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Tropical cyclone (TC) Yasi, thought to be the largest and most severe cyclone to cross the Queensland coast since 1918, made landfall on the southern tropical coast near Mission Beach and continued to track westward across Northern Queensland on February 3, 2011. The warning and response model (WRM) suggests that situational factors, personal characteristics, and social contextual variables influence the degree of threat perceived and protective actions taken.
Aim
The aim of this study was to examine preparation for this impending natural disaster by residents of the affected regions, and to identify the residents’ resource losses and symptoms of psychological distress following TC Yasi.
Methods
A cross-sectional survey was conducted 6-12 months after the cyclone using an adapted tool designed to measure preparedness, loss and psychosocial distress. Four hundred and thirty-three responses were received. Statistical analysis was conducted using Statistical Package for the Social Sciences (SPSS). Categorical characteristics were described using sample size and percentages.
Results
Almost all respondents perceived the cyclone warning as serious or very serious, and more than a third started preparing for the cyclone at least three days before it reached landfall. Overall, 115 (26.7%) respondents reported moderate and 59 (13.7%) reported major property damage; 72 (17.1%) reported a moderate and 49 (11.6%) reported a major change in their feeling of whether they have control over their life; 55 (13.1%) reported a major change in their motivation of getting things done; and 33 (7.9%) reported a major change in their perception of feeling valuable to others. Overall, 142 (34.1%) documented at least one of five symptoms of acute distress.
Conclusion
The findings document the experiences of Australians who have lived through tropical cyclone Yasi. The results support the WRM theory which proposes that people with previous experience take threatened disasters seriously.
UsherK, BuettnerP, WestC, MillisJ, WoodsC, MasonM, BoonH, Chamberlain-SalaunJ. Preparedness for and Impact of Tropical Cyclone Yasi in North Queensland, Australia. Prehosp Disaster Med. 2013;28(3):1-7.
On September 4, 2010 a major earthquake caused widespread damage, but no loss of life, to Christchurch city and surrounding areas. There were numerous aftershocks, including on February 22, 2011 which, in contrast, caused substantial loss of life and major damage to the city. The research aim was to assess how these two earthquakes affected the staff in the General Medicine Department at Christchurch Hospital.
Problem
To date there have been no published data assessing the impact of this type of natural disaster on hospital staff in Australasia.
Methods
A questionnaire that examined seven domains (demographics, personal impact, psychological impact, emotional impact, impact on care for patients, work impact, and coping strategies) was handed out to General Medicine staff and students nine days after the September 2010 earthquake and 14 days after the February 2011 earthquake.
Results
Response rates were ≥ 99%. Sixty percent of responders were <30 years of age, and approximately 60% were female. Families of eight percent and 35% had to move to another place due to the September and February earthquakes, respectively. A fifth to a third of people had to find an alternative route of transport to get to work but only eight percent to 18% took time off work. Financial impact was more severe following the February earthquake, with 46% reporting damage of >NZ $1,000, compared with 15% following the September earthquake (P < .001). Significantly more people felt upset about the situation following the February earthquake than the September earthquake (42% vs 69%, P < .001). Almost a quarter thought that quality of patient care was affected in some way following the September earthquake but this rose to 53% after the February earthquake (12/53 vs 45/85, P < .001). Half believed that discharges were delayed following the September earthquake but this dropped significantly to 15% following the February earthquake (27/53 vs 13/62, P < .001).
Conclusion
This survey provides a measure of the result of two major but contrasting Christchurch earthquakes upon General Medicine hospital staff. The effect was widespread with minor financial impact during the first but much more during the second earthquake. Moderate psychological impact was experienced in both earthquakes. This data may be useful to help prepare plans for future natural disasters.
TovaranonteP, CawoodTJ. Impact of the Christchurch Earthquakes on Hospital Staff. Prehosp Disaster Med. 2013;28(3):1-6.
Vital signs remain important clinical indicators in the management of trauma. Tissue injury and ischemia cause tachycardia and hypertension, which are mediated via the sympathetic nervous system (SNS). Spinal immobilization is known to cause discomfort, and it is not known how this might influence the SNS and contribute to abnormal vital signs.
Hypothesis
This study aimed to establish whether the pain and discomfort associated with spinal immobilization and the maneuvers commonly used in injured patients (eg, log roll) affect the Heart rate (HR), Systolic Blood Pressure (SBP) and Respiratory rate (RR). The null hypothesis was that there are no effects.
Methods
A prospective, unblinded, repeated-measure study of 53 healthy subjects was used to test the null hypothesis. Heart rate, BP and RR were measured at rest (five minutes), after spinal immobilization (10 minutes), following log roll, with partial immobilization (10 minutes) and again at rest (five minutes). A visual analog scale (VAS) for both pain and discomfort were also collected at each stage. Results were statistically compared.
Results
Pain VAS increased significantly during spinal immobilization (3.8 mm, P < .01). Discomfort VAS increased significantly during spinal immobilization, after log roll and during partial immobilization (17.7 mm, 5.8 mm and 8.9 mm, respectively; P < .001). Vital signs however, showed no clinically relevant changes.
Discussion
Spinal immobilization does not cause a change in vital signs despite a significant increase in pain and discomfort. Since no relationship appears to exist between immobilization and abnormal vital signs, abnormal vital signs in a clinical situation should not be considered to be the result of immobilization. Likewise, pain and discomfort in immobilized patients should not be disregarded due to lack of changes in vital signs.
BruijnsS, GulyH, WallisL. Effect of Spinal Immobilization on Heart Rate, Blood Pressure and Respiratory Rate. Prehosp Disaster Med. 2013;28(2):1-5.
Mass-gathering events require varying types and amounts of medical resources to deal with patient presentations as well as careful planning for environmental health management. The Holy Shroud Exhibition was hosted in Torino, Italy, between April and May 2010. The venue was a unique mass-gathering event which lasted several weeks. It was held in a limited area in the center of the city and it was attended by a large and heterogeneous population. A dedicated Health Care Service was created for the event.
Methods
This study is a retrospective analysis of clinical presentations of patients who were managed by the Medical Services during the event. The main study outcomes included Patient Presentation Rate (PPR), type of injuries and illnesses, and the Transport to Hospital Rate (TTHR).
Results
The PPR and TTHR were both low (0.27 and 0.039 respectively). The majority of patients presented with low severity codes and no sudden cardiac death (SCD) or cardiac arrest occurred. Cardiac and trauma emergencies were most frequent categories of presentation. A number of pediatric patients (19.37%) were treated by the event Medical Service. Approximately two million persons participated in the 40-day event.
Conclusion
The experience for this 40-day event supported having an on-site, organized, dedicated Medical Service that decreased overcrowding of the local Emergency Medical System and hospitals. It is recommended that, for such events, there be recruitment of emergency physicians with experience in mass-gathering events, recruitment of pediatricians, and training for professionals during the planning process.
BortolinM, UllaM, BonoA, FerreriE, TomatisM, SgambetterraS. Holy Shroud Exhibition 2010: Health Services During a 40-Day Mass-Gathering Event. Prehosp Disaster Med. 2013;28(3):1-6.
The purpose of this critical review is to look at the current literature regarding mass gatherings and to create further understanding of this area with a particular focus on what the audience brings with them to the event, particularly in a planned event with a cultural theme or focus. Through an understanding of these predispositions and consequent effects on audience behavior in a mass-gathering setting, a more complete understanding of motivation factors of crowds and audiences can also be found.
Methods
A critical review of mass-gathering literature was undertaken by searching various online academic databases. Peer-reviewed scholarly articles relevant to the cultural aspects associated with religious, sporting and music mass gatherings were also analyzed.
Results
Results from the review show that the word “culture” is often used to explain what happens at the event without reflecting how the motivations or behaviors of audiences at an event are influenced by the cultural predispositions of the audience.
Conclusions
By understanding the cultural predispositions of the audience, event planners and designers, event risk managers and event safety personnel are able to better understand the motivation of the audience and how this might impact on audience behavior at the event. Further work needs to be done, however, to investigate the broader range of predispositions. The ultimate aim of developing this understanding is to better inform the health promotion and public health messages that can be developed for a particular type of event based on the likely composition of the audience in attendance.
HuttonA, BrownS, VerdonkN. Exploring Culture: Audience Predispositions and Consequent Effects on Audience Behavior in a Mass-Gathering Setting. Prehosp Disaster Med. 2013;28(3):1-6.
For decades, military humanitarian assistance programs have avoided empirical scrutiny, leaving researchers, the humanitarian community and decision makers without proof of outcome. This Editorial highlights the findings of three major studies that disclose deficits in the quality of the performance and reporting of humanitarian missions, and offer guidance for change. The author suggests that, contrary to current plans to limit the military's role in humanitarian assistance, emerging crises actually increase civilian security risks and that it is time for a new partnership of military and civilian humanitarian resources to evolve in the interest of human security.
BurkleFM. Throwing the Baby Out With the Bathwater: Can the Military's Role in Global Health Crises be Redeemed?. Prehosp Disaster Med.2013;28(3):1–3..
The aim of this study was to assess the effectiveness of written and moulage scenarios using video instruction for mass-casualty triage by evaluating skill retention at six months post intervention.
Methods
Prehospital personnel were instructed in the START method of mass-casualty triage using a video. Moulage and written testing were completed by each participant immediately after instruction and at six months post instruction.
Results
There was a significant decrease in performance between initial and six-month testing, indicating skill decay and loss of retention of triage skills after an extended nonuse period. There were no statistically significant differences between written and moulage testing results at either initial testing or at six months. Prior skill level did not influence test performance on the type of testing conducted or long-term retention of triage skills.
Conclusion
These data confirm the skill deterioration associated with an infrequently used triage method. Further research to more precisely define triage criteria, as well as the ability to apply the criteria in a clinical setting and to rapidly identify patients at risk for morbidity/mortality is needed.
RisaviBL, TerrellMA, LeeW, HolstenDLJr. Prehospital Mass-Casualty Triage Training—Written Versus Moulage Scenarios: How Much Do EMS Providers Retain?. Prehosp Disaster Med. 2013;28(3):1-6.
Synchronized Direct Current Cardioversion (SDC) is an established therapy for the termination of supraventricular tachycardia (SVT – either atrio-ventricular nodal reentry tachycardia (AVNRT) or atrio-ventricular reentrant tachycardia (AVRT)) with poor perfusion. The evidence is extremely limited with regard to the safety and effectiveness of this therapy. In Australia, half of the eight ambulance services include SDC within their clinical practice guidelines for the management of poorly perfused SVT; however the degree of variation in the application of SDC across these guidelines suggests a need to quantify the practice. This case provides a previously unreported example of the safety and effectiveness of prehospital SDC for SVT (with poor perfusion precipitated by a Valsalva Maneuver) by Victorian paramedics, and discusses the available literature regarding the effectiveness and safety of this practice.
SmithG, TaylorD, MorgansA, CameronP. Prehospital Synchronized Electrical Cardioversion of a Poorly Perfused SVT Patient by Paramedics. Prehosp Disaster Med. 2013;28(3):1-4.
The 2005 Gulf Coast hurricane season was one of the most costly and deadly in US history. Hurricane Rita stressed hospitals and led to multiple, simultaneous evacuations. This study systematically identified community factors associated with patient movement out of seven hospitals evacuated during Hurricane Rita.
Methods
This study represents the second of two systematic, observational, and retrospective investigations of seven acute care hospitals that reported off-site evacuations due to Hurricane Rita. Participants from each hospital included decision makers that comprised the Incident Management Team (IMT). Investigators applied a standardized interview process designed to assess evacuation factors related to external situational awareness of community activities during facility evacuation due to hurricanes. The measured outcomes were responses to 95 questions within six sections of the survey instrument.
Results
Investigators identified two factors that significantly impacted hospital IMT decision making: (1) incident characteristics affecting a facility's internal resources and challenges; and (2) incident characteristics affecting a facility's external evacuation activities. This article summarizes the latter and reports the following critical decision making points: (1) Emergency Operations Plans (EOP) were activated an average of 85 hours (3 days, 13 hours) prior to Hurricane Rita's landfall; (2) the decision to evacuate the hospital was made an average of 30 hours (1 day, 6 hours) from activation of the EOP; and (3) the implementation of the evacuation process took an average of 22 hours. Coordination of patient evacuations was most complicated by transportation deficits (the most significant of the 11 identified problem areas) and a lack of situational awareness of community response activities. All evacuation activities and subsequent evacuation times were negatively impacted by an overall lack of understanding on the part of hospital staff and the IMT regarding how to identify and coordinate with community resources.
Conclusion
Hospital evacuation requires coordinated processes and resources, including situational awareness that reflects the condition of the community as a result of the incident. Successful hospital evacuation decision making is influenced by community-wide situational awareness and transportation deficits. Planning with the community to create realistic EOPs that accurately reflect available resources and protocols is critical to informing hospital decision making during a crisis. Knowledge of these factors could improve decision making and evacuation practices, potentially reducing evacuation times in future hurricanes.
DowneyEL, AndressK, SchultzCH. External Factors Impacting Hospital Evacuations Caused by Hurricane Rita: The Role of Situational Awareness. Prehosp Disaster Med. 2013;28(3):1-8.
Hurricanes remain a major threat to hospitals throughout the world. The authors attempted to identify the planning areas that impact hospital management of evacuations and the challenges faced when sheltering-in-place.
Methods
This observational, retrospective cohort study examined acute care institutions from one hospital system impacted by Hurricane Rita in 2005. Investigators used a standardized survey instrument and interview process, previously used in the hospital evacuation context, to examine hospitals’ initial internal situational awareness and subsequent decision making that resulted in evacuation due to Hurricane Rita. Participants from each hospital included representatives from senior leadership and clinical and nonclinical staff that comprised the Incident Management Team (IMT). The main measured outcomes were responses to 95 questions contained in the survey.
Results
Seven of ten eligible hospitals participated in the study. All facilities evacuated the sickest patients first. The most significant factors prompting evacuation were the issuing of mandatory evacuation orders, storm dynamics (category, projected path, storm surge), and loss of regional communications. Hospitals that sheltered-in-place experienced staff shortages, interruptions to electrical power, and loss of water supplies. Three fully-evacuated institutions experienced understaffing of 40%-60%, and four hospitals sustained depressed staffing levels for over four weeks. Five hospitals lost electricity for a mean of 4.8 days (range .5-11 days). All facilities continued to receive patients to their Emergency Departments (EDs) while conducting their own evacuation.
Conclusion
Hospital EDs should plan for continuous patient arrival during evacuation. Emergency Operation Plans (EOPs) that anticipate challenges associated with evacuation will help to maximize initial decision making and management during a crisis situation. Hospitals that shelter-in-place face critical shortages and must provide independent patient care for prolonged periods.
DowneyEL, AndressK, SchultzCH. Initial Management of Hospital Evacuations Caused by Hurricane Rita: A Systematic Investigation. Prehosp Disaster Med. 2013;28(3):1-7.
Earthquakes are natural events that contribute to the transmission of infectious diseases. The aim of this research was to determine whether the observed increase in Escherichia coli (E. coli) bloodstream infections (BSI) during the period March-June 2011 was associated with the February 2011 Christchurch earthquake.
Methods
Descriptive statistics and spatial distributional analysis techniques were used to quantify patients with E. coli BSI in 2009-2011.
Results
E. coli BSI acquired from non-catheter related urinary tract infection (UTI) was the predominant infection type, with the greatest increase during March-June 2011. Bacteremia incidence was higher in females than in males for 2009-2011. In 2011, the median age of patients was 75 years, and an increase in males acquiring such infections was noted. Spatial distributional analysis failed to show direct association between bacteremia cases and liquefaction-related land damage or drinking water contamination. A higher incidence of E. coli BSI post-earthquake in the eastern suburbs, which tend towards a higher level of socioeconomic deprivation, was observed.
Conclusion
A number of possible factors contributing to the observed increase in E. coli BSI acquired from UTI in 2011 were considered. Individuals with higher deprivation indices, males and the elderly may be particularly vulnerable to the effects of a major disaster with subsequent breakdown of infrastructure. These findings have important implications in natural disaster situations, and justify development of strategies to identify UTI and pyelonephritis risk factors and to manage E. coli bacteremia incidence rates.
SchousboeM, LyndsJ, AmbroseC. Increased Incidence of Escherichia Coli Bacteremia Post-Christchurch Earthquake 2011: Possible Associations. Prehosp Disaster Med. 2013;28(3):1-8.
United States foreign policy is tied extensively to health initiatives, many related to the use of military assets. Despite substantial resource investment by the US Department of Defense (DoD) in hospital ship humanitarian assistance and disaster response missions, the impact of this investment is unclear.
Methods
A systematic literature review of both peer-reviewed and grey literature using eight databases representing the international community and multiple sectors was conducted. Data on the characteristics of missions directly related to US Navy hospital ship humanitarian assistance and disaster response from 2004-2012 were extracted and documented.
Results
Of the 1445 sources reviewed, a total of 43 publications met criteria for review. Six (13.9%) met empirical documentation criteria and 37 (86.0%) were considered nonempirical expert opinions and anecdotal accounts that were primarily descriptive in nature. Overall, disaster response accounted for 67.4% (29/43) and humanitarian assistance 25.6% (11/43). Public and private sector participants produced 79.0% (34/43) and 20.9% (9/43) of the publications respectively. Of private sector publications, 88.9% (8/9) focused on disaster response compared to 61.8% (21/34) from the public sector. Of all publications meeting inclusion criteria, 81.4% (35/43) focused on medical care, 9.3% (4/43) discussed partnerships, 4.7% (2/43) training, and 4.7% (2/43) medical ethics and strategic utilization. No primary author publications from the diplomatic, development, or participating host nations were identified. One (2.3%) of the 43 publications was from a partner nation participant.
Discussion
Without rigorous research methods yielding valid and reliable data-based information pertaining to Navy hospital ship mission impact, policy makers are left with anecdotal reports to influence their decision-making processes. This is inadequate considering the frequency of hospital ship deployments used as a foreign policy tool and the considerable funding that is involved in each mission. Future research efforts should study empirically the short- and long-term impacts of hospital ship missions in building regional and civil-military partnerships while meeting the humanitarian and disaster response needs of host nation populations.
LicinaD. Hospital Ships Adrift? Part 1: A Systematic Literature Review Characterizing US Navy Hospital Ship Humanitarian and Disaster Response, 2004-2012. Prehosp Disaster Med.2013;28(3):1–10..
In a mass decontamination during a nuclear, biological, or chemical (NBC) response, the capability to command, control, and communicate is crucial for the proper flow of casualties at the scene and their subsequent evacuation to definitive medical facilities. Information Technology (IT) tools can be used to strengthen medical control, command, and communication during such a response. Novel IT tools comprise a vehicle-based, remote video camera and communication network systems.
During an on-site verification event, an image from a remote video camera system attached to the personal protective garment of a medical responder working in the warm zone was transmitted to the on-site Medical Commander for aid in decision making. Similarly, a communication network system was used for personnel at the following points: (1) the on-site Medical Headquarters; (2) the decontamination hot zone; (3) an on-site coordination office; and (4) a remote medical headquarters of a local government office. A specially equipped, dedicated vehicle was used for the on-site medical headquarters, and facilitated the coordination with other agencies.
The use of these IT tools proved effective in assisting with the medical command and control of medical resources and patient transport decisions during a mass-decontamination exercise, but improvements are required to overcome transmission delays and camera direction settings, as well as network limitations in certain areas.
FuseA, OkumuraT, HagiwaraJ, TanabeT, FukudaR, MasunoT, MimuraS, YamamotoK, YokotaH. New Information Technology Tools for a Medical Command System for Mass Decontamination. Prehosp Disaster Med.2013;28(3):1-3.
During a pandemic influenza, emergency departments will be overwhelmed with a large influx of patients seeking care. Although all hospitals should have a written plan for dealing with this surge of health care utilization, most hospitals struggle with ways to educate the staff and practice for potentially catastrophic events.
Hypothesis/Problem
To better prepare hospital staff for a patient surge, a novel educational curriculum was developed utilizing an emergency department for a patient surge functional drill.
Methods
A multidisciplinary team of medical educators, evaluators, emergency preparedness experts, and technology specialists developed a curriculum to: (1) train novice users to function in their job class in a multi-user virtual environment (MUVE); (2) obtain appropriate pre-drill disaster preparedness training; (3) perform functional team exercises in a MUVE; and (4) reflect on their performance after the drill.
Results
A total of 14 students participated in one of two iterations of the pilot training program; seven nurses completed the emergency department triage course, and seven hospital administrators completed the Command Post (CP) course. All participants reported positive experiences in written course evaluations and structured verbal debriefings, and self-reported increase in disaster preparedness knowledge. Students also reported improved team communication, planning, team decision making, and the ability to visualize and reflect on their performance.
Conclusion
Data from this pilot program suggest that the immersive, virtual teaching method is well suited to team-based, reflective practice and learning of disaster management skills.
GreciLS, RamlollR, HurstS, GarmanK, BeedasyJ, PieperEB, HuangR, HigginbothamE, AghaZ. vTrain: A Novel Curriculum for Patient Surge Training in a Multi-User Virtual Environment (MUVE). Prehosp Disaster Med.2013;28(3):1-8.
The number of civilians killed in Iraq following the 2003 invasion has proven difficult to measure and contentious in recent years. The release of the Wikileaks War Logs (WL) has created the potential to conduct a sensitivity analysis of the commonly-cited Iraq Body Count's (IBC's) tally, which is based on press, government, and other public sources.
Hypothesis
The 66,000 deaths reported in the Wikileaks War Logs are mostly the same events as those previously reported in the press and elsewhere as tallied by iraqbodycount.org.
Methods
A systematic random sample of 2500 violent fatal War Log incidents was selected and evaluated to determine whether these incidents were also found in IBC's press-based listing. Each selected event was ranked on a scale of 0 (no match present) to 3 (almost certainly matched) with regard to the likelihood it was listed in the IBC database.
Results
Of the two thousand four hundred and nine War Log records, 488 (23.8%) were found to have likely matches in IBC records. Events that killed more people were far more likely to appear in both datasets, with 94.1% of events in which ≥20 people were killed being likely matches, as compared with 17.4% of singleton killings. Because of this skew towards the recording of large events in both datasets, it is estimated that 2035 (46.3%) of the 4394 deaths reported in the Wikileaks War Logs had been previously reported in IBC.
Conclusions
Passive surveillance systems, widely seen as incomplete, may also be selective in the types of events detected in times of armed conflict. Bombings and other events during which many people are killed, and events in less violent areas, appear to be detected far more often, creating a skewed image of the mortality profile in Iraq. Members of the press and researchers should be hesitant to draw conclusions about the nature or extent of violence from passive surveillance systems of low or unknown sensitivity.
CarpenterD, FullerT, RobertsL. WikiLeaks and Iraq Body Count: the Sum of Parts May Not Add Up to the Whole—A Comparison of Two Tallies of Iraqi Civilian Deaths. Prehosp Disaster Med. 2013;28(3):1-7.
Kenya's major incidents profile is dominated by droughts, floods, fires, terrorism, poisoning, collapsed buildings, accidents in the transport sector and disease/epidemics. With no integrated emergency services and a lack of resources, many incidents in Kenya escalate to such an extent that they become major incidents. Lack of specific training of emergency services personnel to respond to major incidents, poor coordination of major incident management activities, and a lack of standard operational procedures and emergency operation plans have all been shown to expose victims to increased morbidity and mortality.
This report provides a review of some of the major incidents in Kenya for the period 2000-2012, with the hope of highlighting the importance of developing an integrated and well-trained Ambulance and Fire and Rescue service appropriate for the local health care system.
WachiraB, SmithW. Major Incidents in Kenya: the Case for Emergency Services Development and Training. Prehosp Disaster Med. 2013;28(2):1-4.