Following renewed ethnic violence at the end of September 1996, conflict between Tutsi rebels and the Zairian army spread to North Kivu, Zaire where approximately 700,000 Rwandan Hutu refugees resided following the 1994 genocide. After a major rebel offensive against the camps' militia groups on 15 November, a massive movement of refugees towards Rwanda through Goma town, the capital of North Kivu, began. Massive population movements such as this are likely to be associated with substantial mortality and morbidity.

To study patterns of mortality, morbidity, and health care associated with the Rwandan refugee population repatriation during November 1996.

This study observed the functioning of the health-care facilities in the Gisenyi District in Rwanda and the Goma District in Zaire, and surveyed mortality and morbidity among Rwandan refugees returning from Zaire to Rwanda. Patterns of mortality, morbidity, and health care were measured mainly by mortality and health centre consultation rates.

Between 15 and 21 November 1996, 553,000 refugees returned to Rwanda and 4,530 (8.2/1,000 refugees) consultations took place at the border dispensary (watery diarrhea, 63%; bloody diarrhea, 1%). There were 129 (0.2/1,000) surgical admissions (72% soft tissue trauma) to the Gisenyi hospital in the subsequent two weeks. The average number of consultations from the 13 health centres during the same period was 500/day. Overall, the recorded death rate was 0.5/10,000 (all associated with diarrhea). A total of 3,586 bodies were identified in the refugee camps and surrounding areas of Goma, almost all the result of trauma. Many had died in the weeks before the exodus. Health centres were overwhelmed and many of the deficiencies in provision of health care identified in 1994 again were evident.

Non-violent death rates were low, a reflection of the population's health status prior to migration and immunity acquired from the 1994 cholera out-break. Health facilities were over stretched, principally because of depleted numbers of local, health-care workers associated with the 1994 genocide. Health-care facilities running parallel to the existing health-care system functioned most effectively.

The effectiveness of a tiered emergency medical services system often hinges upon the ability of initial care providers with little or no formal training to identify emergent patient needs and determine the best means to meet those needs.

To determine if out-of-hospital emergency care providers consistently make appropriate triage, transportation, and destination decisions; and to determine if experience and training have an effect on these decisions.

A survey consisting of 14 patient-care scenarios was administered to certified and non-certified out-of-hospital emergency-care providers (n = 311) from 20 randomly selected EMS agencies. These agencies were part of EMS systems that utilize one, two, and three tiered responses by ambulance and fire-based commercial, municipal, and volunteer agencies. Participants were asked to select the most appropriate mode of transport and destination facility using the assumption that they had responded to each scenario in a basic life support ambulance. Answers included transporting the patient to various receiving facilities or requesting a more advanced-level unit to respond to the scene. Transport times to receiving facilities and estimated times of arrival for advanced-level units were provided with each choice. Eight emergency physicians unanimously had agreed upon the most appropriate answer for each scenario. A two-tailed t-test was used to compare the scores of the certified and non-certified groups; and Spearman's Correlation Coefficients were used to test the effects of experience and training.

Non-certified providers (n = 108) had a mean score of 32.6% or 4.6 (SD = 1.84) correct answers; certified providers (n = 203) had a mean score of 41.1% or 5.76 (SD = 2.12) correct answers (p < 0.000001). Spearman's Correlation Coefficients were: 1) individual provider level - (0.3978); 2) agency provider level - (0.2741); 3) hours workea per week - (0.2505); 4) years in EMS - (- 0.0821); 5) commercial or volunteer provider - (0.2398); 6) agency call volume - (0.2012); 7) agency location - (0.0685), and 8) transporting versus non-transporting agency - (0.2523).

A need exists for further education of out-of-hospital emergency care providers with respect to triage, transportation, and destination decisions. Provider experience and level of certification do not appear to affect these critical patient-care decisions.

A mass casualty disaster (MCD) never has occurred in the United States, but such an event remains a fearful possibility. The purpose of this study was to establish baseline information concerning the perceptions relative to the capabilities of the United States to respond to a MCD of persons most likely to involved in the responses to such an event when it does occur.

A survey was constructed in 1995 to query the perceptions of persons in authority in federal, state, and local agencies who would participate in the medical responses to a MCD. Participants were asked to select the most likely scenario, a hurricane or earthquake, that could generate 30,000 casualties within their respective region. The survey requested respondent's perceptions as to the timing of the federal responses and the quality and sufficiency of these responses. The survey also sought information about the availability of plans to meet such a catastrophe in the region, and the frequency with which such plans have been exercised.

Responses were grouped by phase of the responses and whether the respondents were employed by federal, state, or local agencies. Descriptive statistics were used to summarize the data. When appropriate, a one-tailed t-test was used to compare the responses of the groups. A p-value = 0.05 was considered statistically significant.

A total of 104 surveys were distributed of which 88 were completed and returned (85%). Both the federal and state respondents had considerable experienced in this area.

Overall, the federal respondents were more optimistic about the availability, utility, and timely arrival of federal resources to assist regions in meeting the medical needs. In each of the three phases of MCD responses evaluated (medical response, patient evacuation, and definitive care), there was concern that there were insufficient resources to meet the requirements. States and local respondents perceived that initially, they will be on their own for field rescue, life-supporting first-aid, and casualty evacuation. Respondents acknowledged that a combination of local, state, federal, and private resources eventually would be needed to meet the huge demand. Only 31% federal and 26% state/local respondents believed that there will be sufficient combined local, state, federal, and private resources to meet the requirements for the evacuation of casualties to definitive care facilities outside of the region, and another 50% acknowledged the resources would only partially meet these requirements. Sixty-eight percent of state/local respondents believed that there would be insufficient local, state, federal, and private definitive care resources to meet the requirements for definitive care.

While three years have elapsed since the survey was conducted and there have been some improvements in preparedness and responses, concerns center around the perceived lack of resource capability or lack of ability to get the resources to the MCD scene in time to meet requirements. Such perceptions by experienced professionals warrant further review by those at all levels of government responsible for planning and responding to mass casualty disasters.

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.

By introducing an intensified insulin treatment regime to patients with insulin-dependant diabetes mellitus (IDDM), the frequency of long-term complications that the patient will experience has been shown to decrease. The price is an increase in the frequency of severe and mild hypoglycaemic events. Therefore, constant monitoring of these patients is necessary.

This study compares the time until full recovery of IDDM patients with severe hypoglycaemia after treatment with either intravenous glucose or intramuscular glucagon.

14 patients with IDDM with severe hypoglycaemia requiring treatment by the medical staff was randomised to treatment either with 50 ml of 50% glucose intravenously or intramuscular 1 mg glucagon. The time to recovery was recorded. Plasma glucose was measured at fixed intervals to achieve a glycaemia profile. Demographic data were acquired through patient interviews following recovery.

Recovery time between the two groups was significantly different statistically. Recovery time ranged for 1 to 3 minutes for those receiving glucose intravenously and 8 to 21 minutes for those receiving intramuscular glucagon. Characteristic glycaemia profiles were identified and differences were present between the two groups with a greater fluctuating pattern for the glucose group compared to the steadily increasing pattern seen after glucagon treatment. Alcohol was believed to be involved in 8 out of the 14 cases, and thereby, is the major confounding factor in this study.

Intramuscularly administered glucagon is a safe and reliable alternative to intravenous glucose infusion. The fluctuating glyceamia pattern seen after glucose treatment indicates a low risk for secondary hypoglycaemia. However, further studies are necessary to support this assertion.