A Pilot Randomized Controlled Trial of Augmented Reality Just-in-Time Guidance for the Performance of Rugged Field Procedures.

INTRODUCTION: Medical resuscitations in rugged prehospital settings require emergency personnel to perform high-risk procedures in low-resource conditions. Just-in-Time Guidance (JITG) utilizing augmented reality (AR) guidance may be a solution. There is little literature on the utility of AR-mediated JITG tools for facilitating the performance of emergent field care. STUDY OBJECTIVE: The objective of this study was to investigate the feasibility and efficacy of a novel AR-mediated JITG tool for emergency field procedures. METHODS: Emergency medical technician-basic (EMT-B) and paramedic cohorts were randomized to either video training (control) or JITG-AR guidance (intervention) groups for performing bag-valve-mask (BVM) ventilation, intraosseous (IO) line placement, and needle-decompression (Needle-d) in a medium-fidelity simulation environment. For the interventional condition, subjects used an AR technology platform to perform the tasks. The primary outcome was participant task performance; the secondary outcomes were participant-reported acceptability. Participant task score, task time, and acceptability ratings were reported descriptively and compared between the control and intervention groups using chi-square analysis for binary variables and unpaired t-testing for continuous variables. RESULTS: Sixty participants were enrolled (mean age 34.8 years; 72% male). In the EMT-B cohort, there was no difference in average task performance score between the control and JITG groups for the BVM and IO tasks; however, the control group had higher performance scores for the Needle-d task (mean score difference 22%; P = .01). In the paramedic cohort, there was no difference in performance scores between the control and JITG group for the BVM and Needle-d tasks, but the control group had higher task scores for the IO task (mean score difference 23%; P = .01). For all task and participant types, the control group performed tasks more quickly than in the JITG group. There was no difference in participant usability or usefulness ratings between the JITG or control conditions for any of the tasks, although paramedics reported they were less likely to use the JITG equipment again (mean difference 1.96 rating points; P = .02). CONCLUSIONS: This study demonstrated preliminary evidence that AR-mediated guidance for emergency medical procedures is feasible and acceptable. These observations, coupled with AR's promise for real-time interaction and on-going technological advancements, suggest the potential for this modality in training and practice that justifies future investigation.

The 2023 Model Core Content of Disaster Medicine.

INTRODUCTION: Disaster Medicine (DM) is the clinical specialty whose expertise includes the care and management of patients and populations outside conventional care protocols. While traditional standards of care assume the availability of adequate resources, DM practitioners operate in situations where resources are not adequate, necessitating a modification in practice. While prior academic efforts have succeeded in developing a list of core disaster competencies for emergency medicine residency programs, international fellowships, and affiliated health care providers, no official standardized curriculum or consensus has yet been published to date for DM fellowship programs based in the United States. STUDY OBJECTIVE: The objective of this work is to define the core curriculum for DM physician fellowships in the United States, drawing consensus among existing DM fellowship directors. METHODS: A panel of DM experts was created from the members of the Council of Disaster Medicine Fellowship Directors. This council is an independent group of DM fellowship directors in the United States that have met annually at the American College of Emergency Physicians (ACEP)'s Scientific Assembly for the last eight years with meeting support from the Disaster Preparedness and Response Committee. Using a modified Delphi technique, the panel members revised and expanded on the existing Society of Academic Emergency Medicine (SAEM) DM fellowship curriculum, with the final draft being ratified by an anonymous vote. Multiple publications were reviewed during the process to ensure all potential topics were identified. RESULTS: The results of this effort produced the foundational curriculum, the 2023 Model Core Content of Disaster Medicine. CONCLUSION: Members from the Council of Disaster Medicine Fellowship Directors have developed the 2023 Model Core Content for Disaster Medicine in the United States. This living document defines the foundational curriculum for DM fellowships, providing the basis of a standardized experience, contributing to the development of a board-certified subspecialty, and informing fellowship directors and DM practitioners of content and topics that may appear on future certification examinations.

Hockey Puck Strike Rates and Injuries at National Hockey League Games: A Retrospective Analysis of Data from Six Seasons.

IMPORTANCE: This paper provides a large-scale, per-National Hockey League (NHL) season analysis of hockey puck strike (HPS) injury data and also provides estimates of injury frequency and severity. OBJECTIVE: The study's goal was to quantify and describe the rate and type of spectator HPS injuries at NHL games. DESIGN: This was a retrospective review of summary data reports for patients evaluated by on-site health care providers over six seasons (2013-2018). Data were obtained from a single Emergency Medical Service (EMS) agency. SETTING: Location of study was one US-based NHL venue. RESULTS: There were 51 HPS recorded. This accounted for 0.93% of total patient contacts translating to a patient per 10,000 (PPTT) of 0.116. This was compared to a PPTT of 12.6 for all patient contacts. The average age of a patron with a HPS was 31 years old. There was an even split between male and female patrons with HPS. The most common location for a HPS was the head or face (75%) followed by upper extremity injuries. Laceration was most frequently diagnosed followed by contusions and pain. Approximately one-quarter of people struck by hockey pucks were transported to the hospital, with the transport to hospital rate (TTHR) being 0.027, compared to the total TTHR of 2.7. CONCLUSIONS AND RELEVANCE: Hockey is a safe sport to watch, although HPS are the spectator hazard of concern given that pucks can travel into the stands at 100mph. Most injuries are minor and occur only one percent of the time; but when they do occur, these fans tend to need transport to the hospital. Finally, HPS tend to occur along the lateral sides of the rink where the glass level is lower and there is no protective netting.

Foul Ball Rates and Injuries at Major League Baseball Games: A Retrospective Analysis of Data from Three Stadiums.

IMPORTANCE: This paper provides a large-scale, per Major League Baseball (MLB) game analysis of foul ball (FB) injury data and provides estimates of injury frequency and severity. OBJECTIVE: This study's goal was to quantify and describe the rate and type of FB injuries at MLB games. DESIGN: This was a retrospective review of medical care reports for patients evaluated by on-site health care providers (HCPs) over a non-contiguous 11-year period (2005-2016). Data were obtained using Freedom of Information Act (FOIA) requests. SETTING: Data were received from three US-based MLB stadiums. RESULTS: The review reported 0.42-0.55 FB injuries per game that were serious enough to warrant presentation at a first aid center. This translated to a patients per 10,000 fans rate (PPTT) of 0.13-0.23. The transport to hospital rate (TTHR) was 0.02-0.39. Frequently, FB injuries required analgesics but were overwhelmingly minor and occurred less often than non-FB traumatic injuries (5.2% versus 42%-49%). However, FB injured fans were more likely to need higher levels of care and transport to hospital (TH) as compared to people suffering other traumatic injuries at the ballpark. Contusions or head injuries were common. Finally, FB injured fans were often hit in the abdomen, upper extremity, face, or head. It was found that FB injuries appeared to increase with time, and this increase in injuries aligns with the sudden increase in popularity of smartphones in the United States. CONCLUSIONS AND RELEVANCE: These data suggest that in roughly every two or three MLB games, a foul ball causes a serious enough injury that a fan seeks medical attention. This rate is high enough to warrant attention, but is comparable in frequency to other diagnostic categories. Assessing the risk to fans from FBs remains difficult, but with access to uniform data, researchers could answer persistent questions that would lead to actionable changes and help guide public policy towards safer stadiums.

Should I Stay or Should I Go? A Bioethical Analysis of Healthcare Professionals' and Healthcare Institutions' Moral Obligations During Active Shooter Incidents in Hospitals - A Narrative Review of the Literature.

Active shooter incidents (ASI) have unfortunately become a common occurrence the world over. There is no country, city, or venue that is safe from these tragedies, and healthcare institutions are no exception. Healthcare facilities have been the targets of active shooters over the last several decades, with increasing incidents occurring over the last decade. People who work in healthcare have a professional and moral obligation to help patients. As concerns about the possibility of such incidents increase, how should healthcare institutions and healthcare professionals understand their responsibilities in preparation for and during ASI?

How will disaster victims react to first responder commands-A survey of simulated disaster victims.

OBJECTIVE: To determine whether victim behavior and interaction with triage personnel would conform to expected actions as dictated by the Simple Triage and Rapid Treatment (START) triage methodology, which emphasizes that victims will accept their assigned -triage category. METHODS: In total, 105 volunteers were recruited to complete a 32-question survey after portraying victims in a triage-focused mass casualty incident (MCI) simulation. Questions included sociodemographic characteristics, willingness to follow commands of first responders, and willingness to help first responders. The authors examined whether the outcomes differed by demographics, healthcare experience, or disaster exposure of participants. RESULTS: The survey response rate was 90 percent (95/105). The mean age of participants was 31 years (58 percent women). Half of respondents indicated that they would ask responders to change their triage color if they disagreed with it and 75 percent would ask first responders to change their friend or family members' triage colors. Twenty-one percent of victims reported that they would alter their own triage tag to receive treatment faster and 38 percent would alter a friend or family member's triage color. The youngest (<20 years) and oldest (>40 years) respondents were most likely to act maladaptively. CONCLUSION: Triage algorithms rely upon -victims following the instructions of rescuers. This study suggests that maladaptive behavior by some victims should be anticipated.

Disaster Medicine: A Comprehensive Review of the Literature From 2016.

OBJECTIVE: The Society of Academic Emergency Medicine Disaster Medicine Interest Group, the Office of the Assistant Secretary for Preparedness and Response - Technical Resources, Assistance Center, and Information Exchange (ASPR TRACIE) team, and the National Institutes of Health Library searched disaster medicine peer-reviewed and gray literature to identify, review, and disseminate the most important new research in this field for academics and practitioners. METHODS: MEDLINE/PubMed and Scopus databases were searched with key words. Additional gray literature and focused hand search were performed. A Level I review of titles and abstracts with inclusion criteria of disaster medicine, health care system, and disaster type concepts was performed. Eight reviewers performed Level II full-text review and formal scoring for overall quality, impact, clarity, and importance, with scoring ranging from 0 to 20. Reviewers summarized and critiqued articles scoring 16.5 and above. RESULTS: Articles totaling 1176 were identified, and 347 were screened in a Level II review. Of these, 193 (56%) were Original Research, 117 (34%) Case Report or other, and 37 (11%) were Review/Meta-Analysis. The average final score after a Level II review was 11.34. Eighteen articles scored 16.5 or higher. Of the 18 articles, 9 (50%) were Case Report or other, 7 (39%) were Original Research, and 2 (11%) were Review/Meta-Analysis. CONCLUSIONS: This first review highlighted the breadth of disaster medicine, including emerging infectious disease outbreaks, terror attacks, and natural disasters. We hope this review becomes an annual source of actionable, pertinent literature for the emerging field of disaster medicine.

Retrospective Analysis of Mosh-Pit-Related Injuries.

OBJECTIVES: Moshing is a violent form of dancing found world-wide at rock concerts, festivals, and electronic dance music events. It involves crowd surfing, shoving, and moving in a circular rotation. Moshing is a source of increased morbidity and mortality. The goal of this study was to report epidemiologic information on patient presentation rate (PPR), transport to hospital rate (TTHR), and injury patterns from patients who participated in mosh-pits. Materials and Methods Subjects were patrons from mosh-pits seeking medical care at a single venue. The events reviewed were two national concert tours which visited this venue during their tour. The eight distinct events studied occurred between 2011 and 2014. Data were collected retrospectively from prehospital patient care reports (PCRs). A single Emergency Medical Service (EMS) provided medical care at this venue. The following information was gathered from each PCR: type of injury, location of injury, treatment received, alcohol or drug use, Advanced Life Support/ALS interventions required, age and gender, disposition, minor or parent issues, as well as type of activity engaged in when injured. RESULTS: Attendance for the eight events ranged from 5,100 to 16,000. Total patient presentations ranged from 50 to 206 per event. Patient presentations per ten thousand (PPTT) ranged from 56 to 130. The TTHR per 10,000 ranged from seven to 20. The mean PPTT was 99 (95% CI, 77-122) and the median was 98. The mean TTHR was 16 (95% CI, 12-29) and the median TTHR was 17. Patients presenting from mosh-pits were more frequently male (57.6%; P<.004). The mean age was 20 (95% CI, 19-20). Treatment received was overwhelmingly at the Basic Life Support (BLS) level (96.8%; P<.000001). General moshing was the most common activity leading to injury. Crowd surfing was the next most significant, accounting for 20% of presentations. The most common body part injured was the head (64% of injuries). CONCLUSIONS: This retrospective review of mosh-pit-associated injury patterns demonstrates a high rate of injuries and presentations for medical aid at the evaluated events. General moshing was the most commonly associated activity and the head was the most common body part injured. Milsten AM , Tennyson J , Weisberg S , Retrospective analysis of mosh-pit-related injuries. Prehosp Disaster Med. 2017;32(6):636-641.

High-Amplitude Atlantic Hurricanes Produce Disparate Mortality in Small, Low-Income Countries.

OBJECTIVES: Hurricanes cause substantial mortality, especially in developing nations, and climate science predicts that powerful hurricanes will increase in frequency during the coming decades. This study examined the association of wind speed and national economic conditions with mortality in a large sample of hurricane events in small countries. METHODS: Economic, meteorological, and fatality data for 149 hurricane events in 16 nations between 1958 and 2011 were analyzed. Mortality rate was modeled with negative binomial regression implemented by generalized estimating equations to account for variable population exposure, sequence of storm events, exposure of multiple islands to the same storm, and nonlinear associations. RESULTS: Low-amplitude storms caused little mortality regardless of economic status. Among high-amplitude storms (Saffir-Simpson category 4 or 5), expected mortality rate was 0.72 deaths per 100,000 people (95% confidence interval [CI]: 0.16-1.28) for nations in the highest tertile of per capita gross domestic product (GDP) compared with 25.93 deaths per 100,000 people (95% CI: 13.30-38.55) for nations with low per capita GDP. CONCLUSIONS: Lower per capita GDP and higher wind speeds were associated with greater mortality rates in small countries. Excessive fatalities occurred when powerful storms struck resource-poor nations. Predictions of increasing storm amplitude over time suggest increasing disparity between death rates unless steps are taken to modify the risk profiles of poor nations. (Disaster Med Public Health Preparedness. 2016;10:832-837).

Mass Gathering Medical Care: Resource Document for the National Association of EMS Physicians Position Statement.

Mass gatherings are heterogeneous in terms of size, duration, type of event, crowd behavior, demographics of the participants and spectators, use of recreational substances, weather, and environment. The goals of health and medical services should be the provision of care for participants and spectators consistent with local standards of care, protection of continuing medical service to the populations surrounding the event venue, and preparation for surge to respond to extraordinary events. Pre-event planning among jurisdictional public health and EMS, acute care hospitals, and event EMS is essential, but should also include, at a minimum, event security services, public relations, facility maintenance, communications technicians, and the event planners and organizers. Previous documented experience with similar events has been shown to most accurately predict future needs. Future work in and guidance for mass gathering medical care should include the consistent use and further development of universally accepted consistent metrics, such as Patient Presentation Rate and Transfer to Hospital Rate. Only by standardizing data collection can evaluations be performed that link interventions with outcomes to enhance evidence-based EMS services at mass gatherings. Research is needed to evaluate the skills and interventions required by EMS providers to achieve desired outcomes. The event-dedicated EMS Medical Director is integral to acceptable quality medical care provided at mass gatherings; hence, he/she must be included in all aspects of mass gathering medical care planning, preparations, response, and recovery. Incorporation of jurisdictional EMS and community hospital medical leadership, and emergency practitioners into these processes will ensure that on-site care, transport, and transition to acute care at appropriate receiving facilities is consistent with, and fully integrated into the community's medical care system, while fulfilling the needs of event participants.

Retrospective analysis of quality improvement throughput measures at a high-volume community emergency department.

OBJECTIVE: To assess the effect of having a physician or physician's assistant (PA) as patients' first point of contact in our emergency department (ED) on the rate of leaving without being seen (LWBS) and wait time. METHODS: In before and after intervention conducted in the ED at a 265-bed community hospital, data were collected on all patients presenting to the ED during a 70-month period. A physician or PA was stationed in triage 16 hr a day. The screening process included measurement of vital signs, a brief history and physical examination, and computerized physician order entry. RESULTS: During the study period, volume increased from 86,000 to 102,000 patients per year. Monthly averages for ED visits increased 16%, admissions increased 5%, and ambulance visits increased 18%. The rate of LWBS decreased from 3.1% to 1.7%. Door-to-doctor time decreased by 14 min. CONCLUSIONS: Despite an increase in patient census, the LWBS rate and door-to-doctor time decreased. This study of one solution to the issue of ED crowding demonstrates how a process redesign can lead to successful changes in throughput metrics.

Injury patterns and levels of care at a marathon.

INTRODUCTION: Marathons pose many challenges to event planners. The medical services needed at such events have not received extensive coverage in the literature. OBJECTIVE: The objective of this study was to document injury patterns and medical usage at a category III mass gathering (a marathon), with the goal of helping event planners organize medical resources for large public gatherings. METHODS: Prospectively obtained medical care reports from the five first-aid stations set up along the marathon route were reviewed. Primary and secondary reasons for seeking medical care were categorized. Weather data were obtained, and ambient temperature was recorded. RESULTS: The numbers of finishers were as follows: 4,837 in the marathon (3,099 males, 1,738 females), 814 in the 5K race (362 males, 452 females), and 393 teams in the four-person relay (1,572). Two hundred fifty-one runners sought medical care. The day's temperatures ranged from 39 to 73 degrees F (mean, 56 degrees F). The primary reasons for seeking medical were medication request (26%), musculoskeletal injuries (18%), dehydration (14%), and dermal injuries (11%). Secondary reasons were musculoskeletal injuries (34%), dizziness (19%), dermal injuries (11%), and headaches (9%). Treatment times ranged from 3 to 25.5 minutes and lengthened as the day progressed. Two-thirds of those who sought medical care did so at the end of the race. The majority of runners who sought medical attention had not run a marathon before. CONCLUSIONS: Marathon planners should allocate medical resources in favor of the halfway point and the final first-aid station. Resources and medical staff should be moved from the earlier tents to further augment the later first-aid stations before the majority of racers reach the middle- and later-distance stations.

Variables influencing medical usage rates, injury patterns, and levels of care for mass gatherings.

OBJECTIVES: Mass gatherings create difficult environments for which to plan emergency medical responses. The purpose of this study was to identify those variables that are associated with increased medical usage rates (MURs) and certain injury patterns that can be used to facilitate the planning process. METHODS: Patient information collected at three types of mass gatherings (professional American football and baseball games and rock concerts) over a three-year period was reviewed retrospectively. Specific variables were abstracted: (1) event type; (2) gender; (3) age; (4) weather; and (5) attendance. All 216 events (total attendance 9,708,567) studied were held in the same metropolitan region. All MURs are reported as patients per 10,000 (PPTT). RESULTS: The 5,899 patient encounters yielded a MUR of 6.1 PPTT. Patient encounters totaled 3,659 for baseball games (4.85 PPTT), 1,204 for football games (6.75 PPTT), and 1,036 for rock concerts (30 PPTT). The MUR for Location A concerts (no mosh pits) was 7.49 PPTT, whereas the MUR for the one Location B concert (with mosh pits) was 110 PPTT. The MUR for Location A concerts was higher than for baseball, but not football games (p = 0.005). Gender distribution was equal among patrons seeking medical care. The mean values for patient ages were 29 years at baseball games, 33 years at football games, and 20 years at concerts. The MUR at events held when the apparent temperature was 80 degrees F significantly lower statistically than that at events conducted at temperatures <80 degrees F were (18 degrees C) (4.90 vs. 8.10 PPTT (p = 0.005)). The occurrence of precipitation and increased attendance did not predict an increased MUR. Medical care was sought mostly for minor/basic-level care (84%) and less so for advanced-level care (16%). Medical cases occurred more often at sporting events (69%), and were more common than were cases with traumatic injuries (31%). Concerts with precipitation and rock concerts had a positive association with the incidence of trauma and the incidence of injuries; whereas age and gender were not associated with medical or traumatic diagnoses. CONCLUSIONS: Event type and apparent temperature were the variables that best predicted MUR as well as specific injury patterns and levels of care.

Mass-gathering medical care: a review of the literature.

UNLABELLED: Mass-gatherings events provide a difficult setting for which to plan an appropriate emergency medical response. Many of the variables that affect the level and types of medical needs, have not been fully researched. This review examines these variables. METHODS: An extensive review was conducted using the computerized databases Medline and Healthstar from 1977 through May 2002. Articles selected contained information pertaining to mass-gathering variables. These articles were read, abstracted, analyzed, and compiled. RESULTS: Multiple variables are present during a mass gathering, and they interact in complex and dynamic ways. The interaction of these variables contributes to the number of patients treated at an event (medical usage rate) as well as the observed injury patterns. Important variables include weather, event type, event duration, age, crowd mood and density, attendance, and alcohol and drug use. CONCLUSIONS: Developing an understanding of the variables associated with mass gatherings should be the first step for event planners. After these variables are considered, a thorough needs analysis can be performed and resource allocation can be based on objective data.

Hospital responses to acute - onset disasters : A review

Introduction: Hospitals the world over have been involved in disasters, both internal and external. These two types of disasters are independent, but not mutually exclusive. Internal disasters are isolated to the hospital and occur more frequently than do external disaster. External disasters affect the community as well as the hospital. This paper first focuses on common problems encountered during acute-onset disasters, with regards to hospital operations and caring for victims. Spedific injury patterns commonly seen during natural disasters are reviewed. Second, lessons learned from these common problems and their application to hospital disaster plans are reviewed. Methods: An extensive review of the available literature was conducted using the computerized databases Medline and Healthstar from 1977 through March 1999. Articles were selected if they contained information pertaining to a hospital response to a disaster situation or data on specific disaster injury patterns. Selected articles were read, abstracted, analyzed and compiled. Results: Hospitals continually have difficulties and failures in several major areas of operation during a disaster. Common problem areas identified include communication and power failures, water shortage and contamination, physical damage, hazardous material exposure, unorganized evacuations and resource allocation shortages. Conclusions: Lessons learned from past disaster-related operational failures are compiled and reviewed. the importance and types of disaster planning are reviewed(AU)