Terrorist attacks against healthcare facilities involving hostages.

INTRODUCTION: The incidence of terrorist attacks against healthcare facilities has been increasing over recent years. In addition to direct attacks on physical structures, many attacks have involved taking hostages. Hospital and healthcare facilities remain historically underprepared for terrorist attacks, representing vulnerable locations. Yet, studies examining the frequency and reach of hostage-taking incidents within healthcare facilities are limited. METHODS: A search of the Global Terrorism Database was performed. A total of 191,465 terrorist attacks were identified. The database search was narrowed down to healthcare-related terrorist attacks (2,322) and then manually analyzed to only include those incidents which involved hospitals and hostage-taking (64). RESULTS: Sixty-four attacks against hospitals involving hostage-taking were identified. A total of 91 victims were injured in these attacks, and 47 were killed. The attacks affected a total of 23 countries worldwide, conducted largely by unidentified terrorist organizations, with approximately half involving firearms. DISCUSSION: This study shows that terrorist attacks against healthcare facilities that involve -hostage-taking have increased in frequency over the past 10 years and have global reach. Systems may still be underprepared for this potentially increasing phenomenon and require preparedness plans with education and simulated practice in place. Healthcare facilities should consider mitigation strategies such as preparedness drills and additional education.

Terrorist Attacks Against Firefighters, 1970-2019.

Firefighters are a critical component of the emergency response system and therefore a potential target for organizations seeking to disrupt this system. Terrorist organizations may deliberately attack firefighters to both increase the devastation of an attack and impair the affected community's ability to respond to an attack. We performed a focused search of the Global Terrorism Database to identify terrorist attacks against firefighters worldwide. The database includes incidents from 1970 through 2019, with a total of 201,183 entries. These entries were searched for incidents involving firefighters or fire trucks. We analyzed trends in the number of incidents occurring per year, regions of the world impacted, methods employed, and number of casualties inflicted. A total of 42 attacks involving firefighters were identified in the Global Terrorism Database resulting in 26 deaths and 95 wounded. Of the 42 attacks, 12 (28.6%) were secondary attacks, where firefighters responding to an initial attack were themselves targeted. The most common method for both primary and secondary attacks was the use of a bomb or explosive. Although attacks against firefighters are uncommon, they highlight both the strategic value and vulnerability of firefighters to terrorist attacks. Increased efforts must be made to protect firefighters from future terrorist attacks.

Terrorist Attacks Against Performing Arts Venues: Global Trends and Characteristics Spanning 50 Years.

INTRODUCTION: In fostering community and culture through entertainment in shared spaces, performing arts venues have also become targets of terrorism. A greater understanding of these attacks is needed to assess the risk posed to different types of venues, to inform medical disaster preparedness, to anticipate injury patterns, and to reduce preventable deaths. METHODS: A search of the Global Terrorism Database (GTD) was conducted from the year 1970 through 2019. Using pre-coded variables for target/victim type and target subtype, attacks involving "business" and "entertainment/cultural/stadium/casino" were identified. Attacks targeting performing arts venues were selected using the search terms "theater," "theatre," "auditorium," "center," "hall," "house," "concert," "music," "opera," "cinema," and "movie." Manual review by two authors was performed to confirm appropriateness for inclusion of entries involving venues where the primary focus of the audience was to view a performance. Descriptive statistics were performed using R (version 3.6.1). RESULTS: A total of 312 terrorist attacks targeting performing arts venues were identified from January 1, 1970 through December 31, 2019. Two-hundred nine (67.0%) attacks involved cinemas or movie theaters, 80 (25.6%) involved unspecified theaters, and 23 (7.4%) specifically targeted live music performance venues. Two-hundred thirty-four (75.0%) attacks involved a bombing or explosion, 50 (16.0%) damaged a facility or infrastructure, and 17 (5.4%) included armed assault. Perpetrators used explosives in 234 (75.0%) attacks, incendiary weapons in 50 (16.0%) attacks, and firearms in 19 (6.1%) attacks. In total, attacks claimed the lives of 1,307 and wounded 4,201 persons. Though fewer in number, attacks against music venues were responsible for 29.4% of fatalities and 35.0% of those wounded, and more frequently involved the use of firearms. Among 95 attacks falling within the highest quartile for victims killed or wounded (>two killed and/or >ten wounded), 83 (87.4%) involved explosives, seven (7.4%) involved firearms, and three (3.2%) involved incendiary methods. CONCLUSION: While uncommon, terrorist attacks against performing arts venues carry the risk for mass casualties, particularly when explosives and firearms are used.

Terrorist Attacks Against Vaccinators: A Review.

Vaccinators fulfill an important role in a nation's public health by reducing the burden of disease on the population. Understanding patterns of attack employed against vaccinators is important to determine how to protect them. We conducted a search of the Global Terrorism Database for terrorist attacks against vaccinators that occurred between the years 1970 and 2018. Using the search terms "hospital," "healthcare," "clinic," "doctor," "nurses," "vaccinators," and "vaccinations," 2,322 healthcare-related entries were identified. We then manually searched the dataset for incidents related to attacks on vaccinators, which resulted in the identification of 133 attacks against vaccinators. The majority (128 out of 133) of attacks occurred during or after 2010. Every attack except one has occurred in the Middle East, South Asia, or sub-Saharan Africa. Pakistan has seen the most attacks against vaccinators, with 112 incidents recorded. Vaccinators continue to be vulnerable to terrorist attacks. Protection of healthcare personnel during mass vaccination efforts is critical so that they can continue their lifesaving mission.

Terrorist Attacks Against Healthcare Facilities: A Review.

Healthcare facilities play an essential role in response to terrorist attacks, but they also can be "soft targets" due to their accessibility and limited security. In this review, the authors used the Global Terrorism Database to conduct a search on terrorist attacks directed against hospitals and healthcare facilities between 1970 and 2018. Search terms included "healthcare," "doctor," "nurses," "vaccinators," "clinic," and "hospital," which resulted in 2,322 healthcare-related entries. The dataset was then manually searched for attacks on healthcare facilities, resulting in a total of 901 attacks in 74 different countries. The prevalence of healthcare facility attacks has increased, with 57% (515) occurring after 2001. The most common method of attack was bombing, followed by direct attacks on healthcare infrastructure and armed assaults. Healthcare facilities remain vulnerable to violence, and lessons learned in the aftermath of these incidents can be used to raise awareness about important safety-related concerns within the national response framework. Healthcare and security experts must be aware of the vulnerability of this crucial infrastructure and take active steps to prevent attacks.

Difficulty Ventilating: A Case Report on Ventilation Considerations of an Intubated Asthmatic Undergoing Air Medical Critical Care Transport.

The air medical transport of intubated patients is a high-risk mission that requires preplanning before helicopter launch. This case describes a scenario in which the helicopter emergency medical services (HEMS) team was unable to ventilate a patient because of the mechanical limitations of the transport ventilator. The HEMS mission was ultimately aborted, and the patient had to be transported by a ground crew equipped with a hospital-based ventilator. In addition to the optimal medical management of the patient in status asthmaticus, critical care transport crews must be familiar with the treatment of patients exhibiting extremely high peak airway pressures. Specifically, ventilator manipulations as well as the technical specifications of the transport ventilator may preclude the patient from being transported by the HEMS team. It is imperative that the patient's current ventilator setting be evaluated before the launch of the aircraft to prevent any possible delays in patient care.

Terrorists Use of Ambulances for Terror Attacks: A Review.

INTRODUCTION: Using an ambulance as an attack modality offers many advantages to a terrorist organization. Ambulances can carry more explosives than most vehicles and can often bypass security. Yet, studies examining how terrorist organizations have incorporated ambulances into their attacks are lacking. STUDY OBJECTIVE: This article seeks to identify and analyze known instances in which an ambulance has been used in a terrorist attack. METHODS: The Global Terrorism Database (GTD) was searched for terrorist events that involved the use of an ambulance from the years 1970-2018. Variables of event time, location, and loss of life were analyzed. RESULTS: Twenty instances where an ambulance had been used in a terrorist attack were identified from the GTD. Fifteen of the attacks occurred in the Middle East, while the remaining five occurred in Southeast Asia. All attacks except one had occurred after 2001, and 13 had occurred within the past decade. Most attacks (12/20) resulted in up to three people killed, while six attacks had 10-20 casualties. The deadliest attack occurred in Kabul, Afghanistan in 2018 and caused over 100 casualties. One event did not have casualty information in the GTD. In all cases, ambulances were used as vehicle-borne improvised explosive devices (VBIED) by terrorist organizations. CONCLUSION: This study shows that terrorists are increasingly acquiring and utilizing ambulances in their attacks, often with deadly consequences. Security and public health experts must be aware of this hazard and work to deny terrorists access to these vehicles.

Evaluating barriers to community CPR education.

OBJECTIVE: The primary objective of this study is to better understand the preferences of the general public regarding cardiopulmonary resuscitation (CPR) education as it relates to both format and the time and place of delivery. METHODS: Survey data were collected from a convenience sample at large public gatherings in Baltimore, Maryland, between May 23, 2015, and February 11, 2017. The survey was a 23-item single-page instrument administered at fairs and festivals. RESULTS: A total of 516 surveys were available for analysis. Twenty-four percent of the total population reported being very confident in performing CPR (scoring 8 to 10 on a Likert scale). Thirty-two percent of respondents who had previously taken a CPR class reported being very confident in performing CPR. A stepwise decline in reported confidence in performing CPR was observed as the time from last CPR class increased. Among all respondents the most favored instruction style was an instructor-led class. Least favorable was a local learning station at an event. The most favored location for instruction were libraries, while community festivals were least favored. CONCLUSION: Respondent preferences regarding the location and style of the training differed little between socioeconomic groups. Instructor-led instruction at local libraries was the most preferred option. CPR education offered at local learning stations during events and at community festivals were least favored among respondents. This study's findings can be used to more effectively structure CPR outreach and educational programs in an attempt to increase rates of bystander CPR.

Challenges Related to the Implementation of an EMS-Administered, Large Vessel Occlusion Stroke Score.

INTRODUCTION: There is considerable interest in triaging victims of large vessel occlusion (LVO) strokes to comprehensive stroke centers. Timely access to interventional therapy has been linked to improved stroke outcomes. Accurate triage depends upon the use of a validated screening tool in addition to several emergency medical system (EMS)-specific factors. This study examines the integration of a modified Rapid Arterial oCcclusion Evaluation (mRACE) score into an existing stroke treatment protocol. METHODS: We performed a retrospective review of EMS and hospital charts of patients transported to a single comprehensive stroke center. Adult patients with an EMS provider impression of "stroke/TIA," "CVA," or "neurological problem" were included for analysis. EMS protocols mandated the use of the Cincinnati Prehospital Stroke Score (CPSS). The novel protocol authorized the use of the mRACE score to identify candidates for triage directly to the comprehensive stroke center. We calculated specificity and sensitivity for various stroke screens (CPSS and a mRACE exam) for the detection of LVO stroke. The score's metrics were evaluated as a surrogate marker for a successful EMS triage protocol. RESULTS: We included 312 prehospital charts in the final analysis. The CPSS score exhibited reliable sensitivity at 85%. Specificity of CPSS for an LVO was calculated at 73%. For an mRACE score of five or greater, the sensitivity was 25%. Specificity for mRACE was calculated at 75%. The positive predictive value of the mRACE score for an LVO was estimated at 12.50%. CONCLUSION: In this retrospective study of patients triaged to a single comprehensive stroke center, the addition of an LVO-specific screening tool failed to improve accuracy. Reliable triage of LVO strokes in the prehospital setting is a challenging task. In addition to statistical performance of a particular stroke score, a successful EMS protocol should consider system-based factors such as provider education and training. Study limitations can inform future iterations of LVO triage protocols.

Mass-Gathering Medical Care in Electronic Dance Music Festivals.

Introduction Electronic dance music (EDM) festivals represent a unique subset of mass-gathering events with limited guidance through literature or legislation to guide mass-gathering medical care at these events. Hypothesis/Problem Electronic dance music festivals pose unique challenges with increased patient encounters and heightened patient acuity under-estimated by current validated casualty predication models. METHODS: This was a retrospective review of three separate EDM festivals with analysis of patient encounters and patient transport rates. Data obtained were inserted into the predictive Arbon and Hartman models to determine estimated patient presentation rate and patient transport rates. RESULTS: The Arbon model under-predicted the number of patient encounters and the number of patient transports for all three festivals, while the Hartman model under-predicted the number of patient encounters at one festival and over-predicted the number of encounters at the other two festivals. The Hartman model over-predicted patient transport rates for two of the three festivals. CONCLUSION: Electronic dance music festivals often involve distinct challenges and current predictive models are inaccurate for planning these events. The formation of a cohesive incident action plan will assist in addressing these challenges and lead to the collection of more uniform data metrics. FitzGibbon KM , Nable JV , Ayd B , Lawner BJ , Comer AC , Lichenstein R , Levy MJ , Seaman KG , Bussey I . Mass-gathering medical care in electronic dance music festivals. Prehosp Disaster Med. 2017;32(5):563-567.

Evaluating Barriers to Bystander CPR among Laypersons before and after Compression-only CPR Training.

OBJECTIVE: Bystander CPR is an essential part of out-of-hospital cardiac arrest (OHCA) survival. EMS and public safety jurisdictions have embraced initiatives to teach compression-only CPR to laypersons in order to increase rates of bystander CPR. We examined barriers to bystander CPR amongst laypersons participating in community compression-only CPR training and the ability of the training to alleviate these barriers. The barriers analyzed include fear of litigation, risk of disease transmission, fear of hurting someone as a result of doing CPR when unnecessary, and fear of hurting someone as a result of doing CPR incorrectly. METHODS: Laypersons attending community compression-only CPR training were administered surveys before and after community CPR training. Data were analyzed via standard statistical analyses. RESULTS: A total of 238 surveys were collected and analyzed between September 2015 and January 2016. The most common reported motivation for attending CPR training was "to be prepared/just in case" followed by "infant or child at home." Respondents reported that they were significantly more likely to perform CPR on a family member than a stranger in both pre-and post-training responses. Nevertheless, reported self-confidence in and likelihood of doing CPR on both family and strangers increased from pre-training to post-training. There was a statistically significant decrease in reported likelihood of all four barriers to prevent respondents from performing bystander CPR when pre-training responses were compared to post-training responses. Previous CPR training and history of having witnessed a sudden cardiac arrest (SCA) were both associated with decreased barriers to CPR, but previous training had no effect on reported likelihood of or confidence in performing CPR. CONCLUSION: The training initiative studied significantly reduced the reported likelihood of all barriers studied to prevent respondents from performing bystander CPR and also increased the reported confidence in doing CPR and likelihood of doing CPR on both strangers and family. However, it did not alleviate the pre-training discrepancy between likelihood of performing CPR on strangers versus family. Previous CPR training or certification had no impact on likelihood of or confidence in performing CPR.

Prehospital Sepsis Care.

Prehospital care providers are tasked with the delivery of time-sensitive care, and emergency medical services (EMS) systems must match patients to appropriate clinical resources. Modern systems are uniquely positioned to recognize and treat patients with sepsis. Interventions such as administration of intravenous fluid and transporting patients to the appropriate level of definitive care are linked to improved patient outcomes. As EMS systems refine their protocols for the recognition and stabilization of patients with suspected or presumed sepsis, EMS providers need to be educated about the spectrum of sepsis-related presentations and treatment strategies need to be standardized.

The Medical Duty Officer: An Attempt to Mitigate the Ambulance At-Hospital Interval.

INTRODUCTION: A lack of coordination between emergency medical services (EMS), emergency departments (ED) and systemwide management has contributed to extended ambulance at-hospital times at local EDs. In an effort to improve communication within the local EMS system, the Baltimore City Fire Department (BCFD) placed a medical duty officer (MDO) in the fire communications bureau. It was hypothesized that any real-time intervention suggested by the MDO would be manifested in a decrease in the EMS at-hospital time. METHODS: The MDO was implemented on November 11, 2013. A senior EMS paramedic was assigned to the position and was placed in the fire communication bureau from 9 a.m. to 9 p.m., seven days a week. We defined the pre-intervention period as August 2013 - October 2013 and the post-intervention period as December 2013 - February 2014. We also compared the post-intervention period to the "seasonal match control" one year earlier to adjust for seasonal variation in EMS volume. The MDO was tasked with the prospective management of city EMS resources through intensive monitoring of unit availability and hospital ED traffic. The MDO could suggest alternative transport destinations in the event of ED crowding. We collected and analyzed data from BCFD computer-aided dispatch (CAD) system for the following: ambulance response times, ambulance at-hospital interval, hospital diversion and alert status, and "suppression wait time" (defined as the total time suppression units remained on scene until ambulance arrival). The data analysis used a pre/post intervention design to examine the MDO impact on the BCFD EMS system. RESULTS: There were a total of 15,567 EMS calls during the pre-intervention period, 13,921 in the post-intervention period and 14,699 in the seasonal match control period one year earlier. The average at-hospital time decreased by 1.35 minutes from pre- to post-intervention periods and 4.53 minutes from the pre- to seasonal match control, representing a statistically significant decrease in this interval. There was also a statistically significant decrease in hospital alert time (approximately 1,700 hour decrease pre- to post-intervention periods) and suppression wait time (less than one minute decrease from pre- to post- and pre- to seasonal match control periods). The decrease in ambulance response time was not statistically significant. CONCLUSION: Proactive deployment of a designated MDO was associated with a small, contemporaneous reduction in at-hospital time within an urban EMS jurisdiction. This project emphasized the importance of better communication between EMS systems and area hospitals as well as uniform reporting of variables for future iterations of this and similar projects.

2016: emergency medical services annotated literature in review.

In the daily practice of emergency medicine, physicians constantly interact with components of emergency medical services systems. The provision of high-quality care in the prehospital setting requires emergency physicians to remain abreast of recent literature that may inform the care of patients prior to their arrival at the emergency department. This literature review will examine some recent trends in the prehospital literature. In addition, the review will highlight important areas of clinical practice which represent some of the many intersections between emergency medicine and emergency medical services such as cardiac arrest and airway management.

Patients without ST elevation after return of spontaneous circulation may benefit from emergent percutaneous intervention: A systematic review and meta-analysis.

INTRODUCTION: The American Heart Association recommends that post-arrest patients with evidence of ST elevation myocardial infarction (STEMI) on electrocardiogram (ECG) be emergently taken to the catheterization lab for percutaneous coronary intervention (PCI). However, recommendations regarding the utility of emergent PCI for patients without ST elevation are less specific. This review examined the literature on the utility of PCI in post-arrest patients without ST elevation compared to patients with STEMI. METHODS: A systematic review of the English language literature was performed for all years to March 1, 2015 to examine the hypothesis that a percentage of post-cardiac arrest patients without ST elevation will benefit from emergent PCI as defined by evidence of an acute culprit coronary lesion. RESULTS: Out of 1067 articles reviewed, 11 articles were identified that allowed for analysis of data to examine our study hypothesis. These studies show that patients presenting post cardiac arrest with STEMI are thirteen times more likely to be emergently taken to the catheterization lab than patients without STEMI; OR 13.8 (95% CI 4.9-39.0). Most importantly, the cumulative data show that when taken to the catheterization lab as much as 32.2% of patients without ST elevation had an acute culprit lesion requiring intervention, compared to 71.9% of patients with STEMI; OR 0.15 (95% CI 0.06-0.34). CONCLUSION: The results of this systematic review demonstrate that nearly one third of patients who have been successfully resuscitated from cardiopulmonary arrest without ST elevation on ECG have an acute lesion that would benefit from emergent percutaneous coronary intervention.