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Chapter 6 describes how to deal with situations that require adaptations of the protocol described in Chapter 3. Some of these are: emergencies (e.g., psychotic breakdown, suicide attempt or trouble with the police), worrisome conditions that do not yet constitute full-fledged entrenched dependence, very old parents and the implementation of NVR in a psychiatric ward.
The world responded in many different ways to the coronavirus epidemic. Why is that? Three obvious solutions present themselves: different understandings of the nature of the disease and how to tackle it, the nature of the political system in each nation, the history of how pandemics had been dealt with in the past in each country. Upon inspection, none of these explanations seems to work. The scientific understanding of the disease and its means of spreading were broadly similar in all nations. Only at the margins did unorthodox theories hold sway. Most nations claimed to be following expert advice, but what the experts advised differed. Politicians could pick and choose among the counsels they received. Both democracies and autocracies tried each of the three possible approaches to the pandemic, targeted quarantine, broad lockdown, or a hands-off approach. And nations did not obviously follow the tactics they had used in previous epidemics. The heavy hand of past public health interventions, with the state compelling citizens to follow behavioral prescriptions, was harder to implement today.
To study the barriers and enablers of breast-feeding protection and support after the 2017 earthquakes in Mexico.
A qualitative study using a phenomenological approach to analyse data collected from in-depth interviews, virtual ethnography and documentary analysis of newspapers.
Data were collected after the September 2017 earthquakes in Mexico (from 8 September 2017 to 15 May 2018).
The participants included key informants (n 13) from different sectors. Postings retrieved from forty-two Facebook and forty-seven Twitter accounts and a WhatsApp group informed the virtual ethnography analysis. Newspaper material covering the 2017 earthquakes in Mexico (seven newspapers) was retrieved for the documentary analysis.
Interviews with key informants revealed a lack of knowledge, unclear institutional protocols during emergencies and lack of enforcement of existing international frameworks. The virtual ethnography uncovered a strong call for donations in the immediate aftermath of the earthquakes, and generalized donations of formula revealed a tense relationship between actions taken by breast-feeding experts and the negative reactions from the government and citizens. This analysis highlights the relevance of pre-existing networks of experts in protecting and supporting breast-feeding. From the newspaper documentary analysis, similar themes emerged.
This study identified key barriers and enablers in the protection and support of breast-feeding during the 2017 earthquakes in Mexico. Relevant actors should embrace the lessons highlighted in this study because countries such as Mexico are likely to experience other emergencies in the near future.
Physicians’ management of hazardous material (HAZMAT) incidents requires personal protective equipment (PPE) utilization to ensure the safety of victims, facilities, and providers; therefore, providing effective and accessible training in its use is crucial. While an emphasis has been placed on the importance of PPE, there is debate about the most effective training methods. Circumstances may not allow for a traditional in-person demonstration; an accessible video training may provide a useful alternative.
Video training of Emergency Medicine (EM) residents in the donning and doffing of Level C PPE is more effective than in-person training.
Video training of EM residents in the donning and doffing of Level C PPE is equally effective compared with in-person training.
A randomized, controlled pilot trial was performed with 20 EM residents as part of their annual Emergency Preparedness training. Residents were divided into four groups, with Group 1 and Group 2 viewing a demonstration video developed by the Emergency Preparedness Team (EPT) and Group 3 and Group 4 receiving the standard in-person demonstration training by an EPT member. The groups then separately performed a donning and doffing simulation while blinded evaluators assessed critical tasks utilizing a prepared evaluation tool. At the drill’s conclusion, all participants also completed a self-evaluation survey about their subjective interpretations of their respective trainings.
Both video and in-person training modalities showed significant overall improvement in participants’ confidence in doffing and donning PPE equipment (P <.05). However, no statistically significant difference was found in the number of failed critical tasks in donning or doffing between the training modalities (P >.05). Based on these results, the null hypothesis cannot be rejected. However, these results were limited by the small sample size and the study was not sufficiently powered to show a difference between training modalities.
In this pilot study, video and in-person training were equally effective in training for donning and doffing Level C PPE, with similar error rates in both modalities. Further research into this subject with an appropriately powered study is warranted to determine whether this equivalence persists using a larger sample size.
The use of triage systems is one of the most important measures in response to mass-casualty incidents (MCIs) caused by emergencies and disasters. In these systems, certain principles and criteria must be considered that can be achieved with a lack of resources. Accordingly, the present study was conducted as a systematic review to explore the principles of triage systems in emergencies and disasters world-wide.
The present study was conducted as a systematic review of the principles of triage in emergencies and disasters. All papers published from 2000 through 2019 were extracted from the Web of Science, PubMed, Scopus, Cochrane Library, and Google Scholar databases. The search for the articles was conducted by two trained researchers independently.
The classification and prioritization of the injured people, the speed, and the accuracy of the performance were considered as the main principles of triage. In certain circumstances, including chemical, biological, radiation, and nuclear (CBRN) incidents, certain principles must be considered in addition to the principles of the triage based on traumatic events. Usually in triage systems, the classification of the injured people is done using color labeling. The short duration of the triage and its accuracy are important for the survival of the injured individuals. The optimal use of available resources to protect the lives of more casualties is one of the important principles of triage systems and does not conflict with equity in health.
The design of the principles of triage in triage systems is based on scientific studies and theories in which attempts have been made to correctly classify the injured people with the maximum correctness and in the least amount of time to maintain the survival of the injured people and to achieve the most desirable level of health. It is suggested that all countries adopt a suitable and context-bond model of triage in accordance with all these principles, or to propose a new model for the triage of injured patients, particularly for hospitals in emergencies and disasters.
Within out-of-hospital emergencies, Primary Health Care (PHC) pediatricians will likely be the first to provide health care at the scene of a life-threatening emergency (LTE) in children. Pediatricians should be trained to initially intervene, safely and effectively the LTEs, including the activation of Emergency Medical Systems (EMS), an adequate stabilization of patients and transport to the hospital.
The aims of this study are to know the training received for out-of-hospital LTEs by PHC pediatricians of the Principality of Asturias (Spain) and the perception they have about their own theoretical knowledge and practical skills in a series of emergency procedures used in LTEs; also, to analyze the differences according to the geographical context of their work.
This was a cross-sectional, descriptive, and observational study of a sample of 27 PHC pediatricians from PHC Service of Asturias, Spain, from among the total of 88 pediatricians who make up the staff of pediatricians, conducted from April through May 2019. The survey was designed ad hoc using the Curriculum in Primary Care Pediatrics (CPCP) proposed by the European Confederation of Primary Care Pediatricians (ECPCP; Europe), which indicates the theoretical and practical procedures that must be acquired by the PHC pediatricians. It is composed of 30 procedures or techniques employed in LTEs using a 11-point Likert scale rating to detect their self-perception about theoretical knowledge and practical skills from zero (“Minimum”) to 10 (“Maximum”).
There are significant differences in the mean of theoretical knowledge and practical skills in many procedures or techniques studied, depending on the different areas of work.
Asturian pediatricians are generally well-prepared to solve LTEs with a few exceptions. The degree of self-perception and acquisition of general theoretical knowledge and general practical skills in LTEs is heterogeneous, with differences according to the scope of work.
In the aftermath of natural disasters and in the urgency of the deteriorating situation in a “complex emergency”, aid is often provided in a haphazard manner. Organizing appropriate medical help is complicated by differences in the type of disaster, the available infrastructure that remains in place, the status of the country’s wealth, and, occasionally, the outbreak of violence and epidemics. Nevertheless, a sequential order of priorities and changing needs for various types of medical intervention such as (emergency) surgery, rehabilitation, and obstetrics can be made, as for managing medicinal needs, mental health, and communicable diseases. This chapter describes how this medical landscape changes qualitatively and quantitatively and how resources can be adapted dynamically and reflected in the capacity of the emergency medical team (EMT). Recently, disaster-prone countries have seen an expansion in the capacity of national EMTs. For a variety of reasons these are to be preferred over international EMTs, but where the latter are needed it is important that their competencies and capabilities follow both local and general guidelines.
Within out-of-hospital emergencies, primary health care (PHC) nurses must face life-threatening emergencies (LTEs), which are defined as “a situation associated with an imminent life risk that entails the start-up of resources and special means to resolve the situation.”
The objectives of this study were to know the training received for out-of-hospital LTEs by PHC nurses of Asturias, Spain and the perception they have about their theoretical knowledge and practical skills in a series of emergency procedures or techniques used in LTE emergencies; as well as to analyze the differences according to the geographical area of their work.
Cross-sectional, descriptive, and observational study was conducted in 2018 of a sample of PHC service nurses of Asturias, Spain.
A total of 236 nurses from PHC service centers of Asturias, Spain, from among the total of 730 nurses who make up the staff of nurses of the PHC service of Asturias, between April and May 2018, were surveyed. The survey was designed ad hoc using the Doctrinal Body of Emergency Nursing (DBEN) proposed by the Spanish Society of Emergency Medicine (SEMES; Madrid, Spain), which indicates the theoretical and practical procedures that must be acquired by the PHC nurses. It is composed of 37 procedures or techniques employed in LTEs using an 11-point Likert scale rating to detect their self-perception about theoretical knowledge and practical skills from zero (“Minimum”) to ten (“Maximum”).
There were significant differences in the mean of theoretical knowledge and practical skills in many procedures or techniques studied, depending on the different areas of work.
All PHC nurses must be perfectly trained to provide initial quality assistance to the LTE, with both theoretical and practical knowledge of the different techniques, so that it can continue to be attended by the corresponding Emergency Service.
Simulation-based training has a fundamental role in medical education as it allows the learner to gain experience managing emergencies in a safe, controlled environment.
This 1-day course consisted of eight high-fidelity simulation scenarios, followed by a video-assisted debrief focusing on the technical and non-technical (communication skills, teamwork, leadership and situational awareness) aspects of managing ENT and head and neck emergencies.
Eight courses have run since June 2014. Post-course questionnaires demonstrated that candidates’ confidence scores in managing airway and head and neck emergencies increased following completion of the course (p < 0.0001).
This was the first fully immersive ENT simulation course developed in the region. The learning objectives for each scenario were mapped to the ENT Intercollegiate Surgical Curriculum Programme. Feedback from the course indicated a continued demand for this style of training, leading to its inclusion in the training calendar.
Recent natural and infrastructural disasters, such as Hurricanes Sandy (2012) and Katrina (2005) and the Northeastern power outage of 2003, have emphasized the need for hospital staff to be trained in disaster management and response. Even an internal hospital disaster may require the safe and efficient evacuation and transfer of patients with varying medical conditions and complications. A notably susceptible population is renal transplant patients, including those with post-transplant complications.
This descriptive study evaluated staff performance of a vertical evacuation drill of renal transplant patients at State University of New York (SUNY) Downstate Medical Center – University Hospital Brooklyn (UHB; Brooklyn, New York USA).
Thirteen standardized patients, 12 of whom received a renal transplant, with varying medical histories, ambulatory ability, and mental status were vertically evacuated by the transplant staff from the eighth floor to the ambulance entrance on the ground floor. Non-ambulatory patients were transported on portable evacuation sleds.
All patients were evacuated successfully within 3.5 hours. On a post-drill evaluation form, drill participants self-reported largely positive results concerning their own role in the drill and the evacuation drill itself. Drill evaluators observed very different results, including staff reticence, poor training retention, and lack of leadership.
Despite encouraging post-drill evaluation results from the participants, the evacuation drill highlighted several immediate deficiencies. It also demonstrated a significant discrepancy in performance perception between the drill participants and the drill evaluators.
SalwayRJ, AdlerZ, WilliamsT, NwokeF, RoblinP, ArquillaB. The Challenges of a Vertical Evacuation Drill. Prehosp Disaster Med. 2019;34(1):25–29.
A large number of civilian agencies have published guides and recommendations on how to assemble personal and family emergency kits. However, the kits resulting from following these guidelines are impractical, particularly in the event evacuation becomes necessary. This report describes an alternative approach to assembling an emergency kit.
OstrovskiyG, ShemeshAJ. Contents of a Bug-Out Bag. Prehosp Disaster Med. 2018;33(6):647–649.
The purpose of this study was to evaluate role conflict between professional
and familial responsibilities among obstetric health care providers during a
natural disaster between those required to stay in the hospital versus those
who were at home during a catastrophic weather event.
A survey was used of obstetric attending and resident physicians in the
Baylor College of Medicine, Department of Obstetrics and Gynecology
following Hurricane Harvey on August 26, 2017.
Ninety one of 103 physicians (88%) completed the survey. Survey
responses were compared between physicians who worked in the hospital (n
= 47) versus those who were at home (n = 44) during the storm
and its immediate aftermath. Physicians in the hospital and at home agreed
(47% and 48%, respectively, P = 0.94)
that professional duties conflicted with family obligations and felt torn
(49% and 55%, respectively, P = 0.48)
regarding family obligations. A majority of homebound health care providers
disagreed with the statement that professional duties override family
responsibilities, whereas less than half of in-hospital providers felt the
same (68% at-home versus 47% of the hospital-team,
P = 0.10).
As organizations prepare for possible catastrophic situations, institutions
must realize that obstetric health care providers will experience role
conflict between professional and family responsibilities. (Disaster
Med Public Health Preparedness. 2019;13:33–37)
The aim of this study was to assist organizations seeking to develop or improve their medical disaster relief effort by identifying fundamental elements and processes that permeate high-quality, international, medical disaster relief organizations and the teams they deploy.
A qualitative descriptive design was used. Data were gathered from interviews with key personnel at five international medical response organizations, as well as during field observations conducted at multiple sites in Jordan and Greece, including three refugee camps. Data were then reviewed by the research team and coded to identify patterns, categories, and themes.
The results from this qualitative, descriptive design identified three themes which were key characteristics of success found in effective, well-established, international medical disaster relief organizations. These characteristics were first, ensuring an official invitation had been extended and the need for assistance had been identified. Second, the response to that need was done in an effective and sustainable manner. Third, effective organizations strived to obtain high-quality volunteers.
By following the three key characteristics outlined in this research, organizations are more likely to improve the efficiency and quality of their work. In addition, they will be less likely to impede the overall recovery process.
BrobyN, LassetterJH, WilliamsM, WintersBA. Effective International Medical Disaster Relief: A Qualitative Descriptive Study. Prehosp Disaster Med. 2018;33(2):119–126.
Unmanned aircraft vehicles (UAVs) have had a rapid escalation in manageability and affordability, which can be exploited in healthcare. We conducted a systematic review examining the use of drones for health-related purposes.
A search was conducted in Medline, Embase, Global Health, Scopus, CINAHL and SciELO. Experimental studies were selected if the population included human subjects, the intervention was the use of UAVs and there was a health-related outcome.
Of 500 results, five met inclusion criteria during an initial search. An updated search yielded four additional studies. Nine studies, all in high-income countries, were included for systematic syntheses: four studies addressed out-of-hospital cardiac arrest emergencies, three assessed drones for identification of people after accidents, one used drones to transport blood samples and one used drones to improve surgical procedures in war zones.
Research on the use of drones in healthcare is limited to simulation scenarios, and this review did not retrieve any studies from low- and middle-income countries.
Head and neck space infections present with a potential mortality rate of 40–50 per cent. This paper proposes an algorithm-based management of head and neck space infection to prevent life-threatening events.
A total of 225 patients with head and neck space infection were prospectively analysed at our institution. An experimental scoring system determined the level of clinical risk for the development of major complications. Accordingly, patients were classified into three risk groups: low-, intermediate- and high-risk.
Only intermediate- and high-risk patients were hospitalised. Intermediate-risk patients received intravenous medical therapy with daily re-evaluation; 18 of them required delayed surgery. Of the high-risk patients, three required immediate surgical treatment and five received delayed surgery, while in five cases medical therapy was the only treatment received. Low-risk patients were treated in an out-patient setting.
The algorithm-based management of head and neck space infection was successful in enabling the avoidance of lethal complications onset.
The Nepal earthquake of 2015 was a major disaster that exacted an enormous toll on human lives and caused extensive damage to the infrastructure of the region. Similar to other developing countries, Nepal has a network of community health workers (CHWs; known as female community health volunteers [FCHVs]) that was in place prior to the earthquake and continues to function to improve maternal and child health. These FCHVs and other community members were responsible, by default, for providing the first wave of assistance after the earthquake.
Community health workers such as FCHVs could be used to provide formal relief services in the event of an emergency, but there is a paucity of evidence-based literature on how to best utilize them in disaster risk reduction, preparedness, and response. Data are needed to further characterize the roles that this cadre has played in past disasters and what strategies can be implemented to better incorporate them into future emergency management.
In March 2016, key-informant interviews, FCHV interviews, and focus group discussions (FGDs) were conducted in Nepali health facilities using semi-structured guides. The audio-recorded data were obtained with the assistance of a translator (Nepali-English), transcribed verbatim in English, and coded by two independent researchers (manually and with NVivo 11 Pro software [QSR International; Melbourne, Australia]).
Across seven different regions, 14 interviews with FCHVs, two FGDs with community women, and three key-informant interviews were conducted. Four major themes emerged around the topic of FCHVs and the 2015 earthquake: (1) community care and rapport between FCHVs and local residents; (2) emergency response of FCHVs in the immediate aftermath of the earthquake; (3) training requested to improve the FCHVs’ ability to manage disasters; and (4) interaction with relief organizations and how to create collaborations that provide aid relief more effectively.
The FCHVs in Nepal provided multiple services to their communities in the aftermath of the earthquake, largely without any specific training or instruction. Proper preparation, in addition to improved collaboration with aid agencies, could increase the capacity of FCHVs to respond in the event of a future disaster. The information gained from this study of the FCHV experience in the Nepal earthquake could be used to inform risk reduction and emergency management policies for CHWs in various settings worldwide.
FredricksK, DinhH, KusiM, YogalC, KarmacharyaBM, BurkeTF, NelsonBD. Community Health Workers and Disasters: Lessons Learned from the 2015 Earthquake in Nepal. Prehosp Disaster Med. 2017;32(6):604–609.
First-on-call ENT cover is often provided by junior doctors with limited ENT experience; yet, they may have to manage life-threatening emergencies. An intensive 1-day simulation course was developed to teach required skills to junior doctors.
A prospective, single-blinded design was used. Thirty-seven participants rated their confidence before the course, immediately following the course and after a two-month interval. Blinded assessors scored participant performance in two video-recorded simulated scenarios before and after the course.
Participant self-rated confidence was increased in the end-of-course survey (score of 27.5 vs 53.0; p < 0.0001), and this was maintained two to four months after the course (score of 50.5; p < 0.0001). Patient assessment and management in video-recorded emergency scenarios was significantly improved following course completion (score of 9.75 vs 18.75; p = 0.0093).
This course represents an effective method of teaching ENT emergency management to junior doctors. ENT induction programmes benefit from the incorporation of a simulation component.
Behavioral economics is based on the idea that individuals’ decisions are affected by systematic and predictable cognitive biases and that these same biases can be leveraged to change behavior and improve decision-making. Insights from behavioral economics have been used to encourage a range of desired behaviors but have rarely been used in disaster preparedness and response, though traditional efforts by public health practitioners have failed to increase adoption of key preparedness behaviors. In this work, we aim to show how some of the key concepts in the behavioral economics literature are applicable to behaviors related to disaster preparedness and response, and we present ideas for behavioral economics-based interventions that we vetted with public health officials. Two of the best-received interventions were applications of social norms approaches, which leverage social influence bias, and commitment devices, which leverage present bias and loss aversion. Although the current evidence base for the applications of concepts from behavioral economics in disaster preparedness and response is weak, behavioral economics has achieved positive results in similar decision-making contexts. The low cost and potentially high impact of behavioral economics-based interventions warrant further investigation and testing. (Disaster Med Public Health Preparedness. 2016;page 1 of 7)