Management of mass-casualty incidents should optimize outcomes by appropriate prehospital care, and patient triage to the most capably facilities. The number of patients, the nature of injuries, transportation needs, distances, and hospital capabilities and availabilities are all factors to be considered. Patient maldistributions such as overwhelming individual facilities, or transport to facilities incapable of providing appropriate care should be avoided. This report is a critical view of the application of the START triage nomenclature in the prehospital arena following a train crash in Los Angeles County on 26 January 2005.

A scheduled debriefing was held with the major fire and emergency medical services responders, Medical Alert Center staff, and hospitals to assess and review the response to the incident. Site visits were made to all of the hospitals involved. Follow-up questions were directed to emergency department staff that were on duty during the day of the incident.

The five Level-I Trauma Centers responded to the poll with the capacity to receive a total of 12 “Immediate” patients, 2.4 patients per center, the eight Level-II Trauma Centers responded with capacity to receive 17 “Immediate” patients, two patients per center, while the 25 closest community hospitals offered to accept 75 “Immediate” patients, three patients per hospital. These community hospitals were typically about one-half of the size of the trauma centers (average 287 beds versus 548, average 8.7 operating rooms versus 16.6). Twenty-six patients were transported to a community hospital >15 miles from the scene, while eight closer community hospitals did not receive any patients.

The debriefing summary of this incident concluded that there were no consistently used criteria to decide ultimate destination for “Immediates”, and that they were distributed about equally between community hospitals and trauma centers.

Violent patients in the prehospital environment pose a threat to health care workers tasked with managing their medical conditions. While research has focused on methods to control the agitated patient in the emergency department (ED), there is a paucity of data looking at the optimal approach to subdue these patients safely in the prehospital setting.

This study evaluated the efficacy of two different intramuscular medications, midazolam and haloperidol, to determine their efficacy in sedating agitated patients in the prehospital setting.

This was a prospective, randomized, observational trial wherein agitated patients were administered intramuscular haloperidol or intramuscular midazolam to control agitation. Agitation was quantified by the Richmond Agitation and Sedation Scale (RASS). Paramedics recorded the RASS and vital signs every five minutes during transport and again upon arrival to the ED. The primary outcome was mean time to achieve a RASS less than +1. Secondary outcomes included mean time for patients to return to baseline mental status and adverse events.

Five patients were enrolled in each study group. In the haloperidol group, the mean time to achieve a RASS score of less than +1 was 24.8 minutes (95% CI, 8-49 minutes), and the mean time for the return of a normal mental status was 84 minutes (95% CI, 0-202 minutes). Two patients required additional prehospital doses for adequate sedation. There were no adverse events recorded in the patients administered haloperidol.

In the midazolam group, the mean time to achieve a RASS score of less than +1 was 13.5 minutes (95% CI, 8-19 minutes) and the mean time for the return of normal mental status was 105 minutes (95% CI, 0-178 minutes). One patient required additional sedation in the ED. There were no adverse events recorded among the patients administered midazolam.

Midazolam and haloperidol administered intramuscularly appear equally effective for sedating an agitated patient in the prehospital setting. Midazolam appears to have a faster onset of action, as evidenced by the shorter time required to achieve a RASS score of less than +1 in the patients who received midazolam. Haloperidol offers an alternative option for the sedation of an agitated patient. Further studies should focus on continued investigation into appropriate sedation of agitated patients in the prehospital setting.

IsenbergDL , JacobsD . Prehospital Agitation and Sedation Trial (PhAST): A Randomized Control Trial of Intramuscular Haloperidol versus Intramuscular Midazolam for the Sedation of the Agitated or Violent Patient in the Prehospital Environment. Prehosp Disaster Med. 2015;30(5):491–495.

To study the effects of early, advanced prehospital life support on the survival rate of war casualties during the battle of Jalalabad, Afghanistan from 1989–1992.

The outcomes of simple trauma care administered from 1989–1990 were compared to the outcomes of advanced trauma care administered from 1991–1992 in the combat zone. The outcomes were measured by the number of deaths at admission to the referral surgical hospitals in Pakistan.

A total of 3,890 war casualties were treated in the combat zone by paramedics, and were evacuated through light, forward, field clinics to surgical hospitals in Pakistan. Advanced trauma care that was administered in the combat zone reduced the prehospital mortality rate from 26.1% to 13.6% (95% confidence interval for difference = 9.7–15.4%).

In scenarios with protracted evacuation, early and advanced trauma care should be included in the chain of survival. Local paramedics can provide such trauma care with a minimum of resources.

Emergency medical services vehicle collisions (EMVCs) associated with the use of warning “lights and siren” (L&S) are responsible for injuries and death to emergency medical services (EMS) personnel and patients. This study examines patient outcome when medical protocol directs L&S transport.

During four months, all EMS calls initiated as an emergency request for service and culminating in transport to an emergency department (ED) were included. Medical criteria determined emergent (L&S) versus non-emergent transport. Patients with worsened conditions, as reported by EMS providers, were reviewed.

Countywide suburban/rural EMS system.

Ninety-two percent (1,495 of 1,625) of patients were transported non-emergently. Thirteen (1%) of these were reported to have worsened during transport, and none of them suffered any worsened outcome related to the non-L&S transport.

This medical protocol directing the use of warning L&S during patient transport results in infrequent L&S transport. In this study, no adverse outcomes were found related to non-L&S transports.

Societies invest substantial amounts of resources on disaster preparedness of hospitals. However, the concept is not clearly defined nor operationalized in the international literature.

This review aims to systematically assess definitions and operationalizations of disaster preparedness in hospitals, and to develop an all-encompassing model, incorporating different perspectives on the subject.

A systematic search was conducted in five databases: Scopus, PubMed, Web of Science, Disaster Information Management Research Centre, and SafetyLit. Peer-reviewed articles containing definitions and operationalizations of disaster preparedness in hospitals were included. Articles published in languages other than English, or without available full-text, were excluded, as were articles on prehospital care. The findings from literature were used to build a model for hospital disaster preparedness.

In the included publications, 13 unique definitions of disaster preparedness in hospitals and 22 different operationalizations of the concept were found. Although the definitions differed in emphasis and width, they also reflected similar elements. Based on an analysis of the operationalizations, nine different components could be identified that generally were not studied in relation to each other. Moreover, publications primarily focused on structure and process aspects of disaster preparedness. The aim of preparedness was described in seven articles.

This review points at an absence of consensus on the definition and operationalization of disaster preparedness in hospitals. By combining elements of definitions and components operationalized, disaster preparedness could be conceptualized in a more comprehensive and complete way than before. The model presented can guide future disaster preparedness activities and research.

The purpose of this study was to evaluate stress levels in emergency medical services personnel across the United States.

Confidential, 20-question survey tool, Medical Personnel Stress Survey-Abbreviated (MPSS-R). A total score of 50 indicates average stress levels. A score of 12.5 on the subset measurements of somatic distress, job dissatisfaction, organizational stress, and negative attitudes towards patients indicates average levels of stress. Data were analyzed using ANOVA and t-test.

None.

A total of 658 of 3,000 emergency medical technicians (EMTs) (22%) completed the survey. The mean value of 69.3±6.3 for the total stress scores was very high Mean values for the subset scores were: somatic distress = 19.6±3.3; organizational stress = 17.3±2.4; job dissatisfaction = 17.0±2.6; negative attitudes towards patients = 15.5±2.3. Characteristics predicting higher stress were EMT-basic (A) licensure, basic life support (BLS) only service provider, volunteer status, new employee working in a small EMS organization, and providing service to a small town.

Stress levels in EMS personnel were very high, were manifested primarily as somatic distress, secondarily as organizational stress and job dissatisfaction, and lastly as negative patient attitudes. Stress levels and subset manifestations of occupational stress among EMS personnel varied depending on gender, marital status, age, level of training and function, on salaried or volunteer status, length of time as an EMT, and size of the organization, city, and population served. Care should be taken to address stresses peculiar to individual EMS system needs.

The objectives of the study were to develop and evaluate an “all-hazards” hospital disaster preparedness training course that utilizes a combi-nation of classroom lectures, skills sessions, tabletop sessions, and disaster exercises to teach the principles of hospital disaster preparedness to hospital-based employees.

Participants attended a two-day, 16-hour course, entitled Hospital Disaster Life Support (HDLS). The course was designed to address seven core competencies of disaster training for healthcare workers. Specific disaster situations addressed during HDLS included: (1) biological; (2) conventional; (3) radiological; and (4) chemical mass-casualty incidents. The primary goal of HDLS was not only to teach patient care for a disaster, but more important-ly, to teach hospital personnel how to manage the disaster itself. Knowledge gained from the HDLS course was assessed by pre- and post-test evaluations. Additionally, participants completed a course evaluation survey at the conclu-sion of HDLS to assess their attitudes about the course.

Participants included 11 physicians, 40 nurses, 23 administrators/direc-tors, and 10 other personnel (n = 84). The average score on the pre-test was 69.1 ±12.8 for all positions, and the post-test score was 89.5 ±6.7, an improve-ment of 20.4 points (p <0.0001, 17.2–23.5).Participants felt HDLS was edu-cational (4.2/5), relevant (4.3/5) and organized (4.3/5).

Identifying an effective means of teaching hospital disaster pre-paredness to hospital-based employees is an important task. However, the opti-mal strategy for implementing such education still is under debate.The HDLS course was designed to utilize multiple teaching modalities to train hospital-based employees on the principles of disaster preparedness. Participants of HDLS showed an increase in knowledge gained and reported high satisfaction from their experiences at HDLS. These results suggest that HDLS is an effec-tive way to train hospital-based employees in the area of disaster preparedness.

The assessment of hospital disaster preparedness and response performance is a way to find and remove possible gaps and weaknesses in hospital disaster management effectiveness. The aim of this pilot study was to test the association between the level of preparedness and the level of response performance during a full-scale hospital exercise.

This pilot study was conducted in a hospital during a full-scale exercise in the Piedmont region of Italy. The preparedness evaluation was conducted by a group of three experts, three days before the exercise, and the response evaluation was conducted during the exercise. The functional capacity module was used for preparedness evaluation, and the response performance of the “command and control” function of the hospital was evaluated by nine semiquantitative performance indicators.

The preparedness of the chosen hospital was 59%, while the response performance was evaluated as 70%. The hospital staff conducted Simple Triage and Rapid Transport (START) triage while they received 61 casualties, which was 90% correct for the yellow group and 100% correct for the green group.

This pilot study showed that it is possible to use standardized evaluations tools, to simultaneously assess the relationship between preparedness elements and response performance measures. An experimental study including a group of hospitals, also using more comprehensive evaluation tools, should be done to evaluate the correlation between the level of preparedness and the response performance of a hospital, and the impact of hospital disaster planning, on the outcome of disasters victims.

DjalaliA, CarenzoL, RagazzoniL, AzzarettoM, PetrinoR, Della CorteF, IngrassiaPL. Does Hospital Disaster Preparedness Predict Response Performance During a Full-scale Exercise? A Pilot Study. Prehosp Disaster Med. 2014;29(4):1-7.

Very little is known on the impact of recurrent disasters on mental health.

The present study examines the immediate impact of a recurrent flood on mental health and functioning among an affected population in the rural district of Bahraich, Uttar Pradesh, India, compared with a population in the same region that is not affected by floods.

The study compared 318 affected respondents with 308 individuals who were not affected by floods. Symptoms of anxiety and depression were assessed by the Hopkins Symptom Checklist-25 (HSCL-25). Psychological and physical functioning was assessed by using the Short Form-12 (SF-12).

The affected group showed large to very large differences with the comparison group on symptoms of anxiety (D = .92) and depression (D = 1.22). The affected group scored significantly lower on psychological and physical functioning than the comparison group (respectively D = .33 and D = .80). However, hierarchical linear regressions showed no significant relationship between mental health and the domains of functioning in the affected group, whereas mental health and the domains of functioning were significantly related in the comparison group.

This study found a large negative impact of the recurrent floods on mental health outcomes and psychological and physical functioning. However, in a context with recurrent floods, disaster mental health status is not a relevant predictor of functioning. The findings suggest that the observed mental health status and impaired functioning in this context are also outcomes of another mechanism: Both outcomes are likely to be related to the erosion of the social and environmental and material context. As such, the findings refer to a need to implement psychosocial context-oriented interventions to address the erosion of the context rather than specific mental health interventions.

WindTR, JoshiPC, KleberRJ, KomproeIH. The Impact of Recurrent Disasters on Mental Health: A Study on Seasonal Floods in Northern India. Prehosp Disaster Med. 2013;28(3):1-7.

Media reports on disasters may play a role in inspiring charitable giving to fund post-disaster recovery, but few analyses have attempted to explore the potential link between the intensity of media reporting and the amount of charitable donations made. The purposes of this study were to explore media coverage during the first four weeks of the 2010 earthquake in Haiti in order to assess changes in media-intensity, and to link this information to data on contributions for emergency assistance to determine the impact of media upon post-disaster charitable giving.

Data on newspaper and newswire coverage of the 2010 earthquake in Haiti were gathered from the NexisLexis database, and traffic on Twitter and select Facebook sites was gathered from social media analyzers. The aggregated measure of charitable giving was gathered from the Center for Philanthropy at Indiana University. The intensity of media reporting was compared with charitable giving over time for the first month following the event, using regression modeling.

Post-disaster coverage in traditional media and Twitter was characterized by a rapid rise in the first few days following the event, followed by a gradual but consistent decline over the next four weeks. Select Facebook sites provided more sustained coverage. Both traditional and new media coverage were positively correlated with donations: every 10% increase in Twitter messages relative to the peak percentage was associated with an additional US $236,540 in contributions, while each additional ABC News story was associated with an additional US $963,800 in contributions.

While traditional and new media coverage wanes quickly after disaster-causing events, new and social media platforms may allow stories, and potentially charitable giving, to thrive for longer periods of time.

Lobb A, Mock N, Hutchinson PL. Traditional and social media coverage and charitable giving following the 2010 earthquake in Haiti. Prehosp Disaster Med. 2012; 27(4):1-6.

The science underpinning the study of mass-gathering health (MGH) is developing rapidly. Current knowledge fails to adequately inform the understanding of the science of mass gatherings (MGs) because of the lack of theory development and adequate conceptual analysis. Defining populations of interest in the context of MGs is required to permit meaningful comparison and meta-analysis between events.

A critique of existing definitions and descriptions of MGs was undertaken. Analyzing gaps in current knowledge, the authors sought to delineate the populations affected by MGs, employing a consensus approach to formulating a population model. The proposed conceptual model evolved through face-to-face group meetings, structured breakout sessions, asynchronous collaboration, and virtual international meetings.

Reporting on the incidence of health conditions at specific MGs, and comparing those rates between and across events, requires a common understanding of the denominators, or the total populations in question. There are many, nested populations to consider within a MG, such as the population of patients, the population of medical services providers, the population of attendees/audience/participants, the crew, contractors, staff, and volunteers, as well as the population of the host community affected by, but not necessarily attending, the event.

A pictorial representation of a basic population model was generated, followed by a more complex representation, capturing a global-health perspective, as well as academically- and operationally-relevant divisions in MG populations.

Consistent definitions of MG populations will support more rigorous data collection. This, in turn, will support meta-analysis and pooling of data sources internationally, creating a foundation for risk assessment as well as illness and injury prediction modeling. Ultimately, more rigorous data collection will support methodology for evaluating health promotion, harm reduction, and clinical-response interventions at MGs. Delineating MG populations progresses the current body of knowledge of MGs and informs the understanding of the full scope of their health effects.

LundA , TurrisSA , BowlesR , SteenkampM , HuttonA , RanseJ , ArbonP . Mass-gathering Health Research Foundational Theory: Part 1 - Population Models for Mass Gatherings. Prehosp Disaster Med. 2014;29(6):1-7.

Tetanus is a potentially fatal condition that is rare in urban environments but is seen in developing countries and post-natural-disaster. Therefore, the purpose of this report was to review the epidemiology, pathogenesis, and management of tetanus in the trauma patient.

A thorough literature review was conducted to look for the most current and thorough guidelines on the prophylaxis and treatment of tetanus. PUBMED (National Center for Biotechnology Information, National Institutes of Health; Bethesda, Maryland USA), MEDLINE (US National Library of Medicine, National Institutes of Health; Bethesda, Maryland USA), and Cochrane Library (The Cochrane Collaboration; Oxford, United Kingdom) databases were searched for articles in English, published from 2005 to 2015, using the keywords “Tetanus,” “Trauma/Surgery,” and “Disaster.” Controlled trials, randomized controlled trials, trials of adult patients, published guidelines, expert opinions, and review articles were selected and extracted.

Current vaccination schedules in developed countries provide prophylaxis for tetanus. However, when severe natural disasters occur, many patients may not be able to provide a reliable vaccination history. In these situations, tetanus immune globulin (TIG) is indicated; if resources are not limited, both tetanus toxoid and TIG should be given to those with high-risk wounds. If resources are limited, TIG should be reserved for those that would benefit most or those least likely to have the protective antibodies.

Although tetanus is a disease that has a low incidence in the developed world due to high rates of immunization, during large-scale natural disasters, compounding factors like the types of injuries, lack of medical services and supplies, and the delay in treatment associated with an already low immunization rate result in an increased incidence and outbreaks of the disease that has higher mortality in an underdeveloped society. It is important for the urban physician that cares for trauma and critical patients to become familiar with the protocols for treatment and immunization of patients that have tetanus-prone wounds, as well as recognize the potential for outbreaks in the settings of major natural disasters.

FinkelsteinP, TeischL, AllenCJ, RuizG. Tetanus: A Potential Public Health Threat in Times of Disaster. Prehosp Disaster Med. 2017;32(3):339–342.

Theoretically, simulation of disastrous situations has many advantages in that it prepares hospital staff to cope with the real scenario. It is a challenge to create the database and custom-making a friendly software while still keeping it representative of a real situation. This article describes experience with developing and implementing the use of simulation software as a drilling technique used by Israeli hospitals.

The application was developed using SIMAN/ARENA software. Knowledge and a database for a basic multi-casalty incident (MCI) were developed in the pilot phase. It contains detailed description of the casualties which can be compared with the real hospital capabilities (staff and infrastructure). A consensus committe decided the crucial model issues and estaalished the thresholds for quality performance indicators. Interfaces to the each hospital's information management systems (IMS) were developed and the various output documents of each exercised step were updated. Before drilling, the hospital managerial staff received notice and had to prepare the data on the anticipated resources required The simulation staff, as well as representatives from the hospitals, then conducted the limited scale drill (LSD).

During the LSD, the trained hospital staff were given two types of input: 1) copies of reports on patients entering the stations and had to enter them into its IMS; and 2) timed telephone notifications of problems in each station. During a 90 minutes drill, there were about 15 timely reports and 20 telephone problems. The evaluation of the LSD were based mainly on the following: 1) observing the staff solving various problems; 2) constructing a detailed picture of the situation; and 3) measuring the effectiveness of the hospital IMS. The drill ended with a discussion. Lessons are drawn from each drill in order to find methods for optimizing the conduct of the hospital. An animation tool proved to be useful in describing bottle necks in emergency room, diagnostic department, and operating rooms.

Simulation techniques and a preparatory limited scale drill have advantages in evaluating and improving preparedness of hospitals for managing an MCI before a full scale drill is carried out.