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American Journal of Disaster Medicine
Winter 2014, Volume 9
, Number 1


Article
Competency-based pediatric disaster training
Solomon Behar, MD; Rita Burke, PhD, MPH; Jeffrey Upperman, MD; Alan L. Nager, MD, MHA
Winter 2014; pages 5-16

Abstract
Objective: To assess whether participation in a competency-based pediatric disaster educational curriculum increases participants’ knowledge of how to manage pediatric disaster victims. Design: Pretest/post-test intervention study. Setting: Large, urban, academic tertiary hospital. Patients/participants: Three hundred twenty-six clinical and nonclinical healthcare employees. Main outcome measure: Pre-educational and posteducational intervention scores on a 30-item pediatric disaster test. Results: Participants without prior pediatric disaster training had significant improvements between pre-educational and posteducational intervention test scores (p < 0.0001). Conclusions: Our competency-based pediatric disaster educational intervention improved the knowledge of most attendees, the majority of whom infrequently care for pediatric patients. This set of pediatric disaster competencies can be used in future formulation of a standardized curriculum. Key words: disaster education, pediatric, training, competency, preparedness DOI:10.5055/ajdm.2014.0137


Article
Preparedness in America’s prime danger zone and at the Boston Marathon bombing site
Leonard A. Cole, PhD, DDS; Sandra R. Scott, MD; Michael Feravolo, BS; Sangeeta Lamba, MD
Winter 2014; pages 17-24

Abstract
Introduction: The area between Newark and Elizabeth, NJ, contains major transportation hubs, chemical plants, and a dense population. This makes it “the most dangerous two miles in America,” according to counter terrorism officials at the Federal Bureau of Investigation. This study compares medical response capabilities for terror and disaster in Newark, New Jersey’s largest city, with those in Boston in view of that city’s favorable response to the Marathon bombings in April 2013. Boston’s numerous world-class medical facilities offer advantages unavailable in Newark and most other metropolitan locations. Thus, preparedness in Newark, despite its prime-danger designation, can also be instructive for many communities with similar medical resources. Methods: Three categories of response capabilities are assessed: hospital resources, relevant personnel, and symposia/exercises. Data were derived from hospital Web sites, the New Jersey and Massachusetts Hospital Associations, communications with emergency response personnel, and interviews with spokespersons for hospitals. Results: Boston’s population (618,000) is more than twice Newark’s (278,000), and the number of hospitals and hospital beds in each city reflects that proportion. However, Boston’s seven general adult hospitals include five level 1 trauma centers (which can provide comprehensive trauma care), whereas Newark’s four hospitals include only one such center. Beds per 1,000 people are similarly disparate in those trauma centers: five in Boston, 1.5 in Newark. Emergency Medical Services (EMS) personnel based in Boston and Newark are comparable in numbers, though full-time hospital physicians/dentists and nurses are not. The number of doctors at Boston’s five level 1 centers is more than triple that at all four of Newark’s hospitals (5,284 vs 1,494).The disparity between nurses at the two sites is even greater (6,784 vs 1,566). There is greater equivalency between the two cities both in content and frequency of symposia/exercises. Hospitals in each city have conducted numerous tabletop and action exercises including on communications efficiency, power outages, and dealing with a bombing or active shooter. Hospitals in each city also have participated in citywide drills with EMS, police, fire, and other responders. Conclusion: Commonalities in Newark and Boston’s exercise approaches suggest that Boston’s successful response at the Marathon might be replicated at least in part if the Newark area were similarly challenged. Whether Newark and similarly enabled communities would respond with comparable efficiency remains conjectural. Still, maintaining rigorous preparedness efforts seems a self-evident imperative, especially in an area deemed among the country’s most inviting terrorist targets. Key words: terrorism, terror medicine, emergency management, first responders DOI:10.5055/ajdm.2014.0138


Article
Telemedicine for disaster management: Can it transform chaos into an organized, structured care from the distance?
Rifat Latifi, MD, FACS; Elizabeth H. Tilley, PhD
Winter 2014; pages 25-37

Abstract
Background: Telemedicine and advanced technologies that ensure telepresence have become common practice and are an effective way of providing healthcare services. Materials and methods: The authors conducted a traditional narrative review of English literature through search engines (Medline, Pub Med, Embase, and Science Direct) using mesh terms “telemedicine,” “telepresence,” “earthquake,” “disaster,” “natural disaster,” and “man-made disaster” published between January 1, 1980 and September 30, 2013. For our analysis, only published studies were selected when telemedicine or telepresence was reported for disaster management, both in real life and in mock and simulation situations. Original articles, clinical trials, case presentations, and review articles were considered. Books and book chapters were used as well. Data from the International Disaster Database were included in the review to provide a sense of worldwide disaster occurrence. Symposia and other meetings were searched and used when available. Results: Between January 1980 and September 2013, 17,565 disasters recorded. During this study period, 878 articles, chapters, books, and presentations were reported. Of these, only 88 articles and books fulfilled our selection criteria. Six articles described the effectiveness of telemedicine in mock simulations and disaster drills, and 63 presented the need and discussed how telemedicine would be beneficial in disaster response. Only 19 articles provided examples of effective use of telemedicine in disaster response. However, these studies demonstrated telemedicine as a valuable tool for communication between front-line humanitarian aid workers and expert physicians at remote locations. Conclusion: Telemedicine has not been used thus in the management of disasters, despite its great potential. There is an acute need for establishing telemedicine programs in high risk areas for disasters, so that when these disasters strike, existing telemedicine networks can be used, rather than attempting to bring solutions into a chaotic situation postevent. Key words: telemedicine, disaster preparedness, emergency response, trauma, crisis medicine DOI:10.5055/ajdm.2014.0139


Article
Active shooter in the emergency department: A scenario-based training approach for healthcare workers
Joseph G. Kotora, DO; Terry Clancy, PhD, NREMT-P; Lauren Manzon, BA; Varun Malik, BS; Robert J. Louden, PhD; Mark A. Merlin, DO, EMT-P, FACEP
Winter 2014; pages 39-51

Abstract
Background: An active shooter in the emergency department (ED) presents a significant danger to employees, patients, and visitors. Very little education on this topic exists for healthcare workers. Using didactic and scenario-based training methods, the authors constructed a comprehensive training experience to better prepare healthcare workers for an active shooter. Methods: Thirty-two residents, nurses, and medical students participated in a disaster drill onboard a US military base. All were blinded to the scenarios. The study was approved by the institutional review board, and written consent was obtained from all participants. Each participant completed a 10-item pretest developed from the Department of Homeland Security’s IS:907 Active Shooter course. Participants were exposed to a single active shooter scenario followed by a didactic lecture on hostage recovery and crisis negotiation. Participants were then exposed to a scenario involving multiple shooters. Many of the participants were held hostage for several hours. The training concluded with a post-test and debrief. Paired Student’s t-test determined statistical significance between the pretest and post-test questionnaire scores. Results: Paired Student’s t-tests confirmed a statistically significant difference between the pretest and posttest scores for the subjects, as a whole (p < 0.002 [–0.177, –0.041]).There was no difference in scores for nurses (p = 1 [–1.779, 1.779]).The scores for resident physicians (p < 0.01 [–0.192, –0.032]) and medical students (p < 0.01 [–0.334, –0.044]) were found to be significant. Conclusions: Didactic lectures, combined with case-based scenarios, are an effective method to teach healthcare workers how to best manage an active shooter incident. Key words: education, training, internal disaster management, violence, healthcare policy DOI:10.5055/ajdm.2014.0140


Article
Field amputation: Response planning and legal considerations inspired by three separate amputations
Alexander Raines, MD; Jason Lees , MD ; William Fry , MD ; Aaron Parks , JD ; David Tuggle , MD
Winter 2014; pages 53-58

Abstract
Background: Surgical procedures in the field are occasionally required as life-saving measures. Few centers have a planned infrastructure for field physician support. Focused efforts are needed to create teams that can meet such needs. Additionally, certain legal issues surrounding these efforts should be considered. Three cases of field dismemberment inspired this call for preparation. Methods: In one case, an earthquake caused the collapse of a bridge, entrapping a child within a car. A through-knee amputation was required to free the patient with local anesthetic only. The second case was the result of a truck bomb causing the collapse of a building whereby a victim was trapped by a pillar. After retrieval of supplies from a local hospital, a through-knee amputation was performed. The third case involved a young man whose arm became entangled in an oil derrick. This patient was sedated and intubated in an erect position and the arm was amputated. Results: Fortunately, each of these victims survived. However, the care these patients received was unplanned and had the potential for failure. The authors feel that disaster teams, including a surgeon, should be identified in advance as responders to a disaster on short notice. Legal issues including state specific Good Samaritan laws and financial support systems must also be considered. Conclusion: As hospitals and trauma systems prepare for disaster situations, they should consider the eventuality of field dismemberment. This involves identifying a team, including a surgeon, and devising an infrastructure allowing rapid response capabilities, including surgical procedures in the field. Key Words: trauma , mass casualty , field amputation , disaster , dismemberment , Good Samaritan DOI: 10.5055/ajdm.2014.0141


Article
Case study Obstetrical care and women’s health in the aftermath of disasters: The first 14 days after the 2010 Haitian earthquake
Annekathryn Goodman, MD, FACS, FACOG; Lynn Black, MD, MPH; Susan Briggs, MD, MPH, FACS
Winter 2014; pages 59-65

Abstract
Objective: Natural disasters disproportionately injure women and children. Disaster teams need intensive training in the management of obstetrics and women’s healthcare at the disaster site. Design: This article summarizes the obstetrical experience for the International Medical Surgical Response Team (IMSuRT) stationed at Gheskio in Port Au Prince during the first 2 weeks after the 2010 Haitian earthquake. The world’s literature on the impact of disasters on women is reviewed. Setting: Sixty-three members of the IMSuRT and Disaster Medical Assistance Team set up a mobile surgical field hospital after the 2010 Haitian earthquake. One member (AG) managed all the obstetrical care and taught the other team members essentials of labor management and assessment in pregnancy. Patients, participants: Six hundred patients were treated in the first 14 days. Ten percent of these patients were pregnant. There were 12 deliveries. Interventions: All pregnant patients were evaluated by a Sonosite ultrasound device. Pregnant patients with earthquake-related injuries were treated for their injuries. Women in labor were managed by active management in labor. No cesarean sections were needed. Main outcome measure(s):Well-being of mother and babies. Results: Sixty pregnant women presented to the mobile hospital for evaluation from January 17, 2010, through January 28, 2012. Twelve women in labor delivered healthy infants by vaginal delivery. Gestational ages ranges from 34 to 40 weeks. Active management of labor included the use of intravenous Pitocin, which was titrated to contractions. Duration of labor ranged from 2 to 12 hours. Three team members participated in each delivery. Two women were discharged on the same day as their deliveries. Eight women were discharged on the first postpartum day and two on the second postpartum day. Conclusions: Pregnant women suffered severe injuries. Additionally, pregnant women with pre-existing medical conditions were treated after the earthquake. Active management of labor allowed all women to deliver vaginally. The labor management required tremendous team resources to facilitate vaginal deliveries and avoid cesarean sections. Cesarean sections in an austere environment have the potential for devastating consequences such as sepsis, wound dehiscence, and the long-term risks of uterine rupture with subsequent pregnancies. Our experience highlights the need to include trained obstetrical providers on the first response team. Oral presentation: Data from this article were included in the presentation, An urgent need for women’s health specialists in disaster response, at the Disaster Response Workshop, Annual Meeting Society Maternal Fetal Medicine, Dallas, 2012. Key words: obstetrical care, maternal mortality, sexual violence, women’s health, disaster care, first responders, Haitian earthquake DOI:10.5055/ajdm.2014.0142


Article
Editorial The Hartford Consensus to improve survivability in mass casualty events: Process to policy
Lenworth Jacobs, MD, MPH, FACS; Karyl J. Burns , RN, PhD
Winter 2014; pages 67-71

Abstract
Objective: The Joint Committee to Create a National Policy to Enhance Survivability from Mass Casualty Shooting Events was formed to make recommendations to improve survival from intentional mass casualty incidents. This article describes the development of the Hartford Consensus and the process used to disseminate and implement its findings. Main outcome: Members of the Committee included individuals from select public safety organizations. The first meeting of the Committee was held on April 2, 2013, and a second meeting was held on July 11, 2013. Attendance at the second meeting was enlarged and included representatives from the Federal Emergency Management Agency and the National Security Staff of the Office of the President. The results of these meetings became known as the Hartford Consensus. Results: The ideas generated at the meetings produced two documents, one from each meeting. These are referred to as Hartford Consensus I and II. Hartford Consensus I is a concept document and Hartford Consensus II is a call to action that no one should die from uncontrolled bleeding. The recommendations are being incorporated into training programs and have been endorsed by many organizations whose members are involved in the response to mass casualty incidents. Conclusion: The Joint Committee to Create a National Policy to Enhance Survivability from Mass Casualty Shooting Events was successful in stimulating policy to bring about change. Training and resources including tourniquets and hemostatic dressing are being directed to help ameliorate the unfortunate reality of intentional mass injury. Key words: active shooter , mass casualty incidents , hemorrhage control DOI: 10.5055/ajdm.2014.0143

American Journal of Disaster Medicine
Spring 2014, Volume 9
, Number 2


Article
Emotional intelligence in the operating room: Analysis from the Boston Marathon bombing
Beverly P. Chang, MD; Joshua C. Vacanti, MD; Yvonne Michaud, RN, MSN; Hugh Flanagan, MD; Richard D. Urman MD, MBA
Spring 2014; pages 77-85

Abstract
Introduction: The Boston Marathon terrorist bombing that occurred on April 15, 2013 illustrates the importance of a cohesive, efficient management for the operating room and perioperative services. Conceptually, emotional intelligence (EI) is a form of social intelligence used by individuals in leadership positions to monitor the feelings and emotions of their team while implementing a strategic plan. Objective: To describe the experience of caring for victims of the bombing at a large tertiary care center and provide examples demonstrating the importance of EI and its role in the management of patient flow and overall care. Methods: A retrospective review of trauma data was performed. Data regarding patient flow, treatment types, treatment times, and outcomes were gathered from the hospital’s electronic tracking system and subsequently analyzed. Analyses were performed to aggregate the data, identify trends, and describe the medical care. Results: Immediately following the bombing, a total of 35 patients were brought to the emergency department (ED) with injuries requiring immediate medical attention. 10 of these patients went directly to the operating room on arrival to the hospital. The first victim was in an operating room within 21 minutes after arrival to the ED. Conclusion: The application of EI in managerial decisions helped to ensure smooth transitions for victims throughout all stages of their perioperative care. EI provided the fundamental groundwork that allowed the operating room manager and nurse leaders to establish the calm and coordinated leadership that facilitated patient care and teamwork. Key words: Boston Marathon bombing, emotional intelligence, operating room management, disaster management DOI:10.5055/ajdm.2014.0144


Article
An intervention for enhancing public health crisis response willingness among local health department workers: A qualitative programmatic analysis
Krista L. Harrison, PhD; Nicole A. Errett, MSPH; Lainie Rutkow, JD, PhD, MPH; Carol B. Thompson, MS, MBA; Daniel J. Barnett, MD, MPH; et al.
Spring 2014; pages 87-96

Abstract
Objectives: This study evaluated the impact of a novel multimethod curricular intervention using a trainthe-trainer model: the Public Health Infrastructure Training (PHIT). PHIT was designed to 1) modify perceptions of self-efficacy, response efficacy, and threat related to specific hazards and 2) improve the willingness of local health department (LHD) workers to report to duty when called upon. Methods: Between June 2009 and October 2010, eight clusters of US LHDs (n = 49) received PHIT. Two rounds of focus groups at each intervention site were used to evaluate PHIT. The first round of focus groups included separate sessions for trainers and trainees, 3 weeks after PHIT. The second round of focus groups combined trainers and trainees in a single group at each site 6 months following PHIT. During the second focus group round, participants were asked to self-assess their preparedness before and after PHIT implementation. Setting: Focus groups were conducted at eight geographically representative clusters of LHDs. Participants: Focus group participants included PHIT trainers and PHIT trainees within each LHD cluster. Main outcome measure(s): Focus groups were used to assess attitudes toward the curricular intervention and modifications of willingness to respond (WTR) to an emergency; self-efficacy; and response efficacy. Results: Participants reported that despite challenges in administering the training, PHIT was well designed and appropriate for multiple management levels and disciplines. Positive mean changes were observed for all nine self-rated preparedness factors (p < 0.001). The findings show PHIT's benefit in improving self-efficacy and WTR among participants. Conclusions: The PHIT has the potential to enhance emergency response willingness and related self-efficacy among LHD workers. Key Words: emergency preparedness, local health department, willingness to respond, EPPM, self-efficacy DOI:10.5055/ajdm.2014.0145


Article
Academic-community partnerships for sustainable preparedness and response systems
Alexander Isakov, MD, MPH; Patrick O'Neal, MD; John Prescott, MD; Joan Stanley, PhD, RN, CRNP; Jack Herrmann, MSEd, NCC, LMHC; Anne Dunlop, MD, MPH
Spring 2014; pages 97-106

Abstract
Academic institutions possess tremendous resources that could be important for community disaster response and preparedness activities. In-depth exploration of the role of academic institutions in community disaster response has elicited information about particular academic resources leveraged for and essential to community preparedness and response; factors that contribute to the decision-making process for partner engagement; and facilitators of and barriers to sustainable collaborations from the perspectives of academic institutions, public health and emergency management agencies, and national association and agency leaders. The Academic-Community Partnership Project of the Emory University Preparedness and Emergency Response Research Center in collaboration with the Association of Schools of Public Health convened an invitational summit which included leadership from the National Association of County and City Health Officials, Association of State and Territorial Health Officials, Directors of Public Health Preparedness, Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response, CDC Office of Public Health Preparedness and Response, Association of Schools of Public Health, Association of American Medical Colleges, Association of Academic Health Centers, American Association of Colleges of Nursing, Council of State and Territorial Epidemiologists, and American Association of Poison Control Centers. From this convention, emerged recommendations for building and sustaining academic-public health-community collaborations for preparedness locally and regionally. Key words: disaster response, preparedness, public health, disaster resilience DOI:10.5055/ajdm.2014.0146


Article
Mental health outcomes among vulnerable residents after Hurricane Sandy: Implications for disaster research and planning
Joseph A. Boscarino, PhD, MPH; Stuart N. Hoffman, DO; Richard E. Adams, PhD; Charles R. Figley, PhD; Ramon Solhkhah, MD
Spring 2014; pages 107-120

Abstract
Objective: To evaluate mental health outcomes among New Jersey shore residents with health impairments and disabilities after Hurricane Sandy. Design and setting: Six months following Hurricane Sandy, a cross-sectional survey of 200 adults residing in beach communities directly exposed to the storm located in Monmouth County, NJ, was conducted. Main outcome measures: Post-traumatic stress disorder (PTSD), depression, mental health service use, and medication use. Results: The average age of residents surveyed was 59 years (SD = 13.7) and 52.5 percent (95% CI = 45.5-59.4) reported recent hospitalizations, physical limitations, fair to poor health status, multiple chronic health conditions, or physical disabilities. A total of 14.5 percent (95% CI = 10.2-20.1) of residents screened positive for PTSD and 6.0 percent (95% CI = 3.1-10.2) met criteria for depression 6 months after Sandy. In addition, 20.5 percent (95% CI = 15.4-26.7) sought some type of professional counseling after Sandy and 30.5 percent (95% CI = 24.5-37.3) experienced PTSD symptoms, depression, sought professional mental health support, or used psychotropic medications. In multivariate analyses, the best predictors of mental health and service use were having sleep problems, suicidal thoughts, moderate or severe pain, and having high exposure hurricane-related events. Analyses also suggested that noncollege graduates were more likely to receive mental health services (OR = 3.10, p = 0.009), while women were less likely to have depression (OR = 0.12, p = 0.038). Conclusion: Having physical impairments and health conditions were not directly related to adverse mental health outcomes following Sandy, but having sleep problems, pain, or suicidal thoughts were. Further research is needed to assess the health status of community residents with serious health impairments over time following disasters. Key words: mental health services, post-traumatic stress disorder, depression, treatment, disasters, hurricanes, vulnerability DOI:10.5055/ajdm.2014.0147


Article
Embedding a surgeon in a civilian tactical team reduces resource utilization and is cost effective
Lewis J. Kaplan, MD, FACS, FCCM, FCCP; Kevin J. Glenn, BA; Adrian Maung, MD, FACS; Jonathan Mulhern, MBA
Spring 2014; pages 121-125

Abstract
Objective: This study evaluates whether embedding a surgeon in a civilian tactical team (Special Weapons and Tactics [SWAT]) reduces resource utilization during training or deployment and is cost effective. Design: Prospective, noninterventional. Participants: All tactical police surgeon (TPS) activities (2011-2013) were prospectively captured via databases (Bento and Excel) including days of activity, training and deployment care (team members, suspects, and bystanders), academic activity, costs incurred for equipment and training, as well as costs avoided by onscene care and evaluation. Umbrella activities related to non-SWAT care and system referral were recorded. Interventions: None. Main outcome measures: Resource utilization, costs, and outcomes derived from embedding a surgeon in a civilian tactical team. Results: There were 24 days of training and two deployments; 3 days of staff coverage were required. Team members required 18 distinct care episodes; no suspects required care. Bystander care was required twice; both were treated on-scene avoiding transport and hospital care. Non-SWAT care occurred 36 times. No complications occurred except for one urinary track infection. Comorbid medical condition evaluation and management advice in non-SWAT officers, spouses, or significant others occurred 24 times. New health system referral occurred 26 times. Total TPS equipment charges ($6,000) were offset by reduced scene transport ($3,000) and hospital care ($4,000), as well as reduced team member hospital care ($9,000) leading to a net Police Department (PD) charge surplus of (+)$9,000. New referral initial evaluation ($10,400) and operative charges ($30,800) were balanced against lost work ($6,500/d × 3d = $21,500) for a net health system charge surplus of (+)$19,700. One international presentation, three local presentations, and four peer-reviewed and five lay press publications accrued from these activities. Conclusions: A TPS reduces scene and Emergency Department resource utilization and increases new patient health system entry. Establishing a TPS is cost effective for a PD and an academic health system and supports academic productivity but may not be supportable without nonclinical days. Key Words: law enforcement, SWAT, resource utilization, Tactical Emergency Medical Services, trauma surgeon DOI:10.5055/ajdm.2014.0148


Article
Medical support for law enforcement-extended operations incidents
Matthew J. Levy, DO, MSc; Nelson Tang, MD
Spring 2014; pages 127-135

Abstract
Objective: As the complexity and frequency of law enforcement-extended operations incidents continue to increase, so do the opportunities for adverse health and well-being impacts on the responding officers. These types of clinical encounters have not been well characterized nor have the medical response strategies which have been developed to effectively manage these encounters been well described. The purpose of this article is to provide a descriptive epidemiology of the clinical encounters reported during extended law enforcement operations, as well as to describe a best practices approach for their effective management. Design: This study retrospectively examined the clinical encounters of the Maryland State Police (MSP) Tactical Medical Unit (TMU) during law enforcement-extended operations incidents lasting 8 or more hours. In addition, a qualitative analysis was performed on clinical data collected by federal law enforcement agencies during their extended operations. Results: Forty-four percent of missions (455/1,047) supported by the MSP TMU lasted 8 or more hours. Twenty-six percent of these missions (117/455) resulted in at least one patient encounter. Nineteen percent of patient chief complaints (45/238) were related to heat illness/dehydration. Fifteen percent of encounters (36/238) were for musculoskeletal injury/pain. Eight percent of patients (19/238) had nonspecific sick call (minor illness) complaints. The next most common occurring complaints were cold-related injuries, headache, sinus congestion, and wound/laceration, each of which accounted for 7 percent of patients (16/238), respectively. Analysis of federal law enforcement agencies’ response to such events yielded similar clinical encounters. Conclusions: A wide range of health problems are reported by extended law enforcement operations personnel. Timely and effective treatment of these problems can help ensure that the broader operations mission is not compromised. An appropriate operational strategy for managing health complaints reported during extended operations involves the deployment of a well-trained medical support team using the core concepts of tactical emergency medical support. Key words: law enforcement-extended operations medical support, tactical emergency medical support, law enforcement extended operations DOI:10.5055/ajdm.2014.0149


Article
A review of the literature on the validity of mass casualty triage systems with a focus on chemical exposures
Joan M. Culley, PhD, MPH, RN, CWOCN; Erik Svendsen, PhD, MS
Spring 2014; pages 137-150

Abstract
Introduction: Mass casualty incidents (MCIs) include natural (eg, earthquake) or human (eg, terrorism or technical) events. They produce an imbalance between medical needs and resources necessitating the use of triage strategies. Triage of casualties must be performed accurately and efficiently if providers are to do the greatest good for the greatest number. There is limited research on the validation of triage system efficacy in determining the priority of care for victims of MCI, particularly those involving chemicals. Objective: To review the literature on the validation of current triage systems to assign onsite treatment status codes to victims of mass casualties, particularly those involving chemicals, using actual patient outcomes. Methods: The focus of this article is a systematic review of the literature to describe the influences of MCIs, particularly those involving chemicals, on current triage systems related to the onsite assignment of treatment status codes to a victim and the validation of the assigned code using actual patient outcomes. Results: There is extensive literature published on triage systems used for MCI but only four articles used actual outcome data to validate mass casualty triage outcomes including three for chemical events. Currently, the amount and type of data collected are not consistent or standardized and definitions are not universal. Conclusions: Current literature does not provide needed evidence on the validity of triage systems for MCI in particular those involving chemicals. Well-designed studies are needed to validate the reliability, sensitivity, and specificity of triage systems used for MCI including those involving chemicals. Key Words: mass casualty incidents, chemical mass casualty incidents, evidence-based medicine, mass casualty triage systems, validation DOI:10.5055/ajdm.2014.0150


Article
Case study. Use of a fiber optic camera to perform a trauma assessment during a confined space rescue
Joseph G. Kotora, DO, MPH; Michael S. Westrol, MD; Mark A. Merlin, DO
Spring 2014; pages 151-156

Abstract
Objective: Accurate medical evaluation of victims injured during confined space rescues poses significant operational, medical, and logistical challenges for medical providers of all disciplines and experience levels. The Federal Emergency Management Agency (FEMA) teaches rescuers to begin their assessment as soon as verbal contact is obtained with the victim. While a significant amount of information can be obtained by talking to the victim, an accurate assessment of the victim's condition is often limited or impossible. Many professional rescue agencies currently use cameras to locate a victim's position or visualize obstacles that prevent the successful extraction of casualties. However, there is no published literature describing the use of a camera to complete a medical evaluation. Results: The authors describe their use of a fiber optic camera to complete a limited but accurate primary and secondary trauma evaluation of a patient trapped inside an 18 in water pipe for a prolonged period of time. The providers' assessment provided critical information to the rescue team and assisted in the planning and eventual extrication of the patient from the confined space. Moreover, there was very little variation between the findings obtained during the assessment at the scene and the assessment in the receiving facility's trauma bay. Conclusion: When evaluating a trauma patient, there is no substitution for visual inspection and physical diagnosis. The use of a fiber optic camera can assist rescuers and medical providers in obtaining the information they desire, and enable the completion of an accurate patient assessment. The camera may also provide psychological reassurance and ease anxiety, as well as generate prehospital images that can be transmitted to the receiving facility for use in preparation of the casualty. Emergency medical service providers, urban search & rescue teams, fire departments, and other professional rescuers should be trained on the use and limitations of fiber optic cameras during confined space rescues. Furthermore, regulatory agencies such as FEMA should consider integrating the use of fiber optic camera and audiovisual devices into the current training courses offered to professional rescuers. Key words: confined space rescue, trauma, training, education, disaster management DOI:10.5055/ajdm.2014.0151

American Journal of Disaster Medicine
Summer 2014, Volume 9
, Number 3


Article
Meeting children's needs: A mixed-methods approach to a regionalized pediatric surge plan--The Los Angeles County experience
Bridget M. Berg, MPH; Valerie M. Muller, MPH; Millicent Wilson, MD; Roel Amara, RN, BSN; Kay Fruhwirth, RN, MSN; Kathy Stevenson, RN, BSN; Rita V. Burke, PhD, MPH; Jeffrey S. Upperman, MD
Summer 2014; pages 161-169

Abstract
Introduction: Children are one of the most vulnerable populations during mass casualty incidents because of their unique physiological, developmental, and psychological attributes. The objective of this project was to enhance Los Angeles County's (LAC) pediatric surge capabilities. The purpose of this study was threefold: (1) determine gaps in pediatric surge capacity and capabilities; (2) double pediatric inpatient capacity; and (3) document a plan to address gaps and meet pediatric inpatient surge. We hypothesized that LAC would be able to meet the identified pediatric surge target by leveraging resources of hospitals within the region. Deliverables included a pediatric surge plan for LAC, pediatric surge training resources, and pediatric supplies for hospitals participating in LAC's Hospital Preparedness Program (HPP). Methods: After Institutional Review Board approval, the authors used a mixed-methods approach to explore gaps in hospital capacity and capabilities in a large urban county. Hospitals were surveyed via Qualtrics® on 38 questions regarding capacity, staffing, availability of pediatric supplies, and existing pediatric surge plans. Publicly available inpatient bed data were collected from the Office of Statewide Health Planning and Development for the year ending June 2010 and supplemented by hospital survey responses. Population data was used from US Census 2010. This combined dataset was analyzed for capacity, pediatric designations, and capabilities. To supplement this data, three focus groups were conducted between April 2011 and May 2012. Focus group topics included: supplies and training needed for pediatric surge, surge targets, and plan development and functionality. Results: Hospitals varied in pediatric capacity and capability. Forty-six percent of facilities provide inpatient pediatric services. Forty-one hospitals are designated as an Emergency Department Approved for Pediatrics. Identified gaps included: limited pediatric bed capacity, geographic variability, limited pediatric intensive care unit capacity, limited pediatric specialty physician resources, varying availability of pediatric trained staff, less availability of pediatric critical care supplies, and limited ability to accept and receive children. Focus group stakeholders requested advance and just-in-time training and reference guides to supplement the plan. Conclusion: LAC was able to create a pediatric surge plan that doubles pediatric acute and pediatric intensive care bed capacity by using participating HPP hospitals. A tiered system was created based on capacity and capability with varying surge targets and guidance on types of patients that could be cared for at each tier. This plan will assist the LAC Emergency Medical Services Agency distribute pediatric patients during a surge event that disproportionately impacts children. Key words: pediatric, disaster, surge capacity, mixed-methods DOI:10.5055/ajdm.2014.0168


Article
Superficial and invasive infections following flooding disasters
James H. Diaz, MD, MPH&TM, DrPH, FCCM
Summer 2014; pages 171-181

Abstract
Objectives: Given the loss of laboratory infrastructure following flooding disasters, the objectives of this review were (1) to describe current practices in the treatment of aquatic injuries and infections in nondisaster scenarios; (2) to describe how lessons learned from the management of superficial and invasive infections in survivors of the 2004 Indian Ocean tsunami could improve current management practices; (3) to stratify waterborne infections by causative agents and preferred saline levels; and (4) to recommend initial wound and empiric antibiotic management strategies for specific aquatic infections. Design: Retrospective systematic review. Setting: Not applicable. Participants: References were selected to provide clinicians with a broader knowledge of causative aquatic pathogens and their antimicrobial susceptibilities. Interventions: Internet search engines were queried with key words to identify salient case reports, retrospective series, observational studies, and additional references on wound and antimicrobial management from Southeast Asian and other countries providing intensive care to tsunami survivors and from other similar series on the management of flooding and near-drowning victims. Main outcome measures: Identify causative pathogens of aquatic infections and their antimicrobial susceptibilities in flooding disaster victims and recommend effective arsenals of empiric antimicrobial therapies. Results: The causative pathogens of wound and systemic infections in near-drowning and tsunami survivors ranged from typical human skin and enteric contaminants to aquatic organisms and soil contaminants, including fungi. There was an early predominance of polymicrobial Gram-negative causative organisms in wound infections, Unanticipated, delayed mycobacterial and fungal infections occurred frequently, even after traumatic wounds healed. Conclusions: Clinicians who care for victims of flooding disasters and near-drowning can apply lessons learned from the management of tsunami survivors to selecting initial antimicrobials for empiric therapy of aquatic injuries based on their sources and distributions of aquatic exposures. Key words: natural disasters, tsunamis aquatic injuries, near-drowning, marine injuries, marine infections, marine pathogens, traumatic injuries, infections, antimicrobials DOI:10.5055/ajdm.2014.0169


Article
Public health aspects of nuclear and radiological incidents
Seth K. Katz, MD; Steven J. Parrillo, DO, FACOEP-D, FACEP; Doran Christensen, DO; Erik S. Glassman, MS, CCEMT-P; Kimberly B. Gill, PhD
Summer 2014; pages 183-193

Abstract
Radiological and nuclear incidents are low probability but very high risk events. Measures can be, and have been, implemented to limit or prevent the impact on the public. Preparedness, however, remains the key to minimizing morbidity and mortality. Incidents may be related to hospital-based misadministration of radiation in interventional radiology or nuclear medicine, industrial or nuclear power plant accidents. Safety and security measures are in place to prevent or mitigate such events. Despite efforts to prevent them, terrorist-perpetrated incidents with, for example, a radiological dispersal device (RDD) are also possible. Due to a misunderstanding of, or lack of, formal education regarding things in this realm, there can be considerable anxiety, even fear, about radiation-related incidents. Multiple studies evaluating healthcare provider willingness to report to work rank radiation as the hazard that will keep the largest number of workers at home. Even incidents that do not constitute a disaster can spiral out of control quite rapidly, placing considerable demands on community resources. Our communities will face these threats in the future and it is the responsibility of physicians and allied healthcare personnel to be trained and ready to care for those affected. The scope of resources needed to prepare for and respond to such incidents is indeed vast. It encompasses the coordinated effort of first responders and physicians, the preparedness of national agencies involved in responding to such events, and individual community cooperation and solidarity. This article reviews the approach to the short- and long-term effects of a radiological or nuclear incident on an affected population, with a specific focus on the medical and public health issues. It also summarizes the strengths and weaknesses of our current ability to respond effectively and makes recommendations to improve these capabilities. Key words: radiological, nuclear, mass casualty Incident DOI:10.5055/ajdm.2014.0170


Article
Deployable, portable, and temporary hospitals; one state's experiences through the years
Randy D. Kearns, DHA, MSA; Skarote MB, Peterson J, Stringer L. Alson RL, Cairns BA, Hubble MW, Rich PB, Cairns CB, Holmes JH, Runge J, Siler SM, Winslow J
Summer 2014; pages 195-210

Abstract
This article will review the use of temporary hospitals to augment the healthcare system as one solution for dealing with a surge of patients related to war, pandemic disease outbreaks, or natural disaster. The experiences highlighted in this article are those of North Carolina (NC) over the past 150 years, with a special focus on the need following the September 11, 2001 (9/11) attacks. It will also discuss the development of a temporary hospital system from concept to deployment, highlight recent developments, emphasize the need to learn from past experiences, and offer potential solutions for assuring program sustainability. Historically, when a particular situation called for a temporary hospital, one was created, but it was usually specific for the event and then dismantled. As with the case with many historical events, the details of the 9/11 attacks will fade into memory, and there is a concern that the impetus which created the current temporary hospital program may fade, as well. By developing a broader and more comprehensive approach to disaster responses through all-hazards preparedness, it is reasonable to learn from these past experiences, improve the understanding of current threats, and develop a long-term strategy to sustain these resources for future disaster medical needs. Key words: field hospital, temporary hospital, deployable hospital DOI:10.5055/ajdm.2014.0171


Article
Ethical and clinical dilemmas in patients with head and neck tumors visiting a field hospital in the Philippines
Tal Marom, MD; David Segal, MD; Tomer Erlich, MD; Erez Tsumi, MD; Ofer Merin, MD, MHA; Guy Lin, MD
Summer 2014; pages 211-219

Abstract
Objective: To describe clinical and ethical dilemmas in patients presenting with head and neck (H&N) tumors to a field hospital in the “subacute” period following a typhoon. Methods: We retrospectively reviewed charts of H&N patients presenting to an integrated Israeli-Filipino medical facility, which was operated more than 11 days. Results: Of the 1,844 adult patients examined, 85 (5 percent) presented with H&N tumors. Of those, 70 (82 percent) were females, with a mean age of 43 ± 15 years. Thyroid neoplasms were the most common tumors (68, 80 percent). Despite limited resources, we contributed to the workup and treatment of several patients. To better illustrate our dilemmas, we present four key patients, in whom we favored diagnostic/therapeutic interventions in two, and opted to defer any intervention in two. Conclusions: In a relief mission, despite the lack of clinical and pathological staging and questionable continuity of care, surgical interventions can be considered for therapeutic, palliative, and diagnostic purposes. Key words: field hospital, head and neck tumors, clinical ethics DOI:10.5055/ajdm.2014.0172


Article
Book review Toxic Trauma: A Basic Clinical Guide, by David J. Baker. Springer, 2014.
Michael Nurok, MBChB, PhD
Summer 2014; pages 220-220

Abstract
DOI:10.5055/ajdm.2014.173


Article
Ready or not: Does household preparedness prevent absenteeism among emergency department staff during a disaster?
Mary P. Mercer, MD, MPH; Benedict Ancock, MD, MPH; Joel T. Levis, MD, PhD; Vivian Reyes, MD
Summer 2014; pages 221-232

Abstract
Introduction: During major disasters, hospitals experience varied levels of absenteeism among healthcare workers (HCWs) in the immediate response period. Loss of critical hospital personnel, including Emergency Department (ED) staff, during this time can negatively impact a facility's ability to effectively treat large numbers of ill and injured patients. Prior studies have examined factors contributing to HCW ability and willingness to report for duty during a disaster. The purpose of this study was to determine if the degree of readiness of ED personnel, as measured by household preparedness, is associated with predicted likelihood of reporting for duty. Additionally, the authors sought to elucidate other factors associated with absenteeism among ED staff during a disaster. Methods: ED staff of five hospitals participated in this survey-based study, answering questions regarding demographic information, past disaster experience, household disaster preparedness (using a novel,15-point scale), and likelihood of reporting to work during various categories of disaster. The primary outcome was personal predicted likelihood of reporting for duty following a disaster. Results: A total of 399 subjects participated in the study. ED staffs were most likely to report for duty in the setting of an earthquake (95 percent) or other natural disaster, followed by an epidemic (90 percent) and were less likely to report for work during a biological, chemical, or a nuclear event (63 percent). Degree of household preparedness was determined to have no association with an ED HCW's predicted likelihood of reporting for duty. Factors associated with predicted absenteeism varied based on type of disaster and included having dependents in the home, female gender, past disaster relief experience, having a spouse or domestic partner, and not owning pets. Having dependents in the home was associated with predicted absenteeism for all disaster types (OR 0.30-0.66). However, when stratified by gender, the presence of dependents at home was only a significantly associated with predicted absenteeism among women as opposed to men (OR 0.07-0.59 versus OR 0.41-1.02). Discussion: Personal household preparedness, while an admirable goal, appears to have no effect on predicted absenteeism among ED staff following a disaster. Having responsibilities for dependents is the most consistent factor associated with predicted absenteeism among female staff. Hospital and ED disaster planners should consider focusing preparedness efforts less toward household preparedness for staff and instead concentrate on addressing dependent care needs in addition to professional preparedness. Keywords: Emergency Department, disaster preparedness, absenteeism, physician, nurse DOI:10.5055/ajdm.2014.0174

American Journal of Disaster Medicine
Fall 2014, Volume 9
, Number 4


Article
Regional preparedness for mass acetylcholinesterase inhibitor poisoning through plans for stockpiling and interhospital sharing of pralidoxime
John Broach, MD, MPH, MBA, FACEP; Robert Krupa, BS; Steven B. Bird, MD, FACEP, FACMT; Mary-Elise Manuell, MA, MD, FACEP
Fall 2014; pages 237-245

Abstract
Background: Regional preparedness efforts related to the stockpiling and interhospital sharing of critical antidotal medications is an important topic in the age of terrorism and weapons of mass destruction. Little attention has been paid to how well regional preparedness efforts specifically affect availability of pralidoxime (2-PAM) if it were needed to treat a mass poisoning with acetylcholinesterase inhibitors (organophosphorus pesticides or nerve agents). Objectives: The authors sought to assess whether hospitals in one region of Massachusetts (Department of Public Health Region 2, Central Massachusetts) have adequate plans for responding to a large number of patients requiring 2-PAM as might occur after the intentional release of nerve agents or organophosphorus chemicals into a civilian population or the food or water supply. Methods: The Massachusetts DPH Region 2 contains 10 acute care hospitals including one level 1 Trauma Center that is also the only tertiary care hospital in the region. A 13-question online survey was used to assess three important components of 2-PAM availability: 1) the amount of 2-PAM available, 2) regional medication sharing activities, and 3) attitudes and awareness of resources available in the Strategic National Stockpile (SNS). Results: Seven of 10 hospitals participated in the survey (response rate 70 percent). Of these seven hospitals, only 2 (28.5 percent) had any 2-PAM on hand (4 and 6 g). Despite the existence of a region-wide memorandum of understanding that includes medication sharing, only two hospitals’ responses included awareness of this agreement. Two hospitals had considered the problem of inadequate 2-PAM supplies before receiving the survey. Five of 7 (71.4 percent) hospitals would consider accessing the SNS if the need for antidotes were exceeded by their own supply. Conclusion: Recognition of regional planning for sharing of antidotes such as 2-PAM is lacking in the surveyed region and could lead to inability to care for large number of patients affected by an intentional or accidental large-scale release of acetylcholinesterase inhibitors. Key words: disaster medicine, regional preparedness, chemical terrorism, medication stockpiles DOI:10.5055/ajdm.2014.0176


Article
Postcrisis redevelopment of sustainable healthcare systems
Koren V. Kanadanian, MS; Constance K. Haan, MD, MS, MA
Fall 2014; pages 247-258

Abstract
Objective: Research and field experience have identified a global gap in postdisaster rebuilding of healthcare systems due to the current primary focus on returning devastated community infrastructures to predisaster conditions. Disasters, natural or man-made, present an opportunity for communities to rebuild, restructure, and redefine their predisaster states, creating more resilient and sustainable healthcare systems. Design: A model for sustainable postdisaster healthcare rebuilding was developed by bridging identified gaps in the literature on the processes of developing healthcare systems postdisaster and utilizing evidence from the literature on postdisaster community reconstruction. Results: The proposed model—the Sustainable Healthcare Redevelopment Model—is designed to guide communities through the process of recovery, and identifies four stages for rebuilding healthcare systems: (1) response, (2) recovery, (3) redevelopment, and (4) sustainable development. Implementing sustainable healthcare redevelopment involves a bottom-up approach, where community stakeholders have the ability to influence policy decisions. Relationships within internal government agencies and with public-private partnerships are necessary for successful recovery. Conclusion: The Sustainable Healthcare Redevelopment Model can serve as a guideline for delivery of healthcare services following disaster or conflict and use of crisis as a window of opportunity to improve the healthcare delivery system and incorporate resilience into the healthcare infrastructure. Key words: redevelopment, healthcare systems, postcrisis, postdisaster DOI:10.5055/ajdm.2014.0177


Article
Willingness to respond for radiologic incidents: A hands-on approach
John Richard Ludtke, MD, MS; Roopsi Narayan, MPH; Ameer Matariyeh, MPH; Donald Brannen, PhD; Kim Caudill, RN, MPH; Melissa Howell, MS, MBA, MPH, RN, RS; Stephanie Hines, MSES
Fall 2014; pages 259-272

Abstract
The Center for Disease Control and Prevention published two Radiological Terrorism Toolkits: Public Health Officials (PHTK) and Emergency Services Clinicians (ESCTK). The study consisted of training public health workers and Medical Reserve Corps volunteers to rate 10 distinct virtual survivors each and route them through a Community Reception Center (CRC) pretraining and post-training. The training's effect on the rater's radiation medical knowledge and willingness to respond (WTR) was also measured. Correctly routed survivors increased from a baseline 3.6-5.3, of 10 survivors per rater for the PHTK, and to 5.7 for the ESCTK (p = 0.000). Medical knowledge increased from a baseline of 50 percent to 66.7 percent for the PHTK (nine raters) and to 71.4 percent for the ESCTK (seven raters) (p = 0.000). WTR regardless of severity increased from 34.8 percent to 54.4 percent for the PHTK (p = 0.046). Odds of correctly routing survivors decreased with perception of confidence (0.569, 95% CI 0.375-0.863), while perceptions of preparedness (2.1, 1.4-3.2) and prior training increased the odds (1.8, 1.05-3.16). When taking into account raters unwillingness to respond, the odds of correctly routing survivors decreased with perceptions of confidence in detector use (0.556, 0.365-0.846), with confidence to process persons through a CRC (0.390, 0.215-0.709), and by training with the ESCTK (0.252, 0.12-0.53), while perceptions of preparedness (18.7, 8.4-41.6), and demonstrated medical knowledge (20, 3.26-122) increased ability to correctly route survivors. These findings support the local use of PHTK training to develop surge capacity for a radiological emergency and suggest the interaction between the level of confidence and medical knowledge be studied further. Key words: public health, radioactive hazard release, disaster, volunteers, surge capacity DOI:10.5055/ajdm.2014.0178


Article
Three years experience with forward-site mass casualty triage-, evacuation-, operating room-, ICU-, and radiography-enabled disaster vehicles: Development of usage strategies from drills and deployments
Jane L. Griffiths, RN, BAN, MHP; Neil R. Kirby, ASM, MPH, B Bus HRD, BA, Ass Dip App Sc (Ambulance); James A. Waterson, RN, BA (Hons), M. Med Ed
Fall 2014; pages 273-285

Abstract
Objective: Delineation of the advantages and problems related to the use of forward-site operating room-, Intensive Care Unit (ICU)-, radiography-, and mass casualty-enabled disaster vehicles for site evacuation, patient stabilization, and triage. Setting: The vehicles discussed have six ventilated ICU spaces, two ORs, on-site radiography, 21 intermediate acuity spaces with stretchers, and 54 seated minor acuity spaces. Each space has piped oxygen with an independent vehicle-loaded supply. The vehicles are operated by the Dubai Corporate Ambulance Services. Their support hospital is the main trauma center for the Emirate of Dubai and provides the vehicles' surgical, intensivist, anesthesia, and nursing staff. The disaster vehicles have been deployed 264 times in the last 5 years (these figures do not include deployments for drills). Interventions: Introducing this new service required extensive initial planning and ongoing analysis of the performance of the disaster vehicles that offer ambulance services and receiving hospitals a largearray of possibilities in terms of triage, stabilization of priority I and II patients, and management of priority III patients. Preliminary results: In both drills and in disasters, the vehicles were valuable in forward triage and stabilization and in the transport of large numbers of priority III patients. This has avoided the depletion of emergency transport available for priority I and II patients. Conclusions: The successful utilization of disaster vehicles requires seamless cooperation between the hospital staffing the vehicles and the ambulance service deploying them. They are particularly effective during preplanned deployments to high-risk situations. These vehicles also potentially provide self-sufficient refuges for forward teams in hostile environments. Key words: forward site, triage, mass casualty, evacuation, disaster vehicle DOI:10.5055/ajdm.2014.0179


Article
Disaster preparedness education in South Los Angeles faith-based organizations: A pilot study in promoting personal and community preparedness and resiliency
Ann C. Lin, BS; Rita V. Burke, PhD, MPH; Bridget M. Berg, MPH; Valerie M. Muller, MPH; Jeffrey S. Upperman, MD
Fall 2014; pages 287-296

Abstract
Introduction: Faith-based organizations (FBOs) often provide crucial services to their communities during and after disasters, but they largely operate outside of the formal structures that manage disaster preparedness and response. Their status within communities and ability to reach broad populations make them potentially powerful groups to lead and promote health and safety initiatives. Thus, there is opportunity to reduce health and knowledge disparities and increase disaster resiliency by providing disaster preparedness education through FBOs. Problem: This pilot study aims to assess and enhance the current level of disaster knowledge and preparedness of congregation members from six FBOs in the Los Angeles County South Service Planning Area (SPA 6) to promote their community's disaster resiliency. Methods: A structured basic disaster education curriculum was implemented at six FBOs, and participants completed a questionnaire, pre-test and posttest, and satisfaction survey. Frequency distributions of survey questions and mean differences of pre- and post-test scores were obtained. Results: Results of the questionnaire indicated that more than half of the participants had previous experience with disaster preparedness and had taken some steps toward stockpiling supplies but showed gaps in making concrete evacuation plans and meeting places. The mean disaster knowledge test score increased from 5.15 for the pre-test to 8.04 for the post-test (p < 0.0001). The participants reported high satisfaction with the seminar. Conclusions: This pilot study demonstrated that there is interest, as well as need, within the faith-based community to increase personal and community disaster preparedness. The implementation of a structured disaster education seminar for congregation members showed significant immediate improvement in disaster knowledge of the participants. Key words: faith-based, disaster, education, preparedness, Resiliency DOI:10.5055/ajdm.2014.0180


Article
Interlocal collaboration and emergency preparedness: A qualitative analysis of the impact of the Urban Area Security Initiative program
Nicole A. Errett, PhD, MSPH, CPH, CEM; Shannon Frattaroli, PhD, MPH; Beth A. Resnick, MPH; Daniel J. Barnett, MD, MPH; Lainie Rutkow, JD, PhD, MPH
Fall 2014; pages 297-308

Abstract
Objective: Horizontal intergovernmental coordination, or interlocal collaboration, is an ongoing strategy to enhance public health emergency preparedness in the United States. This study aims to understand the impact of interlocal collaboration on emergency preparedness, and how the Urban Area Security Initiative (UASI) program, a federally administered grant program to promote regional preparedness capability development, has influenced perceptions of this relationship. Design: Semistructured interviews were conducted and recorded in early 2014. Transcribed data were coded and iteratively analyzed. A purposive and snowball sampling strategy was used. Setting: Interviews were conducted in person or by phone. Participants: Twenty-eight key informants were interviewed during 24 interviews. Individuals were selected as key informants due to their knowledge of a UASI region(s) and its governance structures, investment strategies, and challenges, as well as knowledge of the UASI program’s history and goals. Main outcome measure(s): Interviews were used to identify, describe, and characterize perceptions of interlocal collaboration, national emergency preparedness, and the UASI grant. Results: Impacts, challenges, incentives, facilitators, and disadvantages to interlocal collaboration were identified. Interlocal collaboration was found to impact preparedness by promoting the perceived dissolution of geopolitical boundaries; developing self-reliant regions; developing regional capabilities; promoting regional risk identification; and creating an appreciation of interlocal collaboration importance. The UASI program was thought to have a profound and unique impact on the development of interlocal collaboration infrastructure and on national preparedness. Conclusions: Interlocal collaborations contribute to overall national preparedness. Grant programs, such as the UASI, can incentivize and foster interlocal collaboration in preparedness. Key words: preparedness, grants, regionalism DOI:10.5055/ajdm.2014.0181


Article
The effects of QuikClot Combat Gauze on hemorrhage control when used in a porcine model of lethal femoral injury
Don Johnson, PhD; Douglas M. Westbrook Jr, BSN; Deanna Phelps, BSN; Jose Blanco, MD; Michael Bentley, CRNA, PhD; James Burgert, CRNA, DNAP; Brian Gegel, CRNA, DNAP
Fall 2014; pages 309-315

Abstract
Objectives: The aims of the study were to 1) determine the effectiveness of QuikClot Combat Gauze (QCG); 2) determine the arterial blood pressure at which rebleeding occurs; 3) determine how much intravenous fluid could be administered before hemorrhage reoccurred, and 4) determine the number extremity movement on rebleeding when QCG was used. Design: This was a prospective, randomized, experimental study. Subjects: Adult Yorkshire pigs were randomly assigned to two groups QCG (n = 10) or control (n = 10). Intervention: After the swine were anesthetized, the investigators transected the femoral artery and vein. After 1 minute of uncontrolled bleeding, QCG was placed in the wound followed by standard wound packing. The control group underwent the same procedures without QCG. After 5 minutes of firm, manual pressure, a pressure dressing was applied. Following 30 minutes, the dressings were removed and blood loss was calculated. If hemostasis occurred, phenylephrine was administered until there was rebleeding. If no bleeding, up to 5 L of IV crystalloid was administered until there was hemorrhage. If no bleeding, the extremity on the side of the hemorrhage was moved through flexion, extension, abduction, and adduction 10 times or until rebleeding occurred. Main outcomes: QCG compared to a control was more effective in controlling hemorrhage, withstanding increases in systolic blood pressure, more latitude in resuscitation fluid, and movement (p < 0.05). Key words: hemorrhage control, QuikClot hemostatic agent, hemostatic agents DOI:10.5055/ajdm.2014.0182