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American Journal of Disaster Medicine
January/February 2007, Volume 2
, Number 1


Article
Guest editorial. Assisting states in planning for pandemic influenza
Ronald W. Manderscheid, PhD; Priscilla S. Golden; C. Lee Smith
January/February 2007; pages 5-8


Article
Brief report. Los Angeles County and the Disaster Resource Center program
Richard Zoraster, MD; Kay Fruhwirth, MSN, RN; Dolores Hill, BSN, RN; Carolyn Meyer, MPA, RN
January/February 2007; pages 10-12


Article
Sounding board. Emergency management of trauma in India: Expectations and reality
B. R. Sharma, MBBS, MD
January/February 2007; pages 13-19

Abstract
Emergency management of trauma in the developing world is at a nascent stage of development. Industrialized cities, rural towns, and villages coexist, with an almost complete lack of organized trauma care. There is no leading national agency to coordinate the various components of a trauma system, and no mechanism for accreditation of trauma centers and professionals exists. Accelerated urbanization and industrialization over the last three to four decades has led to an alarming increase in the rate of accidental injuries, crime, and violence, and ever-increasing terrorist activities over the last two decades have ushered in man-made mass-casualty disasters. However, communicable diseases, maternal and child health, and population control continue to be government priorities, far ahead of trauma care, in countries like India. New initiatives under the National Health Policy 2002 were expected to result in improvements in the systems, but grossly inadequate funding allocation made any significant impact on the outcome impossible. Strengthening in several areas is severely needed to achieve a reasonable level of efficiency, despite significant efforts on the part of the private sector to develop trauma care systems. Key words: trauma, trauma care system, prehospital care, ambulance services, emergency departments


Article
Case report. The quinary pattern of blast injury
Yoram Kluger, MD, FACS; Adi Nimrod, MD; Philippe Biderman, MD; Ami Mayo, MD; Patric Sorkin, MD
January/February 2007; pages 21-25

Abstract
Objective: Bombing is the primary weapon of global terrorism, and it results in a complicated, multidimensional injury pattern. It induces bodily injuries through the well-documented primary, secondary, tertiary, and quaternary mechanisms of blast. Their effects dictate special medical concern and timely implementation of diagnostic and management strategies. Our objective is to report on clinical observations of patients admitted to the Tel Aviv Medical Center following a terrorist bombing. Results: The explosion injured 27 patients, and three died. Four survivors who had been in close proximity to the explosion, as indicated by their eardrum perforation and additional blast injuries, were exposed to the blast wave. They exhibited a unique and immediate hyperinflammatory state, two upon admission to the intensive care unit and two during surgery. This hyperinflammatory state manifested as hyperpyrexia, sweating, low central venous pressure, and positive fluid balance. This state did not correlate with the complexity of injuries sustained by any of the 67 patients admitted to the intensive care unit after previous bombings. Conclusion: The patients’ hyperinflammatory behavior, unrelated to their injury complexity and severity of trauma, indicates a new injury pattern in explosions, termed the “quinary blast injury pattern.” Unconventional materials used in the manufacture of the explosive can partly explain the observed early hyperinflammatory state. Medical personnel caring for blast victims should be aware of this new type of bombing injury. Key words: terrorism, blast injury, hyperinflammation


Article
Original research. Are we ready for terrorism? Emergency medical technicians’ and paramedics’ training and self-perceived competence since September 11
Art Clawson, MS; Nir Menachemi, PhD, MPH; Unho Kim, MPH; Robert G. Brooks, MD, MBA
January/February 2007; pages 26-32

Abstract
The US continues to be a target for terrorist activities that threaten the lives of the populace. Training on preparedness and response for emergency medical technicians (EMTs) and paramedics is critical to the success of an early response to any such attack. Previous surveys have suggested that terrorism-specific training has been modest at best since September 11. In order to gain further insight into emergency personnel’s level of training and competence, we sent surveys to 4,000 EMTs and paramedics in the state of Florida in late 2005 and early 2006. Results show a much higher level of training than previously reported from other states and suggest a direct correlation between the amount and type of training and self-reported competence. Our results suggest that most emergency personnel are receiving terrorism-specific training, but gaps in competencies exist and require the attention of educators and policymakers. Key words: emergency medical technician, paramedic, terrorism-specific training, perceived competence


Article
Literature review. The influence of global warming on natural disasters and their public health outcomes
James H. Diaz, MD, MPH-TM, DrPH
January/February 2007; pages 33-42

Abstract
With a documented increase in average global surface temperatures of 0.6ºC since 1975, Earth now appears to be warming due to a variety of climatic effects, most notably the cascading effects of greenhouse gas emissions resulting from human activities. There remains, however, no universal agreement on how rapidly, regionally, or asymmetrically the planet will warm or on the true impact of global warming on natural disasters and public health outcomes. Most reports to date of the public health impact of global warming have been anecdotal and retrospective in design and have focused on the increase in heat-stroke deaths following heat waves and on outbreaks of airborne and arthropod-borne diseases following tropical rains and flooding that resulted from fluctuations in ocean temperatures. The effects of global warming on rainfall and drought, tropical cyclone and tsunami activity, and tectonic and volcanic activity will have far-reaching public health effects not only on environmentally associated disease outbreaks but also on global food supplies and population movements. As a result of these and other recognized associations between climate change and public health consequences, many of which have been confounded by deficiencies in public health infrastructure and scientific debates over whether climate changes are spawned by atmospheric cycles or anthropogenic influences, the active responses to progressive climate change must include combinations of economic, environmental, legal, regulatory, and, most importantly, public health measures.


Article
Literature review. Hospital disaster preparedness: Mental and behavioral health interventions for infectious disease outbreaks and bioterrorism incidents
Artin Terhakopian, MD; David M. Benedek, MD
January/February 2007; pages 43-50

Abstract
Background: Despite an increasing reliance on outpatient clinics and other ambulatory care facilities, traditional hospitals play a crucial role in the US healthcare system. They provide emergency services on a walk-in basis and are staffed to address issues related to triage. In an era of heightened concern over bioterrorism and a potential influenza pandemic, hospital preparedness for responding to infectious disease outbreaks is essential. During such outbreaks, mental and behavioral health problems may constitute an important part of the demand placed on hospitals. There is now sufficient clinical experience regarding such problems, and tested recommendations are available for hospitals to implement in disaster planning and practice. Objective: This paper summarizes available literature addressing hospital preparedness for mental and behavioral health interventions in the event of an infectious disease outbreak and identifies the barriers to improvement. Methods: A systematic literature review using the MEDLINE database was carried out. Additional articles were selected from the references of the identified sources, and Web sites of relevant agencies and organizations were searched. Results: The review indicates that little literature documents recent hospital performance in or readiness for disaster mental and behavioral health interventions. The available evidence suggests a poor state of hospital readiness for providing such interventions. The problems related to financing such preparedness are likely contributors to this finding and must be overcome if improvements are to be made. Conclusions: More research is needed to categorically examine the preparedness of hospitals for mental and behavioral health interventions during times of disaster. Key words: Hospital, disaster, infectious disease outbreak, mental health, behavioral health

American Journal of Disaster Medicine
March/April 2007, Volume 2
, Number 2


Article
From the editor. Triage in mass casualty incidents: Challenges and controversies
Susan Briggs, MD, MPH, FACS
March/April 2007; pages 57-57


Article
Sounding board. Basic Community Emergency Response Team training to augment medical infrastructure preparedness
Geoffrey Simmons, MD
March/April 2007; pages 59-63


Article
Legal corner. Public health law and disaster medicine: Understanding the legal environment
Thomas A. Gionis, MD, JD, LLM, MBA, MHA, FCLM; Cyril Wecht, MD, JD, FCLM; Lewis W. Marshall, Jr., MS, MD, JD, FAAEP
March/April 2007; pages 64-73

Abstract
Disaster medicine specialists, policy makers, and the public often feel frustrated when they encounter the complex legal framework that surrounds public health emergencies and disasters. Such a framework is particularly difficult to understand when one considers that the federal government has no express powers over public health or disaster management. In fact, under the US Constitution, the states, rather than the federal government, possess public health governance. Although public health sovereignty formally resides within the states, and notwithstanding the federal government’s lack of express constitutional powers over public health crises and disaster management, the federal government has gradually taken on a greater leadership role in managing public health emergencies. In order to clarify the state and federal responsibilities surrounding public health emergencies and disasters, this article explores necessary and pertinent legal topics. These topics include public health duties, public health disasters, state sovereignty, governmental coercion, de facto constitutional empowerment, separation of powers, limited powers, federalism, state police powers, general and federal declarations of emergencies, the Model State Emergency Health Powers Act (MSEHPA), and public health and na-tional security. Key words: public health emergencies, disasters, state sovereignty, governmental coercion, de facto constitutional empowerment, separation of powers, limited powers, federalism, state police powers, general and federal declarations of emergency, the Model State Emergency Health Powers Act (MSEHPA), national security


Article
Activating physicians within a hospital emergency plan: A concept whose time has come?
Kristine M. Gebbie, DrPH, RN; Steve Silber, MD, MBA; Michael McCollum, MPA; Eliot J. Lazar, MD, MBA
March/April 2007; pages 74-80

Abstract
Background: Clinicians are an essential component of the medical response to an emergency in which there are actual or suspected injuries. However, little is known about the institutional notification methods for clinicians during emergencies, particularly for off-site staff. Further, there is little knowledge regarding clinicians’ level of awareness of the emergency plans at hospitals with which they are affiliated, or of their knowledge regarding the notification protocols involved in plan activation during an emergency. If physicians are unaware of how to respond to an actual or threatened emergency, the effectiveness of any hospital emergency plan is severely limited. Objective: This study sought to examine hospital emergency plans, institutional clinician notification, and recall procedures, as well as clinicians’ level of knowledge regarding the emergency notification and recall protocol(s) at the hospital(s) with which they are affiliated. Methods: Written surveys were sent to hospital emergency coordinators, chiefs of service, and individual clinicians employed by a large, multihospital healthcare system in a major urban area. Results: We found that 64 percent of respondents’ hospitals had a recall protocol; of those, 53 percent required that the hospital contact clinicians, with 17 percent of those hospitals using a central operator to make the calls. Of the chiefs of services who participated, 56 percent claimed to be very familiar with their facility’s emergency plan, and 53 percent knew that it had been activated at least once in the past year. Conclusions: Hospital emergency responders are not sufficiently knowledgeable of their institutions’ emergency plans. In order to ensure sufficient surge capacity and timely response, a tiered activation system, intimately familiar to potential responders, should be developed, taught, and drilled by hospitals to formalize physician call-up. Key words: emergency response, hospital emergency plan, clinician notification, clinician awareness


Article
Caregivers and families in medical special needs shelters: An experience during Hurricane Rita
Jessie K. Patton-Levine, BS; Joshua R. Vest, MPH; Adolfo M. Valadez, MD
March/April 2007; pages 81-86

Abstract
Introduction: Local public health departments may assume responsibility for sheltering and providing care for medically needy populations displaced by disasters. In addition, medical special needs shelters will inevitably house persons not requiring medical assistance. The presence of nonpatients may help or hinder shelter operations. This analysis examines the composition, demographics, and medical requirements of a population in a special needs shelter. Methods: Frequencies and ratios were used to describe persons residing in a medical special needs shelter. All data were obtained from registration records from the city of Austin’s medical special needs shelter, established in response to Hurricane Rita in 2005. Results: The medically needy accounted for 58.4 percent of the shelter population. For every 100 patients, the shelter housed 71.2 nonpatients. The most common nonpatients in the shelter were family caregivers (13.1 percent), followed by dependent children (8.0 percent). Most professional caregivers were associated with some type of group facility. Conclusions: Sheltering a medically needy population means caring not only for patients but also for their accompanying caregivers, family, and dependents. Non–medically needy persons utilize shelter capacity and require different resources. Shelter staffing plans should not rely heavily on assistance from accompanying caregivers; instead, they should assume a substantial proportion of shelter capacity will be dedicated to non–medically needy persons. Key words: disaster planning, natural disasters, public health, evacuation, sheltering, mental health


Article
Development of evaluation modules for use in hospital disaster drills
Mollie W. Jenckes, MHSc, BSN; Christina L. Catlett, MD; Edbert B. Hsu, MD, MPH; Karen Kohri Gary B. Green, MD, MPH; Karen A. Robinson, MSc; Eric B. Bass, MD, MPH; Sara E. Cosgrove, MD, MS
March/April 2007; pages 87-95

Abstract
Introduction: Disaster drills are a valuable means of training healthcare providers to respond to mass casualty incidents resulting from acts of terrorism or public health crises. We present here a proposed hospital-based disaster drill evaluation tool that is designed to identify strengths and weaknesses of hospital disaster drill response, provide a learning opportunity for disaster drill participants, and promote integration of lessons learned into future responses. Methods: Clinical specialists, experienced disaster drill coordinators and evaluators, and experts in questionnaire design developed the evaluation modules based upon a comprehensive review of the literature, including evaluations of disaster drills. The tool comprises six evaluation modules designed to capture strengths and weaknesses of different aspects of hospital disaster response. The Predrill Module is completed by the hospital during drill planning and is used to define the scope of the exercise. The Incident Command Center Module assesses command structure, communication between response areas and the command center, and communication to outside agencies. The Triage Zone Module captures the effect of a physical space on triage activities, efficiency of triage operations, and victim flow. The Treatment Zone Module assesses the relation of the zone’s physical characteristics to treatment activities, efficacy of treatment operations, adequacy of supplies, and victim flow. A Decontamination Zone Module is available for evaluating decontamination operations and the use of decontamination and/or personal protective equipment in drills that involve biological or radiological hazardous materials. The Group Debriefing Module provides sample discussion points for drill participants in all types of drills. The tool also has addenda to evaluate specifics for 1) general observation and documentation, 2) victim tracking, 3) biological incidents, and 4) radiological incidents. Conclusion: This evaluation tool will help meet the need for standardized evaluation of disaster drills. The modular approach offers flexibility and could be used by hospitals to evaluate staff training on response to natural or man-made disasters. Key words: hospital, training, disaster drill, mass casualty incident


Article
Literature review. Disaster management of chronic dialysis patients
Richard Zoraster, MD; Raymond Vanholder, MD, PhD; Mehmet S. Sever, MD
March/April 2007; pages 96-106

Abstract
The chronically ill are often the hardest hit by disruptions in the healthcare system—they may be highly dependent on medications or treatments that suddenly become unavailable, they are more physically fragile than the rest of the population, and for socioeconomic reasons they may be more limited in their ability to prepare or react. Medical professionals involved in disaster response should be prepared to care for individuals suffering from the complications of chronic illness, and they must have some idea of how to do so with limited resources. Dialysis-dependent, end-stage renal disease patients are at especially high risk following disasters. Infrastructure damage may make dialysis impossible for days, and few physicians have experience or training in the nondialytic management of end-stage renal disease. Nondialytic management strategies include dietary restrictions, aggressive attempts at potassium removal via resins and cathartics, and adaptations of acute treatment strategies. Appropriate planning and stockpiling of medications such as Kayexalate are critical to minimizing morbidity and mortality. Key words: disaster, extrahospital care, dialysis, nondialytic management, end-stage renal disease

American Journal of Disaster Medicine
May/June 2007, Volume 2
, Number 3


Article
Reuniting children with their families during disasters: A proposed plan for greater success
Sarita Chung, MD; Michael Shannon, MD, MPH
May/June 2007; pages 113-117

Abstract
In the event of a terrorist attack or natural disaster, large numbers of children may be separated from their families and caregivers. Many of these children will present for treatment at emergency departments or be evacuated to relocation sites. Depending on their age, some children may not be able to give their name or may be too frightened to give any information, making identification difficult. At the same time, parents will instinctively rush to hospitals to find their children. In the process, parents may unintentionally obstruct medical care, overwhelm an already stressed staff, and violate patient privacy as they frantically search for their children. Currently, there is no system in the United States that effectively expedites the reunification of children with their families when children can not be identified by healthcare or public health personnel. We propose the creation of a system that employs advanced imaging and feature-extraction technology. We envision a system in which digital images of individual children are captured as they enter a facility, with these images then being automatically transmitted and posted on a secure Web site. Features of each image, such as hair and eye color, would be automatically indexed and cataloged. With the help of trained professionals, parents could enter their child’s features into the system and receive a limited set of images for identification, allowing for rapid reunification of the family. Additional advanced features of such a system will be explored. If successful, the use of such a system would address an important unmet need in pediatric emergency preparedness. Key words: emergency, emergency department, children, identification, family reunification


Article
Medical outreach following a remote disaster: Lessons learned from Hurricane Katrina
Anne Lang Dunlop, MD, MPH; Alexander P. Isakov, MD, MPH; Michael T. Compton, MD, MPH; Melissa White, MD, MPH; Hogai Nassery, MD; Erica Frank, MD, MPH; Karen Glanz, PhD, MPH
May/June 2007; pages 121-132

Abstract
In the aftermath of Hurricane Katrina, many individuals were evacuated to the Atlanta area (1,306 medical evacuees, over 100,000 self-evacuees), placing considerable strain on an already overburdened healthcare system. With the aim of improving future disaster responsiveness, we designed this in-depth case study to identify systemic vulnerabilities and gaps in community responsiveness to an influx of evacuees from a remote disaster. Qualitative methods were used to interview key informants both individually and in focus groups. Coding and content analysis of transcribed interview data were used to identify shared observations and common themes. Twenty-three individuals in leadership roles at the Woodruff Health Sciences Center of Emory University or the Grady Health System completed individual interviews; an additional 24 healthcare providers participated in focus groups. A strategy-based data-coding scheme for interview data was used to identify key foci, including services that met needs of evacuees, unmet needs, service provision that was successful/unsuccessful, underlying reasons for success or failure, and future needs for disaster planning and responsiveness. Analysis of interview data revealed important accomplishments and deficits in the medical community’s response in specific domains of community disaster planning and evaluation. For each key component of community disaster planning and evaluation, there are considerations at the institutional, regional, state, and federal levels. In the current study, these considerations were identified as instrumental in effectively meeting the healthcare needs of the evacuated population. Key words: disaster, evacuation, evacuees, healthcare needs, community response


Article
Integrating authorities and disciplines into the preparedness-planning process: A study of mental health, public health, and emergency management
Madeline Robertson, JD, MD; Betty Pfefferbaum, MD, JD; Catherine R. Codispoti, MHA; Juliann M. Montgomery, MPH
May/June 2007; pages 133-142

Abstract
The process of integrating all necessary authorities and disciplines into an organized preparedness plan is complex, and the inclusion of disaster mental health poses specific challenges. The goals of this project were 1) to identify whether state mental health preparedness was included in state public health and emergency management preparedness plans, 2) to document barriers to entry and strategies reportedly used by state authorities in efforts to incorporate reasonable mental health preparedness into existing public health and emergency management preparedness planning, 3) to employ a theory for organizational change to organize and synthesize this information, and 4) to stimulate further discussion and research supporting coordinated preparedness efforts at the state level, particularly those inclusive of mental health. To accomplish these goals we 1) counted the number of state public health preparedness and emergency management plans that either included, mentioned, or omitted a mental health preparedness plan; 2) interviewed key officials from nine representative states for their reports on strategies used in seeking greater inclusion of mental health preparedness in public health and emergency management preparedness planning; and 3) synthesized these results to contribute to the national dialogue on coordinating disaster preparedness, particularly with respect to mental health preparedness. We found that 15 out of 29 publicly available public health preparedness plans (52 percent) included mental health preparedness, and eight of 43 publicly available emergency management plans (18 percent) incorporated mental health. Interviewees reported numerous barriers and strategies, which we cataloged according to a well-accepted eight-step plan for transforming organizations. Key words: mental health, preparedness, disaster, integration, planning process


Article
Model “code silver” internal lockdown policy in response to active shooters
Scot Phelps, JD, MPH; Robert Russell, BS; Garrett Doering, MS
May/June 2007; pages 143-150

Abstract
Hospitals, even five years past the events of September 11, with their unguarded front doors and unlocked patient rooms have conspicuously failed to implement even basic security procedures to protect the society’s most vulnerable against violence. The degree of complacency is so great that even hospitals that have experienced shootings refuse to institute basic security measures such as metal detectors and identification checks. Over the six-month period, from June through December 2006, there were at least eight hospital shootings in the United States and Canada. This article outlines these shootings and presents a model “Code Silver” policy that hospitals can adopt to mitigate some of the risk of internal hospital shootings. Key concepts of the policy include training hospital staff to “shelter in place” during a violent event, marking locked doors, and having hospital security respond in an appropriate manner. Key words: hospital, physical security, policy, security, violence


Article
Pediatric disaster response in developed countries: Ten guiding principles
Mark A. Brandenburg, MD; Wendy L. Arneson, MS
May/June 2007; pages 151-162

Abstract
Mass casualty incidents and large-scale disasters involving children are likely to overwhelm a regional disaster response system. Children have unique vulnerabilities that require special considerations when developing pediatric response systems. Although medical and trauma strategies exist for the evaluation and treatment of children on a daily basis, the application of these strategies under conditions of resource-constrained triage and treatment have rarely been evaluated. A recent report, however, by the Institute of Medicine did conclude that on a day-to-day basis the US healthcare system does not adequately provide emergency medical services for children. The variability, scale, and uncertainty of disasters call for a set of guiding principles rather than rigid protocols when developing pediatric response plans. The authors propose the following guiding principles in addressing the well-recognized, unique vulnerabilities of children: 1) terrorism prevention and preparedness, 2) all-hazards preparedness, 3) postdisaster disease and injury prevention, 4) nutrition and hydration, 5) equipment and supplies, 6) pharmacology, 7) mental health, 8) identification and reunification of displaced children, 9) day care and school, and 10) perinatology. It is hoped that the 10 guiding principles discussed in this article will serve as a basic framework for developing pediatric response plans and teams in developed countries. Key words: disaster response, pediatrics, preparedness

American Journal of Disaster Medicine
July/August 2007, Volume 2
, Number 4


Article
The Role of Medical Interventions for the Treatment of Healthcare Workersduring the Next Influenza Pandemic
Ann Peterka, DO, MPH
July/August 2007; pages 169-171


Article
Dead bodies, disasters, and the myths about them: Is public health law misinformed?
Thomas A. Gionis, MD, JD, LLM, MBA, MHA, FCLM; Cyril H. Wecht, MD, JD, FCLM; Lewis W. Marshall, Jr., MS, MD, JD, FAAEP; Fred A. Hagigi, DrPH, MBA, MPH
July/August 2007; pages 173-188

Abstract
While the mission of public health is to fulfill society’s interest in ensuring a healthy society as “public health is what we, as a society, do collectively to assure the conditions for people to be healthy,” the mission of public health law is to assist in the creation of those conditions. However, at times of disaster, threats or risks caused by dead bodies often cause dramatic media coverage and public panic, which incite the pas-sage of emergency public health laws. The unfortunate result of such emergency public health laws mandating immediate dead body disposal, often through mass burial, is that proper identification of the deceased is severely hampered, and families are frequently precluded from experiencing the grieving process and are unable to bring closure to such a traumatic event. Are such emergency public health laws misinformed? Are the threats of dead bodies of disasters a threat to the public’s health? Are the perceived public health threats of dead bodies merely a myth—or is their cause for justified concern? Such a rush to burial not only may add to the psychological distress of survivors but it also for-bids them the opportunity of seeing their loved ones being treated with dignity and respect. Additional con-sequence of “emergency” mass burial legislation with-out proper identification include legal problems associated with inheritance, life insurance, remarriage of spouses, parenting of surviving children, and even the threat of diplomatic tensions between nation states resulting from burial of foreign tourists. Disaster medicine specialists are often called upon to comment to the media, advise governmental agencies, and console families, as to the disposition of dead bodies and to the existence of any public health threats caused by the accumulation of human cadavers. Because disaster medicine specialists play a vital role in preserving the public’s health, and because public fears of spread of infectious disease often escalate paralleling the accumulation of dead bodies, disaster medicine specialists must be properly informed of the epidemiologic risks and public health issues that dead bodies of disasters may pose. The purpose of this article is to provide a foundation for disaster medicine specialists in properly advising governments, the public, media, and families regarding the risks and fears concerning the health hazards of human cadavers resulting from disasters. Key words: dead bodies, disasters, myths, infectious diseases, public health law, infectious epidemiology, media panic, postdisaster human cadavers, natural disaster epidemics, burial, pathogens, ground water, cemetery, universal precautions, tuberculosis, blood-borne viruses, gastroenteritis, rescue workers, dead body handlers


Article
A relationship between US healthcare worker smallpox vaccination rates in 2003 and presidential election results in 2004
David G. Schultz, Jr, MPH; Melinda R. Mihelic; F. Matthew Mihelic, MD
July/August 2007; pages 189-194

Abstract
A statistical relationship exists between state per capita smallpox vaccination rates of healthcare workers in 2003 and state presidential election results in2004.The potential implications of political influence on national biosecurity decision making are discussed. Key words: smallpox, vaccination, immunization, healthcare worker, Presidential election


Article
Ready, aye ready? Support mechanisms for healthcare workers in emergency planning: A critical gap analysis of three hospital emergency plans
Carol A. Amaratunga, PhD; Tracey L. O’Sullivan, PhD; Karen P. Phillips, PhD; Louise Lemyre, PhD; Eileen O’Connor, PhD; Darcie Dow, MSc; Wayne Corneil, ScD
July/August 2007; pages 195-210

Abstract
Background: In response to the 2003 global out-break of severe acute respiratory syndrome (SARS),and the threat of pandemic influenza, Canadian hospitals have been actively developing and revising their emergency plans. Healthcare workers are a particularly vulnerable group at risk of occupational exposure during infectious disease outbreaks, as seen during SARS and as documented/reported in the recent National Survey of the Work and Health of Nurses (Statistics Canada,2006).Approximately one third of Canadian nurses identified job strain and poor health, related to their work environment. Three years after SARS, this article presents a critical analysis of the gaps of three hospital pandemic influenza plans in the context of established organizational supports for healthcare workers. Methods: Hospital pandemic influenza plans were obtained from institutional representatives in three Ontario cities. Qualitative gap analysis of these plans was conducted using a checklist of 11 support categories, developed from a review of existing literature and findings from a previous study of focus groups with emergency and critical care nurses. Results: Support mechanisms were identified in the plans; however, gaps were evident in preparation for personal protective equipment, education and informational support, and support during quarantine. Hospital emergency planning could be more robust by including additional organizational supports such as emotional/psychological support services, delineating management responsibilities, human resources, vaccine/anti-viral planning, recognition/compensation, media strategies, and professional development. Conclusions: Since the 2003 SARS outbreak, hospitals have invested in pandemic planning, as evidenced by the comprehensive plans examined here. Organizational support mechanisms for healthcare workers were included in these hospital plans; however, the gaps identified here may have serious implications for employee health and safety, and overall response during a large scale infectious disease outbreak. The authors provide a number of recommendations for consideration in infectious disease pandemic plan development to better support the healthcare workers in their roles as first responders. Key words: healthcare workers, occupational health and safety, infectious diseases, bioterrorism, organizational support, disaster management, hospital, pandemic

American Journal of Disaster Medicine
September/October 2007, Volume 2
, Number 5


Article
Acute posttraumatic stress symptoms and depression after exposure to the2005 Saskatchewan Centennial Air Show disaster: Prevalence and predictors
Steven Taylor, PhD; R. Nicholas Carleton, MA; Peter Brundin, MA
September/October 2007; pages 217-230

Abstract
Objectives: The purpose of this study was to deter-mine the prevalence of acute distress—that is, clinically significant posttraumatic stress symptoms (PTSS) and depression—and to identify predictors of each in a sample of people who witnessed a fatal aircraft collision at the 2005 Saskatchewan Centennial Air Show. Design: Air Show attendees (N = 157) were recruited by advertisements in the local media and completed an Internet-administered battery of questionnaires. Results: Based on previously established cut-offs, 22 percent respondents had clinically significant PTSS and 24 percent had clinically significant depressive symptoms. Clinically significant symptoms were associated with posttrauma impairment in social and occupational functioning. Acute distress was associated with several variables, including aspects of Air Show trauma exposure, severity of prior trauma exposure, low posttrauma social support (ie, negative responses by others),indices of poor coping (eg, intolerance of uncertainty, rumination about the trauma),and elevated scores on anxiety sensitivity, the personality trait of absorption, and dissociative tendencies. Conclusions: Results suggest that clinically significant acute distress is common in the aftermath of witnessed trauma. The statistical predictors (correlates) of acute distress were generally consistent with the results of studies of other forms of trauma. People with elevated scores on theoretical vulnerability factors (eg, elevated anxiety sensitivity) were particularly likely to develop acute distress. Key words: Saskatchewan Air Show Disaster, post-traumatic stress, depression, anxiety sensitivity, acute stress, social support


Article
Planning the bioterrorism response supply chain: Learn and live
Margaret L. Brandeau, PhD; David W. Hutton, MS; Douglas K. Owens, MD, MS; Dena M. Bravata, MD, MS
September/October 2007; pages 231-247

Abstract
Responses to bioterrorism require rapid procurement and distribution of medical and pharmaceutical supplies, trained personnel, and information. Thus, they present significant logistical challenges. On the basis of a review of the manufacturing and service supply chain literature, the authors identified five supply chain strategies that can potentially increase the speed of response to a bioterrorism attack, reduce inventories, and save money: effective supply chain network design; effective inventory management; postponement of product customization and modularization of component parts; coordination of supply chain stakeholders and appropriate use of incentives; and effective information management. The authors describe how concepts learned from published evaluations of manufacturing and service supply chains, as well as lessons learned from responses to natural disasters, naturally occur-ring outbreaks, and the 2001 US anthrax attacks, can be applied to design, evaluate, and improve the bioterrorism response supply chain. Such lessons could also be applied to the response supply chains for disease outbreaks and natural and manmade disasters. Key words: bioterrorism, logistics, supply chain, inventory management


Article
The utility of handheld ultrasound in an austere medical setting in Guatemala after a natural disaster
Anthony J. Dean, MD; Bon S. Ku, MD; Eli M. Zeserson, MD
September/October 2007; pages 249-256

Abstract
Objective: To identify equipment needs, utility, clinical applications, and acuity of diagnoses made by hand-carried ultrasound (HCU) after a natural disaster. Methods: An HCU with four probes (curved array, linear array, phased array, and endocavitary) was taken to the site of a natural disaster in Guatemala as part of the relief effort after mudslides killed approximately 1,000 people. Ultrasound (US) scans were classified by transducer type, anatomic region, presenting complaint, and therapeutic urgency of treatment. Results: Ninety-nine patients received 137 US: 58 pelvic, 34 right upper quadrant,23 renal, six other abdominal, five orthopedic, four cardiac, three pleura and lung, three soft tissue, and one focused assessment by sonography in trauma. Acuity of presenting illness: 23 percent < 24 hours, 15 percent 1-14 days, 44 percent > 14 days. Eighteen percent were performed in prenatal clinic. Results of US ruled in 12 percent with an emergent problem and excluded disease in 42 percent. In 14 percent, US diagnosed a problem needing f/u in < 2weeks, and 32 percent with a problem needing long-term observation. Transducer utilization was general purpose curved array 88 percent, linear array10 percent, endocavitary 8 percent, and phased array 4 percent. Conclusions: HCU has a range of applications in an austere medical setting after a natural disaster. Most can be dealt with using a single transducer. Key words: hand carried, ultrasonography, disasters, emergency


Article
The impact of hurricanes and flooding disasters on hymenopterid-inflicted injuries
James H. Diaz, MD, MPH&TM, DrPH
September/October 2007; pages 257-269

Abstract
Insect bites and stings, often complicated by allergic reactions or skin infections with community-acquired pathogens, are common sources of morbidity following hurricanes and flooding disasters. The hymenopterids are the most commonly stinging arthropods to cause allergic reactions, and include bees, wasps, and ants. To assess the evolving epidemiology of hymenopterid-inflicted injuries, and the impact of hurricanes and flooding disasters on hymenopterid-inflicted injuries in the United States, an epidemiological analysis of the scientific literature on hymenopterid stings and allergic sting reactions was conducted by MEDLINE search, 1966-2006. The increasing incidence of hymenopterid-inflicted injuries following hurricanes and flooding disasters was described. Common immunological reactions to hymenopterid-inflicted injuries were stratified by clinical severity and outcome. Current recommendations for management, prevention, and prophylaxis of hymenopterid-inflicted injuries were presented. Hymenopterid stings and allergic reactions remain common indications for emergency department visits, especially following hurricanes and flooding disasters. Unrecognized anaphylactic reactions to hymenopterid stings remain significant causes of unanticipated deaths outdoors in young people. Disaster planners and managers are obliged to alert regional healthcare providers of the increased risks of hymenopterid-inflicted injuries following flooding disasters and to assure that emergency drug formularies are properly stocked to treat hymenopterid-inflicted injuries. Key words: disasters, natural, hurricanes, floods, bites and stings, insects, Hymenoptera, allergy, anaphylaxis


Article
The 1995 Kikwit Ebola outbreak—Model of virus properties on system capacity and function: A lesson for future viral epidemics
Ryan C.W. Hall, MD; Richard C.W. Hall, MD
September/October 2007; pages 270-276

Abstract
The 1995 Kikwit Ebola outbreak in the Democratic Republic of the Congo is one of the first Ebola out-breaks to be treated in a hospital setting and is one of the most well-studied Ebola epidemics to have occurred to date. Many of the lessons learned from identifying, containing, and treating the epidemic are applicable to future viral outbreaks. This article looks at the characteristics of the Ebola virus and health system issues, which affected the healthcare providers’ ability to contain and treat the virus. It specifically examines factors such as the disease characteristics, surge capacity, supply issues, press involvement, and the involvement of voluntary organizations. Key words: Ebola, Hemorrhagic virus, Surge capacity

American Journal of Disaster Medicine
November/December 2007, Volume 2
, Number 6


Article
Editorial Pandemic preparedness and hard to reach populations
David Vlahov, PhD; Micaela H. Coady, MS; Sandro Galea, MD, DrPH; Danielle C. Ompad, PhD; Jeremiah A. Barondess, MD
November/December 2007; pages 281-284


Article
Effective healthcare system response to consecutive Florida hurricanes
Laura L. Banks, DVM, MPH; Mark B. Shah, MD; Michael E. Richards, MD, MPA
November/December 2007; pages 285-295

Abstract
In September 2004,two consecutive hurricanes(Hurricane Frances and Hurricane Jeanne) made landfall in Stuart, FL, and created healthcare needs that overtaxed the capacity of the local healthcare system. To determine the character and structure of the response to these hurricanes, researchers from the University of New Mexico, Center for Disaster Medicine conducted both a structured written survey of employees and a guided group interview with healthcare system management. The written survey queried staff on topics related to their ability and willingness to get to work and stay at work during the storms. The round-table interview with leadership resulted in analysis of the preexisting Emergency Operations Plan and its use during the storms, including preparation and execution of plans for staffing, facility operation, communication, community resource utilization, and recovery. In addition, the interaction with federally deployed Disaster Medical Assistance Teams was documented and reviewed. In general, prior planning on the part of the healthcare system in Stuart, FL, resulted in a successful response to both hurricanes. Employees were willing and able to provide the necessary care for patients during the hurricanes, overcoming many physical and emotional barriers that arose during the month-long response. These barriers included concern for the safety of family and pets, inoperable or insufficient communication methods, and damage to employees’ personal property and homes. Recommendations for healthcare system preparedness and response were formulated by the researchers based on this healthcare system’s successful response to back-to-back hurricanes, including recommendations for interacting with disaster medical resources. Key words: DMAT, disaster medicine, hurricane, preparedness


Article
Clinical assessment in disaster mental health: A logic of case formulation
O. Lee McCabe, PhD; Michael J. Kaminsky, MD, MBA; Paul R. McHugh, MD
November/December 2007; pages 297-306

Abstract
Despite increased professional attention to the mental health aspects of disaster medicine in recent years, advances in clinical assessment of survivors of mass casualty incidents have been few. Contemporary assessment methods often yield little more than checklists of symptoms that, while they may lead to reliable DSM-IV diagnoses, provide no sense of the individual patient’s plight and so are inadequate for case formulation, treatment planning, and prognosis estimation. The authors describe a comprehensive model for assessing patients developed at the Johns Hopkins Department of Psychiatry and Behavioral Sciences. Relating it to the field of disaster mental health for the first time here, the approach uses four distinct but over-lapping appraisal perspectives, each of which drives a set of exploratory propositions and leads to an under-standing of the essential natures of clinical disorders and their underlying etiologies. The perspectives address the following:(a) what the individual “has”(biologically based disease and physical illness);(b)who the individual “is”(graded dimensions of temperament, disposition, traits, intelligence, etc);(c) what the individual “does”(purposeful, goal-directed, conditioned behavior, etc);and (d) what the individual “has encountered”(his/ her life story and the meaning that has been given to those experiences).Following a description of each perspective from the standpoint of its underlying logic, inquiry domain, and indicated intervention, the authors highlight the potential hueristic value of the model by illustrating numerous testable hypotheses that can be generated through the juxtaposition of the four assessment perspectives with three longitudinal considerations for the management of trauma patients, ie, the stress-related constructs of (pre-incident) resistance,(peri-incident) resilience, and (post-incident) recovery. Key words: disaster mental health, psychological trauma, clinical assessment, case formulation


Article
Primary intervention for memory structuring and meaning acquisition(PIMSMA): Study of a mental health first-aid intervention in the ED with injured survivors of suicide bombing attacks
Shaul Schreiber, MD; Ornah T. Dolberg, MD; Gabriel Barkai, MD; Einat Peles, PhD; Agnes Leor, MD; Elena Rapoport, MD; Jeremia Heinik, MD; Miki Bloch, MD
November/December 2007; pages 307-320

Abstract
Objective: To assess the impact of a structured intervention, the “primary intervention for memory structuring and meaning acquisition”(PIMSMA) per-formed randomly in the emergency department with survivors of suicide bombing attacks, on their medium-term mental health outcome. Design: Follow up and assessment 3-9 months postinjury, and 24 months thereafter. Setting: A tertiary referral general hospital in Tel Aviv, Israel. Participants: Injured survivors of 9 suicide bombing and suicide shooting, men and women aged16-72 at the time of the incident. Main outcome measures: Diagnosis of posttraumatic stress disorder (PTSD) was made using the Hebrew validated version of the DSM-IV SCID-PTSD rating scale. Other psychiatric symptoms were assessed using the following rating scales: impact of event scale (IES),Hamilton rating scale for depression(HAM-D) and for anxiety (HAM-A),and the Pittsburgh sleep quality index (PSQI).Effects of PIMSMA and PTSD level of psychological distress were analyzed using ANOVA and for change over time for continuous variables repeated measured multivariate analyses was performed, and for categorical variables non parametric-related sample McNemar. Logistic regression for variable associated with PTSD was performed. Results: Out of 213 eligible injured survivors evacuated to our ER,129 were retrieved 3-9 months after the incident, and 53 were available for assessment 2 years later. Multivariate analyses for being PTSD vs non-PTSD at the first evaluation, being hospitalized OR = 5.6 (95 percent CI 1.1-27.6) and treated OR = 24.5 (95 percent CI 2.8-200) were the only predictors, with no effect (p = 0.9) for PIMSMA vs other supportive intervention. Predictor for PTSD at the second evaluation were IES severity score at first evaluation OR = 1.1 (95 percent CI 1.04-1.2). Conclusion: The PIMSMA approach is as good as the nonspecific supportive treatment performed routinely in the ED with all survivors of traumatic events of any origin. Further studies are needed to establish valid, evidence-based treatment approaches for the acute aftermath of exposure to severe potentially traumatic events. Key words: PTSD, suicide bombing, terror attack, memory structuring, mental-health first aid, emergency department


Article
The impact of the refugee decision on the trajectory of PTSD, anxiety, and depressive symptoms among asylum seekers: A longitudinal study
Derrick Silove, MBChB (Hons I), MD, FRANZCP; Zachary Steel, MPsych, BA; Ina Susljik, BA, PDip; Naomi Frommer, BA, LLB; Celia Loneragan, BA; Tien Chey, MAppstat; Robert Brooks, PhD; Dominique le Touze, BA, MSc; Mariano Ceollo, BA, MPsych; Mitchell Smith, MBBS; et al.
November/December 2007; pages 321-329

Abstract
Objective: To examine prospectively the trajectory of trauma-related psychiatric symptoms and disability amongst asylum seekers over the course of the refugee determination process. To identify the direct impact of the refugee decision on psychiatric symptoms by adjusting for other variables, namely sociodemographic characteristics, past trauma, and ongoing postmigration stresses. Design: A prospective cohort study of asylum seekers recruited from a random sample of immigration agents in Sydney, Australia. Setting: Consecutive asylum seekers were referred for interview by immigration agents. Interviews were undertaken after the initial application and on average, 3.8 months after the refugee decision. Measures: Measures assessed premigration trauma and postmigration stressors. Mental health status was assessed using the Harvard Trauma Questionnaire and the Hopkins Symptom Checklist-25. Functional impairment was assessed with the Medical Outcomes Study-Short Form 12.Results:Sixty-two of 73 asylum seekers were retained at follow-up. The accepted (16) and rejected(46) groups did not differ on premigration trauma or baseline psychiatric symptoms. Postdecision, the accepted group showed substantial improvements in posttraumatic stress disorder, anxiety, depression, and in mental health functioning, whereas the rejected group maintained high levels of symptoms on all psychiatric indices. Conclusions: Establishing secure residency status for asylum seekers may be important to their recovery from trauma-related psychiatric symptoms. The practical and theoretical implications are discussed. Key words: refugees, asylum seekers, trauma, PTSD, postmigration stress, migration, policy