Survival for avalanche victims is time-dependent, and survival is often reliant on ground companion rescue. Due to the time-critical nature of burial, remote locations, and high frequency of concomitant severe trauma, helicopters are often dispatched to these incidents. While helicopter-based transceiver searches are standard, the most efficient deployment strategy, either using an underslung antenna or hoisting a rescue paramedic (RP) with a handheld transceiver, remains unknown. This study compared the operational efficiency of these two methods in the Norwegian Search-and-Rescue (SAR) Helicopter Service.

A dual randomized, experimental field trial was conducted with the on-duty SAR helicopter and crew at the Ørland Main Airforce Base (Trøndelag, Norway). A simulated avalanche area of 80 × 150 meters was used, and six avalanche transceivers were buried at approximately 0.5m depth across the area. Only one transceiver was active at each run, and the locations were randomized to prevent crew memorization. The sequence of which procedure to use was also randomized. Four operational timestamps were recorded: First Signal, Optimal Signal, RP on Ground, and Transceiver Found.

Over three days, a total of 25 trial runs were performed, 13 with Antenna Search and 12 with RP Hoist Search. The RP Hoist Search was significantly faster in both time to Optimal Signal, with a difference between the groups of 29 seconds (95% CI, 9 – 50), and time for RP on Ground, with a difference between the groups of 124 seconds (95% CI, 98 – 151). For the total time to Transceiver Found, the difference between the groups was 143 seconds (95% CI, 113 – 172; P <0.001). Furthermore, the RP Hoist Search resulted in significantly faster fine search on the ground.

This randomized, experimental field trial comparing two currently used standard search procedures in the Norwegian SAR service showed that the RP Hoist Search was significantly more efficient than the Antenna Search for localizing buried avalanche victims, reducing total localization time by more than two minutes. Given that survival probability is reduced after 10-15 minutes of burial, this time saving may be clinically significant. The findings support that RP Hoist Search is an effective localization strategy for SAR helicopter services with comparable hoist systems.

In Japan, Emergency Life-Saving Technicians (ELSTs) cannot independently perform diagnostic ultrasound under the current legal framework. If ELST-performed focused assessment with sonography for trauma (FAST) is to be introduced in the prehospital setting, technical feasibility during ambulance motion and the viability of remote physician observation must be established.

The study aimed to evaluate the feasibility of ELST-performed FAST in moving ambulances in a controlled manikin setting and to descriptively assess an integrated monitoring system for remote observation.

A prospective observational pilot study was conducted at the Okayama City Fire Department Training Center in Okayama Prefecture, Japan on March 3, 2025. Twenty ELSTs completed structured e-learning and a hands-on workshop using standardized FAST/ER FAN manikins. Participants performed FAST under three fixed-order conditions: stationary (STOP), 15km/hour, and 30km/hour on a 250-m circular course. The primary outcome was the total Task-Specific Checklist (TSC) score (0-24 points). Secondary outcomes were examination time, site-specific TSC subscores, inter-rater agreement, and a descriptive assessment of transmitted image quality by two specialist physicians.

All 20 ELSTs completed the study. Mean total TSC scores were 23.4 (SD = 0.8) in the STOP condition, 23.4 (SD = 0.9) at 15km/hour, and 23.7 (SD = 0.6) at 30km/hour. Compared with the STOP condition, the mean difference in total TSC score was 0.08 points (95% CI, −0.24 to 0.39; P for noninferiority < 0.001) at 15km/hour and 0.33 points (95% CI, −0.04 to 0.69; P for noninferiority < 0.001) at 30km/hour. Both moving conditions met the pre-specified noninferiority criterion relative to the STOP condition. Mean examination times were 36.7 (SD = 14.4) seconds in the STOP condition, 30.3 (SD = 9.8) seconds at 15km/hour, and 31.9 (SD = 14.8) seconds at 30km/hour. Inter-rater agreement for TSC scoring was moderate (weighted kappa, 0.56). Descriptive ratings suggested that transmitted image quality was generally favorable for remote review in this controlled setting.

In this controlled manikin-based pilot study, ELST-performed FAST was technically feasible during moderate ambulance motion, and remote physician observation was feasible. These findings may help inform staged prehospital ultrasound training and future clinical validation under legal and operational constraints.

Heat stroke and heat exhaustion (HS/HE) are life-threatening conditions requiring immediate intervention. Cooling devices play a critical role in emergency and prehospital care, yet their effectiveness and field readiness are inconsistently reported. This systematic review evaluates commercially available cooling devices for the treatment of HS/HE with an emphasis on device feasibility, performance, and suitability for prehospital and remote deployment.

A comprehensive literature search was conducted in August/October 2025 across academic databases (PubMed, Scopus, Cochrane Library, Compendex, Engineering Village, and IEEE Xplore) and gray literature via Google Advanced Search. Academic records were screened using Rayyan, while gray literature was organized in Excel with the aid of a custom HTML scraper. Devices were included if they met the United States Food and Drug Administration (FDA) definition of a medical device, were designed for adult human use, and specifically addressed HS/HE. Parameters extracted included working principle, cooling rate, weight, dimensions, volume, power requirements, external resource demands, and reusability. Cooling performance was benchmarked using thresholds reported by McDermott, et al, and portability was assessed using the MIL-STD-1472H single-person carriage limit of ≤16kg.

A total of 18 devices were identified and evaluated. Only three met the ideal cooling rate threshold (≥0.155°C/minute), and two others achieved acceptable performance (0.078-0.154°C/minute). Approximately 61% of devices did not report cooling rate data. Five devices met field portability criteria (≤16kg), though most were limited by reliance on water, power, or disposable components. Only one device demonstrated feasibility for remote use; this device, however, lacked full reusability.

No device meets the combined criteria of effectiveness, portability, field readiness, and reusability for HS/HE treatment. Current FDA pathways do not require reporting of key performance metrics, highlighting a regulatory gap. There is a need for development of field-appropriate solutions and revised evaluation standards that prioritize cooling performance, resource independence, and usability in austere environments.

Hospitals must ensure preparedness and safety to maintain services during disasters. Results from the Hospital Safety Index (HSI) often indicate that hospitals are safe and capable; however, it is important to verify whether these assessments are consistent across different evaluators. This study compared hospital safety scores between internal evaluators (hospital staff) and external evaluators.

This cross-sectional study was conducted in 2022 using documented hospital safety assessment data from hospitals supervised by Kermanshah University of Medical Sciences (KUMS) in western Iran. Independent-samples t-tests, the intraclass correlation coefficient (ICC), and Bland–Altman plots were used to compare mean scores and assess agreement between evaluators.

For structural safety, the difference between internal and external evaluators was not significant (95% CI, -9.19 to 9.67). In contrast, the differences were pronounced for non-structural safety (95% CI, 7.00 to 20.63) and functional safety (95% CI, 10.56 to 28.84), with both confidence intervals excluding zero. Agreement between evaluators was poor across most hospital safety domains (ICC < 0.05).

Internal evaluators rated their hospitals significantly safer than external evaluators did. Given the pronounced differences in non-structural and functional safety, and the poor inter-rater agreement across most domains, relying solely on internal assessments may mislead hospital managers about disaster preparedness. Hospital managers should therefore regard external evaluation as an opportunity to reveal their hospital’s vulnerabilities in disaster safety.

Triage and data transfer are critical to the medical management of mass-casualty incidents (MCIs). However, the chaotic nature of such events makes it difficult to classify casualties according to structured triage protocols. Furthermore, even when triage is implemented effectively, communication disruptions between the incident scene and dispatch centers can hinder response operations. The aim of this study was to present a drone-integrated system that enables non-contact vital sign measurement, remote triage, and real-time data transmission during MCIs.

The system development process involved three steps: (1) developing the Vital-Sign Measurement Module; (2) developing the Triage Decision Support Module; and (3) developing the User Interfaces and Data Transmission Module to enable information transmission between dispatch centers and response teams. Within the Vital-Sign Measurement Module, heart rate (HR), respiratory rate (RR), oxygen saturation (SpO2), and body temperature (BT) measurement algorithms were developed using the following techniques, respectively: video-based photoplethysmography (vPPG), analysis of thermal temperature fluctuations around the nose, a regression-based neural network approach, and heat maps and thermal thresholding. A pilot study was conducted under controlled indoor conditions to evaluate the accuracy of these algorithms.

The system can measure vital signs by processing drone-captured images, can provide triage decision support, and can transmit victims’ locations, vital signs, and triage categories to response teams and dispatch centers via dedicated user interfaces. A pilot evaluation of the Vital-Sign Measurement Module showed that the relative accuracy rate of the non-contact vital-sign measurement algorithms ranged from 86% to 99%.

The system provides an innovative approach to improving medical response management in MCIs by enabling remote triage and monitoring. Its non-contact vital sign measurement, triage decision support, and near real-time data transmission capabilities provide an infrastructure that can contribute to faster response and improved operational coordination. However, further field trials and development are required to improve the robustness of the vital-sign measurement algorithms to motion, to improve their adaptability to changing environmental conditions, and to maintain high accuracy despite individual differences.

Emergency Medical Services (EMS) demand varies across circadian, weekly, and seasonal timescales. This study is among the first such integrated analyses in the Turkish 112 EMS context.

The primary objective of this study was to characterize circadian patterns in overall EMS case-record volume and across seven clinical groups, as well as hourly, weekly, and seasonal variation in diagnostic composition across eight categories. Secondary objectives were to estimate adjusted temporal associations and evaluate frozen transfer of aggregate daily forecasts from 2024 to the immediately subsequent 2025 holdout.

This retrospective study analyzed 60,811 routinely collected EMS case-record rows from Karaman Province, Türkiye over 731 days in 2024-2025. Interaction, cosinor, and negative binomial (NB) models characterized temporal patterns; aggregate daily case-record volume was forecast using weekly Fourier terms with autoregressive integrated moving average (ARIMA) errors trained on 2024 and frozen for 2025. The data represented provincial case-record workload, an operational proxy for population demand rather than a census of all inbound calls or unique patients.

Case-record volume peaked at 21:00 and was lowest at 06:00; adjusted volume at 21:00 was 3.53-times that at 06:00 (95% CI, 3.28–3.81). Hourly diagnostic composition differed modestly (Cramér V = 0.061). Rhythmicity was detected in all seven clinical groups (all joint-test P values < 0.001), but low full-cell R2 values indicated substantial unexplained hour-date variation; acrophases ranged from 14:41 to 19:14 and relative amplitudes from 28.6% (Respiratory) to 67.9% (Trauma). Standardized Trauma share was higher in summer than winter (25.7% versus 18.1%), whereas Respiratory share was higher in winter than summer (9.7% versus 3.6%). Adjusted volume was higher on Monday than Saturday and higher in August than November (IRRs 1.11 and 1.23, respectively). In the frozen 2025 holdout, the selected model achieved mean absolute scaled error (MASE) = 0.722 and 95% prediction-interval coverage of 96.2%.

Clinical-group rhythms and seasonal composition differences were observed. The frozen evaluation quantified aggregate daily forecast transfer only from 2024 to the immediately subsequent 2025 within one provincial series. Findings support local monitoring of recorded evening workload and seasonal diagnostic composition, particularly the higher Trauma share in summer and the higher Respiratory share in winter.

Neonatal intensive care unit (NICU) evacuation poses distinct operational and ethical challenges because neonates often depend on continuous life-sustaining technologies and specialized care. Although several neonatal or pediatric disaster triage systems have been proposed, actual NICU evacuation cannot be ethically or practically tested under controlled disaster conditions. A reproducible framework comparing evacuation-order strategies is therefore needed.

This study aimed to develop and apply a reproducible simulation framework for NICU evacuation-order evaluation and, within that framework, to compare structured triage with evacuation without triage and quantitative with categorical neonatal triage approaches.

A retrospective simulation study was conducted using routinely recorded clinical triage assessments from a tertiary NICU, comprising 1,079 patient evaluations in 162 neonates across 49 triage days. During clinical practice, clinical severity and triage status had been recorded using the Neonatal Therapeutic Intervention Scoring System (NTISS), Neonatal Extrication Triage (NEXT), and Simple Triage and Rapid Treatment for Neonates, Revised (START-Neo-R); NEXT was a quantitative six-domain resource-dependency score ranging from zero to 12, whereas START-Neo-R was a five-level categorical neonatal triage system. Three evacuation strategies were evaluated: descending-order evacuation using NEXT, descending-order evacuation using START-Neo-R, and evacuation without triage. Evacuation-order performance was quantified using the Total Evacuation Score (TES), defined as the time integral of cumulative NTISS scores among patients remaining in the NICU across sequential evacuation steps. The TES distributions were compared descriptively across strategies rather than inferentially.

Within the 49 observed triage days, both structured triage strategies generated TES distributions shifted lower than those from evacuation without triage. In the direct comparison between NEXT and START-Neo-R, the worst-case TES under NEXT was lower than more than one-half of the START-Neo-R TES distribution on 34 of the 49 observed triage days (69.4%).

In this simulation study using real-world NICU data, TES provided a reproducible framework for comparing neonatal evacuation-order strategies under explicit assumptions. Within this TES-based framework, structured triage generated TES distributions shifted lower than those from evacuation without triage, and NEXT showed a more favorable distribution-based pattern than START-Neo-R on most observed days. These findings suggest that TES-based evaluation may help identify triage strategies that support more transparent and testable NICU evacuation planning.

Mass-casualty incident (MCI) triage algorithms are evaluated against reference standards that operationally define the “critical casualty,” yet the constructs underlying these standards and the completeness of their reporting have not been systematically characterized.

A PRISMA-ScR methodology scoping review was conducted using a pre-registered Open Science Framework (OSF) protocol; MEDLINE, Scopus, Web of Science, and CINAHL were searched on May 5, 2026 for English-language full-text sources that described, derived, validated, or applied a reference standard for distinguishing critical from non-critical casualties in MCI triage. Reference standards were classified using a pre-specified taxonomy, and reporting completeness was assessed with the eight-item Reference Standard Reporting Index for MCI Triage (RSRI-MCI), developed a priori for this review and not externally validated. Two reviewers independently classified and coded all sources.

Sixty sources published from 2001 through 2025 were included. Operationalized reference standards clustered around four foundational methodological sources, while only five sources (8%) analyzed retrospective data from actual MCIs. Five reference-standard families were identified: Life-Saving Intervention (LSI)-Based (38%), Composite/Hybrid (30%), Expert Panel (15%), Outcome/Resource (12%), and Anatomic Severity (5%); LSI-Based and Composite constructs together accounted for approximately two-thirds of the field. Reporting was asymmetric: definition (98%), components (97%), and rationale (88%) were reported almost universally, whereas time window (40%), dead/expectant handling (57%), binary mapping (65%), missing-data handling (58%), and reference-standard limitations (58%) were reported less consistently. Inter-rater agreement was substantial overall (83%) and for family classification (93%; Gwet’s Chance-Corrected Agreement Coefficient [AC1] = 0.919; 95% CI, 0.837–0.980).

Mass-casualty incident triage studies routinely report what their reference standard is but inconsistently report how it is operationalized, particularly its time window. Five reporting recommendations are proposed for future MCI triage validation research.

On March 24, thirteen days after the 2011 Great East Japan Earthquake (GEJE), the Ishinomaki Zone Joint Relief Team (IZJRT) started the Melon Pan System – an ad hoc pharmaceutical coordination system – for the first time in Japan to efficiently prescribe, dispense, deliver, and explain medication to patients in evacuation centers and at their homes. The Japan Red Cross (JRC) Ishinomaki Hospital, a disaster base hospital (DBH), serves as a coordination hub for emergency medical teams (EMTs), pharmacists, and medication supplies.

This study aimed to retrospectively examine trends in medication needs and delivery before (Phase A: March 11 to March 23; 13 days) and after (Phase B: March 24 to April 5; 13 days) the system’s implementation.

Using an anonymized disaster medical record (DMR) database, patient characteristics, number of new and returning patients, prescription numbers, prescribed medications, and prescription durations in Phase A and Phase B were compared. The locations of the evacuation centers with significant improvements in Phase B were identified on a map.

There were 3,830 new patients in Phase A and 6,984 in Phase B. The number of returning patients increased significantly during Phase B. The overall number of prescriptions increased 2.6-times (353.7/day versus 935.2/day) and the number of prescribed medications increased 3.1-times (764.1/day versus 2,367.8/day) in Phase B. The median prescription duration of anti-hypertensive drugs increased from seven days (95% confidence interval [CI], 2-14 days) in Phase A to nine days (95% CI, 3-30 days) in Phase B (P < 0.0001), suggesting that medication was efficiently delivered to people in need. The effect of the system was more prominent in evacuation centers located within the tsunami-inundated areas or remote areas (>10km from the JRC Ishinomaki Hospital), considering that 33 (89.2%) of the 37 evacuation centers where prescriptions increased more than three-fold and 39 (94.9%) of the 41 evacuation centers where the prescription started in Phase B were located in such areas.

The ad hoc pharmaceutical coordination system was effective and necessary, enabling EMTs to focus on patient care and pharmacists to provide personalized pharmaceutical assistance, especially in evacuation centers with limited access. The Melon Pan system was the first pharmaceutical coordination model to be developed in Japan to improve disaster health management.

Shortages of disposable medical equipment can critically impair health care delivery during disasters or armed conflict. Although reprocessing single-use medical devices (SUDs) may represent the only feasible option under such conditions, evidence supporting simple, field-adapted cleaning methods is limited.

In this exploratory study, 90 clinically used SUDs – endotracheal tubes (ETT), laryngeal mask airway (LMA), intravenous administration sets (IVS), syringes (SYR), indwelling urinary catheters (IDC), and nasogastric tubes (NGT) – were collected after surgery in a regional hospital. Devices were randomly allocated to cleaning with peracetic acid (PAA), 70% ethanol, or dishwashing detergent. Each item was brushed, immersed for ten minutes, and then air-dried. Microbiological sampling included pre-cleaning and post-cleaning cultures, and airway devices underwent Polymerase Chain Reaction (PCR) testing for 28 respiratory pathogens. Functional integrity was assessed after cleaning.

All three cleaning agents achieved statistically significant reductions in bacterial load (P < 0.05) with no difference between methods. The PCR testing detected Hemophilus influenzae (H. influenzae) and Staphylococcus aureus (S. aureus) among other pathogens in 47% of airway devices before cleaning; all post-cleaning samples were negative. No structural or functional damage was observed.

Basic cleaning procedures with commonly available agents substantially reduced microbial contamination without impairing device function. These methods cannot replace validated sterilization but may serve as the only viable option when medical supply is critically constrained, such as in disasters or in armed conflict. Preparedness planning should encompass strategic stockpiling, surge production capacity, and resilient supply chains, together with rationing and substitution strategies, and - only as a last resort - protocols for cleaning and reusing single-use medical equipment.

Conflict brings excess and changing demands to local civilian health care resources. While conflict-related needs are often easily identifiable, in the aftermath of disaster or conflict, health care systems may struggle to identify changing needs, and humanitarian actors may initiate responses targeted to traumatic injuries while facing different operational realities.

This study aims to quantify the immediate changes in, and short-term trends of, Emergency Department (ED) patient profiles following a break in conflict, informing humanitarian intervention and the prioritization of local health care resources in future contexts.

A single center, retrospective Interrupted Time Series (ITS) analysis was undertaken comprising of every patient attendance to the Nasser Medical Complex (Gaza Strip) ED from September 1, 2025 through November 30, 2025, inclusive, to evaluate the impact of the ceasefire on October 10, 2025. Binomial and negative binomial regression was used, adjusting for day-of-week confounding, with Newey–West robust standard errors. Coefficients were exponentiated to Incidence Rate Ratios for interpretation as the percentage change in the relevant presentations numbers or trend and were presented with 95% Confidence Intervals (95%CI).

There were 107,631 presentations over the study period, a median of 1,217 (IQR 1,120-1,291) per day prior to, and 1,202 per day (IQR 1,083-1,356) following, the ceasefire. There was no significant step-change in total presentation to the ED following ceasefire, but thereafter, relative to the pre-ceasefire trajectory, attendances experienced a sustained decrease of two percent per day (95%CI, 1.0% to 2.0% reduction; P < 0.001).

There were observed changes to the profile of attendances by diagnostic group, with step-change reductions in trauma admissions, gastrointestinal, and pediatric presentations. There were daily trend reductions for multiple diagnostic groups, including traumatic injuries discharged from the ED, respiratory infections, gastrointestinal presentations, and other medical emergencies.

This study demonstrates that the implementation of a ceasefire has the potential to change presentation patterns to a civilian ED in a conflict area. While there was no step-change following the ceasefire, there was a reversal of the previous trend of rising daily presentations. It should be noted that most presentations both before and after the ceasefire were for non-traumatic events. These findings highlight the need to continue support and resource for the non-traumatic workload of emergency care during crises, a pattern described in other contexts.

Large-scale medical surges (whether arising from mass-casualty incidents [MCIs], pandemic disease, or wartime casualty repatriation) can rapidly overwhelm traditional hospital capacity. Alternate care facilities (ACFs) have been used to decompress hospital systems, yet prior configurations such as convention centers exhibit significant clinical and patient-experience limitations.

This paper describes the development, proof-of-concept validation, and operational framework of the Hotel2Hospital (H2H) Conversion Guidebook, a comprehensive resource enabling hospital emergency management professionals to rapidly convert a suitable hotel into a functional ACF capable of providing hospital-level care.

The H2H Guidebook was developed by Team Colorado, comprising emergency, hospitalist, and virtual medicine physicians, emergency management professionals, medical subject matter experts, architects, engineers, and regulatory specialists from the University of Colorado Hospital (UCH) and All Clear Emergency Management Group, funded under a Defense Health Agency (DHA) National Disaster Medical System (NDMS) Capability Pilot. The framework was informed by operational experience from COVID-19 ACF deployments in Colorado (USA). A proof-of-concept exercise conducted in 2025 at the Hyatt Regency Denver–Aurora Conference Center physically converted portions of a hotel into functional hospital spaces and validated clinical workflows through multi-disciplinary “Day-in-the-Life” simulations.

The proof-of-concept demonstrated that hotels can be successfully converted to provide general Med-Surg and intensive care unit (ICU)-level capacity within four weeks. Key advantages over traditional ACFs included private patient rooms capable of a high level of infection prevention measures, individual heating, ventilation, and air conditioning (HVAC) control, in-room bathrooms with showers, and existing hotel infrastructure supportive of hospital operations while being comprehensive enough to provide full Med-Surg and most ICU-level care. Clinical services including laboratory point-of-care testing, portable radiology, pharmacy, respiratory therapy, telehealth/virtual ICU, and electronic medical record (EMR) integration in the “live” environment were all demonstrated as operationally feasible. A wireless mesh network with cellular, cable, and satellite capabilities was successfully deployed to provide seamless information technology (IT) connectivity with UCH.

Hotel conversion represents a viable, scalable ACF strategy for prolonged medical surge events. The H2H Conversion Guidebook provides a structured, reproducible framework addressing activation, operations, and demobilization. Hospital emergency management professionals, public health agencies, and defense medical planners should consider incorporating the H2H model into sustained surge capacity planning.

Pediatric patients present distinct developmental, psychosocial, and clinical challenges during high-consequence infectious disease (HCID) transport. Despite these differences, national biocontainment transport systems have historically been designed around adult patients, resulting in limited pediatric-specific guidance and operational experience.

The aim of this study was to describe pediatric-specific observations from the inaugural deployment of the US Department of Health and Human Services’ (HHS) Portable Biocontainment Unit (PBCU) during a national full-scale exercise and to identify considerations relevant to pediatric-inclusive HCID transport.

A qualitative, observational evaluation was conducted during the 2025 Tranquil Passport Full-Scale Exercise. Data sources included structured interviews with pediatric actors and caregivers, evaluator observations, and facilitated multi-disciplinary debriefings. Pediatric participants simulated biocontainment transport scenarios within the PBCU across multiple sites and phases of care.

Pediatric transport within the PBCU required advance planning to address developmental, psychosocial, and physiologic needs distinct from adult care. Pediatric participants frequently described confusion or anxiety related to noise, vibration, movement, and the appearance of personnel in personal protective equipment (PPE). Communication challenges associated with masked voices were reported. Caregiver separation due to infection-control requirements was consistently described as stressful. Clinical teams identified benefits of pediatric-specific medication dosing guides and essential medication sets within the confined biocontainment environment.

This inaugural deployment of the PBCU with pediatric participants identified key operational and psychosocial considerations relevant to pediatric-inclusive HCID transport. Findings supported the need for deliberate integration of pediatric-specific planning, communication strategies, and resources within biocontainment transport systems. These observations may also inform pediatric HCID transport planning in international settings where similar challenges are encountered.