A Review of Ambulance Terrorism on the African Continent.

BACKGROUND: In recent decades, an increasing number of terrorist attacks have been carried out against medical institutions, hospitals, and health care workers. These attacks, that often result in high numbers of casualties and impaired access to health services, have a more significant impact on people's sense of security than attacks against military and police targets. Attacks on ambulances - especially on the African continent - have been sparsely studied. This study examines attacks on ambulances on the African continent during the period from 1992-2022 (until December 31, 2021). METHODS: Reports of ambulance terrorism were extracted from the Global Terrorism Database (GTD), RAND Database of Worldwide Terrorism Incidents (RDWTI), United Nation's Safeguarding Health in Conflict Coalition (SHCC) database, Armed Conflict Location and Event Data Project (ACLED), Surveillance System for Attacks on Health Care (SSA) database, and Aid Worker Security Database (AWSD). Furthermore, a grey literature search was performed. The date and location of the attacks, perpetrators, weapon and attack types, and the number of victims (dead and wounded) and hostages were collected. Results were exported into an Excel spreadsheet (Microsoft Corp.; Redmond, Washington USA) for analysis. RESULTS: During the 30-year study period, 166 attacks were observed in 18 African countries. The number of attacks significantly increased since 2016, with 81.3% of the attacks taking place from 2016 to 2022. In total, 193 people died and another 208 were injured. Attacks with firearms were most frequently noted (92 cases; 55.4%), followed by attacks with explosive devices (26 cases; 15.7%). A significant number of ambulances were hijacked (26 cases; 15.7%) and subsequently used for other terrorist attacks. In seven attacks, ambulances were used as vehicle-born improvised explosive devices (VBIEDs). CONCLUSION: In this database study on ambulance terrorism in Africa, it was found that the reported occurrence of attacks increased from 2013 onwards, including the rise of ambulances used as VBIEDs. These findings suggest that ambulance terrorism represents a real, significant risk that both governments and health care institutions must address.

Health Care Organizations: Soft Target during COVID-19 Pandemic.

Health care organizations have been challenged by the coronavirus disease 2019 (COVID-19) pandemic for some time, while in January 2020, it was not immediately suspected that it would take such a global expansion. In the past, other studies have already pointed out that health care systems, and more specifically hospitals, can be a so-called "soft target" for terrorist attacks. This report has now examined whether this is also the case in the context of the COVID-19 pandemic.During the lockdown, hospitals turned out to be the only remaining soft targets for attacks, given that the other classic targets were closed during the lockdown. On the other hand, other important factors have limited the risk of such attacks in hospitals. The main delaying and relative risk-reducing factors were the access control on temperature and wearing a mask, no visits allowed, limited consultations, and investigations.But even then, health care systems and hospitals were prone to (cyber)terrorism, as shown by other COVID-19-related institutions, such as pharmaceuticals involved in developing vaccines and health care facilities involved in swab testing and contact tracing. Counter-terrorism medicine (CTM) and social behavioral science can reduce the likelihood and impact of terrorism, but cannot prevent (state-driven) cyberterrorism and actions of lone wolves and extremist factions.

Preparedness of Belgian civil hospitals for chemical, biological, radiation, and nuclear incidents: are we there yet?

OBJECTIVE: As one of Europe's most densely populated countries with multiple nuclear installations and a prominent petrochemical industry, Belgium is at some reasonable risk for terrorist attacks or accidental chemical, biological, radiation, and nuclear (CBRN) incidents. We hypothesize that local hospitals are not sufficiently prepared to deal with these incidents. MATERIALS AND METHODS: All 138 Belgian hospitals with an emergency department (ED) were sent a survey on their preparedness. Data on hospital disaster planning, risk perception, availability of decontamination units, personal protective equipment, antidotes, radiation detection, infectiologists, isolation measures, and staff training were collected. RESULTS: The response rate was 72%. Although 71% of hospitals reported being at risk for CBRN incidents, only 53% planned for the same in their disaster plans. Only 11% of hospitals had decontamination facilities in front of or at the ED entrance and only 6% had appropriate personal protective equipment for triage and decontaminating teams. Atropine was available at all centers, but more specific antidotes such as hydroxycobolamine, thiosulphate, or pralidoxime were less available (47, 47, and 19%, respectively). Six percent of hospitals had radiodetection equipment with an alarm function and 14% had a nuclear specialist available 24/7. Infectiologists were continuously available in 26% of the total EDs surveyed. Individual isolation facilities were present in 36% of the EDs, and isolation facilities capable of housing larger groups were present in 9%. University hospitals were significantly better prepared than community hospitals. CONCLUSION: There are serious gaps in hospital preparedness for CBRN incidents in Belgium. Lack of financial resources is a major obstacle in achieving sufficient preparedness.

Patients' and relatives' view on witnessed resuscitation in the emergency department: a prospective study.

BACKGROUND: The appropriateness of family witnessing resuscitation (FWR) is an ethical dilemma with most emergency care providers being opponents. We hypothesized that patients and their families prefer to witness resuscitation of their loved ones. METHODS: One hundred and fifty patients treated for potential life-threatening conditions in our emergency department were presented with a survey on FWR in the reconvalescence phase. They were asked to give their opinion supposing their situation had worsened, requiring a resuscitation effort. Their closest relatives were asked to complete a related questionnaire. RESULTS: Mean age was 67 years (patient group) and 55 years (relatives group). Fifty-eight percent of the patients were males with only 33% males in the relatives group. Seventy-two percent of the patients preferred the presence of a relative during resuscitation, although 35% estimate that this could be quite a traumatic experience. Forty-one percent had a history of serious medical problems. In the relatives group, 75% expressed their wish to stay with their loved ones and 49% did not fear that this would be too traumatic. There was a good match in patient and family attitude towards FWR (P<0.001). Relatives of a patient with a serious medical history were significantly more in favour of FWR (P<0.01). CONCLUSION: Our study showed that patients and relatives preferred family presence in emergency department during resuscitation, even when the fear of traumatic effects is considered. It will be a great challenge training emergency care providers for this situation. Staff shortages might compromise the essential support of family members in such situations.

Should relatives witness resuscitation in the emergency department? The point of view of the Belgian Emergency Department staff.

OBJECTIVE: To assess the opinion of Belgian Emergency Department (ED) staff regarding family-witnessed resuscitation (FWR). METHODS: All 142 Belgian EDs were sent a questionnaire on hospital-related data and personal questionnaires for the ED staff concerning their opinion on FWR. Opinions of physicians, nurses and other emergency care providers were compared and related with hospital or sociodemographic data. RESULTS: Eighty-five ED services (60%) responded with a total of 1143 personal questionnaires: of these 79% were nurses, and 19% physicians. Eighty percent of the hospitals had a prehospital intervention team. Only two departments (2.5%) practiced structured FWR; 21% put the relatives in the corridor. Eleven percent did not give any information at all to relatives. Fourteen percent organized 'training in coping with relatives'. Forty-one percent of the staff members had been asked for FWR but only 33% were positive about it. Fifty-six percent thought that relatives could be of use in the shock room. Sixty-six percent experienced it as a burden. Sixty-five percent thought that FWR helps in grieving but 93% feared traumatic distress. Sixty-four percent would like to attend the resuscitation of their own relatives. Thirty-five percent fear a high risk of complaints. Prehospital experience, higher workload, seniority and male staff are significant advantages towards FWR. Emergency physicians are more positive towards FWR, nurses less so, followed by other physicians. CONCLUSION: The Belgian ED staff is still unconvinced about FWR. Despite evidence-based data they still think that resuscitation is traumatizing for relatives. Experience, both in as well as out of hospital, is a positive factor.

Are Belgian senior medical students ready to deliver basic medical care in case of a H5N1 pandemic?

Medical care systems will be overwhelmed if a human H5N1 pandemic should occur. Several national disaster plans, including that of Belgium, focus on maximal treatment at home with senior medical students supporting frontline care. To evaluate the knowledge and preparedness of Belgian senior medical students, an e-mail survey of senior medical students (last two years of education) attending Flemish universities was conducted. A total of 243 students (30%) replied. Only 21.8% of them were aware of the possibility of being involved in this planning. A total of 77.4% estimated H5N1 to be a possible threat to national health. Seventy percent of respondents reacted positively towards the idea of being involved in implementing primary care, and only 9.5% were absolutely opposed to the idea. A total of 82.3% would care for pandemic patients if necessary, but only 41.2% would do so if these patients were children. Only 18.9% estimated themselves to be sufficiently educated regarding H5N1. Ninety-one percent were convinced that care for H5N1-influenza patients should be incorporated into their regular curriculum. Several antiviral products were reported by the students to be efficient for treating H5N1, but only 34.6% correctly chose oseltamavir and/or zanamavir and 35.4% replied "I don't know". A total of 95.5% correctly answered that the regular influenza vaccination doesn't protect against H5N1. The risk for human-to-human transmission was rated to be small by 50.6% (none 21%, high 27.6%). The human infection risk was rated to be small by 74.1% (none 1.6%, high 23%). There is a high level of willingness to participate among senior medical students. However, in the case of pediatric patients they're more reserved. It would be useful to incorporate a focused session on preparedness in the regular teaching program. A legal base for their actions should also be provided. Ethical guidelines on rights and duties in case of a pandemic should be prepared by an international, multidisciplinary group of experts.

Seizures and hyponatremia after excessive intake of diet coke.

We describe a case of epileptic seizures after a massive intake of diet coke. Apart from the hyponatremia due to water intoxication the convulsions can be potentiated by the high dose of caffeine and aspartame from the diet coke. To our knowledge this is the first report of seizures due to excessive diet coke intake.

Differential diagnosis between viral and bacterial meningitis in children.

OBJECTIVE: The differential diagnosis between viral meningitis and bacterial meningitis is often very difficult. The results of peripheral blood and spinal fluid analysis are not 100% accurate. We tried to find a useful 'bedside' decision-making tool, based on laboratory results readily available at the emergency department. METHODS: Retrospective study design. Analysis of a consecutive series of all children (age 0-15 years) admitted to the paediatric ward because of a viral or bacterial meningitis, in the period from 1997 to September 2005. RESULTS: Seventy-one children with viral and 21 with bacterial meningitis were included. Bacterial meningitis occurred at much younger ages than viral meningitis. The paediatrician decided to administer antibiotics in 41 of 71 children with viral meningitis and in all children with bacterial meningitis. We developed a 'bacterial meningitis score' based on C-reactive protein in peripheral blood, as well as glucose and protein in cerebrospinal fluid. Using this score, we could distinguish 54 of 71 patients with viral meningitis from the group with bacterial meningitis. When the dispensing of antibiotics was based on this score, only 16 patients with viral meningitis would receive antibiotics. CONCLUSION: We present a bedside bacterial meningitis score. Using this bacterial meningitis score as a decision-making tool, we would be able to avoid antibiotics in a large number of children with viral meningitis. As this gives a 100% success rate, thus guaranteeing that bacterial meningitis patients would receive the proper therapy, our bacterial meningitis score could be an accurate decision-support tool.

Are Belgian hospitals prepared for an H5N1-pandemic?

OBJECTIVE: Virulent airborne diseases can be a real burden to a nation's health system. The most recent threat is the fear of a mutation-induced H5N1-influenza pandemic. We studied whether Belgian hospitals are able to deal with H5N1-influenza infected patients in the case of a pandemic. Many patients, including children, may require artificial ventilation within 48 h after admission. METHODS: A survey aimed at determining 'availability and preparedness' was sent by e-mail to the different Belgian Emergency Departments. RESULTS AND DISCUSSION: Sixty-five hospitals were finally included. The amount of patients being potentially admitted is limited, owing to the reduced number of intensive care beds equipped with automatic ventilators. Furthermore, the number of available intensive care beds for children is still lower than for adult patients. The number of mortuary places, in the case of a catastrophe, is also insufficient. Although most hospitals set up a disaster plan on H5N1, there are only limited stocks of antiviral medication to protect the hospital staff in the acute phase. A separate triage area is only available in a limited number of hospitals. We conclude that Belgian hospitals and emergency departments are not equipped to deal with potential pandemic situations.