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Natural and complex disasters can cause a dramatic increase in the demand for emergency medical care. Local health services can be overwhelmed, and damage to clinics and hospitals can render them useless. Many countries maintain mobile field hospitals for defense or humanitarian purposes. Dispatching these facilities to disaster-affected countries would seem an ideal response to emergency medical needs. Unfortunately, experience has shown that in the case of natural disasters, field hospitals often have not met the expectations of recipients and donor institutions.
In July 2003, the World Health Organization and Pan American Health Organization sponsored a workshop in El Salvador to discuss the pros and cons of using foreign fieldhospitals in the aftermath of natural disasters. These guidelines are the result of that workshop. The workshop participants identified different phases when foreign field hospitals and specialized medical personnel are most useful. They can provide advanced trauma care and life support if at the disaster site within 48 hours of the impact of an event; they would provide follow-up care for trauma victims and resumption of routine medical care in the two weeks following the event; during rehabilitation and reconstruction phases (from two months to two or more years), a field hospital might serve as a temporary replacement for damaged health facilities. These guidelines propose conditions that field hospitals and their staff should meet for each ofthese phases. The guidelines also outline issues that authorities in donor countriesand disaster-affected countries should discuss before mobilizing a field hospital.
There is a spectrum of several threat agents, ranging from nerve agents and mustard agents to natural substances, such as biotoxins and new, synthetic, bioactive molecules produced by the chemical industry, to the classical biological warfare agents. The new, emerging threat agents are biotoxins produced by animals, plants, fungi, and bacteria. Examples of such biotoxins are botulinum toxin, tetanus toxin, and ricin. Several bioactive molecules produced by the pharmaceutical industry can be even more toxic than are the classical chemical warfare agents. Such new agents, like the biotoxins and bioregulators, often are called mid-spectrum agents. The threat to humans from agents developed by modern chemical synthesis and by genetic engineering also must be considered, since such agents may be more toxic or more effective in causing death or incapacitation than classical warfare agents. By developing effective medical protection and treatment against the most likely chemical and mid-spectrum threat agents, the effects of such agents in a war scenario or following a terrorist attack can be reduced.
Stress debriefing following exposure to a critical incident isbecoming more prevalent. Its aim is to prevent or minimize the development of excessive stress response symptoms that lead to loss of productivity or effectiveness in the workplace or at home. There is little evidence that any form of psychological debriefing is effective. This study evaluated the effectiveness of three intervention strategies, and attempted to correlate the symptoms with the severity of the incidentand level of intervention.
Methods:
A randomized, controlled trial of three levels of critical stress intervention was conducted in the British Columbia Ambulance Service (BCAS), in British Columbia, Canada, among paramedics and emergency medical technicians (EMTs), reporting critical incident stress. Outcomes were measured at one week (Stanford Acute Stress Reaction Questionnaire (SASRQ), the Life Impact Score (LIS), and Schedule of Recent Events (SRE)), and at three months and six months following the intervention (Impact of Events (IE), Coping Mechanisms, LIS, and SRE).
Results:
Fifty calls were received during the 26-month study period (<1 per 10,000 BCAS response calls): 23 were by third parties, but the involved EMT did not call;nine were placed by crew unwilling to participate in the study; 18 subjects enrolled, but six completed no forms. No correlation was found between severity of the incident and scores on the SASRQ, IE, or LIS, or between any of these scores. There was no consistent pattern in the stress scores over time.
Conclusion:
Requests for critical incident stress intervention were uncommon. The need for intervention may not be as great as generally is assumed. Further randomized trials, ideally multicenter studies, are indicated.
In April 1999, during the crisis in Kosovo, the Israeli government launched a medical, field hospital in order to provide humanitarian aid to the Albanian refugees that fled from their homes in Kosovo. This facility was set up by the Medical Corps of the Israeli Defense Forces, in a refugee camp located in Northern Macedonia. During the 16 days during which the hospital functioned, the medical staff treated 1,560 patients and hospitalized >100. The field hospital served as a referral center for all of the other primary clinics that were hastily erected in the camp and its surroundings. This communication elaborates on the various aspects of the humanitarian medical aid that were provided by this medical facility and the conclusions that learned from such a mission.
The events of 11 September 2001 have had a profound effect on disaster planning efforts in the United States. This is true especially in the area of bioter-rorism. One of the major tenets of bioterrorism response is the vaccination of at-riskpopulations. This paper investigates the efficacy of training emergency medical services paramedics to administer vaccines in public health settings as preparation for and response to bioterrorism events and other disaster events.
The concept of vaccination administration by specially trained paramedics is not new. Various programs to provide immunizations for emergency services personnel and at-risk civilian populations have been reported.
Vaccination programs by paramedics should follow the guidelines of the National Vaccine Advisory Committee of the Centers for Disease Control and Prevention (CDC). Thispaper compares the seven standards of the CDC guidelines to routine paramedic practice and education. It is concluded that paramedics are adequately trained to administer vaccines. However, specific training and protocols are needed in the areas of administrative paperwork and patient education. A proposed outline for a paramedic-training program is presented.
Inter-agency coordination in humanitarian assistance dates as a discipline from the 1960s. The United Nations, Red Cross, governmental, and nongovernmental agencies have evolved different mechanisms to achieve it. Present practices in field-based, inter-agency coordination of the health sector remain variable and non-standardized. International experiences in coordination of humanitarian assistance reveal numerous issues of jurisdiction, authority, capacity, and competency. New tools to help overcome these issues in the health-sector coordination include binding principles of engagement, protocols for the assumption of responsibilities, standardized minimum essential data sets, and health-sector component summaries.
Residents of a community who are intentionally exposed to a hazardous biological, chemical, or radiological agent (including medical first-responders and other civil defense personnel who live in that community) will exhibit a spectrum of psychological reactions that will impact the management of the incident. These reactions will range from a variety of behaviors of normal people under abnormal circumstances that either will help or hinder efforts to contain the threatening agent, deliver medical care, and reduce the morbidity, mortality, and costs associated with the disaster, to the development of new, or exacerbation of preexisting, mental disorders.
Anticipating the decisions that people will make and actions they will take as the crisis develops is hindered by the limited number of previous disasters that bear crucial similarities to a terrorist attack with a weapon of mass destruction. Such actions, therefore, could serve as models to predict community reactions. One result of a study that attempted to fill in these gaps suggested that medical first-responders and their spouses/significant others may require separately crafted information and advice to reduce the potential for disharmony within the family that could affect job performance during the crisis.
For those persons who exhibit emotional lability or cognitive deficits, evaluation of their psychiatric signs and symptoms may be more difficult than imagined, especially with exposure to nerve agents. Appreciation of these difficulties, and possession of the skill to sort through them, will be required of those assigned to triage stations. The allocation and utilization of mental health resources as the incident unfolds will be the responsibility of local consequence managers; these managers should be aware of the results of a recently-held workshop that attempted to reach consensus among experts in disaster mental health, based on the peer-reviewed literature, on the efficacy and safety of various approaches to early psychological interventions for victims of mass trauma and disasters.
Thus, psychological factors are likely to be significant in the management of a terrorist incident that involves an agent of mass destruction. Emergency medical workers with managerial responsibilities, whether limited in scope or community-wide, should be aware of these factors, and should train to handle them through effective risk communication as part of their planning and preparation.
The world is becoming ever more interconnected via the Internet, creating both benefits and disadvantages for human communities. This article examines cyber-terrorism, one of the major negative consequences of the Internet. It also examines the potential impact of cyber-terrorism on the health of populations, its possible perpetrators, and its prevention and control.
Measures of effectiveness (MOEs) are defined as operationally quantifiable management tools that provide a means for measuring effectiveness, outcome, and performance. No clear MOEs exist for determining success or failure of the management of a bioterrorism response. This is especially critical because management requires a multi-agency and multi-disciplinary decision-making and evaluation process. It is suggested that the minimum MOEs required to operationally measure outcome must contain a measuring response capacity for: (1) real-time public health surveillance system; (2) full coverage health information system; (3) capacity to measure variance across management timelines; (4) demonstrated decline in mortality and morbidity; (5) control of transmission rates of communicable agents; and (6) resource distribution across the entire population.
Throughout the globe, healthcare providers are increasingly challenged with the specter of terrorism and the fallout from weapons of mass destruction. Preparing for and responding to such manmade emergencies, however, threatens the ethical underpinnings of routine, individualized, patient-centered, emergency healthcare. The exigency of a critical incident can instantly transform resource rich environs, to those of austerity. Healthcare workers, who only moments earlier may have been seeing two to three patients per hour, are instantly thrust into a sea of casualties and more basic lifeboat issues of quarantine, system overload and the thornier determinations of who will be given every chance to live and who will be allowed to die. Beyond the tribulations of triage, surge capacity, and the allocation of scarce resources, terrorism creates a parallel need for a host of virtues not commonly required in daily medical practice, including prudence, courage, justice, stewardship, vigilance, resilience, and charity. As a polyvalent counterpoint to the vices of apathy, cowardice, profligacy, recklessness, inflexibility, and narcissism, the virtues empower providers at all levels to vertically integrate principles of safety, public health, utility, and medical ethics at the micro, meso, and macro levels. Over time, virtuous behavior can be modeled, mentored, practiced, and institutionalized to become one of our more useful vaccines against the threat of terrorism in the new millennium.
The use of chemical warfare agents against civilians and unprotected troops in international conflicts or by terrorists against civilians is considered to be a real threat, particularly following the terrorist attacks on 11 September 2001 against the World Trade Center in New York and against the Pentagon in Washington, DC. Over the past 10 years, terrorists have been planning to use or have used chemical warfare agents on several occasions around the world, and the attacks in 2001 illustrate their willingness to use any means of warfare to cause death and destruction among civilians. In spite of new international treaties with strong verification measures and with an aim to prohibit and prevent the use of weapons of mass destruction, nevertheless, some countries and terrorist groups have been able to develop, produce, and use such weapons, particularly nerve agents, in domestic terrorist attacks or during warfare in international conflicts. This article reviews current medical therapy for nerve-agent intoxication and discusses possible future improvement of medical therapies.
Present medical counter-measures against nerve agents are not sufficiently effective particularly in protecting the brain. Therefore, new and more effective countermeasures must be developed to enable better medical treatment of civilians and military personnel following exposure to nerve agents. Therefore, it is important with an enhanced effort by all countries, to improve and increase research in medical countermeasures, in the development of protective equipment, and in carrying out regular training of medical and emergency personnel as well as of military nuclear, biological, or chemical (NBC) units. Only then will nations be able to reduce the risk from and prevent the use of such weapons of mass destruction (WMD).