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At this time, no triage method is considered better than another in comparison to the outcome of the casualties. It is important and useful to identify a triage method that can be used for both adults and children at the same time. It should consider the anatomical and physiological differences between adults, children, and infants.
Objectives
To revise and adapt the current triage system in use in the Piemonte Emergency Medical Services for the first triage in a validated method that is effective for adults, children, and babies in order to unify and simplify the triage system.
Methods
In accordance with pediatricians, the “Triage Sieve” procedure and parameters were revised into a single method.
Results
Setting the height of the casualty was considered to be both quick and easy. In this revised method, all the casualties are classified with the sieve methods, but some changes have been introduced. Casualties with a stature < 59 cm are classified as infants, and are therefore priority T1 (red) in every case. Casualties > 60 cm but < 120 cm in stature are classified as children. Children with a respiratory rate < 15 or > 40 breaths per minute and a heart rate < 80 or > 160 beats per minute are classified as T1.
Conclusions
Children will probably be over-triaged in this method, but the authors do not consider that a substantial problem. This first triage system is simple and effective. But, it has not yet been tested effectively during an actual mass-casualty incident or disaster.
The devastating Haiti earthquake of January 10, 2010 resulted in 250,000 dead, more than 300,000 wounded and at least 1.3 million displaced. As the poorest nation in the Western Hemisphere, life in Haiti was already fraught with poverty and one of the highest HIV rates in the world. After the earthquake, life in Haiti became intolerable. As Chief Medical Officer of Florida One DMAT, the author helped to coordinate medical relief operations at the US Embassy in Port-au-Prince beginning within 60 hours of the earthquake. The author and his FL1 DMAT team supported medical relief operations not only at the US Embassy but also at the Toussaint L'Ouverture International Airport for air evacuation of survivors to Miami and at Terminal Varreux for coordination of ingress/egress casualty operations for the USNS Comfort hospital ship.
Results
Unique lessons were learned in this first ever deployment of US DMATs on foreign soil. The presentation will describe the medical operations, the triage process, the challenges of operating on foreign soil, and the results of the relief efforts. Recommendations will be offered to facilitate future international DMAT deployments including development of Standard Operating Procedures (SOPs) for DMAT international deployments and increased coordination between the US Department of State (who have jurisdiction over US assets on foreign soil) and the US Department of Health & Human Services (who are the coordinating governmental department for DMAT operations).
Acute care addresses immediate resuscitation and early disposition to definitive care. Delay in final disposition from the emergency department (ED) affects outcomes in terms of morbidity and mortality. An audit was performed to assess the impact of protocols on red area disposition time.
Methods
An audit of red (resuscitation) area disposition time was performed among patients with compromised airway, breathing, and circulation. The red area disposition time was defined as the time from ED arrival to red area disposition. Pre-protocol data from nursing report books were reviewed for ED to operating room (OR), ED to intensive care unit (ICU), and overall disposition time between September 2007 and January 2008. Similar outcomes were documented after implementation of protocols during February to December 2008.
Results
In the pre-protocol period, 992 red area patients were enrolled out of 10,000 ED visits. Out of which 527 (53.1%) were shifted to the OR and 222 (22.3%) to ICU. The average ED disposition time was 3.5 hours (range 2–5). Similarly, 1797 red area patients were enrolled in the post-protocol period out of 25,928. Of these, 453 (25.2%) patients were shifted to the OR, and 423 (23.7%) were shifted to the ICU. The average ED disposition time was 1.5 hours (range 10 minutes–3 hours).
Conclusions
Implementation of protocols improves the red area disposition time of the ED. Auditing is an important tool to address patient safety issues.
The ongoing shelling of missiles on the city of Sderot in Israel for the past 8 years have caused damage in terms of life and property as well as have put more than 25,000 residents under significant and ongoing threat. A recent study examining the impact of living under these conditions has revealed that 28.4% of the area residents suffer from PTSD and 75%–94% of the children reported to experience posttraumatic symptoms (Gelkopf, Berger, Bleich, Cohen, submitted). Despite the psychological needs of the residents, mental health service utilization has been sparse due to many residents not feeling safe to leave their homeland fear the stigmatization in attending public mental-health clinics. In order to resolve this dilemma, we have developed a community home-based family intervention delivered through a mobile unit of professionals who provide mental-health services for to traumatized families in their homes. The model incorporates family systemic approach with trauma-focused cognitive-behavioral technique and narrative strategies. I will outline the model and present an evaluation of its efficacy in reducing PTSD and in improving daily functioning in adults and children. I will also describe several cases illustrating the model. Finally, we conclude that such a model may be useful in providing mental-health services in major disaster, such as Tsunamis, earthquakes and floods, particularly in developing countries where mental health capacity is limited and where local populations will not always have the means or be able to reach clinics.
The 26–29 November 2008, terrorist attacks in Mumbai, have been referred to as “India's 9/11”. Violent events in Mumbai over the past six decades were researched to understand the changing pattern of violent injuries.
Methods
A complex, retrospective, descriptive study on terrorist events was performed, using event reports, legal reports, newspaper reports, and police and hospital lists. The distribution of victims to various city hospitals, the critical radius, surge capacity, and nature of interventions required were assessed. The profile of those killed in the attacks was noted by sex, nationality, and occupation. Besides the overall mortality and case-fatality ratio, the critical mortality was calculated based on the death rates among the critically injured.
Results
In 51 violent events in Mumbai over a 60-year period (1950–2009), 1,582 people were killed and 4,145 were injured. In the Mumbai terrorist attacks of 2008, the financial loss due to direct physical damage was INR 847,612,971 (US$18.5 million). Among those killed, the average age was 33.4 years, 80% were male, and 12% were foreign nationals. The case-fatality ratio for this event was 36.2% and the mortality among the critically injured (critical mortality rate) was 11%. Among the injured, 79% were male and the average age was 33.21 years (three months–85 years); 38.5% of patients arriving at the hospitals required major surgical intervention.
Conclusions
The injuries of violent events in Mumbai have been changing due to the use of heavy firepower and explosives. Strengthening the public hospitals for trauma care is a medical counter-terrorism response for future terrorist attacks. These attacks have affected the lives of the common person in Mumbai, in terms of increased security checks, alerts, and fear of further attacks. These are areas of further research.
A hospital disaster drill is commonly carried out based on the activities assigned beforehand by the occupational description. However, it is difficult for each staff the role is fixing to understand the global image of a disaster correspondence in a hospital disaster when their role is assigned and fixed. We have developed the understandable drill about the whole practice at each hospital in disaster. We keenly realized the necessity of a standard disaster medicine. Therefore we have developed the disaster drill which can be held per hospital. As a goal of a course, each hospital personnel could understand the global image of the disaster, and aimed at the daily course which can master necessary minimum skill to correspond a disaster in each hospital. From the reasons above, we created the course which consisted of a lecture, individual skill training, and a gross training. As essential skill, it starts with (1) management of disaster countermeasures office (2) management of triage post (3) treatment at room (4) support of conveyance between hospitals (5) information control. In order to employ these individual skill booths efficiently we divided attendances into five groups. Five hospitals started from 2008, were carried out 11 times, and about 500 persons took this disaster drill on a course. We expect that cost to bellower, the course to be simpler, and the quality of training will improve by holding this course repeatedly.
Acute pain assessment and management in trauma victims is often overlooked in emergency department (ED). Visual analogue scale is the preferred scale for assessment and management of pain however, its role in a busy ED is limited. The objective of this study was to evaluate the feasibility of verbal and visual analogue scale among emergency care providers.
Methods
Emergency caregivers were instructed to use both pain scales wherever feasible for assessment, management, and monitoring of pain in 100 non-consecutive alert patients. A separate, pre-tested survey questionnaire addressing the feasibility of each pain scales was surveyed among emergency care providers (emergency physicians, nursing staff). A Likert scale (1 to 5) was assessed for cooperativeness, availability of time for assessment, the format, the peak period feasibility, the monitoring ease and the amount of work load. Binary scale (yes and no) was used to measure the overall utility in assessment and management of pain.
Results
Out of 100 patients enrolled, the verbal analogue score was used in all patients and visual analogue score was used in 30 patients. The average Likert scale score for verbal analogue score questionnaire was 1.7 and the average Likert scale score for visual analogue score questionnaire was 3.9. On the overall utility both scales were found to be useful in all patients.
Conclusions
Both the scales were found to be useful in overall assessment and management of pain. However, there was a favorable trend towards using verbal analogue scale among emergency care providers.
Evolving health systems frequently seek guidance with emergency medicine related topics. This has lead to countless international collaboration between organizations attempting to meet this need.
Background
Paraiba, a state of 3.6 million, ranks near the bottom in Brazil for per capita income. The medical establishment has private, public and military systems without emergency medicine training and no disaster plans. HHI and Harvard International Emergency Medicine Fellowship are academic research and service oriented organizations with an emergency medicine and disaster preparedness focus. In 2009 a request for technical assistance was made to HHI from Paraiba, concerning disaster preparedness, clinical emergency medicine and pre-hospital training.
Methods
Exchange of correspondence surrounding needs and expectations of the partner organizations was conducted until the August 2010. During August a series of meetings was conducted among the civilian, military and federal representatives and a collaborating body was formed under the guidance of UFP consisting of SAMU (prehospital care), the medical school and the five main hospitals of the city. In September HHI staff conducted a series of meetings and assessments in Paraiba. Plan Evaluation, educational and programmatic steps were decided on to be conducted over the several year project. Space and resources for the training center at the UFP was allocated. Establishment of 8–12 teaching modules for practicing physicians and nurses, built and taught by local staff with HHI support will be implemented and become a requirement to work in emergency areas. An assessment of disaster risks and emergency metrics will be conducted concomitantly. Exchange of staff between Brazil and USA will occur throughout the project.
Conclusion
No standard model of collaboration exists regarding international emergency medicine and disaster planning but ours demonstrates that exchange of information can evolve to match the abilities and expectations of both parties.
The study investigated psychological impact of tsunami of men and women with disabilities two years after the tsunami disaster. A total of 248 tsunami affected people with disabilities aged between 16 to 85 years were included in the final sample. And the sample consisted of 132 males with the men age 37.9 years, and 116 females with the men age 40.6 years. SRQ (psychological distress), IES (post-traumatic stress), WHO- DAS (psychosocial disability functioning) and QOL (quality of life) were administered. In addition to scale administration to 248 people, formal discussions were held with 27 mentally retarded people and their guardians/parents, thus making the total sample of 275. Main effects of gender were found significant on IES i.e. post-traumatic stress and main effects of type of disability was found significant on physical QOL, psychological QOL, and post-traumatic stress. Main effects of severity of disability was found significant on all variables. t-tests have been found out to study the inter group differences. All findings have been discussed in the light of supporting studies and theories. Long-term psychosocial and psychiatric interventions are suggested to be provided till the reconstruction and rebuilding phase continues, however, the challenge still remains for the strategy of mainstreaming disabled specific designed interventions within the community based psychosocial care services framework.
Staff education and qualification is a safety issue to maintain employees ready to act whenever the catastrophe plan is deflagrated especially since it only happens once in a while. Considering that catastrophe is an unexpected event and most of the time an unusual scenario, the risk of inefficient patient care and unsafe situations for employees and for the environment is high.
Objective
To describe the e-learning as a continuous training methodology to keep staff prepared to manage victims from a catastrophic situation whenever it happens.
Methodology
E-learning is a methodology for distance learning with focused content, pedagogy, technology and instructional system design aimed to deliver education. E-learning has advantages such as: a rapid update, customization of content, access flexibility, continued availability, reduced time for learning, training of a large number of employees with access control and release reporting. The development of e-learning is based on the following phases: analysis of topic relevance, evaluation by expert professional, relevance and applicability as educational strategy, planning and content construction with related areas, development of the storyboard and formatting with an instructional designer. The content of the e-learning Catastrophe Plan include definition of catastrophe, STAR screening method, roles and responsibilities, attendance flows, tests. Its duration was 30 minutes.
Results
During 03 months the e-learning of Catastrophe Plan was available in the intranet to Albert Einstein employees. A total of 3104 employees were trained representing 56% of target public (n = 5541). After this period, the e-learning became constantly available and part of the new employees admission process.
Conclusion
E-learning is an innovative educational methodology that contributes to the retention and generation of knowledge. The care and support team during the simulations in 2010 showed better performance when compared to 2009 due to the capability of this tool to spread the knowledge.
Recent Scientific Writings about Consequences of disasters on Workers Danielle Maltais, Ph.D. and Simon Gauthier, M.Sc. University of Quebec in Chicoutimi (UQAC) When an application of emergency measures is issued following a natural or technological disaster, or a disaster caused by human negligence, in many countries social workers and nurses play a central role in the support to the victims not only during the period of social disturbance but also at the time of the return to a normal life. These workers sometimes find themselves plunged within various intervention sectors where work conditions are often difficult. Once juxtaposed to the characteristics attached to disasters (nature, suddenness, duration, intensity, etc), the characteristics of the workers (intervention skills, training received, intrinsic efforts made, etc) and to the characteristics of the organizations (expectations towards their employees, organizational support offered to the employees, extrinsic efforts required, etc), these conditions increase their level of vulnerability by exposing them to environments harsh to manage. This vulnerability experienced by the workers in an emergency period can be reflected through symptoms such as anxious disorders and exhaustion. This poster will present the major findings of recent studies in this field (impact of disaster on the psychological health of workers) while under lighting personal, contextual and organizational factors which either contribute to the presence of psychological health issues for the workers or facilitate their resilience.
Catastrophe Biologique dans la Ville de Rio. Silveira L, Plotkowski LM, Arouche I, Borghi D, Julien H. Sécretariat d'Etat de ls Santé et Defense Civile.. Au début de l'été de 2007 la ville Rio a subi une catastrophe responsable de 232 morts (42% d'enfants ) et 150.00 malades. En quelques semaines, l'épidémie de dengue a bloqué toute la structure de soins de Rio. Les hôpitau pourtant dotés de plans blancs, n'ont pu faire face a l'afflux massif de patients. La gravité était due au choc hypovolémique par perte de plasma, plus qu'aux hémorragies. La diffusion alarmiste de la presse a augmenté les réactions de panique populaire. En février 2008, chaque heure des centaines de nouveaux cas ont été enregistrés. Les autorités réunies (Secrétariat d” État de la Santé et Sécurité Civile, Le Service de santé du Sapeur Pompier, de l Ármée de Terre, de la Marine et de l' Armée de L'Air) ont décidé d'installer 12 PMA (Hôpitaux de Campagne) pour trier les malades et les hydrater sur place. Chaque “ Tente d'Hydratation” a été équipée d'un laboratoire d'analyse (hémogramme et plaquettes ) de 30 lits pour l'hydratation en perfusion, deux lits de réanimation et une ambulance, pour le transfert vers l'hôpital de référence. Près de 1000 professionnels de santé y ont travaillé. Dans le premier mois, 49 700 consultation on été assurées dans les PMA. Les patients étaient tous triés et 10 % ont eu besoin d'une hydratation par perfusion pendant 12 heures en moyenne. Seulement 2% des malades ont été hospitalisés. Le diagnostique précoce et l'hydratation rapide a permis aux PMA de renvoyer les malades chez eux, de réduire efficacement l'afflux hospitalier et la mortalité par dengue. Les PMAs ont été démontés progressivement à mesure du contrôle de l'épidémie, jusqu'a 2 mois plus tard.
This case study presents the development of a prehospital system in Jaffna, Sri Lanka. The case then outlines the development of the system, examines its first year of operations, and investigates possible reasons for the results of the development of the prehospital system in Jaffna. Finally, the case discusses the continued operations of the system.
Methods
This case study qualitatively researches the development of the Jaffna prehospital care system by looking at indicators of success in human resources, technical knowledge and community awareness. The case study also quantitatively examines the utilization and financial performance of the system during its first year of operation.
Results
According to indicators, the implementation of the model and its functioning can arguably be considered successful in terms of utility, and in many regards financial stability. The system has already responded to over 2,000 emergency calls in its first eleven months of operation. The main ambulance and call center has managed to operate at only a $13.50 USD loss during its first twelve months of operation. It has established quality standards by utilizing trained Emergency Medical Technicians (EMT) and ambulances featuring basic life saving equipment. The system has also integrated itself as a part of the overall health system of the community it is serving.
Conclusions
The system's success in development should be examined as a potential model for implementing prehospital care in a developing and middle-income country setting, while keeping in mind factors outside of the system that were integral to its developmental success.
Wildfires can injure animals both from burns and inhalation of smoke and particulates. In 2006 a rapidly moving grass wildfire burned 12 square miles in Yolo County. Approximately 1400 sheep on the range suffered variable degrees of burns. A coordinated effort of triage and individual treatment or humane euthanasia was performed by the UC Davis Veterinary Emergency Response Team.
Methods
Animals: Two sheep ranches with 1100 (ranch A) and 300 (ranch b) adult sheep of different breeds, ranging in age from 1-6 years of age. Initial owner evaluation: Both ranchers considered humane destruction of all sheep showing evidence of burned discoloration, estimated to be over 95% of 1400 sheep. Ranch B attempted shooting comprised sheep but stopped and requested aid from UC Davis as did ranch A. Veterinary initial evaluation and communications: Several burned sheep were visible from the roadway. Many sheep were standing with limited movement and some were recumbent. Triage was performed by bringing food and water sources to the sheep and those not eating and drinking were evaluated first. Gunshot euthanasia following AVMA guidelines based on veterinary determination of hopeless prognosis was used. Veterinary team members (N = 25) coordinated treatments, communications with public health, animal control, and press media, carcass disposal, volunteer management, and acquisition of office of emergency services resources.
Treatment
Topical treatment of eyes and skin burns with silver sulfadiazine ointment, administration of systemic antibiotics (LA 200), pain relief (flunixine meglumine), wound debridement, and cesarean section of late term terminal sheep were performed.
Results
Over 500 sheep were euthanized by gunshot and the remainder (approximately 900) recovered lasting from 1-42 days. Progression of burn injury to skin, udder, face, and hoofs persisted for 42 days.
Conclusion
A coordinated veterinary response provided humane care and triage of this mass casualty animal emergency.
ICT are introduced into organizations with the goals of managing resources, increasing efficiency and work productivity and reducing workload. In the context of developing countries, these goals are accentuated given the existing conditions. The aim of this study was to identify hospital institutional capacity indicators to provide recommendations to an emergency management database system operating in the Western Cape province of South Africa as http://hospitalbedbureau.co.za/.
Methodology
A two round modified Expert Delphi study was conducted by email. A panel of 16 experts drawn from the fields of emergency medicine, critical care, trauma surgery and disaster medicine were consulted. Participants were initially asked to propose hospital institutional capacity indicators that warranted inclusion in the emergency management database system currently operating in Cape Town, South Africa. In the second round these proposals were collated and scored using a 7 point Likert scale. Areas that did not reach consensus in the Delphi study will be presented as synopsis statements for discussion at the Emergency Medicine Symposium hosted by the department of Accident and Emergency Western Cape.
Results
Round 1 comprised 237 statements. Consensus was defined a priori to be > 80%. A total of 52 of 237 statements had reached consensus upon completion of the Delphi study. This represented 21.9% of the total number of statements. Of these 20 reached consensus at > 90% and 32 reached consensus at > 80%.
Conclusion
The use of a Delphi study achieved consensus in aspects of hospital institutional capacity that can be translated into practical recommendations for implementation by the local emergency management database system. Additionally, areas of non-consensus have been identified where further work is required.
The first decade of the 21st century will go down in history as an era of major disasters. Disasters have occurred in all corners of the world and ranged from events such as the 11 September attack, the London bombings, the Asian Tsunami, Hurricane Katrina, earthquakes in India, Iran, Pakistan, China, and Haiti, and cyclones and floods in Bangladesh and Myanmar. The unavoidable common factor of all these disasters was the massive number of casualties and deceased witnessed within a short period. The effective intervention of governmental agencies to manage casualties during the immediate aftermath of a disaster often is restricted by many technical and circumstantial factors. However, it was observed during the last decade that during disasters, volunteer members of the affected and surrounding communities form a huge supportive force to meet most urgent tasks, including managing the dead. This was best witnessed in 2004, after the Asian tsunami disaster. The management of the dead during disasters is a multidisciplinary, multi-stage task and a medico-legal emergency that should be commenced during the immediate post-disaster period. Community first responders comprise an easily accessible, readily available task force in the field of managing the dead, especially in the recovery and transportation of dead during disasters. The first attempt to regularize the role of community first responders during disasters was made in 2005 with the post-Asian tsunami experience through a joined effort of many international organizations. Since then, south Asian countries have been more concerned about developing capacity of first responders via community-based disaster management schemes. The services of first responders could be greatly enhanced through training and integrating them into mass casualty management plans in less resourced countries as elaborated in this paper.
Although the exact burden of foodborne disease is unknown, diarrheal diseases kill approximately 2.2 million people annually. Even in developed countries foodborne illness is estimated to affect over 20% of the population annually. During natural disasters existing food safety and security measures may be damaged and mission priorities during emergencies may prevent inspection agencies from conducting normal inspections and enforcing government regulations. This breakdown in the food safety infrastructure may lead to increases in foodborne diseases within the local population and relief workers. The risk in this latter group is possibly magnified by their immunologic naïveness to local pathogens and an outbreak among relief workers can severely impact support operations, interfere with the aid delivery, and may result in the loss of life. In addition to natural disease transmission, there is the potential for terrorist organizations to target relief workers through deliberate contamination of the food and water supplies. Consequently, relief agencies should consider both food safety and security during disaster operations. A Food and Water Risk Assessment (FWRA) is a tool for identifying potential high risk food items and practices in local food sources and facilities and examines the overall food operation, the food facilities and equipment, water potability, cleaning and sanitation, pest control, employee health and sanitation, food security, and the source of the food items. The FWRA identifies risk items and provides mitigative control measures designed to reduce the residual risk to acceptable levels and minimize potential disruption of mission operations. Although the ultimate goal is protecting the health of the relief workers, the FWRA can also be used as a tool to improve the food safety practices of local food facilities and suppliers which will in turn help to reduce the incidence of foodborne disease among the local population during the disaster relief operations and beyond.
Japanese Disaster Medical Assistance Team (DMAT) has important duties to support and reinforce functionally insufficient key disaster hospitals in the large-scale disasters. However, it is difficult for Japanese DMAT to fulfill these duties in the current circumstances, because the DMAT consists of individual institutions and Teams have less experience to work in the other institutions. To resolve the issues, disaster drills for some DMATs which consist of several institutions have been held since 2008. We evaluated the effectiveness of the drills and educational system.
Methods
Investigation was performed by surveillance questionnaires to 129 participants in the drill (staffs from DMATs, Red Cross and local government, and sham patients). The questionnaires are: A. Was the cooperative medical practice performed smoothly? B. Was the support for hospitals conducted effectively?, C. Was the medical record for wide-area transportation completed? (for our staffs only), D. Was our activity enough? (for participants excluding us), and E. Was the drill beneficial?
Results
85 participants including 30 staffs in our institution answered the questionnaires (65.9%). The number of participants who answered ‘Yes’ was as follows: A. 48 (56.5%), B. 64 (75.3%), C. 8 (26.7%), D. 44 (83.0%) and E. 81 (95.3%).
Discussion
Although the cooperative medical practice was not so smooth, it was recognized that members in DMATs got mutual trust by their high knowledge and skills. And it was suggested that DMAT could not command and control the hospital staffs without their understanding the equipments and documentations used by DMAT. And it is ideal to change the mindset of hospital top managements towards the disaster medicine through the repeated drills.
Conclusion
The repeated disaster drills at the local area is essential to make DMAT function sufficiently.
Developing an e-learning platform addressing security and rescue forces to eradicate the lack of disaster preparedness underscored by diverse studies. In order to reach this aim the performance of a needs analysis is essential.
Methods
The audience of security and rescue forces was clustered in (emergency) physicians, fire-fighters, policemen, Paramedics and members of the Federal Agency for Technical Relief (THW). For each cluster a questionnaire was developed and corrected by specialists in disaster care. The questions were about previous knowledge, habits of studying; further training habits and internet requirements.
Results
The questioner was posted online during 4 months and was filled in by 1142 persons (141 physicians, 194 fire-fighters, 108 policeman, 444 rescue workers and 255 members of the THW). The biggest lacks in previous knowledge were shown in reacting on CBRN-incidents. 64, 1% thought they were not able to act correctly in case of chemical contamination. The most important learning tools were books, lectures, seminars and the principle of learning by doing. The reasons for using an e-learning platform were saving time, high quality of the tutorials (77% thought it important), quicker reach of information, multimedia formats of the taught facts and links to further information. 55, 2% were slightly unsatisfied with the actual pool of further trainings. The most frequently used sources of information were the internet (78, 8% use it frequently) and colleagues.
Conclusions
The survey shows that lacks in disaster preparedness in Germany definitively exist but it also reflects that most of the security and rescue forces are motivated to do further trainings and use therefore new technologies. But they require a high quality of teaching and a reasonable use of them. There is a need for using innovative Methods, and user-friendly web-based instruction and information modules to address all security and rescue forces in Germany.
Pakistan is a developing country with a basic prehospital system in some cities. The prehospital services are a mixture of government and private ambulances.There is no central regulatory body for them and no central command to control the influx and out flux of ambulances from the scene.
Objective
In this paper, five episodes of terrorist incidents in the country and will try to estimate the number of ambulances on the scene.
Methods
Retrospective data was collected and triangulation was done by three sources: (1) ambulance records; (2) visual estimation; and (3) print media. An estimate of total ambulances was reached along with dead and injured. Furthermore medical transport capacity was calculated where possible.
Results
In majority of the incidents, it was found that there was a huge influx of ambulances beyond the need. This further adds to the chaos and confusion already present on the scene of disaster.
Conclusions
A Command and Control Center should be established to direct all ambulance control and movements.