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American Journal of Disaster Medicine
Winter 2012, Volume 7
, Number 1


Article
Decontamination and management of human remains following incidents of hazardous chemical release
Veronique D. Hauschild, MPH; Annetta Watson, PhD; Robert Bock, JD
Winter 2012; pages 5-29

Abstract
Objective: To provide specific guidance and resources for systematic and orderly decontamination of human remains resulting from a chemical terrorist attack or accidental chemical release. Design: A detailed review and health-based decision criteria protocol is summarized. Protocol basis and logic are derived from analyses of compoundspecific toxicological data and chemical/physical characteristics. Setting: Guidance is suitable for civilian or military settings where human remains potentially contaminated with hazardous chemicals may be present, such as sites of transportation accidents, terrorist operations, or medical examiner processing points. Patients and participants: Guidance is developed from data-characterizing controlled experiments with laboratory animals, fabrics, and materiel. Main outcome measure(s): Logic and specific procedures for decontamination and management of remains, protection of mortuary affairs personnel, and decision criteria to determine when remains are sufficiently decontaminated are presented. Results: Established procedures as well as existing materiel and available equipment for decontamination and verification provide reasonable means to mitigate chemical hazards from chemically exposed remains. Unique scenarios such as those involving supralethal concentrations of certain liquid chemical warfare agents may prove difficult to decontaminate but can be resolved in a timely manner by application of the characterized systematic approaches. Decision criteria and protocols to “clear” decontaminated remains for transport and processing are also provided. Conclusions: Once appropriate decontamination and verification have been accomplished, normal procedures for management of remains and release can be followed. Key words: mortuary affairs, human remains, decontamination, chemical warfare agent, toxic industrial chemical DOI:10.5055/ajdm.2012.0077


Article
Optimal emergency personnel allocation after a natural disaster
James S. Davis, MD; Bassan J. Allan, MD, MBA; Amy M. Pearlman, BS; Daniel P. Carvajal, BBA, PMP; Carl I. Schulman, MD, PhD, MSPH
Winter 2012; pages 31-36

Abstract
Objective: Little work has been devoted to the links between natural disasters, subsequent Emergency Medical Services (EMS) network utilization, triage, and public awareness. The aim of this study was to investigate the types and distribution of emergency calls recorded after each South Florida hurricane during the 2005 season, identifying target areas for public health education, and emergency personnel use and training. Design: Retrospective database review. Setting: Miami-Dade Fire Rescue (MDFR) emergency dispatch headquarters. Patients, participants: All persons making 911 phone calls to the MDFR emergency dispatch headquarters in the 3 days before and after category 3 or higher hurricanes during 2005. Interventions: None. Results: There were 192,363 emergencies reported in 2005. The mean number of 911 emergencies reported per day for the 3 days before and after Katrina was 503 ± 26 and 819 ± 105, respectively (p = 0.007). The mean number for Wilma was 533 ± 42 before and 800 ± 63 after (p = 0.004). However, Rita had no impact on the number of 911 emergencies reported. Katrina resulted in a statistically significant increase in 911 calls for breathing (p = 0.03), convulsions and seizures (p = 0.02), and hazardous situations (p = 0.04). Rita led to an increase in convulsions and seizures (p = 0.03). Lastly, Wilma caused a rise in breathing emergencies (p = 0.02) and hazardous situations (p = 0.02). Conclusions: This study suggests that 911 calls regarding respiratory complaints, convulsions, seizures, and hazardous situations can be expected to significantly increase after a hurricane. Educational initiatives, EMS resource allocation, and modified triage systems designed to target these areas may limit EMS system-wide strain and improve health outcomes following natural disasters. Key words: emergency, hurricane, 911, EMS DOI:10.5055/ajdm.2012.0078


Article
The use of volunteer interpreters during the 2010 Haiti earthquake: Lessons learned from the USNS COMFORT Operation Unified Response Haiti
Clydette Powell, MD, MPH, FAAP; Claire Pagliara-Miller, RN, PhD
Winter 2012; pages 37-47

Abstract
On January 12, 2010, a 7.0 magnitude Richter earthquake devastated Haiti, leading to the world’s largest humanitarian effort in 60 years. The catastrophe led to massive destruction of homes and buildings, the loss of more than 200,000 lives, and overwhelmed the host nation response and its public health infrastructure. Among the many responders, the United States Government acted immediately by sending assistance to Haiti including a naval hospital ship as a tertiary care medical center, the USNS COMFORT. To adequately respond to the acute needs of patients, healthcare professionals on the USNS COMFORT relied on Haitian Creole-speaking volunteers who were recruited by the American Red Cross (ARC). These volunteers complemented full-time Creole-speaking military staff on board. The ARC provided 78 volunteers who were each able to serve up to 4 weeks on board. Volunteers’ demographics, such as age and gender, as well as linguistic skills, work background, and prior humanitarian assistance experience varied. Volunteer efforts were critical in assisting with informed consent for surgery, family reunification processes, explanation of diagnosis and treatment, comfort to patients and families in various stages of grieving and death, and helping healthcare professionals to understand the cultural context and sensitivities unique to Haiti. This article explores key lessons learned in the use of volunteer interpreters in earthquake disaster relief in Haiti and highlights the approaches that optimize volunteer services in such a setting, and which may be applicable in similar future events. Key words: Haiti, earthquake, COMFORT, interpreter, volunteer DOI:10.5055/ajdm.2012.0079


Article
Bioterrorism and disaster preparedness among medical specialties
Joshua E. Lane, MD, MBA; Jacob Dimick, BS, MHS; Michael Syrax, BA, MA; Madhusudan Bhandary, PhD; Bruce S. Rudy, DEd, PA-C
Winter 2012; pages 48-60

Abstract
Objective: A core priority of all medical specialties includes information for members regarding inherent priorities and principles. The authors sought to investigate the priority and contribution of various medical specialties to the fields of bioterrorism, terrorism, disaster preparedness, and emergency preparedness. Design: A mixed study design (quantitative and qualitative) was used to identify pertinent characteristics of various medical specialties. A scored survey analysis of resources available from the representative organizations and/or societies of the primary medical specialties and select subspecialties was examined and scored based on availability, ease of accessibility, updated status, and content. A MEDLINE search completed through PubMed using the medical subject headings bioterrorism, terrorism, disaster preparedness, and emergency preparedness coupled with specific medical specialties was conducted to assess the involvement and contribution of each to the medical literature. Main outcome measures: The primary study outcome was to evaluate the priority of and existing resources available to members for bioterrorism/terrorism and disaster/emergency preparedness among various medical specialties as reflected by their representative organizations and scientific publication. Results: The search of individual medical specialties and of the medical literature (2000-2010) revealed that these topics (via keywords bioterrorism, terrorism, disaster preparedness, and emergency preparedness) are indeed a priority topic for the majority of medical specialties. A number of specialties with expectant priority in these topics were confirmed. All seven primary care specialties demonstrated a core priority of these topics and offered resources. The MEDLINE (PubMed) search yielded 7,228 articles published from 2000 to 2010. Conclusion: Bioterrorism/terrorism and disaster/emergency preparedness are priority topics of most medical specialties. This core priority is demonstrated by both the medical specialty resources in addition to the contribution of scientific articles from these medical specialties. This reflects the diverse medical care that is necessary for terrorist threats and the collaborative efforts that will help to make the medical response to these threats more cohesive. Key words: bioterrorism, terrorism, disaster preparedness, emergency preparedness, medical specialty DOI:10.5055/ajdm.2012.0080


Article
Global responsibility in mass casualty events: The Israeli experience in Japan
Ofer Merin, MD; Nehemia Blumberg, MD; David Raveh, MD; Ariel Bar, MD; Masafumi Nishizawa, MD; Ophir Cohen-Marom, MD
Winter 2012; pages 61-64

Abstract
Objective: To describe humanitarian aid following the 2011 earthquake and tsunami in Japan. Setting: A field hospital deployed in a small Japanese coastal village devastated by a major tsunami. Patients: Thousands of Japanese refugees with minimal access to medical care. Results: After well-coordinated diplomatic efforts, our medical delegation was the first foreign team to deploy in Japan. Our facility served as a regional referral center for specialized medical treatment. Conclusions: Following major disasters, even highly modernized countries will face an urgent surge in the need of medical resources. These situations emphasize the need for global responsibility to provide assistance. Key words: earthquake, tsunami, mass disaster, humanitarian aid DOI:10.5055/ajdm.2011.0081


Article
Prairie North: A joint civilian/military mass casualty exercise highlights the role of the National Guard in community disaster response
George Vukotich, PhD; Jamil D. Bayram, MD, MPH, EMDM, MEd; Miriam I. Miller, MPH, CHEC
Winter 2012; pages 65-72

Abstract
In a joint military/civilian exercise conducted in June 2010, military National Guard medical and decontamination response efforts proved to be paramount in supporting hospital resources to sustain an adequate response during a simulated terrorist event. Traditionally, hospitals include local responders in their disaster preparedness but overlook other available state and federal resources such as the National Guard. Lessons learned from the exercise included the value of regular joint disaster planning and training between the military and civilian medical sectors. Additionally, military communication and medical equipment compatibility with the civilian infrastructure was identified as one of the top areas for the improvement of this joint exercise. Involving the National Guard in community disaster planning provides a valuable medical support asset that can be critical in responding to multiple casualty events. National Guard response is inherently faster than its federal counterpart. Based on the findings from our joint exercise, states are encouraged to incorporate their corresponding National Guard in civilian critical medical infrastructure disaster preparedness activities, as the National Guard can be an integral part of the disaster response efforts in real multiple casualty events. Key words: civilian/military, disaster, support operations, National Guard, Rush University Medical Center DOI:10.5055/ajdm.2012.0082


Article
Medical papyri show the effects of the Santorini eruption heavily influenced the development of ancient medicine
Siro I. Trevisanato, PhD
Winter 2012; pages 73-80

Abstract
Exposure to ash from the catastrophic Santorini eruption radically changed Bronze Age medicine, triggering the development of new remedies, the wide dissemination of medical data, and the transfer of technologies. These developments were identified in medical papyri thanks to remedies for ailments linked to volcanic matter, an oddity in Egypt, a country without volcanoes. The anomaly was traced back to the Santorini eruption, which through volcanic ash, acidified bodies of waters, and acid rain affected the whole eastern Mediterranean without sparing Egypt. Using available technology, doctors developed new remedies for severe irritation to eyes from ash and for burns on the skin, or imported foreign remedies as exemplified by paragraph 28 of the London Medical Papyrus (L28), thus resorting to technology transfer even if so crude. Furthermore, medical manuals rather than being guarded by families of physicians were now used to disseminate remedies as widely as possible. Finally, besides providing historical data, the medical reaction to the Santorini eruption could still be of use today. The remedies could be integrated in manuals for emergency situations for population left without adequate medical infrastructure at a time of exposure to heavy volcanic fallout or acidified rain. Key words: ancient medicine, burns, Ebers Papyrus, Edwin Smith Papyrus, Eshmun, London Medical Papyrus, medical papyri, paleobiology, Santorini eruption DOI:10.5055/ajdm.2012.0083

American Journal of Disaster Medicine
Spring 2012, Volume 7
, Number 2


Article
The impact of the earthquake and humanitarian assistance on household economies and livelihoods of earthquake-affected populations in Haiti
Thomas D. Kirsch, MD; Eva Leidman, MSPH; William Weiss, DrPH; Shannon Doocy, PhD
Spring 2012; pages 85-94

Abstract
Objective: On January 12, 2010, one of the most destructive earthquakes in history struck the Haitian capital Port-au-Prince. This study aims to characterize the impact of the earthquake and humanitarian response on well being of the affected households as means of evaluating the effectiveness of response efforts. Design: A stratified 60 × 20 cluster survey was conducted in Port-au-Prince internally displaced persons camps (n = 600) and neighborhoods (n = 596) in January 2011. Clusters were assigned using probability proportional to size sampling and data were collected using interviewer-administered questionnaires. Results: The earthquake affected incomes in 90 percent of camp and 73 percent of neighborhood households (p < 0.001); camp households were consistently worse off by most measures of economic and food security. As compared to camps, living in a neighborhood was associated with increased odds of better/same income status (Odds ratio, OR: 1.78, Confidence interval, CI: 1.25-2.53), employment (OR: 1.47, 1.01-2.14), and food access (OR: 1.83, CI: 1.33-2.52).With respect to earthquake impacts, damage to the home was associated with decreased odds of better/same food access (OR: 0.55, CI: 0.33-0.93) and injuries with decreased odds of better/same income status (OR: 0.57, CI: 0.37, 0.87).Within 1 month of the earthquake, 89 percent of camp and 46 percent in neighborhood households had received humanitarian assistance (p = 0.001); however, receipt of aid was not associated with improved income, employment, or food access at 1 year postearthquake. Conclusions: The immediate impacts of injury and mortality had marginal influences on long-term household economic security, whereas displacement into camps was stongly associated with negative outcomes for income, employment, and food access. Key words: Haiti, earthquake, disaster, impact, displacement, livelihoods, economic recovery DOI:10.5055/ajdm.2012.0084


Article
Contribution of the administrative database and the geographical information system to disaster preparedness and regionalization
Kazuaki Kuwabara, MD, DPH; Shinya Matsuda, MD, PhD; Kiyohide Fushimi, MD, PhD; Koichi B. Ishikawa, PhD; Hiromasa Horiguchi, PhD; Kenji Fujimori, MD, PhD
Spring 2012; pages 95-103

Abstract
Objective: Public health emergencies like earthquakes and tsunamis underscore the need for an evidence-based approach to disaster preparedness. Using the Japanese administrative database and the geographical information system (GIS), the interruption of hospital-based mechanical ventilation administration by a hypothetical disaster in three areas of the southeastern mainland (Tokai, Tonankai, and Nankai) was simulated and the repercussions on ventilator care in the prefectures adjacent to the damaged prefectures was estimated. Design, setting, and patients: Using the database of 2010 including 3,181,847 hospitalized patients among 952 hospitals, the maximum daily ventilator capacity in each hospital was calculated and the number of patients who were administered ventilation on October xx was counted. Interventions: Using GIS and patient zip code, the straight-line distances among the damaged hospitals, the hospitals in prefectures nearest to damaged prefectures, and ventilated patients’ zip codes were measured. The authors simulated that ventilated patients were transferred to the closest hospitals outside damaged prefectures. Outcomes: The increase in the ventilator operating rates in three areas was aggregated. Results: One hundred twenty-four and 236 patients were administered ventilation in the damaged hospitals and in the closest hospitals outside the damaged prefectures of Tokai, 92 and 561 of Tonankai, and 35 and 85 of Nankai, respectively. The increases in the ventilator operating rates among prefectures ranged from 1.04 to 26.33-fold in Tokai; 1.03 to 1.74-fold in Tonankai, and 1.00 to 2.67-fold in Nankai. Conclusion: Administrative databases and GIS can contribute to evidenced-based disaster preparedness and the determination of appropriate receiving hospitals with available medical resources. Key words: administrative database, disaster preparedness, evidence-based regionalization DOI:10.5055/ajdm.2012.0085


Article
The impact of alternative diagnoses on the utility of influenza-like illness case definition to detect the 2009 H1N1 pandemic
Dino P. Rumoro, DO, FACEP; Jamil D. Bayram, MD, MPH, EMDM, MEd; Julio C. Silva, MD, MPH; Shital C. Shah, PhD; Marilyn M. Hallock, MD; Gillian S. Gibbs, MPH; Michael J. Waddell, MS
Spring 2012; pages 105-110

Abstract
Objective: To investigate the impact of excluding cases with alternative diagnoses on the sensitivity and specificity of the Centers for Disease Control and Prevention’s (CDC) influenza-like illness (ILI) case definition in detecting the 2009 H1N1 influenza, using Geographic Utilization of Artificial Intelligence in Real- Time for Disease Identification and Alert Notification, a disease surveillance system. Design: Retrospective cross-sectional study design. Setting: Emergency department of an urban tertiary care academic medical center. Patients: 1,233 ED cases, which were tested for respiratory viruses from September 5, 2009 to May 5, 2010. Main Outcome Measure: The main outcome measures were positive predictive value, negative predictive value, sensitivity, specificity, and accuracy of the ILI case definition (both including and excluding alternative diagnoses) to detect H1N1. Results: There was a significant decrease in sensitivity (?2 = 9.09, p < 0.001) and significant improvement in specificity (?2 = 179, p < 0.001), after excluding cases with alternative diagnoses. Conclusion: When early detection of an influenza epidemic is of prime importance, pursuing alternative diagnoses as part of CDC’s ILI case definition may not be warranted for public health reporting due to the significant decrease in sensitivity, in addition to the resources required for detecting these alternative diagnoses. Key words: H1N1, influenza-like illness, public health, syndromic surveillance DOI:10.5055/ajdm.2012.0086


Article
Pediatric patients in a disaster: Part of the all-hazard, comprehensive approach to disaster management
Sharon E. Mace, MD; Constance Doyle, MD; Susan Fuchs, MD; Marianne Gausche-Hill, MD; Kristi L. Koenig, MD; Annalise Sorrentino, MD; Ramon W. Johnson, MD
Spring 2012; pages 111-125

Abstract
Disasters affect all ages of patients from the newborn to the elderly. Disaster emergency management includes all phases of comprehensive emergency management from preparedness to response and recovery. Disaster planning and management has frequently overlooked the unique issues involved in dealing with the pediatric victims of a disaster. The following will be addressed: disaster planning and management as related to pediatric patients and the integration of pediatric disaster management as part of an all-hazard, comprehensive emergency management approach. Key recommendations for dealing with children, infants, and special needs patients in a disaster are delineated. Key words: disaster, pediatric disasters, infants and children DOI:10.5055/ajdm.2012.0087


Article
Nursing homes’ preparedness plans and capabilities
Hilary Eiring, MPH; Sarah C. Blake, MA, PhD Candidate; David H. Howard, PhD
Spring 2012; pages 127-135

Abstract
Objectives: To assess nursing homes’ capabilities to evacuate or shelter-in-place during a disaster and to determine their actual preparedness-related capacity. Design: A 27-question survey assessing disaster preparedness plans and capabilities in nursing homes. Respondents and nonresponders were compared based on characteristics from the Nursing Home Compare Web site using t tests for continuous variables and ?2 test for categorical variables. Probit regression was used to estimate the relationships between nursing home characteristics and dichotomous measures of preparedness. Setting: Web and paper surveys of nursing home administrators. Participants: Nursing home administrators in California, Florida, and Georgia. Main outcome measures: Number of disaster drills, days supply of emergency food and water, evacuation transportation and destination. Results: All facilities reported conducting at least one disaster drill per year. Only 55 percent of facilities used a template to develop their disaster plans and 74 percent of facilities reported that they discuss their disaster plans with local or state emergency management officials. Most facilities (81 percent) have generators. All but 19 (7 percent) of nursing homes are able to shelter-in-place for 2 days or longer. Ambulance services are the most common form of transportation (76 percent). Most facilities (73 percent) plan to evacuate residents to nursing homes affiliated with their corporate group. Discussion: Almost all respondents conducted disaster drills, discussed preparedness with local officials, and were able to shelter-in-place for at least 2 days. However, many facilities rely on resources that may not be available during a large disaster. Key words: nursing homes, administrators, preparedness, capacity, evacuation DOI:10.5055/ajdm.2012.0088


Article
Impact of Hurricane Ike on the call volumes of Houston Fire Department emergency medical services
Lt. Elise Cooper, MD, MPH; James R. Langabeer II, PhD; Diaa Alqusairi, MS; David Persse, MD, EMT-P, FACEP
Spring 2012; pages 137-144

Abstract
Introduction: Little is known about the capacity and activity of emergency medical services (EMS) during large-scale disasters. This article provides a case study of the role of EMS in one large urban city during a major hurricane. Methods: The authors analyzed changes in call volume data from the City of Houston Fire Department’s EMS during Hurricane Ike. Descriptive and statistical analyses are used to explain surges and statistical differences in volumes. Results: Demand for EMS care can increase approximately 40 percent during surges in the disaster cycle, placing extreme burdens on system capacity and workload. The largest increase in demand came from respiratory problems, falls, and chest pains, with the largest decrease in calls from motor vehicle accidents. Conclusions: A strategy for managing surges in prehospital care from major disasters is a requirement for modern EMS. Key words: EMS, disaster medicine, Hurricane Ike DOI:10.5055/ajdm.2012.0089


Article
Games, simulations, and learning in emergency preparedness: A review of the literature
Debra K. Olson, DNP, MPH, FAAOHN; Mary M. Hoeppner, EDD, MS, RN; Kurtis Scaletta, MA; Megan Peck, BA; Ryan Newkirk, PhD, MPH
Spring 2012; pages 145-154

Abstract
Between 2007 and 2011, a comprehensive review of the literature was conducted to identify the usefulness of educational games and simulations in developing and evaluating the competency of public health professionals to prepare for, respond to, and recover from emergencies. This article presents an overview of the literature related to the use of games and simulations in education and training, summarizes key findings, identifies key features of gaming simulation design for educational effectiveness, and suggests that use of these emerging teaching and learning strategies be considered in the development of a comprehensive approach for creating and evaluating competency. Key words: health education, health professionals, games, simulations, emergency preparedness, public health preparedness DOI:10.5055/ajdm.2012.0090


Article
Applying behavioral science to workforce challenges in the public health emergency preparedness system
O. Lee McCabe, PhD; Carlo C. DiClemente, PhD; Jonathan M. Links, PhD
Spring 2012; pages 155-166

Abstract
When disasters and other broad-scale public health emergencies occur in the United States, they often reveal flaws in the pre-event preparedness of those individuals and agencies charged with responsibility for emergency response and recovery activities. A significant contributor to this problem is the unwillingness of some public health workers to participate in the requisite planning, training, and response activities to ensure quality preparedness. The thesis of this article is that there are numerous, empirically supported models of behavior change that hold potential for motivating role-appropriate behavior in public health professionals. The models that are highlighted here for consideration and prospective adaptation to the public health emergency preparedness system (PHEPS) are the Transtheoretical Model of Intentional Behavior Change (TTM) and Motivational Interviewing (MI). Core concepts in TTM and MI are described, and specific examples are offered to illustrate the relevance of the frameworks for understanding and ameliorating PHEPS-based workforce problems. Finally, the requisite steps are described to ensure the readiness of organizations to support the implementation of the ideas proposed. Key words: transtheoretical model, willingness to respond, willingness to train DOI:10.5055/ajdm.2012.0091

American Journal of Disaster Medicine
Summer 2012, Volume 7
, Number 3


Article
Editorial. Service provision in disaster preparation, response, and recovery for individuals with predisaster mental illness
Andra Teten Tharp, PhD; Joseph I. Constans, PhD; Rob Yin, LISW; Greer Sullivan, MD, MSPH; Jennifer J. Vasterling, PhD; Jeff Rouse, MD; Merritt D. Schreiber, PhD; Michael King, PhD
Summer 2012; pages 171-174

Abstract
Individuals with preexisting mental disorders are at increased risk for negative outcomes following a disaster and are one type of vulnerable subpopulation that requires special consideration in disaster preparedness, response, and recovery. We describe evidence of the increased risk for individuals with predisaster mental illness as well as tools for field triage, the critical role of partnerships in preparedness and response, and integration of mental health as a priority in emergency management systems. Considering individuals with predisaster mental disorders at each phase of a disaster may ameliorate some negative postdisaster outcomes, such as suicide. Key words: disaster, mental health, PTSD DOI:10.5055/ajdm.2012.0092


Article
High-fidelity multiactor emergency preparedness training for patient care providers
Lancer A. Scott, MD; P. Tim Maddux, BS; Jennifer Schnellmann, PhD, ELS; Lauren Hayes, BS; Jessica Tolley, BS; Amy E. Wahlquist, MS
Summer 2012; pages 175-188

Abstract
Background: Providing comprehensive emergency preparedness training (EPT) for patient care providers is important to the future success of emergency preparedness operations in the United States. Disasters are rare, complex events involving many patients and environmental factors that are difficult to reproduce in a training environment. Few EPT programs possess both competency-driven goals and metrics to measure life-saving performance during a multiactor simulated disaster. Methods: The development of an EPT curriculum for patient care providers—provided first to medical students, then to a group of experienced disaster medical providers—that recreates a simulated clinical disaster using a combination of up to 15 live actors and six high-fidelity human simulators is described. Specifically, the authors detail the Center for Health Professional Training and Emergency Response’s (CHPTER’s) 1-day clinical EPT course including its organization, core competency development, medical student self-evaluation, and course assessment. Results: Two 1-day courses hosted by CHPTER were conducted in a university simulation center. Students who completed the course improved their overall knowledge and comfort level with EPT skills. Conclusions: The authors believe this is the first published description of a curriculum method that combines high-fidelity, multiactor scenarios to measure the life-saving performance of patient care providers utilizing a clinical disaster scenario with >10 patients at once. A larger scale study, or preferably a multicenter trial, is needed to further study the impact of this curriculum and its potential to protect provider and patient lives. Key words: high-fidelity simulation, simulator, simulation, performance, performance-based, emergency preparedness, disaster medicine, disaster training, training, medical trainee, medical student, health professional, healthcare worker, first responder, emergency medical services, first receiver DOI:10.5055/ajdm.2012.0093


Article
Occupational and public health considerations for work-hour limitations policy regarding public health workers during response to natural and human-caused disasters
Murray R. Berkowitz, DO, MA, MS, MPH
Summer 2012; pages 189-198

Abstract
This article examines the occupational health considerations that might impact the health and wellbeing of public health workers during responses to natural (eg, floods and hurricanes) and humancaused (eg, terrorism, war, and shootings) disasters. There are a number of articles in the medical literature that argue the impact of how working long hours by house staff physicians, nurses, and first-responders may pose health and safety concerns regarding the patients being treated. The question examined here is how working long hours may pose health and/or safety concerns for the public health workers themselves, as well as to those in the communities they serve. The health problems related to sleep deprivation are reviewed. Current policies and legislations regarding work-hour limitations are examined. Policy implications are discussed. Key words: disaster response, disaster workers, occupational health, public health, work-hour limitations DOI:10.5055/ajdm.2012.0094


Article
Impact of coping styles on post-traumatic stress disorder and depressive symptoms among pregnant women exposed to Hurricane Katrina
Olurinde Oni, MD, MS; Emily W. Harville, PhD; Xu Xiong, MD, DrPH; Pierre Buekens, MD, PhD
Summer 2012; pages 199-209

Abstract
Objective: Experiencing natural disasters such as hurricanes is associated with post-traumatic stress disorder (PTSD) and depression. We examined the role played by perceived stress and coping styles in explaining and modifying this association among pregnant women exposed to Hurricane Katrina. Design: The study comprised 192 women (133 from New Orleans and 59 from Baton Rouge) who were pregnant during Hurricane Katrina or became pregnant immediately after the hurricane. Women were interviewed regarding their hurricane experience, perceived stress, and mental health outcomes. Coping styles was assessed using the Brief COPE, PTSD symptoms using the Post-Traumatic Checklist, and depressive symptoms using the Edinburgh Depression Scale. Multivariable regression models were run to determine the effects of coping styles on mental health and the interactions among coping styles, hurricane experience, and perceived stress on mental health. Results: Apart from the positive reframing and humor coping styles, all coping styles correlated positively with PTSD or depression (p < 0.05). The instrumental support, denial, venting, and behavioral disengagement coping styles were significantly associated with worsened PTSD symptoms among those who reported higher perceived stress (p < 0.05). Use of a humor coping style seemed to reduce the effect of perceived stress on depressive symptoms (p = 0.02 for interaction) while use of instrumental support (p = 0.04) and behavioral disengagement (p < 0.01) were both associated with more symptoms of depression among those who perceived more stress. There were no strong interactions between coping style and hurricane experience. Conclusion: Coping styles are potential moderators of the effects of stress on mental health of pregnant women. Key words: stress-coping styles, post-traumatic stress disorder, depression, Hurricane Katrina, perceived stress DOI:10.5055/ajdm.2012.0095


Article
Ethical implications of diversity in disaster research
Matthew R. Hunt, PhD, PT; James A. Anderson, PhD; Renaud F. Boulanger, HBA
Summer 2012; pages 211-221

Abstract
Enhancing the effectiveness, efficiency, and fairness of interventions is an increasing source of concern in the field of disaster response. As a result, the expansion of the disaster relief evidence base has been identified as a pressing need. There has been a corresponding increase in discussions of ethical standards and procedures for disaster research. In general, these discussions have focused on elucidating how traditional research ethics concerns can be operationalized in disaster settings. Less attention has been given to the exploration of the ethical implications of heterogeneity within the field of disaster research. Hence, while current efforts to discuss the ethics of disaster research in low-resource settings are very encouraging, it is clear that further initiatives will be crucial to promote the ethical conduct of disaster research. In this article, we explore how the ethical review of disaster research conducted in low-resource settings should account for this diversity. More specifically, we consider how the nature of the project (what?), sociopolitical and physical environment of research sites (where?), temporal proximity to the disaster event (when?), objectives motivating the research (why?), and identity of the stakeholders involved in the research process (who?) all relate to the ethics of disaster research. Key words: developing countries, disasters, ethics, IRBs, human subjects research DOI:10.5055/ajdm.2012.0096


Article
A quick primer for setting up and maintaining surgical intensive care in an austere environment: Practical tips from volunteers in a mass disaster
Randeep S. Jawa, MD; Jagtar S. Heir, DO; David Cancelada, MD; David H. Young, MD; David W. Mercer, MD
Summer 2012; pages 223-229

Abstract
The provision of critical care in any environment is resource intensive. However, the provision of critical care in an austere environment/mass disaster zone is particularly challenging. While providers are well trained for care in a modern intensive care unit, they may be underprepared for resource-poor environments where there are limited or unfamiliar equipment and fewer support personnel. Based primarily on our experiences at a field hospital in Haiti, we created a short guide to critical care in a mass disaster in an austere environment. This guide will be useful to the team of physicians, nurses, respiratory care, logistics, and other support personnel who volunteer in future critical care relief efforts in limited resource settings. Key words: intensive care, austere, disaster, oxygen, mechanical ventilation DOI:10.5055/ajdm.2012.0097


Article
Evaluating the efficacy of the AAP “Pediatrics in Disaster” course: The Chinese experience
Lindsey Cooper, MD; Hongyan Guan, MD; Kathleen M. Ventre, MD; Yaohua Dai, MD; Zonghan Zhu, MD; Spencer Li, MPA; Stephen Berman, MD
Summer 2012; pages 231-248

Abstract
Objective: “Pediatrics in Disasters” (PEDS) is a course designed by the American Academy of Pediatrics to provide disaster preparedness and response training to pediatricians worldwide. China has managed to sustain the course and adapt its content for local needs. China has also experienced several natural disasters since the course’s inception, providing an opportunity to evaluate the impact of courses that took place in Beijing and Sichuan, in 2008-2010. Methods: We used pretesting/post-testing, participant surveys, and in-depth interviews to evaluate whether the course imparted cognitive knowledge, was perceived as useful, and fostered participation in relief efforts and disaster preparedness planning. Results: In Beijing and Sichuan, post-test scores were 16 percent higher than pretest scores. On immediate postcourse surveys, 86 percent of Beijing and Sichuan respondents rated the course as very good or excellent. On 6-month surveys, participants identified emotional impact of disasters, planning/triage, and nutrition as the three most useful course modules. Twelve of 75 (16 percent) of Beijing respondents reported direct involvement in disaster response activities following the course; eight of 12 were first-time responders. Participant interviews revealed a need for more training in providing nutritional and psychological support to disaster victims and to train a more diverse group of individuals in disaster response. Conclusions: PEDS imparts cognitive knowledge and is highly valued by course participants. Emotional impact of disasters, planning/triage, and nutrition modules were perceived as the most relevant modules. Future versions of the course should include additional emphasis on emotional care for disaster victims and should be extended to a broader audience. Key words: PEDS in disaster, pediatric disaster education, evaluation, efficacy, outcomes, disaster response training, disaster planning training, American Academy of Pediatrics, China DOI:10.5055/ajdm.2012.0098

American Journal of Disaster Medicine
Fall 2012, Volume 7
, Number 4


Article
Eye of the storm: Analysis of shelter treatment records of evacuees to Acadiana from Hurricanes Katrina and Rita
L. Philip Caillouet, PhD, FHIMSS; P. Joseph Paul, MBA; Steven M. Sabatier, MBA; Kevin A. Caillouet, PhD
Fall 2012; pages 253-271

Abstract
Objective: The objective of this study is to gain insight into the medical needs of disaster evacuees, through a review of experiential data collected in evacuation shelters in the days and weeks following Hurricanes Katrina and Rita in 2005, to better prepare for similar events in the future. Armed with the information and insights provided herein, it is hoped that meaningful precautions and decisive actions can be taken by individuals, families, institutions, communities, and officials should the Louisiana Gulf Coast—or any other area with well-known vulnerabilities—be faced with a future emergency. Design: Demographic and clinical data that were recorded on paper documents during triage and treatment in evacuation shelters were later transcribed into a computerized database management system, with cooperation of the Department of Health Information Management at The University of Louisiana at Lafayette. Analysis of those contemporaneously collected data was undertaken later by the Louisiana Center for Health Informatics. Setting: Evacuation shelters, Parish Health Units, and other locations including churches and community centers were the venue for ad hoc clinics in the Acadiana region of Louisiana. Patients, participants: The evacuee-patients—3,329 of them—whose information is reflected in the subject dataset were among two geographically distinct but similarly distressed groups: 1) evacuees from Hurricane Katrina that devastated New Orleans and other locales near Louisiana and neighboring states in late August 2005 and 2) evacuees from Hurricane Rita that devastated Southwest Louisiana and neighboring areas of Texas in September 2005.Patient data were collected by physicians, nurses, and other volunteers associated with the Operation Minnesota Lifeline (OML) deployment during the weeks following the events. Interventions: Volunteer clinicians from OML provided triage and treatment services and documented those services as paper medical records. As the focus of the OML “mission of mercy” was entirely on direct individually specific evaluation and care, no population-based experimental hypothesis was framed nor was the effectiveness of any specific intervention researched at the time. Main outcome measure(s): This study reports experiential data collected without a particular preconceived hypothesis, because no specific outcome measures had been designed in advance. Results: Data analysis revealed much about the origins and demographics of the evacuees, their hurricane-related risks and injuries, and the loss of continuity in their prior and ongoing healthcare. Conclusions: The authors believe that much can be learned from studying data collected in evacuee triage clinics, and that such insights may influence personal and official preparedness for future events. In the Katrina-Rita evacuations, only paper-based data collection mechanisms were used—and those with great inconsistency—and there was no predeployed mechanism for close-to-real-time collation of evacuee data. Deployment of simple electronic health record systems might well have allowed for a better real-time understanding of the unfolding of events, upon arrival of evacuees in shelters. Information and communication technologies have advanced since 2005, but predisaster staging and training on such technologies is still lacking. Key words:Acadiana, evacuation, health informatics, hurricane, Katrina, Louisiana, Operation Minnesota Lifeline, Rita, shelter, triage DOI:10.5055/ajdm.2012.0099


Article
Developing a trauma critical care and rehab hospital in Haiti: A year after the earthquake
Gillian A. Hotz, PhD; Zakiya B. Moyenda, MD, MBA; Jerry Bitar, MD; Marlon Bitar, MD; Henri R. Ford, MD; Barth A. Green, MD; David M. Andrews, MD; Enrique Ginzburg, MD
Fall 2012; pages 273-279

Abstract
Objective: Prior to the devastating earthquake in Haiti, January 12, 2010, a group of Haitian physicians, leaders and members of Project Medishare for Haiti, a Nongovernmental Organization, had developed plans for a Trauma Critical Care Network for Haiti. Design: One year after the earthquake stands a 50-bed trauma critical care and rehab hospital that employs more than 165 Haitian doctors, nurses and allied healthcare professionals, and administrative and support staff in Port-Au-Prince. Hospital Bernard Mevs Project Medishare (HBMPM) has been operating with the following two primary goals: 1) to provide critical- care- and trauma-related medical and rehabilitation services and 2) to provide clinical education and training to Haitian healthcare professionals.1 Results: These goals have been successfully accomplished, with more than 43,000 outpatients seen, 6,500 emergency room visits, and about 2,300 surgical procedures performed. Daily patient care has been managed by Haitian medical staff as well as more than 2,400 international volunteers including physicians, nurses, and allied healthcare professionals. With the continued assistance of weekly volunteers, many programs and services have been developed; however, many challenges remain. Conclusions: This article highlights the development and progress of HBMPM over the last year with emphasis on developing inpatient and outpatient services, which include surgical, clinical laboratory, wound care, radiology, rehabilitation, and prosthesis/orthotics programs. Some of the challenges faced and how they were managed will be discussed as well as future plans to conduct more training and education to increase the building of medical capacity for Haiti. Key words: earthquake, trauma, critical care, surgery, volunteers, Haiti DOI:10.5055/ajdm.2012.0100


Article
Healthcare delivery aboard US Navy hospital ships following earthquake disasters: Implications for future disaster relief missions
V. Franklin Sechriest II, MD; Vern Wing, MS; G. Jay Walker, BA; Maureen Aubuchon, BS; David W. Lhowe, MD
Fall 2012; pages 281-294

Abstract
Objective: Since 2004, the US Navy has provided ship-borne medical assistance during three earthquake disasters. Because Navy ship deployment for disaster relief (DR) is a recent development, formal guidelines for equipping and staffing medical operations do not yet exist. The goal of this study was to inform operational planning and resource allocation for future earthquake DR missions by 1) reporting the type and volume of patient presentations, medical staff, and surgical services and 2) providing a comparative analysis of the current medical and surgical capabilities of a hospital ship and a casualty receiving and treatment ship (CRTS). Design: The following three earthquake DR operations were reviewed retrospectively: 1) USNS Mercy to Indonesia in 2004, 2) USNS Mercy to Indonesia in 2005, and 3) USNS Comfort/USS Bataan to Haiti in 2010. (The USS Bataan was a CRTS.) Mission records and surgical logs were analyzed. Descriptive and statistical analysis was performed. Comparative analysis of hospital ship and CRTS platforms was made based on firsthand observations. Results: For the three missions, 986 patient encounters were documented. Of 1,204 diagnoses, 80 percent were disaster-related injuries, more than half of which were extremity trauma. Aboard hospital ships, healthcare staff provided advanced (Echelon III) care for disaster-related injuries and various nondisaster- related conditions. Aboard the CRTS, staff provided basic (Echelon II) care for disaster-related injuries. Conclusions: Our data indicate that musculoskeletal extremity injuries in sex- and age-diverse populations comprised the majority of clinical diagnoses. Current capabilities and surgical staffing of hospital ships and CRTS platforms influenced their respective DR operations, including the volume and types of surgical care delivered. Key words: hospital ship, US Navy, earthquake, CRTS, disaster relief DOI:10.5055/ajdm.2012.0101


Article
Emergency detention of persons with certain mental disorders during public health disasters: Legal and policy issues
Jon S. Vernick, JD, MPH; Maxim Gakh, JD, MPH; Lainie Rutkow, JD, PhD, MPH
Fall 2012; pages 295-302

Abstract
Public health emergencies (disasters) are associated with mental health conditions ranging from mild to severe. When persons pose a danger to themselves or others, a brief emergency detention allows a mental health assessment to determine if a lengthier involuntary civil commitment is needed. Involuntary commitment requires participation of the civil justice system to provide constitutionally mandated due process protections. However, disasters may incapacitate the judicial system, forcing emergency detainees to be prematurely released if courts are unavailable. The authors review state laws regarding emergency detention of persons deemed a potential mental health-related danger. Although some states are well prepared for the dual impact of disasters on mental health and the court system, important gaps exist.The authors recommend that state laws anticipate the need for brief extensions of emergency detention periods without court participation. States should also include mental health considerations in their disaster preparedness plans for the court system. Key words: law, emergency detention, mental Health DOI:10.5055/ajdm.2012.0102


Article
Participatory public health systems research: Value of community involvement in a study series in mental health emergency preparedness
O. Lee McCabe, PhD; Felicity Marum, MHA; Natalie Semon, MSEd; Adrian Mosley, MSW, LCSW-C; Howard Gwon, MS; Charlene Perry, RN, BSN; Suzanne Straub Moore, MEd; Jonathan M. Links, PhD
Fall 2012; pages 303-312

Abstract
Background: Concerns have arisen over recent years about the absence of empirically derived evidence on which to base policy and practice in the public health system, in general, and to meet the challenge of public health emergency preparedness, in particular. Related issues include the challenge of disaster-caused, behavioral health surge, and the frequent exclusion of populations from studies that the research is meant to aid. Objective: To characterize the contributions of nonacademic collaborators to a series of projects validating a set of interventions to enhance capacity and competency of public mental health preparedness planning and response. Methods: Setting(s): Urban, suburban, and rural communities of the state of Maryland and rural communities of the state of Iowa. Participants: Study partners and participants (both of this project and the studies examined) were representatives of academic health centers (AHCs), local health departments (LHDs), and faith-based organizations (FBOs) and their communities. Procedures: A multiple-project, case study analysis was conducted, that is, four research projects implemented by the authors from 2005 through 2011 to determine the types and impact of contributions made by nonacademic collaborators to those projects. The analysis involved reviewing research records, conceptualizing contributions (and providing examples) for government, faith, and (nonacademic) institutional collaborators. Results: Ten areas were identified where partners made valuable contributions to the study series; these “value-areas” were as follows: 1) leadership and management of the projects; 2) formulation and refinement of research topics, aims, etc; 3) recruitment and retention of participants; 4) design and enhancement of interventions; 5) delivery of interventions; 6) collection, analysis, and interpretation of data; 7) dissemination of findings; 8) ensuring sustainability of faith/government preparedness planning relationships; 9) optimizing scalability and portability of the model; and 10) facilitating translational impact of study findings. Conclusions: Systems-based partnerships among academic, faith, and government entities offer an especially promising infrastructure for conducting participatory public health systems research in domestic emergency preparedness and response. Key words: public health systems research, participatory research, disaster mental health, psychological first aid training, guided preparedness planning DOI:10.5055/ajdm.2012.0103


Article
A comparison of different types of hazardous material respirators available to anesthesiologists
Keith A. Candiotti, MD; Yiliam Rodriguez, MD; Ilya Shekhter, MS; Catalina Castillo-Pedraza, MD; Lisa Forman Rosen, MA; Kristopher L. Arheart, EdD; David J. Birnbach, MD, MPH
Fall 2012; pages 313-319

Abstract
Objective: Despite anesthesiology personnel involvement in initial treatment of patients exposed to potentially lethal agents, less than 40 percent of US anesthesiology training programs conduct training to manage these patients.1 No previous studies have evaluated performance of anesthesiologists wearing protective gear. The authors compared the performance of anesthesiologists intubating a high-fidelity mannequin while wearing either a powered air-purifying respirator (PAPR) or a negative pressure respirator (NPR). Methods: Twenty participants practiced intubations on a high-fidelity simulator until comfortable. Each subject performed 10 repetitions, initially without any gear, then while wearing a protective suit, gloves, and respirator. The order of gear use was randomized and all subjects used both devices. Time for task completion were recorded, and at the end of the trial, subjects were asked to rate their comfort with the equipment. Results: After controlling for other variables, overall statistically slower total performance times were observed with use of the PAPR when compared to the control arm and use of the NPR (p = 0.01 and p < 0.007, respectively). Of the total 90 intubations, only one proved to be esophageal and initially undetected. Conclusions: The use of an NPR or PAPR does not preclude an anesthesiologist from successfully intubating, but practice is necessary. The slightly better performance with the NPR is weighed against the improved comfort of the PAPR and the fact that PAPR users could wear eyeglasses. Neither type of gear allowed the users to auscultate the lung fields to confirm correct endotracheal tube placement. Key words: weapons of mass destruction, HAZMAT gear, infectious disease control, mass casualty DOI:10.5055/ajdm.2012.0104


Article
Business continuity after catastrophic medical events: The Joplin Medical Business Continuity Report
Paul K. Carlton Jr, MD, FACS; Dottie Bringle, RN, BSN, MSHSA
Fall 2012; pages 321-331

Abstract
On May 22, 2011, The St Johns Mercy Medical Center in Joplin, MO, was destroyed by an F-5 tornado. There were 183 patients in the building at that time in this 367-bed Medical Center. The preparation and response were superbly done and resulted in many lives saved. This report is focused on the reconstitution phase of this disaster response, which includes how to restore business continuity. As 95 percent of our medical capacity resides in the private sector in the United States, we must have a proper plan for how to restore business continuity or face the reality of the medical business failing and not providing critical medical services to the community. A tornado in 2007 destroyed a medical center in Sumter County, GA, and it took more than 365 days to restore business continuity at a cost of $18M. The plan executed by the Mercy Medical System after the disaster in Joplin restored business continuity in 88 days and cost a total of $6.6M, with all assets being reusable. The recommendation from these lessons learned is that every county, state, and Federal Emergency Management Agency region has a plan on the shelf to restore business continuity and the means to be able to do so. The hard work that the State of Missouri and the Mercy Medical System did after this disaster can serve as a model for the nation in how to quickly recover from any loss of medical capability. Key words: disaster recovery, reconstitution, business continuity DOI:10.5055/ajdm.2012.0105