Applying temporal framework of team processes to emergency medical services (EMS): perceptions of EMS providers

Effective teamwork has been shown to optimize patient safety. However, teamwork research in Emergency Medical Services (EMS) is sparse. Before successful interventions can be implemented, the appropriate content of such interventions should be determined. We tested the applicability of a teamwork processes framework in emergency care (Fernandez et al., 2008) to the EMS context. We recruited participants from an EMS agency in Houston, TX, using purposive sampling. Full-time employees with a valid EMT/paramedic license were eligible. Using semi-structured format, we queried respondents on task/team functions and enablers/obstacles of teamwork in EMS. Phone interviews were recorded and transcribed. Structural coding was based on our theoretical model. Through a deliberative process, we combined codes into candidate themes. Analytic memos during coding and analysis identified potential themes, which were reviewed/refined, and compared against our framework. We reached saturation once 32 respondents completed interviews. Among participants, 30 (94%) were male; the median experience was 15 years. Our analysis identified the team processes in the Marks’ Teamwork Process Model in four domains: Action, Planning, Reflection and Interpersonal Processes. Additionally, the concepts cited as being central to team effectiveness in EMS were: leadership, crew familiarity, team cohesion, interpersonal trust, shared mental models, and procedural knowledge. The revised model was useful for describing teamwork processes that providers employ to drive performance in EMS. Additionally, we identified emergent concepts that influence teamwork processes in EMS. Our findings inform our understanding of teamwork processes in EMS, and may be useful in guiding future team-based interventions tailored to EMS.2019-11-08T00:00:00

The Initial Response to the Boston Marathon Bombing

We discuss the strengths of the medical response to the Boston Marathon bombings that led to the excellent outcomes. Potential shortcomings were recognized, and lessons learned will provide a foundation for further improvements applicable to all institutions

Together for Emergency Medicine in the United Arab Emirates!

As I began writing this article, I was stunned realizing that September 2019 marks the anniversary of a ten-year journey for the specialty of emergency medicine (EM) in the United Arab Emirates (UAE). I had returned home to the UAE after 17 years’ acquiring and refining knowledge and skills as well as building experience and expertise abroad. This included medical school studies in Ireland,1 an Emergency Medicine (EM) Residency training in Montreal, Quebec2, a Prehospital Care fellowship in Toronto, Ontario,3 a Disaster Medicine fellowship in Boston, Massachusetts4, and finally a public health graduate degree in Baltimore, Maryland5. Throughout that time spent in nations where EM was well-developed, I was persistently asking myself, “What can I learn from here to allow me to develop EM back home?”. This challenging journey was certainly exciting and beneficial and exposed me to so many different “systems”, to their strengths and weaknesses, to the different approaches used to address problems, needs and day-to-day operations, and reinforced my belief that there is room and a need for flexibility, variability and diversity in the EM models one could build

Emergency Medical Response in Mass Casualty Tunnel Incidents—with Emphasis on Prehospital Care

Responding to mass casualty incidents in a tunnel environment is problematic not least from a prehospital emergency medical services (EMS) perspective. The aim of this review was to 1) categorize preconditions for emergency response in tunnel environments based on Haddon’s matrix and 2) identify specific EMS knowledge of providing prehospital care. Twenty eight articles, reports and book chapters were selected for further analysis. Firstly, sorting the data from each included article was done according to Haddon’s matrix. The result covers human factors, technical factors, physical environmental factors and socioeconomic environmental factors all related to preconditions for emergency response. To describe the EMS’s knowledge the data was also sorted according to command and safety, communication, assessment, and triage treatment and transport, also known as CSCATT. Few studies, especially of high quality, actually provide detailed information regarding emergency response to tunnel incidents and those that do, often have a main focus on management by the rescue service. While many incidents studied were caused by fires in tunnels, thus requiring rescue service in action, the subsequent EMS response issues that have taken place appear to have been given limited attention. To optimize the survival rates and health of the injured, as well as to provide a safe and effective work environment for the emergency services, there is a need to explore the event phase

First-Responders and Emergency Department Healthcare Provider Interactions During Emergency Situations: A Grounded Theory Study

Interactions between and among first-responders and emergency department (ED) healthcare providers impact the way in which patients are managed during emergency situations. The purpose of this study was to develop a grounded theory to explain the interactions between and among first-responders and ED healthcare providers during emergency situations. Interprofessional collaboration and teamwork has been extensively studied, however little is known about interactions that include first-responders. This study was guided by Strauss and Corbin’s (1990) approach to grounded theory. Data were collected through 256 hours of first-responder and ED observational opportunities and informal interviews with accompanying detailed field notes. As well, in-depth semi-structured interviews were conducted with 15 first-responders and ED healthcare providers. Data were organized using NVivo 10 software. A constant comparative approach consistent with grounded theory was used to analyze the field notes, interview transcripts, and policy documents until theoretical saturation was achieved. The proposed theoretical model, the Interactional Theory of Emergency Response and Care (ITERC), explains the interactions between and among first-responders and ED healthcare providers. Coming together for public safety is the core category that helps to describe the social processes of interactions of first-responders and ED healthcare providers during emergency situations. The four domains or subcategories provide further explanation of the micro, meso, and macro contexts that facilitate and/or impede interactions during emergency response and care. Factors that support first-responders and ED healthcare providers in their coming together for public safety include role clarity, clear communication, IPE, shared policies, and strategies to enhance systems issues such as managing offload delays. Given the importance of interactions between and among first-responders and ED healthcare providers and the effects on public safety, the ITERC may provide a beginning blueprint to guide educators, administrators, and policy makers in planning strategies to enhance the micro, meso, and macro factors influencing emergency response and care

Threat assessment, sense making, and critical decision-making in police, military, ambulance, and fire services

Military and emergency response remain inherently dangerous occupations that require the ability to accurately assess threats and make critical decisions under significant time pressures. The cognitive processes associated with these abilities are complex and have been the subject of several significant, albeit service specific studies. Here, we present an attempt at finding the commonalities in threat assessment, sense making, and critical decision-making for emergency response across police, military, ambulance, and fire services. Relevant research is identified and critically appraised through a systematic literature review of English-language studies published from January 2000 through July 2020 on threat assessment and critical decision-making theory in dynamic emergency service and military environments. A total of 10,084 titles and abstracts were reviewed, with 94 identified as suitable for inclusion in the study. We then present our findings focused on six lines of enquiry: Bibliometrics, Language, Situation Awareness, Critical Decision Making, Actions, and Evaluation. We then thematically analyse these findings to reveal the commonalities between the four services. Despite existing single or dual service studies in the field, this research is significant in that it is the first examine decision making and threat assessment theory across all four contexts of military, police, fire and ambulance services, but it is also the first to assess the state of knowledge and explore the extent that commonality exists and models or practices can be applied across each discipline. The results demonstrate all military and emergency services personnel apply both intuitive and formal decision-making processes, depending on multiple situational and individual factors. Institutional restriction of decision-making to a single process at the expense of the consideration of others, or the inappropriate training and application of otherwise appropriate decision-making processes in certain circumstances is likely to increase the potential for adverse outcomes, or at the very least restrict peak performance being achieved. The applications of the findings of the study not only extend to facilitating improved practice in each of the individual services examined, but provide a basis to assist future research, and contribute to the literature exploring threat assessment and decision making in dynamic contexts

Threat assessment, sense making, and critical decision-making in police, military, ambulance, and fire services

Military and emergency response remain inherently dangerous occupations that require the ability to accurately assess threats and make critical decisions under significant time pressures. The cognitive processes associated with these abilities are complex and have been the subject of several significant, albeit service specific studies. Here, we present an attempt at finding the commonalities in threat assessment, sense making, and critical decision-making for emergency response across police, military, ambulance, and fire services. Relevant research is identified and critically appraised through a systematic literature review of English-language studies published from January 2000 through July 2020 on threat assessment and critical decision-making theory in dynamic emergency service and military environments. A total of 10,084 titles and abstracts were reviewed, with 94 identified as suitable for inclusion in the study. We then present our findings focused on six lines of enquiry: Bibliometrics, Language, Situation Awareness, Critical Decision Making, Actions, and Evaluation. We then thematically analyse these findings to reveal the commonalities between the four services. Despite existing single or dual service studies in the field, this research is significant in that it is the first examine decision making and threat assessment theory across all four contexts of military, police, fire and ambulance services, but it is also the first to assess the state of knowledge and explore the extent that commonality exists and models or practices can be applied across each discipline. The results demonstrate all military and emergency services personnel apply both intuitive and formal decision-making processes, depending on multiple situational and individual factors. Institutional restriction of decision-making to a single process at the expense of the consideration of others, or the inappropriate training and application of otherwise appropriate decision-making processes in certain circumstances is likely to increase the potential for adverse outcomes, or at the very least restrict peak performance being achieved. The applications of the findings of the study not only extend to facilitating improved practice in each of the individual services examined, but provide a basis to assist future research, and contribute to the literature exploring threat assessment and decision making in dynamic contexts

Construction and Implementation of First Aid Courses in Rural Populations: A Narrative Review

Colombia has been through five decades of civil war and unrest between the state and guerrilla groups and is currently in the process of healing. Several measures have been taken to aid the peace process, one of them being the Colombian-Norwegian cooperation Rural Health for Peace (RHfP) that aims to strengthen primary health care (PHC) in the areas most afflicted by the war. A previous study done by Søndenå (verbal communication, not yet published) have shown that even though there is no state funded health care in a rural village in Colombia, the inhabitants there make up their own kind of “micro healthcare” with the resources they have. The need for a first aid course was mentioned during the interviews Søndenå carried out. There is a strong local will to act, so there is a potential for targeted training to further enhance learning in regard to health. The purpose of this thesis is thus to perform a literature search to explore what a first aid course in a rural setting could and should contain

Recent developments in military transfusion practice and their impact on civilian healthcare

Introduction. Massive haemorrhage is the leading cause of preventable death following trauma. The mortality rate is high unless actively managed from Point of Injury (POI). However, during the last decade advances in military medicine, including transfusion support, appear to have delivered extraordinary survival advantages. A new transfusion policy was introduced in 2007 in response to the emerging analysis of combat experience underpinned by a revised understanding of the pathophysiology of trauma. Transfusion support was redesigned as part of Damage Control Resuscitation (DCR) to mitigate Trauma Induced Coagulopathy. The Massive Transfusion Capability was an ambitious programme designed to provide transfusion support throughout the continuum of care. The success has led to transfusion support being considered in military and civilian environments where there is a risk of haemorrhage but there is minimal medical infrastructure. Developments such as: a more portable cold chain; whole blood and lyophilised products offered Remote Damage Control Resuscitation (RDCR) whilst addressing the logistic tail. The delivery of the military capability has required considerable innovation during an era in which transfusion practice became subject to an increase in legislative and regulatory measures. The overall objective of this study is to evaluate the recent developments in military transfusion practice and to assess the impact on civilian practice. Methods. The study describes the developments in military transfusion support in a linear sequence from 2006 to 2016. The adoption of military principles and practice is then explored in the context of civilian practice and national emergency transfusion preparedness for Mass Casualty Events (MCE). The source material thesis is derived from the author’s military and civilian, professional and academic practice. The thesis submission is structured around four aims; two military thematic areas which are the recent changes in UK military blood transfusion practice and the development of prehospital transfusion. These are followed by two civilian themes; the introduction of Massive Transfusion Protocols (MTPs) and transfusion planning for Mass Casualty Events (MCEs). The military data has been extracted from the UK Joint Theatre Trauma Registry complimented by quality management systems. The civilian data is derived from the relevant Trauma Registries, Patient Administration Systems and Laboratory Information Management Systems. Descriptive statistics were used to summarize the number of components by year, speciality and patient demographics. Statistical analysis was performed using a variety of software tools. Results. The paradigm of military transfusion has changed in the last decade. The developments have been credited with contributing to survival of the critically injured. Survival is the product of the entire system of care, which – in this setting of combat, incorporates the early external haemorrhage control, hybrid resuscitation; rapid and physician-led recovery from the battlefield, damage control surgery, transfusion support and expert critical care. It is thus not possible to ascertain the individual contribution of transfusion however it has been an important element. Transfusion support is increasingly being considered in at risk environments with minimal infrastructure and logistic support. The collection of Whole blood from a pre-tested Emergency Donor panel is a viable transfusion management option. Knowledge sharing from the Bergen based Blood Far Forward program has enabled the further development of UK military practice. In addition, the concept of the safe universal whole blood donor has informed the wider transfusion community leading to the acceptance of group O Low titre as a new standard. Massive Transfusion Protocols (MTP) have been successfully introduced into civilian practice for both trauma and other causes of massive haemorrhage. Massive Transfusion (MT) is a phenomenon of surgery not trauma and the organisational principles can be applied to all causes of haemorrhage. MT is resource intensive and has implications for both hospital and blood service organisation. However, the civilian studies have not demonstrated a survival advantage and the definitions of MT require standardisation to allow comparison of practice and the design of further studies. The pattern of blood use in civilian Mass Casualty Events differs from that seen in the recent military experience in Afghanistan and Iraq. Far fewer injured require blood and few require Massive Transfusion and haemostatic component support. However, military style planning has added value to the preparation for MCEs and the response to Major Incidents. Elements of military planning have included the optimisation of pre-hospital care, haemorrhage control, transfusion triage, MTPs and emergency donor management. Transfusion Emergency Preparedness should become an integrated part of healthcare emergency planning. Conclusions. Transfusion has emerged as an essential and successful element of modern combat care. The success must be placed in the context of the whole healthcare system, especially pre-hospital care. The nature of military and civilian trauma differs however, many of the recent lessons identified have been intelligently applied to civilian hospital healthcare. Military practice has also informed both pre-hospital emergency care, blood component development and transfusion planning for MCEs. In turn, combat care has benefitted from civilian transfusion governance and regulatory expertise. The continued military-civilian collaboration and innovation in transfusion practice has the potential to benefit not only the military, but also the wider healthcare community

Improving disaster response evaluations : Supporting advances in disaster risk management through the enhancement of response evaluation usefulness

Future disasters or crises are difficult to predict and therefore hard to prepare for. However, while a specific event might not have happened, it can be simulated in an exercise. The evaluation of performance during such an exercise can provide important information regarding the current state of preparedness, and used to improve the response to future events. For this to happen, evaluation products must be perceived as useful by the end user. Unfortunately, it appears that this is not the case. Both evaluations and their products are rarely used to their full extent or, in extreme cases, are regarded as paper-pushing exercises.The first part of this research characterises current evaluation practice, both in the scientific literature and in Dutch practice, based on a scoping study, document and content analyses, and expert judgements. The findings highlight that despite a recent increase in research attention, few studies focus on disaster management exercise evaluation. It is unclear whether current evaluations achieve their purpose, or how they contribute to disaster preparedness. Both theory and practice tend to view, and present evaluations in isolation. This limited focus creates a fragmented field that lacks coherence and depth. Furthermore, most evaluation documentation fails to justify or discuss the rational underlying the selected methods, and their link to the overall purpose or context of the exercise. The process of collecting and analysing contextual, evidence-based data, and using it to reach conclusions and make recommendations lacks methodological transparency and rigour. Consequently, professionals lack reliable guidance when designing evaluations.Therefore, the second part of this research aimed to gain an insights into what make evaluations useful, and suggest improvements. In particular, it highlights the values associated with the methodology used to record and present evaluation outcomes to end users. The notion of an ‘evaluation description’ is introduced to support the identification of four components that are assumed to influence the usefulness of an evaluation: its purpose, object description, analysis and conclusion. Survey experiments identified that how these elements – notably, the analysis and/ or conclusions – are documented significantly influences the usefulness of the product. Furthermore, different components are more useful depending on the purpose of the report (for learning or accountability). Crisis management professionals expect the analysis to go beyond the object of the evaluation, and focus on the broader context. They expect a rigorous evaluation to provide them with evidence-based judgements that deliver actionable conclusions and support future learning.Overall, this research shows that the design and execution of evaluations should provide systematic, rigorous, evidence-based and actionable outcomes. It suggests some ways to manage both the process and the products of an evaluation to improve its usefulness. Finally, it underlines that it is not the evaluation itself that leads to improvement, but its use. Evaluation should, therefore, be seen as a means to an end