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Change must begin with education. Theme 8 explored issues that need attention in Disaster Medicine education.
Methods:
Details of the methods used are provided in the introductory paper. The chairs moderated all presentations and produced a summary that was presented to an assembly of all of the delegates. The chairs then presided over a workshop that resulted in the generation of a set of action plans that then were reported to the collective group of all delegates.
Results:
Main points developed during the presentations and discussion included: (1) formal education, (2) standardized definitions, (3) integration (4) evaluation of programs and interventions, (5) international cooperation, (6) identifying the psychosocial consequences of disaster, (7) meaningful research, and (8) hazard, impact, risk and vulnerability analysis.
Discussion:
Three main components of the action plans were identified as evaluation, research, and education. The action plans recommended that: (1) education on disasters should be formalized, (2) evaluation of education and interventions must be improved, and (3) meaningful research should be promulgated and published for use at multiple levels and that applied research techniques be the subject of future conferences.
Conclusions:
The one unanimous conclusion was that we need more and better education on the disaster phenomenon, both in its impacts and in our response to them. Such education must be increasingly evidence-based.
To study the volume effect of isotonic and hypertonic crystalloid fluid during ambulance transports after mild trauma, a prospective case-control study was initiated, using the ambulance and helicopter transport system in Stockholm.
Methods:
The hemodilution resulting from intravenous infusion of 1.0 L of Ringer's acetate solution (n = 7) or 250 ml of 7.5% sodium chloride (n = 3) over 30 minutes (min) was measured every 10 min during 1 hour when fluid therapy was instituted at the scene of an accident, or on arrival at the hospital. The dilution was studied by volume kinetic analysis and compared to that of matched, healthy controls who received the same fluid in hospital.
Result:
The hemodilution at the end of the infusions averaged 7.7% in the trauma patients and 9.1% in the controls, but the dilution was better maintained after trauma. The kinetic analysis showed that the size of the body fluid space expanded by Ringer's solution was 4.6 L and 3.8 L for the trauma and the control patients, respectively, while hypertonic saline expanded a slightly larger space. For both fluids, trauma reduced the elimination rate constant by approximately 30%.
Conclusion:
Mild trauma prolonged the intravascular persistence of isotonic and hypertonic crystalloid fluid as compared to a control group.
Disaster medicine has come to the forefront and has become the focus of interest not only in the medical community, but also in the eyes of the public. The 5th APCDM was convened in Vancouver, Canada, 27–30 September 2000. It brought together over 300 delegates from 32 countries to share their experiences and thoughts regarding disaster events and how to effectively manage them.
The conference was devoted to the task of establishing priorities and creating an Agenda for Action. From the discussions, key actions required were defined:
Communications: (1) Identify existing regional telehealth groups and gather lessons to be learned from them; (2) Form a telehealth advisory group to work with regional groups to compile telehealth initiatives, identify international protocols in telehealth already in existence, and solicit feedback before setting international standards; and (3) Increase corporate partnerships in the fields of telehealth and telecommunications, and invite corporations to send delegates to future APCDM meetings. This should be an initiative of the APCDM, the World Association of Disaster and Emergency Medicine (WADEM), or the European Society of Emergency Medicine.
Education and research: (1) Formalize education in disaster medicine and management. The World Health Organization and WADEM should take a leadership role; (2) WADEM is requested to hold a conference with a focus on qualitative research; (3) WHO is requested to continue the provision of international research teams, but to advocate for the development of national disaster research infrastructure; (4) Make research findings and reports available on web sites of such organizations as WHO and PAHO; (5) Develop the translation of research for community utilization. The WHO and PAHO are organizations that are requested to consider this action; and (6) WADEM/APCDM are requested to focus future conferences on applied research.
Information and data: (1) Create an “Information and Data Clearinghouse on Disaster Management” to collect, collate, and disseminate information; (2) Collect data using standardized tools, such as CAR or Hazmat indices; (3) Analyze incentives and disincentives for disaster readiness and establish mechanisms for addressing the obstacles to preparedness; and (4) WADEM is requested to develop a web site providing a resource list of interdisciplinary institutions and response activities, organized by country, topic, and research interests. Links to other pertinent web sites should be provided.
Interdisciplinary development: (1) Focus on the interdisciplinary nature of disaster response through more conferences encompassing grassroots efforts and through WADEM publications; (2)Develop and apply a standardized template of Needs Assessment for use by multidisciplinary teams. Team Needs Assessment is essential to determine the following: (a) Local response and international assistance required; (b) Appropriate command system; and (c) Psychosocial impact and support necessary.
Psychosocial aspects: (1) Incorporate relief for caregivers into action plans. This should include prime family members who also are caregivers; and (2) Implement measures that give survivors control over the recovery process.
Response management. (1) Define relationships and roles between governments, military and security personnel, non-governmental organizations (NGOs), and civic groups. Use an international legal framework and liability to reinforce accountability of disaster responders; (2) Establish a more sophisticated use of the media during disasters; (3) Establish standards in key areas. WADEM is requested to write “White Papers” on standards for the following areas: (a) management, (b) health/public health, (c) education/training, (d) psychosocial, and (e) disaster plans; (4) Establish task forces to anticipate and resolve issues around evolving and emerging disasters (e.g., chemical and biological terrorism, landmines, emerging infectious diseases). WADEM was again identified as the vehicle for promoting this action.
The responsibility of the next meeting of the Asia-Pacific Conference on Disaster Medicine will be to measure progress made in these areas by assessing how well these collective decisions have been implemented.
Multidisciplinary team interaction has become a commonplace phrase in the discussion of disaster response. Theme 6 explored multidisciplinary team interactions and attempted to identify some of the key issues and possible solutions to the seemingly intractable problems inherent in this endeavour.
Methods:
Details of the methods used are provided in the introductory paper. The Cochairs moderated all presentations and produced a summary that was presented to an assembly of all of the delegates. The Cochairs then presided over a workshop that resulted in the generation of a set of Action Plans that then were reported to the collective group of all delegates.
Results:
Main points developed during the presentations and discussion included: (1) promotion of multidisciplinary collaboration, (2) standardization, (3) the Incident Command System, (4) professionalism, (5) regional disparities, and (6) psychosocial impact.
Discussion:
Action plans recommended: (1) a standardized template for Needs Assessment be developed, implemented, and applied using collaboration with international organizations, focusing on needs and criteria appropriate to each type of event, and (2) team needs assessments be recognized for local responses and for determination of when international assistance may be required, for planning a command system, and for evaluating the psychosocial impact.
Conclusions:
There is a clear need for the development of standardized methods for the assessment of needs, development and implementation of a command structure, and for appreciation of regional differences and the psychosocial impact of all interventions.
The need for the application of international standards has been evolving over the last decade. Consistency is needed not just in how we respond, but in when we respond. The discussions in this theme reflected on the progress of standard setting both at the local level and internationally.
Methods:
Details of the methods used are provided in the introductory paper. The chairs moderated all presentations and produced a summary that was presented to an assembly of all of the delegates. The chairs then presided over a workshop that resulted in the generation of a set of action plans that then were reported to the collective group of all delegates.
Results:
Main points developed during the presentations and discussion included: (1) requirement of standards of care for ALL disasters and core parameters, (2) process and procedure is best when there is interagency collaboration and coordination, (3) problems in disasters are management-related, not skill-related, and (4) standards of care must encompass evolving emergencies (e.g., emerging diseases, landmines).
Discussion:
The action plans for Theme 5 included: (1) develop positions of standards for management, health and public health, education and training, research, psychosocial aspects, and disaster plans; (2) advocate for actions and task forces to deal with evolving and emerging disasters, terrorism, landmines, and emerging infections; (3) proactively work to advocate and facilitate the multidisciplinary and multiorganizational requirements for disaster management; and (4) develop a resource list of interdisciplinary institutions and activities organized by country and topic including the design and maintenance of a website.
Conclusions:
There is a clear need for international standards for the management of disasters. Positions and advocacy for these positions are required to define and implement such standards.
Rapid innovations and improvements in communication technologies have opened many new channels for health education and delivery, as well as disaster management. Theme 2 examined the role and applicability of these technologies to Disaster Medicine and Management and the various issues involved in their use.
Methods:
Details of the methods used are provided in the introductory paper. The chairs moderated all presentations and produced a summary that was presented to an assembly of all of the delegates. The chairs then presided over a workshop that resulted in the generation of a set Action Plans that then were reported to the collective group of all delegates.
Results:
Main points developed during the presentations and discussion included harnessing convergence, seeking interoperability, building partnerships and making it appropriate. This group identified four Principles of Action underlying its plan: (1) investigate possibilities, (2) identify stake-holders, (3) invite participation, and (4) involve discussants in activities.
Discussion:
Action plans were categorized into three areas that included “thinking globally, acting regionally”, forming a telehealth advisory group, and increasing corporate partnerships.
Conclusions:
Technology is opening many opportunities that have applications in disaster management. To optimize benefits, goals and standards must be agreed upon and implemented.
The discussions in this theme provided an opportunity to address the unique hazards facing the Pacific Rim.
Methods:
Details of the methods used are provided in the preceding paper. The chairs moderated all presentations and produced a summary that was presented to an assembly of all of the delegates. Since the findings from the Theme 3 and Theme 7 groups were similar, the chairs of both groups presided over one workshop that resulted in the generation of a set of action plans that then were reported to the collective group of all delegates.
Results:
The main points developed during the presentations and discussion included: (1) communication, (2) coordination, (3) advance planning and risk assessment, and (4) resources and knowledge.
Discussion:
Action plans were summarized in the following ideas: (1) plan disaster responses including the different types, identification of hazards, focusing training based on experiences, and provision of public education; (2) improve coordination and control; (3) maintain communications, assuming infrastructure breakdown; (4) maximize mitigation through standardized evaluations, the creation of a legal framework, and recognition of advocacy and public participation; and (5) provide resources and knowledge through access to existing therapies, the media, and increasing and decentralizing hospital inventories.
Conclusions:
The problems in the Asia-Pacific rim are little different from those encountered elsewhere in the world. They should be addressed in common with the rest of the world.
A disaster manager must be able to evaluate staff members in order to make effective staffing decisions during the transitions between phases of a disaster and to help improve the performance of the operation by determining what aspects of an individual's work needs improvement. Criteria for personnel appraisal and measures of performance, objective or subjective, are essential to conduct a fair and thorough evaluation. Errors introduce bias into the appraisal in the form of a “halo” effect, harsh or lenient ratings, a central tendency error, or recency effect, but recognition of these errors helps reduce their effect. A results-based appraisal program is favored because it focuses on what the worker achieves. Regular appraisal periods are suggested for optimal improvement in performance. Suggestions are given for an effective personnel appraisal, such as focusing on positive work performance, being aware of biases in judging people, and being specific when citing examples of work performance.
Disaster is a collective responsibility requiring coordinated response from all parts of society. This theme focused on coordination and management issues in a diverse range of scenarios.
Methods:
Details of the methods used are provided in the preceding paper. The chairs moderated all presentations and produced a summary that was presented to an assembly of all of the delegates. Although the main points developed in Themes 1 and 4 were different from each other (as reported in the Results section), their implementation was similar. Therefore, the chairs of both groups presided over one workshop that resulted in the generation of a set of Action Plans that then were reported to the collective group of all delegates.
Results:
The main points developed during the presentations and discussions included: (1) the need for evidence-based assessments and planning, (2) the need for a shift in focus to health-sector readiness, (3) empowerment of survivors, (4) provision of relief for the caregivers, (5) address the incentives and disincentives to attain readiness, (6) engage in joint preparation, response, and training, (7) focus on prevention and mitigation of the damage from events, and (8) improve media relations. There exists a need for institutionalization of processes for learning from experiences obtained from disasters.
Discussion:
Action plans presented include: (1) creation of an Information and Data Clearinghouse on Disaster Management, (2) identification of incentives and disincentives for readiness and develop strategies and interventions, and (3) act on lessons learned from evidence-based research and practical experience.
Conclusions:
There is an urgent need to proactively establish coordination and management procedures in advance of any crisis. A number of important insights for improvement in coordination and management during disasters emerged.
A disaster is characterized by an imbalance between needs and supplies. In circumstances in which there occur mass casualties, it is not possible to provide care for all of the victims. Thus, it may be necessary to triage the casualties according to pre-established priorities. The performance of triage is associated with many ethical issues.
Currently, no Europe-wide agreement on triage and ethics exists. One system based on a categorization into four groups is proposed. Triage should be avoided whenever possible, but, when it is required, there is an obligation to respect human rights and the humanitarian laws, especially with reference to the Geneva Convention of 1864 and the Universal Declaration of Human Rights of 1948. The condition of informed consent must be followed, even in mass casualty situations. Triage always must follow established medical criteria and cannot be based on any other principles. Triage implies constant re-evaluation of victims as conditions of the victims and of available resources change continuously. In order to facilitate international coordination and cooperation, a universal classification system must be adopted.
This is a report of the impact of the ice storm that struck eastern Canada on 04–09 January 1998. The storm deposited ice some 100 mm thick on the ground and on the electric power lines and eventually left 1.4 million households and much of the infrastructure without electrical power.
Data were obtained through non-structured interviews of those involved. Most of the larger hospitals were equipped with emergency generating equipment and were able to provide most essential services. For most hospitals, non-emergency services were compromised. Many other medical facilities, including clinics had to be shut down, and smaller hospitals were forced to transfer some patients to larger institutions. In addition, hospitals experienced a marked increase in the number of emergency department visits including an increase in the number of persons with injuries, respiratory tract infections, or heart problems. A marked increase in carbon-monoxide intoxication was observed: 50 persons required the use of hyperbaric oxygen and six persons died of CO poisoning.
Prehospital services not only experienced a marked increase in the number of emergency responses, but also were utilized to provide transportation of non-ill or injured persons, equipment, and supplies. Home care was interrupted and many patients dependent upon power had to be transported to hospitals. Many hospitals opened their buildings to provide shelter to the families of many of their employees and medical staff. This helped to keep staffing at a better level than if they had to find shelter and essential services elsewhere.
The transmission and sharing of information was severely limited due in part to the loss of power and inability to access television. This led to the distribution of misleading or incorrect information.
This storm was exemplary of our dependence upon electrical power and that we are not prepared to cope with the loss of electricity.
The reported case of a stab wound to the chest occurred in an isolated area with no specialized surgical care available. The need for transport and specifically by air, introduced particular questions in management. On a humanitarian basis and in line with its mandate, the Peace Monitoring Group, a United Nations endorsed entity in Bougainville, Papua New Guinea, provided transport to a facility with an appropriate standard of care. The questions of need for patient evacuation and chest drainage, with the timing of this maneuver are considered.
The discussions in this theme provided an opportunity to share specific experiences with disasters that occurred outside of the Asia-Pacific Rim.
Methods:
Details of the methods used are provided in the preceding paper. The chairs moderated all presentations and produced a summary that was presented to an assembly of all of the delegates. Since the findings from the Theme 7 and Theme 3 groups were similar, the chairs of both groups presided over one workshop that resulted in the generation of a set of action plans that then were reported to the collective group of all delegates.
Results:
The main points developed during the presentations and discussion included: (1) disaster response planning, (2) predetermined command and organizational structure, (3) rapid response capability, (4) mitigation, and (5) communications and alternatives.
Discussion:
The action plans presented are in common with those presented by Theme 3, and include: (1) plan disaster responses including the different types, identification of hazards, training based on experiences, and provision of public education; (2) improving coordination and control; (3) maintaining communications assuming infrastructure breakdown; (4) maximizing mitigation through standardized evaluations, creation of a legal framework, and recognition of advocacy and public participation; and (5) providing resources and knowledge through access to existing therapies, using the media, and increasing decentralization of hospital inventories.
Conclusions:
Most of the problems that occurred outside the Asia-Pacific rim relative to disaster management are similar to those experienced within it. They should be addressed in common with the rest of the world.