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The 12 January 2010 earthquake that struck Port-au-Prince, Haiti caused >200,000 deaths, thousands of injuries requiring immediate surgical interventions, and 1.5 million internally displaced survivors. The earthquake destroyed or disabled most medical facilities in the city, seriously hampering the ability to deliver immediate life- and limb-saving surgical care. A Project Medishare/University of Miami Miller School of Medicine trauma team deployed to Haiti from Miami within 24 hours of the earthquake. The team began work at a pre-existing tent facility in the United Nations (UN) compound based at the airport, where they encountered 225 critically injured patients. However, non-sterile conditions, no means to administer oxygen, the lack of surgical equipment and supplies, and no anesthetics precluded the immediate delivery of general anesthesia. Despite these limitations, resuscitative care was administered, and during the first 72 hours following the event, some amputations were performed with local anesthesia. Because of these austere conditions, an anesthesiologist, experienced and equipped to administer regional block anesthesia, was dispatched three days later to perform anesthesia for limb amputations, debridements, and wound care using single shot block anesthesia until a better equipped tent facility was established. After four weeks, the relief effort evolved into a 250-bed, multi-specialty trauma/intensive care center staffed with >200 medical, nursing, and administrative staff. Within that timeframe, the facility and its staff completed 1,000 surgeries, including spine and pediatric neurological procedures, without major complications. This experience suggests that when local emergency medical resources are completely destroyed or seriously disabled, a surgical team staffed and equipped to provide regional nerve block anesthesia and acute pain management can be dispatched rapidly to serve as a bridge to more advanced field surgical and intensive care, which takes longer to deploy and set up.
Post-earthquake engineering and epidemiologic assessments are important for the development of injury prevention strategies. This paper describes mortality and its relationship to building collapse patterns and initial medical responses following the 1992 earthquake in Erzincan, Turkey.
The study consisted of: 1) background data collection and review; 2) design and implementation of a field survey; and 3) site inspection of building collapse patterns. The survey included: 1) national (n = 11) and local (n = 17) officials; 2) medical and search and rescue (SAR) workers (n = 38); and 3) a geographically stratified random sample of lay survivors (n = 105). The survey instruments were designed to gather information regarding location, injuries, initial actions and prior training of survivors and responders, and the location, injuries, and management of dead and dying victims. A case-control design was constructed to assess the relationship between mortality, location, and building collapse pattern.
There was extensive structural damage throughout the region, especially in the city where mid-rise, unreinforced masonry buildings (MUMBs) incorporating a “soft” first floor design (large store windows for commercial use) and one story adobe structures were most vulnerable to collapse. Of 526 people who died in the city, 87% (n = 456) were indoors at the time of the earthquake. Of these, 92% (n = 418) died in MUMBs. Of 54 witnessed deaths, 55% (n = 28) of victims died slowly, the majority of whom (n = 26) were pinned or trapped (p <0.05). Of 42 MUMB occupants identified through the survey, those who died (n = 25) were more likely to have been occupying the ground floor when compared with survivors (n = 28) (p <0.01). Official medical and search and rescue responders arrived after most deaths had occurred. Prior first-aid or rescue training of lay, uninjured survivors was associated with a higher likelihood of rescuing and resuscitating others (p <0.001).
During an earthquake, MUMBs with soft ground floor construction are highly lethal, especially for occupants on the ground floor, suggesting that this building type is inappropriate for areas of seismic risk. The vulnerability of MUMBs appears due to a lack of lateral force resistance as a result of the use of glass store fiont windows and the absence of shear walls. The prevalence of this building type in earthquake-prone regions needs to be investigated further. A large portion of victims dying in an earthquake die slowly at the scene of injury. Prior public first-aid and rescue training programs increase participation in rescue efforts in major earthquakes and may improve survival.
When a disaster occurs, a major difficulty is knowing where to find accurate information, and how to help coordinate efforts to share accurate information in a quick and organized manner. The establishment of a global information network, that is in place before a disaster occurs, could link all the communication efforts for relief. We propose that a Global Health Unit for Disaster and Relief Coordination be set up as part of the Global Health Network, utilizing the Internet as its backbone. This Unit would establish the links for the disaster information mosaic.
Anecdotal observations about prehospital emergency medical care in major natural and human-made disasters, such as earthquakes, have suggested that some injured victims survive the initial impact, but eventually die because of a delay in the application of life-saving medical therapy.
A multidisciplinary, retrospective structured interview methodology to investigate injury risk factors, and causes and circumstances of prehospital death after major disasters was developed. In this study, a team of United States researchers and Costa Rican health officials conducted a survey of lay survivors and health care professionals who participated in the emergency medical response to the earthquake in Costa Rica on 22 April 1991.
Fifty-four deaths occurred prior to hospitatization (crude death rate = 0.4/1,000 population). Seventeen percent of these deaths (9/54) were of casualties who survived the initial impact but died at the scene or during transport. Twenty-two percent (2/9) were judged preventable if earlier emergency medical care had been available. Most injuries and deaths occurred in victims who were inside wooden buildings (p <.O1) as opposed to other building types or were pinned by rubble from building collapse. Autopsies performed on a sample of victims showed crush injury to be the predominant cause of death.
A substantial proportion of earthquake mortality in Costa Rica was protracted. Crush injury was the principal mechanism of injury and cause of death. The rapid institution of enhanced prehospital emergency medical services may be associated with a significant life- saving potential in these events.
The siege of Sarajevo is a longterm, human-made, medical disaster of international significance. The delivery of emergency health care provided to the large civilian population held captive in that war zone for an extended time was studied.
In May 1993, a humanitarian and fact-finding visit to Sarajevo was conducted. Physicians, administrators, and public health officials were interviewed; epidemiological data were acquired—the resuscitation of war casualties at the two largest hospitals were observed; and local published reports and videotaped footage on the organization and delivery of prehospital and hospital care were reviewed. The videotapes also served to document war crimes.
Daily bombardment and sniper fire directed at civilians have caused a steady stream of casualties (64,130, or an average of 119 killed or injured per day in 18 months). Eighty percent of the victims were civilian. Despite hazardous conditions from direct shelling, disruption of vital lifelines, and shortage of supplies, medicines, oxygen, and anesthetics, the physicians continue to provide at least a minimum standard of resuscitative care. Seventy percent of all war victims were transported to hospitals in private vehicles. Most casualties (93%) received some form of prehospital, basic first-aid from lay bystanders or first responders. From November 1992 to February 1993, 27,733 patients were treated in hospitals, resulting in 2,139 major surgical procedures. The primary cause of death in 71 of 273 victims was prolonged hemorrhagic, hypovolemic shock. Sixty-one percent of these victims died within 24 hours of injury.
Continuous needs assessment be accompanied by rapid delivery of outside aid. International “peacekeeping” forces should protect hospitals and their staffs, and ensure the entry of supplies and evacuation of some patients. A public trained in life-supporting first-aid, and physicians and paramedics with experience in advanced life support may have enhanced lifesaving efforts in Sarajevo.
The 1991 earthquake in the Limón area of Costa Rica presented the opportunity to examine the effectiveness of a decade of disaster preparedness.
Costa Rica's concentrated work in disaster preparedness would result in significantly better management of the disaster response than was evident in earlier disasters in Guatemala and Nicaragua, where disaster preparedness largely was absent.
Structured interviews with disaster responders in and outside of government, and with victims and victims' neighbors. Clinical and epidemiologic data were collected through provider agencies and the coroner's office.
Medical aspects of the disaster response were effective and well-managed through a network of clinic-based radio communications. Nonmedical aspects showed confusion resulting from: 1) poor government understanding of the roles and responsibilities of the central disaster coordinating agency; and 2) poor extension of disaster preparedness activities to the rural area that was affected by the earthquake.
To be effective, disaster preparedness activities need to include all levels of government and rural, as well as urban, populations.
Each of us has witnessed news reports and graphic television scenes of the willful targeting of innocent noncombatants by military forces; the displacement of tens of thousands of men, women, and children; and the diabolical genocidal tactics of “ethnic cleansing” of the war in Bosnia and Herzegovina. An international effort to establish a United Nations war crimes tribunal is being developed, but even this plan is running out of steam for lack of funding. These events are unfolding in “civilized” and “enlightened” Europe. We all know what is happening, yet world leaders have been reluctant to intervene.
To investigate the adequacy of hospital disaster preparedness in the Osaka, Japan area.
Questionnaires were constructed to elicit information from hospital administrators, pharmacists, and safety personnel about self-sufficiency in electrical, gas, water, food, and medical supplies in the event of a disaster. Questionnaires were mailed to 553 hospitals.
A total of 265 were completed and returned (Recovery rate; 48%). Of the respondents, 16% of hospitals that returned the completed surveys had an external disaster plan, 93% did not have back-up plans to accept casualties during a disaster if all beds were occupied, 8% had drugs and 6% had medical supplies stockpiled for disasters. In 78% of hospitals, independent electric power generating plants had been installed. However, despite a high proportion of power-plant equipment available, 57% of hospitals responding estimated that emergency power generation would not exceed six hours due to a shortage of reserve fuel. Of the hospitals responding, 71% had reserve water supply, 15% of hospitals responding had stockpiles of food for emergency use, and 83% reported that it would be impossible to provide meals for patients and staff with no main gas supply.
No hospitals fulfilled the criteria for adequate disaster preparedness based on the categories queried. Areas of greatest concern requiring improvement were: 1) lack of an external disaster plan; and 2) self-sufficiency in back-up energy, water, and food supply. It is recommended that hospitals in Japan be required to develop plans for emergency operations in case of an external disaster. This should be linked with hospital accreditation as is done for internal disaster plans.
The fundamental goal of emergency medical response in disaster is to save lives and reduce injury and permanent disability. It has been observed that urgent emergency medical care of seriously injured earthquake casualties trapped under building rubble, cannot be provided unless the victims have been extricated and transported to medical facilities by friends or relatives, or are accessible to field rescue and medical teams. Equally important is the fact that extrication of seriously injured, trapped victims by laypersons is hazardous, unless the following conditions are met: 1) the rescuer has basic knowledge of extrication, and; 2) there is early application of effective life-supporting first-aid (LSFA) and/or advanced trauma life support (ATLS) at the scene. Time is the critical factor in such an effort. In previous studies of death and dying in earthquakes, it was noted that extrication of trapped victims will be attempted by survivors. Therefore, it is suggested that citizens living in regions of high seismic risk and trained in basic search and rescue and in LSFA are the most immediate resource for early response after an earthquake. An accompanying paper addresses the issue of citizen LSFA training. This paper focuses on the basic concepts of search and rescue training for the lay public.
In catastrophic disasters such as major earthquakes in densely populated regions, effective Life-Supporting First-Aid (LSFA) and basic rescue can be administered to the injured by previously trained, uninjured survivors (co victims). Administration of LSFA immediately after disaster strikes can add to the overall medical response and help to diminish the morbidity and mortality that result from these events. Widespread training of the lay public also may improve bystander responses in everyday emergencies. However, for this scheme to be effective, a significant percentage of the lay population must learn the eight basic steps of LSFA. These have been developed by the International Resuscitation Research Center in collaboration with the World Association for Emergency and Disaster Medicine, the City of Pittsburgh Department of Public Safety, and the American Red Cross (Pennsylvania chapter). They include: 1) scene survey; 2) airway control; 3) rescue breathing (mouth-to-mouth); 4) circulation (chest compressions; may be omitted for disasters, but should be retained for everyday bystander response); 5) abdominal thrusts for choking (may be omitted for disasters, but retained for everyday bystander response); 6) control of external bleeding; 7) positioning for shock; and 8) call for help.
National medical responses to catastrophic disasters have failed to incorporate a resuscitation component.
This study sought to determine the lifesaving potentials of modern resuscitation medicine as applied to a catastrophic disaster situation. Previous articles reported the preliminary results (I), and methodology (II) of a structured, retrospective interview study of the 1988 earthquake in Armenia. The present article (III) reports and discusses the definitive findings, formulates conclusions, and puts forth recommendations for future responses to catastrophic disasters anywhere in the world.
Observations include: 1) The lack of adequate construction materials and procedures in the Armenian region contributed significantly to injury and loss of life; 2) The uninjured, lay population together with medical teams including physicians in Armenia were capable of rapid response (within two hours); 3) Due to a lack of Advanced Trauma Life Support (ATLS) training for medical teams and of basic first-aid training of the lay public, and scarcity of supplies and equipment for extrication of casualties, they were unable to do much at the scene. As a result, an undetermined number of severely injured earthquake victims in Armenia died slowly without the benefit of appropriate and feasible resuscitation attempts.
1) Widespread adoption of seismic-resistant building codes for regions of high seismic risk; 2) The lay public living in these regions should be trained in life-supporting first-aid (LSFA) and basic rescue techniques; 3) Community-wide emergency medical services (EMS) systems should be developed world-wide (tai-lored to the emergency needs of each region) with ATLS capability for field resuscitation; 4) Such systems be prepared to extend coverage to mass casualties; 5) National disaster medical system (NDMS) plans should provide integration of existing trauma-EMS systems into regional systems linked with advanced (heavy) rescue (public works, fire, police); and 6) New techniques and devices for victim extrication should be developed to enable rapid extrication of earthquake casualties within 24 hours.
The study of a disaster which has occurred cannot be researched using the traditional techniques as it is not possible to conceive or conduct controlled, randomized experiments for such an event. Paper I of this series described non-experimental, scientific methodologies which were applied to study the detection-extrication-resuscitation activities which occurred following the devastating 1988 earthquake in the Republic of Armenia, USSR. This paper critically evaluates the methodologies used for the Armenia study and proposes modifications in these methods for application to the study of future disasters.
Approaches which could be applied to the study of future disasters are defined and critically evaluated from the view of reliability, validity, costs, and practicability. The revised set of protocols is discussed in terms of: 1) the structured interview process; 2) training of personnel to conduct, synthesize, and evaluate the interviews; 3) the time required to complete the interview process; 4) sampling techniques; 5) mechanisms for cross-checking the data; and 6) the addition of preliminary data collection immediately following or during the event. Use of this revised approach should assist in the collection and analysis of data associated with future disasters so that it is possible to: 1) further enhance life-saving and reduce mortality; 2) improve relief efforts; 3) reduce damage to communities; 4) evaluate the long-term effects of such events; and 5) assist in better preparation for future events.