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It is believed that dopamine resistance sets in within 72–92 hours following therapy. However, in the authors' experience, spinal cord injury patients may require dopamine to maintain blood pressure over several weeks.
Objectives
This study aims to: (1) assess the incidence and duration of of dopamine dependence in cervical cord injury patients; and (2) find the relation (if any) of dopamine dependent hypotension with outcome of spinal cord injured patients.
Methods
This was a prospective, observational study carried out over 2-month period in the neurosurgery intensive care unit (ICU) at JPN Apex Trauma Centre, AIIMS. All cervical spine injury patients who had hypotension during the hospital stay were included in the study. History, clinical findings, requirement of ionotropic support, management, and outcome were recorded for all enrolled subjects.
Results
During the study period 48 patients were admitted with cervical spine injury in the ICU. Of these, 26 patients (54%) had hypotension and were constituted the study group. Eleven patients had complete spinal cord injury (power 0/5) and 15 patients had incomplete spinal cord injury. Twenty-four patients were on ventilator support and two were on oxygen masks. The mean dose of dopamine which the patient receives during the treatment was 7.5 mcg/kg/min with the maximum and minimum doses of 20mcg/kg/min and 2 mcg/kg/min. The mean duration of dopamine support was 17 days (Range 6–48 days). Eight patients (31%) required intermittent dopamine support and 18 patients (70%) required continuous support. The in-hospital mortality was 61% (n = 16). Mortality was significantly lower in patients who received intermittent ionotropic support as compared to those who required continuous ionotropic support (p < 0.01).
Conclusion
The patients with spinal cord injury are dependent on dopamine throughout their recovery period. The patients who required intermittent ionotropic support had significant better outcome compared to those who required continuous ionotropic support.
In this study, the mean daily and annual radiation exposure of the radiology department staff, other hospital health staff, and public volunteers was compared at Maresal Cakmak Military Hospital in Erzurum, Turkey.
Methods
The NEB.211 Dose–Rate Meter with a Gaiger–Müller counter was used to measure the amount of radiation. Six radiology department health staff carried the NEB.211 device during seven working hours. At the end of the day, total absorbed dosages were noted. The same measurements were also done for the six health staff of the other departments and six non-hospital volunteers. Seventeen additional hours were noted for the non-hospital volunteers. The mean value of 17 hours of daily measurements (3.31 mSv) was added to the both group's working hours measurements and the total daily radiation amounts were calculated.
Results
There was no statistical difference between each three groups in working hours (p = 0.087), daily and annual equivalent dosages (for both p = 0.099).
Discussion
The radiology department health staff was exposed to radiation under the border of equivalent dosage which is determined by Turkish Automic Energy Authority. Public volunteers were seen as they were exposed the radiation over the determined border of equivalent dosage. Nonetheless, with changes depending on living standards, the physical properties of living spaces and geographical circumstances per capita exposed annual dosage is about 2.4–2.8 mSv throughout the world. There was no significant statistical difference between the amounts of equivalent dosage which were exposed to the radiology department health staff, the other hospital staff and public members.
Singapore, albeit a small country, has one of the highest lightning activities in the world. However, injuries related to this spectacular weather phenomenon are under-reported and rarely a subject of study. Most reported cases dealt with lightning-caused fatalities but lightning-caused accidents are not always fatal. Actual reported international data showed that about 80% of lightning victims survived, with or without after effects. This study reviewed the cases of lightning-related injuries who presented to Tan Tock Seng Hospital, Emergency department.
Methods
This is a case series of 5 patients. All 5 patients presented to Tan Tock Seng Hospital, Emergency Department after a thunderstorm. All were undergoing military training when the incident happened. The circumstances surrounding their injury and their presentation and symptomatology were reviewed.
Results
In our study, three possible mechanisms of injury were identified through a side flash which occurred when the lightning hit the tree and traveled partly down that tree before a portion jumped to the nearby victims; through the concussive effect of the shock waves produced by the lightning; and through step voltage mechanism wherein the lightning after hitting the tree traveled into the ground where victims were standing. Two patients were diagnosed with rhabdomyolysis, one suffered from sensory-neural hearing loss, and one patient had a mild conjunctivitis as a result of tissue inflammation. Other symptoms included retrograde amnesia, parasthesia, tinnitus, and a single episode of seizure which resolved spontaneously. All our patients survived the ordeal and were discharged well back to their premorbid states.
Conclusion
This paper supports existing evidence that lightning-caused accidents are not always fatal and that victims may survive with no or little side effects given proper medical treatment.
To examine how did Hyogo prefecture renovate disaster medical services system from the lessons of the Great Hanshin -Awaji Earthquake.
Method
Countermeasures after the experience of the Earthquake were 1. Establishment of disaster-related medical information network which was introduced to each of various institutions to collect and disseminate medical information at the time of disaster. 2. Designation of sixteen hospitals as Disaster Medical Centers, which were expected to play leading role in disaster management,and to receive many patients at a time of disasters. 3. Construction of Hyogo Emergency Medical Center which was designated as a main Disaster Medical Center to train medical staffs, to operate the Emergency Medical Information Control Center.
Results
We have several training courses for medical staffs. The most important training course is the DMAT (Disaster Medical Assistant Team)training course. DMAT trainigs held at two main Disaster Medical Centers, east National Disaster Medical Center, west Hyogo Emergency Medical Center. More than three hundreds teams have been cultivated now. We experienced five disasters in Hyogo prefecture in these seven years. 2 were natural disasters by the typhoon. 3 were a collision of the ship, the collision of the truck, train derailments each. A big JR train accident occurred in Amagasaki city of Hyogo on April 25,2005. Hyogo Emergency Medical Center worked as the emergency information control center, dispatched doctor attended ambulance, performed on-site triage and first aid, dispatched second team by helicopter, received four severe cases by helicopters, dispatched third team in the evening and provided confined space medicine, and took initiative of surveillance study of the casualties.
Conclusion
Disaster medical services system from the lessons of the Earthqukake functioned at the time of the JR Train accident.
Despite technological advancements, India is vulnerable to disasters. Disasters of any etiology have the common denominator of a large number of deaths in a short span of time. Thus, the Administration is saddled with the indomitable task of retrieving and recovering dead bodies, then identifying them to enable the handing over of the remains to their next-of-kin. Initial media focus is often based on the myth that dead bodies cause epidemics. Therefore, bodies often are placed in mass burials or mass cremations universally, without being identified and without preserving the individuality of the deceased. This culminates into social, psychological, emotional, economic, and legal repercussions (financial compensation, property rights, inheritance, and issues of remarriage) regarding the legacy of the deceased, thereby exacerbating the damage caused by disasters. With the paradigm shift from the erstwhile response-centric approach after the enactment of the Disaster Management Act in 2005, to the holistic management of disasters, the National Disaster Management Authority embarked on the task of formulating the guidelines on this sensitive and vital issue. These Guidelines are designed to provide not only technical information, but also dwell on administrative aspects that will support the correct approach in handling dead bodies with the highest possible quality of standards/measures, and functioning in an interdisciplinary manner to ensure positive identification of victims. Management of the dead after disasters is under the ambit of the Incident Response System being incorporated in the National, State and District “all hazard” Disaster Management Plans are intended to achieve the desired aim that no unidentified body should be laid to rest.
Using a Computer Simulation (CS) to improve training and event management of paramedics for Mass Casualty Incidents (MCI). Eli Jaffe, Avi Dagan, Eyal Zahavi, Einat Aviel, Bruria Adini. The Department of Emergency Medicine, Ben-Gurion University of the Negev Magen David Adom (MDA) is the national emergency organization in Israel. Over the past few decades MDA personnel have been required to deal with MCIs involving large numbers of casualties. Recently, there have been fewer terrorist related MCIs, however, there is a continuing need for to maintain the knowledge and skills of paramedics to manage MCIs.
Objective
To examine performance of paramedics exposed to a CS compared to a control group exposed to a traditional lecture based learning experience.
Method
An interactive CS based on the MDA standard operating procedure for managing MCIs was developed. The participants were randomly divided into two groups. Group 1 received the lecture format, and Group 2 the CS. Both groups were given a pre-test (Group 1 average score 56.3, Group 2 average score 53.1), and two post-tests. One immediately following completion of the intervention, and a second a month after completion of the course.
Results
Average scores for the CS Group (n = 15) was significantly different on the first post-test (Group 1 average score 53.2, Group 2 average score 68.7), by 30% and on the second (Group 1 average score 71.9, Group 2 average score 80.8) by 12% compared to the Lecture Group (N = 17) (P = < 0.00).
Conclusion
CS allow for the use of multiple media formats based on real events, and are able to replicate reality using real media material. MDA has recommended that continuing education interventions for emergency medical personnel for maintaining knowledge and skills required for the management of MCIs utilize a CS based training methods.
The formal training for Emergency Medical Technician (EMT) in Taiwan was legislated by Emergency Medical Care Services Act in 1995. Very little research discusses the competency of EMTs. The purpose of this study was to assess the determinants of competency for the EMT-II in Taiwan.
Method
In June 2005, a cross-sectional survey was targeted on firefighters with EMT-II certificate and having a minimum work experience of three months in central Taiwan. Kirkpatrick's (1994) four-level model guided the development of conceptual framework and questionnaire. Structural Equation Modeling (SEM) was adopted for the analysis.
Results
One thousand and seventy-three EMT-IIs were included in the study. Majority of them were male (99.4%) with an average age of 34.46 years old. Among them, 96.5% were careered EMTs with 130.33 months of field experiences. The competency of EMT-II was measured by 4 indicators of error reduction, quality improvement, achievement orientation, and efficiency improvement. The construct of ‘Capability Enhancement’ dominated EMT-IIs' ‘Competency’, followed by ‘Length of Time for Field experience’, ‘Instructor Expertise’, ‘TA Expertise’, and ‘Willingness to Learn’. Both ‘Age’ and ‘Total Course Time’ had a negative effect on ‘Competency’. ‘Capability Enhancement’ was mainly influenced by ‘Practice Absorption’ and ‘Theory Absorption’, followed by “Willingness to Learn”, ‘Instructor Expertise’, ‘Total Course Time’, ‘TA Expertise’, ‘Self Confidence’ and ‘Practicum Time in Ambulance Station’. However, the construct of ‘Teaching Technique” imposed a negative effect on ‘Capability Enhancement’.
Conclusion
The SEM model explains 75.7% of the variances in competency for EMT-IIs. The ‘Competency’ is dominated by ‘Capability Enhancement’. Improving the quality of course, instead of time, and recruiting younger EMT-IIs may advance the competency. Modification of ‘Teaching Technique’ may enhance the capability of EMT-IIs.
A 43-year-old patient with well healthy in the past was admitted after a accidental falling down injury. Upon arrival at the Emergent Department, he was unresponsive. (Glasgow coma scale = E1V1M1). The continuous Electrocardiological monitor demonstrated ventricular fibrillation without pulse, and the defibrillation (360 J) with intravenous Epinephrine (1 mg) push was given. The electrocardiogram (ECG) returned to sinus tachycardia. The endotracheal tube was intubated to keep airway patent and ventilation under the unstable vital sign. Ten minutes later, the polymorphic ventricular tachycardia (torsade de pointes) were recorded by continuous ECG. After defibrillation (360 J) twice with intravenous Epinephrine (1 mg) and Amiodarone (150 mg), the rhythm returned to normal sinus rhythm, and the vital sign recovered gradually. The laboratory evaluation showed no abnormality. The cranial computed tomography was done thereafter which showed occipital bone fracture with subarachnoid hemorrhage, subdural hemorrhage and epidural hemorrhage (Figure 2, arrows indicated hemorrhage). Clinical study has shown increased sympathetic activity in patients with acute intracranial hemorrhage. The increased level of catecholamines would lead to QT prolongation or hypokalemia, which are the predisposing factors of the development of torsade de pointes. Although, the definitive confirmation of a cause and effect relationship about intracranial hemorrhage and torsade de pointes is still controversial, the life-threatening arrhythmia, including atrioventricular blocks, ventricular tachycardia, and fibrillation, which accompany acute cerebral accidents in patients without cardiac disease is observed in many case reports. In our experience and clinical observation, patients should be constantly monitored after acute cerebral events. Besides, the treating team should be familiar with and well-trained in the diagnosis and treatment of cardiac arrhythmias.
The most obvious deficiency in the current evaluation of disaster response is the lack of objective, quantifiable measures of performance. This frequently leads to assessments that are highly subjective depending on the evaluator, does not provide those who are planning with targets to achieve, and does not allow for measures that they have improved their preparedness. The goal of this research project is to offer recommendations for government agencies at the federal, regional, and local levels, public health departments, and health care institutions to aid in the development of pediatric emergency management performance measures.
Interventions
The goal was achieved through the application of traditional quality principles to the assessment of emergency management efforts and to the use of innovative analytic methodologies to develop comprehensive approaches to performance measurement in emergency management.
Discussion and Observations
When one discusses performance measures, it is important to remember that these are metrics we use to improve the quality of care. With regard to emergency management, performance measures are used to increase capacity and efficiency. A classic approach to health care performance measures is to discuss them with regard to the domains of structure, process, and outcome. Recently, in addition to these domains, volume has also become an important predictor of clinical outcomes. Although we believe that these domains can be applied to emergency management functions and the development of performance measures for disasters, there are some fundamental differences when compared with their use in development and categorization of traditional health care metrics which have been built in to our modification of these domains to emergency preparedness. This approach, quantitative methodology and consensus development process, when applied, will significantly advance pediatric preparedness. Ultimately, these pediatric specific measures must exist and be used to assess current levels of performance and guide resource allocation and targeted improvement efforts.
As the number of disasters caused by natural and non-natural hazards increase, so does the emphasis placed on healthcare security planning for the influx of patients that often accompany such events. This presentation expands on a previously published examination of national healthcare security systems and emphasizes the role of security in the hospital environment during disasters in China, India, and Japan. National emergency preparedness planning systems and disaster type are examined. Elements of planning for a mass-casualty incident (MCI) that most directly impact security planning include mass-notification alert systems, patient routing processes to hospitals (from an MCI scene) and within hospitals (emergency department flow), staffing, disaster triage, patient identification, tracking and discharge, volunteer tracking, and the adaptability and flexibility of space and processes.
Methods
Researchers conducted extensive literature reviews of country-specific health care and physical security elements of patient surge. The comparative analysis was augmented by communication with national healthcare security experts.
Conclusions
Positive associations exist between increased disasters and the level of priority and funding given to healthcare security measures in disaster planning. National characteristics of governance, landmass, disaster history, and population influenced the development of healthcare security systems and planning for patient surge incidents. Planning for the mental health impact of terrorism victims, and its subsequent impact to patient surge into hospitals was more relevant in the literature for both India and Japan.
Emergency response and vulnerable older people: some keys for better practices Danielle Maltais, Ph.D. professor and Taha-Abderrafie Maala, M.Sc student, Social Work Teaching Unit, Department of Human Sciences, University of Quebec in Chicoutimi (UQAC). In the event of a natural or technological disaster, certain groups of people, some of elderly, are more vulnerable than others because they do not have easy access to the community resources. For example, several older people, especially those with a physical or cognitive incapacity and those with a low income, do not generally have a car available which can hinder their evacuation during a flood, an earthquake or a hurricane. Moreover, several elders live in older buildings not built to resist to shocks of all kinds. Older people, particularly those with a physical or cognitive incapacity, those with a low income or those without a social network belong to groups at risk to undergo wounds, to die or develop post-disaster health problems. Considering this, several researchers and national or international government and private as well as non-profit organizations such as World Health Organization, the International Red Cross or HelpAge International produced several guides on intervention aiming to support workers caring for the elderly during a disaster. The purpose of this communication is to present the main outstanding facts and recommendations of these various documents in order to heighten the participants' awareness of the importance to take into account the specificities of older people during the application of emergency measures and the recovery period of a community.
If foot-and-mouth disease (FMD) was detected in the United States (U.S.), a national animal health emergency would be declared and livestock and allied industries would feel the immediate impacts of animal and product movement restrictions, animal quarantines, disease surveillance activities and other necessary measures implemented to control the disease. These control measures, while necessary to contain the outbreak, would have impacts on the normal business practices of uninfected livestock producers in affected regions, and potentially disrupt interstate commerce. Such impacts would be most disruptive to industries producing perishable products and utilizing ‘just-in-time’ supply models. One significantly impacted sector would be the U.S. dairy industry whose operations rely upon daily animal, product and other supportive movements, and do not have the capacity to store milk for more than 24-48 hours. Disruption of normal milk movement in the U.S. could affect the provision of milk and milk products, as well as create significant milk disposal, environmental and animal welfare issues. The challenge of controlling and eliminating FMD while at the same time maintaining the long term viability of the U.S. dairy industry, represents a complex and multifaceted challenge. The United States Department of Agriculture (USDA) is collaborating in preparedness initiatives and pre-event, academia-facilitated emergency management planning efforts with states and livestock industries. A key element, critical to a successful outcome from this initiative is the involvement of industry throughout the process. One such effort is the ‘Secure Milk Supply’ (SMS) Plan project and its initial goal is to develop agreed upon processes and procedures to pick up, transport, and pasteurize milk from uninfected farms in FMD control areas thus helping to maintain business continuity for dairy producers, haulers, and processors. This presentation will describe the current approach to FMD control in the U.S., issues of special relevance to the dairy industry and the progress and planned future directions of the USDA sponsored SMS Plan.
Successful patient outcomes in the setting of ocular emergencies depend on correct recognition and assessment as well as appropriate initial management. The purpose of this study is to describe the clinico-epidemiological findings and management options in patients with ocular injuries in the emergency room of a rural hospital.
Material and Methods
In this retrospective review the records of patients who were treated for ocular trauma from June 2010 to December 2010 in the emergency room of MM Institute of Medical Sciences and Research, Mullana (Ambala) were reviewed. The following data for all patients were recorded: age, sex, date and time of injury, involved eye, circumstance and mechanism of injury, initial visual acuity, details of appropriate investigation, immediate management and outcome.
Results
A total 46 patients were included in the study. Young adult male patients were more commonly involved. Most of the patients presented within 12hours of injury. Left eye was involved in 14 patients; right in 12 and 10 patients had injuries to both eyes. Most common mode of injury was mechanical. The patients who sustained bilateral ocular injuries were due to chemical burns (7 cases) and electrocution (3 cases). Most of the patients were managed conservatively. The surgical treatment offered were repair of corneal tears, removal of foreign bodies. The visual outcome was excellent in most of the patients.
Conclusions
Ocular injuries can have wide range of etiological factors and presentation and assessment of ocular emergencies can be made difficult by a lack of sophisticated facilities. However, a concise patient history, general observation and basic ocular tests can lead to a firm diagnosis and thereby appropriate management.
A trap gun (TG) is a locally manufactured, illegal barreled weapon with a simple trigger mechanism. Trap guns are frequent in agricultural areas of the country. Once the gun is set, it bursts automatically upon the triggering. Since there is no present person selecting the target, the gun injures both animals and humans. A retrospective study was carried out to identify geo-spatial distribution, seasonal variation and injury patterns of TG injuries brought to Teaching Hospital Anuradhapura during 2007 to 2009. A prospective study will identify those in a more detailed manner. The abstract discusses some findings of this ongoing study and the retrospective study. In 2007 there were 107 TG injuries, and 68 in 2008. In 2009 the number increased to 126. Of the victims, 97.5% were males. The mean age was 36.98 years (SD = 11.36), with an age range of 13–69 years and an Inter Quartile Range (IQR) of 29–43 years. The majority of the injuries were lower limb injuries. A significant percentage showed compound fractures and soft tissue injuries. Amputations due to vascular injuries were low (1.5%). Of the cases, 99.5% were from peripheral rural villages. Tap gun injuries are less common during the “Yala” farming season extending from May to September, during which Anuradhapura gets less rain. Yet number of TG victims steadily increases as the “Yala” progresses. This trend continues during the initial half of “Maha” season. It gradually deceases in the latter part of “Maha”. Trap gun injuries remain below average from February to July with the lowest number in April. The incidence of TG injuries is higher in Northwesterly administrative areas throughout the year, which share a common border with the “Wilpattu” game reserve. Further studies should be carried out to identify behavioral and socio-economical risks and economics of TG injuries.
In a hypothetical situation, an emergency services team is launched to treat a man who collapsed in the street. The team finds John Doe's mobile phone, and within seconds retrieves the required clinical parameters from his Mobile Medical Record (MMR), thus, providing a life-saving treatment suited to his personal health condition. This study seeks to determine if the necessary clinical parameters, required at emergency situations have ever been examined in order to best match both emergency situations and cellular technology.
Objective
To characterize the clinical parameters that make up an MMR in the context of saving lives, and to propose a model for an MMR in emergency medicine.
Methods
The essential emergency medicine clinical parameters in the context of life-saving treatments were characterized through interviews with prehospital and hospital experts in emergency medicine. The results were analyzed with the help of a cellular multimedia expert in order to best incorporate the clinical parameters into cellular phones as MMRs.
Conclusion
Emergency medicine teams chose individual and specific clinical parameters in a certain order of appearance from the general medical record that should assembly, in their opinion, an emergency medicine MMR. A MMR was chosen by the emergency medicine treatment teams as one of their preferred communication methods. The MMR model, if applied correctly, will provide the emergency medicine treatment teams an available, reliable, homogeneous database of real time clinical parameters adapted to life-saving conditions. The MMR model represents a conceptual revolution of taking the medical record from the caregiver and transferring it to the patient, which can be constantly at hand at any given time or place in their mobile phones.
Financing the care and treatment of victims of emergencies and disasters is a critically important area for policy. It needs deliberations to evolve policies that will be relevant, robust and enduring. This is more so as the ideological and political leanings of a people determine what will be allowed and what policies endure. The sustainability of the funding model makes a large impact on the success of the treatment, in this case the specialized treatment needed in the traumatic event of emergency and disaster. The paper defined emergencies and disasters and observed that though the timing of funding is critical in the events, the volume and complexity of funding is higher in the latter. The paper reviewed the several current models in use today, particularly with locus on costs which should be incorporated in a payment model, including flag fall or set-up costs (for instance managing new patient records), consumables, investigations (such as pathology and diagnostic imaging) and pharmacological services (prescriptions, logistics of procurement under crisis, etc,) staffing costs which in public hospital emergency departments often do not vary within a shift i.e. emergency departments rarely draw staff from ward areas to the emergency departments to assist with unpredicted demand peaks- but which may become significant in event of disasters. These models are essentially public funded. The paper also highlighted the political underpinnings which make each of the current models popular in each of the ideological settings. The pros and cons associated with the models are reviewed in depth. The paper concludes, after the ideological/funding analysis, by recommending a private/public mix of funding. Details of this proactive funding approach are given and ways to modify and adapt them to different ideological (political) backgrounds suggested.
Disasters cause destruction, but also bring opportunities for development. A lack of this perspective in disaster management leads to planning and managerial follies. The reconstruction and rehabilitation program from the Latur earthquake (Maharashtra, India) should be used as a starting point. Leh, the largest district of India, was hit by a cloudburst and subsequent flashfloods on 05–07 August 2010. The monetary value of the total damages is estimated to be approximately Rs 225 crores. A total of 87% of the affected infrastructure required complete reconstruction. The rest received partial damages. This paper uses field data collected on development needs in 112 villages over a span of five years (just preceding the disaster) and data for damage assessment from the 42 affected villages collected immediately after the disaster. The paper does a careful assessment of the damages in the flashflood, analyses the pre-existing developmental requirements of all the villages in the district, and explores the possibilities of integrating post-disaster reconstruction with the pre-existing developmental requirements. In India, post-disaster reconstruction quite often is an elaboration of short-term, makeshift arrangements, thereby giving rise to obvious developmental concerns. Merits and demerits of this strategy will be discussed. This research examines the financial implications of integrating reconstruction projects with development programs. It also looks into the sustainability of development, and how can this serve as a strategy in making communities more resilient to future disasters.
The general public's association with livestock (cattle, sheep and horses) raises a need for public safety. During emergency/disasters, animals are accidentally/intentionally released from containment structures. Loose livestock become agitated with unpredictable behavior which is a risk to both humans and animals. Specific training/protocols for responders are necessary for dealing with livestock.
Problem
Livestock running loose in populated areas raises risks to people, especially during capture attempts. Untrained personnel subject themselves to undue danger when assisting with livestock capture. Capture plans should be in place in advance and training should be provided to first responders on safety issues regarding animals.
Methods
A review of a loose livestock event brought forth the following considerations: (1) Evaluate the risks of a loose livestock/public event; (2) Inspect containment facility and identify secondary containment barriers, including fencing, buildings, rivers, etc.; (3) Develop plan for capture and containment within the immediate facility and surrounding area; (4) Provide training: training exercises, animal capture, basic animal behavior, and Incident Command System for first responders; (5) Arrange for emergency care or humane euthanasia for injured animals; (6) Coordinate capture and transport activities with local livestock experts.
Results
Production of a comprehensive loose livestock plan can prevent injury and/or death to both people/animals. Agencies involved in safety and emergency response should have a well written plan that can be used by all appropriate local agencies involved in loose livestock response. The utilization of a loose livestock worksheet (template) with professional training is essential for emergency response agencies.
Conclusion
Disaster managers should develop a comprehensive plan and training program with other local agencies in advance of an event to respond effectively to capture loose livestock.
Cruising has become a major part of the tourist industry. In 2010, the total passengers carried worldwide was estimated at 18.4 million, on about 230 cruise ships. Large ships can hold up to 6,000 passengers and > 2,000 crew members. A large cruise ship is rather like an island, with two different communities: the well-trained crew, hopefully prepared for every eventuality and trying to make their guest's stay as pleasant as possible; and the guests, there to have fun. The guest population varies, with up to 40% under 21 years old during school breaks, and the average age is in the fifties or sixties on longer cruises to scenic places such as Alaska. Most of the time ships cannot be reached by helicopter and the medical teams need to cope with a wide range of emergencies from cardiopulmonary, trauma, and psychiatric issues. There are strict public health measures enforced and a range of legislation reducing the risks of cruising to a minimum. This paper reviews the training of the crew for medical emergencies, the incidence of disease, the incidence of medical disembarkation and major incidents on board, and the role of medical teams.