Editorial
Questioning the Validity of Science
- Samuel J. Stratton
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- Published online by Cambridge University Press:
- 12 February 2014, p. 1
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From Cradle of European Civilization to Grave Austerity: Does Greece Face a Creeping Health Disaster?
- Jeffrey Levett
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- 29 November 2013, pp. 2-3
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. .Levett J From Cradle of European Civilization to Grave Austerity: Does Greece Face a Creeping Health Disaster? Prehosp Disaster Med.2013 ;28 (6 ):1 -2 While the global financial crisis started on the American continent, Greece has felt the biggest shock. As a result of government-imposed austerity measures following the implementation of the Memorandum of Understanding,* population health and the health sector have been impacted. This adds a burden to the national health system (NHS), already facing compromised efficiency and effectiveness. Cuts in health and social protection budgets are an additional exacerbation. These events have precipitated serious discussion, variable opinions, and related activity, but there is limited research on the public health impact of austerity.1 In 2011, I suggested that the Memorandum could be damaging to health and that there is a creeping health disaster2 while Kentikelenis referred to the omens of disaster.3 If austerity was tested like a medication in a clinical trial, it would have been stopped long ago, given its deadly side effects, according to Stuckler and Basu.4 According to Blyth, austerity is a dangerous idea.5 In terms of the Utstein template,6–8 austerity is designated a health hazard, which can be exacerbated when national governance is weak.9 The outcome is a creeping disaster of uncertain dynamics.†
Original Research
Dynamic Temperature and Humidity Environmental Profiles: Impact for Future Emergency and Disaster Preparedness and Response
- William J. Ferguson, Richard F. Louie, Chloe S. Tang, Kyaw Tha Paw U, Gerald J. Kost
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- 02 January 2014, pp. 4-12
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Introduction
During disasters and complex emergencies, environmental conditions can adversely affect the performance of point-of-care (POC) testing. Knowledge of these conditions can help device developers and operators understand the significance of temperature and humidity limits necessary for use of POC devices. First responders will benefit from improved performance for on-site decision making.
ObjectiveTo create dynamic temperature and humidity profiles that can be used to assess the environmental robustness of POC devices, reagents, and other resources (eg, drugs), and thereby, to improve preparedness.
MethodsSurface temperature and humidity data from the National Climatic Data Center (Asheville, North Carolina USA) was obtained, median hourly temperature and humidity were calculated, and then mathematically stretched profiles were created to include extreme highs and lows. Profiles were created for: (1) Banda Aceh, Indonesia at the time of the 2004 Tsunami; (2) New Orleans, Louisiana USA just before and after Hurricane Katrina made landfall in 2005; (3) Springfield, Massachusetts USA for an ambulance call during the month of January 2009; (4) Port-au-Prince, Haiti following the 2010 earthquake; (5) Sendai, Japan for the March 2011 earthquake and tsunami with comparison to the colder month of January 2011; (6) New York, New York USA after Hurricane Sandy made landfall in 2012; and (7) a 24-hour rescue from Hawaii USA to the Marshall Islands. Profiles were validated by randomly selecting 10 days and determining if (1) temperature and humidity points fell inside and (2) daily variations were encompassed. Mean kinetic temperatures (MKT) were also assessed for each profile.
ResultsProfiles accurately modeled conditions during emergency and disaster events and enclosed 100% of maximum and minimum temperature and humidity points. Daily variations also were represented well with 88.6% (62/70) of temperature readings and 71.1% (54/70) of relative humidity readings falling within diurnal patterns. Days not represented well primarily had continuously high humidity. Mean kinetic temperature was useful for severity ranking.
ConclusionsSimulating temperature and humidity conditions clearly reveals operational challenges encountered during disasters and emergencies. Understanding of environmental stresses and MKT leads to insights regarding operational robustness necessary for safe and accurate use of POC devices and reagents. Rescue personnel should understand these principles before performing POC testing in adverse environments.
,Ferguson WJ ,Louie RF ,Tang CS ,Paw U KT .Kost GJ Dynamic Temperature and Humidity Environmental Profiles: Impact for Future Emergency and Disaster Preparedness and Response . Prehosp Disaster Med.2014 ;29 (1 ):1 -8 .
Chronic Conditions and Household Preparedness for Public Health Emergencies: Behavioral Risk Factor Surveillance System, 2006-2010
- Jean Y. Ko, Tara W. Strine, Pamela Allweiss
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- Published online by Cambridge University Press:
- 13 December 2013, pp. 13-20
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Introduction
Individuals with chronic conditions often experience exacerbation of those conditions and have specialized medical needs after a disaster. Less is known about the level of disaster preparedness of this particular population and the extent to which being prepared might have an impact on the risk of disease exacerbation. The purpose of this study was to examine the association between self-reported asthma, cardiovascular disease, and diabetes and levels of household disaster preparedness.
MethodsData were analyzed from 14 US states participating in the 2006-2010 Behavioral Risk Factor Surveillance System (BRFSS), a large state-based telephone survey. Chi-square statistics and adjusted prevalence ratios were calculated.
ResultsAfter adjusting for sociodemographic characteristics, as compared to those without each condition, persons with cardiovascular disease (aPR = 1.09; 95% CI, 1.01-1.17) and diabetes (aPR = 1.13; 95% CI, 1.05-1.22) were slightly more likely to have an evacuation plan and individuals with diabetes (aPR = 1.04; 95% CI, 1.02-1.05) and asthma (aPR = 1.02; 95% CI, 1.01-1.04) were slightly more likely to have a 3-day supply of prescription medication. There were no statistically significant differences in the prevalence for all other preparedness measures (3-day supply of food and water, working radio and flashlight, willingness to leave during a mandatory evacuation) between those with and those without each chronic condition.
ConclusionDespite the increased morbidity and mortality associated with chronic conditions, persons with diabetes, cardiovascular disease, and asthma were generally not more prepared for natural or man-made disasters than those without each chronic condition.
,Ko JY ,Strine TW .Allweiss P Chronic Conditions and Household Preparedness for Public Health Emergencies: Behavioral Risk Factor Surveillance System, 2006-2010 . Prehosp Disaster Med.2014 ;29 (1 ):1 -8 .
Médecins Sans Frontières Experience in Orthopedic Surgery in Postearthquake Haiti in 2010
- Carrie Lee Teicher, Kathryn Alberti, Klaudia Porten, Greg Elder, Emannuel Baron, Patrick Herard
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- 15 January 2014, pp. 21-26
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Introduction
During January 2010, a 7.0 magnitude earthquake struck Haiti, resulting in death and destruction for hundreds of thousands of people. This study describes the types of orthopedic procedures performed, the options for patient follow-up, and limitations in obtaining outcomes data in an emergency setting.
ProblemThere is not a large body of data that describes larger orthopedic cohorts, especially those focusing on internal fixation surgeries in resource-poor settings in postdisaster regions. This article describes 248 injuries and over 300 procedures carried out in the Médecins Sans Frontières-Orthopedic Centre Paris orthopedic program.
MethodsSurgeries described in this report were limited to orthopedic procedures carried out under general anesthesia for all surgical patients. Exclusion factors included simple fracture reduction, debridement, dressing changes, and removal of hardware. This data was collected using both prospective and retrospective methods; prospective inpatient data were collected using a data collection form designed promptly after the earthquake and retrospective data collection was performed in October 2010.
ResultsOf the 264 fractures, 204 were fractures of the major long bones (humerus, radius, femur, tibia). Of these 204 fractures of the major long bones, 34 (16.7%) were upper limb fractures and 170 (83.3%) were lower limb fractures. This cohort demonstrated a large number of open fractures of the lower limb and closed fractures of the upper limb. Fractures were treated according to their location and type. Of the 194 long bone fractures, the most common intervention was external fixation (36.5%) followed by traction (16.7%), nailing (15.1%), amputation (14.6%), and plating (9.9%).
ConclusionThe number of fractures described in this report represents one of the larger orthopedic cohorts of patients treated in a single center in the aftermath of the 2010 earthquake in Haiti. The emergent surgical care described was carried out in difficult conditions, both in the hospital and the greater community. While outcome and complication data were limited, the proportion of patients attending follow-up most likely exceeded expectations and may reflect the importance of the rehabilitation center. This data demonstrates the ability of surgical teams to perform highly-specialized surgeries in a disaster zone, and also reiterates the need for access to essential and emergency surgical programs, which are an essential part of public health in low- and medium-resource settings.
. ,Teicher CL ,Alberti K ,Porten K ,Elder G ,Baron E .Herard P Médecins Sans Frontières Experience in Orthopedic Surgery in Postearthquake Haiti in 2010 . Prehosp Disaster Med.2014 ;29 (1 ):1 -6
Characteristics of Hospitals Diverting Ambulances in a California EMS System
- Christopher A. Kahn, Samuel J. Stratton, Craig L. Anderson
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- 22 January 2014, pp. 27-31
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Introduction
While several reports discuss controversies regarding ambulance diversion from acute care hospitals and the mortality, financial, and resource effects, there is scant literature related to the effect of hospital characteristics.
Hypothesis/ProblemThe objective of this study was to describe specific paramedic receiving center characteristics that are associated with ambulance diversion rates in an Emergency Medical Services system.
MethodsA retrospective observational study design was used. The study was performed in a suburban EMS system with 27 paramedic receiving centers studied; one additional hospital present at the beginning of the study period (2000-2008) was excluded due to lack of recent data. Hospital-level and population-level characteristics were gathered, including diversion rate (hours on diversion/total hours open), for-profit status, number of specialty services (including trauma, burn, cardiovascular surgery, renal transplant services, cardiac catheterization capability [both interventional and diagnostic], and burn surgery), average inpatient bed occupancy rate (total patient days/licensed bed days), annual emergency department (ED) volume (patients per year), ED admission rate (percent of ED patients admitted), and percent of patients leaving without being seen. Demographic characteristics included percent of persons in each hospital's immediate census tract below the 100% and 200% poverty lines (each considered separately), and population density within the census tract. Bivariate and regression analyses were performed.
ResultsDiversion rates for the 27 centers ranged from 0.3%-14.5% (median 4.5%). Average inpatient bed occupancy rate and presence of specialty services were correlated with an increase in diversion rate; occupancy rate showed a 0.08% increase in diversion hours per 1% increase in occupancy rate (95% CI, 0.01%-0.16%), and hospitals with specialty services had, on average, a 4.1% higher diversion rate than other hospitals (95% CI, 1.6%-6.7%). Other characteristics did not show a statistically significant effect. When a regression was performed, only the presence of specialty services was related to the ambulance diversion rate.
ConclusionsHospitals in this study providing specialty services were more likely to have higher diversion rates. This may result in increased difficulty getting patients requiring specialty care to centers able to provide the needed level of service. Major limitations include the retrospective nature of the study, as well as reliance on multiple data systems.
. ,Kahn C ,Stratton S .Anderson C Characteristics of Hospitals Diverting Ambulances in a California EMS System . Prehosp Disaster Med.2014 ;29 (1 ):1 -5
Is Prehospital Endotracheal Intubation Associated with Improved Outcomes In Isolated Severe Head Injury? A Matched Cohort Analysis
- Efstathios Karamanos, Peep Talving, Dimitra Skiada, Melanie Osby, Kenji Inaba, Lydia Lam, Ozgur Albuz, Demetrios Demetriades
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- 13 December 2013, pp. 32-36
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Introduction
Prehospital endotracheal intubation (ETI) following traumatic brain injury in urban settings is controversial. Studies investigating admission arterial blood gas (ABG) patterns in these instances are scant.
HypothesisOutcomes in patients subjected to divergent prehospital airway management options following severe head injury were studied.
MethodsThis was a retrospective propensity-matched study in patients with isolated TBI (head Abbreviated Injury Scale (AIS) ≥ 3) and Glasgow Coma Scale (GCS) score of ≤ 8 admitted to a Level 1 urban trauma center from January 1, 2003 through October 31, 2011. Cases that had prehospital ETI were compared to controls subjected to oxygen by mask in a one to three ratio for demographics, mechanism of injury, tachycardia/hypotension, Injury Severity Score, type of intracranial lesion, and all major surgical interventions. Primary outcome was mortality and secondary outcomes included admission gas profile, in-hospital morbidity, ICU length of stay (ICU LOS) and hospital length of stay (HLOS).
ResultsCases (n = 55) and controls (n = 165) had statistically similar prehospital and in-hospital variables after propensity matching. Mortality was significantly higher for the ETI group (69.1% vs 55.2% respectively, P = .011). There was no difference in pH, base deficit, and pCO2 on admission blood gases; however the ETI group had significantly lower pO2 (187 (SD = 14) vs 213 (SD = 13), P = .034). There was a significantly increased incidence of septic shock in the ETI group. Patients subjected to prehospital ETI had a longer HLOS and ICU LOS.
ConclusionIn isolated severe traumatic brain injury, prehospital endotracheal intubation was associated with significantly higher adjusted mortality rate and worsened admission oxygenation. Further prospective validation of these findings is warranted.
. ,Karamanos E ,Talving P ,Skiada D ,Osby M ,Inaba K ,Lam L ,Albuz O .Demetriades D Is Prehospital Endotracheal Intubation Associated with Improved Outcomes In Isolated Severe Head Injury? A Matched Cohort Analysis . Prehosp Disaster Med.2013 ;28 (6 ):1 -5
Outcome Accuracy of the Emergency Medical Dispatcher's Initial Selection of a Diabetic Problems Protocol
- Jeff Clawson, Greg Scott, Weston Lloyd, Brett Patterson, Tracey Barron, Isabel Gardett, Christopher Olola
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- 10 December 2013, pp. 37-42
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Introduction
Diabetes mellitus, although a chronic disease, also can cause acute, sudden symptoms requiring emergency intervention. In these cases, Emergency Medical Dispatchers (EMDs) must identify true diabetic complaints in order to determine the correct care. In 911 systems utilizing the Medical Priority Dispatch System (MPDS), International Academies of Emergency Dispatch-certified EMDs determine a patient's chief complaint by matching the caller's response to an initial pre-scripted question to one of 37 possible chief complaints protocols. The ability of EMDs to identify true diabetic-triggered events reported through 911 has not been studied.
ObjectiveThe primary objective of this study was to determine the percentage of EMD-recorded patient cases (using the Diabetic Problems protocol in the MPDS) that were confirmed by either attending paramedics or the hospital as experiencing a diabetic-triggered event.
MethodsThis was a retrospective study involving six hospitals, one fire department, and one ambulance service in Salt Lake City, Utah USA. Dispatch data for one year recorded under the Diabetic Problems protocol, along with the associated paramedic and hospital outcome data, were reviewed/analyzed. The outcome measures were: the percentage of cases that had diabetic history, percentage of EMD-identified diabetic problems cases that were confirmed by Emergency Medical Services (EMS) and/or hospital records as true diabetic-triggered events, and percentage of EMD-identified diabetic patients who also had other medical conditions. A diabetic-triggered event was defined as one in which the patient's emergency was directly caused by diabetes or its medical management. Descriptive statistics were used for categorical measures and parametric statistical methods assessed the differences between study groups, for continuous measures.
ResultsThree-hundred ninety-three patient cases were assigned to the Diabetic Problems Chief Complaint protocol. Of the 367 (93.4%) patients who had a documented history of diabetes, 279 (76%) were determined to have had a diabetic-triggered event. However, only 12 (3.6%) initially assigned to this protocol did not have a confirmed history of diabetes.
ConclusionsUsing the MPDS to select the Diabetic Problems Chief Complaint protocol, the EMDs correctly identified a true diabetic-triggered event the majority of the time. However, many patients had other medical conditions, which complicated the initial classification of true diabetic-triggered events. Future studies should examine the associations between the five specific Diabetic Problems Chief Complaint protocol determinant codes (triage priority levels) and severity measures, eg, blood sugar level and Glasgow Coma Score.
. ,Clawson J ,Scott G ,Lloyd W ,Patterson B ,Barron T ,Gardett I .Olola C Outcome Accuracy of the Emergency Medical Dispatcher's Initial Selection of a Diabetic Problems Protocol . Prehosp Disaster Med.2013 :28 (6 ):1 -6
Use of a Hooked Cutting Device Compared With Scissors for the Emergency Exposure of Critically Ill and Injured Patients
- Nelson Tang, Matthew J. Levy, Jeffrey Harrow, Nina Bingham
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- Published online by Cambridge University Press:
- 13 December 2013, pp. 43-46
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Introduction
The initial assessment of critical patients includes prompt identification of life-threatening conditions. Any device or technique that can aid in this process may ultimately save lives. This study examined whether clothing could be removed faster with the use of a hooked cutting device as compared with the commonly-used heavy-duty, blunt-tipped, serrated scissors.
MethodsThis study took place in an urban academic emergency department of a Level-1 trauma center. Human patient simulator mannequins were clothed in identical shirts and pants. The time required for clinical personnel to expose the patient using each device was measured. Each of the 50 participants was queried regarding their tactile comfort using each device.
ResultsThe mean time for shirt removal using scissors was 83 seconds (SD = 55 seconds; 95% CI, 68-99). The mean time for shirt removal using the hook device was 28 seconds (SD = 21 seconds; 95% CI, 22-34). The mean time for pants removal using scissors was 69 seconds (SD = 40 seconds; 95% CI, 56-73). The mean time for pants removal using the hook device was 19 seconds (SD=15 seconds; 95% CI, 15-23).
ConclusionsThe hooked device was 69% faster at removing clothing than traditionally-used scissors. Though simple in concept, these implications can be life saving, particularly in conditions of uncontrolled, life-threatening external hemorrhage.
. ,Tang N ,Levy M ,Harrow J .Bingham N Use of a Hooked Cutting Device Compared With Scissors for the Emergency Exposure of Critically Ill and Injured Patients . Prehosp Disaster Med.2013 ;28 (6 ):1 -4
Diagnosis According to Time of Arrival at “The Great New York State Fair”
- Katherine Nacca, Jay Scott, William Grant
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- Published online by Cambridge University Press:
- 15 January 2014, pp. 47-49
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Objective
To study the diagnoses of patients presenting to a medical facility within a mass-gathering public event, “The Great New York State Fair” (NYSF) based on chief complaints, diagnoses, and time of arrival. The goal of the study was to assess the need for increased staffing, services, or supplies during certain times of day for an event that gathers approximately 1 million patrons over a 12-day span. Patrons occupy the grounds between the hours of 10 am and 11 pm, while workers and staff are on the grounds around the clock.
MethodTriage data gathered by trained medical students was collected from all of the patients seen during the 2009 NYSF from 12 am to 11:59 pm. Triage information was categorized based on the nature of complaint, physician impression, and time of arrival to assess for trends in the distribution of common chief complaints and diagnoses at a mass-gathering medical care facility.
ResultsThe early hours of the NYSF were occupied mostly with treatment of minor first aid complaints, while later hours were occupied more commonly by orthopedic complaints. Insect stings were the most frequent complaint throughout the day.
ConclusionDaytime and evening hours at the fair have a significant number of orthopedic diagnoses and may benefit from specific staff and equipment sufficient to handle these complaints. Stings and minor first aid injuries are also significant and may benefit from adequate stocking of the infirmary for such events. Major medical complaints, including cardiac and neurological complaints, did occur but were a minor part of the total patient population.
. ,Nacca K ,Scott J .Grant W Diagnosis According to Time of Arrival at “The Great New York State Fair” Prehosp Disaster Med.2014 ;29 (1 ):1 -3
Reduction in STEMI Transfer Times Utilizing a Municipal “911” Ambulance Service
- Joseph C. Tennyson, Mark R. Quale
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- Published online by Cambridge University Press:
- 22 January 2014, pp. 50-53
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Introduction
The time interval from diagnosis to reperfusion therapy for patients experiencing ST-segment elevation myocardial infarction (STEMI) has a significant impact on morbidity and mortality.
HypothesisIt is hypothesized that the time required for interfacility patient transfers from a community hospital to a regional percutaneous coronary intervention (PCI) center using an Advanced Life Support (ALS) transfer ambulance service is no different than utilizing the “911” ALS ambulance.
MethodsQuality assurance data collected by a tertiary care center cardiac catheterization program were reviewed retrospectively. Data were collected on all patients with STEMI requiring interfacility transfer from a local community hospital to the tertiary care center's PCI suite, approximately 16 miles away by ground, 12 miles by air. In 2009, transfers of patients with STEMI were redirected to the municipal ALS ambulance service, instead of the hospital's contracted ALS transfer service. Data were collected from January 2007 through May 2013. Temporal data were compared between transports initiated through the contracted ALS ambulance service and the municipal ALS service. Data points included time of initial transport request and time of ambulance arrival to the sending facility and the receiving PCI suite.
ResultsDuring the 4-year study period, 63 patients diagnosed with STEMI and transferred to the receiving hospital's PCI suite were included in this study. Mean times from the transport request to arrival of the ambulance at the sending hospital's emergency department were six minutes (95% CI, 4-7 minutes) via municipal ALS and 13 minutes (95% CI, 9-16 minutes) for the ALS transfer service. The mean times from the ground transport request to arrival at the receiving hospital's PCI suite when utilizing the municipal ALS ambulance and hospital contracted ALS ambulance services were 48 minutes (95% CI, 33-64 minutes) and 56 minutes (95% CI 52-59 minutes), respectively. This eight-minute period represented a 14% (P = .001) reduction in the mean transfer time to the PCI suite for patients transported via the municipal ALS ambulance.
ConclusionIn the appropriate setting, the use of the municipal “911” ALS ambulance service for the interfacility transport of patients with STEMI appears advantageous in reducing door-to-catheterization times.
. ,Tennyson JC .Quale MR Reduction in STEMI Transfer Times Utilizing a Municipal “911” Ambulance Service . Prehosp Disaster Med.2014 ;29 (1 ):1 -4
Comprehensive Review
Disaster Health After The 2011 Great East Japan Earthquake
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- Mayumi Kako, Paul Arbon, Satoko Mitani
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- Published online by Cambridge University Press:
- 22 January 2014, pp. 54-59
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Introduction
The March 11, 2011 disaster was unparalleled in the disaster history of Japan. There is still enormous effort required in order for Japan to recover from the damage, not only financially, but psychosocially. This paper is a review of the studies that have been undertaken since this disaster, from after the March 11th disaster in 2011 to the end of 2012, and will provide an overview of the disaster-health research literature published during this period.
MethodsThe Japanese database Ichushi Ver. 5 was used to review the literature. This database is the most frequently used database in Japanese health-sciences research. The keywords used in the search were “Higashi Nihon Dai-shinsai” (The Great East Japan Earthquake).
ResultsA total of 5,889 articles were found. Within this selection, 163 articles were categorized as original research (gencho ronbun). The articles were then sorted and the top four key categories were as follows: medicine (n = 98), mental health (n = 18), nursing (n = 13), and disaster management (n = 10). Additional categories were: nutrition (n = 4), public health (n = 3), radiology, preparedness, and pharmacology (n = 2 for each category). Nine articles appeared with only one category label and were grouped as “others.”
ConclusionThis review provides the current status of disaster-health research following the Great East Japan Earthquake. The research focus over the selected period was greatly directed towards medical considerations, especially vascular conditions and renal dialysis. Considering the compounding factors of the cold temperatures at the time of the disaster, the geography, the extensive dislocation of the population, and the demographics of an aging community, it is noteworthy that the immediate and acute impact of the March 11th disaster was substantial compared with other events and their studies on the impact of disaster on chronic and long-term illness. The complexity of damage caused by the earthquake event and the associated nuclear power plant event, which possibly affected people more psychologically than physically, might also need to be investigated with respect to long term objectives for improving disaster preparedness and management.
. ,Kako M ,Arbon P .Mitani S Disaster Health After The 2011 Great East Japan Earthquake . Prehosp Disaster Med.2014 ;29 (1 ):1 -6
Special Report
Reshaping US Navy Pacific Response in Mitigating Disaster Risk in South Pacific Island Nations: Adopting Community-Based Disaster Cycle Management
- Erik J. Reaves, Michael Termini, Frederick M. Burkle, Jr.
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- Published online by Cambridge University Press:
- 23 December 2013, pp. 60-68
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The US Department of Defense continues to deploy military assets for disaster relief and humanitarian actions around the world. These missions, carried out through geographically located Combatant Commands, represent an evolving role the US military is taking in health diplomacy, designed to enhance disaster preparedness and response capability. Oceania is a unique case, with most island nations experiencing “acute-on-chronic” environmental stresses defined by acute disaster events on top of the consequences of climate change. In all Pacific Island nation-states and territories, the symptoms of this process are seen in both short- and long-term health concerns and a deteriorating public health infrastructure. These factors tend to build on each other. To date, the US military's response to Oceania primarily has been to provide short-term humanitarian projects as part of Pacific Command humanitarian civic assistance missions, such as the annual Pacific Partnership, without necessarily improving local capacity or leaving behind relevant risk-reduction strategies. This report describes the assessment and implications on public health of large-scale humanitarian missions conducted by the US Navy in Oceania. Future opportunities will require the Department of Defense and its Combatant Commands to show meaningful strategies to implement ongoing, long-term, humanitarian activities that will build sustainable, host nation health system capacity and partnerships. This report recommends a community-centric approach that would better assist island nations in reducing disaster risk throughout the traditional disaster management cycle and defines a potential and crucial role of Department of Defense's assets and resources to be a more meaningful partner in disaster risk reduction and community capacity building.
. ,Reaves EJ ,Termini M Burkle FM Jr. Reshaping US Navy Pacific Response in Mitigating Disaster Risk in South Pacific Island Nations: Adopting Community-Based Disaster Cycle Management . Prehosp Disaster Med.2014 ;29 (1 ):1 -9
Development of an Evaluation Framework Suitable for Assessing Humanitarian Workforce Competencies During Crisis Simulation Exercises
- Hilarie Cranmer, Jennifer L. Chan, Stephanie Kayden, Altaf Musani, Philippe E. Gasquet, Peter Walker, Frederick M. Burkle, Jr., Kirsten Johnson
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- Published online by Cambridge University Press:
- 15 January 2014, pp. 69-74
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The need to provide a professionalization process for the humanitarian workforce is well established. Current competency-based curricula provided by existing academically affiliated training centers in North America, the United Kingdom, and the European Union provide a route toward certification. Simulation exercises followed by timely evaluation is one way to mimic the field deployment process, test knowledge of core competences, and ensure that a competent workforce can manage the inevitable emergencies and crises they will face. Through a 2011 field-based exercise that simulated a humanitarian crisis, delivered under the auspices of the World Health Organization (WHO), a competency-based framework and evaluation tool is demonstrated as a model for future training and evaluation of humanitarian providers.
. ,Cranmer H ,Chan J ,Kayden S ,Musani A ,Gasquet P ,Walker P ,Burkle F .Johnson K Development of an Evaluation Framework Suitable for Assessing Humanitarian Workforce Competencies During Crisis Simulation Exercises . Prehosp Disaster Med.2014 ;29 (1 ):1 -6
Emergency Medicine Systems Advancement through Community-based Development
- Martha M. Bloem, Christina M. Bloem, Juliana Rosentsveyg, Bonnie Arquilla
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- 16 January 2014, pp. 75-79
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Humanitarian health programs frequently focus on immediate relief and are supply side oriented or donor driven. More emphasis should be placed on long-term development projects that engage local community leaders to ensure sustainable change in health care systems. With the Emergency Medicine Educational Exchange (EMEDEX) International Rescue, Recover, Rebuild initiative in Northeast Haiti as a model, this paper discusses the opportunities and challenges in using community-based development to establish emergency medical systems in resource-limited settings.
,Bloem MM ,Bloem CM ,Rosentsveyg J .Arquilla B Emergency Medicine Systems Advancement through Community-based Development . Prehosp Disaster Med.2014 ;29 (1 ):1 -5 .
A Sustainable Training Strategy for Improving Health Care Following a Catastrophic Radiological or Nuclear Incident
- Daniel J. Blumenthal, Judith L. Bader, Doran Christensen, John Koerner, John Cuellar, Sidney Hinds, John Crapo, Erik Glassman, A. Bradley Potter, Lynda Singletary
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- Published online by Cambridge University Press:
- 12 February 2014, pp. 80-86
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The detonation of a nuclear device in a US city would be catastrophic. Enormous loss of life and injuries would characterize an incident with profound human, political, social, and economic implications. Nevertheless, most responders have not received sufficient training about ionizing radiation, principles of radiation safety, or managing, diagnosing, and treating radiation-related injuries and illnesses. Members throughout the health care delivery system, including medical first responders, hospital first receivers, and health care institution support personnel such as janitors, hospital administrators, and security personnel, lack radiation-related training. This lack of knowledge can lead to failure of these groups to respond appropriately after a nuclear detonation or other major radiation incident and limit the effectiveness of the medical response and recovery effort. Efficacy of the response can be improved by getting each group the information it needs to do its job. This paper proposes a sustainable training strategy for spreading curricula throughout the necessary communities. It classifies the members of the health care delivery system into four tiers and identifies tasks for each tier and the radiation-relevant knowledge needed to perform these tasks. By providing education through additional modules to existing training structures, connecting radioactive contamination control to daily professional practices, and augmenting these systems with just-in-time training, the strategy creates a sustainable mechanism for giving members of the health care community improved ability to respond during a radiological or nuclear crisis, reducing fatalities, mitigating injuries, and improving the resiliency of the community.
. ,Blumethal D ,Bader J ,Christensen D ,Koerner J ,Cuellar J ,Hinds S ,Crapo J ,Glassman ES ,Potter AB .Singletary L A Sustainable Training Strategy for Improving Health Care Following a Catastrophic Radiological or Nuclear Incident . Prehosp Disaster Med.2014 ;29 (1 ):80 -86
Solastalgia: Living With the Environmental Damage Caused By Natural Disasters
- Sri Warsini, Jane Mills, Kim Usher
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- 17 January 2014, pp. 87-90
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Forced separation from one's home may trigger emotional distress. People who remain in their homes may experience emotional distress due to living in a severely damaged environment. These people experience a type of ‘homesickness’ similar to nostalgia because the land around them no longer resembles the home they knew and loved. What they lack is solace or comfort from their home; they long for the home environment to be the way it was before. “Solastalgia” is a term created to describe feelings which arise in people when an environment changes so much that it negatively affects an individual's quality of life. Such changed environments may include drought-stricken areas and open-cut mines. The aim of this article is to describe how solastalgia, originally conceptualized as the result of man-made environmental change, can be similarly applied to the survivors of natural disasters. Using volcanic eruptions as a case example, the authors argue that people who experience a natural disaster are likely to suffer from solastalgia for a number of reasons, which may include the loss of housing, livestock and farmland, and the ongoing danger of living in a disaster-prone area. These losses and fears challenge people's established sense of place and identity and can lead to feelings of helplessness and depression.
. ,Warsini S ,Mills J .Usher K Solastalgia: Living With the Environmental Damage Caused By Natural Disasters . Prehosp Disaster Med.2014 :29 (1 );1 -4
Case Report
Reconsidering Policy of Casualty Evacuation in a Remote Mass-Casualty Incident
- Bruria Adini, Robert Cohen, Elon Glassberg, Bella Azaria, Daniel Simon, Michael Stein, Yoram Klein, Kobi Peleg
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- Published online by Cambridge University Press:
- 15 November 2013, pp. 91-95
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Objectives
Inappropriate distribution of casualties in mass-casualty incidents (MCIs) may overwhelm hospitals. This study aimed to review the consequences of evacuating casualties from a bus accident to a single peripheral hospital and lessons learned regarding policy of casualty evacuation.
MethodsMedical records of all casualties relating to evacuation times, injury severity, diagnoses, treatments, resources utilized and outcomes were independently reviewed by two senior trauma surgeons. In addition, four senior trauma surgeons reviewed impact of treatment provided on patient outcomes. They reviewed the times for the primary and secondary evacuation, injury severity, diagnoses, surgical treatments, resources utilized, and the final outcomes of the patients at the point of discharge from the tertiary care hospital.
ResultsThirty-one survivors were transferred to the closest local hospital; four died en route to hospital or within 30 minutes of arrival. Twenty-seven casualties were evacuated by air from the local hospital within 2.5 to 6.15 hours to Level I and II hospitals. Undertriage of 15% and overtriage of seven percent were noted. Four casualties did not receive treatment that might have improved their condition at the local hospital.
ConclusionsIn MCIs occurring in remote areas, policy makers should consider revising the current evacuation plan so that only immediate unstable casualties should be transferred to the closest primary hospital. On site Advanced Life Support (ALS) should be administered to non-severe casualties until they can be evacuated directly to tertiary care hospitals. First responders must be trained to provide ALS to non-severe casualties until evacuation resources are available.
. ,Adini B ,Cohen R ,Glassberg E ,Azaria B ,Simon D ,Stein M ,Klein Y .Peleg K Reconsidering Policy of Casualty Evacuation in a Remote Mass-Casualty Incident . Prehosp Disaster Med.2013 ;28 (6 ):1 -5
Brief Report
Cervical Spine Fractures in Elderly Patients with Hip Fracture After Low-Level Fall: An Opportunity to Refine Prehospital Spinal Immobilization Guidelines?
- Lori L. Boland, Paul A. Satterlee, Paul R. Jansen
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- Published online by Cambridge University Press:
- 22 January 2014, pp. 96-99
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Background
Conventional prehospital spine-assessment approaches based on low index of suspicion and mechanism of injury (MOI) result in the liberal application of spinal immobilization in trauma patients. A painful distracting injury (DI), such as a suspected hip fracture, historically has been a sufficient condition for immobilization, even in an elderly patient who suffers a simple fall from standing and exhibits no other risk factors for spinal injury. Because the elderly are at increased risk of hip fracture from low-level falls, and are also particularly susceptible to the discomfort and morbidity associated with immobilization, the prevalence of cervical spine (c-spine) fracture in this patient population was examined.
MethodsHospital billing records were used to identify all cases of traumatic femur fracture in Minnesota (USA) in 2010-2011. Concurrent diagnosis and external cause codes were used to estimate the prevalence of c-spine fracture by age and MOI.
ResultsAmong 1,394 patients with femur fracture, 23 (1.7%) had a c-spine fracture. When the MOI was a fall from standing or sitting height and the patient age was ≥65, the prevalence dropped to 0.4% (2/565). The prevalence was similar when the definition of hip fracture additionally included pelvis fractures (0.5%; 11/2,441). Eight of the 11 patients with c-spine fracture had diagnosis codes indicative of criteria other than the DI that likely would have resulted in immobilization (eg, head injury and compromised mental status).
ConclusionsC-spine fracture is extremely rare in elderly patients who sustain hip fracture as a result of a low-level fall, and appears to be accompanied frequently by other known predictors of spinal injury besides DI. More research is needed to determine whether conservative use of spinal immobilization may be warranted in elderly patients with hip fracture after low-level falls when the only criteria for immobilization is the distracting hip injury.
. ,Boland LL ,Satterlee PA .Jansen PR Cervical Spine Fractures in Elderly Patients with Hip Fracture After Low-Level Fall: An Opportunity to Refine Prehospital Spinal Immobilization Guidelines? Prehosp Disaster Med.2014 ;29 (1 ):1 -4
Waterworks, a Full-Scale Chemical Exposure Exercise: Interrogating Pediatric Critical Care Surge Capacity in an Inner-City Tertiary Care Medical Center
- Vikas S. Shah, Lauren C. Pierce, Patricia Roblin, Sarah Walker, Marte N. Sergio, Bonnie Arquilla
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- Published online by Cambridge University Press:
- 13 December 2013, pp. 100-106
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Introduction
Pediatric Intensive Care Unit (PICU) resources are overwhelmed in disaster as the need to accommodate influx of critically-ill children is increased. A full-scale chlorine overexposure exercise was conducted by the New York Institute for All Hazard Preparedness (NYIAHP) to assess the appropriateness of response of Kings County Hospital Center's (KCHC's) PICU surge plan to an influx of critically-ill children. The primary endpoint that was assessed was the ability of the institution to follow the PICU surge plan, while secondary endpoints include the ability to provide appropriate medical management.
MethodsThirty-six actors/patients (medical students or emergency medicine residents) were educated on presentations and appropriate medical management of patients after a chlorine overexposure, as well as lectures on drill design and expected PICU surge response. Victims presented to the hospital after simulated accidental chlorine overexposure at a public pool. Twenty-two patients with 14 family members needed evaluation; nine of these patients would require PICU admission. Three of nine PICU patients were low-fidelity mannequins. In addition to the 36 actor/patient evaluators, each area had two to four expert evaluators (disaster preparedness experts) to assess appropriateness of global response. Patients were expected to receive standard of care. Appropriateness of medical decisions and treatment was assessed retrospectively with review of electronic medical record.
ResultsThe initial PICU census was three of seven; two of these patients were transferred to the general ward. Of the nine patients that required Intensive Care Unit (ICU) admission, six actor/patients were admitted to the PICU, one was admitted to the Surgical Intensive Care Unit (SICU), one went to the Operating Room (OR), and one was admitted to a monitored-surge general pediatric bed. The remaining 13 actor/patients were treated and released. Medical, nursing, and respiratory staffing in the PICU and the general ward were increased by two main mechanisms (extension of work hours and in-house recruitment of additional staff). Emergency Department (ED) staffing was artificially increased prior to the drill. With the exception of ocular fluid pH testing in patients with ocular pruritus, all necessary treatments were given; however, an unneeded albuterol treatment was administered to one patient. Chart review showed adequate discharge instructions in four of 13 patients. Nine patients without respiratory complaints in the ED were not instructed to observe for dyspnea. All patients were in the PICU or alternate locations within 90 minutes.
DiscussionThe staff was well versed in the major details of KCHC's PICU surge plan, which allowed smooth transition of patient care from the ED to the PICU. The plan provided for a roadmap to achieve adequate medical, nursing, and respiratory therapists. Medical therapy was appropriate in the PICU; however, in the ED, patients with ocular complaints did not receive optimal care. In addition, written discharge instruction and educational material regarding chlorine overexposure to all patients were not consistently provided. The PICU surge plan was immediately accessible through the KCHC intranet; however, not all participants were cognizant of this fact; this decreased the efficiency with which the roadmap was followed. An exaggerated ED staff facilitated evaluation and transfer of patients.
ConclusionDuring disasters, the ability to surge is paramount and each hospital addresses it differently. Hospitals and departments have written surge plans, but there is no literature available which assesses the validity of said plans through a rigorous, structured, simulated disaster drill. This study is the first to assess validity and effectiveness of a hospital's PICU surge plan. Overall, the KCHC PICU surge plan was effective; however, several deficiencies (mainly in communication and patient education in the ED) were identified, and this will improve future response.
,Shah VS ,Pierce LC ,Roblin P ,Walker S ,Sergio MN .Arquilla B Waterworks, a Full-Scale Chemical Exposure Exercise: Interrogating Pediatric Critical Care Surge Capacity in an Inner-City Tertiary Care Medical Center . Prehosp Disaster Med.2014 ;29 (1 ):1 -7 .