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Abstract Background To minimize loss of life, modern mass casualty response requires swift identification, efficient triage categorization, and rapid hemorrhage control. Current training methods remain suboptimal. Our objective was to train first responders to triage a mass casualty incident using Virtual Reality (VR) simulation and obtain their impressions of the training’s quality and effectiveness. We trained subjects in a triage protocol called Sort, Assess, Lifesaving interventions, and Treatment and/or Transport (SALT) Triage then had them respond to a terrorist bombing of a subway station using a fully immersive virtual reality simulation. We gathered learner reactions to their virtual reality experience and post-encounter debriefing with a custom electronic survey. The survey was designed to gather information about participants’ demographics and prior experience, including roles, triage training, and virtual reality experience. We then asked them to evaluate the training and encounter and the system’s potential for training others. Results We received 375 completed evaluation surveys from subjects who experienced the virtual reality encounter. Subjects were primarily paramedics, but also included medical learners as well as other emergency medical service (EMS) professionals. Most participants (95%) recommended the experience for other first responders and rated the simulation (95%) and virtual patients (91%) as realistic. Ninety-four percent (94%) of participants rated the virtual reality simulator as “excellent” or “good.” We observed some differences between emergency medical service and medical professionals regarding their prior experience with disaster response training and their opinions on how much the experience contributed to their learning. We observed no differences between subjects with extensive virtual reality experience and those without. Conclusions Our virtual reality simulator is an automated, customizable, fully immersive virtual reality system for training and assessing personnel in the proper response to a mass casualty incident. Participants perceived the simulator as an adequate alternative to traditional triage and treatment training and believed that the simulator was realistic and effective for training. Prior experience with virtual reality was not a prerequisite for the use of this system.

Abstract Objective The COVID‐19 pandemic required unprecedented changes to emergency medical services (EMS) educational frameworks in the United States. It is unclear if pandemic‐related changes impacted paramedic educational outcomes. We aimed to evaluate curricular and performance changes resulting from the initial COVID‐19 pandemic on paramedic educational programs. Methods We performed a retrospective cross‐sectional evaluation of paramedic educational programs in 2019 and 2020 using the Committee on Accreditation of Educational Programs for the Emergency Medical Services Professions annual reports. These reports contain detailed program components and measures of program success. We included programs reporting at least one graduate in the study period. Descriptive statistics (proportions [%], median [interquartile range, IQR]) were calculated for paramedic program characteristics in 2019 and 2020, as well as pandemic specific curriculum changes. Wilcoxon rank‐sum and Fisher's exact tests were used to evaluate differences in characteristics by year. Results The number of paramedic educational programs in our population decreased from 640 programs in 2019 to 612 in 2020, with a statistically significant decrease in clinical hours (2019: 219 [IQR 168‒272]; 2020: 200.5 [IQR 157‒261]). There was no difference in first or third‐attempt certification examination success between years. Temporary shutdown was experienced in 34% of programs (duration: 3 weeks [2‒7]) and 72% of required curricular changes. Curricular changes commonly included decreased in‐person education (86%), traditional classroom lectures (78%), number of clinical sites (78%), and increased online didactic education (92%). Only 20% of programs decreased laboratory simulation or total training hours. Conclusion During the pandemic, paramedic educational programs changed educational delivery with no observed differences on overall program performance. Identifying key curricular changes and best practices for implementation may be necessary to better optimize future educational delivery.

Abstract Objectives Despite the significant disease burden due to cardiac arrest, there is a relative paucity of randomized controlled trials (RCTs) to inform definitive management. We aimed to evaluate the current scope of cardiac arrest RCTs published between 2015 and 2022. Methods We conducted a search in October 2023 of MEDLINE, Embase, and Web of Science for cardiac arrest RCTs. We included trials published between 2015 and 2022 enrolling human subjects suffering from non‐traumatic cardiac arrest. Descriptive statistics were reported and the Mann Kendall test was used to evaluate for temporal trends in the number of trials published annually. Results We identified 1764 unique publications, 87 RCTs were included after title/abstract and full‐text review. We found no significant increase in trials published annually (eight in 2015 and 16 in 2022, p = 1.0). Geographic analysis of study centers found 31 countries represented; Denmark (n = 13, 15%) and the United States (n = 9, 10%) conducted the majority of trials. Nearly all trials included adults (n = 84, 97%) and few included children (n = 9, 10%). The majority of trials focused on out‐of‐hospital cardiac arrest (n = 62, 71%). Thirty‐eight (44%) trials used an intervention characterized as a process improvement; 28 (32%) interventions were characterized as a drug and 20 (23%) as a device. Interventions were implemented with similar frequency in the prehospital (33%) and intensive care unit (38%) setting, as well as similarly between the intra‐arrest (53%) and post‐arrest (46%) periods. Twenty (27%) trials selected a primary outcome of survival at ≥ 28 days. Conclusions Publication of cardiac arrest RCTs remained constant between 2015 and 2022. We identified significant gaps including a lack of trials examining in‐hospital cardiac arrest and pediatric patients.

Abstract Objectives Safety policies enacted in response to the emergence of coronavirus disease 2019 (COVID‐19) have greatly affected the working environments of emergency medical service (EMS) clinicians. Our objective was to evaluate whether changes in the EMS environment during the COVID‐19 pandemic were associated with increased workplace conflict. Methods This evaluation was a cross‐sectional analysis of a random sample of 19,497 national certified EMS clinicians who were selected to receive an electronic survey in April 2022. The survey included an assessment of their level of stress using the Perceived Stress Scale instrument and examined changes in their working environment they perceived had occurred due to the emergence of COVID‐19. Logistic regression modeling was used to evaluate the associations between workforce demographics, infrastructure, scheduling, and policies to and COVID‐19‐induced coworker conflict. Results A total of 1686 responses were evaluated (response rate 10%). We found that COVID‐19 was reported to have exacerbated conflict between coworkers in 51% of responses. Respondents who perceived an increase in coworker conflict due to COVID‐19 self‐reported higher levels of stress than the rest of the respondents. Perceptions of the impact of COVID‐19 on conflict had also an association with the level of certification, indicating that national registered paramedics were more likely than emergency medical technicians to report coworker conflict due to COVID‐19 (adjusted odds ratio [AOR] 1.30, 95% confidence interval [CI] 1.05–1.61). Multivariable analysis highlighted the impact of mandatory overtime policies, reported by 27% of the respondents and associated with higher odds of exacerbated coworker conflict in our model (AOR 2.05, 95% CI 1.62–2.60). Conclusions These findings indicate that conflict can be considered a potential indicator of high levels of stress in the EMS workforce and may be a reliable signal to monitor when implementing mandates that affect EMS clinicians and their workloads.

Background The transition from medical student to intern is a recognized educational gap. To help address this, the Association of American Medical Colleges developed the Core Entrustable Professional Activities for entering residency. As these metrics outline expectations for all graduating students regardless of specialty, the described procedural expectations are appropriately basic. However, in procedure-heavy specialties such as emergency medicine, the ability to perform advanced procedures continues to contribute to the disconnect between undergraduate and graduate medical education. To prepare our graduating students for their internship in emergency medicine, we developed a simulation-based mastery learning curriculum housed within a specialty-specific program. Our overall goal was to develop the students’ procedural competency for central venous catheter placement and endotracheal intubation before graduation from medical school.Methods Twenty-five students participated in a simulation-based mastery learning procedures curriculum for ultrasound-guided internal jugular central venous catheter placement and endotracheal intubation. Students underwent baseline assessment, deliberate practice, and post-test assessments. Both the baseline and post-test assessments used the same internally developed checklists with pre-established minimum passing scores.Results Despite completing an emergency medicine rotation and a critical care rotation, none of the students met the competency standard during their baseline assessments. All twenty-five students demonstrated competency on both procedures by the end of the curriculum. A second post-test was required to demonstrate achievement of the central venous catheter and endotracheal intubation minimum passing scores by 16% and 28% of students, respectively.Conclusions Students demonstrated procedural competency for central venous catheter placement and endotracheal intubation by engaging in simulation-based mastery learning procedures curriculum as they completed their medical school training. With three instructional hours, students were able to achieve basic procedural competence for two common, high-risk procedures they will need to perform during emergency medicine residency training.

Objective: Public health surveillance is essential for improving community health. The Cardiac Arrest Registry to Enhance Survival (CARES) is a surveillance system for out-of-hospital cardiac arrest (OHCA). We describe results of the organized statewide implementation of Ohio CARES. Methods: We performed a retrospective analysis of CARES enactment in Ohio. Key elements included: establishment of statewide leadership, appointment of a dedicated coordinator, conversion to a statewide subscription, statewide dissemination of information, fundraising from internal and external stakeholders, and conduct of resuscitation academies. We identified all adult (≥18 years) OHCA reported in the registry during 2013–2020. We evaluated OHCA characteristics before (2013–2015) and after (2016–2019) statewide implementation using chi-square test. We evaluated trends in OHCA outcomes using the Cochran-Armitage test of trend. Results: Statewide CARES promotion increased participation from 2 (urban) to 136 (129 urban, 7 rural) EMS agencies. Covered population increased from 1.2 M (10% of state) to 4.8 M (41% of state). After statewide implementation, OHCA populations increased male (58.1% vs 60.8%, p

ABSTRACTIncreasing vaccination acceptance has been essential during the COVID-19 pandemic and in preparation for future public health emergencies. This study aimed to identify messaging strategies to encourage vaccine uptake by measuring the drivers of COVID-19 vaccination among the general public. A survey to assess COVID-19 vaccination acceptance and hesitancy was advertised on Facebook in February–April 2022. The survey included items asking about COVID-19 vaccination status and participant demographics, and three scales assessing medical mistrust, perceived COVID-19 risk, and COVID-19 vaccine confidence (adapted from the Oxford COVID-19 vaccine confidence and complacency scale). The main outcome was vaccination, predicted by patient demographics and survey scale scores. Of 1,915 survey responses, 1,450 (75.7%) were included, with 1,048 (72.3%) respondents reporting they had been vaccinated. In a multivariable regression model, the COVID-19 vaccine confidence scale was the strongest predictor of vaccination, along with education level and perceived COVID-19 risk. Among the items on this scale, not all were equally important in predicting COVID-19 vaccination. The items that best predicted vaccination, at a given score on the COVID-19 vaccine confidence scale, included confidence that vaccine side effects are minimal, that the vaccine will work, that the vaccine will help the community, and that the vaccine provides freedom to move on with life. This study improved our understanding of perceptions most strongly associated with vaccine acceptance, allowing us to consider how to develop messages that may be particularly effective in encouraging vaccination among the general public for both the COVID-19 pandemic and future public health emergencies.

Summary: The evolution of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) continues to challenge the efficacy of vaccination efforts against coronavirus disease 2019 (COVID-19). The Omicron XBB lineage of SARS-CoV-2 has presented dramatic evasion of neutralizing antibodies stimulated by mRNA vaccination and COVID-19 convalescence. XBB.1.16, characterized by two mutations relative to the dominating variant XBB.1.5, i.e., E180V and K478R, has been on the rise globally. In this study, we compare the immune escape of XBB.1.16 with XBB.1.5, alongside ancestral variants D614G, BA.2, and BA.4/5. We demonstrate that XBB.1.16 is strongly immune evasive, with extent comparable to XBB.1.5 in bivalent-vaccinated healthcare worker sera, 3-dose-vaccinated healthcare worker sera, and BA.4/5-wave convalescent sera. Interestingly, the XBB.1.16 spike is less fusogenic than that of XBB.1.5, and this phenotype requires both E180V and K478R mutations to manifest. Overall, our findings emphasize the importance of the continued surveillance of variants and the need for updated mRNA vaccine formulations.

Abstract Objective Although 911 calls for acute shortness of breath are common, the role of emergency medical services (EMS) in acute asthma care is unclear. We sought to characterize the demographics, course, and outcomes of adult emergency department (ED) patients with asthma in the United States receiving initial EMS care. Methods We analyzed data from the 2016–2019 National Hospital Ambulatory Medical Care Survey (NHAMCS). We included patients aged ≥18 years with an ED visit diagnosis of asthma, stratifying the cases according to initial EMS care. Accounting for the survey design of NHAMCS, we generated nationalized estimates of the number of EMS and non‐EMS asthma visits. Using logistic regression, we determined the associations between initial EMS care and patient demographics (age, sex, race, and insurance type), ED course (initial vital signs, triage category, testing, medications), and outcomes (hospital admission, ED length of stay). Results Of 435 million adult ED visits during 2016–2019, there were ≈5.3 million related to asthma (1.3 million annually, 1.2%; 95% confidence interval [CI], 1.1%–1.4%). A total of 602,569 (150,642 annually, 11.3%; 95% CI, 8.6%–14.8%) ED patients with asthma received initial EMS care. Compared with non‐EMS asthma patients, EMS asthma patients were more likely to present with an “urgent” ED triage category (odds ratio [OR], 22.2; 95% CI, 6.6–74.9) and to undergo laboratory (OR, 2.78; 95% CI, 1.41–5.46) or imaging tests (OR, 2.42; 95% CI, 1.21–4.83). ED patients with asthma receiving initial EMS care were almost 3 times more likely to be admitted to the hospital (OR, 2.81; 95% CI, 1.27–6.25). There were no differences in demographics, ED use of β‐agonists or corticosteroids, or ED length of stay between EMS and non‐EMS asthma patients. Conclusions Approximately 1 in 10 adult ED patients with asthma receive initial care by EMS. EMS asthma patients present to the ED with higher acuity, undergo more diagnostic testing in the ED, and are more likely to be admitted. Although limited in information regarding the prehospital course, these findings highlight the more severe illness of asthma patients transported by EMS and underscore the importance of EMS in emergency asthma care.

Abstract Objective There is growing concern with the strength and stability of the emergency medical services (EMS) workforce with reports of workforce challenges in many communities in the United States. Our objective was to estimate changes in the EMS workforce by evaluating the number of clinicians who enter, stay, and leave. Methods A 4‐year retrospective cohort evaluation of all certified EMS clinicians at the emergency medical technician (EMT) level or higher was conducted for 9 states that require national EMS certification to obtain and maintain EMS licensure. The study spanned 2 recertification cycles (2017–2021) for 2 workforce populations: the certified workforce (all EMS clinicians certified to practice) and the patient care workforce (the subset who reported providing patient care). Descriptive statistics were calculated and classified into 1 of 3 categories: EMS clinicians who entered, stayed in, or left each respective workforce population. Results There were 62,061 certified EMS clinicians in the 9 included states during the study period, and 52,269 reported providing patient care. For the certified workforce, 80%–82% stayed in and 18%–20% entered the workforce. For the patient care workforce, 74%–77% stayed and 29%–30% entered. State‐level rates of leaving each workforce ranged from 16% to 19% (certified) and 19% to 33% (patient care). From 2017 to 2020, there was a net growth of both the certified (8.8%) and patient care workforces (7.6%). Conclusions This was a comprehensive evaluation of both the certified and patient care EMS workforce dynamics in 9 states. This population‐level evaluation serves as the first step for more detailed analyses to better understand workforce dynamics in EMS.

Summary: Omicron subvariants continuingly challenge current vaccination strategies. Here, we demonstrate nearly complete escape of the XBB.1.5, CH.1.1, and CA.3.1 variants from neutralizing antibodies stimulated by three doses of mRNA vaccine or by BA.4/5 wave infection, but neutralization is rescued by a BA.5-containing bivalent booster. CH.1.1 and CA.3.1 show strong immune escape from monoclonal antibody S309. Additionally, XBB.1.5, CH.1.1, and CA.3.1 spike proteins exhibit increased fusogenicity and enhanced processing compared with BA.2. Homology modeling reveals the key roles of G252V and F486P in the neutralization resistance of XBB.1.5, with F486P also enhancing receptor binding. Further, K444T/M and L452R in CH.1.1 and CA.3.1 likely drive escape from class II neutralizing antibodies, whereas R346T and G339H mutations could confer the strong neutralization resistance of these two subvariants to S309-like antibodies. Overall, our results support the need for administration of the bivalent mRNA vaccine and continued surveillance of Omicron subvariants.

Abstract Objective Recent concerns for the strength and stability of the emergency medical services (EMS) workforce have fueled interest in enhancing the entry of EMS clinicians into the workforce. However, the educational challenges associated with workforce entry remain unclear. Our objective was to evaluate the educational pathway of entry into the EMS workforce and to identify factors that lead to the loss of potential EMS clinicians. Methods This is a cross‐sectional evaluation of all US paramedic educational programs, with enrolled students, in the 2019 Committee on Accreditation of Educational Programs for the EMS Professions annual report survey. This data set includes detailed program characteristics and metrics including program attrition rate (leaving before completion), and certifying exam pass rates. Descriptive statistics were calculated, and multivariable logistic regression analysis was conducted to evaluate the association between high program attrition rates (>30%) and program specific characteristics. Results In 2019, 640 accredited programs met inclusion with 17,457 students enrolled in paramedic educational programs. Of these, 13,884 students successfully graduated (lost to attrition, 3,573/17,457 [21%]) and 12,002 passed the certifying exam on the third attempt (lost to unable to certify, 1,882/17,457 [11%]). High program attrition rates were associated with longer programs (>12 months), small class sizes (

Abstract As mass casualty incidents continue to escalate in the United States, we must improve frontline responder performance to increase the odds of victim survival. In this article, we describe the First Responder Virtual Reality Simulator, a high‐fidelity, fully immersive, automated, programmable virtual reality (VR) simulation designed to train frontline responders to treat and triage victims of mass casualty incidents. First responder trainees don a wireless VR head‐mounted display linked to a compatible desktop computer. Trainees see and hear autonomous, interactive victims who are programmed to simulate individuals with injuries consistent with an explosion in an underground space. Armed with a virtual medical kit, responders are tasked with triaging and treating the victims on the scene. The VR environment can be made more challenging by increasing the environmental chaos, adding patients, or increasing the acuity of patient injuries. The VR platform tracks and records their performance as they navigate the disaster scene. Output from the system provides feedback to participants on their performance. Eventually, we hope that the First Responder system will serve both as an effective replacement for expensive conventional training methods as well as a safe and efficient platform for research on current triage protocols.

Introduction: Emergency medicine (EM) programs train residents to perform clinical procedures with known iatrogenic risks. Currently, there is no established framework for graduating medical students to demonstrate procedural competency prior to matriculating into residency. Mastery-based learning has demonstrated improved patient-safety outcomes. Incorporation of this framework allows learners to demonstrate procedural competency to a predetermined standard in the simulation laboratory prior to performing invasive procedures on patients in the clinical setting. This study describes the creation and implementation of a competency-based procedural curriculum for first-year EM residents using simulation to prepare learners for supervised participation in procedures during patient care. Methods: Checklists were developed internally for five high-risk procedures (central venous line placement, endotracheal intubation, lumbar puncture, paracentesis, chest tube placement). Performance standards were developed using Mastery-Angoff methods. Minimum passing scores were determined for each procedure. Over a two-year period, 38 residents underwent baseline assessment, deliberate practice, and post-testing against the passing standard score to demonstrate procedural competency in the simulation laboratory during intern orientation. Results: We found that 37% of residents required more than one attempt to achieve the minimum passing score on some procedures, however, all residents ultimately met the competency standard on all five high-risk procedures in simulation. One critical incident of central venous catheter guideline retention was identified in the simulation laboratory during the second year of implementation. Conclusion: All incoming first-year EM residents demonstrated procedural competence on five different procedures using a mastery-based educational framework. A competency-based EM curriculum allowed for demonstration of procedural competence prior to resident participation in supervised clinical patient care.

Reasons for COVID-19 hesitancy are multi-faceted and tend to differ from those for general vaccine hesitancy. We developed the COVID-19 Vaccine Concerns Scale (CVCS), a self-report measure intended to better understand individuals’ concerns about COVID-19 vaccines. We validated the scale using data from a convenience sample of 2,281 emergency medical services providers, a group of professionals with high occupational COVID-19 risk. Measures included the CVCS items, an adapted Oxford COVID-19 vaccine hesitancy scale, a general vaccine hesitancy scale, demographics, and self-reported COVID-19 vaccination status. The CVCS had high internal consistency reliability (α = .89). A one-factor structure was determined by exploratory and confirmatory factor analyses (EFA and CFA), resulting in a seven-item scale. The model had good fit (X2[14] = 189.26, p

Introduction: It is unclear how best to identify “high-risk” areas for out-of-hospital cardiac arrest (OHCA) and if neighborhood-level interventions improve bystander cardiopulmonary resuscitation (BCPR). Our objectives were to 1) identify and compare community characteristics between high and low-risk neighborhoods; and 2) examine change in BCPR after a targeted hands-only CPR intervention. Methods: This was a cross-sectional analysis of OHCA events in Franklin County, Ohio between 1/1/2010–12/31/2017. Adult (≥18 years) OHCAs in a non-healthcare setting with emergency medical services resuscitation attempted were included. High-risk neighborhoods based on OHCA incidence and BCPR rates were identified using global Empirical Bayes, Local Moran’s I, and spatial scan statistic. We compared characteristics of high and low-risk neighborhoods and examined change in BCPR. Results: From the 3,841 included OHCAs, the mean adjusted OHCA incidence per census tract was 0.81 per 1,000, BCPR rate was 37.2%, and survival to hospital discharge was 11.5%. Of the 35 census tracts identified as high-risk, ten persisted from previous work. OHCA incidence was higher in high-risk neighborhoods (1.30 per 1,000 vs. 0.73, p

Abstract Objective As the COVID‐19 pandemic began, there were significant concerns for the strength and stability of the emergency medical services (EMS) workforce. These concerns were heightened with the closure of examination centers and the cessation of certification examinations. The impact of this interruption on the EMS workforce is unclear. Our objective was to evaluate the impact of COVID‐19 on initial EMS certification in the United States. In addition, we evaluated mitigation measures taken to address these interruptions. Methods This study was a cross‐sectional evaluation of the National Certification Cognitive Examination administration and results for emergency medical technician (EMT) and paramedic candidates. We compared the number of examinations administered and first‐attempt pass rates in 2020 (pandemic) to 2019 (control). Descriptive statistics and 2 one‐sided tests of equivalence were used to assess if there was a relevant difference of ±5 percentage points. Results Total number of examinations administered decreased by 15% (EMT, 14%; paramedic, 7%). Without the addition of EMT remote proctoring, the EMT reduction would have been 35%. First‐time pass rates were similar in both EMT (−0.9%) and paramedic (−1.9%) candidates, which did not meet our threshold of a relevant difference. Conclusion COVID‐19 has had a measurable impact on examination administration for both levels of certification. First‐time pass rates remained unaffected. EMT remote proctoring mitigated some of the impact of COVID‐19 on examination administration, although a comparison with mitigation was not assessed. These reductions indicate a potential decrease in the newly certified workforce, but future evaluations will be necessary to assess the presence and magnitude of this impact.

Abstract Background Describing the US emergency medical services workforce is important to understand gaps in recruitment and retention and inform efforts to improve diversity. Our objective was to describe the characteristics and temporal trends of emergency medical technicians (EMTs) and paramedics in the United States. Methods We performed a repeated cross‐sectional evaluation of US Census Bureau's American Community Survey 1‐year Public Use Microdata Sample data sets from 2011–2019. We included respondents working as an EMT or paramedic. Survey‐weighted descriptive statistics of demographic and employment characteristics were calculated. Trend analysis was conducted using joinpoint regression to estimate slope and annual percent change (APC). Results The total estimated number of EMTs and paramedics in the United States increased from 216,310 (95%CI 204,957–227,663) in 2011 to 289,830 (95%CI 276,918–302,743) in 2019 (APC 3.0%; 95%CI 1.4%, 4.7%). There was a slight increase in the proportion of females (2011, 31%; 2019, 35%). There was a significant decrease in proportion of non‐Hispanic whites (2011, 80%; 2019, 72%; APC −1.5%; 95%CI −2.0%, −0.9%) with concurrent increases in other racial/ethnic groups (e.g., Hispanics, 2011, 10%; 2019, 13%). About half worked >40 hours per week, with little change over time. Between 15% and 18% lived and worked in different states, and about 40% traveled ≥30 minutes to their workplace. Conclusions The number of EMTs and paramedics actively working in EMS as their primary paid occupation has increased over time. However, there have been only modest changes in their demographic diversity.

Abstract Introduction To evaluate emergency medical services (EMS) professional response to escalating threats of violence during simulated patient encounters and describe differences in behaviors by characteristics. Methods EMS professionals of a large county‐based system participated in 1 of 4 standardized patient care scenarios. Each 8‐minute scenario included escalated threats of violence such that EMS personnel should escape the scene for safety. Trained evaluators recorded EMS professionals' performance using standardized data elements. Outcomes included EMS personnel escape and verbal de‐escalation attempts. Descriptive statistics and univariable odds ratios (OR) with 95% confidence intervals (95% CI) are reported. Results There were 270 EMS professionals evaluated as individual members of 2‐person crews. Overall, 54% escaped the unsafe scene and 54% made an adequate de‐escalation attempt; 20% did not make an adequate de‐escalation attempt nor escape the unsafe scene. Paramedics demonstrated lower odds of escaping compared to emergency medical technicians (OR: 0.40; 95% CI: 0.17–0.94), yet greater odds of adequate de‐escalation (OR: 3.17, 95% CI: 1.38–7.31). EMS professionals with more than 20 years of experience (OR: 0.32, 95% CI: 0.13–0.79, ref:2 years or less) and those with military experience (OR: 0.37; 95% CI: 0.17–0.81) demonstrated reduced odds of escaping. Crisis intervention team (CIT) training was associated with reduced odds of escape (OR: 0.38; 95% CI: 0.21–0.69), but increased odds of adequate de‐escalation (OR: 2.19; 95% CI: 1.19–4.04). Conclusions Nearly half of EMS professionals did not remove themselves from a simulated patient care scenario with an escalating threat of physical violence. EMS‐specific training for de‐escalation as a first‐line technique, recognizing imminent violence, and leaving a dangerous environment is needed.

The COVID-19 pandemic has profoundly affected the lives of almost every individual in every nation, with numbers of infections continuing to grow. Across these nations, first responders are essential in their roles addressing emergencies, despite their risk of exposure to COVID-19 in the course of their work. We sought to understand the impacts of the COVID-19 pandemic on the lives of volunteer firefighters in the United States, an understudied group of these first responders. Interviews were conducted with volunteer firefighters between September and November 2021. Interviews were analyzed using deductive dominant thematic analysis. Thirty-three firefighters were interviewed who had an average of 22 years of service and a mean age of 52 years. Interviewees described pandemic-related challenges including the fear of COVID exposure and frustrations with work and personal relationships. They also identified unexpected work-related benefits including a deepened commitment to serve and improvements to training and safety. Further, some volunteers noted personal benefits such as developing stronger connections with others, having a new outlook on life, and observing goodwill. Our findings provide insight into the multifaceted and complex impact of the COVID-19 pandemic on volunteer firefighters.

Abstract Objective Our objective was to quantify the associations between sleep duration and perceived and chronic stress with ideal cardiovascular health (CVH) among emergency medical services (EMS) personnel from county‐based EMS agencies. Methods We conducted a cross‐sectional survey of cardiovascular disease (CVD)‐free EMS personnel from 4 US EMS agencies. The questionnaire consisted of the Pittsburgh Sleep Quality Index (PSQI), Perceived Stress Scale (PSS), Chronic Burden Scale, and the CVH components (smoking, body mass index, physical activity, diet, blood glucose, blood pressure, cholesterol, each scored 0–2 points). The components were summed and ideal CVH considered 11–14 points. Mixed effects logistic regression models with a random intercept for agency were used to estimate the odds of ideal CVH for good sleep quality (PSQI

Abstract Objective Our objective was to identify research priorities to understand the impact of COVID‐19 on initial emergency medical services (EMS) education. Methods We used a modified Delphi method with an expert panel (n = 15) of EMS stakeholders to develop consensus on the research priorities that are most important and feasible to understand the impact of the COVID‐19 pandemic on initial EMS education. Data were collected from August 2020 to February 2021 over 5 rounds (3 electronic surveys and 2 live virtual meetings). In Round 1, participants submitted research priorities over 9 specific areas. Responses were thematically analyzed to develop a list of research priorities reviewed in Round 2. In Round 3, participants rated the priorities by importance and feasibility, with a weighted score (2/3*importance+1/3*feasibility) used for preliminary prioritization. In Round 4, participants ranked the priorities. In Round 5, participants provided their agreement or disagreement with the group's consensus of the top 8 research priorities. Results During Rounds 1 and 2, 135 ideas were submitted by the panel, leading to a preliminary list of 27 research priorities after thematic analysis. The top 4 research priorities identified by the expert panel were prehospital internship access, impact of lack of field and clinical experience, student health and safety, and EMS education program availability and accessibility. Consensus was reached with 10/11 (91%) participants in Round 5 agreeing. Conclusions The identified research priorities are an important first step to begin evaluating the EMS educational infrastructure, processes, and outcomes that were affected or threatened through the pandemic.

(1) Background: COVID-19 vaccination status varies widely among law enforcement and emergency medical services professionals. Though at high risk of exposure, these first responders have demonstrated significant vaccine hesitancy, with only 70% reportedly vaccinated. We sought to understand whether similar vaccine hesitancy exists for first responders and their household contacts around COVID-19 boosters. (2) Methods: In a prospective longitudinal cohort of first responders and their household contacts, survey data was collected, including demographics, medical history, COVID-19 exposure risks, and vaccination and/or booster status. The statistical analysis focused on primary vaccination and booster rates of both the first responders and their household contacts. (3) Results: Across 119 study participants, 73% reported having received some combination of vaccine and/or booster, and 26% were unvaccinated. Vaccinated individuals were older, reported less prior exposure to COVID-19 and had more comorbidities. Only 23% reported having received a COVID-19 booster. Pairing of the data for household contacts demonstrated a 60% agreement to receive primary vaccination but only a 20% agreement for boosters within households. (4) Conclusions: This study provides insight into the vaccination and booster rates of first responders and household contacts. Focused efforts to enhance vaccinations is essential for the protection and maintenance of this critical workforce.

Background Settings where Emergency Medical Services (EMS) are provided to stabilize patients and transport them to locations better equipped to provide comprehensive care, “prehospital settings,” are not frequently considered when designing packaged products. Packaging design is an understudied area, potentially impacting both healthcare provider behavior and patient outcomes. Our objectives were to: 1) describe difficulties associated with packaging in prehospital settings 2) investigate the coping strategies used by paramedics when difficulties occurred, and 3) assess the potential impacts these difficulties had on patient care. Methods An online, cross-sectional survey was distributed via email using the National EMS Certification database maintained by the National Registry of Emergency Medical Technicians (NREMT) to a random sample of nationally-certified paramedics. Eligible respondents were aged 18 and older, employed as paramedics and had administered care in a prehospital setting within the previous 12 months. Survey items explored difficulties experienced and coping strategies used when difficulty was encountered identifying or opening medications and/or medical supplies. Descriptive statistics and logistic regression were calculated to analyse responses for trends. Results Of the 12,000 emails sent, 1,912 participants responded (response rate = 16%). After removing respondents who had not administered care within the past 12 months and partial surveys, data from 1,702 respondents were analysed. Nearly 20% of all respondents reported that they had experienced difficulties identifying (21.1%) or opening (20.5%) medications and identifying (17.0%) or opening (23.4%) medical supplies within the past year. Between 1.2% (identifying a medication) and 3.0% (opening supplies) of those included in the analysis indicated that reported difficulties had negatively impacted patient care. Common coping strategies reported to deal with difficulty opening included partner assistance, tool use (scissors, pens, and knives), and the use of teeth, all potential pathways for the transmission of microbes, conceivably further impacting outcomes. Conclusion More thoughtfully designed packaging for prehospital settings has the potential to benefit both EMS providers and the patients that they care for.

BackgroundSettings where Emergency Medical Services (EMS) are provided to stabilize patients and transport them to locations better equipped to provide comprehensive care, "prehospital settings," are not frequently considered when designing packaged products. Packaging design is an understudied area, potentially impacting both healthcare provider behavior and patient outcomes. Our objectives were to: 1) describe difficulties associated with packaging in prehospital settings 2) investigate the coping strategies used by paramedics when difficulties occurred, and 3) assess the potential impacts these difficulties had on patient care.MethodsAn online, cross-sectional survey was distributed via email using the National EMS Certification database maintained by the National Registry of Emergency Medical Technicians (NREMT) to a random sample of nationally-certified paramedics. Eligible respondents were aged 18 and older, employed as paramedics and had administered care in a prehospital setting within the previous 12 months. Survey items explored difficulties experienced and coping strategies used when difficulty was encountered identifying or opening medications and/or medical supplies. Descriptive statistics and logistic regression were calculated to analyse responses for trends.ResultsOf the 12,000 emails sent, 1,912 participants responded (response rate = 16%). After removing respondents who had not administered care within the past 12 months and partial surveys, data from 1,702 respondents were analysed. Nearly 20% of all respondents reported that they had experienced difficulties identifying (21.1%) or opening (20.5%) medications and identifying (17.0%) or opening (23.4%) medical supplies within the past year. Between 1.2% (identifying a medication) and 3.0% (opening supplies) of those included in the analysis indicated that reported difficulties had negatively impacted patient care. Common coping strategies reported to deal with difficulty opening included partner assistance, tool use (scissors, pens, and knives), and the use of teeth, all potential pathways for the transmission of microbes, conceivably further impacting outcomes.ConclusionMore thoughtfully designed packaging for prehospital settings has the potential to benefit both EMS providers and the patients that they care for.

Some healthcare professionals, including emergency medical service (EMS) professionals, remain hesitant about receiving COVID-19 vaccines. This study sought to understand EMS professionals’ perspectives regarding COVID-19 vaccination. Using open-ended comments from a national survey deployed electronically to over 19,000 EMS professionals in April of 2021, we examined perspectives about acceptance of and hesitancy toward COVID-19 vaccines. Survey comments revealed differences in perspectives between vaccinated and unvaccinated EMS professionals regarding their personal role in improving public health through COVID-19 vaccination as well as vaccine benefits and the protection conferred by vaccination. Unvaccinated individuals also expressed concerns over the research and development of the COVID-19 vaccines that led to their decision not to get vaccinated. Individuals who were vaccinated suggested ways to increase uptake of the vaccine including having healthcare professionals serve as leaders for vaccination and educating individuals about COVID-19 vaccination through credible resources. Vaccine hesitancy remains a challenge to achieving herd immunity to COVID-19 through vaccination, even among healthcare professionals. Understanding the perspectives of those who have chosen not to be vaccinated can help direct strategies to reduce confusion and concerns. The perspectives of vaccinated individuals may also be valuable in identifying opportunities to promote vaccination in the professional setting.

Introduction: Intravascular volume status is an important clinical consideration in the management of the critically ill. Point-of-care ultrasonography (POCUS) has gained popularity as a non-invasive means of intravascular volume assessment via examination of the inferior vena cava (IVC). However, there are limited data comparing different acquisition techniques for IVC measurement by POCUS. The goal of this evaluation was to determine the reliability of three IVC acquisition techniques for volume assessment: subxiphoid transabdominal long axis (LA), transabdominal short axis (SA), and right lateral transabdominal coronal long axis (CLA) (aka “rescue view”). Methods: Volunteers were evaluated by three experienced emergency physician sonographers (EP). Gray scale (B-mode) and motion-mode (M-mode) diameters were measured and IVC collapsibility index (IVCCI) calculated for three anatomic views (LA, SA, CLA). For each IVC measurement, we calculated descriptive statistics, intra-class correlation coefficients (ICC), and two-way univariate analyses of variance. Results: EPs evaluated 39 volunteers, yielding 351 total US measurements. Measurements of the three views had similar means (LA 1.9 ± 0.4cm; SA 1.9 ± 0.4cm; CLA 2.0 ± 0.5cm). For B-Mode, LA had the highest ICC (0.86, 95% CI [0.76-0.92]) while CLA had the poorest ICC (0.74, 95% CI [0.56-0.85]). ICCs for all M-mode IVCCI were low. Significant interaction effects between anatomical view and EP were observed for B-mode and M-mode measurements. Post-hoc analyses revealed difficulty in consistent view acquisition between EPs. Conclusion: Inter-rater reliability of the IVC by EPs was highest for B-mode LA and poorest for all M-Mode IVC collapsibility indices (IVCCI). These results suggest that B-mode LA holds the most promise to deliver reliable measures of IVC diameter. Future studies may focus on validation in a clinical setting as well as comparison to a reference standard. [West J Emerg Med. 2017;18(3)496-501.]

Background Current cardiac arrest guidelines have limited high‐quality scientific evidence to support recommendations for care. The quality of scientific evidence on which guidelines are based may correlate with improved patient outcomes and meaningful survival. We sought to develop a prioritized list of knowledge gaps in resuscitation to assist researchers, policy makers, and funding agencies in their decision‐making process. Methods and Results A 4‐stage modified Delphi method was used with a panel of cardiac arrest experts. Experts addressed the prompt: “What are the top 3 gaps in knowledge involving cardiac arrest care that should be research priorities for National Institutes of Health/American Heart Association funding to have the greatest impact on public health?” Knowledge gaps were identified in the initial round, rated in a second round, and rank ordered in the third round, and they underwent final review and consensus (final round). The outcome was 10 knowledge gaps, with prioritization of the top 3 gaps. A total of 61 gaps, with 19 distinct themes, were identified by participants. The 10 knowledge gaps most likely to affect public health identified by the expert panel included, in order, the following: telecommunicator cardiopulmonary resuscitation, hemodynamic monitoring for goal‐directed resuscitation, reasons why bystanders fail to respond, optimization of postarrest care, out‐of‐hospital cardiac arrest identification and response, individualizing resuscitation strategies, predicting patients at risk, tools for neuroprognostication, optimal airway management, and optimizing educational strategies. Conclusions Ten priorities for cardiac arrest research were identified, but consensus was not reached on the prioritized top 3. Future research should address these gaps to potentially improve resuscitation guideline evidence quality.

Introduction: Emergency endotracheal intubation (ETI) is a common and critical procedure performed in both prehospital and in-hospital settings. Studies of prehospital providers have demonstrated that rescuer position influences ETI outcomes. However, studies of in-hospital rescuer position for ETI are limited. While we adhere to strict standards for the administration of ETI, we posited that perhaps requiring in-hospital rescuers to stand for ETI is an obstacle to effectiveness. Our objective was to compare in-hospital emergency medicine (EM) trainees’ performance on ETI delivered from both the seated and standing positions. Methods: EM residents performed ETI on a difficult airway mannequin from both a seated and standing position. They were randomized to the position from which they performed ETI first. All ETIs were recorded and then scored using a modified version of the Airway Management Proficiency Checklist. Residents also rated the laryngeal view and the difficulty of the procedure. We analyzed comparisons between ETI positions with paired t-tests. Results: Forty-two of our 49 residents (85.7%) participated. Fifteen (35.7%) were female, and all three levels of training were represented. The average number of prior ETI experiences among our subjects was 44 (standard deviation=34). All scores related to ETI performance were statistically equivalent across the two positions (performance score, number of attempts, time to intubation success, and ratings of difficulty and laryngeal view). We also observed no differences across levels of training. Conclusion: The position of the in-hospital provider, whether seated or standing, had no effect on the provider’s ETI performance. Since environmental circumstances sometimes necessitate alternative positioning for effective ETI administration, our findings suggest that there may be value in training residents to perform ETI from both positions.

BackgroundCardiac arrest (CA) is a leading cause of death in the United States, claiming over 450 000 lives annually. Improving survival depends on the ability to conduct CA research and on the translation and implementation of research findings into practice. Our objective was to provide a descriptive analysis of annual National Institutes of Health (NIH) funding for CA research over the past decade. Method and ResultsA search within NIH RePORTER for the years 2007 to 2016 was performed using the terms: “cardiac arrest” or “cardiopulmonary resuscitation” or “heart arrest” or “circulatory arrest” or “pulseless electrical activity” or “ventricular fibrillation” or “resuscitation.” Grants were reviewed and categorized as CA research (yes/no) using predefined criteria. The annual NIH funding for CA research, number of individual grants, and principal investigators were tabulated. The total NIH investment in CA research for 2015 was calculated and compared to those for other leading causes of death within the United States. Interrater reliability among 3 independent reviewers for fiscal year 2015 was assessed using Fleiss κ. The search yielded 2763 NIH‐funded grants, of which 745 (27.0%) were classified as CA research (κ=0.86 [95%CI 0.80‐0.93]). Total inflation‐adjusted NIH funding for CA research was $35.4 million in 2007, peaked at $76.7 million in 2010, and has decreased to $28.5 million in 2016. Per annual death, NIH invests ≈$2200 for stroke, ≈$2100 for heart disease, and ≈$91 for CA. ConclusionsThis analysis demonstrates that the annual NIH investment in CA research is low relative to other leading causes of death in the United States and has declined over the past decade.

Introduction: The ACGME requires that residents perform scholarly activities prior to graduation, but this is difficult to complete and challenging to support. We describe a residency research program, taking advantage of environmental change aligning resident and faculty goals, to become a contributor to departmental cultural change and research development. Methods: A research program, Scholar Quest (SQ), was developed as a part of an Information Mastery program. The goal of SQ is for residents to gain understanding of scholarly activity through a mentor-directed experience in original research. This curriculum is facilitated by providing residents protected time for didactics, seed grants and statistical/staff support. We evaluated total scholarly activity and resident/faculty involvement before and after implementation (PRE-SQ; 2003-2005 and POST-SQ; 2007-2009). Results: Scholarly activity was greater POST-SQ versus PRE-SQ (123 versus 27) (p