First aid (FA) services are provisioned on-site as a preventive measure at most public events. In Flanders, Belgium, the Belgian Red Cross-Flanders (BRCF) is the major provider of these FA services with volunteers being deployed at approximately 10,000 public events annually. The BRCF has systematically registered information on the patients being treated in FA posts at major events and mass gatherings during the last 10 years. This information has been collected in a web-based client server system called “MedTRIS” (Medical Triage and Registration Informatics System). MedTRIS contains data on more than 200,000 patients at 335 mass events. This report describes the MedTRIS architecture, the data collected, and how the system operates in the field. This database consolidates different types of information with regards to FA interventions in a standardized way for a variety of public events. MedTRIS allows close monitoring in “real time” of the situation at mass gatherings and immediate intervention, when necessary; allows more accurate prediction of resources needed; allows to validate conceptual and predictive models for medical resources at (mass) public events; and can contribute to the definition of a standardized minimum data set (MDS) for mass-gathering health research and evaluation.

GogaertS, Vande veegaeteA, ScholliersA, VandekerckhoveP. “MedTRIS” (Medical Triage and Registration Informatics System): A Web-based Client Server System for the Registration of Patients Being Treated in First Aid Posts at Public Events and Mass Gatherings. Prehosp Disaster Med. 2016;31(5):557–562.

Telehealth has great promise to improve and even revolutionize emergency response and recovery. Yet telehealth in general, and direct-to-consumer (DTC) telehealth in particular, are underutilized in disasters. Direct-to-consumer telehealth services allow patients to request virtual visits with health care providers, in real-time, via phone or video conferencing (online video or mobile phone applications). Although DTC services for routine primary care are growing rapidly, there is no published literature on the potential application of DTC telehealth to disaster response and recovery because these services are so new. This report presents several potential uses of DTC telehealth across multiple disaster phases (acute response, subacute response, and recovery) while noting the logistical, legal, and policy challenges that must be addressed to allow for expanded use.

Uscher-PinesL, FischerS, ChariR. The Promise of Direct-to-Consumer Telehealth for Disaster Response and Recovery. Prehosp Disaster Med. 2016;31(4):454–456.

The International Council of Nurses (ICN; Geneva, Switzerland) and the World Association for Disaster and Emergency Medicine (WADEM; Madison, Wisconsin USA) joined together in 2014 to review the use of the ICN Framework of Disaster Nursing Competencies. The existing ICN Framework (version 1.10; dated 2009) formed the starting point for this review. The key target audiences for this process were members of the disaster nursing community concerned with pre-service education for professional nursing and the continuing education of practicing professional nurses. To minimize risk in the disaster nursing practice, competencies have been identified as the foundation of evidence-based practice and standard development. A Steering Committee was established by the WADEM Nursing Section to discuss how to initiate a review of the ICN Framework of Disaster Nursing Competencies. The Steering Committee then worked via email to develop a survey to send out to disaster/emergency groups that may have nurse members who work/respond in disasters. Thirty-five invitations were sent out with 20 responses (57%) received. Ninety-five percent of respondents knew of the ICN Framework of Disaster Nursing Competencies, with the majority accessing these competencies via the Internet. The majority of those who responded said that they make use of the ICN Framework of Disaster Nursing Competencies with the most common use being for educational purposes. Education was done at a local, national, and international level. The competencies were held in high esteem and valued by these organizations as the cornerstone of their disaster education, and also were used for the continued professional development of disaster nursing. However, respondents stated that five years on from their development, the competencies also should include the psychosocial elements of nurses caring for themselves and their colleagues. Additionally, further studies should explore if there are other areas related to the disaster nursing practice (in addition to psychosocial concerns) that may be missing or not fully developed. Finally, the authors of this report recommend that future research explore how the ICN Framework of Disaster Nursing Competencies do or do not assist in maintaining best practices in this field and improve outcomes for victims of disaster.

HuttonA, VeenemaTG, GebbieK. Review of the International Council of Nurses (ICN) Framework of Disaster Nursing Competencies. Prehosp Disaster Med. 2016;31(6):680–683.

ColeJB, HoJD, BirosMH. Randomizing Patients without Consent: Waiver vs Exception from Informed Consent. Prehosp Disaster Med.2016;31(4):457–458.

Excited delirium syndrome (ExDS) is defined by marked agitation and confusion with sympathomimetic surge and incessant physical struggle, despite futility, which may lead to profound pathophysiologic changes and sudden death. Severe metabolic derangements, including lactic acidosis, rhabdomyolysis, and hyperthermia, occur. The pathophysiology of excited delirium is a subject of ongoing basic science and clinical research. Positive associations with ExDS include male gender, mental health disorders, and substance abuse (especially sympathomimetics).

Excited delirium syndrome patients often exhibit violent, psychotic behavior and have “superhuman” strength which can result in the patient fighting with police and first responders. Continued struggle can cause a patient with ExDS to experience elevated temperature (T) and acidosis which causes enzymes to fail, leading to sudden death from cardiovascular collapse and multi-system organ failure. Therefore, effective early sedation is optimal to stop this fulminant process.

Treatment of ExDS must be focused on rapidly, safely, and effectively sedating the patient and providing intensive, supportive care. Benzodiazepines, like midazolam, may not be ideal to sedate ExDS patients since their onset takes several minutes, and their side effects include loss of airway control and respiratory depression. Injectable antipsychotic medications have a relatively slow onset and may cause prolongation of the QTc interval. Ketamine is the ideal medication to sedate patients with ExDS. Ketamine has a rapid, predictable onset within three to four minutes when given by intramuscular (IM) injection. It does not adversely affect airway control, breathing, heart rate, or blood pressure (BP).

In this retrospective case series, prehospital scenarios in which ExDS patients received ketamine by paramedics for sedation, and their subsequent treatment in the emergency department (ED) and hospital, are described. It is demonstrated that ketamine administered by paramedics in the prehospital setting of a community hospital based Emergency Medical Services (EMS) system is a safe and effective treatment for ExDS.

ScaggsTR, GlassDM, HutchcraftMG, WeirWB. Prehospital Ketamine is a Safe and Effective Treatment for Excited Delirium in a Community Hospital Based EMS System. Prehosp Disaster Med. 2016;31(5):563–569.

A 32-year-old, fit and healthy, Caucasian male presented with a less than 24-hour history of palpitations with the onset following participation in helicopter underwater escape training (HUET). He reported no chest pain, shortness of breath, syncope, or pre-syncope symptoms. On examination, an irregularly irregular pulse was noted at a rate of 120 beats per minute with a blood pressure of 132/84. There was no evidence of congestive cardiac failure. The electrocardiogram (ECG) demonstrated atrial fibrillation at 97 beats per minute with a normal axis, normal QRS complexes, and a QTc of 399 ms. Bloods were all within normal limits and a chest x-ray showed no abnormality. The patient was loaded with amiodarone and reverted to sinus rhythm with a normal post-reversion ECG. Five years on, following further HUET, the patient presented with an identical presentation. His ECG showed fast atrial fibrillation at a rate of 115 beats per minute. On this occasion, he was sedated and Direct Current cardioverted with reversal to sinus rhythm after one shock. It was felt that the precipitating factor for this patient’s atrial fibrillation, in both cases, was HUET. The case discussed describes a previously fit and well subject who developed a sustained arrhythmia secondary to cold water submersion. Evidence suggests water submersion can provoke cardiac arrhythmias via the suggested theory of “autonomic conflict.” It has been proposed that a number of unexplained deaths related to water submersion may be secondary to arrhythmogenic syncope.

KaurPP, DrummondSE, FurykJ. Arrhythmia Secondary to Cold Water Submersion during Helicopter Underwater Escape Training. Prehosp Disaster Med. 2016;31(1):108–110.

This is a report of a thoracic vertebral fracture in a 79-year-old male survivor of out-of-hospital cardiac arrest with chest compressions provided by a LUCAS 2 (Physio-Control Inc.; Lund Sweden) device. This is the first such report in the literature of a vertebral fracture being noted in a survivor of cardiac arrest where an automated compression device was used.

MarshallRT, KotechaH, ChibaT, TennysonJ. Thoracic Spine Fracture in a Survivor of Out-of-Hospital Cardiac Arrest with Mechanical CPR. Prehosp Disaster Med. 2016;31(6):684–686.

HorneS, NutbeamT. You Can’t Make a Silk Purse Out of a Sow’s Ear: Time to Start Again with MCI Triage. Prehosp Disaster Med.2016;31(4):459–460.

Accidental hypothermia can lead to untoward cardiac manifestations and arrest. This report presents a case series of severe accidental hypothermia with cardiac complications in three emergency patients who were treated with extracorporeal membrane oxygenation (ECMO) and survived after re-warming. The aim of this discussion was to encourage more clinicians to consider ECMO as a re-warming therapy for severe hypothermia with circulatory collapse and to prompt discussion about decreasing the barriers to its use.

NiehausMT, PechulisRM, WuJK, FreiS, HongJJ, SandhuRS, GreenbergMR. Extracorporeal Membrane Oxygenation (ECMO) for Hypothermic Cardiac Deterioration: A Case Series. Prehosp Disaster Med. 2016;31(5):570–571.

This is a report of a fortunate story of an unusual AK-47 bullet trajectory which took place during the Paris (France) attack of November 13th, 2015. A young man, trying to protect his girlfriend, interfered between her and a shooter. He had been wounded in the posterior compartment of the thigh. The bullet penetrated him and, instead of exiting, rebound against his Smartphone, which was in the front pocket of his pants. Thanks to that, the missile bullet did not injure his girlfriend but ended its trajectory in the fat tissue of his thigh.

ThabouillotO, PerrierP, RocheNC, AgardD, BarbierO, MartinG, ViantE, LeclereJB. A Fortunate Story of an Unusual AK-47 Bullet Trajectory: Always Keep a Smartphone in Your Pocket. Prehosp Disaster Med, 2016;31(3):343–345.

The treatment of newborns in a disaster zone can be extremely challenging. The effects of the disaster combine with local health care disparity to give these neonates little chance of survival in the event of even minor complications. Rescue teams arriving at such locations must be prepared to handle and to aid these difficult situations using improvisation and ingenuity to overcome many of the unexpected hurdles. A discussion of the difficulties faced in the Philippines following a typhoon and recommendations for future teams are presented.

MendlovicJ, AlbukrekD, DaganD, MerinO, WeiserG. Improvised Neonatal Care–Realizing the Gaps in a Disaster Zone. Prehosp Disaster Med. 2016;31(1):111–113.

As one of the largest marathons worldwide, the Bank of America Chicago Marathon (BACCM; Chicago, Illinois USA) accumulates high volumes of data. Race organizers and engaged agencies need the ability to access specific data in real-time. This report details a data visualization system designed for the Chicago Marathon and establishes key principles for event management data visualization. The data visualization system allows for efficient data communication among the organizing agencies of Chicago endurance events. Agencies can observe the progress of the race throughout the day and obtain needed information, such as the number and location of runners on the course and current weather conditions. Implementation of the system can reduce time-consuming, face-to-face interactions between involved agencies by having key data streams in one location, streamlining communications with the purpose of improving race logistics, as well as medical preparedness and response.

HankenT, YoungS, SmilowitzK, ChiampasG, WaskowskiD. Developing a Data Visualization System for the Bank of America Chicago Marathon (Chicago, Illinois USA). Prehosp Disaster Med. 2016;31(5):572–577.