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In Maryland, there have been no military/civilian training exercises of the Medical Mutual Aid Agreement for >20 years. The aims of this paper are to describe the National Disaster Medical System (NDMS), to coordinate military and civilian medical mutual aid in response to arrival of overseas mass casualties, and to evaluate the mass-casualty reception and bed “urge” capacity of Maryland NDMS Hospitals.
Methods:
Three tabletop exercises and a functional exercise were performed using a simulated, overseas, military mass-casualty event. The first tabletop exercise was with military and civilian NMDS partners.The second tested the revised NDMS activation plan. The third exercised the Authorities of State Emergency Medical System and Walter Reed Army Medical Center Directors of Emergency Medicine over Maryland NDMS hospitals, and their Medical Mutual Aid Agreement.The functional exercise used Homeland Security Exercise Evaluation Program tools to evaluate reception, triage, staging, and transportation of 160 notional patients (including 20 live, moulaged “patients”) and one canine.
Results:
The first tabletop exercise identified deficiencies in operational protocols for military/civilian mass-casualty reception, triage, treatment, and problems with sharing a Unified Command. The second found improvements in the revised NDMS activation plan.The third informed expectations for NDMS hospitals. In the functional exercise, all notional patients were received, triaged, dispatched, and accounted in military and five civilian hospitals within two hours. The canine revealed deficiencies in companion/military animal reception, holding, treatment, and evacuation. Three working groups were suggested: (1) to ensure 100% compliance with triage tags, patient accountability, and return of equipment used in mass casualty events and exercises; (2) to investigate making information tech-nology and imaging networks available for Emergency Operation Centers and Incident Command; and (3) to establish NDMS training, education, and evaluation to further integrate and support civil-military operations.
Conclusions:
The exercises facilitated military/state inter-agency coopera-tion, resulting in revisions to the Maryland Emergency Operations Plan across all key state emergency response agencies. The recommendations from these exercises likely apply to the vast majority of NDMS activities in the US.
A sudden and extensive power failure occurred at Karolinska University Hospital in Huddinge on Easter Saturday, 07 April 2007. The power failure lasted one hour and 22 minutes, but it took a longer time for activities to return to normal. It put many patients at great risk, particularly in the intensive care unit and other departments with critically ill patients. This report details the conditions and response at Karolinska University Hospital during the power failure and provides lessons learned for future events.
Bag-valve-mask ventilation is a key component of life support, but only one handheld resuscitator is designed to operate in contaminated or toxic atmospheres.
Methods:
After Institutional Review Board approval, the efficacy of this device was evaluated. The distal trachea of a LaerdalTM Airway Management Trainer was connected to a mechanical Draeger Volumeter 3000TM to enable determination of the minute volume delivered by BVM ventilation. Nineteen paramedics wearing chemical, biological, radiological, or nuclear (CBRN) protective equipment were asked to ventilate this modified airway trainer, either with or without a CBRN filter attached to the inlet filtration system of the AMBUTM Mark III Resuscitator. The maximum levels of minute ventila-tion achieved were compared. Values are given as mean ±SD. A paired t-test was used to detect any differences between the two groups, p-values of <0.05 were defined to show statistical significance.
Results:
The described model allowed a reproducible and reliable measurement of the delivered minute ventilation. All paramedics were able to operate the device without prior CBRN training. The maximum minute volume achieved without the filter was 9.5 ±2.7 l/min. Use of the inlet CBRN filtra-tion system reduced the maximum minute volume to 6.3 ±2.0 l/min, reduction: 23%. The achieved maximum minute volumes ranged from 15 to 4.9 l/min in the controls and from 9.8 to 1.4 l/min in the CBRN group. Four paramedics were unable to achieve a minute volume >5 l/min in the CBRN group, one participant failed to achieve that value in the control group. The inherent breathing resistance of the CBRN filter appears to reduce the inflow of air into the self-inflatable bag. This delay in refilling may have resulted in a reduced achievable minute volume.
Conclusions:
The range of maximum minute volumes observed in both groups highlights the need for continuous BVM ventilator training.
The objective of this study was to evaluate the rapid training of medical students and their ability to provide effective manual ventilation using the bag-valve-mask technique.
Methods:
A rapid training session highlighting essential aspects of the correct bag-valve-mask technique was given to 31 medical students.This was followed by a simulated experience with a certified respiratory therapist, monitored according to a checklist of essential bag-valve-mask (BVM) competency requirements. Pretest and post-test surveys assessed the medical students' knowledge and ability to provide adequate BVM technique.
Results:
Thirty-one students participated. Presurvey results demonstrated a clear identification of the potential risk for a disaster (pandemic, natural, bioterrorist) with 55% of students responding that a definite risk did exist. Their usefulness in such an event also was ascertained with 55% of students replying they would assist with basic medical tasks, assist doctors, or assist with cardiopulmonary resuscitation. Post-survey results administered after a 30-minute didactic session on the basic features of resuscitation equipment and the essential components of BVM technique demonstrated that a majority of students knew the proper head positioning maneuvers in cases not involving trauma (93%) and in cases involving trauma (72%). All students completed and passed the competency checklist.
Conclusions:
Medical students can be rapidly trained and be utilized as a potential resource to carry out the potentially lifesaving task of manual ventilation using the BVM technique in a disaster situation in which the availability of mechanical ventilators and respiratory therapists may be limited.
The effect of immediate exposure to traumatic events and gender differences is under-studied in the literature. Most studies focus on acute stress disorder (ASD) and post-traumatic stress disorder (PTSD) phases in order to measure gender differences, and tend to neglect the immediate expo-sure to the disaster.
Hypothesis:
The main hypothesis was that female rescue personnel would exhibit higher levels of acute stress symptoms, dissociation, and depressive symptoms in the 24 hours following a traumatic event.
Methods:
Twenty-three rescue personnel participated in a search and rescue operation at the Bet-Yehoshua train crash in Israel. The rescue personnel group was divided based on gender. Each participant completed a demographic questionnaire including questions that assessed psychological symptoms and issues such as perceived threat to life, the Impact of Event Scale Revised (IES-R), the Dissociative Experience Scale (DES), and the Center of Epidemiologic Studies Depression questionnaire (CES-D). Statistical inferences were calculated using t-tests and chi-square tests, along with testing of covariance (MANCOVA) in order to indentify which factors are related to psychiatric symptomatology following the immediate exposure to disaster.
Results:
The results suggest that among rescue personnel, women did not differ in their levels of acute stress, dissociation, and depressive symptoms from men.
Conclusions:
These results suggest the possibility that the gender differences in reactions to traumatic events do not emerge in the acute stress reactions (ASR) phase (up to 24 hours after the event), but later on when people have time to process the trauma. Another possibility that may explain the discrepancy between this study and the common knowledge in the literature is that women rescue personnel are considered a highly selected group, which does not reflect on the general population of women. More studies are needed in order to substantiate these results.
Two regional hospitals were struck by lightning during a one-month period. The first hospital, which had 236 beds, suffered a direct strike to the building. This resulted in a direct spread of the power peak and temporary failure of the standard power supply.The principle problems, after restoring standard power supply, were with the fire alarm system and peripheral network connections in the digital radiology systems. No direct impact on the hardware could be found. Restarting the servers resolved all problems. The second hospital, which had 436 beds, had a lightning strike on the premises and mainly experienced problems due to induction. All affected installations had a cable connection from outside in one way or another. The power supplies never were endangered. The main problem was the failure of different communication systems (telephone, radio, intercom, fire alarm system). Also, the electronic entrance control went out. During the days after the lightening strike, multiple software problems became apparent, as well as failures of the network connections controlling the technical support systems. There are very few ways to prepare for induction problems. The use of fiberoptic networks can limit damage. To the knowledge of the authors, these are the first cases of lightning striking hospitals in medical literature.
Medical care systems will be overwhelmed if a human H5N1 pandemic should occur. Several national disaster plans, including that of Belgium, focus on maximal treatment at home with senior medical students supporting frontline care. To evaluate the knowledge and preparedness of Belgian senior medical students, an e-mail survey of senior medical students (last two years of education) attending Flemish universities was conducted.
A total of 243 students (30%) replied. Only 21.8% of them were aware of the possibility of being involved in this planning. A total of 77.4% estimated H5N1 to be a possible threat to national health. Seventy percent of respon-dents reacted positively towards the idea of being involved in implementing primary care, and only 9.5% were absolutely opposed to the idea. A total of 82.3% would care for pandemic patients if necessary, but only 41.2% would do so if these patients were children. Only 18.9% estimated themselves to be suf-ficiently educated regarding H5N1. Ninety-one percent were convinced that care for H5N1-influenza patients should be incorporated into their regular curriculum. Several antiviral products were reported by the students to be effi-cient for treating H5N1, but only 34.6% correctly chose oseltamavir and/or zanamavir and 35.4% replied “I don't know”. A total of 95.5% correctly answered that the regular influenza vaccination doesn't protect against H5N1. The risk for human-to-human transmission was rated to be small by 50.6% (none 21%, high 27.6%). The human infection risk was rated to be small by 74.1% (none 1.6%, high 23%).
There is a high level of willingness to participate among senior medical students. However, in the case of pediatric patients they're more reserved. It would be useful to incorporate a focused session on preparedness in the regular teaching program. A legal base for their actions should also be provided. Ethical guidelines on rights and duties in case of a pandemic should be prepared by an international, multidisciplinary group of experts.
An environment in which traffic regulations are not strictly enforced often is characterized by carnage from motor vehicular crashes resulting in severe injuries with unacceptably high mortality. The descriptive demographics and injury characteristics of pedestrian road crash victims presenting to a tertiary medical center in southwestern Nigeria are presented in order to provide baseline epidemiology as a first step in determining areas of potential mitigation for care of unintentional injuries.
Methods:
Consecutive pedestrian road traffic crash patients treated in the Accident and Emergency Department of a tertiary hospital were prospective-ly reviewed from March 2007 to February 2008 to determine baseline demo-graphics and clinical outcomes.
Results:
A total of 184 patients with a mean value of the ages of 31.4 years were studied; 27% of the patients were <11 years of age. The male to female ratio was 1.6:1. Fifty-four percent of the victims were struck by automobiles and 29% were struck by motorcycles. Sixty-five percent were struck while crossing common thoroughfares. Head injury was sustained in 61% of patients. The mortality rate was 31.0% (n = 57). The clinical course leading to death showed 22.8% of the patients who died initially experienced hemorrhagic shock, 17.5% suffered a severe head injury, and 17.5% suffered aspiration. Autopsy confirmed brainstem herniation in 28.1% of the patients who died. The average interval between injury and death was 5.5 ±13.6 days (range: 0–77 days). In this setting, three out of every ten patients experienc-ing pedestrian vehicular trauma will die before leaving the hospital.The elder-ly are most at risk, with two-thirds of victims dying from injuries sustained.
Conclusions:
This raises serious questions about the prehospitaland hospi-tal-based emergency services for vehicular road crash victims in this environ-ment, and confirms the World Health Organization findings that Africa has the highest rate overall for unintentional injury deaths. A system-wide program must be put in place that addresses proven prevention measures across all sectors of the community.
On 26 December 2003, at 05:26 hours, an earthquake of magnitude 6.6 (Richter scale) caused a disaster in the Bam region of Southeastern Iran, which had a population of approximately 102,000. In this study, the clinical and laboratory features and therapeutic interventions in pediatric (three months to 14 years) crush victims were analyzed. Determination of the type and amount of fluid therapy for prevention of acute renal failure (ARF) was the main aim of this study.
Methods:
The clinical and laboratory data and therapeutic interventions provided to 31 pediatric crush victims were collected. Early and vigorous fluid resuscitation was immediately performed. Resuscitation of the children from hypovolemic shock was initiated by interavenous (IV) administration of normal saline until the signs and symptoms of shock disappeared. For victims with crush injuries, an alkaline intravenous solution, up to 3 to 5 times more than maintenance doses was provided. In this study, there were two groups with decreasing severity of injury: (1) crush injury (CI), with or without ARF; and (2) non-crush injury (Non-CI). According to the above mentioned classification, there were 15 and 16 patients in group I and II, respectively.
Results:
The mean time spent under the rubble was 2.2 ±2.5 hours and 0.5 ±0.5 hours in Groups I and II, respectively. Seventy-five percent of ARF patients (n = 8), were admitted to the hospital the day of the earthquake (Day 0) and the day after earthquake (Day 1). In non-ARF patients (n = 7), 85.7% of the victims were admitted on Day 0 and Day 1. In Group II (ARF and non-ARF), all patients were admitted within three days after the earthquake. Although ARF did not develop in any of the children without CI, it was observed in eight of 15 patients with CI. There was no significant difference between CI with ARF (n = 8) and CI without ARF (n = 7) patients, in terms of the admission date, time of admission, hospitalization duration, and time under the rubble (TUR). Admission SGOTs were significantly different between these two groups. The ratio of the amount of delivered IV fluid (DL) to expected (EX) was based on weight of children was the only fluid therapy parameter in which there was a statistically significant difference between ARF and non-ARF groups. It was 3.6 ±0.99 in ARF and 4.8 ±0.74 in Nnon-ARF group (p = 0.01).
Conclusions:
Early intravenous volume replacement may prevent both ARF and dialysis need that may develop on the basis of rhabdomyolysis. In adults, six liters or 12–14 liters of fluids for prophylaxis of ARF in crush syndrome, were suggest-ed. In children, it seems that DL/EX ratio (delivered to expected ratio) is the best marker for evolution of IV fluid therapy in pediatric patients. In children with crush injuries, DL/EX ratio of >4.8 was sufficient for the prevention of ARF.
On 08 October 2005, an earthquake measuring 7.6 on the Richter scale, struck Pakistan's autonomous state of Kashmir and part of Indian-administrated Kashmir. The official death toll in Pakistan was 79,000, and nearly 1,400 in Kashmir. This study reports the findings of a three-week health needs assessment to understand the needs of rural, older people post-earthquake. This study was conducted in February 2006 in the Neelum Valley of Kashmir, Pakistan, four months after the earthquake.
Hypothesis:
During emergency relief, the vulnerability and health needs of older people in rural settings are different than are those in of urban areas.
Methods:
A comparative, descriptive study was performed using health information to compare the differences between rural and urban health needs and the utilization of services of older people after the earthquake. Semi-structured interviews were conducted to collect information regarding demographic background, medical and drug history, self-reported health status, healthcare access and utilization, and social/financial concerns. Clinical records were reviewed and physical indicators for older patients also were collected on-site.
Results:
The health profile, access to health care, service availability, and prevalence of non-communicable diseases differ between urban and rural settings. The greatest gap in health services at all sites was that non-communicable disease management was inadequate during non-acute, post-earthquake medical care. Health service utilization varied by gender, as in conservative rural areas, older, traditional women were less likely to receive medical services while older men were less likely to access psychological services in all sites.
Conclusions:
This is the first study to compare the post-earthquake healthcare needs of older people in urban and rural settings. Findings highlight specific health needs and issues related to long-term, chronic disease management. Given the global pattern of aging of the population, it is important to strengthen the capacity to respond appropriately to medical disasters, which includes preparedness for treating the health needs of older people.
In a cold, wet, or windy environment, cold exposure can be considerable for an injured or ill person. The subsequent autonomous stress response initially will increase circulatory and respiratory demands, and as body core temperature declines, the patient's condition might deteriorate. Therefore, the application of adequate insulation to reduce cold exposure and prevent body core cooling is an important part of prehospital primary care, but recommendations for what should be used in the field mostly depend on tradition and experience, not on scientific evidence.
Objective:
The objective of this study was to evaluate the thermal insulation properties in different wind conditions of 12 different blankets and rescue bags commonly used by prehospital rescue and ambulance services.
Methods:
The thermal manikin and the selected insulation ensembles were setup inside a climatic chamber in accordance to the modified European Standard for assessing requirements of sleeping bags. Fans were adjusted to provide low (< 0.5 m/s), moderate (2–3 m/s) and high (8–9 m/s) wind condi-tions. During steady state thermal transfer, the total resultant insulation value, Itr (m2 °C/Wclo; where °C = degrees Celcius, and W = watts), was calculated from ambient air temperature (°C), manikin surface temperature (°C), and heat flux (W/m2).
Results:
In the low wind condition, thermal insulation of the evaluated ensembles correlated to thickness of the ensembles, ranging from 2.0 to 6.0 clo (1 clo = 0.155 m2 °C/W), except for the reflective metallic foil blankets that had higher values than expected. In moderate and high wind conditions, thermal insulation was best preserved for ensembles that were windproof and resistant to the compressive effect of the wind, with insulation reductions down to about 60–80% of the original insulation capacity, whereas wind permeable and/or lighter materials were reduced down to about 30–50% of original insulation capacity.
Conclusions:
The evaluated insulation ensembles might all be used for prehospital protection against cold, either as single blankets or in multiple layer combinations, depending on ambient temperatures. However, with extended outdoor, on-scene durations, such as during prolonged extrications or in mul-tiple casualty situations, the results of this study emphasize the importance of using a windproof and compression resistant outer ensemble to maintain adequate insulation capacity.
The concept of protecting civilians in armed conflict is enshrined in international humanitarian law and widely acknowledged in humanitarian norms. Making this concept operational in humanitarian service delivery is a challenge. Yet, there are many ways in which humanitarian workers could learn from local people about underlying tensions in their community and with these new insights adjust service delivery accordingly.
The 2009 WG developed a qualitative verbal tool that could be used by humanitarian field staff to assist them in understanding issues of civilian protection from the local perspective. The attributes and uses of this tool are described in detail in this WG report. The fundamental aim of this tool is to enhance the capacity of humanitarian workers in their daily work to observe markers of activity and behavior and to inquire and listen from local people about what these markers might or might not mean. The WG emphasized the needs for confidentiality, focus on service delivery (not legal or advocacy work), and iterative routine integration of information gained into field team deliberations. The proposed tool is offered as a possible pilot step towards improving humanitarian understanding and response to local civilian protection needs.
Healthcare professionals require a unique knowledge base to function effectively during a hospital's response to a mass-casualty incident (MCI). A survey of 128 physicians, nurses, and emergency medical technicians involved in trauma care was conducted to assess their knowledge base and how it affected their decision-making in response to a MCI following a terrorist bombing. Three-quarters of the study group responded that ≥20% of the surviving victims were critically injured. Only half of the responders indicated that the main objective of medical management is identifying and treating patients with critical injuries. Forty percent of responders indicated that they would not triage a critically injured victim to immediate care. This survey indicates that further education in the principles of MCI management should be based on critical evaluation of the literature.
Populations displaced by conflict face numerous threats to their psychological well-being; consequently, the prevalence of mental health problems, including anxiety, depression, and post-traumatic stress disorder can be elevated as compared to populations who have not experienced forced displacement.
Problem:
Little is known about the mental health needs of displaced Iraqis. The factors associated with a need for psychological services among patients at seven clinics served by two NGOs that are known sources of care for the displaced Iraqi population in Amman, Jordan were explored.
Methods:
The survey was conducted in January and February 2008 and included a random sample of care seekers from seven clinics selected using interval sampling. Interviews on the health needs of displaced Iraqis and their access to services, including mental health services lasting approximately 20 minutes were conducted.
Results:
Of the 664 survey participants, 49% (95% CI = 45–53%) of respondents reported needing mental health services and 5% (95% CI = 3–8%) of those in need had access to services. The length of time spent in Jordan (adjusted OR = 1.08; 95% CI = 1.00–1.11) was associated with the need for mental health services and the adjusted odds of requiring psychological services was 39% less for individuals from outside of Baghdad as compared to Baghdad residents (OR = 0.61; 95% CI = 0.38–0.98). Responders citing violence as a factor were twice as likely to be from Baghdad (OR = 2.28; 95% CI = 1.03–6.91), while interviewees reporting displacement as a cause for needing mental health services were twice as likely to be female (OR = 2.14; 95% CI = 1.12–4.18). In individuals 35–44 years of age (OR = 0.36; 95% CI = 0.14–0.87) the need for mental health services due to displacement decreased by 64%, while being a part of a female-headed household decreased the need by 81% (OR = 0.19; 95% CI = 0.06–0.57%).
Conclusions:
More attention should be given to expanding the local Jordanian health system capacity for the provision of mental service. Targeted social and psychiatric interventions that are culturally sensitive and aligned with Inter-Agency Standing Committee recommendations should be developed to compliment and expand the existing mental health service capacity in Jordan.
It is common for students and professionals considering a career in humanitarian health to have questions regarding the scope and nature of humanitarian work as well as the avenues by which one can enter the field. Because the profession is emerging and complex, answers to these questions may be difficult to find. This paper addresses several frequently asked questions of prospective humanitarian health professionals with information, experience and advice from current experts in the field. Special thanks to the distinguished contributors.
Evidence is defined as data on which a judgment or conclusion may be based. In the early 1990s, medical clinicians pioneered evidence-based decision-making. The discipline emerged as the use of current best evidence in making decisions about the care of individual patients. The practice of evidence-based medicine required the integration of individual clinical expertise with the best available, external clinical evidence from systematic research and the patient's unique values and circumstances. In this context, evidence acquired a hierarchy of strength based upon the method of data acquisition.
Subsequently, evidence-based decision-making expanded throughout the allied health field. In public health, and particularly for populations in crisis, three major data-gathering tools now dominate: (1) rapid health assessments; (2) population based surveys; and (3) disease surveillance. Unfortunately, the strength of evidence obtained by these tools is not easily measured by the grading scales of evidence-based medicine. This is complicated by the many purposes for which evidence can be applied in public health—strategic decision-making, program implementation, monitoring, and evaluation. Different applications have different requirements for strength of evidence as well as different time frames for decision-making. Given the challenges of integrating data from multiple sources that are collected by different methods, public health experts have defined best available evidence as the use of all available sources used to provide relevant inputs for decision-making.
The global impact of severe acute respiratory syndrome (SARS) brought attention to the role of healthcare professionals as “first receivers” during infectious disease outbreaks, a collateral aspect to their role as responders. This article records and reports concerns expressed by Canadian emergency and critical care nurses in terms of organizational and social supports required during infectious disease outbreaks. The nature of work-family and family-work conflict perceived and experienced by nurses during infectious disease outbreaks, as well as the supports needed to enable them to balance their social roles during this type of heightened stress, are explored.
Methods:
Five focus groups consisting of 100 nurses were conducted using a Structured Interview Matrix facilitation technique.
Results:
Four emergent themes included: (1) substantial personal/professional dilemmas; (2) assistance with child, elder, and/or pet care; (3) adequate resources and vaccinations to protect families; and (4) appropriate mechanisms to enable two-way communication between employees and their families under conditions of quarantine or long work hours.
Conclusions:
Social and organizational supports are critical to help buffer the effects of stress for nurses and assist them in managing difficult role conflicts during infectious disease outbreaks. These supports are necessary to improve response capacity for bio-disasters.