Pediatric disaster preparedness curriculum across emergency medicine residencies.

OBJECTIVE: To assess pediatric disaster medicine (PDM) instruction in emergency medicine (EM) residency programs and to identify barriers to integrating these skills into EM training. METHODS: National survey study of United States EM Residency Program Directors (PDs) and Assistant PDs during the 2021-2022 academic year. RESULTS: Of the 186 EM residency programs identified, a total of 24 responses were recorded with a response rate of 12.9 percent. Importance of training was rated 5.79 (standard deviation 2.51) using the Likert scale ranging from 1 to 10. Out of 24 programs, 17 (70.8 percent) do not have any PDM training as part of residency training. Live drill, simulation, and tabletop were identified as most effective methods to deliver PDM training with the Likert scale score of 4.78, 4.6, and 4.47, respectively. Senior trainees' level of -knowledge/skills with family reunification (Likert 2.09/5; chemical-biological-radiological-nuclear explosive 2.95/5) and mass casualty preparation of the emergency department (3.3/5) as assessed by the respondents. The main barrier to education included logistics, eg, space and costs (Likert 3.7/5), lack of didactic time (3.7/5), and limited faculty knowledge, skill, or experience (3.3/5). CONCLUSION: PDM training is lacking and requires standardization. This study highlights the opportunity for the creation of a model for EM resident education in PDM.

Syndromic Surveillance Implementation During Disaster Events.

INTRODUCTION: Disease surveillance is an integral part of public health. These systems monitor disease trends and detect outbreaks, whereas they should be evaluated for efficacy. The United States Centres for Disease Control and Prevention publish Guidelines for Evaluating Surveillance Systems to encourage efficient and effective use of public health surveillance that are accepted worldwide. OBJECTIVE: This study reviews syndromic surveillance during natural and man-made disasters internationally. It aims to (1) review the performance of syndromic surveillance via pre-specified attributes during disaster and to (2) understand its strengths and limitations. METHODS: PubMed was systematically searched for the articles assessing syndromic surveillance during a disaster. A narrative review was carried out based on those articles. Updated Guidelines for Evaluating Public Health Surveillance Systems were used to review performance of systems. RESULTS: 5,059 studies from PubMed were evaluated, and 16 met inclusion criteria. The majority of these studies considered the implementation of syndromic surveillance useable during disaster events. Studies described systems giving relevant and timely information. Simplicity and timeliness were the most highlighted attributes. CONCLUSION: Syndromic surveillance is simple, flexible, useful and usable during a disaster. Timely data can be obtained, but the quality of this type of data is sensitive to incomplete and erroneous reporting; because of this, a standardized approach is necessary to optimize these systems.

Combating the Opioid Crisis and Its National Security Threat Through CReDO: A Multidisciplinary Solution With Disaster Medicine Implications.

For the first time in history, the United States surpassed 100 000 overdose-related deaths in a 12-month period, driven by synthetic opioids such as fentanyl. Also, for the first time, potential chemical weapons are readily available on the streets and the dark web. Opioids represent a rare trifecta, used for licit pain management, as an illicit drug of abuse, and with potential use as a weapon of terror. Community-based Response to Drug Overdose (CReDO) is an initiative to unite agencies, disciplines, government, and private partners in 1 coordinated opioid emergencies response plan under nationwide standards, and can be integrated into the disaster medicine discipline due to the risk of mass casualty incidents involving fentanyl or its derivatives. Attention to the opioid crisis through CReDO will save lives by promoting information sharing between disciplines, shortened response time to overdose clusters, community collaboration to identify criminal distribution networks, and holistic approaches to addiction.

Factors associated with international humanitarian aid appeal for disasters from 1995 to 2015: A retrospective database study.

INTRODUCTION: International humanitarian aid during disasters should be needs-based and coordinated in response to appeals from affected governments. We identify disaster and population factors associated with international aid appeal during disasters and hence guide preparation by international humanitarian aid providers. METHODS: In this retrospective database analysis, we searched the Emergency Events Database for all disasters from 1995 to 2015. Disasters with and without international aid appeals were compared by location, duration, type of disaster, deaths, number of people affected, and total estimated damage. Logistic regression was used to examine the association of each factor with international aid appeal. RESULTS: Of 13,961 disasters recorded from 1995 to 2015, 168 (1.2%) involved international aid appeals. Aid appeals were more likely to be triggered by disasters which killed more people (OR 1.29 [95% confidence interval (CI) 1.02-1.64] log10 persons), affected more people (OR 1.85 [95%CI 1.57-2.18] / log10 persons), and occurred in Africa (OR 1.67 [95%CI 1.06-2.62). Earthquakes (OR 4.07 [95%CI 2.16-7.67]), volcanic activity (OR 6.23 [95%CI 2.50-15.53]), and insect infestations (OR 12.14 [95%CI 3.05-48.35]) were more likely to trigger international aid appeals. International aid appeals were less likely to be triggered by disasters which occurred in Asia (OR 0.46 [95%CI 0.29-0.73]) and which were transport accidents (OR 0.12 [95%CI 0.02-0.89]). CONCLUSION: International aid appeal during disasters was associated with greater magnitude of damage, disasters in Africa, and specific types of disasters such as earthquakes, volcanic activity, and insect infestations. Humanitarian aid providers can focus preparation on these identified factors.

Threat awareness training for non-governmental organizations deploying humanitarian aid workers into conflict environments.

INTRODUCTION: The current war in Ukraine and the subsequent deployment of Non-Governmental Organizations (NGOs) from around the world has highlighted the many potential dangers faced by humanitarian aid workers operating in conflict zones. Humanitarian aid workers may face both direct and indirect threats and aggression while on deployment, and given the rising number of global conflicts, the authors postulate a need to incorporate threat awareness training as part of pre-deployment training. METHODS: A list of the top 22 rated NGOs providing international aid was obtained from CharityWatch. All 22 were contacted via their public email addresses or website contact pages to find out if they provide any form of security, tactical or threat awareness training. RESULTS: Of the 13 NGOs that responded, 7 did not deploy staff into recent conflict zones or surroundings. All 6 NGOs who deployed staff into Ukraine or surrounding border countries, provided either security, tactical or threat awareness training to their staff. CONCLUSION: With the rising number of conflicts and disasters around the world, humanitarian aid workers are increasingly exposed to hostile environments and there is a compelling need for NGOs to ensure staff are adequately trained and prepared to handle any dangers and threats they may face. In this study, all 6 of the studied NGOs which deployed staff to the conflict zone confirmed some type of security or threat awareness training ranging from in-house security briefs to extensive, multi-day, commercially run courses such as Hostile Environment Awareness Training course.

Emergency Medical Services Preparedness in Dual Disasters: War in the Era of COVID-19 in Armenia.

INTRODUCTION: Emergency Medical Services (EMS) is a critical part of Disaster Medicine and has the ability to limit morbidity and mortality in a disaster event with sufficient training and experience. Emergency systems in Armenia are in an early stage of development and there is no Emergency Medicine residency training in the country. As a result, EMS physicians are trained in a variety of specialties.Armenia is also a country prone to disasters, and recently, the Armenian EMS system was challenged by two concurrent disasters when the 2020 Nagorno-Karabakh War broke out in the midst of the SARS-CoV-2/coronavirus disease 2019 (COVID-19) pandemic. STUDY OBJECTIVE: This study aims to assess the current state of disaster preparedness of the Armenian EMS system and the effects of the simultaneous pandemic and war on EMS providers. METHODS: This was a cross-sectional study conducted by anonymous survey distributed to physicians still working in the Yerevan EMS system who provided care to war casualties and COVID-19 patients. RESULTS: Survey response rate was 70.6%. Most participants had been a physician (52.1%) or EMS physician (66.7%) for three or less years. The majority were still in residency (64.6%). Experience in battlefield medicine was limited prior to the war, with the majority reporting no experience in treating mass casualties (52.1%), wounds from explosives (52.1%), or performing surgical procedures (52.1%), and many reporting minimal to no experience in treating gunshot wounds (62.5%), severe burns (64.6%), and severe orthopedic injuries (64.6%). Participants had moderate experience in humanitarian medicine prior to war. Greater experience in battlefield medicine was found in participants with more than three years of experience as a physician (z-score -3.26; P value <.01) or as an EMS physician (z-score -2.76; P value <.01) as well as being at least 30 years old (z-score -2.11; P value = .03). Most participants felt they were personally in danger during the war at least sometimes (89.6%). CONCLUSION: Prior to the COVID-19 pandemic and simultaneous 2020 Nagorno-Karabakh War, EMS physicians in Armenia had limited training and experience in Disaster Medicine. This system, and the frontline physicians on whom it relies, was strained by the dual disaster, highlighting the need for Disaster Medicine training in all prehospital medical providers.

Variance Analysis of Expatriate Pre-Hospital Provider Training in Bahrain.

Introduction: The absence of local Emergency Medical Services (EMS) educational programs in Bahrain has given rise to an EMS workforce comprised predominantly of expatriate personnel with varying educational backgrounds that require further training before being licensed as EMS providers in Bahrain. Methods: A qualitative variance analysis was performed comparing desired core competencies for EMS practice in neighbouring Saudi Arabia, used as a comparator for Bahrain, with core competencies extracted from national curricula of the major countries from which expatriate providers originate. Results: Major core competencies not covered by the expatriate providers' curricula were identified as follows: working in an autonomous environment, requiring different critical thinking and decision-making skills, assessment and treatment during transportation, disaster response, EMS knowledge base, and coping with the different stressors of the prehospital environment. Conclusion: These results can form the basis for additional customized training programs for expatriate EMS providers working in Bahrain, with the goal of improving and standardizing EMS care in the country.

Preparing for the Second Surge: Preventing Posttraumatic Stress Disorder and Building Resilience for Health Care Workers in the Face of COVID-19.

The global community needs to be aware of the potential psychosocial consequences that may be experienced by health care workers who are actively managing patients with coronavirus disease (COVID-19). These health care workers are at increased risk for experiencing mood and trauma-related disorders, including posttraumatic stress disorder (PTSD). In this concept article, strategies are recommended for individual health care workers and hospital leadership to aid in mitigating the risk of PTSD, as well as to build resilience in light of a potential second surge of COVID-19.

Trend Analysis on Road Traffic Collision Occurrence in Nigeria.

OBJECTIVES: Road traffic collisions (RTC) result in a significant number of preventable deaths worldwide. In 2010, the United Nations General Assembly launched, "The Decade of Action for Road Safety (2011-2020)" with the stated goal to "reduce road traffic deaths and injuries by 50% by 2020." This study aims to analyze trends in RTC numbers and subsequent deaths with respect to road safety laws in Nigeria and to suggest suitable interventions. METHODS: Annual reports for the period 2007-2017 were obtained from the Federal Road Safety Corps of Nigeria. These reports were analyzed for trends in RTC, including reported causes, fatalities, injuries, and casualties. RESULTS: Overall total injuries, casualties, and fatalities increased by 74.7%, 61.2%, and 9.6%, respectively. Analysis showed that the 3 main causes of RTC were speed violation, loss of control, and dangerous driving. CONCLUSIONS: Although current trends do not suggest that Nigeria will accomplish its initial goal of decreasing fatalities by 50% by 2020, there has been a reduction in the number of crashes resulting from dangerous driving. Further interventions such as implementing automated speed monitoring, collaboration, and data sharing between federal and regional agencies, and improving the state of road networks should be implemented to decrease fatalities further.

Developing Telemedicine Curriculum Competencies for Graduate Medical Education: Outcomes of a Modified Delphi Process.

PURPOSE: Telemedical applications have only recently begun to coalesce into the field of telemedicine due to varying definitions of telemedicine and issues around reimbursement. This process has been accelerated by the COVID-19 pandemic and the ensuing expansion of telemedicine delivery. This article demonstrates the development of a set of proposed competencies for a telemedicine curriculum in graduate medical education. METHOD: A modified Delphi process was used to create a panel of competencies. This included a systematic review of the telemedicine literature through November 2019 to create an initial set of competencies, which were analyzed and edited by a focus group of experts in January 2020. Initial competencies were distributed in a series of 3 rounds of surveys to a group of 23 experts for comments and rating from April to August 2020. Competencies that obtained a score of 4.0 or greater on a 5-point Likert scale in at least 2 rounds were recommended. RESULTS: Fifty-five competencies were developed based on the systematic review. A further 32 were added by the expert group for a total of 87. After 3 rounds of surveys, 34 competencies reached the recommendation threshold. These were 10 systems-based practice competencies, 7 professionalism, 6 patient care, 4 practice-based learning and improvement, 4 interpersonal and communication skills, and 3 medical knowledge competencies. CONCLUSIONS: Half (17/34) of the competencies approved by the focus group and surveyed expert panel pertained to either systems-based practice or professionalism. Both categories exhibit more variation between telemedicine and in-person practice than other categories. The authors offer a set of proposed educational competencies that can be used in the development of curricula for a wide range of providers and are based on the best evidence and expert opinion available.

The Psychosocial Impact of Compounding Humanitarian Crises Caused by War and COVID-19 Informing Future Disaster Response.

The coronavirus disease 2019 (COVID-19) pandemic has caused the greatest global loss of life and economic impact due to a respiratory virus since the 1918 influenza pandemic. While health care systems around the world faced the enormous challenges of managing COVID-19 patients, health care workers in the Republic of Armenia were further tasked with caring for the surge of casualties from a concurrent, large-scale war. These compounding events put a much greater strain on the health care system, creating a complex humanitarian crisis that resulted in significant psychosocial consequences for health care workers in Armenia.

The Holy Month of Ramadan: Mass-Gathering Event Implications for Hospital Surge Capacity Planning in Saudi Arabia.

OBJECTIVES: The goal of this study is to determine the impact of the Holy Month of Ramadan on emergency department (ED) and hospital resource utilization in comparison to the time of Hajj and the rest of the year, so as to better define future resource needs of hospitals responding to events of this large size and duration. METHODS: A retrospective chart review was conducted of electronic medical records, ED visits, and hospital admissions during Ramadan, Hajj, and all other months over a three-year period on the Hijra calendar (1438-1440) or Gregorian (2016-2019). Primary outcomes were the change in the number of ED visits, hospital admissions, and intensive care unit (ICU) admissions during Ramadan in comparison to during Hajj and other months. Secondary outcomes included mortality; number of surgeries by specialty; and admissions to cardiac, respiratory, orthopedic, and neurosurgery wards. RESULTS: During the three years, ED visits increased during Ramadan by 83.0%, 74.8%, and 40.3%, respectively, when compared to non-Hajj, non-Ramadan months. Hospital admissions rose by 21.05%, 50.96% and 48.22%. Combined ED and in-hospital mortality rose by 15.21%, 21.47%, and 1.39%. While there was a large increase in ICU admissions during Ramadan of 1440 (May 2019), this was not a trend seen in other years. Despite there only being two years of data for comparison, there was a trend towards increased admissions to all specialty wards. There was an average 46.69% increase in admissions to the general surgery ward during Ramadan months compared to other months, a 31.06% increase in admissions to the orthopedic surgery ward, and a 44.05% increase in admissions to the cardiac care unit. CONCLUSIONS: Ramadan is associated with a significant increase in the population of Makkah (Mecca), Saudi Arabia. Despite this study only focusing on a three-year period, and some variables with only two years of data available, it demonstrates a significant increase in ED visits, hospital admissions, and mortality during Ramadan compared to non-Hajj/non-Ramadan months. During mass gatherings of this size, it would benefit local and regional hospital systems to devote increased resources to patient care, especially to the ED, to prevent morbidity and mortality.

Practical Solutions for Healthcare Worker Protection During the COVID-19 Pandemic Response in the Ambulatory, Emergency, and Inpatient Settings.

OBJECTIVE: Protecting healthcare workers is an essential component of a successful response to the COVID-19 pandemic. The resource intensive nature of infectious disease protection, budgetary constraints, and global shortages of personal protective equipment (PPE) make this a daunting task. Practical, easily implemented strategies for healthcare workers (HCW) protection are needed. METHODS: We cross-reference the "Systems, Space, Staff, and Stuff" paradigm from disaster management and the "Hierarchy of Controls" approach to infection prevention from the Center for Disease Control and Prevention (CDC) to generate a narrative overview of worker protection strategies relevant to COVID-19. RESULTS: Alternative types of PPE, management of hazards, and reorganizing how people work can optimize HCWs protection. CONCLUSIONS: A comprehensive PPE strategy can utilize the "systems, space, staff, stuff" paradigm of disaster management to identify new or underutilized solutions to HCWs protection.

Counter-Terrorism Medicine: Creating a Medical Initiative Mandated by Escalating Asymmetric Attacks.

INTRODUCTION: Since 2001, a burgeoning interest by health care professionals in the growing asymmetrical terrorist threat and its impact on health care preparation and response has seen significantly increased academic output around this nebulous subject. Despite this, there has failed to be a consolidation of this sub-specialty. DISCUSSION: This editorial argues for the consolidation of the body of experience gathered since 2001 into an initiative called Counter-Terrorism Medicine (CTM). It proposes that previously discrete sub-specialty areas can be consolidated, with improvements in collective understanding, and can build on previous work to provide a non-political health care focused definition of terrorist events, based on the triad of Violence, Intent, and Heath Care Impact. It notes the importance this defining triad has in health care planning and response considerations. Finally, it defines the parameters of CTM within the larger specialty of Disaster Medicine (DM). CONCLUSION: There is a growing body of academic work on the health care implications of terrorism. The time is right to coalesce these into an initiative referred to as CTM and to consider this as a discrete part of DM.

A dignitary medicine curriculum developed using a modified Delphi methodology.

BACKGROUND: Dignitary medicine is an emerging field of training that involves the specialized care of diplomats, heads of state, and other high-ranking officials. In an effort to provide guidance on training in this nascent field, we convened a panel of experts in dignitary medicine and using the Delphi methodology, created a consensus curriculum for training in dignitary medicine. METHODS: A three-round Delphi consensus process was performed with 42 experts in the field of dignitary medicine. Predetermined scores were required for an aspect of the curriculum to advance to the next round. The scores on the final round were used to determine the components of the curriculum. Scores below the threshold to advance were dropped in the subsequent round. RESULTS: Our panel had a high degree of agreement on the required skills needed to practice dignitary medicine, with active practice in a provider's baseline specialty, current board certification, and skills in emergency care and resuscitation being the highest rated skills dignitary medicine physicians need. Skills related to vascular and emergency ultrasound and quality improvement were rated the lowest in the Delphi analysis. No skills were dropped from consideration. CONCLUSIONS: The results of our work can form the basis of formal fellowship training, continuing medical education, and publications in the field of dignitary medicine. It is clear that active medical practice and knowledge of resuscitation and emergency care are critical skills in this field, making emergency medicine physicians well suited to practicing dignitary medicine.

Use of Dimensional Analysis in the X-, Y-, and Z-Axis to Predict Occurrence of Injury in Human Stampede.

BACKGROUND: Human stampedes (HS) may result in mass casualty incidents (MCI) that arise due to complex interactions between individuals, collective crowd, and space, which have yet to be described from a physics perspective. HS events were analyzed using basic physics principles to better understand the dynamic kinetic variables that give rise to HS. METHODS: A literature review was performed of medical and nonmedical sourced databases, Library of Congress databases, and online sources for the term human stampedes resulting in 25,123 references. Filters were applied to exclude nonhuman events. Retrieved references were reviewed for a predefined list of physics terms. Data collection involved recording frequency of each phrase and physics principle to give the final proportions of each predefined principle used a single-entry method for each of the 105 event reports analyzed. Data analysis was performed using the R statistics packages "tidyverse", "psych", "lubridate", and "Hmisc" with descriptive statistics used to describe the frequency of each observed variable. RESULTS: Of the 105 reports of HS resulting in injury or death reviewed, the following frequency of terms were found: density change in a limited capacity, 45%; XY-axis motion failure, 100%; loss of proxemics, 100%; deceleration with average velocity of zero, 90%; Z-axis displacement pathology (falls), 92%; associated structure with nozzle effect, 93%; and matched fluid dynamic of high pressure stagnation of mass gathering, 100%. CONCLUSIONS: Description or reference to principles of physics was seen in differing frequency in 105 reports. These include XY-axis motion failure of deceleration that leads to loss of human to human proxemics, and high stagnation pressure resulting in the Z-axis displacement effect (falls) causing injury and death. Real-time video-analysis monitoring of high capacity events or those with known nozzle effects for loss of proxemics and Z-axis displacement pathology offers the opportunity to prevent mortality from human stampedes.

Dignitary Medicine: A Novel Area of Medical Training.

Dignitary medicine (DM) involves the provision of healthcare to government leaders and other high-profile individuals collectively referred to as "dignitaries." Due to the unique circumstances around their lifestyle, dignitaries often receive suboptimal healthcare. We define the requisite skills needed to practice DM based on the available literature and provide a framework for training providers in these skills. A review of the English language medical literature focussing on adult subjects was performed, searching for terms such as "dignitary medicine," "VIP medicine," and "protective medicine." Literature was gathered from CINAHL, Google Scholar, PubMed, EBSCOHost, and San Bernardino County Library databases and then analyzed by experienced DM providers. A total of 23 relevant articles were eligible for review. No meta-analyses on the subject exist. We found that existing studies highlight skills in wellness, executive health, and protective medicine, which form the backbone of DM. The burgeoning field of DM encompasses several disciplines and skills. We strongly recommend a structured curriculum for the field of DM, focused on dignitary wellness, executive health, and protective medicine.

Earthquake-Related Orthopedic Injuries in Adult Population: A Systematic Review.

Introduction Earthquake-related trauma results in crush injuries and bony- and soft-tissue trauma. There are no systematic reviews analyzing the typical injury patterns and treatments in "Mega-Mass-Casualty" earthquakes. The characterization of an injury pattern specific to disaster type, be it natural or manmade, is imperative to build an effective disaster preparedness and response system. METHODS: The systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). A comprehensive search strategy was developed to identify all publications relating to earthquakes and the orthopedic treatment in adult patients. The following databases were searched: PubMed (Medline; US National Library of Medicine, National Institutes of Health; Bethesda, Maryland USA), Ovid (Ovid Technologies; New York, New York USA), Web of Science (Thomson Reuters; New York, New York USA), and The Cochrane Library (The Cochrane Collaboration; Oxford, United Kingdom). RESULTS: The searches identified 4,704 articles: 4,445 after duplicates were removed. The papers were screened for title and abstract and 65 out of those were selected for full-text analysis. The quality of data does not permit a standard-of-care (SOC) to be defined. Scarcity and poor quality of the data collected also may suggest a low level of accountability of the activity of the international hospital teams. Qualitatively, it is possible to define that there are more open fractures during daytime hours than at night. Excluding data about open and closed fractures, for all types of injuries, the results underline that the higher the impact of the earthquake, as measured by Richter Magnitude Scale (RMS), the higher is the number of injuries. Discussion Regarding orthopedic injuries during earthquakes, special attention must be paid to the management of the lower limbs most frequently injured. Spinal cord involvement following spine fractures is an important issue: this underlines how a neurosurgeon on a disaster team could be an important asset during the response. Conservative treatment for fractures, when possible, should be encouraged in a disaster setting. Regarding amputation, it is important to underline how the response and the quality of health care delivered is different from one team to another. This study shows how important it is to improve, and to require, the accountability of international disaster teams in terms of type and quality of health care delivered, and to standardize the data collection. Bortolin M , Morelli I , Voskanyan A , Joyce NR , Ciottone GR . Earthquake-related orthopedic injuries in adult population: a systematic review. Prehosp Disaster Med. 2017;32(2):201-208.