Introduction
Emergency Medical Services (EMS) is a well-recognized pillar of Disaster Medicine. As first responders on scene in the immediate aftermath of an event, when the degree of morbidity and mortality is highest, EMS is a critical part of disaster response.Reference Sorani, Tourani, Khankeh and Panahi1,Reference Fernandez, Studnek, Margolis, Mac Crawford, Bentley and Marcozzi2 An EMS system that is well-trained and experienced in disaster response can limit the number of deaths and injuries associated with a disaster event.Reference Ciottone, Biddinger and Darling3 It is, therefore, important that disaster preparedness and response capabilities be assessed and maximized within each EMS system.
The Republic of Armenia is a country prone to disasters. By estimation of the World Health Organization (WHO; Geneva, Switzerland), “more than 80% of Armenians are at risk of exposure to catastrophic events.”4 Armenia has suffered numerous earthquakes, including the 1988 Spitak earthquake that led to 25,000 deaths, and is susceptible to natural disasters such as floods, landslides, and temperature extremes.4 The country’s antiquated nuclear power plant and long-term conflict with Azerbaijan put Armenia further at risk for man-made disaster events.Reference Chekijian, Truzyan, Stepanyan and Bazarchyan5 The Armenian health care system was confronted with a unique challenge during the simultaneous SARS-CoV-2/coronavirus disease 2019 (COVID-19) pandemic and recent war with Azerbaijan, tasking the EMS system with war casualty care during a pandemic that was already overwhelming the country’s medical system.Reference Harutyunyan, Mukhaelyan and Hertelendy6
The need for EMS system modernization was identified in 1991 when the country first declared independence from the Soviet Union.Reference Baghdassarian, Donaldson, Depiero, Chernett and Sule7,Reference Chekijian8 Although a regional EMS training center was subsequently established in 1994 through United States Agency for International Development (USAID; Washington, DC USA) funding, in partnership with Boston University (Boston, Massachusetts USA), the University of Massachusetts (Worcester, Massachusetts USA), and the Ministry of Health (Yerevan, Armenia),9 there has been little progress in updating EMS education.Reference Baghdassarian, Donaldson, Depiero, Chernett and Sule7 The majority of the country’s EMS is concentrated in Armenia’s capital city, Yerevan, and is provided by the Yerevan Municipal Ambulance Service (YMAS).Reference Chekijian, Truzyan, Stepanyan and Bazarchyan5 With 50 ambulances divided across their main station and seven substations, YMAS responds to an average of 750-800 calls daily.10 Typically, YMAS responds to calls within the city boundaries of Yerevan, and response times average between 15 and 20 minutes depending on the season.10 Armenia follows the Franco-German model, with each ambulance staffed by a physician in addition to a nurse and driver.Reference Chekijian, Truzyan, Stepanyan and Bazarchyan5 At the present, there are 318 physicians in YMAS, 102 of whom are full time.10 A high percentage of calls result in on-site treatment, and there is a low hospital transfer rate.Reference Baghdassarian, Donaldson, Depiero, Chernett and Sule7 As there is no formal Emergency Medicine residency training in the country to date; ambulance physicians have training in a variety of specialties such as General Medicine, Pediatrics, Cardiology, or Obstetrics and Gynecology.Reference Chekijian, Truzyan, Stepanyan and Bazarchyan5 Only two physicians currently working for YMAS have formal training in EMS.10
The recent war with Azerbaijan that occurred during the height of the COVID-19 pandemic quickly overwhelmed Armenia’s health care system. On September 27, 2020, the “44-day war” broke out between Armenia and Azerbaijan over the disputed territory of Nagorno-Karabakh, a region historically inhabited by ethnic Armenians but internationally recognized as part of Azerbaijan.11 The war claimed the lives of more than 5,000 soldiers from the two sides and at least 143 civilians,12 as well as resulting in substantial population displacement as the majority of the 75,000 inhabitants of Nagorno-Karabakh migrated to Armenia,Reference Balalian, Berberian and Chiloyan13 thereby exacerbating the growing humanitarian crisis.Reference Kazaryan, Edwin and Darzi14 The six-week war saw at least a seven-fold increase in the daily number of cases of COVID-19,Reference Balalian, Berberian and Chiloyan13–15 as population displacement, overcrowded living spaces, war, and social mobilization encouraged disease proliferation.Reference Chekijian8,Reference Balalian, Berberian and Chiloyan13,Reference Markosian, Layne, Petrosyan, Shekherdimian, Kennedy and Khachadourian16 Armenia’s EMS system, already stretched to capacity by the COVID-19 pandemic, was given the additional burden of caring for and evacuating war casualties, sometimes requiring ambulances dispatched from Yerevan six hours away.Reference Harutyunyan, Mukhaelyan and Hertelendy6 During the height of the pandemic, YMAS calls increased to 1,000-1,200 calls daily.10
There is a paucity of literature that examines disaster preparedness within the Armenian EMS system or the effect of a simultaneous war and pandemic on any EMS system. This study aims to assess the current state of disaster preparedness of the Armenian EMS system, as well as the effects of a simultaneous pandemic and war on EMS providers. It is hoped that this information can guide future EMS disaster training programs, both locally and globally.
Methods
Study Design
This was a cross-sectional study conducted by anonymous survey that utilized five-point Likert scales. The survey questions were designed by subject matter experts in Disaster Medicine and EMS. Questions were initially written in English and were then translated to Armenian. The Armenian translation was reviewed by multiple bilingual study authors, who are health care professionals and native Armenian speakers. Surveys were administered electronically, with both the English and Armenian translation.
This study was approved by the Ministry of Health in Armenia and granted exempt status by the Institutional Review Board [Protocol #2021P000967].
Data Collection
Surveys were distributed from April 9, 2022 through May 7, 2022 to prehospital physicians employed by the Yerevan EMS system who provided care to casualties of the war with Azerbaijan as well as COVID-19 patients in the same time period. Participants were selected by sampling all EMS physicians still working in the system who met inclusion criteria. There were 85 prehospital physicians who met inclusion criteria. Data were collected via Research Electronic Data Capture (REDCap, version 11.1.17; Vanderbilt University, Nashville, Tennessee, United States of America), a secure web application for databases and online surveys. A total of 85 surveys were distributed.
Data Analysis
The Mann-Whitney U test was used to compare differences in dependent variables between two independent groups. The Kruskal-Wallis test was used to determine differences in a dependent variable between three or more groups. P values of ≤.05 were considered statistically significant. To assess the degree of provider battlefield medicine experience prior to the 2020 Nagorno-Karabakh War, a composite score of the sum of each provider’s answer to eight survey questions was calculated (experience in battlefield medicine, mass casualties, gunshot wounds, wounds from explosives, severe burns, severe bleeding/hemorrhagic shock, extreme orthopedic extremity injuries, and performing surgical procedures such as thoracostomy and cricothyroidotomy). To assess the degree of provider humanitarian medicine experience prior to the war, a composite score of the sum of each provider’s answer to four survey questions was calculated (experience in humanitarian medicine, treating severe respiratory illness, using personal protective equipment [PPE], and treating starvation or dehydration). These were chosen as indicators of experience in the field in humanitarian medicine, with pandemic illness, and with displaced populations.
Results
The initial survey response rate was 70.6% (n = 60). Twelve surveys were incomplete and were removed from analysis. The age of survey participants ranged from 24 to 56 years old, with a median age of 29 years old (Table 1). The majority (75%) of survey participants were male. Most (64.6%) participants were in residency training at the time of survey completion. Of 48 participants, 25 (52.1%) had been a physician for zero-to-three years and 23 (47.9%) had been a physician for greater than three years. Many participants (66.7%) had three or less years of experience as an EMS physician. Participants came from a wide variety of medical specialties, with the most common specialty being cardiology, followed by anesthesiology. Only three participants (6.3%) were emergency physicians. The majority (62.5%) of participants worked primarily in a community hospital prior to joining YMAS, versus 10.4% who worked in an academic hospital, and 27.1% who worked in neither a community nor academic hospital. Nearly all survey participants (97.9%) volunteered specifically to transport wounded soldiers from the war zone.
Table 1. Participant Characteristics
Abbreviation: EMS, Emergency Medical Services.
Battlefield medicine experience prior to the 2020 Nagorno-Karabakh War was limited in survey participants (Table 2). The majority of participants had no experience in treating mass casualties, wounds from explosives, or performing surgical procedures such as thoracostomy and cricothyroidotomy. More than one-half of the survey participants reported minimal or no experience in prior battlefield medicine and in treating gunshot wounds, severe burns, and severe orthopedic extremity injuries such as limb amputations. A large number (62.5%) of participants reported at least some experience in treating severe bleeding and hemorrhagic shock.
Table 2. Battlefield Medicine Experience Prior to the 2020 Nagorno-Karabakh War, n = 48
Survey participants reported a moderate amount of experience with humanitarian medicine prior to the 2020 Nagorno-Karabakh War, with 45.83% citing at least some prior experience. Most participants had at least some experience treating severe respiratory illness (85.4%) and in using PPE (68.8%). The majority of participants (81.3%) reported minimal or no experience in treating starvation or dehydration.
Due to the low number of total survey participants, some categories of survey responses were combined in order to create a composite score which could give better insight into their prior experiences. A greater degree of experience in battlefield medicine prior to the 2020 Nagorno-Karabakh War was found in participants with more than three years of experience working as a physician (z-score −3.26; P value <.01; Mann-Whitney U test) as well as participants with more than three years of experience working as an EMS physician (z-score −2.76; P value <.01; Mann-Whitney U test). Participants who were at least 30 years old had more experience in battlefield medicine than those who were younger than 30 years old (z-score −2.11; P value = .03; Mann-Whitney U test). Cardiologists reported significantly less battlefield medicine experience than other specialties (z-score 2.53; P value = .01; Mann-Whitney U test). There was no significant difference in battlefield medicine experience prior to the war in participants who worked at academic versus community hospitals before becoming an EMS physician, however those providers who did not work in a hospital before becoming an EMS physician had less experience in battlefield medicine than those who worked in academic or community hospitals (H statistic 6.71; P value = .03; Kruskal-Wallis test).
There was no correlation found between years of physician experience (three years of physician experience or less versus more than three years; z-score −0.79; P value = .43; Mann-Whitney U test), completion of residency training (z-score 0.01; P value = .99; Mann-Whitney U test), age (<30 years old versus ≥30 years old; z-score −1.28; P value = .20; Mann-Whitney U test), or years of experience as an EMS physician (three years or less versus more than three years; z-score −1.88; P value = .06; Mann-Whitney U test) with experience in humanitarian medicine prior to the war. There was no difference in humanitarian medicine experience across the various medical specialties (anesthesiologists versus others, cardiology versus others, emergency medicine/ICU/urgent care versus others, orthopedics versus others, or surgical specialty versus others; P values >.05). No correlation was found between the type of hospital participants worked in prior to becoming an EMS physician (academic, community, or neither) and experience in humanitarian medicine prior to the war (H statistic 2.00; P value = .37; Kruskal-Wallis test).
During the war, 89.6% of participants felt that they were personally in danger during the fighting at least sometimes. On average, participants reported that rarely to sometimes during the war they treated gunshot wounds, wounds from explosives, severe burns, severe bleeding or hemorrhagic shock, extreme orthopedic extremity injuries such as limb amputation, starvation, or dehydration. Many providers transported or treated patients who required emergency surgery for battlefield injuries, with 41.7% reporting often and 20.8% reporting sometimes. Eighteen of 48 participants (37.5%) reported treating patients with severe respiratory illness often, and 16.7% reported treating this condition always. Most providers (62.6%) needed to use PPE to treat patients sometimes or often. Of 48 participants, only 11 reported consistently having the PPE they felt they needed for patient care; 37 participants did not have access to the PPE they felt they needed at times.
Discussion
Emergency Medical Services is a critical component of Disaster Medicine. In the immediate aftermath of a disaster, an EMS system that is well-trained and experienced in disaster response can limit the degree of death and injury associated with a disaster event.Reference Ciottone, Biddinger and Darling3
In the present study, older practitioners as well as those practicing for more years as either a physician or EMS physician were found to have more experience in battlefield medicine. However, in the Armenian EMS system, a number of physicians are young and inexperienced. The median age of survey participants was 29 years old. More than one-half of the participants had been a physician for three or less years, and 66.7% had been an EMS physician for three or less years. The limited degree of experience is in part due to the large number of residents and recent graduates in the EMS system. According to current data, of the 318 physicians working for YMAS, 141 are still in residency training.10 This leads to a system in which a large proportion of frontline providers on scene lack experience, and there may also be a dearth of leadership.
Given the lack of Emergency Medicine residencies, most EMS physicians come from varying specialties.Reference Chekijian, Truzyan, Stepanyan and Bazarchyan5 This study population was made up of 20.8% cardiologists, 14.6% anesthesiologists, 10.4% orthopedists, and 20.8% general surgeons or surgical subspecialists. Only 6.3% were emergency physicians. The remaining survey participants came from a range of specialties including Neurology, Psychiatry, Radiology, Rheumatology, and Obstetrics and Gynecology. This leads to a wide range of experiences and abilities as physicians with differing scopes of practice are asked to work in the field where their particular skills may be less relevant, and many providers lack formal training in Disaster Medicine. As EMS physicians in Armenia are often relatively new physicians and tend to have limited experience in EMS and Emergency Medicine, it is to be expected that many providers are inexperienced in disaster response, and it is therefore imperative that these providers are given sufficient training in Disaster Medicine.
It is rare that an EMS system must respond to two simultaneous, large-scale disasters, and literature on EMS systems in dual disaster scenarios is extremely limited. The Armenian EMS system was uniquely tested when a large-scale war broke out during the height of the COVID-19 pandemic causing a subsequent humanitarian crisis, necessitating EMS response on multiple fronts. Prior to the COVID-19 pandemic, 40% of EMS responses were “double calls,” in which a second ambulance is dispatched after the first team completes its evaluation for the purpose of providing specialty treatment such as cardiac, neurologic, or psychiatric care,Reference Chekijian, Truzyan, Stepanyan and Bazarchyan5 thereby ideally matching a provider with pertinent training to the patient’s pathology. However, in the case of this dual disaster response, during which there was a physician shortage forcing EMS physicians to work long hours without substantial backup help,Reference Harutyunyan, Mukhaelyan and Hertelendy6 providers of all sorts of specialty backgrounds were responding to potentially critically ill patients often outside of their scope of expertise.
Although it has traditionally been rare that an EMS system must respond to dual large-scale disasters, the current war in Ukraine with resulting humanitarian crisis is an important reminder of the applicability of the present study. The Ukrainian EMS system now faces a civilian population lacking in basic needs, migration, and attacks on medical facilities and ambulances,17 at a time when the COVID-19 pandemic still exists. As natural and man-made disasters continue to occur, it follows that other EMS systems will be required to respond to multiple large-scale disasters as the Armenian system did, and highlights the need for all EMS systems to have the proper training to respond to multiple concurrent disasters.
This study illustrates the fact that, in the setting of these dual disasters, there is a large Disaster Medicine skillset that is required. The 2020 Nagorno-Karabakh War saw a variety of attack modalities, including drone attacks, phosphorus bombs, shelling, and rocket strikes.Reference Chekijian8,Reference Chekijian and Bazarchyan18 The war in turn led to massive population displacement and resulted in a humanitarian crisis as disruption of access to electricity, clean water, and medical services ensued, and people fled to shelters or bunkers to escape attack, causing an exacerbation of the existing COVID-19 pandemic.Reference Balalian, Berberian and Chiloyan13 Forced to respond on multiple fronts, EMS providers were challenged with treating a combination of gruesome war wounds, ill patients in respiratory distress, and displaced victims of the humanitarian crisis. On average, study participants reported treating gunshot wounds, wounds from explosives, severe burns, severe bleeding or hemorrhagic shock, extreme orthopedic injuries such as limb amputation, and starvation or dehydration at least rarely to sometimes during the fighting. Many providers transported or treated patients who required emergency surgery for battlefield injuries. A large number of study participants reported treating patients with severe respiratory illness often to always, and the majority of participants needed to use PPE at least sometimes.
The results of this study suggest there is some disparity between the Disaster Medicine experience level of YMAS physicians and the clinical conditions they are required to treat. Although providers reported experience in treating severe bleeding, respiratory illness, and using PPE, they had little experience in other areas of Disaster Medicine. Prior to the war, the majority of participants had no experience in treating mass casualties, wounds from explosives, or performing surgical procedures such as thoracostomy or cricothyroidotomy. More than one-half of the survey participants reported minimal or no experience in treating gunshot wounds, severe burns, and severe orthopedic extremity injuries such as limb amputations. The vast majority of participants had minimal or no experience in treating starvation or dehydration. A physician who specializes in cardiology, radiology, or psychiatry is unlikely to be comfortable treating battlefield injuries such as gunshot wounds, wounds from explosives, or limb amputations, just as an orthopedist is unlikely to be comfortable treating patients in respiratory distress from COVID-19 without further training. In an EMS system where providers have a variety of different specialty backgrounds and lack Emergency Medicine training, it is of the utmost importance that the EMS curriculum include training in Disaster Medicine.
For an inexperienced provider to treat complex medical and trauma patients in a dual disaster scenario without relevant training is not only challenging from a medical perspective, but also risks causing mental health sequelae for the provider involved. Studies have suggested that exposure to multiple disasters yields a degree of psychological distress that may be cumulative,Reference Niitsu, Takaoka and Uemura19 with higher prevalence of anxiety, depression, and posttraumatic stress disorder seen in dual disaster exposure versus single.Reference Lowe, McGrath and Young20 One study found that more symptoms of emotional stress are seen in people who are impacted by a prior disaster in addition to COVID-19.Reference Podubinski and Glenister21 Most EMS physicians in Armenia were already suffering from emotional stress due to the pandemic. Accounts from health care workers describe the emotional demands of caring for very ill patients with COVID-19 while fearing becoming infected themselves, having to treat patients even when being personally infected, and working shifts that were nearly 24 hours long with little sleep during the pandemic.Reference Harutyunyan, Mukhaelyan and Hertelendy6 In the present study, 77.1% of participants reported not having access to the PPE they felt they needed to treat patients. With the outbreak of war, providers found themselves treating gruesome war injuries, transporting war casualties up to six hours, and additionally tending to wounded or deceased colleagues as ambulances, health care workers, and medical facilities became the target of enemy drone attacks and artillery.Reference Harutyunyan, Mukhaelyan and Hertelendy6,Reference Chekijian and Bazarchyan18 In this study, the vast majority of participants (89.6%) felt that they were personally in danger during the fighting at least sometimes.
It should be noted that nearly all survey participants regardless of specialty background and prior experience volunteered to transport war casualties, despite the majority feeling that their own life was in danger in doing so. This speaks to the tremendous dedication of the EMS physicians in Armenia and willingness to practice outside their scope of expertise to treat patients in grave need of medical assistance. It also reinforces that a formal Disaster Medicine curriculum for all EMS providers may be beneficial.
Armenian EMS physicians have little formal training in Disaster Medicine, yet practice in a country prone to disasters. The Armenian EMS system was recently tested by concurrent, dual large-scale disasters during the 2020 Nagorno-Karabakh War on top of the COVID-19 pandemic, a unique challenge rarely seen in other EMS systems. This study demonstrates a need for specific Disaster Medicine training in the Armenian EMS curriculum.
Limitations
This study was limited by the survey response rate and had a total of 48 participants after removing all incomplete surveys from analysis. Due to the sensitive and emotionally provoking subject of this survey, the limited response rate may represent hesitance to report. The vast majority of survey participants volunteered to transport war casualties, which may create some selection bias as opposed to a scenario in which providers were forced to care for patients at the battle front rather than volunteering. The survey utilized for this study is not an externally validated tool, given the unique nature of the dual disaster event. Terms describing provider level of experience used in this survey are based on the participants’ subjective impression. The language barrier may also have affected the accuracy of survey responses, but the survey and recruitment e-mail were translated to Armenian and checked by multiple different health care providers who are primary Armenian speakers. In addition, the time that has lapsed since the war with Azerbaijan may have also altered participants’ perceptions.
Conclusion
Prior to the COVID-19 pandemic and simultaneous 2020 Nagorno-Karabakh War, EMS physicians in Armenia had limited training and experience in Disaster Medicine. This system, and the frontline physicians on whom it relies, was strained by the dual disaster, highlighting the need for Disaster Medicine training in all prehospital medical providers.
Conflicts of interest
Authors Anushavan Virabyan and Taguhi Stepanyan are currently employed by the Yerevan State Medical Emergency Service JSC (Yerevan Municipal Ambulance Service). Author Hakob Harutyunyan was formerly employed by the Yerevan State Medical Emergency Service JSC.
