Exposure to a Virtual Reality Mass-Casualty Simulation Elicits a Differential Sympathetic Response in Medical Trainees and Attending Physicians.

BACKGROUND: Previous studies have demonstrated the use of virtual reality (VR) in mass-casualty incident (MCI) simulation; however, it is uncertain if VR simulations can be a substitute for in-person disaster training. Demonstrating that VR MCI scenarios can elicit the same desired stress response achieved in live-action exercises is a first step in showing non-inferiority. The primary objective of this study was to measure changes in sympathetic nervous system (SNS) response via a decrease in heart rate variability (HRV) in subjects participating in a VR MCI scenario. METHODS: An MCI simulation was filmed with a 360º camera and shown to participants on a VR headset while simultaneously recording electrocardiography (EKG) and HRV activity. Baseline HRV was measured during a calm VR scenario immediately prior to exposure to the MCI scenarios, and SNS activation was captured as a decrease in HRV compared to baseline. Cognitive stress was measured using a validated questionnaire. Wilcoxon matched pairs signed rank analysis, Welch's t-test, and multivariate logistic regression were performed with statistical significance established at P <.05. RESULTS: Thirty-five subjects were enrolled: eight attending physicians (two surgeons, six Emergency Medicine [EM] specialists); 13 residents (five Surgery, eight EM); and 14 medical students (six pre-clinical, eight clinical-year students). Sympathetic nervous system activation was observed in all groups during the MCI compared to baseline (P <.0001) and occurred independent of age, sex, years of experience, or prior MCI response experience. Overall, 23/35 subjects (65.7%) reported increased cognitive stress in the MCI (11/14 medical students, 9/13 residents, and 3/8 attendings). Resident and attending physicians had higher odds of discordance between SNS activation and cognitive stress compared to medical students (OR = 8.297; 95% CI, 1.408-64.60; P = .030). CONCLUSIONS: Live-actor VR MCI simulation elicited a strong sympathetic response across all groups. Thus, VR MCI training has the potential to guide acquisition of confidence in disaster response.

Disasters on campus: A cross-sectional survey of college EMS systems' preparedness to respond to mass casualty incidents.

OBJECTIVE: The objective of this study was to assess the training and readiness levels of Collegiate Emergency Medical Service (EMS) providers to respond to mass casualty incidents (MCIs). METHODS: An anonymous cross-sectional survey of Collegiate EMS providers was performed. PARTICIPANTS: Participants were US-based EMS providers affiliated with the National Collegiate Emergency Medical Services Foundation. OUTCOME MEASURES: The main outcome measures were levels of EMS experience and MCI training, subjective readiness levels for responding to various MCI scenarios, and analyzing the effect of the COVID-19 pandemic on MCI response capabilities. RESULTS: Respondents had a median age of 21 years (interquartile range IQR 20, 22), with 86 percent (n = 96/112) being trained to the Emergency Medical Technician-Basic level. Providers reported participating in an average of 1.6 MCI trainings over the last four years (IQR, 1.0, 2.2). Subjective MCI response readiness levels were highest with active assailant attacks followed by large event evacuations, natural disasters, hazardous material (HAZMAT) incidents, targeted automobile ramming attacks, explosions, and finally bioweapons release. Disparate to this, only 18 percent of participants reported training in the fundamentals of tactical and disaster medicine. With respect to the effect of the COVID-19 pandemic on MCI readiness, 27 percent of respondents reported being less prepared, and there was a statistically significant decrease in subjective readiness to respond to HAZMAT incidents. CONCLUSION: Given low rates of MCI training but high rates of self-assessed MCI preparedness, respondents may overestimate their readiness to adequately respond to the complexity of a real-world MCI. More objective assessment measures are needed to evaluate provider preparedness.

Healthcare Challenges in the Era of Cybersecurity.

As a result of the extensive integration of technology into the healthcare system, cybersecurity incidents have become an increasing challenge for the healthcare industry. Recent examples include WannaCry, a nontargeted ransomware attack on more than 150 countries worldwide that temporarily crippled parts of the National Health Service in the United Kingdom, and the 2016 ransomware attack on Los Angeles's Hollywood Presbyterian Medical Center. The attacks cost millions of dollars in lost revenue and fines, as well as significant reputational damage. Efforts are needed to devise tools that allow experts to more accurately quantify the actual impact of such events on both individual patients and healthcare systems as a whole. While the United States has robust disaster preparedness and response systems integrated throughout the healthcare and government sectors, the rapidly evolving cybersecurity threat against healthcare entities is outpacing existing countermeasures and challenges in the "all-hazards" disaster preparedness paradigm. Further epidemiologic research of clinical cybersecurity attacks and their effects on patient care and clinical outcomes is necessary to prevent and mitigate future attacks.

Report from the COVID-19 Virtual Summit, Disaster Experts Speak Out, March 31, 2020.

This article captures the webinar narrative on March 31, 2020 of four expert panelists addressing three questions on the current coronavirus disease 2019 (COVID-19) pandemic. Each panelist was selected for their unique personal expertise, ranging from front-line emergency physicians from multiple countries, an international media personality, former director of the US Strategic National Stockpile, and one of the foremost international experts in disaster medicine and public policy. The forum was moderated by one of the most widely recognized disaster medical experts in the world. The four panelists were asked three questions regarding the current pandemic as follows:1.What do you see as a particular issue of concern during the current pandemic?2.What do you see as a particular strength during the current pandemic?3.If you could change one thing about the way that the pandemic response is occurring, what would you change?

Preparation and response to a targeted automobile ramming mass casualty (TARMAC) attack: An analysis of the 2017 Charlottesville, Virginia TARMAC attack.

Targeted automobile ramming mass casualty (TARMAC) attacks have recently become a common modality for those wishing to inflict mass harm. Intentional vehicular ramming is a unique wounding mechanism and deserves special consideration. An emergency response case analysis of the 2017 TARMAC attack in Charlottesville was conducted to review preparedness and identify shortcomings at the University of Virginia Health System University Hospital. Intentional mass blunt trauma is unique to TARMAC events, and current all-hazards approach preparedness may not suffice. TARMAC attacks warrant further attention by disaster medicine specialists; with adequate data, researchers may identify injury patterns and "lessons learned" that may improve mitigation strategies, provider preparation, and overall emergency care.

The utility of point-of-care ultrasound in targeted automobile ramming mass casualty (TARMAC) attacks.

As terrorist actors revise their tactics to outmaneuver increasing counter-terrorism security measures, a recent trend toward less-sophisticated attack methods has emerged. Most notable of these "low tech" trends are the Targeted Automobile Ramming MAss Casualty (TARMAC) attacks. Between 2014 and November 2017, 18 TARMAC attacks were reported worldwide, resulting in 181 deaths and 679 injuries. TARMAC attack-related injuries are unique compared to accidental pedestrian trauma and other causes of mass casualty incidents (MCI), and therefore they require special consideration. No other intentional mass casualty scenario is the result of a blunt, non-penetrating trauma mechanism. Direct vehicle impact results in high-power injuries including blunt trauma to the central nervous system (CNS), and thoracoabdominal organs with crush injuries if the victims are run over. Adopting new strategies and using existing technology to diagnose and treat MCI victims with these injury patterns will save lives and limit morbidity. Point-of-care ultrasound (POCUS) is one such technology, and its efficacy during MCI response is receiving an increasing amount of attention. Ultrasound machines are becoming increasingly available to emergency care providers and can be critically important during a MCI when access to other imaging modalities is limited by patient volume. By taking ultrasound diagnostic techniques validated for the detection of life-threatening cardiothoracic and abdominal injuries in individuals and applying them in a TARMAC mass casualty situation, physicians can improve triage and allocate resources more effectively. Here, we revisit the high-yield applications of POCUS as a means of enhanced prehospital and hospital-based triage, improved resource utilization, and identify their potential effectiveness during a TARMAC incident.

Misrepresentation of scholarly works by integrated plastic surgery applicants.

BACKGROUND: Many authors report alarming rates of false or questionable claims of scholarly achievement among residency applicants. The authors sought to further elucidate the authenticity of such inappropriate declarations by simultaneously conducting an investigation of a selected pool of integrated plastic surgery applicants. The authors' hypothesis is that the percentage of citations claimed by many authors to be false was erroneously high because of failure of an adequate search or prolonged time from submission to publication for many journals. METHODS: Applications received by the University of Michigan Integrated Plastic Surgery Residency Program for the 2008 National Residency Match Program match were reviewed 2 years after being submitted by the applicants. Scholarly works listed as published, accepted, or in-press, including journal articles, abstracts, and book chapters, were investigated. Those listed as submitted were excluded. An exhaustive search was conducted that included PubMed, Google Scholar, Ovid UM-MedSearch, hardcopy journals in the authors' medical library, and phone calls to regional societies. RESULTS: The authors' sample represented 63 percent of all integrated plastic surgery applicants for the 2008 National Residency Match Program, which included 102 applicants citing 342 scholarly works. Of these, 319 (93 percent) were verified. Of the remaining 23 citations, 15 (4 percent) by seven applicants (7 percent) were unverifiable, whereas eight (2 percent) by seven applicants were confirmed as misrepresentations. CONCLUSIONS: The majority (93 to 98 percent) of integrated plastic surgery applicants are truthful regarding scholarly achievement. Applicants should be given the benefit of the doubt and the opportunity to confirm their claims when we cannot.