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Tourniquet Application by Urban Police Officers: The Aurora, Colorado Experience

Jerome JE, Pons PT, Haukoos JS, Manson J, Gravitz S 21(1). 71 - 76 (Journal Article)

Background: Uncontrolled external hemorrhage is a common cause of preventable death. The Hartford Consensus recommendations presented the concept of a continuum of care, in which police officers should be considered an integral component of the emergency medical response to active shooter incidents. Recent publications have reported individual cases of tourniquet application by police officers. This report analyzed all documented cases of hemorrhage control using tourniquets applied by police officers in a single large metropolitan police department. Methods: A retrospective computerized search of all public safety communications center reports and police officer documentation for cases of tourniquet application was conducted by searching for the word "tourniquet." Each case was evaluated for indication and appropriateness using Stop The Bleed criteria for tourniquet placement. In addition, police response time was compared to emergency medical services (EMS) response time in an effort to determine if there was a time difference in response to the bleeding patient that could potentially impact patient outcomes. Results: Forty- three cases were identified over the 6-year period ending in December 2019. The majority of cases involved gunshot wounds and most were civilian victims. Injured police officers accounted for two cases (gunshot wound and dog bite). Review of the officers' narratives indicated that most applications appeared justified using the Stop The Bleed criteria (two cases were questionable if a tourniquet was necessary and one may have been placed in an incorrect location). On average, police arrived 4 minutes sooner than EMS did. Conclusion: Several reports in the literature document the success of police officer application of tourniquets to control limb hemorrhage. Most of the reports involved a small number of case reports. This is the largest case series to date from a single urban police department.

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Applications of Fish Oil Supplementation for Special Operators

Heileson JL, Funderburk LK, Cardaci TD 21(1). 78 - 85 (Journal Article)

Fish oil supplementation (FOS) is beneficial for human health and various disease states. FOS has recently received attention related to its anabolic and anti-catabolic effects on skeletal muscle and cognitive performance. Since Special Operations Forces (SOF) personnel endure rigorous combat and training environments that are mentally and physically demanding, FOS may have important applications for the SOF Warfighter. The purpose of this narrative review is to explore the evidence for FOS and its application to multiple physiological and psychological contexts experienced by SOF personnel. For physical performance, FOS may promote lean body mass (LBM) accretion; however, there seems to be minimal impact on strength, power, or endurance. During physiological stress, FOS may preserve strength, power, LBM (during muscle disuse, not weight loss) and enhance recovery. For cognition, FOS likely improves reaction time, mental fatigue, and may reduce the incidence and severity of mild traumatic brain injury; however, FOS has minimal impact on attentional control and mood states. No safety concerns were evident. In conclusion, there are multiple applications of FOS for SOF personnel. Due to the minimal safety concerns and potential anabolic, anti-catabolic and cognitive benefits, FOS is a viable method to promote and sustain SOF Warfighter physical and cognitive performance. Although promising, the FOS trials to date have not been conducted in the context of the multi-stressor environments experienced by SOF personnel, thus, future studies should be conducted in a SOF population.

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Immediate Paramedic Tactical Response Unit in a Civilian Emergency Medical Service: The First Year Experience

Kamarainen A, Virtanen J, Lintunen J, Kolkkinen J, Nykopp I, Isotalo M, Valimaa J, Uotila T 21(1). 90 - 93 (Journal Article)

Purpose: An immediate paramedic tactical response unit was implemented into a civilian emergency medical services (EMS) system. This was compared with the preexisting traditional tactical EMS support (TEMS). The primary aim of the study was to evaluate the effect on tasking frequencies. The secondary aims of the study were to assess mission timings and the effect on patient encounters. Methods: Paramedics with tactical emergency medical training provided immediate response on a 24/7 basis. They responded to support police in high-risk TEMS scenarios and incidents in a Tactical Emergency Casualty Care (TECC) role. Tasking frequencies, timings, and clinical input were compared between the first year of immediate response and 3 preceding years of TEMS. Results: The number of TEMS dispatches increased from an average of 5 to 54 annually. The median time from dispatch to scene arrival decreased from a median of 54 minutes (interquartile range [IQR] 39-65) to 17 minutes (IQR 11-26) (p < .0001). The overall mission duration decreased from a median of 3 hr 13 min (IQR 2 h 29 min to 4 h 40 min) to 1 h 12 min (IQR 34 min-1 h 18 min) (p < .0001). The number of treated patients increased from one minor injury annually to 13 severe and six minor injuries annually. Conclusions: Implementing immediate tactical paramedic response significantly decreases response time and mission duration and increases the number of activations and resultant number of treated patients.

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The Use of Chest Seals in Treating Sucking Chest Wounds: A Comparison of Existing Evidence and Guideline Recommendations

Kuhlwilm V 21(1). 94 - 101 (Journal Article)

Introduction: Sucking chest wounds occur when injuries penetrate the thorax and inhalation results in air entering the pleural cavity. Well documented in the prehospital environment, treatment should be chest seal application to attempt prevention of an expanding pneumothorax. However, a seal might occlude the pathway for the escape of air and lead to a worsening tension pneumothorax. Methods: The author conducted a literature search of studies reporting the efficacy of various chest seals for treating sucking chest wounds and the prevention of a tension pneumothorax. Study results were compared to current international guidelines. Results/Discussion: Included were four studies testing chest seals in a swine model of hemopneumothorax. Vented and unvented chest seals stabilized cardiorespiratory parameters after an open pneumothorax, but only vented chest seals showed more success at preventing a tension pneumothorax. Chest seals with flutter valves seemed to be inferior. An additional study showed that vertical movements and soiled skin were more stressful on the applied chest seals. Eight international guidelines were identified: four focused on the tactical environment, and four appeared to be more civilian-oriented. Only two of the civilian-oriented guidelines did not prefer vented chest seals. Conclusion: Vented chest seals seem to be superior to unvented chest seals, and most international guidelines have updated their recommendations for the use of vented chest seals. However, frequent physical examinations for early signs of a developing or worsening tension pneumothorax are the best medical care.

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Lessons Learned on the Battlefield Applied in a Civilian Setting

Cordier P, Benoit C, Belot-De Saint Leger F, Pauleau G, Goudard Y 21(1). 102 - 105 (Journal Article)

We report the case of a civilian 27-year-old man treated in a military hospital in France who sustained multiple stab wounds, including one in the left groin, with massive external bleeding. When first responders arrived, the patient was in hemorrhagic shock. A tourniquet and two intraosseous catheters were placed to start resuscitative care. On the patient's arrival at the hospital, bleeding was not controlled, so a junctional tourniquet was put in place and massive transfusion was started. Surgical exploration revealed a laceration of the superficial femoral artery and a disruption of the femoral vein. Vascular damage control was achieved by a general surgeon and consisted of primary repair of the superficial femoral artery injury and venous ligation. The patient was discharged from the intensive care unit after 2 days and from the hospital after 8 days. This case illustrates some of the persistent challenges shared between military and civilian trauma care. The external control of junctional hemorrhage is not easily achievable in the field, and junctional tourniquets have been therefore incorporated in the Tactical Combat Casualty Care guidelines. French lyophilized plasma was used for massive transfusion because it has been proven to be a logistically superior alternative to fresh-frozen plasma. Management of vascular wounds by nonspecialized surgeons is a complex situation that requires vascular damage-control skills; French military surgeons therefore follow a comprehensive structured surgical training course that prepares them to manage complex penetrating trauma in austere environments. Finally, in this case, lessons learned on the battlefield were applied to the benefit of the patient.

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Watch Where You Point That: Pneumomediastinum From Pneumatic Nail Gun Injury to the Hand

Nam JJ, Kelly WF 21(1). 106 - 108 (Journal Article)

Pneumatic nail guns are hand-held tools used in industrial and construction settings. Nail guns cause the most trauma with hospitalization among construction workers. To our knowledge, we report for the first time a case of pneumomediastinum from a nail gun injury to the hand. Our patient was a 40-year-old male construction worker who shot a nail gun into his hand. He became acutely dyspneic and was found to have a pneumomediastinum due to air insufflation. He later underwent tube thoracostomy and intubation. To our knowledge, this is the first report of pneumomediastinum from a nail gun injury to the hand.

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Aligning and Assessing Core Attributes of Spiritual Fitness for Optimizing Human Performance

Alexander DW, Deuster PA 21(1). 109 - 112 (Journal Article)

The United States Special Operations Command (SOCOM)'s Preservation of the Force and Family Program (POTFF) identifies spiritual performance (SP) as a key pillar for holistically caring for and optimizing the performance of all Special Operations Forces (SOF) and their families. Enhancing SP is key to sustaining core spiritual beliefs, values, awareness, relationships and experiences. The SOCOM Spiritual Fitness Scale (SSFS) enables religious support teams in SOF communities and beyond to reliably measure SP according to POTFF's definition of SP and the Chairman of the Joint Chiefs of Staff Instruction (CJCSI) on Spiritual Fitness (SF). The three subscales of the SSFS relate to core attributes of SP/SF, which were identified through factor analysis during iterations of the tool's development. Directly aligning SP/SF programs with the core attributes of SSFS will allow chaplains to support both theists and nontheists and to retain certain traditional chaplain activities which no longer have universal connection to religious ministry in the public discourse. Chaplains are also empowered to immediately begin conducting relevant and spiritual assessments. We will illustrate how a chaplain can align SP initiatives with the three core attributes of SP/SF and leverage the SSFS to assess baseline unit needs, conceive and develop evidence-based initiatives, conduct rolling program assessments, and articulate program efficacy to key leaders and collaborators.

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Cutaneous Leishmaniasis

Crecelius EM, Burnett MW 21(1). 113 - 114 (Journal Article)

Leishmaniasis is a parasitic infection that can involve the skin, mucosal membranes, and internal organs. Soldiers are at highrisk of leishmaniasis when conducting operations in endemic regions. Medical providers should have a low threshold to consider Leishmaniasis as the cause of persisting skin lesions.

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Vitamin A and Bone Fractures

Knapik JJ, Hoedebecke BL 21(1). 115 - 119 (Journal Article)

Vitamin A is a generic term describing compounds that have the same biological activity as retinol. Dietary vitamin A can be obtained from "provitamin A" carotenoids (e.g., ß-carotene) found in plant foods such as carrots, cantaloupes, and sweet peppers, or as "preformed vitamin A" found in many dietary supplements, animal livers, and vitamin A-fortified foods, such as breakfast cereals, milk, cheese, and yogurt. Low consumption of vitamin A can cause night blindness, reduce immune function, and have detrimental developmental effects. Several lines of evidence suggest that excessive dietary intake of vitamin A might be associated with an increased risk of bone fractures. Meta-analysis of observational human studies that have examined vitamin A and fractures suggests that dietary consumption of large amounts of vitamin A in the form of ß-carotene likely has a protective effect, reducing the risk of fractures. On the other hand, meta-analyses that have specifically examined hip fractures have shown that total vitamin A (all types) or retinol consumption may increase the risk of hip fractures. Until more information is available, it is advisable to consume vitamin A primarily from plant sources, avoid excessive consumption from dietary supplements and animal sources, and lower consumption from fortified foods.

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Tourniquet Use on a Pediatric Patient

Gattere M, Scaffei N, Gozzetti L, Alessandrini M 21(1). 120 - 123 (Journal Article)

As a result of the increasing use and application of military tourniquets in civilian settings, it is necessary to evaluate the size and effectiveness of the equipment on patients that differ from the military-aged population for whom the devices have been primarily created. This case report describes the application of a tourniquet on a pediatric patient while also profiling a common situation in which the Combat Application Tourniquet GEN 7 (C-A-T Resources) might be used in civilian care systems. The case is that of a 14-month-old child who suffered a limb amputation secondary to a road accident in Italy and the ensuing life-saving treatment. The intervening nurse at the scene had been trained on the use of hemorrhage-control devices through the American College of Surgeons "Stop the Bleed" campaign.

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Limb Position Change Affects Tourniquet Pressure

Wall PL, Buising CM, Hingtgen E, White A, Jensen J 21(1). 11 - 17 (Journal Article)

Background: Limb position changes are likely during transport from injury location to definitive care. This study investigated passive limb position change effects on tourniquet pressure and occlusion. Methods: Triplicate buddy-applied OMNA® Marine Tourniquet applications to Doppler-based occlusion were done to sitting and laying supine mid-thigh (n=5) and sitting mid-arm (n=3). Tourniqueted limb positions were bent/straight/bent and straight/bent/straight (randomized first position order, 5 seconds/position, pressure every 0.1 second, two-way repeated measures ANOVA). Results: Sitting thigh occlusion pressures leg bent were higher than straight (median, minimum-maximum; 328, 307-403mmHg versus 312, 295-387mmHg, p = .013). In each recipient, the pressure change for each position change for each limb had p < .003. In each recipient, when sitting, leg bent to straight increased pressure (326, 276-415mmHg to 371, 308-427mmHg bent first and 275, 233-354mmHg to 311, 241-353mmHg straight first), and straight to bent decreased pressure (371, 308-427mmHg to 301, 262-388mmHg bent first and 312, 265-395mmHg to 275, 233-354mmHg straight first). When laying, position changes from leg bent first resulted in pressure changes in each recipient but not in the same directions in each recipient. From laying leg straight first, in each recipient changing to bent increased the pressure (295, 210-366mmHg to 328, 255-376mmHg) and to straight decreased the pressure (328, 255-376 mmHg to 259, 210-333 mmHg). Sitting arm bent occlusion pressures were lower than straight (230, 228-252mmHg versus 256, 250-287mmHg, p = .026). Arm position changes resulted in pressure changes in each recipient but not in the same directions in each recipient. Changes in pressure trace character (presence or absence of rhythmically pulsatile traces) and Doppler-based occlusion were consistent with limb position-induced changes in tourniquet pressure (each p ≤ .001 leg, p = .071 arm traces, and p = .188 arm occlusion). Conclusions: Passive limb position changes can cause significant changes in tourniquet pressure. Therefore, tourniquet adequacy should be reassessed after any limb position change.

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Fall 2020 Journal (Vol 20 Ed 3)

Vol 20 Ed 3
Fall 2020 Journal of Special Operations Medicine
ISSN: 1553-9768

View the Table of Contents
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Airway Management in Prolonged Field Care

Dye C, Keenan S, Carius BM, Loos PE, Remley MA, Mendes B, Arnold JL, May I, Powell D, Tobin JM, Riesberg JC, Shackelford SA 20(3). 141 - 156 (Journal Article)

This Role 1, prolonged field care (PFC) clinical practice guideline (CPG) is intended to be used after Tactical Combat Casualty Care (TCCC) Guidelines, when evacuation to higher level of care is not immediately possible. A provider must first and foremost be an expert in TCCC, the Department of Defense standard of care for first responders. The intent of this PFC CPG is to provide evidence and experience-based solutions to those who manage airways in an austere environment. An emphasis is placed on utilizing the tools and adjuncts most familiar to a Role 1 provider. The PFC capability of airway is addressed to reflect the reality of managing an airway in a Role 1 resource-constrained environment. A separate Joint Trauma System CPG will address mechanical ventilation. This PFC CPG also introduces an acronym to assist providers and their teams in preparing for advanced procedures, to include airway management.

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Life and Limb In-Flight Surgical Intervention: Fifteen Years of Experience by Joint Medical Augmentation Unit Surgical Resuscitation Teams

DuBose JJ, Stinner DJ, Baudek A, Martens D, Donham B, Cuthrell M, Stephens T, Schofield J, Conklin CC, Telian S 20(4). 47 - 52 (Journal Article)

Background: Expedient resuscitation and emergent damage control interventions remain critical tools of modern combat casualty care. Although fortunately rare, the requirement for life and limb salvaging surgical intervention prior to arrival at traditional deployed medical treatment facilities may be required for the care of select casualties. The optimal employment of a surgical resuscitation team (SRT) may afford life and limb salvage in these unique situations. Methods: Fifteen years of after-action reports (AARs) from a highly specialized SRTs were reviewed. Patient demographics, specific details of encounter, team role, advanced emergent life and limb interventions, and outcomes were analyzed. Results: Data from 317 casualties (312 human, five canines) over 15 years were reviewed. Among human casualties, 20 had no signs of life at intercept, with only one (5%) surviving to reach a Military Treatment Facility (MTF). Among the 292 casualties with signs of life at intercept, SRTs were employed in a variety of roles, including MTF augmentation (48.6%), as a transport capability from other aeromedical platforms, critical care transport (CCT) between MTFs (27.7%), or as an in-flight damage control capability directly to point of injury (POI) (18.2%). In the context of these roles, the SRT performed in-flight life and limb preserving surgery for nine patients. Procedures performed included resuscitative thoracotomy (7/9; 77.8%), damage control laparotomy (1/9; 11.1%) and extremity fasciotomy for acute lower extremity compartment syndrome (1/11; 11%). Survival following in-flight resuscitative thoracotomy was 33% (1/3) when signs of life (SOL) were absent at intercept and 75% (3/4) among patients who lost SOL during transport. Conclusion: In-flight surgery by a specifically trained and experienced SRT can salvage life and limb for casualties of major combat injury. Additional research is required to determine optimal SRT utilization in present and future conflicts.

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An Analysis and Comparison of Prehospital Trauma Care Provided by Medical Officers and Medics on the Battlefield

Fisher AD, Naylor JF, April MD, Thompson D, Kotwal RS, Schauer SG 20(4). 53 - 59 (Journal Article)

Background: Role 1 care represents all aspects of prehospital care on the battlefield. Recent conflicts and military operations conducted on behalf of the Global War on Terrorism have resulted in medical officers (MOs) being used nondoctrinally on combat missions. We are seeking to describe Role 1 trauma care provided by MOs and compare this care to that provided by medics. Methods: This is a secondary analysis of previously described data from the Prehospital Trauma Registry and the Department of Defense Trauma Registry from April 2003 through May 2019. Encounters were categorized by type of care provider (MO or medic). If both were documented, they were categorized as MO; those without either were excluded. Descriptive statistics were used. Results: A total of 826 casualty encounters met inclusion criteria. There were 418 encounters categorized as MO (57 with MO, 361 with MO and medic), and 408 encounters categorized as medic only. The composite injury severity score (median, interquartile range) was higher for casualties treated by the medic cohort (9, 3.5-17) than for the MO cohort (5, 2-9.5; P = .006). There was no difference in survival to discharge between the MO and medic groups (98.6% vs. 95.6%; P = .226). More life-saving interventions were performed by MOs compared to medics. MOs demonstrated a higher rate of vital sign documentation than medics. Conclusion: More than half of casualty encounters in this study listed an MO in the chain of care. The difference in proportion of interventions highlights differences in provider skills, training and equipment, or that interventions were dictated by differences in mechanisms of injury.

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Facing Adversity and Factors Affecting Resilience: A Qualitative Analysis of the Lived Experiences of Canadian Special Operations Forces

Richer I, Frank C 20(4). 60 - 67 (Journal Article)

Special Operations Forces (SOF) personnel are required to withstand considerable physical and psychological hardship. Research examining resilience and mental health among SOF personnel is limited and has provided mixed results; in addition, minimal research has been undertaken on the subjective experiences of adversity and the process of resilience among SOF personnel. This unique qualitative study describes the lived experience of Canadian SOF personnel, the challenges they face, and the factors they believe impact their resilience. Seventy Canadian SOF personnel participated in in-depth, semistructured interviews. A thematic analysis of the interviews revealed that operational demands, paired with an organizational culture of performance, were important stressors for most participants, negatively affecting both themselves and their families. SOF organizations select members with resilient characteristics; however, the same characteristics that make these members resilient also lead to self-imposed pressure to perform and avoid taking time for proper recovery. Team members were reported to help such members process difficult or traumatic experiences and facilitate their seeking care. Findings provide insight into the adverse experiences that participants encountered while serving in an SOF organization and the intertwined individual, social, and organizational factors affecting their resilience. Results point to the importance of managing and mitigating the impact of high operational tempo and a culture of performance to protect the health and wellness of SOF personnel and their families

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A Comparison of the iGel Versus Cricothyrotomy by Combat Medics Using a Synthetic Cadaver Model: A Randomized, Controlled Pilot study

Schauer SG, April MD, Fairley R, Uhaa N, Hudson IL, Johnson MD, Keen DE, De Lorenzo RA 20(4). 68 - 72 (Journal Article)

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Riot Medicine: Civil Disturbance Applications of the National Tactical Emergency Medical Support Competency Domains

Pennardt A, West M 20(4). 73 - 76 (Journal Article)

The Portland, Oregon, Bureau of Fire & Rescue (PF&R) established a tactical emergency medical support team embedded within the Police Bureau's Rapid Response Team (RRT). The authors describe the team's training and their recent work.

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Isolating Populations to Control Pandemic Spread in an Austere Military Environment

Hall AB, Dixon M, Dennis AJ, Wilson RL 20(4). 92 - 94 (Journal Article)

Background: The COVID-19 pandemic has been a struggle for medical systems throughout the world. In austere locations in which testing, resupply, and evacuation have been limited or impossible, unique challenges exist. This case series demonstrates the importance of population isolation in preventing disease from overwhelming medical assets. Methods: This is a case series describing the outbreak of COVID-19 in an isolated population in Africa. The population consists of a main population with a Role 2 capability, with several supported satellite populations with a Role 1 capability. Outbreaks in five satellite population centers occurred over the course of the COVID-19 pandemic from its start on approximately 1 March 2020 until 28 April 2020, when a more robust medical asset became available at the central evacuation hub within the main population. Results: Population movement controls and the use of telehealth prevented the spread within the main population at risk and enabled the setup of medical assets to prepare for anticipated widespread disease. Conclusion: Isolation of disease in the satellite populations and treating in place, rather than immediately moving to the larger population center's medical facilities, prevented widespread exposure. Isolation also protected critical patient transport capabilities for use for high-risk patients. In addition, this strategy provided time and resources to develop infrastructure to handle anticipated larger outbreaks.

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A Spanish Intentional Mass-Casualty Incidents Medical Response Model: Delphi Consensus

Roca G, Martin L, Borraz D, Serrano L, Lynam B 20(4). 95 - 99 (Journal Article)

The increase in global violence in recent years has changed the paradigm of emergency health care, requiring early medical response to victims in hostile settings where the usual work cannot be done safely. In Spain, this specific role is provided by the Tactical Environment Medical Support Teams (in Spanish, EMAETs). The Victoria I Consensus document defines and recognizes this role, whose main lines of work are the emergency medical response to the tactical team and to the victims in areas under indirect threat, provided that the tactical operators can guarantee their safety. To reinforce the suitability of this approach, we submitted the possible outcomes of this response model to a panel of national experts to assess this proposal in the different areas of Spain. The chosen research design is a conventional Delphi method, based on the content of the Victoria I Consensus response model. The panel of 52 expert reviewers from 11 different regions were surveyed anonymously; a high degree of accord was recognized when the congruence of the responses exceeded 75%. Consensus agreement was reached in all sections of the survey after two iterations. Specific contributions and recommendations were made to achieve unanimous consensus despite the population and resource differences in the country. Our results suggest that the EMAET approach is useful in areas with short response times. However, in more sparsely populated areas, this may not be feasible, and a more pragmatic response model may be suitable.

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