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American Journal of Disaster Medicine
January/February 2010, Volume 5
, Number 1


Article
Deployment and operation of a transportable burn intensive care unit in response to a burn multiple casualty incident
COL David J. Barillo, MD, FACS; COL Leopoldo C. Cancio, MD, FACS; COL Richard S. Stack, MD, FACS; LCDR Shamus R. Carr, MD; CPT Kristine P. Broger, RN, MHA, CCRN; SSG David M. Crews, LVN; LTC Evan M. Renz, MD, FACS; COL Lorne H. Blackbourne, MD, FACS
January/February 2010; pages 5-13

Abstract
In many hospitals, intensive care units (ICUs) operate at or above capacity on a daily basis. Multiple casualty incidents will create a sudden need for additional ICU beds and hospital planning for disaster response must anticipate the need for rapid ICU expansion. In this article, the authors describe the management of 6 patients who were burned in Guam and successfully transported a distance of 7,268 miles to San Antonio, TX, for tertiary burn center care. The mission required creation of a temporary burn ICU at Tripler Army Medical Center in Hawaii, approximately midway between the referring hospital and the receiving burn center. A method of creating a temporary burn center is described. Lessons learned, including the need to standardize equipment, and to cross-train and cross-credential medical personnel, are applicable to both military and civilian mass casualty management. Key words: burn, mass casualty, aeromedical evacuation, CCATT DOI:10.5055/ajdm.2010.0001


Article
Pandemic-related ability and willingness in home healthcare workers
Robyn R. M. Gershon, MHS, DrPH; Lori A. Magda, MA; Allison N. Canton, BA; Halley E. M. Riley, BA; Faith Wiggins, BA; Wayne Young, MBA; Martin F. Sherman, PhD
January/February 2010; pages 15-26

Abstract
Objective: To assess pandemic-related attitudes and behavioral intentions of home healthcare workers (HHCWs). Design: Cross-sectional survey. Setting: New York City. Participants: A convenience sample of 384 HHCWs. Main Outcome Variables: Ability and willingness to report to work during a pandemic influenza outbreak. Results: A large proportion of HHCWs reported that they would be either unable or unwilling (or both) to provide care to their current (83 percent) or new (91 percent) patients during a pandemic. Ability was significantly associated with not having children living at home, having alternatives to mass transportation, not having a spouse/partner employed as a first responder or healthcare worker, and having longer tenure (ie, six or more years) in homecare. During an outbreak, 43 percent of HHCWs said they would be willing to take care of current patients and only 27 percent were willing to take care of new patients. Willingness to care for both current and new patients was inversely associated with fear for personal safety (p < 0.01). Provision of key elements of a respiratory protection program was associated with decreased fear (p < 0.05).Most participants (86 percent) had not received any work-based, pandemic related training, and only 5 percent reported that their employer had an influenza pandemic plan. Conclusions: Given that a large majority of the participating HHCWs would either be unable or unwilling to report to duty during a pandemic, potential shortfalls in this workforce may occur. To counter this, organizations should focus on strategies targeting intervenable barriers to ability and to willingness (ie, the provision of a vaccine and respiratory protection programs). Key words: home healthcare workers, ability, willingness, influenza pandemic, surge capacity DOI:10.5055/ajdm.2010.0002


Article
Pediatric disaster preparedness of a hospital network in a large metropolitan region
Rizaldy R. Ferrer, PhD; Darshi Balasuriya, MPH; Ellen Iverson, MPH; Jeffrey S. Upperman, MD, FAAP, FACS
January/February 2010; pages 27-34

Abstract
Objectives: We describe pediatric-related emergency experiences and responses, disaster preparation and planning, emergency plan execution and evaluation, and hospital pediatric capabilities and vulnerabilities among a disaster response network in a large urban county in the West Coast of the United States. Methods: Using semistructured key informant interviews, the authors conducted qualitative research between March and April 2008. Eleven hospitals and a representative from the community clinic association agreed to participate (86 percent response rate) and a total of 22 key informant interviews were completed. Data were analyzed using ATLAS.ti.v.5.0, a qualitative analytical software program. Results: Although hospitals have infrastructure to respond in the event of a large-scale disaster, well established disaster preparedness plans have not fully accounted for the needs of children. The general hospitals do not anticipate a surge of pediatric victims in the event of a disaster, and they expect that children will be transported to a children’s hospital as their conditions become stable. Conclusions: Even hospitals with well-established disaster preparedness plans have not fully accounted for the needs of children during a disaster. Improved communication between disaster network hospitals is necessary as incorrect information still persists. Key words: pediatric, disaster preparedness, hospital network DOI:10.5055/ajdm.2010.0003


Article
Quality control in disaster medicine training—Initial regional medical command and control as an example
Heléne Nilsson, RN; Tore Vikström, MD, PhD; Anders Rüter, MD, PhD
January/February 2010; pages 35-40

Abstract
Objective: The aim of this study was to show the possibility to identify what decisions in the initial regional medical command and control (IRMCC) that have to be improved. Design: This was a prospective, observational study conducted during nine similar educational programs for regional and hospital medical command and control in major incidents and disasters. Eighteen management groups were evaluated during 18 standardized simulation exercises. Main Outcome Measure: More detailed and quantitative evaluation methods for systematic evaluation within disaster medicine have been asked for. The hypothesis was that measurable performance indicators can create comparable results and identify weak and strong areas of performance in disaster management education and training. Methods: Evaluation of each exercise was made with a set of 11 measurable performance indicators for IRMCC. The results of each indicator were scored 0, 1, or 2 according to the performance of each management group. Results: The average of the total score for IRMCC was 14.05 of 22. The two best scored performance indicators, No 1 “declaring major incident” and No 2 “deciding on level of preparedness for staff,” differed significantly from the two lowest scoring performance indicators, No 7 “first information to media” and No 8 “formulate general guidelines for response.” Conclusion: The study demonstrated that decisions such as “formulating guidelines for response” and “first information to media” were areas in initial medical command and control that need to be improved. This method can serve as a quality control tool in disaster management education programs. Key words: performance indicators, disaster management, education, quality measurement DOI:10.5055/ajdm.2010.0004


Article
Experiences of Iraqi doctors in Jordan during conflict and factors associated with migration
Shannon Doocy, PhD; Sana Malik, MPH; Gilbert Burnham, MD, PhD
January/February 2010; pages 41-47

Abstract
Objectives: To document the experiences of Iraqi doctors residing in Jordan before departure from Iraq and to assess factors associated with migration. Methods: Respondent-driven sampling was used to obtain information from 401 Iraqi doctors arriving in Jordan after the invasion of 2003. Three seeds were used and chains were carried out to 10-11 waves of respondents; interviews were carried out either in person or by mobile phone. Results: Migration of Iraqi doctors to Jordan peaked in 2006; 94 percent of doctors were from Baghdad and 25 percent had been internally displaced before migration to Jordan. Departure from Iraq was associated with a violent event in 61 percent (confidence interval [CI]: 56-65) of cases and 75 percent (CI: 70-79) of doctor households experienced a violent event before migration. Kidnappings or assassination attempts were reported by 17 percent (CI: 25-34) of doctors; male sex and older age were significantly associated with increased risk in multivariate models. Only 30 percent (CI: 25-34) of doctors reported they have plan to return to Iraq when the conflict is over and 6 percent (CI: 4-9) reported planning to return to Iraq within a year; the majority (52 percent, CI: 47-57) planned to settle in a third country. Conclusions: Iraq has lost many of its doctors as a result of the conflict, and the majority of those displaced in Jordan have no plans to return. The human capital losses associated with the large-scale displacement of Iraqi doctors are substantial and have left a critical void in human capital that will likely impact the health system for decades. Key words: Iraq, conflict, violence, doctors, migration, human capital DOI:10.5055/ajdm.2010.0005


Article
Response capabilities of the National Guard: A focus on domestic disaster medical response
Daniel Bochicchio, MD, FCCP
January/February 2010; pages 49-55

Abstract
The National Guard has a 373-year history of responding to the nation’s call to duty for service both at home and abroad (The National Guard Bureau Web site: Available at http://www.ngb.army.mil/default. aspx.). The National Guard (NG) is a constitutionally unique organization (United States Constitution, US Government Printing Office Web site: Available at http://www.gpoaccess.gov/constitution/index.html.). Today’s Guard conducts domestic disaster response and civilian assistance missions on a daily basis. Yet, the NG’s role, mission, and capabilities are not well-known or understood. The National Response Framework (NRF) places significant responsibility on the local and state disaster planners (Department of Homeland Security: National Response Framework. US Department of Homeland Security, Washington, DC, January 2008).The public health professionals are an integral component of the disaster planning community. It is critical that the public health community be knowledgeable of types and capabilities of all the response assets at their disposal. Key words: disaster preparedness, National Guard, disaster response, chemical and biological preparedness, emergency management, public health planning DOI:10.5055/ajdm.2010.0006


Article
Hurricane Katrina and the need for changes in the federal funding of disaster mental health
Carl F. Weems, PhD
January/February 2010; pages 57-59

Abstract
Recent findings showing chronic post-traumatic stress disorder and other mental health symptoms in individuals exposed to Hurricane Katrina cogently argues for changes in the federal funding of mental health following disasters. This commentary discusses the evidence for protracted high rates of mental health problems in both adults and children following Katrina. The limitations to current mental health funding legislation post-disaster are noted, and initial suggestions for additional disaster-related mental health funding programs are made. Key words: PTSD, mental health, funding DOI:10.5055/ajdm.2010.0007


Article
Mass gathering medical care: To calculate the Medical Usage Rate of Galway Races
Waqar Shah, AFRCSI
January/February 2010; pages 61-64

Abstract
Medical Usage Rate (MUR) of Galway Races: The Galway Races is the most popular horse-racing festival in Ireland. It takes place for a week starting from the last Monday in July. The races are held at Ballybrit race course in Galway. During the 7 days of racing, about 180,000 people attend. The average temperature in Galway around that time of the year is around 15-20°C. The aim of this study is to calculate the MUR of Galway Races and to develop a model to predict the MUR for Galway Races in future. The MUR of Galway Races is calculated by looking retrospectively at the medical records of the last 11 years of Galway Races from 1997 to 2007. The Galway Races has a MUR of 3.67 patient per ten thousand. Based on the figures for last 10 years, the predictive MUR for Galway Races 2008 calculated before the races and actual figures in 2008 races is comparable. Key words: mass, gathering, medical, care DOI:10.5055/ajdm.2010.0008

American Journal of Disaster Medicine
March/April 2010, Volume 5
, Number 2


Article
The Transitional Medical Model: An innovative methodology for a community’s disease outbreak and pandemic preparedness and response plan
Paul Rega, MD, FACEP; Christopher Bork, PT, PhD, EMT-B, FASAHP; Michael Bisesi, PhD, CIH; Jeffrey Gold, MD; Kelly Burkholder-Allen, RN, MSEd
March/April 2010; pages 69-81

Abstract
Infectious disease outbreaks, epidemics, and subsequent pandemics are not typical disasters in the sense that they often lack clearly delineated phases. As in any event that is biological in nature, its onset may be gradual with signs and symptoms that are so subtle that they go unrecognized, thus missing opportunities to invoke an early response and implement containment strategies. An infectious disease outbreak—whether caused by a novel virus, a particularly virulent influenza strain, or newly emerging or resistant bacteria with the capability of human-to-human transmission—can quickly degrade a community’s healthcare infrastructure in advance of coordinated mitigation, preparation, and response activities. The Transitional Medical Model (TMM) was developed to aid communities with these crucial phases of disaster response as well as to assist with the initial steps within the recovery phase. The TMM is a methodology that provides a crosswalk between the routine operations and activities of a community’s public health infrastructure with action steps associated with the mitigation, preparedness, response, and recovery phases of an infectious disease outbreak. Key words: infectious disease outbreak, disease outbreak, epidemic, pandemic, influenza, novel virus, emerging disease DOI:10.5055/ajdm.2010.0009


Article
Pediatric issues in disaster management, Part 1: The emergency medical system and surge capacity
Sharon E. Mace, MD; Ghazala Sharieff, MD; Andrew Bern, MD; Lee Benjamin, MD; Dave Burbulys, MD; Ramon Johnson, MD; Merritt Schreiber, PhD
March/April 2010; pages 83-93

Abstract
Although children and infants are likely to be victims in a disaster and are more vulnerable in a disaster than adults, disaster planning and management has often overlooked the specific needs of pediatric patients. The authors discuss key components of disaster planning and management for pediatric patients, including emergency medical services, hospital/facility issues, evacuation centers, family separation/reunification, children with special healthcare needs (SHCNs), mental health issues, and overcrowding/ surge capacity. Specific policy recommendations and an appendix with detailed practical information and algorithms are included. The first part of this three-part series on pediatric issues in disaster management addresses the emergency medical system from the field to the hospital and surge capacity including the impact of crowding. The second part addresses the appropriate setup and functioning of evacuation centers and family separation and reunification. The third part deals with special patient populations: children with SHCNs and mental health issues. Key words: disaster, pediatric disasters, pediatrics, children, infants DOI:10.5055/ajdm.2010.0010


Article
Chemically contaminated casualties: Different problems and possible solutions
Joseph Scanlon, BJ, DPA, MA
March/April 2010; pages 95-105

Abstract
The initial response to mass casualty incidents is usually informal as uninjured and injured survivors and passersby assist the injured and take them to medical centers. This creates some problems, for example, most victims go to one or two hospitals and the least injured arrive first; but, on the whole, it works. However, the same response does not work when victims are contaminated, and some of the solutions that work when victims are only injured do not work when victims are contaminated. This article suggests an approach that accepts the reality of what happens—the first receiving hospital becomes contaminated—and suggests how planning can begin with that as a starting point. It stressed that current plans are based on false assumptions and that this can lead to inadequate preparation. Key words: mass casualties, contamination, emergency planning DOI:10.5055/ajdm.2010.0011


Article
Federal and state public health authority and mandatory vaccination: Is Jacobson v Massachusetts still valid?
Lewis W. Marshall Jr, MS, MD, JD, LLM; Brenda L. Marshall, EdD, APN; Glenn Valladares, MD, MBA
March/April 2010; pages 107-112

Abstract
Novel H1N1 influenza virus infected more than 43,000 people, killed 353 and spread to more than 122 countries within a few months. The World Health Organization declared a stage 6 worldwide pandemic. Healthcare workers and hospitals prepared for the worst. Federal and State regulations provided the legal framework to allow for the preparation and planning for a pandemic. One State had mandated both seasonal and Novel H1N1 vaccination of all healthcare workers in an effort to reduce transmission of influenza in healthcare facilities. The US Supreme Court decided in 1905 that the police power of the State permitted a State Department of Health the leeway to mandate vaccination in the face of a contagious disease. Law suits were filed, and a temporary injunction barring mandatory vaccination was entered by the court. While awaiting a court hearing, the mandatory vaccination regulation was rescinded because of the shortage of both seasonal and H1N1 vaccine. Based on the current state of the pandemic and the shortage of vaccination, it is possible that the US Supreme Court would uphold mandatory vaccination in a pandemic. Keywords: pandemic, mandatory vaccination, public health authority, novel H1N1 influenza virus DOI:10.5055/ajdm.2010.0012


Article
Emotional and biological stress measures in Katrina survivors relocated to Oklahoma
Phebe Tucker, MD; Haekyung Jeon-Slaughter, PhD; Betty Pfefferbaum, MD, JD; Qaiser Khan, MPH; Nathan J. Davis, MD
March/April 2010; pages 113-125

Abstract
Objectives: The authors assessed relocated Hurricane Katrina survivors’ emotional and biological stress measures 20 months postdisaster to understand effects of both hurricane exposure and forced relocation on emotional and physical health. Design: Psychiatric diagnoses, post-traumatic stress disorder (PTSD) and depressive symptoms, and biological stress measures were compared for total survivor and control groups and subgroups by PTSD diagnoses and lifetime trauma. Setting: Outpatient university psychiatry clinics in Oklahoma City and Tulsa. Participants: Thirty-four healthy adult Katrina survivors relocated to Oklahoma, and 34 healthy, demographically matched Oklahoma comparison participants. Main Outcome Measures: Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, assessed Axis I psychiatric disorders. Clinician-Administered PTSD Scale and Beck Depression Inventory quantified PTSD and depression symptoms. Biological stress measures were physiologic reactivity (heart rate and blood pressure responses to a trauma interview), interleukin-2 (IL-2; cell-mediated immunity), and interleukin-6 (IL- 6; proinflammatory cytokine). Results: Both groups had high lifetime trauma exposure. Among survivors, current hurricane-related and predisaster PTSD were diagnosed in 35.3 and 11.8 percent. Controls had current (11.8 percent) and lifetime (14.7 percent) PTSD. Survivors’ PTSD and depression symptom levels were higher than controls and within illness ranges. The survivors had higher IL-6 than nontraumatized controls, higher IL-6 in the presence of PTSD, and higher baseline heart rates and mean arterial blood pressure reactivity than controls. Conclusions: Higher IL-6 and autonomic measures for several Katrina survivor subgroups than control subgroups may confer future cardiovascular risks. The results are discussed relative to increased myocardial infarct rates in New Orleans after Katrina. Even healthy survivors should be assessed for cardiovascular risks and mental health sequelae. Key words: hurricane survivors, Hurricane Katrina, biological stress measures, psychophysiologic reactivity, interleukin-6, post-traumatic stress disorder DOI:10.5055/ajdm.2010.0013


Article
Health issues of internally displaced persons in Pakistan: Preparation for disasters in future
Mohammad Wasay, MD, FRCP, FAAN; Khalid Mushtaq, MBBS, MCPS, DTCD
March/April 2010; pages 126-128

Abstract
Army action against terrorism in Pakistan led to the largest human migration in this century. About 3.4 million people (internally displaced persons, IDPs) were displaced. The authors visited all major camps and some houses in Mardan area and interviewed IDPs and doctors at these camps and areas to identify medical needs and current state of provision of medical care. This disaster largely represented displacement of millions of people (IDPs) including women and children to a new weather and environment in overcrowded refugee camps and houses. Influx of large number of displaced people created excessive burden for already deprived local health services. The medical issues and requirements for these IDPs living in camps were totally different from a disaster like earthquake. Global response to this disaster was slow and less effective. The need for a WHO coordination center for creating quick and urgent response for such kind of disasters in future is emphasized in this article. Key words: refugees, disaster, migration, health DOI:10.5055/ajdm.2010.0014


Article
Case study Using an H1N1 vaccination drive-through to introduce healthcare students and their faculty to disaster medicine
Paul Rega, MD; Christopher Bork, PhD; Yixing Chen, MPH; Donna Woodson, MD; Patricia Hogue, PhD; Susan Batten, PhD
March/April 2010; pages 129-136

Abstract
Currently, the H1N1 pandemic does not approach the worst-case scenarios that have been predicted by the Centers for Disease Control and Prevention and the World Health Organization. Nevertheless, its impact, fueled by its predilection for nontraditional victims, assorted governmental miscalculations, and journalistic hyperbole, has led to an environment of both fear and skepticism. In this environment, the healthcare infrastructure must sift through relevant data, set aside political rhetoric, weigh the risk-benefit ratio of health-related mandates and recommendations, interact with diverse agencies and departments, and still attend to the medical, psychological, and educational needs of its patients and the community at large. Despite the challenges presented by the H1N1 pandemic, there is also an opportunity for expanded interdisciplinary education. Recent and past events, here and abroad, have demonstrated that in times of great healthcare need, professional students, through either volunteerism or impressments, have been an important asset in disaster medicine and mass gatherings.1-5 The current H1N1 situation affords healthcare educators an opportunity to expose the current generation of students to disaster medicine and management of care for aggregates and populations. This educational motive is reinforced by the students’ own altruistic desire to not only volunteer in a pandemic but also to act on the belief that it is their obligation.5 Therefore, the purpose of this article is to describe the preparedness and response roles of healthcare students and their faculty at a major university during the H1N1 crisis as an introduction to the interdisciplinary approach to disaster medicine and mass gatherings. Key words: H1N1, disaster medicine, vaccination, drive-through DOI:10.5055/ajdm.2010.0015

American Journal of Disaster Medicine
May/June 2010, Volume 5
, Number 3


Article
Healthcare ethics: The experience after the Haitian earthquake
Mill Etienne, MD, MPH; Clydette Powell, MD, MPH, FAAP; Dennis Amundson, DO, MS, FACP
May/June 2010; pages 141-147

Abstract
On January 12, 2010, a 7.0 Richter earthquake devastated Haiti and its public health infrastructure leading to a worldwide humanitarian effort. The United States sent forces to Haiti’s assistance including the USNS Comfort, a tertiary care medical center on board a ship. Besides setting a transparent triage and medical regulating system, the leadership on the Comfort instituted a multidisciplinary Healthcare Ethics Committee to assist in delivering the highest level efficient care to the largest number of victims. Allocation of resources was based on time-honored ethics principles, the concept of mass casualty triage in the setting of resource constraints, and constructs developed by the host nation’s Ministry of Health. In offering aid in austere circumstances, healthcare practitioners must not only adhere to the basic healthcare ethics principles but also practice respect for communities, cultures, and traditions, as well as demonstrate respect for the sovereignty of the host nation. The principles outlined herein should serve as guidance for future disaster relief missions. This work is in accordance with BUMEDINST 6010.25, Establishment of Healthcare Ethics Committees. Key words: disaster relief, Haiti, earthquake, Operation Unified Response, humanitarian assistance DOI:10.5055/ajdm.2010.0016


Article
Pediatric issues in disaster management, Part 2: Evacuation centers and family separation/reunification
Sharon E. Mace, MD; Ghazala Sharieff, MD; Andrew Bern, MD; Lee Benjamin, MD; Dave Burbulys, MD; Ramon Johnson, MD; Merritt Schreiber, PhD
May/June 2010; pages 149-161

Abstract
Although children and infants are likely to be victims in a disaster and are more vulnerable in a disaster than adults, disaster planning and management has often overlooked the specific needs of pediatric patients .We discuss key components of disaster planning and management for pediatric patients including emergency medical services, hospital/facility issues, evacuation centers, family separation/reunification, children with special healthcare needs, mental health issues, and overcrowding/surge capacity. Specific policy recommendations and an appendix with detailed practical information and algorithms are included. The first part of this three part series on pediatric issues in disaster management addresses the emergency medical system from the field to the hospital and surge capacity including the impact of crowding. The second part addresses the appropriate set up and functioning of evacuation centers and family separation and reunification. The third part deals with special patient populations: the special healthcare needs patient and mental health issues. Key words: disaster, pediatric disasters, pediatrics, children and infants DOI:10.5055/ajdm.2010.0017


Article
Utilizing paramedics for in-patient critical care surge capacity
Michael J. Reilly, DrPH(c), MPH, NREMT-P; David Markenson, MD, EMT-P
May/June 2010; pages 163-168

Abstract
Introduction: While many hospitals have developed preliminary emergency department and in-patient surge plans, the ability to surge is often limited by critical resources. The resource which is often the most limited is usually the human resource and within this category the limiting factor is almost universally nursing. As a result, nursing shortages can result in an inability of a hospital or emergency department to create surge capacity to deal with large numbers of ill or injured patients. Utilizing paramedics in acute-care hospitals or at alternate care sites could serve as expansion staff to supplement existing nursing staff, allowing fewer nurses to care for a larger numbers of patients during a disaster, act of terrorism, or public health emergency. While the procedures performed for nursing do vary from hospital to hospital, there are national certifications for both emergency nursing (CEN®) and critical care nursing (CCRN®) that can be used to establish a standard for comparison. Methods: A detailed review and curriculum mapping of the specific educational objectives and competencies of the US Department of Transportation National Standard Curriculum for the Emergency Medical Technician-Paramedic as well as the competencies and criteria for board certification as a Certified Emergency Nurse (CEN) and Critical Care Registered Nurse (CCRN) was performed. Results: Approximately 90 percent of the CEN and CCRN knowledge skills and competencies are met or exceeded by the National Standard Paramedic Curriculum. Conclusions:With appropriate training and orientation, paramedics may be used in an in-patient setting to augment emergency and critical care nursing staff during a disaster, act of terrorism, or public health emergency. Key words: surge capacity, paramedic, nursing, critical care, education, training, standard of care DOI:10.5055/ajdm.2010.0018


Article
O2C3: A unified model for emergency operations planning
Mark E. Keim, MD
May/June 2010; pages 169-179

Abstract
The leadership in each jurisdiction of the world has been described as legally, morally, and politically responsible for ensuring that necessary and appropriate actions are taken to protect people and property from the consequences of emergencies and disasters. As emergencies often evolve rapidly and become too complex for effective improvisation, a government can successfully discharge its emergency management responsibilities only by taking action beforehand. This requires preparedness in advance of the disaster event. Accordingly, preparedness measures should not be improvised or handled on an ad hoc basis. Key words: public health preparedness, disasters, emergency operations plan, capability-based planning, information technology, objective-based planning, Homeland Security Presidential Directives DOI:10.5055/ajdm.2010.0019


Article
Hurricane Katrina experience and the risk of post-traumatic stress disorder and depression among pregnant women
Xu Xiong, MD, DrPH; Emily W. Harville, PhD; Donald R. Mattison, MD; Karen Elkind-Hirsch, PhD; Gabriella Pridjian, MD; Pierre Buekens, MD, PhD
May/June 2010; pages 181-187

Abstract
Objective: Little is known about the effects of disaster exposure and intensity on the development of mental disorders among pregnant women. The aim of this study was to examine the effect of exposure to Hurricane Katrina on mental health in pregnant women. Design: Prospective cohort epidemiological study. Setting: Tertiary hospitals in New Orleans and Baton Rouge, USA. Participants: Women who were pregnant during Hurricane Katrina or became pregnant immediately after the hurricane. Main outcome measures: Post-traumatic stress disorder (PTSD) and depression. Results: The frequency of PTSD was higher in women with high hurricane exposure (13.8 percent) than women without high hurricane exposure (1.3 percent), with an adjusted odds ratio (aOR) of 16.8 (95% confidence interval: 2.6-106.6) after adjustment for maternal race, age, education, smoking and alcohol use, family income, parity, and other confounders. The frequency of depression was higher in women with high hurricane exposure (32.3 percent) than women without high hurricane exposure (12.3 percent), with an aOR of 3.3 (1.6-7.1). Moreover, the risk of PTSD and depression increased with an increasing number of severe experiences of the hurricane. Conclusions: Pregnant women who had severe hurricane experiences were at a significantly increased risk for PTSD and depression. This information should be useful for screening pregnant women who are at higher risk of developing mental disorders after disaster. Key words: depression, disaster, Hurricane Katrina, post-traumatic stress disorder, pregnancy DOI:10.5055/ajdm.2010.0020


Article
Hard times call for creative solutions: Medical improvisations at the Israel Defense Forces field hospital in Haiti
Guy Lin, MD; Haim Lavon, MD; Reuven Gelfond, RN, BA; Avi Abargel, MD, MHA; Ofer Merin, MD
May/June 2010; pages 188-192

Abstract
Mass disaster medicine is characterized by the need to manage limited resources that are far inadequate to meet the population’s demands. Under these hectic conditions, lack of specific medical equipment is expected and requires improvisation using available items. We describe the innovative use of medical improvisations at the Israel Defense Forces field hospital, working in the earthquake zone, Port-au-Prince, Haiti, on January 2010. Creative solutions were found to several problems in a variety of medical fields: blood transfusion, debridement and coverage of complex wounds, self-production of orthopedic hardware, surgical exposure, and managing maxillofacial injuries. We hope that the methods described will help to inspire medical teams working in disaster regions. Key words: improvisations, field hospital, Haiti, earthquake DOI:10.5055/ajdm.2010.0021

American Journal of Disaster Medicine
July/August 2010, Volume 5
, Number 4


Article
Flash flood preparedness in Golestan province of Iran: A community intervention trial
Ali Ardalan, MD, PhD; Kourosh Holakouie Naieni, PhD; Mahmood Mahmoodi, PhD; Ali-Mohamad Zanganeh, MD; Abbas-Ali Keshtkar, MD, PhD; Mohamad-Reza Honarvar, MD, MPH; Mohamad-Javad Kabir, MSc
July/August 2010; pages 197-214

Abstract
Objective: To evaluate effectiveness of a community-based preparedness program for flash floods Design: A controlled community intervention trial with preassessment and postassessment. Setting: Fifteen intervention villages and 16 control villages in Golestan province of Iran Participants: People more than six years of age. Intervention: Intervention program consisted assembling Village Disaster Taskforces (VDTs), training of VDTs and community, evacuation drill, and program monitoring. Main outcome measures: Individual participation in household preparedness actions including, preparedness meeting, risk mapping, preparation of emergency supplies, assisting vulnerable people, and evacuation drill. Results: Our intervention improved preparedness of local community for flash floods in term of all interested outcome measures. For instance, adjusted odds ratio for participation in an evacuation drill in intervention area in postassessment compared with preassessment was 29.05 (95% confidence interval [CI]: 21.77-38.76), whereas in control area it was 2.69 (95% CI: 1.96-3.70). Difference in these odds ratios was statistically significant (p < 0.001). Participation in a family preparedness meeting and risk mapping were helpful in motivating individuals to take other preparedness actions. Women were found prepared as much as the men. Younger people showed lower participation in preparation of family emergency supplies but higher attendance in evacuation drills. Participation in evacuation drills decreased with increasing age. It was a positive association between risk perception and taking all preparedness actions. Conclusion: Flood preparedness programs should focus on participatory risk assessment and preparedness techniques, strive to improve risk perception and female capabilities, and ensure providing assistance to the older people during evacuation. Key words: flash floods, community-based, preparedness, Iran DOI:10.5055/ajdm.2010.0022


Article
Enhancing healthcare sector coordination through infrastructure and logistics support
Richard M. Zoraster, MD, MPH
July/August 2010; pages 215-219

Abstract
The International Response to the 2004 Southeast Asia Tsunami was noted to have multiple areas of poor coordination, and in 2005, the “Health Cluster” approach to coordination was formulated. However, the 2010 Haiti response suggests that many of the same problems continue and that there are significant limitations to the cluster meetings. These limitations include the inconsistent attendance, poor dissemination of information, and perceived lack of benefit to providers. This article proposes that healthcare coordination would be greatly improved with logistical support, leading to improved efficiency and outcomes for those affected by disasters. Key words: disaster, World Health Organization, cluster, response, coordination DOI:10.5055/ajdm.2010.0023


Article
Longitudinal expandable shelter for medical response during disasters
Roberto Miniati, MS; Fabrizio Dori, MS; Ernesto Iadanza, MS; Marco Lo Sardo, BSEE; Sergio Boncinelli, MD
July/August 2010; pages 221-227

Abstract
Introduction: During medical emergencies, hospitals represent the final point of the whole rescue process. Therefore, effective health mobile structures have to be inserted between hospitals and the place of the event with the aim of giving the best of cures (using appropriate and easy to use equipment) for a safer and faster evacuation to hospitals. Methods: Literature review and national and international disaster medicine standards were the basis for this study to provide clinical, hygienical, and organizational needs to satisfy for the medical structure design. Project requirements have been obtained by analyzing structural, organizational, and clinical process necessities. Structural requirements respond to the possibility of installation on every ground type, resistance to every weather condition, and necessity of easy and fast transportation. Technological equipment is obtained from clinical evaluation for patient stabilization. Results: The designed structure results to be a longitudinal expandable shelter (LES) for medical emergencies response organized in three internal functional areas. Possibility of automatic expandability allows rapid transportation and easy deployment. The functional internal organization provides three areas: “Diagnostic,” “Therapeutic,” and “Pre-evacuation monitoring.” Further, longitudinal expandability supports the basic hygienical rules in healthcare processes allowing the unidirectional flow of casualties from dirtier to cleaner areas of the structure. Conclusions: LES represents the answer to expressed requisites by disaster medicine standards and guidelines. It aims to provide an efficient and effective support for sanitary aid in response to disasters or emergencies, by improving aspects related to effectiveness, hygiene, and quality of clinical performances especially for highest critical cases. Key words: medical shelter, disaster management, new technology, field rescue DOI:10.5055/ajdm.2010.0024


Article
Disaster preparedness education and a Midwest Regional Poison Center
Kathy Lehman-Huskamp, MD; Terri Rebmann, PhD, RN, CIC; Frank G. Walter, MD; Julie Weber, BS Pharm, CSPI; Anthony Scalzo, MD
July/August 2010; pages 229-236

Abstract
Objective: To assess knowledge and comfort related to disaster preparedness and response gained and retained from a disaster medicine workshop given to Certified Specialists in Poison Information (CSPI). Design: A pilot study with a pre-post intervention design. Setting: A Midwest Regional Poison Center. Participants: All CSPIs employed at the participating Poison Center (N = 27) were recruited. Participation ranged from 44 percent (n = 12) for the 4-month postworkshop knowledge quiz to 78 percent (n = 21) for the preworkshop survey. Intervention: A disaster medicine workshop was given to the CSPIs. Quizzes and surveys were done preworkshop and then repeated at 1 week, 4 months, and 14 months postworkshop. Main Outcome Measures: CSPI knowledge and comfort pertaining to disaster-related calls. Results: CSPIs’ comfort levels with calls regarding major chemical or nuclear/radiation disasters significantly increased and stayed elevated during all follow-up periods [Kruskal-Wallis ?2 (3) = 13.1, p = 0.01]. The average preworkshop quiz score was 58.2 percent. A statistically significant increase in mean quiz score was demonstrated amongst preworkshop and postworkshop scores at all tested time intervals (F = 18.8, p < 0.001). Conclusions: CSPIs’ knowledge regarding disaster management significantly increased after a disaster medicine workshop, and this knowledge was significantly retained for the 14-month duration of this study. Currently, there are no uniform guidelines for Poison Centers regarding disaster response training. Studies targeted at the development of educational competencies for CSPIs and disaster response would help to standardize this much needed education. Key words: disaster medicine, Poison Center, education DOI:10.5055/ajdm.2010.0025


Article
Round table. Considerations for the vertical evacuation of hospitalized patients under emergency conditions
Paul P. Rega, MD, FACEP; Gregory Locher, EMT-P; Heidi Shank, RN, BSN; Kendra Contreras, RN, BSN; Christopher E. Bork, PhD, EMT-B, FASAHP
July/August 2010; pages 237-246

Abstract
Hospitals and other healthcare institutions in the twenty-first century face myriad challenges to their survival against a number of threats from many sources. A number of those threats, eg, internal, external, accidental, or intentional, may require the prompt evacuation of both patients and staff. Although rare, this possibility is becoming more frequent in the United States. Unfortunately, despite accrediting agencies’ mandates, there is a profound paucity of strategic and tactical guidelines in the medical literature. The purpose of this article is to present a strategic methodology for evacuation, particularly emergent evacuation, within the National Incident Command System/Hospital Incident Command System framework and to explore the tactics that should be considered when relocating multiple patients in various degrees of medical compromise. Key words: hospital, evacuation, HICS, disaster, healthcare facilities DOI:10.5055/ajdm.2010.0026


Article
Case study. An influenza exercise in a major urban setting. II. Development of a health emergency operations center
Wendy H. Lyons, RN, MSL; Frederick M. Burkle Jr, MD, MPH, DTM, FAAP, FACEP; Alisa Diggs, PA, MPH; Teresa Ehnert, MS
July/August 2010; pages 247-255

Abstract
Strong relationships and partnerships must be developed for the mitigation of untoward secondary events and positive outcomes during large-scale disasters. Although a health-related emergency operations center-like structure within the Incident Command Structure is advantageous for every community, the process by which it is developed within a large urban setting will be a unique challenging task and requires unprecedented collaboration, cooperation, and coordination. This study explains the necessary components of a uniquely demanding development process leading to a health-related emergency operations center for Maricopa County, Arizona, the creation of which has significantly improved the effectiveness of multiagency involvement, communication, and decision making. Similar challenges will be faced by other urban settings. Key words: pandemic planning, emergency response planning, urban disaster planning, health emergency operations centers, disaster exercises, hospital system planning, NIMS compliance, Incident Command System, Hospital Incident Command System, Medical Coordination Center, alternate care sites, governmental and civilian coordination, disaster communications DOI:10.5055/ajdm.2010.0027

American Journal of Disaster Medicine
September/October 2010, Volume 5
, Number 5


Article
Pediatric issues in disaster management, Part 3: Special healthcare needs patients and mental health issues
Sharon E. Mace, MD; Ghazala Sharieff, MD; Andrew Bern, MD; Lee Benjamin, MD; Dave Burbulys, MD; Ramon Johnson, MD; Merritt Schreiber, PhD
September/October 2010; pages 261-274

Abstract
Although children and infants are likely to be victims in a disaster and are more vulnerable in a disaster than adults, disaster planning and management has often overlooked the specific needs of pediatric patients. We discuss key components of disaster planning and management for pediatric patients including emergency medical services, hospital/facility issues, evacuation centers, family separation/reunification, children with special healthcare needs, mental health issues, and overcrowding/surge capacity. Specific policy recommendations and an appendix with detailed practical information and algorithms are included. The first part of this three part series on pediatric issues in disaster management addresses the emergency medical system from the field to the hospital and surge capacity including the impact of crowding. The second part addresses the appropriate set up and functioning of evacuation centers and family separation and reunification. The third part deals with special patient populations: the special healthcare needs patient and mental health issues. Key words: disaster, pediatric disasters, pediatrics, children and infants DOI:10.5055/ajdm.2010.0028


Article
Disaster preparedness among medical students: A survey assessment
Kori Sauser, MD; Rita V. Burke, PhD, MPH; Rizaldy R. Ferrer, PhD; Catherine J. Goodhue, CPNP; Nikunj C. Chokshi, MD; Jeffrey S. Upperman, MD, FACS, FAAP
September/October 2010; pages 275-284

Abstract
Objective: To describe the level of preparedness in performing medical procedures of medical students at one allopathic medical school and to determine the level of willingness to perform these procedures in the event of a disaster. Design: Cross-sectional survey. Setting: US allopathic medical school associated with a county hospital. Participants: All third- and fourth-year medical students (344) in the 2007-2008 academic year were invited to participate. One hundred ninety-five students participated in this study (response rate = 57.6 percent). Main outcome measures: Information on demographic characteristics, personal disaster experience, personal disaster preparedness, and overall preparedness level and willingness to perform various medical procedures was collected. Multiple regression analysis was used to identify the factors predicting procedural willingness during a disaster. Results: Demographics and personal disaster preparedness were not statistically significant between third-year medical students (M3) and fourth-year medical students (M4). Although procedural preparedness was significantly higher in M4 than M3, willingness to perform these procedures in a disaster was not different. Fourth-year students, first receivers (students’ anticipated field is in emergency medicine or surgery), not having had a personal disaster experience, and increased procedural preparedness independently impact procedural willingness in a disaster. However, when controlled for the covariate effects in the regression model, only first receivers, no past personal disaster experience, and increased procedural preparedness predicted willingness to perform medical procedures during a disaster. Conclusions: Third- and fourth-year students possess skills that may prove useful in a disaster response. Further investigations are necessary to determine how medical students may be utilized during these events. Key words: disaster preparedness, willingness, medical students DOI:10.5055/ajdm.2010.0029


Article
Evidence-based point-of-care tests and device designs for disaster preparedness
T. Keith Brock, BS; Daniel M. Mecozzi, BS; Stephanie Sumner, BS; Gerald J. Kost, MD, PhD, MS, FACB
September/October 2010; pages 285-294

Abstract
Objectives: To define pathogen tests and device specifications needed for emerging point-of-care (POC) technologies used in disasters. Design: Surveys included multiple-choice and ranking questions. Multiple-choice questions were analyzed with the ?2 test for goodness-of-fit and the binomial distribution test. Rankings were scored and compared using analysis of variance and Tukey’s multiple comparison test. Participants: Disaster care experts on the editorial boards of the American Journal of Disaster Medicine and the Disaster Medicine and Public Health Preparedness, and the readers of the POC Journal. Results: Vibrio cholera and Staphylococcus aureus were top-ranked pathogens for testing in disaster settings. Respondents felt that disaster response teams should be equipped with pandemic infectious disease tests for novel 2009 H1N1 and avian H5N1 influenza (disaster care, p < 0.05; POC, p < 0.01). In disaster settings, respondents preferred self-contained test cassettes (disaster care, p < 0.05; POC, p < 0.001) for direct blood sampling (POC, p < 0.01) and disposal of biological waste (disaster care, p < 0.05; POC, p < 0.001). Multiplex testing performed at the POC was preferred in urgent care and emergency room settings. Conclusions: Evidence-based needs assessment identifies pathogen detection priorities in disaster care scenarios, in which Vibrio cholera, methicillin-sensitive and methicillin-resistant Staphylococcus aureus, and Escherichia coli ranked the highest. POC testing should incorporate setting-specific design criteria such as safe disposable cassettes and direct blood sampling at the site of care. Key words: cassette, direct sampling, Haiti, Katrina, pathogen detection, tsunami,Vacutainer DOI:10.5055/ajdm.2010.0030


Article
The need for blood products in patients with crush syndrome
Rumeyza Kazancioglu, MD; Binnur Pinarbasi, MD; Bahar Artim Esen, MD; Aydin Turkmen, MD; Mehmet S. Sever, MD
September/October 2010; pages 295-301

Abstract
Objectives: Crush syndrome is typical for multisystem involvement because of coexisting major surgical and/or medical problems. Treatment of patients with crush syndrome following mass disasters is even more problematic as hundreds of patients are admitted to hospitals and need therapy at once. In this study, the authors evaluated the need of blood and blood products in patients hospitalized due to crush syndrome after the Marmara earthquake in a single center. Methods: The clinical and laboratory variables regarding 60 patients with crush syndrome (30 males and 30 females; mean age: 31.3 ± 13.8 years) hospitalized at a tertiary center that were documented on the preformed questionnaires distributed by International Society of Nephrology Task Force at the aftermath of the earthquake were analyzed by Statistical Package for Social Sciences for Windows software version 13.0 (SPSS Inc, Chicago, IL, USA). Results: Thirty-nine patients (16 males and 23 females; mean age: 30.1 ± 12.6 years) were transfused with 589 U of blood, 840 U of fresh frozen plasma, and 172 U of human albumin during the hospitalization. Most of the transfusions were performed during the first week after the hospitalization. Conclusions: As a result, the preparation for disasters should also include logistic plans for obtaining sufficient amount of blood and blood products to be used in the early aftermath of the event. Key words: blood, blood products, crush syndrome DOI:10.5055/ajdm.2010.0031


Article
Chief complaints and diagnoses of displaced Israelis seeking medical treatment during the 2006 Israel-Lebanon War
Joshua D. Lipsitz, PhD; Deena Zimmerman, MD, MPH; Nahum Kovalski, MD; Raz Gross, MD, MPH; Rachel Hammel, MD
September/October 2010; pages 305-314

Abstract
Objective: To examine patterns of visits by residents of northern Israel displaced during the Israel-Lebanon War of 2006 to an urgent care system in central Israel and to compare these patterns with those of local patients. Design: Retrospective analysis of electronic medical records. Setting: Urgent care clinic system in and around Jerusalem, Israel. Participants: Patients residing in northern Israel who presented from July 12 to August 21, 2006. Local patients who presented during the same time period were used for comparison. Interventions: None. Main outcome measures: Chief complaints, discharge diagnoses, demographics, and visit characteristics. Results: There were a total of 1,175 visits for 938 northern patients, reflecting 6.7 percent of total visits to this system. Overall age distribution of northerners was generally similar. As a proportion of visits, adult northerners were less likely to visit for chief complaints of injury or laceration and more likely to visit for complaint of back pain. They were more likely to have a discharge diagnosis of chest pain, anxiety, or hypertension. Northern children and adolescents were less likely to visit due to injury or fall or to have a discharge diagnosis of fracture. They were more likely to have a discharge diagnosis of gastroenteritis or tonsillitis. Conclusions: Patterns of common discharge diagnoses were generally similar between northern and local residents, with the exception of fewer injury-related visits and more anxiety-related visits. Urgent care appears to have served an important function for displaced individuals during this war, mostly for routine medical needs. Key words: urgent, immediate, healthcare, utilization, War DOI:10.5055/ajdm.2010.0032


Article
Mitigate, adapt, or suffer: Peak oil’s new disaster paradigm
Gerard S. Doyle, MD, MPH
September/October 2010; pages 315-319

Abstract
Objectives: To address the impacts of peak oil (PO) on human health and to propose new public health preparedness models and measures mandated by these impacts. Design: Review of relevant literature. Articles were obtained by searching the PubMed database (including manual searches using “related citations” tool) plus Google and Google Scholar search engines using terms such as “peak oil,” “energy scarcity,” “human health,” “public health,” and “preparedness.” Results: Forty-six journal articles were reviewed. Conclusions: The projections about PO are concerning, as illustrated by minor PO events in the recent past. There are many opportunities for devising beneficial solutions within healthcare to mitigate the effects of PO. It is essential for disaster medicine professionals to become aware of PO and to advocate for change in clinical practice with patients as well as policy leaders. If we fail to mitigate the effects of PO on healthcare, we will be left with the less pleasant options of adapting to PO or suffering its effects. Key words: petroleum, peak oil, public health, disasters, energy scarcity DOI:10.5055/ajdm.2010.0033

American Journal of Disaster Medicine
November/December 2010, Volume 5
, Number 6


Article
A comprehensive disaster training program to improve emergency physicians’ preparedness: A 1-year pilot study
Dino P. Rumoro, DO; Jamil D. Bayram, MD, MPH, EMDM; Mamta Malik, MD, MPH; Yanina A. Purim-Shem-Tov, MD, MS
November/December 2010; pages 325-331

Abstract
Objectives: The main objective of this pilot study was to measure the effectiveness of a 1-year comprehensive training program on the long-term cognitive competence in disaster preparedness among attending emergency physicians (EPs). Design: Ten attending EPs participated in a yearlong training program in disaster preparedness and management. A baseline pretraining test and self-evaluation questionnaire were administered to the participants. Post-training written test and self-evaluation questionnaire were repeated at 12 months after the completion of the program. Setting: The study took place at an urban tertiary care medical center from July 2007 to June 2008. Interventions: The training program was divided into three main categories: didactic core topics, formally recognized courses, and a practicum (drill). Main outcome measures: Pretraining and posttraining test scores in addition to pretraining and posttraining self-assessments were compared for disaster preparedness in various areas. Results: There was a statistically significant increase in the overall post-test versus pretest scores on the written examination for the entire group (44.4 vs 29.8, p < 0.005). In addition, statistically significant increases in each area of disaster preparedness were noted for the self-assessments (2.7 ± 0.82 vs 3.9 ± 0.56, p = 0.01), where 1 means not prepared at all and 5 means extremely well prepared. Conclusions: Disaster preparedness is an essential area of clinical competence for EPs. Participation in a yearlong pilot training program demonstrated a statistically significant increase in cognitive competence among a pilot sample of EPs. More research is needed to validate the content of the training program and its instruments of evaluation. Key words: disaster training, emergency physicians, emergency preparedness, medical education, clinical competence DOI:10.5055/ajdm.2010.0034


Article
Preparedness for the evaluation and management of mass casualty incidents involving anticholinesterase compounds: A survey of emergency department directors in the 12 largest cities in the United States
James M. Madsen, MD, MPH, FCAP, FACOEM, COL, MC-FS, USA; Michael I. Greenberg, MD, MPH
November/December 2010; pages 333-351

Abstract
Objectives: Anticholinesterases include carbamate and organophosphorus (OP) insecticides and nerve agents. Release of these compounds can flood emergency departments (EDs) with large numbers of poisoned victims and worried individuals. It was hypothesized that despite the focus of disaster preparedness on large metropolitan areas, EDs in these cities would still report self-perceptions of deficiencies in preparedness for mass casualty incidents (MCIs) involving these chemicals. Design and setting: A secure and anonymous online survey was prepared and piloted, and E-mail invitations were sent to the physician directors of the 220 continuously staffed EDs in the 12 most populous incorporated cities in the United States. Results: Forty-six ED directors could not be contacted despite repeated attempts. Of the remaining 174 directors, eight declined and 89 took the survey, for a response rate of 51.1 percent. Fewer than 20 percent were very confident in the effectiveness of their training, and only 4.9 percent were very confident that drills had given them the preparation that they needed. Only 45.7 percent of reporting hospitals had a board-certified medical toxicologist to help in such an emergency. Almost two-thirds (73.6 percent) of those familiar with the online Radiation Event Medical Management (REMM) module from the National Library of Medicine and the National Institutes of Health thought that a chemical counterpart to REMM would be either moderately or very helpful for MCIs involving anticholinesterases. Conclusions: This study demonstrates that physician ED directors perceived marked deficiencies in their abilities to respond to this kind of toxicological emergency and suggests critical directions for remediation of these deficiencies. Key words: cholinesterase inhibitors, chemical terrorism, organophosphorus compounds, disaster medicine, emergency medicine, REMM,CHEMM DOI:10.5055/ajdm.2010.0035


Article
Hospital-based special needs patient decontamination: Lessons from the shower
Julie Bulson, MPA, BSN, RN; Timothy C. Bulson, MS; Kathi S. Vande Guchte, FRO-T, HERT-T
November/December 2010; pages 353-360

Abstract
Objectives: A hospital-based decontamination team tested whether it could (1) perform effective technical decontamination while maintaining safety of staff and patients; (2) safely accommodate unique needs in the showers, including guide dogs and motorized wheelchairs; (3) identify needs of special needs populations by patient type, including blindness, hearing loss, and cognitive learning disabilities; (4) outline effective use of federal preparedness funds to support planning and execution of tabletop and mock victim drills; and (5) demonstrate the ability of a community hospital to act as a catalyst for community-wide disaster response improvements. Design: A series of five disaster exercises were used to test hypotheses and to generate quality improvement results. Setting: Fixed emergency department decontamination facilities. Patients/participants: A total of 39 hospital-based decontamination team members, 40 other drill staff, and 35 mock victims were included. Main outcome measures: Three priority decontamination operations changes resulted from each of the five completed drills. Results: Formulated prioritized list of decontamination team procedural changes to improve patient safety and technical decontamination and to generate a table of best practices to share. Conclusions: With enhanced training, disaster drills participation of community response agencies and special needs patients, community hospitals can improve safety while accommodating unique patient needs. Key words: hospital decontamination, special needs patient, pediatric decontamination, tabletop drill, functional exercise DOI:10.5055/ajdm.2010.0036


Article
Suicidality following a natural disaster
Nilamadhab Kar, MD, DPM, DNB, MRCPsych
November/December 2010; pages 361-368

Abstract
Objectives: It was intended to study the suicidal cognitions and behaviors following a super-cyclone. Design: Cross-sectional evaluation study. Setting: Community. Participants: Using simple random procedure, 12 months after a super-cyclone, 540 victims were selected. Main outcome measures: Suicidal cognitions and behaviors through the Suicidality Screening Questionnaire. This included items on whether life was worth living, death wishes, suicidal idea, plan, and attempt, and history of a suicide attempt. Self- Reporting Questionnaire was used to screen for possible psychiatric morbidity. The influence of various sociodemographic factors, degree of exposure, and clinical variables on suicidal cognitions and attempt was studied. Results: A considerable number of victims had suicidal cognitions: death wishes (66.4 percent), suicidal ideas (38.0 percent), and suicidal plans (18.3 percent). Sixty-eight persons (12.6 percent) of the sample had made suicide attempts after the cyclone. The risk of a suicide attempt was high in persons with current psychiatric morbidity, past history of psychiatric illness, postcyclone thoughts of life not worth living, suicidal ideation and plans, and living with inadequate support. Conclusions: There was a reported increase of suicidal cognitions and attempts within 12 months following a natural disaster. Awareness of increased suicidality, attention to associated risk factors, and support regarding these may help in the prevention of suicide following disasters. Key words: attempted suicide, natural disaster, prevention, risk factor, suicide DOI:10.5055/ajdm.2010.0037


Article
Mechanical ventilation in disaster situations: A new paradigm using the AGILITIES Score System
Eric P. Wilkens, MD, MPH; Gary M. Klein, MD, MPH, MBA
November/December 2010; pages 369-384

Abstract
Background: The failure of life-critical systems such as mechanical ventilators in the wake of a pandemic or a disaster may result in death, and therefore, state and federal government agencies must have precautions in place to ensure availability, reliability, and predictability through comprehensive preparedness and response plans. Methods: All 50 state emergency preparedness response plans were extensively examined for the attention given to the critically injured and ill patient population during a pandemic or mass casualty event. Public health authorities of each state were contacted as well. Results: Nine of 51 state plans (17.6 percent) included a plan or committee for mechanical ventilation triage and management in a pandemic influenza event. All 51 state plans relied on the Centers for Disease Control and Prevention Flu Surge 2.0 spreadsheet to provide estimates for their influenza planning. In the absence of more specific guidance, the authors have developed and provided guidelines recommended for ventilator triage and the implementation of the AGILITIES Score in the event of a pandemic, mass casualty event, or other catastrophic disaster. Conclusions: The authors present and describe the AGILITIES Score Ventilator Triage System and provide related guidelines to be adopted uniformly by government agencies and hospitals. This scoring system and the set of guidelines are to be used in disaster settings, such as Hurricane Katrina, and are based on three key factors: relative health, duration of time on mechanical ventilation, and patients’ use of resources during a disaster. For any event requiring large numbers of ventilators for patients, the United States is woefully unprepared. The deficiencies in this aspect of preparedness include (1) lack of accountability for physical ventilators, (2) lack of understanding with which healthcare professionals can safely operate these ventilators, (3) lack of understanding from where additional ventilator resources exist, and (4) a triage strategy to provide ventilator support to those patients with the greatest chances of survival. Key words: triage, mechanical ventilator, disaster, influenza, death, resource, pandemic DOI:10.5055/ajdm.2010.0038


Article
Dilemmas and controversies within civilian and military organizations in the execution of humanitarian aid in Iraq: A review
Melinda J. Morton, MD, MPH; Gilbert M. Burnham, MD, PhD
November/December 2010; pages 385-391

Abstract
Civilian humanitarian assistance organizations and military forces are working in a similar direction in many humanitarian operations around the world. However, tensions exist over the role of the military in such operations. The purpose of this article is to review cultural perspectives of civilian and military actors and to discuss recent developments in civil-military humanitarian collaboration in the provision of health services in Iraq for guiding such collaborative efforts in postconflict and other settings in future. Optimal collaborative efforts are most likely to be achieved through the following tenets: defining appropriate roles for military forces at the beginning of humanitarian operations (optimally the provision of transportation, logistical coordination, and security), promoting development of ongoing relationships between civilian and military agencies, establishment of humanitarian aid training programs for Department of Defense personnel, and the need for the military to develop and use quantitative aid impact indicators for assuring quality and effectiveness of humanitarian aid. Key words: civil military, humanitarian assistance, Iraq DOI:10.5055/ajdm.2010.0039