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This paper highlights the use of information technology (IT) in disaster management and public health management of disasters. Effective health response to disasters will depend on three important lines of action: (1) disaster preparedness; (2) emergency relief; and (3) management of disasters. This is facilitated by the presence of modern communication and space technology, especially the Internet and remote sensing satellites. This has made the use of databases, knowledge bases, geographic information systems (GIS), management information systems (MIS), information transfer, and online connectivity possible in the area of disaster management and medicine.
This paper suggests a conceptual model called, “The Model for Public Health Management of Disasters for South Asia”. This Model visualizes the use of IT in the public health management of disasters by setting up the Health and Disaster Information Network and Internet Community Centers, which will facilitate cooperation among all those in the areas of disaster management and emergency medicine. The suggested infrastructure would benefit the governments, non-government organizations, and institutions working in the areas of disaster and emergency medicine, professionals, the community, and all others associated with disaster management and emergency medicine. The creation of such an infrastructure will enable the rapid transfer of information, data, knowledge, and online connectivity from top officials to the grassroots organizations, and also among these countries regionally. This Model may be debated, modified, and tested further in the field to suit the national and local conditions. It is hoped that this exercise will result in a viable and practical model for use in public health management of disasters by South Asian countries.
The true threat of bioterrorism remains mysterious and elusive to the common citizen. It principally has become the dominion of a few “experts”, many of whom have limited apparent expertise, who have failed to effectively communicate the risks and realities to society, and have instead created an air of uncertainty surrounding the topic. Unlike the great classic deceptions of modern life (e.g., “the check is in the mail”), the misinformation and misperceptions associated with bioterrorism can be dangerous and are not merely humorous. Indeed, it is possible to grasp the facts as well as fallacies associated with bioterrorism, and, as a result, demystify this nightmare scenario and prepare for the “unthinkable”.
British police officers authorized to carry firearms may need to make judgments about the severity of injury of individuals or the relative priority of clinical need of a group of injured patients in tactical and non-tactical situations. Most of these officers receive little or no medical training beyond basic first aid to enable them to make these clinical decisions. Therefore, the aim of this study is to determine the accuracy of triage decision-making of firearms-trained police officers with and without printed decision-support materials.
Methods:
Eighty-two police firearms officers attending a tactical medicine course (FASTAid) were recruited to the study. Data were collected using a paper-based triage exercise that contained brief, clinical details of 20 adults and 10 children. Subjects were asked to assign a clinical priority of immediate or priority 1 (P1); urgent or priority 2 (P2); delayed or priority 3 (P3); or dead, to each casualty. Then, they were provided with decision-making materials, but were not given any instruction as to how these materials should be used. Subjects then completed a second triage exercise, identical to the first, except this time using the decision-support materials.
Data were analyzed using mixed between-within subjects analysis of variance. This allowed comparisons to be made between the scores for Exercise 1 (no decision-support material) and Exercise 2 (with decision-support material). It also allowed any differences between those students with previous triage training and those without previous training to be explored.
Results:
The use of triage decision-making materials resulted in a significant increase in correct responses (p <0.001). Improvement in accuracy appears to result mainly from a reduction in the extent of under-triage. There were significant differences (p <0.05) between those who had received previous triage training and those who had not, with those having received triage training doing slightly better.
Conclusion:
It appears that significant improvements in the accuracy of triage decision-making by police firearms officers can be achieved with the use of appropriate triage decision-support materials. Training may offer additional improvements in accuracy, but this improvement is likely to be small when decision-support materials are provided. With basic clinical skills and appropriate decision-support materials, it is likely that the police officer can make accurate triage decisions in a multiple-casualty scenario or make judgments of the severity of injury of a given individual in both tactical and non-tactical situations.
The identification of factors influencing emotional adjustment after injury may elucidate the design of assessment and treatment procedures in emergency medicine settings and suggest targets for early intervention to prevent the later development of psychological impairment. Personal, social, and material resources may be influential factors and require further evaluation.
Hypotheses:
Greater experiential avoidance, social constraints on discussing the trauma experience, and loss of material resources would be associated with more of the symptoms of posttraumatic stress and depression following traumatic injury.
Methods:
Participants (n = 47) at a mean of 7.4 months post-injury, completed a telephone interview assessment, including evaluation of sociodemographic characteristics, conservation of resources, social constraints, acceptance and commitment, and symptoms of post-traumatic stress disorder (PTSD) and depression. Hypotheses were tested using multivariate regression analyses.
Results:
Only greater social constraints were uniquely predictive of greater PTSD symptomatology. Higher levels of experiential avoidance, social constraints, and loss of material resources all were associated with greater levels of depression.
Conclusion:
Assessment of personal coping style, receptivity of social network, and loss of potential material resources following traumatic injury may facilitate identification of individuals at-risk for poorer post-injury adaptation. Psychosocial interventions targeting such individuals may be promising.
No universally accepted methods for objective evaluation of the function of the Incident Command System (ICS) in disaster exercises currently exist. An ICS evaluation method for disaster simulations was derived and piloted.
Methods:
A comprehensive variable list for ICS function was created and four distinct ICS evaluation methods (quantitative and qualitative) were derived and piloted prospectively during an exercise. Delay times for key provider-victim interactions were recorded through a system of data collection using participant and observer-based instruments. Two different post exercise surveys (commanders, other participants) were used to assess knowledge and perceptions of assigned roles, organization, and communications. Direct observation by trained observers and a structured debriefing session also were employed.
Results:
A total of 45 volunteers participated in the exercise that included 20 mock victims. First, mean, and last victim delay times (from exercise initiation) were 2.1, 4.0, and 9.3 minutes (min) until triage, and 5.2, 11.9, and 22.0 min for scene evacuation, respectively. First, mean, and last victim delay times to definitive treatment were 6.0, 14.5, and 25.0 min. Mean time to triage (and range) for scene Zones I (nearest entrance), II (intermediate) and III (ground zero) were 2.9 (2.0–4.0), 4.1 (3.0–5.0) and 5.2 (3.0–9.0) min, respectively. The lowest acuity level (Green) victims had the shortest mean times for triage (3.5 min), evacuation (4.0 min), and treatment (10.0 min) while the highest acuity level (Red) victims had the longest mean times for all measures; patterns consistent with independent rather than ICS-directed rescuer activities. Specific ICS problem areas were identified.
Conclusions:
A structured, objective, quantitative evaluation of ICS function can identify deficiencies that can become the focus for subsequent improvement efforts.
This lesson describes how a government decides whether and how much it should spend on vulnerability reduction. There are techniques and methods by which decision-makers compare development alternatives. The differences between the risk that a potentially catastrophic event will occur and uncertainty are described, with uncertainty providing greater difficulty in economic analyses. There is a range of methods for identifying the complex mix of competing costs and benefits associated with any restructuring of investment priorities to accomplish disaster mitigation. The possibilities are described in terms of the opportunity costs and present value. Impact and consequent losses include: (1) direct monetary effects; (2) indirect monetary effects; (3) direct, non-monetary effects; (4) indirect, non-monetary effects; and (5) loss of non-renewable natural resources. The difficulties in assigning values to these effects are described, as well as the means of judging the costeffectiveness of such interventions. An advantage of screening projects using a framework of analytical methods is that it can assist in focusing on a variety of possible outcomes and make the factors influencing these outcomes quite explicit.
Alexandra Hospital (AH) was one of the public hospitals in Singapore that responded to the severe acute respiratory syndrome (SARS) crisis. Being the only public hospital that remained “SARS-free”, i.e., with no documented intra-institutional spread of disease, AH had to tackle a sudden, two-fold surge in hospital attendances and patient volume. Being the oldest hospital with a traditional open ward design and lack of proper isolation facilities, tough command and control policies had to be implemented to reduce the risk of a SARS outbreak. Stringent infection control measures, screening and triage, clinical procedures, and administrative policies all were important factors in helping the hospital balance the need to run routine operations while “fighting” SARS. Staff and people management also were crucial in keeping the workforce healthy and maintaining their morale and confidence during this difficult period.
This lesson is a continuation of Disasters and Development: Part 2: Understanding and Exploiting Disaster-Development Linkages published in Prehospital and Disaster Medicine in Volume 17, Number 3. It identifies the goals of a specific damage mitigation project that can be incorporated into a regular development project and the mechanisms for obtaining the mitigation component of such a project. Mechanisms for assessing the success of such a project are discussed. It stresses the importance of the application of building codes, associated training programs, and more extensive use of zoning regulations in urban development that decrease the population at risk and the likelihood of damage to industrial facilities. Disasters can elevate the development potential of a society at risk for damage from a hazard. The political impact of damage and disruption can be a catalyst for change. Development opportunities often are compromised because of an excessive focus on relief assistance. Interventions designed to mitigate the damage from a given hazard are particularly effective when they focus on areas at particularly high risk for actualization of the hazard. Support from the private sector, including the non-formal sector, is a key element of successful reconstruction management. The period of recovery is an opportunity for general assistance to government with administrative procedures, including enhanced management training programs.
Recently, there has been speculation that suicide
rates increase after a disaster. Yet, in spite of
anecdotal reports, it is difficult to demonstrate
a systematic relationship between suicide and
disaster. Suicides are fairly rare events, and
single disasters rarely have covered geographic
areas with large enough populations to be able to
find statistically significant differences in such
relatively rare events (annual suicide rates in
the United States average 12/100,000
population).
Hypothesis:
Suicide rates increased in the three calendar
years (1994–1996) following the Northridge
earthquake as compared to the three calendar years
(1991–1993) prior to the earthquake. Likewise the
suicide rates for 1993 are compared with the rates
in 1994. By looking at the suicide rates in a
three-year period after the earthquake, the
additional disasters that befell Southern
California in 1995 and 1996 may have had an
additive effect on psychological disorders and
suicide rates that can be measured.
Methods:
Data on suicide mortality were compiled for the
years from 1989 through 1996. Differences in rates
for 1993 compared with 1994 and for three-year
periods before and after the earthquake (1991–1993
vs. 1994 –1996) were analyzed using a
z-statistic.
Results:
There is a statistically significant difference
in the rates for the years prior to the earthquake
(1991–1993) when pooled and compared to the
suicide rates for the years after the earthquake
(1994–1996). The rates of suicide are lower in the
three years following the earthquake (11.85 vs.
13.12/100,000 population) than they are in the
three years prior to the earthquake
(z = -3.85, p
<0.05). Likewise, there is a similar difference
when comparing 1993 to 1994 (11.77 vs. 13.84,
z = -3.57, p
<0.05). The patterns of suicide remain similar
over time, with males and non-Hispanic Whites
having the highest rates of suicide.
Conclusion:
It does not appear that suicide rates increase as
a result of earthquakes in this setting. This
study demonstrates that the psychological impacts
of the Northridge earthquake did not culminate in
an increase in the rates of suicide.
Resumen Introducción: Recientemente, la preparación y
entrenamiento para la atención de incidentes con
víctimas múltiples ha recibido mayor atención en el
nivel hospitalario.
Objetivos:
Revisar la evidencia existente sobre la
efectividad de los simulacros de desastres,
intervenciones basadas en la tecnología y
ejercicios de gabinete para el entrenamiento del
personal hospitalario en la respuesta a incidentes
con víctimas múltiples.
Early defibrillation improves survival for patients
suffering cardiac arrest from ventricular
fibrillation (VF) or ventricular tachycardia (VT).
Automated external defibrillators (AEDs) should be
placed in locations in which there is a high
incidence of out-of-hospital cardiac arrest (OOHCA).
The study objective was to identify high-risk, rural
locations that might benefit from AED placement. A
retrospective review of OOHCA in a rural community
during the past 5.5 years was conducted. The OOHCAs
that occurred in non-residential areas were
categorized based on location. Nine hundred, forty
OOHCAs occurred during the study period of which 265
(28.2%) happened in non-residential areas. Of these,
127 (47.9%) occurred in healthcare-related
locations, including 104 (39.2%) in extended care
facilities. No location used in this study had more
than two OOHCAs. Most (52.1%) non-residential OOHCAs
occurred as isolated events in 146 different
locations. Almost half of the OOHCAs that occurred
in non-residential areas took place in
healthcare-related facilities suggesting that
patients at these locations may benefit from AED
placement. First responders with AEDs are likely to
have the greatest impact in a rural community.
In Latin America, there is a preponderance of
prehospital trauma deaths. However, scarce
resources mandate that any improvements in
prehospital medical care must be cost-effective.
This study sought to evaluate the
costeffectiveness of several approaches to
improving training for personnel in three
ambulance services in Mexico.
Methods:
In Monterrey, training was augmented with
PreHospital Trauma Life Support (PHTLS) at a cost
of [US]$150 per medic trained. In San Pedro,
training was augmented with Basic Trauma Life
Support (BTLS), Advanced Cardiac Life Support
(ACLS), and a locally designed airway management
course, at a cost of $400 per medic. Process and
outcome of trauma care were assessed before and
after the training of these medics and at a
control site.
Results:
The training was effective for both intervention
services, with increases in basic airway maneuvers
for patients in respiratory distress in Monterrey
(16% before versus 39% after) and San Pedro (14%
versus 64%). The role of endotrachal intubation
for patients with respiratory distress increased
only in San Pedro (5% versus 46%), in which the
most intensive Advanced Life Support (ALS)
training had been provided. However, mortality
decreased only in Monterrey, where it had been the
highest (8.2% before versus 4.7% after) and where
the simplest and lowest cost interventions were
implemented. There was no change in process or
outcome in the control site.
Conclusions:
This study highlights the importance of assuring
uniform, basic training for all prehospital
providers. This is a more cost-effective approach
than is higher-cost ALS training for improving
prehospital trauma care in environments such as
Latin America.
The diagnosis of endotracheal tube (ETT)
mal-position may be delayed in extreme
environments. Several methods are utilized to
confirm proper ETT placement, but these methods
can be unreliable or unavailable in certain
settings. Thoracic sonography, previously utilized
to detect pneumothoraces, has not been tested to
assess ETT placement.
Hypothesis:
Thoracic sonography could correlate with
pulmonary ventilation, and thereby, help to
confirm proper ETT placement.
Methods:
Thirteen patients requiring elective intubation
under general anesthesia, and data from two trauma
patients were evaluated. Using a portable,
hand-held, ultrasound (PHHU) machine, sonographic
recordings of the chest wall visceral-parietal
pleural interface (VPPI) were recorded bilaterally
in each patient during all phases of airway
management: (1) preoxygenation; (2) induction; (3)
paralysis; (4) intubation; and (5) ventilation.
Results: The VPPI could be well-imaged for all of
the patients. In the two trauma patients, right
mainstem intubations were noted in which specific
pleural signals were not seen in the left chest
wall VPPI after tube placement. These signs
returned after correct repositioning of the ETT
tube. In all of the elective surgery patients,
signs correlating with bilateral ventilation in
each patient were imaged and correlated with
confirmation of ETT placement by
anesthesiology.
Conclusions:
This report raises the possibility that thoracic
sonography may be another tool that could be used
to confirm proper ETT placement. This technique
may have merit in extreme environments, such as in
remote, prehospital settings or during aerospace
medical transports, in which auscultation is
impossible due to noise, or capnography is not
available, and thus, requires further scientific
evaluation.
Waisman et al1have once
more highlighted the very real challenge of triaging
children in mass-casualty events (MCE) in the
pre-hospital setting. Difficulties encountered
measuring vital signs and different patterns of
injury, reflecting significant anatomical and
physiological differences, necessitates a modified
approach when applying traditional “adult” triage
methods to paediatric trauma victims. When using
physiological parameters to triage children, their
faster respiratory rates and heart rates frequently
result in younger children being triaged to a higher
category than their injuries demand. These
differences become less apparent during adolescence,
as the young person matures into adulthood.
Hospital disaster manuals and response plans
often lack formal command structure; instead, they
rely on the presence of key individuals who are
familiar with hospital operations, or who are in
leadership positions during routine, day-to-day
operations. Although this structure occasionally
may prove to be successful, it is unreliable, as
this leadership may be unavailable at the time of
the crisis, and may not be sustainable during a
prolonged event. The Hospital Emergency Incident
Command System (HEICS) provides a command
structure that does not rely on specific
individuals, is flexible and expandable, and is
ubiquitous in the fire service, emergency medical
services, military, and police agencies, thus
allowing for ease of communication during event
management.
Methods:
A descriptive report of the implementation of the
HEICS throughout a large healthcare network is
reviewed. Results and Conclusions: Implementation
of the HEICS provides a consistent command
structure for hospitals that enables consistency
and commonality with other hospitals and disaster
response entities.
Emergency medical services (EMS) responses to
mass gatherings have been described frequently,
but there are few reports describing the response
to a single-day gathering of large magnitude.
Objective:
This report describes the EMS response to the
largest single-day, ticketed concert held in North
America: the 2003 “Toronto Rocks!” Rolling Stones
Concert.
Methods:
Medical care was provided by paramedics,
physicians, and nurses. Care sites included
ambulances, medically equipped, all-terrain
vehicles, bicycle paramedic units, first-aid
tents, and a 124-bed medical facility that
included a field hospital and a rehydration unit.
Records from the first-aid tents, ambulances,
paramedic teams, and rehydration unit were
obtained. Data abstracted included patient
demographics, chief complaint, time of incident,
treatment, and disposition.
Results:
More than 450,000 people attended the concert and
1,870 sought medical care (42/10,000 attendees).
No record was kept for the 665 attendees simply
requesting water, sunscreen, or bandages. Of the
remaining 1,205 patients, the average of the ages
was 28 ±11 years, and 61% were female.
Seven-hundred, ninety-five patients (66%) were
cared for at one of the first-aid tents.
Physicians at the tents assisted in patient
management and disposition when crowds restricted
ambulance movement. Common complaints included
headache (321 patients; 27%), heat-related
complaints (148; 12%), nausea or vomiting (91;
7.6%), musculoskeletal complaints (83; 6.9%), and
breathing problems (79; 6.6%). Peak activity
occurred between 14:00 and 19:00 hours, when 102
patients per hour sought medical attention.
Twenty-four patients (0.5/10,000) were transferred
to off-site hospitals.
Conclusions:
This report on the EMS response, outcomes, and
role of the physicians at a large single-day mass
gathering may assist EMS planners at future
events.
Aspirin is commonly administered for acute
coronary syndromes in the prehospital setting. Few
studies have addressed the incidence of adverse
effects associated with prehospital administration
of aspirin. Objective: To determine the incidence
of adverse events following the administration of
aspirin by prehospital personnel.
Methods:
Multi-center, retrospective, case series that
involved all patients who received aspirin in the
prehospital setting from (01 August 1999–31
January 2000). Patient encounter forms of the
emergency medical services (EMS) of a metropolitan
fire department were reviewed. All patients who
had a potential cardiac syndrome (i.e., chest
pain, dyspnea) as documented on the EMS forms were
included in the review. Exclusion criteria
included failure to meet inclusion criteria, and
chest pain secondary to apparent noncardiac causes
(i.e., trauma). Hospital charts were reviewed from
a subset of patients at the participating
hospitals. The major outcome was an adverse event
following prehospital administration of aspirin.
This outcome was evaluated during the EMS
encounter, at emergency department discharge, or
at six and 24-hours post-aspirin ingestion. An
adverse event secondary to aspirin ingestion was
defined as anaphylaxis or allergic reactions, such
as rash or respiratory changes.
Results:
A total of 25,600 EMS encounter forms were
reviewed, yielding 2,399 patients with a potential
cardiac syndrome. Prior to EMS arrival, 585
patients had received aspirin, and 893 were
administered aspirin by EMS personnel. No patients
had an adverse event during the EMS encounter. Of
these patients, 229 were transported to
participating hospitals and 219 medical records
were available for review with no adverse
reactions recorded during their hospital
course.
Conclusion:
Aspirin is rarely associated with adverse events
when administered by prehospital personnel for
presumed coronary syndromes.