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Pre-Hospital (e.g., EMS)
Topic Collection
May 16, 2023

Topic Collection: Pre-Hospital (e.g., EMS)

The moments between either the onset of illness due to a public health emergency or an illness/ injury as a result of any type of incident are critical and often determine the difference between survival, serious illness or injury, or death. Prehospital providers are an important resource to support preparedness, response and recovery. It is important to note that that the prehospital scope of practice varies from state to state and prehospital providers rely on medical protocols or online medical direction as part of patient care or treatment in the field.

The resources in this Topic Collection include information on both traditional and evolving pre-hospital roles (e.g., mobile prehospital care and community paramedicine). We note that during a disaster, the community paramedicine framework has the potential for broad use in shelter-based care, home visits, home triage/treatment, and other roles, reducing the burden on more traditional emergency medical services. Included are research articles, fact sheets, algorithms, and templates that describe the role of emergency medical services in disasters and public health emergencies and can help first responders prepare for and respond to a variety of events.

More specific information can be found in the following ASPR TRACIE Topic Collections: Fatality Management, Responder Safety and Health, Burn, Explosives (e.g., bomb, blast) and Mass Shooting, Mental/Behavioral Health (non-responders), Pre-Hospital Victim Decontamination, Alternate Care Sites, Mass Gatherings/Special Events, Pediatric, and Trauma Care and Triage.

Each resource in this Topic Collection is placed into one or more of the following categories (click on the category name to be taken directly to that set of resources). Resources marked with an asterisk (*) appear in more than one category.

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Must Reads

American College of Surgeons. (2015). See Something, Do Something: Improving Survival Strategies to Enhance Survival in Active Shooter and Intentional Mass Casualty Events: A Compendium. Bulletin of the American College of Surgeons. 100(15).
This document was developed by the Hartford Consensus (a team of healthcare leaders) and is a comprehensive compendium of resources and supporting documents that first responders can use to facilitate planning and training and enhance survivability from mass casualty and active shooter events.
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  • Meghan Treber test
    9/21/2019 2:21:41 PM
ASPR TRACIE. (2019). Mass Casualty Trauma Triage: Paradigms and Pitfalls.
This ASPR TRACIE roundtable summary can help emergency medical system (EMS) medical directors and EMS systems planners and hospital emergency planners to key differences between “conventional” MCIs and mass violence events when: the scene is dynamic; the number of patients far exceeds usual resources; and usual triage and treatment paradigms may fail.
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ASPR TRACIE. (2023). EMS Infectious Disease Playbook.
This playbook (updated in 2023) synthesizes multiple sources of information in a single planning document addressing the full spectrum of infectious agents to create a concise reference resource for emergency medical services (EMS) agencies developing their service policies. The information can be incorporated into agency standard operating procedures and reviewed by the EMS medical director.
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  • Bridget Kanawati Thank you for your interest in this resource. Unfortunately, funding restrictions preclude our being able to provide printed versions of our resources so all of our products, including this one, are only available electronically. ASPR TRACIE Team
    3/26/2020 2:12:41 PM
  • Frances Thorpe I agree with Tracy, is there a way to order this publication in hard copy format? The information contained in this publication highlights agency infection control policies and is a great resource to have in the department library.
    3/26/2020 12:21:36 PM
  • Tracy Miller Is there any way to order a printed and bound version?
    8/9/2018 5:16:09 PM
Boone, C., Avery, L., and Malone, T. (2015). A Research Study of Ambulance Operations and Best Practice Considerations for Emergency Medical Services Personnel. Department of Homeland Security, Science and Technology Directorate.
This document summarizes a study and provides guidelines and promising practices for designing ambulance patient compartments for crashworthiness, ensuring patient safety and comfort, and enhancing responder safety.
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Bulger, E., Snyder, D., Schoelles, K., et al. (2014). An Evidence-Based Prehospital Guideline for External Hemorrhage Control: American College of Surgeons Committee on Trauma. Prehospital Emergency Care. 18(2):163-173.
This guideline is a culmination of an extensive literature review on the use of tourniquets and hemostatic agents for managing life-threatening extremity and junctional hemorrhage. An expert panel examined the results of the literature review, then provided recommendations for emergency medical services care.
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California Emergency Medical Services Authority. (2023). Disaster Medical Services Division — Ambulance Strike Team.
This webpage defines Ambulance Strike Teams and how they are used in California and includes links to related resources (e.g., the Ambulance Strike Team [AST]/Medical Task Force [MTF] System Manual and a reimbursement schedule).
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Catlett, C., Jenkins, J.L., and Millin, M.G. (2011). Role of Emergency Medical Services in Disaster Response: Resource Document for the National Association of EMS Physicians Position Statement. Prehospital Emergency Care. 15(3):420-5.
The authors expand upon the position statement released by the National Association of EMS Physicians (also included in this collection) regarding the role of emergency medical services personnel in disasters.
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Duncan, E. Colver, K., Dougall, N., et al. (2014). Consensus on Items and Quantities of Clinical Equipment Required to Deal with Mass Casualties Big Bang Incident: A National Delphi Study. BMC Emergency Medicine. 14: 5.
British researchers developed an expert consensus regarding the essential items and minimum quantities of clinical equipment necessary to care for 100 patients on the scene of a mass casualty explosion event.
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Federal Emergency Management Agency. (2012). Operational Templates and Guidance for EMS Mass Incident Deployment.
The goal of this detailed report is to share model policies and practices across a variety of disciplines and provider types and help the emergency medical services (EMS) field deploy more effectively to planned and spontaneous mass care incidents. Case studies and event templates are included that can help EMS planners develop related policies and templates.
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Federal Interagency Committee on EMS. (2014). National Implementation of the Model Uniform Core Criteria for Mass Casualty Incident Triage.
This report summarizes the Model Uniform Core Criteria for mass casualty triage and highlights strategies and action steps member agencies can take to support national implementation of the criteria.
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Hanfling, D., Hick, J., and Stroud, C. (2013). Crisis Standards of Care: A Toolkit for Indicators and Triggers *. (Free registration required.) Institute of Medicine: National Academies Press.
This toolkit contains key concepts, guidance, and practical resources to help individuals across the emergency response system develop plans for crisis standards of care. Chapter 7 includes sample indicators, triggers, and sample tactics for use in the transition from conventional surge to contingency surge to crisis surge, and a return from crisis response to conventional response (detailed specifically for emergency medical services using slow-onset and no-notice scenarios).
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Loma Linda University Children's Hospital. (2013). Pediatric/Neonatal Disaster Reference Guide: Bridging the Gap Between EMS and Hospital Care.
This guide was created to help emergency managers, coordinators, and hospitals in their efforts to develop their own specific departmental Emergency Operations Plan that addresses the special needs of children and infants.
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National Conference of State Legislatures. (2016). Beyond 911: State and Community Strategies for Expanding the Primary Care Role of First Responders.
This website highlights resources and case studies in the field of Community Paramedicine which may assist others with implementing this type of pre-hospital care.
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National Highway Traffic Safety Administration. (2019). National EMS Scope of Practice Model.
This model explains the four levels of emergency medical services licensure: Emergency Medical Responder, Emergency Medical Technician, Advanced EMT, and Paramedic. The role, skills, and necessary knowledge base are highlighted for each level.
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Schenk, E. , Wetunge, G., Mann, C., et al. (2014). Epidemiology of Mass Casualty Incidents in the United States. Prehospital Emergency Care. 81(3).
The authors report on characteristics and frequency of mass casualty incidents in the U.S. during 2010 (as reported by emergency medical services personnel).
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U.S. Chemical Safety Board. (2016). West Fertilizer Explosion and Fire.
This report details the 2013 West (Texas) Fertilizer Company fire and explosion which resulted in 15 deaths (12 emergency responders) and more than 260 injuries. The emergency response is detailed in Section 7 of the report.
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U.S. Fire Administration. (2013). Fire/Emergency Medical Services Department Operational Considerations and Guide for Active Shooter and Mass Casualty Incidents. Federal Emergency Management Agency.
This white paper includes checklists and step-by-step considerations for active shooter event planning and response by pre-hospital providers, and references the framework suggested by the Hartford Consensus.
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Wolf-Fordham, S., Twyman, J., and Hamad, C. (2014). Educating First Responders to Provide Emergency Services to Individuals with Disabilities. Disaster Medicine and Public Health Preparedness. 8(6):533540.
The authors measured the effectiveness of an online program to increase emergency responder knowledge, planning, and response surrounding children and adults with disabilities. They found significant levels of gains in participant knowledge and simulated applied skills.
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Community Paramedicine

Amadi-Obi, A., Gilligan, P., Owens, N., et al. (2014). Telemedicine in Pre-Hospital Care: A Review of Telemedicine Applications in the Pre-Hospital Environment. International Journal of Emergency Medicine. 7(29).
The authors examined 39 studies related to telemedicine that met their inclusion criteria and determined that telemedicine can have a positive effect on emergency medical care.
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Bigham, B., Kennedy, S., Drennan, I., et al. (2013). Expanding Paramedic Scope of Practice in the Community: A Systematic Review of the Literature. (Free registration required.) Prehospital Emergency Care. 17(3).
The authors undertook an extensive literature review to help gain a clear understanding of the emerging research surrounding the concept of community paramedicine. Results were promising, but research is limited.
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California Emergency Medical Services Authority. (n.d.). Introduction to Community Paramedicine. (Accessed 8/7/2023.)
This website provides an overview of community paramedicine, as well as information on the 13 Community Paramedicine pilot projects in a dozen California locations that are being conducted by the California Emergency Medical Services Authority (EMSA), in collaboration with the California Health Care Foundation (CHCF). The projects focus on providing services where access to healthcare is limited or when a short-term intervention is needed.
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Community Paramedic. (2016). The Community Paramedic Program—A New Way of Thinking.
This website includes information on the Community Paramedic Program, which provides training for first responders at the appropriate level to serve communities more broadly in the areas of: primary care, public health, disease management, prevention and wellness, mental health, and oral health. The program also adapts to the specific needs and resources of each community.
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Iezzoni, L., Dorner, S., and Ajayi, T. (2016). Community Paramedicine Addressing Questions as Programs Expand. The New England Journal of Medicine. 374:1107-1109.
The authors provide an overview of community paramedicine in the United States and abroad and highlight several areas for more research.
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National Conference of State Legislatures. (2016). Beyond 911: State and Community Strategies for Expanding the Primary Care Role of First Responders.
This website highlights resources and case studies in the field of Community Paramedicine which may assist others with implementing this type of pre-hospital care.
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Patterson, D. and Skillman, S. (2012). National Consensus Conference on Community Paramedicine: Summary of an Expert Meeting.
This report provides a summary of topics covered by the 2012 National Consensus Conference on Community Paramedicine (CP) attendees. Though somewhat dated it remains relevant and is divided into six main sections with gaps and future goals: Education and Expanded Practice Roles; Integration of CP Providers with Other Health Providers; Medical Direction and Regulation; Funding and Reimbursement; Data, Performance Improvement, and Outcome Evaluation; and Community Paramedicine Research Agenda.
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Pennsylvania Coalition of Nurse Practitioners. (2016). Five New Studies: Nurse Practitioners Expand Access to Health Care, Lower Costs, Improve Outcomes.
The article addresses five separate studies that concluded that nurse practitioners expand access to care, improve patient health outcomes, boost rural health care, lower primary care costs and reduce emergency room admissions.
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South Carolina Office of Rural Health. (2014). Blueprint for Community Paramedicine Programs Especially for EMS Agencies. Version 1: The Abbeville Experience.
This document was designed around the resources and tools that were paramount in the development of Abbeville’s Community Paramedicine program. Version one, The Abbeville Experience, showcases examples, resources, tools, recommendations, lessons learned and best practices. As a result, the Blueprint is specific to South Carolina and is geared towards emergency medical services agencies.
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U.S. Department of Health and Human Services, Health Resources and Services Administration, Office of Rural Health Policy. (2012). Community Paramedicine Evaluation Tool.
This document addresses the need for each community paramedicine program to define its system-specific health status benchmarks and performance indicators and to use a variety of community health and public health interventions to improve the community’s health status. It also addresses reducing the burden of illness, chronic disease, and injury as a community-wide public health problem, not strictly as a patient care issue.
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University of Minnesota, University of North Carolina at Chapel Hill, and University of Southern Maine. (2014). The Evidence for Community Paramedicine in Rural Areas: State and Local Finding and the Role of the State Flex Program.
The authors of this study examined the evidence base for community paramedicine in rural communities, the role of community paramedics in rural healthcare delivery systems, the challenges faced by states in implementing community paramedicine programs, and the role of the state Flex programs in supporting development of community paramedicine programs. Additionally, the article provides a snapshot of community paramedicine programs currently being developed and/or implemented in rural areas.
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Education and Training

Chaput, C.J., Deluhery, M.R., Stake, C.E., et al. (2007). Disaster Training for Prehospital Providers. Prehospital Emergency Care. 11(4):458-465.
The authors describe findings from a survey of prehospital healthcare providers to determine mass casualty event (MCE) training knowledge retention, self-assessed levels of preparedness for MCEs, and preferred educational formats. Drills and lectures were the most used and preferred formats for disaster training.
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Department of Emergency Health Services. (n.d.). Emerging Infectious Diseases Videos for Prehospital Providers. (Accessed 8/7/2023.) University of Maryland Baltimore County.
This instructional series, comprised of nine modules (listed at the top of the page), includes an introduction to infectious diseases, basic infection control concepts, considerations for personal protective equipment (including donning and doffing), personnel decontamination, patient transport, and transfer of patient care for patients with Ebola and other highly infectious diseases.
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Wolf-Fordham, S., Twyman, J., and Hamad, C. (2014). Educating First Responders to Provide Emergency Services to Individuals with Disabilities. Disaster Medicine and Public Health Preparedness. 8(6):533540.
The authors measured the effectiveness of an online program to increase emergency responder knowledge, planning, and response surrounding children and adults with disabilities. They found significant levels of gains in participant knowledge and simulated applied skills.
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Emergency Medical Services Triage

ASPR TRACIE. (2019). Mass Casualty Trauma Triage: Paradigms and Pitfalls.
This ASPR TRACIE roundtable summary can help emergency medical system (EMS) medical directors and EMS systems planners and hospital emergency planners to key differences between “conventional” MCIs and mass violence events when: the scene is dynamic; the number of patients far exceeds usual resources; and usual triage and treatment paradigms may fail.
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Barnett, A., Wang, N., Sahni, R., et al. (2013). Variation in Prehospital Use and Uptake of the National Field Triage Decision Scheme. Official Journal of the National Association of EMS Physicians and the National Association of State EMS Directors. 17(2):135-.
The objective of this study was to compare the use of field triage criteria by emergency medical services personnel in six regions. The researchers ultimately found a large variation between the frequency and type of field triage criteria used and suggested opportunities for incorporating updated guidelines.
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Federal Interagency Committee on EMS. (2014). National Implementation of the Model Uniform Core Criteria for Mass Casualty Incident Triage.
This report summarizes the Model Uniform Core Criteria for mass casualty triage and highlights strategies and action steps member agencies can take to support national implementation of the criteria.
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Newgard, C., Mann, N., Hsia, R., et al. (2014). Patient Choice in the Selection of Hospitals by 9-1-1 Emergency Medical Services Providers in Trauma Systems. Academic Emergency Medicine: Official Journal of the Society for Academic Emergency Medicine. 20(9): 911919.
This retrospective study examines the reasons cited by emergency medical services providers for selecting hospital destinations based on criteria such as injury severity, field triage status, and patient or family choice. The authors found that hospital selection was most influenced by patient or family choice.
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Guidance

American College of Emergency Physicians. (2019). EMS and Disaster Preparedness.
This webpage features links to disaster preparedness resources geared towards emergency medical service providers.
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American College of Surgeons. (2015). See Something, Do Something: Improving Survival Strategies to Enhance Survival in Active Shooter and Intentional Mass Casualty Events: A Compendium. Bulletin of the American College of Surgeons. 100(15).
This document was developed by the Hartford Consensus (a team of healthcare leaders) and is a comprehensive compendium of resources and supporting documents that first responders can use to facilitate planning and training and enhance survivability from mass casualty and active shooter events.
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  • Meghan Treber test
    9/21/2019 2:21:41 PM
ASPR TRACIE. (2016). Mass Burn Event Overview. U.S. Department of Health and Human Services, Office of the Assistant Secretary for Preparedness and Response.
This document provides guidance for healthcare coalitions, burn centers, state public health preparedness professionals, healthcare entities, and other stakeholders planning for a burn mass casualty incident.
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ASPR TRACIE. (2018). Mass Violence/Active Shooter Incidents: EMS Considerations.
This ASPR TRACIE tip sheet (which is part of a series) can help emergency medical systems planners incorporate issues related to pre-event, initial response, and support for hospitals into their no-notice incident plans.
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Boone, C., Avery, L., and Malone, T. (2015). A Research Study of Ambulance Operations and Best Practice Considerations for Emergency Medical Services Personnel. Department of Homeland Security, Science and Technology Directorate.
This document summarizes a study and provides guidelines and promising practices for designing ambulance patient compartments for crashworthiness, ensuring patient safety and comfort, and enhancing responder safety.
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Hanfling, D., Hick, J., and Stroud, C. (2013). Crisis Standards of Care: A Toolkit for Indicators and Triggers *. (Free registration required.) Institute of Medicine: National Academies Press.
This toolkit contains key concepts, guidance, and practical resources to help individuals across the emergency response system develop plans for crisis standards of care. Chapter 7 includes sample indicators, triggers, and sample tactics for use in the transition from conventional surge to contingency surge to crisis surge, and a return from crisis response to conventional response (detailed specifically for emergency medical services using slow-onset and no-notice scenarios).
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Healthcare Ready. (2018). Controlled Substances in Emergency Situations and the 2017 Protecting Patient Access to Emergency Medications Act (PPAEMA).
This four-page fact sheet provides information about controlled substances in emergencies and the 2017 Protecting Patient Access to Emergency Medications Act (PPAEMA). It discusses how PPAEMA applies to Emergency Medical Services (EMS) Agencies, and Pharmacists and Patients, including how a pharmacist may dispense controlled substances during emergencies upon receipt of “oral authorization from a prescribing individual practitioner.”
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Hodge, J., Orenstein, D., and Weidenaar, K. (2014). Expanding the Roles of Emergency Medical Services Providers: A Legal Analysis. Association of State and Territorial Health Officials.
This document highlights potential methods to increase opportunities to engage emergency medical services (EMS) providers for day-to-day activities in communities across the United States. The report summarizes a review and analysis of the existing legal environment that either facilitates, or imposes barriers to, expanded roles of EMS.
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Loma Linda University Children's Hospital. (2013). Pediatric/Neonatal Disaster Reference Guide: Bridging the Gap Between EMS and Hospital Care.
This guide was created to help emergency managers, coordinators, and hospitals in their efforts to develop their own specific departmental Emergency Operations Plan that addresses the special needs of children and infants.
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National Highway Traffic Safety Administration. (2019). National EMS Scope of Practice Model.
This model explains the four levels of emergency medical services licensure: Emergency Medical Responder, Emergency Medical Technician, Advanced EMT, and Paramedic. The role, skills, and necessary knowledge base are highlighted for each level.
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The Joint Committee to Create a National Policy to Enhance Survivability from Mass Casualty Shooting Events. (2013). Active Shooter and Intentional Mass-Casualty Events: The Hartford Consensus II. Bulletin of the American College of Surgeons.
The author summarizes findings from a meeting of The Hartford Consensus on active shooter and mass casualty events. The group emphasizes the need for on-scene collaboration between emergency medical services and law enforcement, and highlights the supportive role that uninjured bystanders can also play in the response effort.
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U.S. Department of Health and Human Services. (2007). Public Health Emergency Response: A Guide for Leaders and Responders.
The U.S. Department of Health and Human Services created this document to help public officials and first responders understand their role during a public health emergency.
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* U.S. Fire Administration. (2013). Fire/Emergency Medical Services Department Operational Considerations and Guide for Active Shooter and Mass Casualty Incidents. Federal Emergency Management Agency.
This white paper includes checklists and step-by-step considerations for active shooter event planning and response by pre-hospital providers, and references the framework suggested by the Hartford Consensus.
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U.S. Government Publishing Office. (2017). Protecting Patient Access to Emergency Medications Act of 2017.
Part of this Act allows emergency medical services agencies to receive DEA registration in order to administer controlled substances (II-IV) “outside the physical presence of a medical director or authorizing medical professional.”
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Infectious Disease (e.g., Ebola, pandemic influenza)

Aengst, J., Walker-Stevenson, G., Harrod, T., et al. (2022). Uncomfortable Yet Necessary: The Impact of PPE on Communication in Emergency Medicine. International Journal for Quality in Health Care. 34(4): mzac095..
The authors describe results from focus groups and interviews with fire-based EMS responders about the effects of COVID-19 on the delivery of care. They found that PPE use affected responders’ efficiency in responding to calls, ability to detect patient symptoms; and ability to communicate with patients and their loved ones, their fellow responders, transport agencies, and hospitals and clinicians. Responders also reported facing hostility from members of the public opposed to their use of PPE. The authors describe some of the solutions used to address communications challenges and suggest areas in need of additional research.
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ASPR TRACIE. (2017). EMS & Infectious Diseases: Challenges & Resources for Provider Protection.
The speakers in this webinar discuss the emergency medical services (EMS) Infectious Disease Playbook and how EMS professionals can use it in their daily practice.
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  • Meghan Treber This is a great resource!
    7/17/2017 2:25:31 PM
Bredmose, P., Diczbalis, M., Butterfield, E., et al. (2020). Decision Support Tool and Suggestions for the Development of Guidelines for the Helicopter Transport of Patients with COVID-19. Scandinavian Journal of Trauma, Resuscitation, and Emergency Medicine. 28(1):43.
The authors offer recommendations on the safe helicopter transport of COVID-19 patients, focusing on the selection of which patients to transport, infection prevention strategies, and key decisions at the referral hospital, during the flight, at mission completion, and in the community. They also provide a decision support framework that may be used to develop local plans and protocols.
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Centers for Disease Control and Prevention. (2015). Interim Guidance for Emergency Medical Services (EMS) Systems and 9-1-1 Public Safety Answering Points (PSAPs) for Management of Patients under Investigation (PUIs) for Ebola Virus Disease (EVD) in the United States.
This guidance was developed to ensure that emergency medical services providers and other first responders are safe and patients are appropriately managed while handling inquiries and responding to patients under investigation.
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Centers for Disease Control and Prevention. (2018). Q&A's about the Transport of Pediatric Patients (< 18 years of age) Under Investigation or with Confirmed Ebola.
This webpage provides first responders with helpful information specific to protecting themselves, younger patients, and patients’ family members by answering the frequently asked questions about Ebola and transporting young patients.
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Jenkins, J., Hsu, E., Russell, A., et al. (2022). Infection Prevention and Control for the Emergency Medical Services and 911 Workforce. U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality.
This technical brief summarizes current evidence related to EMS and 911 workforce exposures to infectious pathogens and practices to prevent, recognize, and control exposures and illness.
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Lemay, F., Vanderschuren, A., and Alain, J. (2020). Aeromedical Evacuations During the COVID-19 Pandemic: Practical Considerations for Patient Transport. Canadian Journal of Emergency Medicine. 22(5):584-586.
In this commentary, the authors describe five lessons learned from their aeromedical organization’s experience transferring 50 confirmed or suspected COVID-19 patients.
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Lowe, J., Jelden, K., Schenarts, P., et al. (2014). Considerations for Safe EMS Transport of Patients Infected with Ebola Virus. (Abstract only.) Prehospital Emergency Care. 19(2):179-183.
The authors discuss the coordinated response between the Nebraska Biocontainment Unit (through the Nebraska Medical Center in Omaha) and Omaha Fire Department's EMS to transport patients with confirmed Ebola virus from West Africa from the airport to the high-level isolation unit. Three critical areas have been identified from their experience and are addressed in this article: ambulance preparation, appropriate selection and use of personal protective equipment, and environmental decontamination.
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National Highway Traffic Safety Administration. (2007). EMS Pandemic Influenza Guidelines for Statewide Adoption.
This document provides broad-based pandemic influenza guidelines for consideration by state and local emergency medical services agencies, including the basic planning assumptions underpinnings those recommended guidelines.
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New York State Department of Health, and New York State Emergency Medical Services. (2014). Ebola Virus Disease (EVD) In-Service EMS Training Outline.
This document provides information on Ebola (e.g., how it is transmitted, signs and symptoms), and several recommendations to EMS personnel including use of personal protective equipment, cleaning EMS transport vehicles after transporting a patient with suspected or confirmed Ebola, follow-up and/or reporting measures by EMS personnel after caring for a suspected or confirmed Ebola patient, among others.
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U.S. Department of Health and Human Services. (2006). Emergency Medical Service and Non-Emergent (Medical) Transport Organizations Pandemic Influenza Planning Checklist.
This checklist was created to help emergency medical services and non-emergent (medical) transport organizations measure and improve their preparedness for responding to pandemic influenza.
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Lessons Learned

Arnold, C. (2016). Responders from the Berkeley Balcony Collapse Reflect on Incident Challenges. Journal of Emergency Medical Services.
The author describes the incident, the challenges and strengths of the response, and highlights the lessons learned by firefighters and other responders who worked the scene of a 5th floor balcony collapse during a party.
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Bulger, E., Snyder, D., Schoelles, K., et al. (2014). An Evidence-Based Prehospital Guideline for External Hemorrhage Control: American College of Surgeons Committee on Trauma. Prehospital Emergency Care. 18(2):163-173.
This guideline is a culmination of an extensive literature review on the use of tourniquets and hemostatic agents for managing life-threatening extremity and junctional hemorrhage. An expert panel examined the results of the literature review, then provided recommendations for emergency medical services care.
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Hick, J.L., Ho, J.D., Heegaard, W.G., et al. (2008). Emergency Medical Services Response to a Major Freeway Bridge Collapse. (Abstract only.) Disaster Medicine and Public Health Preparedness. 2(S1): S17-S24.
The authors discuss the emergency medical services response to the bridge collapse, noting the successes and lessons learned (e.g., patient tracking, communications).
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Kearns, R.D., Myers, B., Cairns, C.B., et al. (2014). Hospital Bioterrorism Planning and Burn Surge. Biosecurity Bioterrorism. 12(1):20-8.
This article discusses how using an all-hazards approach to bioterrorism response planning helped to prepare hospitals in the Raleigh/Durham, NC area to care for casualties from a plant explosion in June 2009. The rescue, response, and resuscitation of survivors by first responders and first receivers, as well as efforts to develop burn surge, are described.
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Mountain Plains Regional Disaster Health Response System (MPRDHRS). (2023). Marshall Fire Learning Series: EMS.
This 1.5-hour video is part of a four-video series which details how Mountain View Fire Rescue, EMS, and the Boulder County Sheriff’s Office responded to the Marshall Fire on December 31, 2021. The panel is composed of emergency responders who discuss their experiences during the fire.
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Pereira, B.,Morales W., Cardoso, R., et al. (2013). Lessons Learned From a Landslide Catastrophe in Rio de Janeiro, Brazil. (Free registration required.) American Journal of Disaster Medicine. 8(4):253-8.
The authors discuss lessons learned from this flood and landslide event in 2011, with a focus on pre-hospital and hospital organization and management of patients. They also describe the most common injuries treated (injuries were to the extremities, most requiring only wound cleaning, debridement, and suture), and note that the primary cause of death was from asphyxia due to drowning or mud burial.
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Ramme, A.J., Vira, S., and McLaurin, T.M. (2015). Superstorm Sandy's Forgotten Patient: A Lesson in Emergency Preparedness in Severe Obesity. Obesity. 23(2):253-4.
The authors describe the challenges associated with evacuation of a morbidly obese patient during Superstorm Sandy, and how those challenges influenced the decision not to evacuate the patient, even in the absence of power and running water.
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Rankin, J. (2016). These are War Wounds: Brussels Hospitals Treat Terror Attack Victims. The Guardian.
The author describes the revisions to hospital emergency plans since the Paris terror attacks and the types of injuries treated by staff from Erasmus Hospital in Brussels.
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Redhead, J., Ward, P., and Batrick, N. (2005). The London Attacks--Response: Prehospital and Hospital Care. The New England Journal of Medicine. 353:546-547.
The authors detail the medical response to the 2005 London public transportation bombing. They discuss the nature of injuries, how a treatment center was set up in a nearby hotel, and the process of handing burn patients over to a regional burn center.
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Schenk, E. , Wetunge, G., Mann, C., et al. (2014). Epidemiology of Mass Casualty Incidents in the United States. Prehospital Emergency Care. 81(3).
The authors report on characteristics and frequency of mass casualty incidents in the U.S. during 2010 (as reported by emergency medical services personnel).
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Sugerman, D. and Armstrong, J. (2013). Prevention and Treatment of Injuries Following Hurricanes and Tornadoes. Centers for Disease Control and Prevention.
This one-hour webinar covers the provision of pre-hospital care; the patterns of injury seen after hurricanes and tornadoes, including appropriate initial management; appropriate emergency risk communication messages; and the importance of data collection to improve messaging and response efforts.
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U.S. Chemical Safety Board. (2016). West Fertilizer Explosion and Fire.
This report details the 2013 West (Texas) Fertilizer Company fire and explosion which resulted in 15 deaths (12 emergency responders) and more than 260 injuries. The emergency response is detailed in Section 7 of the report.
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U.S. Department of Homeland Security. (2023). Homeland Security information Network.
Registered users can access Sensitive but Unclassified information on this site that includes lessons learned, after-action reports, situational awareness tools, and other resources for emergency healthcare responders.
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Pediatric Issues 

Garst, L., Gordon, J. and Peters, E. (2018). Engage – Calm – Distract: Understanding and Responding to Children in Crisis. A Resource Kit for EMS and Emergency Department Providers. Colorado Department of Public Health & Environment.
Responders report that their own emotional responses, lack of experience in working with children, and the emotions of family members can negatively affect the quality of care when responding to pediatric emergencies. This resource kit provides information, strategies, and activities to help both pre-hospital and hospital emergency providers reduce the emotional distress of children in crisis. Quickly engaging, calming, and distracting children and their caregivers can improve both immediate and long-term physical and emotional outcomes for pediatric patients.
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Koziel, J.R., Meckler, G., Brown, L., et al. (2014). Barriers to Pediatric Disaster Triage: A Qualitative Investigation. (Abstract only.) Prehospital Emergency Care Journal. 19(2).
The authors conducted a qualitative evaluation of paramedics’ self-reported obstacles to pediatric disaster triage performance using a 10-victim, multiple-family house fire simulation. Respondents indicated difficulty with triaging multiple child disaster victims “due to emotional obstacles; unfamiliarity with pediatric physiology; and struggles with triage rationale and efficiency.”
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Lowe, C.G. (2009). Pediatric and Neonatal Interfacility Transport Medicine After Mass Casualty Incidents. (Abstract only.) The Journal of Trauma. 67(2 Suppl): S168-71.
A mass casualty incident can present major challenges for a critical care transport team, which is essential for the safe interfacility movement of critically ill patients. The author reviews the capabilities and limitations of pediatric and neonatal critical care transport teams and factors that hindered the evacuation of pediatric and neonatal patients after Hurricane Katrina to provide recommendations to improve the efficiency and efficacy of interfacility transport of pediatric patients.
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Steve, S., Rebecca, L., Rhonda, D., et al. (2007). Prehospital Preparedness for Pediatric Mass-Casualty Events. (Abstract only.) Pediatrics. 120(4).
The authors examined the preparedness levels of U.S. emergency medical services agencies specific to the care of children who are involved in mass-casualty events. Less than 15% reported pediatric-specific mass casualty plans, and while almost 70% reported participating in local disaster drills within the past year, fewer than half of those drills included pediatric victims.
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Plans, Tools, and Templates

ASPR TRACIE. (2023). EMS Infectious Disease Playbook.
This playbook (updated in 2023) synthesizes multiple sources of information in a single planning document addressing the full spectrum of infectious agents to create a concise reference resource for emergency medical services (EMS) agencies developing their service policies. The information can be incorporated into agency standard operating procedures and reviewed by the EMS medical director.
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  • Bridget Kanawati Thank you for your interest in this resource. Unfortunately, funding restrictions preclude our being able to provide printed versions of our resources so all of our products, including this one, are only available electronically. ASPR TRACIE Team
    3/26/2020 2:12:41 PM
  • Frances Thorpe I agree with Tracy, is there a way to order this publication in hard copy format? The information contained in this publication highlights agency infection control policies and is a great resource to have in the department library.
    3/26/2020 12:21:36 PM
  • Tracy Miller Is there any way to order a printed and bound version?
    8/9/2018 5:16:09 PM
Bucks County Emergency Health Services. (2016). Mass Casualty Response Plan.
This plan includes a county-specific resource table (that lists equipment by capability) and an appendix dedicated to responding to school bus accidents.
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California Emergency Medical Services Authority. (2023). Disaster Medical Services Division — Ambulance Strike Team.
This webpage defines Ambulance Strike Teams and how they are used in California and includes links to related resources (e.g., the Ambulance Strike Team [AST]/Medical Task Force [MTF] System Manual and a reimbursement schedule).
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Contra Costa Health Services. (2018). Emergency Medical Services Multi-Casualty Incident Plan.
This county mass casualty plan lists responsibilities for a variety of roles (e.g., helicopter providers, law enforcement, and communications centers) and includes checklists and a CHEMPACK mobilization plan as appendices. Additional resources are available on this webpage.
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County of Santa Clara, Emergency Medical Services. (2014). EOA Emergency Ambulance Staffing Contingency Plan.
The plan was designed for managers of the Santa Clara County Emergency Medical Service System to help them manage staffing shortages of any cause within the county's 911 Exclusive Operation Area. It is separated into phases and includes sections on public information and messaging and a variety of checklists.
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Duncan, E. Colver, K., Dougall, N., et al. (2014). Consensus on Items and Quantities of Clinical Equipment Required to Deal with Mass Casualties Big Bang Incident: A National Delphi Study. BMC Emergency Medicine. 14: 5.
British researchers developed an expert consensus regarding the essential items and minimum quantities of clinical equipment necessary to care for 100 patients on the scene of a mass casualty explosion event.
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Federal Emergency Management Agency. (2012). Operational Templates and Guidance for EMS Mass Incident Deployment.
The goal of this detailed report is to share model policies and practices across a variety of disciplines and provider types and help the emergency medical services (EMS) field deploy more effectively to planned and spontaneous mass care incidents. Case studies and event templates are included that can help EMS planners develop related policies and templates.
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Illinois Department of Public Health. (2018). Catastrophic Incident Response Annex.
This annex describes and guides Illinois' state-level response and care of patients, including crisis care and resource allocation, during a catastrophic incident that incapacitates the local, regional, and/or state health care system and prevents the ability to provide conventional and/or contingency care. It includes a concept of operations and sections on roles, responsibilities, resource requirements, and recovery. Attachment 6 has specific recommendations for EMS adaptations during catastrophic incidents.
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Metropolitan Emergency Services Board (MN). (2012). Mass Casualty Incident Response Plan.
This fact sheet (developed for agencies in Minnesota) lists considerations and steps for emergency medical services (EMS) to take during a mass casualty incident. Information is provided for ambulance operators (focused on loading patients and leaving the scene), EMS command, EMS operations, and transportation supervisors.
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Michigan Department of Health and Human Services. (2019). MI-MEDIC. Michigan Medication Emergency Dosing and Intervention Cards.
These color-coded cards were designed to help emergency healthcare practitioners provide care for patients based on weight and age. Instructions for each age/weight group are provided on two cards: Conditions/Medications and Cardiac Resuscitation. The cards can be saved and/or printed for future use.
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Paramedic Protocol Provider. (n.d.). EMS Protocols. (Accessed 8/7/2023.)
This webpage includes links to many state and county emergency medical services protocols including incident response and mass casualty incident plans.
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Rappahannock EMS Council. (2018). Regional Mass Casualty Incident (MCI) Plan.
This plan was developed to help emergency medical services providers in a specific region in Virginia provide a patient care via a unified, coordinated and immediate mutual aid response to any type of mass casualty incident including activation of regional / coalition coordinating entities. Two unique feature of this plan are its sections on training and exercise and air operations.
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State of Florida, Department of Health. (2018). Florida Ambulance Deployment Standard Operating Procedure.
This document outlines steps for marshalling and deploying ground and air emergency medical services during a disaster. The Concept of Operations section includes considerations for notice and no-notice events, communications, and resource management. Duties and responsibilities for select roles are also specified.
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* U.S. Fire Administration. (2013). Fire/Emergency Medical Services Department Operational Considerations and Guide for Active Shooter and Mass Casualty Incidents. Federal Emergency Management Agency.
This white paper includes checklists and step-by-step considerations for active shooter event planning and response by pre-hospital providers, and references the framework suggested by the Hartford Consensus.
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Utah Department of Health, Bureau of EMS and Preparedness. (2011). Utah Mass Casualty Incident Plan.
This state-developed plan was developed to provide a coordinated response to the single site disaster that could overwhelm the day-to-day emergency health care delivery system. It is designed to support local disaster plans.
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Virginia Office of Emergency Medical Services and Virginia Department of Health. (2007). Emergency Medical Services (EMS) Surge Planning Template and Toolbox for Mass Casualty Incidents (MCI) in Virginia.
This planning tool can help emergency medical service (EMS) providers develop their own mass casualty incident plans. Several annexes are included under the section "EMS Mutual Aid and Surge Tool Box List." Note this is based on some historical assumptions for on-scene triage and injury patterns that may not be applicable to a mass violence event (access the ASPR TRACIE Mass Casualty Trauma Triage Paradigms and Pitfalls document: https://files.asprtracie.hhs.gov/documents/aspr-tracie-mass-casualty-triage-final-508.pdf).
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Agencies and Organizations

American College of Emergency Physicians. EMS and Disaster Preparedness.
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American Trauma Center. Trauma Information Exchange Program (TIEP).
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Emergency Nurses Association.
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EMSWORLD.
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International Academies of Emergency Dispatch.
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National Association of Emergency Medical Technicians.
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National Association of State EMS Officials.
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National EMS Information System.
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National Highway Traffic Safety Administration, Office of EMS. EMS.gov.
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Paramedic Protocol Provider. EMS Protocols.
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U.S. Department of Health and Human Services. Office of the Assistant Secretary for Preparedness and Response.
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This ASPR TRACIE Topic Collection was comprehensively reviewed in March and April 2016 by the following subject matter experts (listed in alphabetical order):

Eric Alberts, BS, FPEM, CHS-V, CDP-1, CHPP, CHEP, SEM, CFRP, FABCHS, Manager, Emergency Preparedness, Orlando Health, Inc. (Hospital System); Jim Bolen, MS, Planning Section Chief (T), Butler County / State of Ohio AHIMT; Julie Bulson, MPA, BSN, RN, Director, Emergency Preparedness, Spectrum Health Hospital Group; Patricia Frost, RN, MS, PNP, Director Emergency Medical Services, Contra Costa Health Services; John Hick, MD, HHS ASPR and Hennepin County Medical Center; Mark P. Jarrett, MD, MBA, MS, SVP & Chief Quality Officer, Associate Chief Medical Officer, Northwell Health, and Professor of Medicine, Hofstra Northwell School of Medicine; Brad Learn, Regional Healthcare Preparedness Coordinator, Kentucky Department for Public Health; and Joseph W. Schmider, State EMS Director, Texas Department of State Health Services, Office of EMS/Trauma System Coordination.
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