative patient (59%), and managing a traumatic brain injury (44%). In the hospital setting, most patients had a blood gas performed (73%), ventilator management occurred for 21% of patients, and administration of packed red blood cells occurred for 21% of patients. CONCLUSIONS: Nursing-type interventions were frequently required during the first 72 hours of casualty care. The frequency of the required interventions demonstrates the need for ongoing nursing skills training for medics supporting casualties in the setting of prolonged casualty care.

Blood Product Administration During the Role 1 Phase of Care: The Prehospital Trauma Registry Experience.

BACKGROUND: The majority of combat deaths occur in the prehospital setting. Efforts to increase survival including blood transfusions are made in the prehospital setting. The blood products available in the Role 1 setting include whole blood (WB), red blood cells (RBCs), fresh frozen plasma (FFP), and lyophilized (freeze-dried) plasma (FDP). METHODS: This is a secondary analysis of a previously published dataset within the Prehospital Trauma Registry (PHTR) from 2003 through May 2019. Deterministic linking was used when possible with the DoD Trauma Registry for outcome data. Descriptive statistics were used to analyze the data. RESULTS: We identified 1,357 patient encounters in the PHTR. Within that group, 28 patients received a prehospital blood product, with 41 total administrations: WB (18), RBCs (12), FFP (6), FDP (3), and blood not otherwise specified (2). Outcome data were available for 17 of the 28 patients. The median injury severity score was 20, with the thorax being the most frequent seriously injured body region. Most (94%) patients survived to discharge. The median ICU days was 11 (Interquartile Range [IQR] 3-19), and the median hospital days was 19 (IQR 8-29). The average volume (units) of RBCs was 6.0 (95% CI 1.9-10.1), WB 2.8 (95% CI 0.0-5.6), platelets 0.7 (95% CI 0.0-1.4), and FFP 5.0 (95% CI 1.2-8.8). CONCLUSIONS: The use of prehospital blood products is uncommon in U.S. combat settings. Patients who received blood products sustained severe injuries but had a high survival rate. Given the infrequent but critical use and potentially increased need for adequate prolonged casualty care in future near-peer conflicts, optimizing logistical chain circulation is required.

Characterizing pediatric supermassive transfusion and the contributing injury patterns in the combat environment.

BACKGROUND: Trauma is the leading cause of pediatric mortality in the United States. Often, these patients require supermassive transfusion (SMT), which we define as receipt of >80 mL/kg blood products, double the proposed volume for standard pediatric massive transfusion (MT). Evaluating the blood volumes, injury patterns, clinical findings, and prehospital interventions predictive for SMT are critical to reducing pediatric mortality. We describe the pediatric casualties, injury patterns, and clinical findings that comprise SMT. METHODS: We retrospectively analyzed pediatric trauma data from the Department of Defense Trauma Registry from January 2007-2016. We stratified patients into two cohorts based on blood products received in the first 24 h after injury: 1) those who received 40-80 mL/kg (MT), or 2) those who received >80 mL/kg (SMT). We evaluated demographics, injury patterns, prehospital interventions, and clinical findings. RESULTS: Our original dataset included 3439 pediatric casualties. We identified 536 patients who met inclusion parameters (receipt of ≥40 mL/kg of blood products [whole blood, packed red blood cells, fresh frozen plasma, platelets, or cryoprecipitate]). The MT cohort included 271 patients (50.6%), and the SMT cohort comprised 265 patients (49.4%). Survival to discharge was significantly lower (78% for SMT, 86% for MT; p < 0.011) in the SMT cohort. Multivariable analysis of injury patterns revealed serious injuries (Abbreviated Injury Scale 3-6) to the extremities (OR 2.13, 95% CI 1.45-3.12) and abdomen (OR 1.65, 1.08-2.53) were associated with SMT. Wound dressings (41% versus 29%; p = 0.003), tourniquets (23% vs 12%; p = 0.001), and IO access (17% vs 10%; p = 0.013) were more common in the SMT group. Age-adjusted hypotension was significantly higher in the SMT group (41%, n = 100 vs 23%, n = 59; p < 0.001) with no statistical difference detected in tachycardia (87%, n = 223 vs 87%, n = 228; p = 0.932). CONCLUSIONS: Our research demonstrates that pediatric SMT patients are at increased risk of mortality. Our study highlights the seriousness of extremity injuries in pediatric trauma patients, identifying associations between severe injuries to the extremities and abdomen with the receipt of SMT. Prehospital interventions of wound dressing, tourniquets, and IO access were more frequent in the SMT cohort. Our research determined that hypotension was associated with SMT, but tachycardia was not a reliable predictor of SMT over MT.

A Descriptive Analysis of Battlefield First Responder and Combat Lifesaver Interventions during the Role 1 Phase of Care.

BACKGROUND: Battlefield first responders (BFR) are the first non-medical personnel to render critical lifesaving interventions for combat casualties, especially for massive hemorrhage where rapid control will improve survival. Soldiers receive medical instruction during initial entry training (IET) and unit-dependent medical training, and by attending the Combat Lifesaver (CLS) course. We seek to describe the interventions performed by BFRs on casualties with only BFRs listed in their chain of care within the Prehospital Trauma Registry (PHTR). METHODS: This is a secondary analysis of a dataset from the PHTR from 2003-2019. We excluded encounters with a documented medical officer, medic, or unknown prehospital provider at any time in their chain of care during the Role 1 phase to isolate only casualties with BFR medical care. RESULTS: Of the 1,357 encounters in our initial dataset, we identified 29 casualties that met inclusion criteria. Pressure dressing was the most common intervention (n=12), followed by limb tourniquets (n=4), IV fluids (n=3), hemostatic gauze (n=2), and wound packing (n=2). Bag-valve-masks, chest seals, extremity splints, and nasopharyngeal airways (NPA) were also used (n=1 each). Notably absent were backboards, blizzard blankets, cervical collars, eye shields, pelvic splints, hypothermia kits, chest tubes, supraglottic airways (SGA), intraosseous (I/O) lines, and needle decompression (NDC). CONCLUSIONS: Despite limited training, BFRs employ vital medical skills in the prehospital setting. Our data show that BFRs largely perform medical interventions within the scope of their medical knowledge and training. Better datasets with efficacy and complication data are needed.

Virtual Reality-Based Resilience Programs: Feasibility and Implementation for Inpatient Oncology Nurses.

The high prevalence of compassion fatigue contributes to burnout among oncology nurses. Interventions are needed to support individuals across diverse roles and practice settings in oncology. Virtual reality (VR) is an emerging technology that has been applied in healthcare education and training and is being explored as an intervention to reduce stress and support wellness for healthcare providers. This article reviews recommendations from an implementation project about a VR intervention for oncology nurses.

En Route Resuscitation - Utilization of CCATT to Transport and Stabilize Critically Injured and Unstable Casualties.

INTRODUCTION: The U.S. Air Force utilizes specialized Critical Care Air Transport Teams (CCATT) for transporting "stabilized" patients. Given the drawdown of military forces from various areas of operation, recent CCATT operations have increasingly involved the evacuation of unstable and incompletely resuscitated patients from far forward, austere locations. This brief report describes unique cases representative of the evolving CCATT mission and provides future direction for changes in doctrine and educational requirements in preparation for en route combat casualty care. METHODS AND MATERIALS: This case series describes three patients who required significant resuscitation during CCATT transport from austere locations between April and November 2017. Approval for this project was received from the US Air Force 59th Medical Wing Institutional Review Board as non-research. RESULTS: Case 1: CCATT was dispatched to transport patient 1 who was reported to have a head injury after a fall. Upon evaluation of the patient onboard the aircraft, it was discovered that the patient was in cardiac arrest. Cardiopulmonary resuscitation was performed during tactical takeoff with frequent combat maneuvers. The patient developed a palpable pulse after three rounds of CPR, three doses of epinephrine, and one unit of packed red blood cells. Point of care laboratory analysis demonstrated a profoundly elevated lactate level. Cyanide poisoning was a concern but there was no antidote available in the available equipment set. After delivery to a medical facility, blood samples were positive for cyanide. Over the next 2 weeks, the patient improved and was discharged home, neurologically intact. Case 2: Patient 2 sustained complex blast injuries and bilateral lower extremity amputations. He required early transport for continuous renal replacement therapy (CRRT). The patient received 200 units of blood products in the 24 hours prior to transport and developed renal failure, pulmonary edema, and elevated ICP. During the 7 hour flight, Patient 2 received frequent adjustments of vasopressor medications, multiple Dakins solution soaks and flushes, and 1 unit of fresh frozen plasma. He remained alive 2 months later. Case 3: The team was notified to collect an urgent patient with a blast lung injury and bilateral lower extremity amputations. The ground team encountered difficulty ventilating the patient. Patient 3 arrived in the back of a pickup truck accompanied by medics and being bag valve mask ventilated with a pulse oximetry reading of 65%. He was secured to the floor of the aircraft which departed within 5 minutes of arrival. An ultrasound of the lungs showed no pneumothorax. By the end of the flight, the patient's oxygen saturation had risen to 95% and he was delivered to the emergency department in stable condition. He later passed away in the operating room due to severe blast lung and cardiac contusion. CONCLUSION: This brief report demonstrates the need of CCATT in the transport of unstable patients from forward deployed locations. The Air Force has adapted and is continuing to adapt CCATT training, equipment, onboard diagnostics and therapies, and team members' clinical skills to meet en route care combat casualty needs.

Above, Beyond, and Over the Side rails: Evaluating the New Memorial Emergency Department Fall-Risk-Assessment Tool.

INTRODUCTION: Patient falls are a significant issue in hospitalized patients and financially costly to hospitals. The Joint Commission requires that patients be assessed for fall risk and interventions in place to mitigate the risk of falls. It is imperative to have a patient population/setting specific fall risk assessment tool to identify patients at risk for falling. The purpose of this study was to evaluate the reliability and validity of the 2013 Memorial ED Fall Risk Assessment tool (MEDFRAT) specifically designed for the ED population. METHOD: A two-phase prospective design was used for this study. Phase one determined the interrater reliability of the MEDFRAT. Phase two assessed the validity of the MEDFRAT in an emergency department (ED) within a 600-bed academic/teaching institution; Level II Trauma Center with >100,000 annual patient visits. RESULTS: The Memorial ED Fall Risk Assessment Tool was validated in this ED setting. The tool demonstrated positive interrater reliability (k=0.701) and when implemented with a falls prevention strategy and staff education demonstrated a 48% decrease in ED fall rate (0.57 falls/1000 patient visits) post implementation during the study period. DISCUSSION: The MEDFRAT, an evidenced based ED-specific fall risk tool was implemented on the basis of the risk factors consistently identified in the literature: prior fall history, impaired mobility, altered mental status, altered elimination, and the use of sedative medication. The Memorial ED Fall Risk Assessment Tool demonstrated to be a valid tool for this hospital system.

Guideline-Driven Care Improves Outcomes in Patients with Traumatic Rib Fractures.

There is no established national standard for rib fracture management. A clinical practice guideline (CPG) for rib fractures, including monitoring of pulmonary function, early initiation of aggressive loco-regional analgesia, and early identification of deteriorating respiratory function, was implemented in 2013. The objective of the study was to evaluate the effect of the CPG on hospital length of stay. Hospital length of stay (LOS) was compared for adult patients admitted to the hospital with rib fracture(s) two years before and two years after CPG implementation. A separate analysis was done for the patients admitted to the intensive care unit (ICU). Over the 48-month study period, 571 patients met inclusion criteria for the study. Pre-CPG and CPG study groups were well matched with few differences. Multivariable regression did not demonstrate a difference in LOS (B = -0.838; P = 0.095) in the total study cohort. In the ICU cohort (n = 274), patients in the CPG group were older (57 vs 52 years; P = 0.023) and had more rib fractures (4 vs 3; P = 0.003). Multivariable regression identified a significant decrease in LOS for those patients admitted in the CPG period (B = -2.29; P = 0.019). Despite being significantly older with more rib fractures in the ICU cohort, patients admitted after implementation of the CPG had a significantly reduced LOS on multivariable analysis, reducing LOS by over two days. This structured intervention can limit narcotic usage, improve pulmonary function, and decrease LOS in the most injured patients with chest trauma.

Treating Decompression Sickness: Military Flight Simulation Site-Community Hospital Partnership.

BACKGROUND: High-altitude flight simulation familiarizes military trainees with the symptoms of hypoxia to prepare them for emergency situations. Decompression sickness (DCS) can occur as a result of these simulations. In cases when ground-level supplemental oxygen does not resolve symptoms, hyperbaric oxygen (HBO) therapy is indicated. Many military hyperbaric chambers have been closed because of cost reductions, necessitating partnerships with community hospitals to ensure access to treatment. MATERIALS AND METHODS: This article describes the unique arrangement between a community hospital in Colorado and a military training site to treat DCS cases emergently. We gathered cost data from the community hospital to estimate and compare the cost of providing HBO therapy in the hospital versus a standalone chamber similar to the former military hyperbaric chamber. RESULTS: Since the closure of the military hyperbaric chamber, the community hospital treated an estimated 50 patients with DCS requiring HBO therapy attributed to high-altitude flight simulation between October 2003 and April 2015. Cost to the institution providing HBO treatment varies widely on the basis of patient volume. Assuming a volume of five treatments, per-treatment cost at a standalone center is $95,380. In contrast, per-treatment cost at the hospital assuming a volume of 1,000 treatments commensurate with the hospital's ability to bill for other services is $698 per treatment. CONCLUSION: The cost analysis demonstrates that the per-treatment cost of operating a standalone HBO therapy center may be greater than 100 times that of operating a center at a community hospital, suggesting the arrangement is beneficial to the military.

Community Implementation of a Prehospital Spinal Immobilization Guideline.

OBJECTIVE: The purpose of this study was to qualitatively describe the underpinnings of the successful implementation of a collaborative prehospital spinal immobilization guideline throughout the emergency medical services (EMS) community in two counties in Colorado. We also describe lessons learned that may be beneficial to other communities considering similar initiatives. METHODS: Qualitative data were collected from key informants who were directly involved in the implementation of a new prehospital spinal immobilization guideline among four community hospitals in two different hospital systems and the associated EMS providers within the two counties. We interviewed a purposively selected sample of emergency department (ED) physicians and other ED staff, hospital decision makers, EMS educators as well as fire department and EMS medical directors. Data were collected and reviewed until saturation was achieved. We conducted qualitative analysis to summarize and synthesize themes. RESULTS: Ten key informants were interviewed, at which point saturation was achieved and several clear themes emerged. Participants described successful community-wide guideline implementation despite a history of competition, isolation, and conflict between the various EMS organizations and hospitals on past EMS and trauma initiatives. Factors related to success included the nearly universal perception that the initiative was "cutting edge" and thus an important paradigm shift in care for the community, as a whole. Participants reported the ability of community stakeholders to jointly assure a collaborative approach, characterized by intensive education for EMS personnel and others involved, and the ability of the community to together secure the new equipment required for success. CONCLUSIONS: Key informants described a convergence of factors as leading to the successful implementation of a prehospital spinal immobilization guideline. Lessons learned regarding how to overcome a tradition of competition and isolation to allow for success may be useful to other communities considering similar initiatives.

Intervening to Improve Compassion Fatigue Resiliency in Forensic Nurses.

Evidence suggests that forensic nurses (FNs) may be predisposed to compassion fatigue (CF) as a result of the challenges of the profession including high caseloads, role ambiguity, prosecution goals, vicarious traumatization, attending to survivors' emotional needs, and empowering victims. The purpose of this exploratory study was to determine the prevalence of CF in a convenience sample of 55 FNs and examine the treatment effectiveness of a multifaceted education program in an intervention subset. The intervention was intended to increase compassion satisfaction (CS) and decrease CF symptoms in FNs in one organization who participated in the training. The hypothesis was that the FNs will have moderate to high CF and moderate to high CS and the CF intervention will add in CF prevention and resiliency as measured with an improvement in the Professional Quality of Life test scores (B. H. ). In the prevalence sample, 69% of the FNs had moderate to low CS, 73% had moderate to high burnout, and 73% had moderate to high levels of secondary traumatic stress (STS). In the intervention group, the education program resulted in a statistically significant increase in CS and decreases in STS symptoms.