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American Journal of Disaster Medicine
Winter 2013, Volume 8
, Number 1


Article
Results of in-hospital triage in 17 mass casualty trainings: Underestimation of life-threatening injuries and need for re-triage
Christian Kleber, MD; Detlef Cwojdzinski; Markus Strehl; Stefan Poloczek, MD, MPH; Norbert P. Haas, MD
Winter 2013; pages 5-11

Abstract
Background: In-hospital triage is the key factor for successful management of an overwhelming number of patients in lack of treatment capacity. The main goal of in-hospital triage is to identify casualties with life-threatening injuries and to allocate immediate medical aid. For the first time, we evaluate the quality of in-hospital triage in the German capital Berlin. Methods: In this prospective observational study of 17 unheralded external mass casualty trainings for Berlin disaster hospitals in 2010/2011, we analyzed the in-hospital triage of 601 rouged casualty actors. Evaluation was performed by structured external survey and interview of the casualty actors after the disaster training. In 93 percent (n = 558), complete data were available and suitable for statistical analysis. Results: The primary triage category was allocated correctly to 61 percent (n = 338) of the simulated injury severity. The following measurements were performed: anamnesis in 77 percent, physical examination 71 percent, blood pressure in 68 percent, heart rate in 61 percent, and oxygen saturation in 25 percent. Additive radiological diagnostics were used: 38 percent X-ray, 16 percent computer tomography, and 7 percent ultrasound. On an average, 1.6 ± 1.2 diagnostic tools were used to allocate injury severity to rouged casualties. Of all the rouged casualties, 24 percent overtriage and 16 percent undertriage were observed. Overtriage was significantly infrequent in level I trauma centers (p = 0.03). Of the patients with life-threatening injuries, 18 percent was undertriaged. Of the 62 percent with secondary right allocation to triage category, re-triage was only used in 4 percent. Conclusion: The accuracy of in-hospital triage is low (61 percent). Predominately, the problem of overtriage (24 percent) due to insufficient triage training in contrast to undertriage (16 percent) occurs. The diagnostic triage adjuncts, ultrasound and re-triage, should be routinely used to lower the rate of undetected life threat in mass casualty incidents. Furthermore, a standardized training program and triage algorithm for in-hospital triage should be established. Key words: disaster, triage, overtriage, undertriage, hospital DOI:10.5055/ajdm.2013.0106


Article
A pan-European study of capabilities to manage mass casualties from the release of chemical agents: The MASH project
David J. Baker, FRCA; Virginia S. G. Murray, FRCP; Pierre A. Carli, MD
Winter 2013; pages 13-23

Abstract
The European Union (EU) Mass Casualties and Health (MASH) project that ran between 2008 and 2010 was designed to study the management of mass casualties from chemical and radiological releases and associated health implications. One area of study for this project concerned arrangements within EU Member States for the management of mass casualties following a chemical release. This was undertaken via a confidential online questionnaire that was sent to selected points of contact throughout the EU. Responses were obtained from 18 states from respondents holding senior positions in chemical planning and incident response. Information gathered shows a lack of uniformity within the EU about the organization of responses to chemical releases and the provision of medical care. This article presents the overall findings of the study demonstrating differences between countries on planning and organization, decontamination, prehospital emergency medical responses, clinical diagnoses, and therapy and aftercare. Although there may be an understandable reluctance from national respondents to share information on security and other grounds, the findings, nevertheless, revealed substantial differences between current planning and operational responses within the EU states for the management of mass chemical casualties. The existing international networks for response to radiation incidents are not yet matched by equivalent networks for chemical responses yet sufficient information was available from the study to identify potential deficiencies, identify common casualty management pathways, and to make recommendations for future operations within the EU. Improvements in awareness and training and the application of modern information and communications will help to remedy this situation. Specialized advanced life support and other medical care for chemical casualties appear lacking in some countries. A program of specialized training and action are required to apply the findings revealed by the MASH study into a unified cross-border emergency medical response. Key words: MASH, European, mass, chemical, casualty, management DOI:10.5055/ajdm.2013.0107


Article
A decision process for determining whether to conduct responder health research following large disasters
John A. Decker, MS; Max Kiefer, MS; Dori B. Reissman, MD, MPH; Renée Funk DVM, MPH; John Halpin, MD, MPH; Bruce Bernard, MD, MPH; Richard L. Ehrenberg, MD; Christine R. Schuler, PhD; Elizabeth Whelan, PhD; Kyle Myers, MS; John Howard, MD
Winter 2013; pages 25-33

Abstract
Disasters often set the stage for scientific inquiry within the field of occupational safety and health. This is especially true when the long-term consequences of exposures associated with a particular disaster are unclear. However, a responder research study can be costly and difficult to design, and researchers must consider whether the proposed study will produce useful, reliable results and is a prudent public health investment. The decision process can be segregated into various components, including scientific rationale that should be formally recognized as critical to efficiently and effectively determine whether a research study is warranted. The scientific rationale includes certain controlling or “gatekeeper” factors that should be present to proceed with research. Key words: disaster research, responder research, postdisaster research, surveillance, health monitoring DOI:10.5055/ajdm.2013.0108


Article
Emergency preparedness in a sample of persons with disabilities
Robyn R. M. Gershon, MHS, DrPH; Lewis E. Kraus, MPH, MCP; Victoria H. Raveis, PhD; Martin F. Sherman, PhD; June I. Kailes, MSW
Winter 2013; pages 35-47

Abstract
Objective: The objective of this study was to characterize emergency preparedness in this vulnerable population, and to ascertain the role of the personal assistant (PA) and the potential impact of prior emergency experience on preparedness efforts. Design: Cross-sectional Internet-based survey conducted in 2011. Setting: Convenience sample. Participants: Two-hundred fifty-three community residents with cognitive and/or physical disabilities, all receiving personal assistance services. Main outcome variables: Emergency preparedness, operationalized as responses to a seven-item scale. Results: The mean score for the emergency preparedness scale was 2.32 (SD = 2.74), range 0-7. Even though 62.8 percent (n = 159) of the participants had previously experienced one or more large-scale emergencies, only 47.4 percent (n = 120) of the entire sample and 55.3 percent (n = 88) of those with actual emergency experience reported preparing an emergency plan. Sixty-three percent (n = 76) of those reporting a plan had involved their PA in its development. Participants who reported such involvement were significantly more likely to have higher scores on the emergency preparedness scale (p < 0.001). Participants who had experienced a prior emergency were also more likely to score higher on the emergency preparedness scale (p < 0.001). In general, participants reported limited attention to other basic preparedness recommendations: only 28 percent (n = 70) had prepared a “go-bag” with necessary supplies, 29 percent (n = 74) had developed a strategy for communicating with their PA during emergencies, and 32 percent (n = 81) had stockpiled emergency supplies. Of particular importance, only 26 percent (n = 66) had made alternative back-up plans for personal assistance. Conclusions: Involving the PA in the planning process and experiencing an emergency were both significantly associated with higher emergency preparedness scores in this sample of people living with disabilities. However, critical deficiencies in preparedness were noted, such as lack of back-up plans for replacing their PA. Despite a concerted national effort to improve preparedness in the population of people living with disabilities, important preparedness gaps remain. These findings highlight the need for additional study on emergency preparedness barriers in people living with disabilities so that effective strategies to reduce vulnerabilities can be identified. Key words: disabled, disaster preparedness, personal assistant DOI:10.5055/ajdm.2013.0109


Article
Public health preparedness and response competency model methodology
Elizabeth Ablah, PhD, MPH; Elizabeth McGean Weist, MA, MPH, CPH; John E. McElligott, MPH, CPH; Laura A. Biesiadecki, MSPH, CPH; Audrey R. Gotsch, DrPH, MCHES; C. William Keck, MD, MPH; Kristine M. Gebbie, DrPH, RN
Winter 2013; pages 49-56

Abstract
Objective: The Pandemic and All-Hazards Preparedness Act calls for establishing a competency-based training program to train public health practitioners. To inform such training, the Centers for Disease Control and Prevention and the Association of Schools of Public Health managed groups of experts to produce a competency model which could function as a national standard of behaviorally based, observable skills for the public health workforce to prevent, protect against, respond to, and recover from all hazards. Design: A systematic review of existing competency models generated a competency model of proposed domains and competencies. Participants: National stakeholders were engaged to obtain consensus through a three-stage Delphi-like process. Results: The Delphi-like process achieved 84 percent, 82 percent, and 79 percent response rates in its three stages. Three hundred sixty six unique individuals responded to the three-round process, with 45 percent (n = 166) responding to all three rounds. The resulting competency model features 18 competencies within four core learning domains targeted at midlevel public health workers. Conclusions: Practitioners and academics have adopted the Public Health Preparedness and Response Core Competency Model, some of whom have formed workgroups to develop curricula based on the model. Efforts will be needed to develop evaluation materials for training and education programs to refine the model as well as for future training and education initiatives. Key words: public health preparedness, competencies, midlevel DOI:10.5055/ajdm.2013.0110


Article
La Gloria, Mexico: The possible origins and response of a worldwide H1N1 flu pandemic in 2009
Sahar Hashmi,, MD
Winter 2013; pages 57-64

Abstract
This article traces the spread and route of the H1N1 pandemic in 2009 from its possible origin in La Gloria to Mexico City. A lack of health control measures or nonpharmaceutical interventions (NPIs) in La Gloria accounts for the unprecedented high basic reproductive number (R0) in that town and a higher incidence of H1N1 flu in Mexico City. We analyzed data collected from Mexican news articles, the Healthmaps dataset, the Google search engine, and telephone interviews with Mexican community physicians and residents. Our article uses a simple Susceptible Infected and Recovered model based on the data collected, to show the relationship between the disease curve and the implementation of NPI use. As a result of this study, we conclude that, with strict government measures to control the disease over an extended period of time, it is possible that many hundreds or even thousands of lives might be saved in the future. Key words: La Gloria, Mexico, R0, R(t), nonpharmaceutical interventions DOI:10.5055/ajdm.2013.0111


Article
Assessing hospital disaster preparedness in Shiraz, Iran 2011: Teaching versus private hospitals
Hamideh Mahdaviazad, MD; Gholam Reza Abdolahifar, MD, MPH
Winter 2013; pages 65-73

Abstract
Background: In disasters, hospitals play a crucial role in supplying essential medical care to the society but there is no standardized checklist for assessing hospital disaster preparedness. Objectives: The objective of this study was to recognize and compare almost all the components of disaster preparedness between teaching and private hospitals in Shiraz, Iran, focusing on incident command systems (ICS), communications, surge capacity, human resources, supply management, logistic service, case management, surveillance, laboratory and operating room management. Methods: From May to August 2011, we assessed the preparedness of teaching and private hospitals in Shiraz, using the 10-key component World Health Organization checklist. Results: Twenty four out of 31 hospitals responded. The scores for preparedness of ICS, communication, surge capacity and human resources was 73.9 percent, 67.3 percent, 49 percent, and 52.6 percent respectively. The preparedness scores for supply management and logistic services were 68.5 percent and 61.8 percent. While the levels of preparedness of laboratory and operating room management were low, preparedness of the surveillance system and case management were 66.7 percent and 70.8 percent, respectively. The average total preparedness of all hospitals was 59.5 percent, with scores of 62.2 percent in teaching hospitals and 55 percent in private hospitals. Conclusion: At the time of our study, the total preparedness among hospitals was at the intermediate level, but in some key components such as operating room management, surge capacity, and human resources, the total preparedness was very limited and at an early stage of development, therefore, requiring urgent attention and improvement. Key words: hospitals, preparedness, disasters DOI:10.5055/ajdm.2013.0112


Article
IDEAS & INNOVATIONS. Pediatric Surge Pocket Guide: Review of an easily accessible tool for managing an influx of pediatric patients
Ann C. Lin, BS; Rita V. Burke, PhD, MPH; Sadina Reynaldo, PhD; Bridget M. Berg, MPH; Jeffrey S. Upperman, MD, FAAP, FACS
Winter 2013; pages 75-82

Abstract
As seen in recent disasters, large-scale crisis events have the potential to cause significant pediatric death and injury. During such disaster situations, both distance and decreased mobility will likely limit access to pediatric hospitals. Thus, all hospitals, regardless if they regularly treat children or not, should anticipate an influx of pediatric patients in the event of a disaster. The Pediatric Surge Pocket Guide was developed for and distributed at a Pediatric Medical Surge Workshop held by the Los Angeles County Department of Public Health in June 2009. Designed both as a supplement to the workshop training and as an effective stand-alone resource, the Guide provides comprehensive pediatric-specific recommendations for hospitals experiencing a surge in pediatric capacity. Because of its unique pocket-size format, the Guide has the potential to be a readily accessible tool with application to a wide range of disaster or nondisaster situations, for use in hospital or nonhospital settings, and by pediatric specialists, nonspecialists, and nonclinicians alike. Key words: pediatric, hospital surge, disaster DOI:10.5055/ajdm.2013.0113

American Journal of Disaster Medicine
Spring 2013, Volume 8
, Number 2


Article
Internal radiation exposure of Ground Self-Defense Force members involved in the management of the Fukushima Nuclear Power Plant disaster
Yutaka Naoi, MD; Akira Fujikawa, MD; Yukishige Kyoto, MD; Naoaki Kunishima, MD; Masahiro Ono, RT; Yukie Watanabe, Nrs
Spring 2013; pages 87-90

Abstract
When the Great East Japan Earthquake occurred on March 11, 2011, the Ground Self-Defense Force (GSDF) was dispatched nationally to Northeast area in Japan. The highly trained GSDF members were simultaneously assigned to various missions for the Fukushima Nuclear Power Plants disaster. The missions of GSDF terminated on August 31, 2011. Special medical examinations were conducted for the members as they returned to each military unit. GSDF members who were assigned to the nuclear power plant were at risk of radiation exposure; therefore, pocket dosimeters were used to assess external radiation exposure. A few months after the mission was terminated, measurements of internal radiation exposure were performed. This is the first report of the internal exposure of GSDF members who worked in the restricted radiation contamination area. Here, we report the amounts of internal and external exposure of and the equipment used by the GSDF members. Key words: disaster, Fukushima Nuclear Plant, internal radiation exposure, Japan Ground Self- Defense Force DOI:10.5055/ajdm.2013.0114


Article
Is portable ultrasonography accurate in the evaluation of Schanz pin placement during extremity fracture fixation in austere environments?
Brian P. Dahl, MD, FAWM; Aaron J. Pemberton, MD; Ryan T. Beck, MD; I. Bulent Cetindag, MD; Christopher D. Wohltmann, MD; Mark McAndrew, MD
Spring 2013; pages 91-96

Abstract
Objective: The purpose of this study was to investigate the efficacy of ultrasonography to confirm Schanz pin placement in a cadaveric model, and the interobserver repeatability of the ultrasound methodology. Design: This investigation is a repeated measures cadaveric study with multiple examiners. Participants: Cadaveric preparation and observations were done by an orthopaedic traumatologist and resident, and two general surgery traumatologists. Interventions: A total of 16 Schanz pins were equally placed in bilateral femora and tibiae. Four examiners took measurements of pin protrusion beyond the distal cortices using first ultrasonography and then by direct measurement after gross dissection. Main Outcome Measure(s): Distal Schanz pin protrusion length measurements from both ultrasonography and direct measurement post dissection. Results: Schanz pin protrusion measurements are underestimated by ultrasonography (p < 0.01) by an average of 10 percent over the range of 5 to 18 mm, and they display a proportional bias that increases the under reporting as the magnitude of pin protrusion increases. Ultrasound data demonstrate good linear correlation and closely represent actual protrusion values in the 5 to 12 mm range. Interobserver repeatability analysis demonstrated that all examiners were not statistically different in their measurements despite minimal familiarity with the ultrasound methodology (p > 0.8). Conclusions: Despite the statistical imparity of pin protrusion measurement via ultrasound compared to that of gross dissection, a consideration of the clinical relevance of ultrasound measurement bias during an austere operating theatre leads to the conclusion that ultrasonography is an adequate methodology for Schanz pin protrusion measurement. Key words: Schanz pin, protrusion, ultrasound, external fixation DOI:10.5055/ajdm.2013.0115


Article
Gleaning data from disaster: A hospital-based data mining method to study all-hazard triage after a chemical disaster
Jean B. Craig, PhD, MS, BS; Joan M. Culley, PhD, MPH, MS, RN, CWOCN; Abbas S. Tavakoli, DrPH, MPH, ME; Erik R. Svendsen, PhD, MS, BS
Spring 2013; pages 97-111

Abstract
Objective: To describe the methods of evaluating currently available triage models for their efficacy in appropriately triaging the surge of patients after an all-hazards disaster. Design: A method was developed for evaluating currently available triage models using extracted data from medical records of the victims from the Graniteville chlorine disaster. Setting: On January 6, 2005, a freight train carrying three tanker cars of liquid chlorine was inadvertently switched onto an industrial spur in central Graniteville, SC. The train then crashed into a parked locomotive and derailed. This caused one of the chlorine tankers to rupture and immediately release ~60 tons of chlorine. Chlorine gas infiltrated the town with a population of 7,000. Participants: This research focuses on the victims who received emergency care in South Carolina. Results: With our data mapping and decision tree logic, the authors were successful in using the available extracted clinical data to estimate triage categories for use in our study. Conclusions: The methodology outlined in this article shows the potential use of well-designed secondary analysis methods to improve mass casualty research.The steps are reliable and repeatable and can easily be extended or applied to other disaster datasets. Key words: triage, chemical disaster, mass casualty, methods for disaster research DOI:10.5055/ajdm.2013.0116


Article
Risk factors for mortality in landslide- and flood-affected populations in Uganda
Shreya Agrawal, MSPH, MPA; Yuri Gorokhovich, MA, PhD; Shannon Doocy, PhD
Spring 2013; pages 113-122

Abstract
Objective: Assess mortality risk factors including age, sex, and disaster type, in the March 2010 floods and landslides in Eastern Uganda and to compare time period, cause, location, and receipt of medical care among landslide and flood fatalities. Design: A stratified cluster survey was conducted of 802 affected households in community and camp locations. Setting: Flood and landslide affected populations in the East Uganda the districts of Baduda and Butaleja. Respondents: Adult household members in 802 households were surveyed regarding household member deaths in the floods and landslides areas. Main Outcome Measures: The primary outcome measure was the odds of death associated with age, sex, and disaster type (flood or landslide). The secondary outcome measure was the odds of event (landslide or flood) among fatalities associated with sex, age, time period of death, and cause of death. Results: The odds of death were significantly higher in landslide affected populations than in flood affected populations (OR 3.06, 95% CI 2.20-4.25, p < 0.001). Time period of death (p = 0.016), type of death (p < 0.001), death after seeking medical care (p = 0.033), month of death (p < 0.001), and cause of death (p < 0.001) were significantly associated with increased odds of death due to landslides as compared to floods. Conclusion: More deaths occurred due to landslides than floods, and landslide deaths were more immediate, with a majority occurring on the day of the event. Females and younger age groups faced a greater risk of death from the landslide than the flood. Key words: flood, landslide, natural disasters, Uganda, mortality DOI:10.5055/ajdm.2013.0117


Article
Disaster-related fatalities among US citizens traveling abroad
Robert Partridge, MD, MPH; David Bouslough, MD, MPH; Lawrence Proano, MD
Spring 2013; pages 123-126

Abstract
Objective: To describe the locations and risk of death associated with natural disaster fatalities for US citizens traveling abroad. Design, setting, and participants: A retrospective database review of US citizen disaster deaths occurring worldwide. Interventions: None. Main outcome measures: Information on fatalities due to disasters was abstracted from the US Department of State Web site reporting deaths of US citizens abroad by non-natural causes from October 2002 through June 2012. The main outcome measures were the frequency of disaster deaths and countries where disasters occurred. Descriptive statistics and rates were used to evaluate the study data. Results: There were 7,963 total non-natural deaths of US citizens traveling abroad during the study period. Of these, 163 (2.0 percent) were disaster-related deaths, involving 19 disaster events in 15 countries. Only two disaster-related events resulted in more than two deaths of US travelers—the 2010 earthquake in Haiti causing 121 fatalities (74.2 percent of disaster deaths), and the 2004 tsunami in Thailand causing 22 fatalities (13.5 percent of disaster deaths).The approximate annual mean death rate for US citizen travelers as a result of disaster events is 0.27 deaths/1 million travelers, compared with 1.4 deaths/1 million residents due to disaster annually within the United States. Conclusions: The risk of disaster-related fatality is low for US citizens traveling abroad. Although disaster-related death among travelers is unpredictable, during a period of almost 10 years, there was only one reported death due to disaster in the five countries most frequently visited by US travelers. Further investigation may identify population-, seasonal-, country-, or location-specific risks from which prevention strategies can be developed. Key words: disaster, fatalities, US citizens, abroad DOI:10.5055/ajdm.2013.0118


Article
Italian medical students and disaster medicine: Awareness and formative needs
Luca Ragazzoni, MD; Pier Luigi Ingrassia, MD, PhD; Gianluca Gugliotta, MD; Marco Tengattini, MD; Jeffrey Michael Franc, MD, FCFP.EM; Francesco Della Corte, MD
Spring 2013; pages 127-136

Abstract
Objective: Over the last century, the number of disasters has increased. Many governments and scientific institutions agree that disaster medicine education should be included in the standard medical curriculum. Italian medical students’ perceptions of mass casualty incidents and disasters and whether—and if so to what extent—such topics are part of their academic program were investigated. Design, setting, and participants: A Web-based survey was disseminated to all students registered with the national medical students’ association (Segretariato Italiano Studenti Medicina), a member of the International Federation of Medical Students’ Associations. The survey consisted of 14 questions divided into four sections. Results: Six hundred thirty-nine medical students completed the survey; 38.7 percent had never heard about disaster medicine; 90.9 percent had never attended elective academic courses on disaster medicine; 87.6 percent had never attended nonacademic courses on disaster medicine; 91.4 percent would welcome the introduction of a course on disaster medicine in their core curriculum; and 94.1 percent considered a knowledge of disaster medicine important for their future career. Conclusions: Most of the students surveyed had never attended courses on disaster medicine during their medical school program. However, respondents would like to increase their knowledge in this area and would welcome the introduction of specific courses into the standard medical curriculum. Key words: academic curriculum, disaster medicine, medical education, medical students DOI:10.5055/ajdm.2013.0119


Article
Evaluation of regional hospitals’ use of children in disaster drills
Aaron H. Gardner, MD; Michael R. FitzGerald, PhD; Hamilton P. Schwartz, MD; Nathan L. Timm, MD
Spring 2013; pages 137-143

Abstract
Objective: Describe the prevalence of pediatric casualties in disaster drills by community hospitals and determine if there is an association between the use of pediatric casualties in disaster drills and the proximity of a community hospital to a tertiary children’s hospital. Design: Survey, descriptive study. Setting: Tertiary children’s hospital and surrounding community hospitals. Participants: Hospital emergency management personnel for 30 general community hospitals in the greater Cincinnati, Ohio region. Interventions: None Main Outcome Measure(s): The utilization of pediatric casualties in community hospital disaster drills and its relationship to the distance of those hospitals from a tertiary children’s hospital. Results: Sixteen hospitals reported a total of 57 disaster drills representing 1,309 casualties. The overwhelming majority (82 percent [1,077/1,309]) of simulated patients from all locations were 16 years of age or older. Those hospitals closest to the children’s hospital reported the lowest percentage of pediatric patients (10 percent [35/357]) used in their drills. The hospitals furthest from the children’s hospital reported the highest percentage of pediatric patients (32 percent [71/219]) used during disaster drills. Conclusions: The majority of community hospitals do not incorporate children into their disaster drills, and the closer a community hospital is to a tertiary children’s hospital, the less likely it is to include children in its drills. Focused effort and additional resources should be directed toward preparing community hospitals to care for children in the event of a disaster. Key words: disaster, drills, children, hospital, emergency preparedness DOI:10.5055/ajdm.2013.0120


Article
Case study. An academic medical center’s response to widespread computer failure
Nicholas Genes, MD, PhD; Michael Chary, PhD; Kevin W. Chason, DO
Spring 2013; pages 145-150

Abstract
As hospitals incorporate information technology (IT), their operations become increasingly vulnerable to technological breakdowns and attacks. Proper emergency management and business continuity planning require an approach to identify, mitigate, and work through IT downtime. Hospitals can prepare for these disasters by reviewing case studies. This case study details the disruption of computer operations at Mount Sinai Medical Center (MSMC), an urban academic teaching hospital. The events, and MSMC’s response, are narrated and the impact on hospital operations is analyzed. MSMC’s disaster management strategy prevented computer failure from compromising patient care, although walkouts and time-to-disposition in the emergency department (ED) notably increased. This incident highlights the importance of disaster preparedness and mitigation. It also demonstrates the value of using operational data to evaluate hospital responses to disasters. Quantifying normal hospital functions, just as with a patient’s vital signs, may help quantitatively evaluate and improve disaster management and business continuity planning. Key words: electronic health record, computer security, medical informatics, disaster planning, hospital administration DOI:10.5055/ajdm.2013.0121

American Journal of Disaster Medicine
Summer 2013, Volume 8
, Number 3


Article
Editorial The wide-area medical transportation following the Great East Japan Earthquake: The Japanese government’s control and coordination
Tetsu Okumura, MD, PhD
Summer 2013; pages 155-156

Abstract
DOI:10.5055/ajdm.2013.0122


Article
Effective purpose in transnational humanitarian healthcare providers
Donna J. Perry, PhD, RN
Summer 2013; pages 157-168

Abstract
Objective: To advance knowledge regarding the education and support needs of staff deployed to international settings from a US academic medical center (AMC). Design: A qualitative approach rooted in phenomenology called, Transcendental Method for Research with Human Subjects was used. A flexible interview guide was used to guide participants into self-reflection about the decision to participate in global healthcare, educational preparation, field experiences, and return. Setting: The study was conducted at a US AMC. Participants: Sample size was 15 and included nurses, physicians, and therapists who had participated in disaster and/or developmental humanitarian global health deployments. Purposive sampling with a maximum variation approach was used along with snowball sampling. Sample size was determined by reaching horizonal understanding of participants. Main outcome measures: The study sought to elicit and analyze responses from participants in an open-ended manner. Results: Analysis revealed the following seven themes: a) the yearning to relieve suffering, b) getting ready, c) making a difference, d) bad things happening to wonderful people, e) challenging and sustaining factors, f) dialectical alienation, and g) knowing what really matters. The concept of “effective purpose” emerged from interpretation of these themes. Conclusions: Most participants found their experiences to be beneficial and meaningful but faced challenges in the field. Knowledge and skills varied among providers. Education and support are critical for healthcare professionals who engage in transnational healthcare. Recommendations for staff preparation are provided. Key words: global health, humanitarian, international deployment, staff education, effective purpose DOI:10.5055/ajdm.2013.0123


Article
Health consequences of involuntary exposure to benzene following a flaring incident at British Petroleum refinery in Texas City
Mark A. D’Andrea, MD, FACRO; Omesh Singh, DO; G. Kesava Reddy, PhD, MHA
Summer 2013; pages 169-179

Abstract
Objective: Environmental exposure to benzene can lead to deleterious effects on many biological systems including blood-forming organs, liver, and kidneys. The authors sought to investigate the health consequences of benzene exposure following a flaring incident that occurred at the British Petroleum (BP) refinery in Texas City, TX. Subjects and participants: A cohort of subjects who were exposed to a daily sustained release of toxic chemicals including more than 7,711 kg (17,000 lb) of benzene for a total duration of 40 days due to BP’s flaring incident. Interventions: Not applicable to an observational study. Methods: Subjects who underwent physical and clinical evaluation between June 2010 and October 2012 were included. Demographic and clinical laboratory data were collected and analyzed. Hematologic data such as white blood cell (WBC) counts, platelet counts, hemoglobin, hematocrit, blood urea nitrogen (BUN), and creatinine levels in the serum were evaluated. In addition, data on alkaline phosphatase (ALP), aspartate amino transferase (AST), and alanine amino transferase (ALT) levels in the serum were examined. Urinary phenol was evaluated as a benzene metabolite. The outcomes were compared between exposed and unexposed patients. Results: A total of 200 subjects (benzene exposed, n = 100 and unexposed, n = 100) were included. Benzene exposed subjects showed significantly higher levels of WBC (×103 per µL) count (8.6 ± 5.4 vs 6.5 ± 2.0, p = 0.0003) and platelet (×103 per µL) count (291.3 ± 82.7 vs 264.1 ± 74.0, p = 0.0076) compared with the unexposed subjects. ALP (IU/L) was significantly elevated in the benzene exposed subjects compared with the unexposed subjects (121.2 ± 73.7 vs 65.4 ± 23.6, p = 0.000). Similarly, benzene exposed subjects had significantly higher levels of AST (IU/L) compared with unexposed subjects (23.4 ± 11.8 vs 19.5 ± 8.9, p = 0.0089). Conclusion: This retrospective pilot study found that environmental benzene exposure from the BP’s flaring incident appears to pose significant health risks including specific alteration of blood cells and liver enzymes, indicating that subjects exposed to benzene may be at a higher risk of developing hepatic or blood related disorders. Key words: benzene poisoning, blood disorders, chemical exposure, health impact, hematologic toxicity, hepatotoxicity, petroleum refinery, urinary metabolites of benzene DOI:10.5055/ajdm.2013.0124


Article
Innovations in point-of-care testing for enhanced United States disaster caches
Corbin M. Curtis, BS; Richard F. Louie, PhD, FACB; John H. Vy, BS; William J. Ferguson, BS; Mandy Lam; Anh-Thu Truong; Michael J. Rust, PhD; Gerald J. Kost, MD, PhD, MS, FACB
Summer 2013; pages 181-204

Abstract
Objective: To describe, innovate, recommend, and foster the implementation of point-of-care (POC) testing in disaster caches to enhance crisis standards of care and to improve triage, diagnosis, monitoring, treatment, and management of victims and volunteers in complex emergencies and disasters. Design and settings: The authors compared POC testing in United States disaster caches to commercially available POC testing to enhance the caches and to reflect current state-of-the-art diagnostic capabilities. The authors also provided recommendations based on literature review and knowledge from newly developed POC technologies from the UC Davis Point-of-Care Technologies Center. Results: Presently, US POC testing caches comprise chemistry/electrolytes, pregnancy, hemoglobin, cardiac biomarkers, hematology, fecal occult blood, drugs of abuse, liver function, blood gases, and limited infectious diseases. Deficiencies with existing POC tests for cardiac biomarkers, hematology, and infectious diseases should be eliminated. POC resources can be customized for pandemics, complex emergencies, or disasters based on geographic location and potential infectious diseases. Additionally, a new thermally stabilized container can help alleviate environmental stresses that reduce test quality. Conclusions: Innovations in POC technologies can improve response preparedness with enhanced diagnostic capabilities. Several innovations, such as the i-STAT® Wireless, OraQuick ADVANCE® HIV-1/2, VereTrop™ Lab-on-a-Chip, and new compact hematology analyzers will improve test clusters that facilitate evidence-based decision making and crisis standards of care during US national disaster responses. Additionally, strategic resources and operator training should be globally harmonized to improve the efficiency of international responses. Key words: analytical errors, cardiac troponin I, crisis standards of care, deployment logistics, disaster preparedness and response framework, preparedness, quality assurance, resiliency DOI:10.5055/ajdm.2013.0125


Article
Effects of environmental conditions on point-of-care cardiac biomarker test performance during a simulated rescue: Implications for emergency and disaster response
Richard F. Louie, PhD, FACB; William J. Ferguson, BS; Corbin M. Curtis, BS; John H. Vy, BS; Chloe S. Tang, BS; Gerald J. Kost, MD, PhD, MS, FACB
Summer 2013; pages 205-212

Abstract
Objective: To characterize the effects of environmental stress on point-of-care (POC) cardiac biomarker testing during a simulated rescue. Design: Multiplex test cassettes for cardiac troponin I (cTnI), brain natriuretic peptide (BNP), CKMB, myoglobin, and D-dimer were exposed to environmental stresses simulating a 24-hour rescue from Hawaii to the Marshall Islands and back. We used Tenney environmental chambers (T2RC and BTRC) to simulate flight conditions (20°C, 10 percent relative humidity) and ground conditions (22.3-33.9°C, 73-77 percent). We obtained paired measurements using stressed versus control (room temperature) cassettes at seven time points (T1-7 with T1,2,6,7 during flight and T3-5 on ground). We analyzed paired differences (stressed minus control) with Wilcoxon signed rank test. We assessed the impact on decision-making at clinical thresholds. Results: cTnI results from stressed test cassettes (n _ 10) at T4 (p < 0.05), T5 (p < 0.01), and T7 (p < 0.05) differed significantly from control, when testing samples with median cTnI concentration of 90 ng/L. During the ground rescue, 36.7 percent (11/30) of cTnI measurements from stressed cassettes generated significantly lowered results. At T5, 20 percent (2/10) of cTnI results were highly discrepant— stressed cassettes reported normal results, when control results were >100 ng/L. With sample median concentration of 108 pg/mL, BNP results from stressed test cassettes differed significantly from controlls (p < 0.05). Conclusion: Despite modest, short-term temperature elevation, environmental stresses led to erroneous results. False negative cTnI and BNP results potentially could miss acute myocardial infarction and congestive heart failure, confounded treatment, and increased mortality and morbidity. Therefore, rescuers should protect POC reagents from temperature extremes. Key words: austere environments, disaster preparedness, medical errors, Pacific Islands, and quality assurance DOI:10.5055/ajdm.2013.0126


Article
Case study Simple, school-based mass distribution as a small-town strategy
David Knauf, RS, MS, MPH; Scot Phelps, JD, MPH
Summer 2013; pages 213-221

Abstract
Objective: Test a radically simple school-based point-of-dispensing model. Design: Prospective study. Setting: Community Participants: Community residents with children at one middle school. Interventions: Rapid dispensing of medication. Main Outcome Measure(s): 1) Measure and extrapolate ability to distribute medications to Darien residents through school-based distribution model; 2) assess if using a limited staffing model with limited training was functional. Identify stress points; 3) understand the existing school communication model; 4) track and extrapolate the breakdown of adult-to-child doses distributed and compare to existing census data; and 5) measure throughput of school-based distribution model in the 50-minute drop-off period. Results: 1) This exercise supported the concept that rapid medication distribution through the public schools is an appropriate strategy for health departments, particularly departments with limited resources. 2) Just-in-time briefing worked well as a training strategy. The primary stress points identified were in restock—if medication was in blister packs, we would not be able to stock vests with 100 of each as they are substantially bigger than mints. 3) The secure Darien Public School notification system was ideal for distributing information to parents since they tend to receive school communication on a regular basis and by definition, access is limited to town residents. 4) When asked about household size, most drivers indicated “two adults and two (or more) children.”We distributed medication for 784 adults and 963 children. This ratio was higher than the 2010 Census, which had an average household size of 3.08 in Darien. 5) In 50 minutes, using a mix of Health Department and school staff, medication was distributed to 1,747 residents, almost 10 percent of the population. The hourly throughput from this model was distribution to 2,096 people per hour or 699 people per distributor per hour. This compares favorably to almost every other nonmedical distribution model. Conclusions: Using four Health Department staff and six public school staff, we distributed medication to 784 adults and 963 pediatric residents in 50 minutes at one school. If we extrapolated that across the six other public schools in Darien, we could provide medication to more than 10,000 residents within 8 hours. While we are cognizant of the limitations and drawbacks of this model, we strongly believe that it is the only practical solution to the problem of rapid distribution of medication to the entire community. Key words: point of dispensing, point of distribution, models, simple DOI:10.5055/ajdm.2013.0127

American Journal of Disaster Medicine
Fall 2013, Volume 8
, Number 4


Article
Trauma-Focused Early Intensive Cognitive Behavioral Intervention (TF-EICBI) in children and adolescent survivors of suicide bombing attacks (SBAs). A preliminary study
Agnes Leor, MD; Orna T. Dolberg, MD; Shira Pagorek Eshel, PhD; Yaron Yagil, PhD; Shaul Schreiber, MD
Fall 2013; pages 227-234

Abstract
Objectives: To describe and evaluate the impact of an early intervention (Trauma-Focused Early Intensive Cognitive Behavioral Intervention, TF-EICBI) in children and adolescents who were victims of suicide bombing attacks (SBAs) in Israel. Design: Description of an intervention and preliminary experience in its use. Setting: An acute trauma center of a Child and Adolescent Psychiatric Unit in a Department of Psychiatry of a university-affiliated medical center. Participants: Ten children and adolescents who were victims of SBAs and underwent early interventions (EIG) were compared to 11 adolescent victims who received no intervention (NEIG).The EIG included all the children and adolescent survivors of various SBAs that had occurred during 1 year who presented to our hospital after the TF-EICBI was implemented (June 2001). The NEIG comprised all adolescents girls <18 years of age at follow-up who survived one SBA (at the “Dolphinarium” Discotheque) before the TF-EICBI was available. Main outcome measures: At the time of the 1-year post-SBA follow-up, all 21 subjects were assessed by the Structured Clinical Interview for Axis 1 DSMIII R Disorders (SCID), and the Child Behavior Checklist (CBCL). Results: One (10 percent) EI subject and four (36.4 percent) NEI subjects had post-traumatic stress disorder. The mean CBCL total score and most of the mean CBCL behavior problem scores were significantly higher (p < 0.021) among the NEI group members. Conclusions: Intervention was effective in preventing and lowering mental morbidity of children and adolescents after SBAs. Key words: early emotional intervention, children and adolescents, acute stress response, suicide bombing attacks, trauma DOI:10.5055/ajdm.2013.0128


Article
Community health facility preparedness for a cholera surge in Haiti
Linda Meta Mobula, MD, MPH; Gabrielle A. Jacquet, MD, MPH; Kristin Weinhauer, MSN, MPH; Gladys Alcidas, RN, MPH; Hans-Muller Thomas, MD, MPH; Gilbert Burnham, MD, PhD
Fall 2013; pages 235-241

Abstract
With increasing population displacement and worsening water insecurity after the 2010 earthquake, Haiti experienced a large cholera outbreak. Our goal was to evaluate the strengths and weaknesses of seven community health facilities’ ability to respond to a surge in cholera cases. Since 2010, Catholic Relief Services (CRS) with a number of public and private donors has been working with seven health facilities in an effort to reduce morbidity and mortality from cholera infection. In November 2012, CRS through the Centers for Disease Control and Prevention (CDC)’s support, asked the Johns Hopkins Center for Refugee and Disaster Response to conduct a cholera surge simulation tabletop exercise at these health facilities to improve each facility’s response in the event of a cholera surge. Using simulation development guidelines from the Pan American Health Organization and others, a simulation scenario script was produced that included situations of differing severity, supply chain, as well as a surge of patients. A total of 119 hospital staff from seven sites participated in the simulation exercise including community health workers, clinicians, managers, pharmacists, cleaners, and security guards. Clinics that had challenges during the simulated clinical care of patients were those that did not appropriately treat all cholera patients according to protocol, particularly those that were vulnerable, those that would need additional staff to properly treat patients during a surge of cholera, and those that required a better inventory of supplies. Simulation-based activities have the potential to identify healthcare delivery system vulnerabilities that are amenable to intervention prior to a cholera surge. Key words: cholera, emergency, preparedness, healthcare, surge, Haiti DOI:10.5055/ajdm.2013.0129


Article
Ethical dilemmas related to predictions and warnings of impending natural disaster
Kai-Lit Phua, PhD; J. W. Hue, BS
Fall 2013; pages 243-252

Abstract
Scientists and policy makers issuing predictions and warnings of impending natural disaster are faced with two major challenges, that is, failure to warn and issuing a false alarm. The consequences of failure to warn can be serious for society overall, for example, significant economic losses, heavy infrastructure and environmental damage, large number of human casualties, and social disruption. Failure to warn can also have serious for specific individuals, for example, legal proceedings against disaster research scientists, as in the L’Aquila earthquake affair. The consequences of false alarms may be less serious. Nevertheless, false alarms may violate the principle of nonmaleficence (do no harm), affect individual autonomy (eg, mandatory evacuations), and may result in the “cry wolf” effect. Other ethical issues associated with natural disasters include the promotion of global justice through international predisaster technical assistance and postdisaster aid. Social justice within a particular country is promoted through greater postdisaster aid allocation to the less privileged. Key words: ethics, natural disasters, natural hazards, risk assessment, disaster prediction, disaster warning DOI:10.5055/ajdm.2013.0130


Article
Lessons learned from a landslide catastrophe in Rio de Janeiro, Brazil
Bruno Monteiro Tavares Pereira, MD, MSc; Wellington Morales, MD; Ricardo Galesso Cardoso, MD; Rossano Fiorelli, MD, PhD; Gustavo Pereira Fraga, MD, PhD; Susan M. Briggs, MD, MPH
Fall 2013; pages 253-258

Abstract
Introduction: On January, 2011, a devastating tropical storm hit the mountain area of Rio de Janeiro State in Brazil, resulting in flooding and mudslides and leaving 30,000 individuals displaced. Objective: This article explores key lessons learned from this major mass casualty event, highlighting prehospital and hospital organization for receiving multiple victims in a short period of time, which may be applicable in similar future events worldwide. Methods: A retrospective review of local hospital medical/fire department records and data from the Health and Security Department of the State were analyzed. Medical examiner archives were analyzed to determine the causes of death. Results: The most common injuries were to the extremities, the majority requiring only wound cleaning, debridement, and suture. Orthopedic surgeries were the most common operative procedures. In the first 3 days, 191 victims underwent triage at the hospital with 50 requiring admission to the hospital. Two hundred fifty patients were triaged at the hospital by the end of the fifth day.The mortis cause for the majority of deaths was asphyxia, either by drowning or mud burial. Conclusion: Natural disasters are able to generate a large number of victims and overwhelm the main channels of relief available. Main lessons learned are as follows: 1) prevention and training are key points, 2) key measures by the authorities should be taken as early as possible, and 3) the centralization of the deceased in one location demonstrated greater effectiveness identifying victims and releasing the bodies back to families. Key words: landslide, disaster medicine, mudslide DOI:10.5055/ajdm.2013.0131


Article
Syrian revolution: A field hospital under attack
Ahmed Hasanin, MD; Ahmed Mukhtar, MD; Ali Mokhtar, MD; Ahmed Radwan, MD
Fall 2013; pages 259-265

Abstract
Background: Syrian revolution that began on March 15, 2011 represents not only a political crisis but also a humanitarian one where many relief attempts for saving civil injured were tried. Methods: A secret field hospital organized by the medical Arab union was set in Al-Bab town in the district of Aleppo. Egyptian volunteer physicians were the operating team who reached Syria through the Turkish border. Medical supplies were delivered from Turkey and medical equipments were taken from the government hospital which was not running at that time. Many Syrian volunteers helped in running this field hospital most of them were non-medical personnel who were trained to help in some medical purposes. Results: Total number of cases referred to the hospital was 75. Surgical intervention was needed for 28 patients. Most common procedures needed were vascular procedures (32 percent), orthopedic procedures (32 percent), and abdominal exploration (25 percent). Median injury severity score (ISS) for admitted patients were 21 with interquartile range (14-21). Two patients died intraoperatively due to massive bleeding. Conclusion: Setting up a field hospital in such an area with unsafe conditions needs good communication with medical and relief organizations in the site of crisis, selection of a location as near as possible to the Turkish border, developing a convenient triaging plan, and training nonmedical volunteers to do simple tasks. Key words: Syrian revolution, field hospital, anesthesia DOI:10.5055/ajdm.2013.0132


Article
First responder and physician liability during an emergency
Amanda Eddy, BA
Fall 2013; pages 267-272

Abstract
First responders, especially emergency medical technicians and paramedics, along with physicians, will be expected to render care during a mass casualty event. It is highly likely that these medical first responders and physicians will be rendering care in suboptimal conditions due to the mass casualty event. Furthermore, these individuals are expected to shift their focus from individually based care to community- or population-based care when assisting disaster response. As a result, patients may feel they have not received adequate care and may seek to hold the medical first responder or physician liable, even if they did everything they could given the emergency circumstances. Therefore, it is important to protect medical first responders and physicians rendering care during a mass casualty event so that their efforts are not unnecessarily impeded by concerns about civil liability. In this article, the author looks at the standard of care for medical first responders and physicians and describes the current framework of laws limiting liability for these persons during an emergency. The author concludes that the standard of care and current laws fail to offer adequate liability protection for medical first responders and physicians, especially those in the private sector, and recommends that states adopt clear laws offering liability protection for all medical first responders and physicians who render assistance during a mass casualty event. Key words: liability, first responders, physicians, standard of care, emergency, mass casualty event DOI:10.5055/ajdm.2013.0133


Article
Mainland China nurses’ willingness to report to work in a disaster
Alice Yuen Loke, PhD, MN, BSN, RN; Wai Man Olivia Fung, DHSc, MPH, BN, RN; Xiwen Liu, MSc, RN
Fall 2013; pages 273-282

Abstract
A cross-sectional study among a convenience sample of nurses in China was conducted to understand the factors affecting Chinese nurses’ willingness to report to work in a disaster. A total of 946 questionnaires were collected. Nearly 90 percent of nurses regarded disaster self-help information, an evacuation plan, and contingency measures a must in preparing for disaster care. Many nurses indicated willingness to work during a disaster that may threaten the safety of their family members than when there is a life-threatening infectious disease outbreak (83.6 and 69.6 percent, p = 0.000). Nurses with longer years of clinical experience were more willing to work in both situations (p = 0.014 and 0.000). Fear of contracting an infectious disease and spreading it to family members was a major factor for nurses’ unwillingness to report to work. Hospital administrators should understand their workforce’s willingness in reporting to work and provide appropriate disaster training and support to maximize workforce in a disaster. Key words: workforce, nurses in China, willingness to report to work, disaster DOI:10.5055/ajdm.2013.0134


Article
Effectiveness of three just-in-time training modalities for N-95 mask fit testing
David Jones, MD; Genevieve Stoler, MD; Joe Suyama, MD
Fall 2013; pages 283-286

Abstract
Objective: To compare and contrast three different training modalities for fit testing N-95 respirator face masks. Design: Block randomized interventional study. Setting: Urban university. Participants: Two hundred eighty-nine medical students. Interventions: Students were randomly assigned to video, lecture, or slide show to evaluate the effectiveness of the methods for fit testing large groups of people. Main outcome measures: Ease of fit and success of fit for each instructional technique. Results: Mask 1 was a Kimberly-Clark duckbill N-95 respirator mask, and mask 2 was a 3M™carpenters N-95 respirator mask. “Ease of fit” was defined as the ability to successfully don a mask in less than 30 seconds. “Success of fit” was defined as the ability to correctly don a mask in one try. There were no statistical differences by training modality for either mask regarding ease of fit or success of fit. Conclusion: There were no differences among video presentation, small group demonstration, and self-directed slide show just-in-time training modalities for ease of fit or success of fit N-95 respirator mask fitting. Further study is needed to explore more effective fit training modalities. Key words: infectious diseases, personal protective equipment, N-95 respirator masks DOI:10.5055/ajdm.2013.0135


Article
Case study. A community outreach influenza vaccination drive as a model for mass disaster prophylaxis
Joshua Lawrenz, BS; Joseph Puetz, MS; Stephanie Kuschel, BS; John Rudzinski, MD
Fall 2013; pages 287-292

Abstract
In October 2012, more than 120 student and faculty volunteers from six different health professional schools (medical, pharmacy, and nursing) vaccinated 430 individuals against influenza at five point of distribution sites in Winnebago County, IL, at no cost to the recipients. In total, 18 organizations, including faith-based and nonprofit groups, organized this vaccination drive, targeting an at-risk population of homeless and impoverished individuals. Preclinical students were provided just-in-time training in vaccine administration and Incident Command System methodology. This community-wide collaborative effort uniquely demonstrates the effectiveness of student volunteerism in emergency preparedness, as well as providing a model for mass prophylaxis in a disaster scenario. Key words: Influenza, vaccination, disaster, students, volunteerism DOI:10.5055/ajdm.2013.0136