On 14 August 2003, New York City and a large portion of the northeastern United States experienced the largest blackout in the history of the country. An analysis of such a widespread disaster on emergency medical service (EMS) operations may assist in planning for and managing such disasters in the future.

A retrospective review of all EMS activity within New York City's 9-1-1 emergency telephone system during the 29 hours during which all or parts of the city were without power (16:11 hours (h) on 14 August 2003 until 21:03 h on 15 August 2003) was performed. Control periods were established utilizing identical time periods during the five weeks preceding the blackout.

Significant increases were identified in the overall EMS demand (7,844 incidents vs. 3,860 incidents; p<0.001) as well as in 20 of the 62 calltypes of the system, including ca rd i ac arrests (119 vs.76, p= 0.043).Significant decreases were found only among calls related to psychological emergencies (114 vs. 221; p= 0.006) and drugor alcohol-related emergencies (78 vs. 146; p = 0.009). Though median response times increased by only 60 seconds, median call-processing times within the 9-1-1 emergency telephone system EMS dispatch center of the city increased from 1.1 to 5.5 minutes.

The citywide blackout resulted in dramatic changes in the demands upon the EMS system of New York City, the types of patients for whom EMS providers were assigned to provide care, and the dispositions for those assignments. During this time of increased, system-wide demand, the use of cross-trained firefighter and first-responder engine companies resulted in improved response times to cardiac arrest patients. Finally, the ability of the EMS dispatch center to process the increased requests for EMS assistance proved to be the rate-limiting step in responding to these emergencies.These findings will prove useful in planning for future blackouts or any disaster that may broadly impact the infrastructure of a city.

Exsanguination from a femoral artery wound can occur in sec-onds and may be encountered more often due to increased use of body armor. Some military physicians teach compression of the distal abdominal aorta (Abdominal Aorta) with a knee or a fist as a temporizing measure.

The objective of this study was to evaluate if complete collapse of the Abdominal Aorta was feasible and with what weight it occurs.

This was a prospective, interventional study at a Level-I, academ-ic, urban, emergency department with an annual census of 80,000 patients. Written, informed consent was obtained from nine male volunteers after Institutional Research Board approval. Any patient who presented with abdominal pain or had undergone previous abdominal surgery was excluded from the study. Subjects were placed supine on the floor to simulate an injured soldier. Various dumbbells of increasing weight were placed over the distal Abdominal Aorta, and pulsed-wave Doppler measurements were taken at the right common femoral artery (CFA). Dumbbells were placed on top of a tightly bundled towel roughly the surface area of an adult knee. Flow measurements at the CFA were taken at increments of 20 pounds. This was repeated with weight over the proximal right artery iliac and distal right iliac artery to eval- uate alternate sites. Descriptive statistics were utilized to evaluate the data.

The mean velocity through the CFA was 75.8 cm/ sec at 0 pounds. Compression of the Abdominal Aorta ranging 80 to 140 pounds resulted in no flow in the CFA. A steady decrease in mean flow velocity was seen starting with 20 pounds. Flow velocity decreased more rapidly with compression of the prox- imal right iliac artery, and stopped in all nine volunteers by 120 pounds of pressure. For all nine volunteers, up to 80 pounds of pressure over the distal iliac artery failed to decrease CFA flow velocity, and no subject was able to tolerate more weight at that location.

Flow to the CFA can be stopped completely with pressure over the distal Abdominal Aorta or proximal iliac artery in catastrophic wounds. Compression over the proximal iliac artery worked best, but a first responder still may need to apply upward of 120 pounds of pressure to stop exsanguination.

Since the terrorist attacks of 11 September 2001, the amount of terrorism preparedness training has increased substantially. However, gaps continue to exist in training for the mental health casualties that result from such events. Responders must be aware of the mental health effects of terror-ism and how to prepare for and buffer these effects. However, the degree to which responders possess or value this knowledge has not been studied.

Multi-disciplinary terrorism preparedness training for healthcare professionals was conducted in Kansas in 2003. In order to assess knowledge and attitudes related to mental health preparedness training, post-test surveys were provided to 314 respondents 10 months after completion of the training. Respondents returned 197 completed surveys for an analysis response rate of 63%.

In general, the results indicated that respondents have knowledge of and value the importance of mental health preparedness issues. The respon-dents who reported greater knowledge or value of mental health preparedness also indicated significantly higher ability levels in nationally recognized bioterrorism competencies (p <0.001).

These results support the need for mental health components to be incorporated into terrorism preparedness training. Further studies to determine the most effective mental health preparedness training content and instruction modalities are needed.

On 04 September 2005, 1,589 Hurricane Katrina evacuees from the New Orleans area arrived in Oklahoma. The Oklahoma State Department of Health conducted a rapid needs assessment of the evacuees housed at a National Guard training facility to determine the medical and social needs of the population in order to allocate resources appropriately.

A standardized questionnaire that focused on individual and household evacuee characteristics was developed. Households from each shel-ter building were targeted for surveying, and a convenience sample was used.

Data were collected on 197 households and 373 persons. When com-pared with the population of Orleans Parish, Louisiana, the evacuees sampled were more likely to be male, black, and 45–64 years of age. They also were less likely to report receiving a high school education and being employed pre-hurricane. Of those households of <1 persons, 63% had at least one missing household member. Fifty-six percent of adults and 21% of children reported having at least one chronic disease. Adult women and non-black persons were more likely to report a pre-existing mental health condition. Fourteen percent of adult evacuees reported a mental illness that required medication pre-hur-ricane, and eight adults indicated that they either had been physically or sex-ually assaulted after the hurricane. Approximately half of adults reported that they had witnessed someone being severely injured or dead, and 10% of per-sons reported that someone close to them (family or friend) had died since the hurricane. Of the adults answering questions related to acute stress disor-der, 50% indicated that they suffered at least one symptom of the disorder.

The results from this needs assessment highlight that the evac-uees surveyed predominantly were black, of lower socio-economic status, and had substantial, pre-existing medical and mental health concerns. The evac-uees experienced multiple emotional traumas, including witnessing grotesque scenes and the disruption of social systems, and had pre-existing psy-chopathologies that predisposed this population to post-traumatic stress dis-order (Post-traumatic Stress Disorder).x When disaster populations are displaced, mental health and social service providers should be available immediately upon the arrival of the evacuees, and should be integrally coordinated with the relief response. Because the displaced population is at high risk for disaster-related mental health problems, it should be monitored closely for persons with PTSD. This displaced population will likely require a substantial re-establishment of financial, medical, and educational resources in new communities or upon their return to Louisiana.

It is important to identify what kinds of drugs are required by disaster-affected populations so that appropriate donations are allocated. On 26 December 2003, an earthquake with an amplitude of 6.3 on the Richter scale struck southeastern Iran, decimating the city of Bam. In this study, the most frequently utilized and prescribed drugs for Bam outpatients during the first six months after the Bam Earthquake were investigated.

In this descriptive, cross-sectional study, the data were collected randomly from 3,000 prescriptions of Bam outpatients who were examined by general practitioners from Emergency Medical Assistance Teams in 12 healthcare centers during the first six months after the Bam Earthquake. The data were analyzed for: (1) patient sex; (2) number of drugs/prescriptions; (3) drug category; (4) drug name (generic or brand); (5) route of administration; (6) percent of visits where the most frequent drug categories were prescribed; and (7) the 25 most frequently prescribed drugs, using World Health Organization (WHO) indicators of drug use in health facilities.

Male patients represented 47.4% and females 52.6% of the total number of outpatients. The mean number of drugs/prescriptions was 3.5 per outpatient. Oral administration was the most frequent method of administration (81.7%), followed by injections (10.9%). Respiratory drugs were the most frequently used drugs (14.2%), followed by analgesics/non-steroidal anti-inflammatory drugs (non-steroidal anti-inflammatory drugs) (11.3%), antibacterials (11.2%), gastroinestinal (GI) drugs (9.6%), and central nervous system drugs (7%). Penicillins (6.8%), cold preparations (8%), and systemic anti-acids (ranitidine and omeprazole) were among the 25 most frequently used drugs by outpatients and inhabitants of Bam during the first six months after the Bam Earthquake.

Respiratory, analgesic, antibacterial, gastrointestinal, and psychiatric medications were among the most commonly prescribed pharmaceuticals after the catastrophic Bam Earthquake.The results of this study may help to predict the needs of patients during future disasters and prevent unnecessary donations of medicine.

Physicians and nurses are integral components of the public health bioterrorism surveillance system. However, most published bioterrorism preparedness surveys focus on gathering information related to selfassessed knowledge or perceived needs and abilities.

A survey of physicians and nurses in Hawaii was conducted to assess objective knowledge regarding bioterrorism agents and diseases and perceived response readiness for a bioterrorism event.

During June and July 2004, an anonymous survey was mailed up to three times to a random sample of all licensed physicians and nurses residing in Hawaii.

The response rate was 45% (115 of 255) for physicians and 53% (146 of 278) for nurses. Previous bioterrorism preparedness training associated significantly with knowledge-based test performance in both groups. Only 20% of physicians or nurses had had previous training in bioterrorism preparedness, and <15% felt able to respond effectively to a bioterrorism event. But, >70% expressed willingness to assist the state in the event of a bioterrorist attack.

Additional bioterrorism preparedness training should be made available through continuing education and also should become a component of both medical and nursing school curricula. It is important to provide the knowledge necessary for physicians and nurses to improve their ability to perform in the event of a bioterrorist attack.

Lessons on question content and refinement of a 2003 Agency for Healthcare Research and Quality-Health Resources Services Administration (Agency for Healthcare Research and Quality-Health Resources Services) pilot hospital preparedness assessment tool designed to capture activities in more detail than previous studies are reported in this study.

Responses from fixed-choice questions, including organizational and geographical differences, were analyzed using the chi-square test. Openended questions were evaluated qualitatively.

Of the respondents, 91% had developed plans and 97% designated a bio-event coordinator, but only 47% had allocated funds. Urban hospitals were more likely to participate in regional infectious disease monitoring. Hospitals that participated in a network were more likely to fund preparedness, share bio-event coordinators and medical directors, and provide advanced training.

Several issues deserve further study: (1) hospital networks may provide the structure to promote preparedness; (2) specific procedures (e.g., expanding outpatient treatment capacity) have not been tested; and (3) special attention should be directed towards integrating non-urban hospitals into regional surveillance systems to ensure early identification of infectious disease outbreaks.

An important issue in disaster medicine is the establishment of standards that can be used as a template for evaluation. With the establishment of standards, the ability to compare results will improve, both within and between different organizations involved in disaster management.

Performance indicators were developed for testing in simulations exercises with the purpose of evaluating the skills of hospital management groups. The objective of this study is to demonstrate how these indicators can be used to create numerically expressed results that can be compared.

Three different management groups were tested in standardized simulation exercises. The testing took place according to the organization's own disaster plan and within their own facilities. Trained observers used a predesigned protocol of performance indicators as a template for the evaluation.

The management group that scored lowest in management skills also scored lowest in staff skills.

The use of performance indicators for evaluating the management skills of hospital groups can provide comparable results in testing situations and could provide a new tool for quality improvement of evaluations of real incidents and disasters.

The importance of accessing care within the first hour after injury has been a fundamental tenet of trauma system planning for 30 years. However, the scientific basis for this belief either has been missing or largely derived from case series from trauma centers. This study sought to determine the correlation between prehospital times and outcomes among severely injured elderly patients.

This is a cross-sectional, observational study. All adults (<18 years of age) with acute trauma as defined by The International Classification of Diseases Ninth Edition, Clinical Modification diagnostic codes and E-codes were included. Poisonings, single system burns, and late effects of injury were excluded. Chi-square and Student's ttest were used for significance testing. To assess the predictive effects of prehospital time and outcomes, three inde-pendent logistic regression models were constructed for both young and elderly groups, with hospital length of stay, mortality, and complications as individual dependent variables. Statistical significance was set at the 0.05 level.

Of 41,041 cases, 37,276 were >_18 years of age. Of the 1,866 with an Injury Severity Score (ISS) >15, 1,205 were young and 661 elderly. Logistic regression results showed that prehospital time correlated significantly with hospital length of stay (p = 0.001) and complications (p = 0.016), but not with mortality (p = 0.264) among young patients, whereas in the elderly group prehospital time had no significant predictive effect for length of stay, complica- tions, or mortality (p = 0.512, p = 0.512, and p = 0.954 respectively).

This population-based study has demonstrated that prehospital time correlates with length of stay and complications in young patients. In elderly patients, prehospital time failed to show correlation with any outcomes measured.

Percutaneous, transtracheal jet ventilation (percutaneous transtracheal jet ventilation) is an effective way to ventilate both adults and children. However, some authors suggest that a resuscitation bag can be utilized to ventilate through a cannula placed into the trachea.

Percutaneous transtracheal ventilation (percutaneous transtracheal ventilation) through a 14-gauge catheter is ineffective when attempted using a resuscitation bag.

Eight insufflation methods were studied. A 14-gauge intravenous catheter was attached to an adult resuscitation bag, a pediatric resuscitation bag, wall-source (wall) oxygen, portable-tank oxygen with a regulator, and a jet ventilator (JV) at two flow rates. The resuscitation bags were connected to the 14-gauge catheter using a 7 mm adult endotracheal tube adaptor connected to a 3 cc syringe barrel. The wall and tank oxygen were connected to he 14-gauge catheter using a three-way stopcock. The wall oxygen was tested with the regulator set at 15 liters per minute (LPM) and with the regulator wide open. The tank was tested with the regulator set at 15 and 25 LPM. The JV was connected directly to the 14-gauge catheter using JV tubing supplied by the manufacturer. Flow was measured using an Ohmeda 5420 Volume Monitor. A total of 30 measurements were taken, each during four seconds of insufflation, and the results averaged (milliliters (ml) per second (sec)) for each device.

Flow rates obtained using both resuscitation bags, tank oxygen, and regulated wall oxygen were extremely low (adult 215 ±20 ml/sec; pediatric 195 ±19 ml/sec; tank 358 ±13 ml/sec; wall at 15 l/min 346 ±20 ml/sec). Flow rates of 1,394 ±13 ml were obtained using wall oxygen with the regulator wide open. Using the JV with the regulator set at 50 pounds per square inch (psi), a flow rate of 1,759 ±40 was obtained.These were the only two methods that produced flow rates high enough to provide an adequate tidal volume to an adult.

Resuscitation bags should not be used to ventilate adult patients through a 14-gauge, transtracheal catheter. Jet ventilation is needed when percutaneous transtracheal ventilation is attempted. If jet ventilation is attempted using oxygen supply tubing, it must be connected to an unregulated oxygen source of at least 50 psi.

A mass toxicological event (MTE) caused by an act of terrorism or an industrial incident can create large numbers of ambulatory casualties suffering from mild intoxication, acute stress reaction (ASR), and exacerbation of chronic diseases or iatrogenic insult (such as atropine overdose). The logistical and medical management of this population may present a challenge insuch a scenario. The aim of this article is to describe the concept of the Israeli Home Front Command (HFC) of a “Mild Casualties Center” (MCC) for a chemical scenario, and to analyze the results of two large-scale drills that have been used to evaluate this concept.

Two large-scale drills were conducted. One MCC drill was located in a school building and the second MCC drill was located in a basketball stadium. These medical centers were staffed by physicians, nurses, and medics, both military (reservists) and civilian (community, non-hospital teams). Two hundred simulated patients entered the MCC during each of the drills, and drill observers assessed how these patients were managed for two hours.

Of the casualties, 28 were treated in the “medical treatment site”, 10 of which were relocated to a nearby hospital. Only four casualties were treated in the large “mental care site”, planned for a much higher burden of “worried well” patients. Documentation of patient data and medical care was sub-optimal.

A MCC is a logistically suitable solution for the challenge of managing thousands of ambulatory casualties. The knowledge of the medical team must be bolstered, as most are unfamiliar with both nerve gas poisoning and with ASR. Mild casualties centers should not be located within hospitals and must be staffed by non-hospital, medical personnel to achieve the main task of allowing hospital teams to focus on providing medical care to the moderate and severe nerve gas casualties, without the extra burden of caring for thousands of mild casualties.

Emergency preparedness can be defined by the preparedness pyramid, which identifies planning, infrastructure, knowledge and capabilities, and training as the major components of maintaining a high level of preparedness.The aim of this article is to review the characteristics of contingency plans for mass-casualty incidents (MCIs) and models for assessing the emergency preparedness of hospitals.

Emergency preparedness should focus on community preparedness, a personnel augmentation plan, and communications and public policies for funding the emergency preparedness. The capability to cope with a MCI serves as a basis for preparedness for non-conventional events. Coping with chemical casualties necessitates decontamination of casualties, treating victims with acute stress reactions, expanding surge capacities of hospitals, and integrating knowledge through drills. Risk communication also is important.

An annual assessment of the emergency plan is required in order to assure emergency preparedness. Preparedness assessments should include: (1) elements of disaster planning; (2) emergency coordination; (3) communication; (4) training; (5) expansion of hospital surge capacity; (6) personnel; (7) availability of equipment; (8) stockpiles of medical supplies; and (9) expansion of laboratory capacities. The assessment program must be based on valid criteria that are measurable, reliable, and enable conclusions to be drawn. There are several assessment tools that can be used, including surveys, parameters, capabilities evaluation, and self-assessment tools.

Healthcare systems are required to prepare an effective response model to cope with MCIs. Planning should be envisioned as a process rather than a production of a tangible product. Assuring emergency preparedness requires a structured methodology that will enable an objective assessment of the level of readiness.

Mass-casualty incidents (MCIs) are on the rise. The ability to locate, identify, and triage patients quickly and efficiently results in better patient outcomes. Poor lighting due to time of day, inclement weather, and power outages can make locating patients difficult. Efficient methods of locating patients allow for quicker transport to definitive care.

The objective of this study was to evaluate the methods currently used in mass-casualty collection, and to determine whether the use of the Simple Triage and Rapid Treatment (START) triage tag system can be improved by using easily discernable tags (glow sticks) in conjunction with the standard triage tags.

Numerous drills were performed utilizing the START triage method. In Trial A, patients were identified with the triage tags only. In Trial B, patients were identified using triage tags and glow sticks. Four rounds of triage drills were performed in low ambient light for each Trial, and the differences in casualty collection times were compared.

Casualty relocation and collection times were considerably shorter in the trials that utilized both the glow sticks and triage tags. An average of 2.58 minutes (31.75%) were saved during the casualty collections. In addition, fewer patient errors occurred during the trials in which the glow sticks were used. Between the four rounds, an average of four patient errors occurred during the trials that utilized the triage tags. However, there was an average of only one patient error for the drills when participants utilized both the triage tags and the glow sticks.

The use of the highly visible glow sticks, in conjunction with the START triage tags, allowed for more rapid and accurate casualty collection in suboptimal lighting. The use of the glow sticks made it easier to relocate previously triaged patients and arrange for expeditious transport to definitive care. In addition, the glow sticks reduced the number of patient errors. Most importantly, there was a significant reduction in the number of patients that initially were triaged via the START method, but were overlooked during casualty collection and transport.