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American Journal of Disaster Medicine
Winter 2015, Volume 10
, Number 1


Article
Strategies to maintain operating room functionality following the complete loss of the recovery room due to an internal disaster
Elise C. Metzler, MD; Bhavani S. Kodali, MD; Richard D. Urman, MD, MBA; Hugh L. Flanagan, MD; Monica Sa Rego, MD; Joshua C. Vacanti, MD
Winter 2015; pages 5-12

Abstract
The post-anesthesia care unit (PACU) is a major contributor to the operating room (OR) process flow and efficiency. A sudden failure of hospital facility infrastructure due to a burst pipe resulted in the complete loss of a 66-bed combined preoperative and PACU facility of a major academic medical center. The OR suites were undamaged. The clinical and administrative challenges of caring for surgical patients without the usual preoperative and postoperative care areas are discussed. Our strategy for maintaining OR functions and management of patient flow, OR personnel, case prioritization, and equipment needs are detailed from the time of initial crisis until restoration of these clinical care areas. Utilization of the hospital disaster Incident Command Structure and the activation and decision support provided by the hospital Emergency Operations Center (EOC) for the week immediately following the crisis, helped maintain OR functionality. Key words: post-anesthesia care unit (PACU), Incident Command Structure, internal disaster, flooding DOI:10.5055/ajdm.2015.0183


Article
Comparison of START triage categories to emergency department triage levels to determine need for urgent care and to predict hospitalization
Rick Hong, MD; Ryan Sexton, MD; Benjamin Sweet, MD; Gerard Carroll, MD; Caitlin Tambussi, BA; Brigitte M. Baumann, MD, MSCE
Winter 2015; pages 13-21

Abstract
Objective: To compare Emergency Severity Index (ESI) triage levels and Simple Triage and Rapid Treatment (START) triage colors for urgent care and hospitalization. Design: Cross sectional. Setting: Inner city emergency department (ED). Participants: Patients years transported by Emergency Medical Services (EMS) participating in the state triage tag exercise, October 9-15, 2011. Interventions: EMS assigned each patient a START triage tag. ED staff recorded tag number and color. Demographics, vital signs, 22 emergent interventions, and disposition were obtained via chart review. Institutional review board approval was obtained. Main outcome measures: Presence of more than two abnormal vital sign on arrival and need for more than one emergent intervention in ED were considered indicators of acuity and severity. START triage colors were recategorized as urgent (Red, Yellow) and less acute (Green, White), and ESI was recategorized as urgent (1, 2, 3) and less acute (4, 5). Results: Both ED and EMS staff were blinded to the study, and 95% confidence intervals were presented for statistical significance. Of 233 participants, START triage colors were Black = 0, Red = 12 percent, Yellow = 26 percent, Green = 53 percent, and White = 9 percent. ESI triage levels were level 1 = 1 percent, level 2 = 34 percent, level 3 = 51 percent, level 4 = 14 percent, and level 5 = 1 percent. ESI (1, 2, 3) identified 88 percent (75-95 percent) of 49 patients with abnormal vital signs; START (Red, Yellow) only identified 51 percent (35-64 percent). Twenty-one patients needed emergent intervention. ESI (1, 2, 3) identified 95 percent (76-99 percent) of these patients; START (Red, Yellow) identified 33 percent (17-55 percent). ESI (1, 2, 3) identified 98 percent of the 96(92-100 percent) admitted patients; only 48 percent (38-58 percent) were tagged START (Red, Yellow). Conclusion: ESI better identified patients with abnormal vital signs, those who needed emergent interventions, and those admitted than START. Key words: ESI, START, triage, acuity, admission DOI:10.5055/ajdm.2015.0184


Article
Emergency preparedness of families of children with developmental disabilities: What public health and safety emergency planners need to know
Susan Wolf-Fordham, JD; Carol Curtin, MSW; Melissa Maslin, MEd; Linda Bandini, PhD; Charles D. Hamad, PhD
Winter 2015; pages 23-34

Abstract
Objective: To assess the emergency preparedness knowledge, behaviors, and training needs of families of children with developmental disabilities (DD). Design: An online survey. Participants: A sample of 314 self-selecting US parents/guardians of children with DD, aged birth-21 years. Main outcome measures: 1) Preparedness self-assessment; 2) self-report regarding the extent to which families followed 11 specific preparedness action steps derived from publicly available preparedness guides; and 3) parent training and support needs. Results: Although most participants assessed themselves to be somewhat to moderately well prepared, even those who reported being “very well prepared” had taken fewer than half of 11 recommended action steps. Most participants expressed a need for preparedness support; virtually all the respondents felt that training was either important or very important. Conclusions: Children with disabilities are known to be particularly vulnerable to negative disaster impacts. Overall, parents in this study appeared under-prepared to meet family disaster needs, although they recognized its importance. The results suggest opportunities and methods for public health and safety planning, education and outreach to parents of children with DD who would benefit from targeted training such as information and skill building to develop effective family preparedness plans and connections to local emergency management and responders. Key words: children, developmental disabilities, emergencies, disasters, functional and access needs, emergency planning, emergency preparedness DOI:10.5055/ajdm.2015.0185


Article
The contribution of on-call, volunteer first responders to mass-casualty terrorist attacks in Israel
Evan Avraham Alpert, MD; Ari M. Lipsky, MD, PhD; Navid Daniel Elie, BS; Eli Jaffe, EMT-P, PhD
Winter 2015; pages 35-39

Abstract
Objective: To describe the contributions of on-call, volunteer first responders to mass-casualty terrorist attacks in Israel during the Second Intifada. Design: Descriptive study evaluating data obtained from postevent debriefings after 15 terrorist attacks in Israel between 2001 and 2004. Results: An average of 7.9 deaths (median 7.0, interquartile range [IQR] 2.5-12.5) and 53.8 injuries (median 50.0, IQR 34.0-62.0) occurred in each of these attacks. The average number of volunteers responding to each event was 50.3 (median 43.0, IQR 27.5-55.5). The volunteers were involved in extricating victims from imminent danger, and performing emergent tasks such as bag-valve ventilation, tourniquet application, and intravenous line insertion. They were also integral to the rapid evacuation of casualties from the scene. Conclusion: On-call, volunteer first responders are an integral part of Israel's emergency medical response to mass-casualty terrorist attacks. This system may be used as a model for the development of similar services worldwide. Key words: first responders, mass-casualty incident, volunteer DOI:10.5055/ajdm.2015.0186


Article
Local health department workers, public policy, and willingness to respond during emergencies
Lainie Rutkow, JD, PhD, MPH; Jon S. Vernick, JD, MPH; Carol B. Thompson, MS, MBA; Robert Hudson, MSN; Daniel J. Barnett, MD, MPH
Winter 2015; pages 41-50

Abstract
Objectives: To determine whether an association exists between a state's authority to declare a public health emergency and local public health workers’ response willingness. Design: The 2009-2010 Johns Hopkins~Public Health Infrastructure Response Survey Tool included questions about demographics and attitudes/beliefs regarding local public health workers’ response willingness during public health emergencies. Survey data were merged with data about presence/absence of a law granting states the authority to declare a public health emergency. Logistic regression analyses were performed with the presence/absence of the law and were adjusted for individuals’ demographic and locale characteristics. Setting: Data were collected from eight clusters of local health department workers in nine states. Participants: Two thousand nine hundred ninety-three local health department workers. Main outcome measure: Willingness to respond to four different public health emergency scenarios. Results: For naturally occurring and human-caused disasters, in unadjusted analyses, there was no statistically significant difference in willingness to respond between individuals living in states with a law that allowed for a governmental declaration of public health emergency and those living in states without such a law. Adjusted analyses yielded similar results. Conclusions: While laws giving the state the authority to declare a public health emergency are not associated with response willingness, findings may reflect the fact that states rarely declare public health emergencies, giving local public health workers few opportunities to become familiar with the implementation of these laws. In light of this, local health departments should consider altering their own internal policies to promote response willingness among their employees. Key words: disaster planning/legislation & jurisprudence, health policy, rescue work DOI:10.5055/ajdm.2015.0187


Article
Development of a disaster preparedness curriculum for medical students: A pilot study of incorporating local events into training opportunities
Katherine A. Pollard, BA; Daniel J. Bachmann, MD; Marek Greer, MD, MPH; David P. Way, MEd; Nicholas E. Kman, MD
Winter 2015; pages 51-59

Abstract
Objective: Contemporary disasters, like the outbreak of Ebola in West Africa, have piqued the interest of medical students in disaster preparedness. The topic is also a requirement of undergraduate medical education.1 Yet current literature suggests that disaster preparedness education is lacking. Our objective was to pilot a curriculum to augment medical students’ disaster preparedness education by marshalling local resources to provide practical hands-on experiences. Design: This pilot curriculum consisted of lectures; simulations; asynchronous learning materials; a large-scale, regional disaster exercise; and preparation for and participation in a real-time mass gathering. Outcomes were measured by student performance on written tests and evaluations of each activity. Setting: Academic Health Center with associated medical school. Participants: Fifty-two medical students participated in at least one of the six activities during this voluntary pilot program. Premedical students and residents (n = 57) participated in some activities. Results: Forty-one medical students took either the pretest or the post-test over the curriculum. Only eight students took both. A paired t test comparing pretest to post-test scores using imputed missing data (t = -11.72, df = 40, p = 0.001) was consistent with an analysis using only complete data (t = -2.35, df = 7, p = 0.05), implying that student scores improved significantly over time. Evaluations indicated a student preference for hands-on over didactic or independent learning activities. Conclusions: This pilot curriculum was designed to capitalize on practical hands-on training opportunities for our medical students, including participation in a disaster exercise and a mass-gathering event. These opportunities provided effective and engaging disaster preparedness education. Key words: disaster planning, emergency preparedness, education, medical, undergraduate DOI:10.5055/ajdm.2015.0188


Article
Effects of sternal intraosseous and intravenous administration of Hextend on time of administration and hemodynamics in a swine model of hemorrhagic shock
Don Johnson, PhD; Christian Penaranda, BSN; Kent Phillips, BSN; Daniel Rice, BSN; Lauren Vanderhoek, BSN; Brian Gegel, CRNA, DNAP; James Burgert, CRNA, DNAP; Jose Blanco, MD
Winter 2015; pages 61-67

Abstract
Objective: Disasters may cause traumatic injuries leading to hemorrhage. Hemorrhage is the leading cause of death for military and civilian trauma casualties. The US Army's Tactical Combat Casualty Care guidelines recommend administering a 500 mL Hextend bolus via the intravenous (IV) or intraosseous (IO) routes for patients in hypovolemic shock. The purposes of this study were to compare administration time of Hextend and the effects on hemodynamics when Hextend is administered by the sternal IO (SIO) and IV routes in a swine model of hemorrhagic shock. Design: This was a prospective, experimental study with random assignment. Setting: The study was implemented at an animal vivarium. Subjects: Yorkshire-cross (N = 21) swine were used. Intervention: Each swine was hemorrhaged 30 percent of their total blood volume to simulate a class II hemorrhage; 500 mL of Hextend was administered by the SIO and IV routes after hemorrhage. The control group did not receive any resuscitative fluids. Main outcome measurements: The predetermined variables of the study were time of administration and hemodynamics over 8 minutes. Hemodynamic data were collected every 2 minutes until administration was complete. Results: There were no significant differences in the time to administer Hextend between the SIO (616 ± 166 seconds) and the IV groups (534 ± 151 seconds) (p = 0.37). There were no significant differences between the SIO and IV groups relative to hemodynamics (p > 0.05), but both were significantly different than the control group (p < 0.05). Conclusion: The SIO route is an effective method of administering Hextend. Key words: hemorrhage, shock, Hextend, Hetastarch, infusion time, intraosseous DOI:10.5055/ajdm.2015.0189


Article
Simple infrared thermometry in fever detection: Consideration in mass fever screening
David E. Hogan, DO, MPH, FACEP; Stacia Shipman, DO; Keri Smith, DO
Winter 2015; pages 69-74

Abstract
Objective: The need to rapidly screen patients during outbreaks has prompted Cutaneous Infrared Thermometry (CIT) use. Little is known of CIT performance in this context. What are the performance characteristics of simple CIT in detecting fever? Design: Prospective cohort, sequential convenience sample. Participants: All patients presenting to the study Emergency Department for care. Intervention: CIT and oral temperature measurements. Main outcomes: Fever defined as oral temperature = 38°C. CIT is measured simultaneously with oral temperatures. Comparisons of temperatures are expressed as means and 95% confidence intervals. Means are compared using Student's t test. Limits of agreement are measured using Bland-Altman. Receiver operating characteristics are determined. Results: There are 548 cases comprising 224 males, 324 females, with mean age 26 years. The mean temperature difference is 12.95°C, (13.18-9.08°C) p = 0.0001. Bland-Altman demonstrates bias at 8.680 (-9.084 to -8.275) p = 0.0001 with upper and lower level bias values of 18.124 (18.819-17.435) and 0.768 (0.076-1.459), respectively. Based on Receiver Operator Characteristics analysis, detection of hyperpyrexia at a CIT of 35.3°C provided sensitivity of 0.236 (0.143-0.359), specificity 0.977 (0.959-0.989), positive predictive value 0.589 (0.325-0.810), negative predictive value 0.904 (0.891- 0.919), and accuracy of 0.888 (0.861-0.913). Conclusions: The use of a readily available CIT measurement device predicted hyperpyrexia about 59 percent of the time and the absence of hyperpyrexia about 90 percent of the time. This is consistent with previous reports of more complex infrared measurement devices. Although commonly used in mass fever screening, the current performance characteristics of CIT are limited and may add little to detection of target diseases in a mass screening context. Key words: Cutaneous Infrared Thermometry, mass fever screening, border screening, cutaneous fever screening, CIT DOI:10.5055/ajdm.2015.0190


Article
Use of an automated drug distribution cabinet system in a disaster response mobile Emergency Department
Herman Morchel, MD, MEE, BSEE; Chinwe Ogedegbe, MD, MPH; Nilesh Desai, BS, RPh, MBA; Brian Faley, PharmD; Nasir Mahmood, MS; Gary Del Moro, BS, AHIMT; Joseph Feldman, MD
Winter 2015; pages 75-78

Abstract
Objective: This article describes the innovative use of an automated drug distribution cabinet system for medication supply in a disaster response mobile Emergency Department vehicle. Prior to the use of the automated drug distribution cabinet system described in this article, the mobile hospitals were stocked as needed with drugs in individual boxes and draws. Experience with multiple deployments found this method to be very cumbersome and labor intensive, both in preparation, operational use, and demobilization. Setting: For a recent deployment to provide emergency medical care at the 2014 Super Bowl football event, the automated drug distribution cabinet system in the Institution's main campus Emergency Department was duplicated and incorporated into the mobile Emergency Department. Results: This method of drug stocking and dispensing was found to be far more efficient than gathering and placing drugs in onboard draws and racks. Conclusions: Automated drug distribution cabinet systems can be used to significantly improve patient care and overall efficiency in mobile hospital deployments. Key words: mobile Emergency Department, disaster response, Super Bowl, automated drug distribution cabinet system, mobile medical units, encrypted microwave Ethernet bridge, Electronic Medical Record, pharmaceutical supply, Super Storm Sandy DOI:10.5055/ajdm.2015.0191

American Journal of Disaster Medicine
Spring 2015, Volume 10
, Number 2


Article
Pediatric disaster preparedness and response and the nation's children's hospitals
Kristin C. Lyle, MD; Jerrod Milton, RPh, MBA; Daniel Fagbuyi, MD; Roxanna LeFort, MD; Paul Sirbaugh, DO, MBA; Jacqueline Gonzalez, ARNP, MSN, MBA; Jeffrey S. Upperman, MD, FAAP, FACS; Tim Carmack, CFO; Michael Anderson, MD
Spring 2015; pages 83-91

Abstract
Objective: Children account for 30 percent of the US population; as a result, many victims of disaster events are children. The most critically injured pediatric victims would be best cared for in a tertiary care pediatric hospital. The Children's Hospital Association (CHA) undertook a survey of its members to determine their level of readiness to respond to a mass casualty disaster. Design: The Disaster Response Task Force constructed survey questions in October 2011. Setting and participants: The survey was distributed via e-mail to the person listed as an “emergency manager/disaster contact” at each association member hospital and was designed to take less than 15 minutes to complete. Main outcome measures: The survey sought to determine how children's hospitals address disaster preparedness, how prepared they feel for disaster events, and how CHA could support their efforts in preparedness. Results: One hundred seventy-nine surveys were distributed with a 36 percent return rate. Seventy percent of respondent hospitals have a structure in place to plan for disaster response. There was a stronger level of confidence for hospitals in responding to local casualty events than for those responding to large-scale regional, national, and international events. Few hospitals appear to interact with nonmedical facilities with a high concentration of children such as schools or daycares. Conclusions: Little commonality exists among children's hospitals in approaches to disaster preparedness and response. Universally, respondents can identify a disaster response plan and routinely participate in drills, but the scale and scope of these plans and drills vary substantially. Key words: emergency management, pediatrics disaster response, children's hospitals, disaster preparedness and response, disasters, regional disaster response, hospital disaster plans DOI:10.5055/ajdm.2015.0193


Article
Assessment of the accuracy of the Medical Response to Major Incidents (MRMI) course for interactive training of the response to major incidents and disasters
Kristina Lennquist Montán, RN; Per Örtenwall, MD, PhD; Sten Lennquist, MD, PhD
Spring 2015; pages 93-107

Abstract
Background and aims: The benefit of simulation models for interactive training of the response to major incidents and disasters has been increasingly recognized during recent years and a variety of such models have been reported. However, reviews of this literature show that the majority of these reports have been characterized by significant limitations regarding validation of the accuracy of the training related to given objectives. In this study, precourse and postcourse self-assessment surveys related to the specific training objectives, as an established method for curriculum validation, were used to validate the accuracy of a course in Medical Response to Major Incidents (MRMI) developed and organized by an international group of experts under the auspices of the European Society for Trauma and Emergency Surgery. Methods: The studied course was an interactive course, where all trainees acted in their normal roles during two full-day simulation exercises with real time and with simultaneous training of the whole chain of response: scene, transport, the different functions in the hospital, communication, coordination, and command. The key component of the system was a bank of magnetized casualty cards, giving all information normally available as a base for decisions on triage and primary management. All treatments were indicated with attachments on the cards and consumed time and resources as in reality. The trainees’ performance was recorded according to prepared protocols and a measurable result of the response could be registered. This study was based on five MRMI courses in four different countries with altogether 235 participants from 23 different countries. In addition to conventional course evaluations and recording of the performance during the 2 exercise days, the trainees’ perceived competencies related to the specific objectives of the training for different categories of staff were registered on a floating scale 1-10 in self-assessment protocols immediately before and after the course. The results were compared as an indicator of to which extent the training fulfilled the given objectives. These objectives were set by an experienced international faculty and based on experiences from recent major incident and disasters. Results: Comparison of precourse and postcourse self-assessments of the trainees’ perceived knowledge and skills related to the given objectives for the training showed a significant increase in all the registered parameters for all categories of participating staff. The average increase was for prehospital staff 74 percent (p < 0.001), hospital staff 65 percent (p < 0.001), and staff in coordinating/administrative functions 81 percent (p < 0.001). Conclusions: The significant differences in the trainees’ self-assessment of perceived competencies between the precourse and postcourse surveys indicated that the methodology in the studied course model accurately responded to the specific objectives for the different categories of staff. Key words: curriculum evaluation, educational validation, simulation, training, major incident, disaster medicine, mass-casualty training DOI:10.5055/ajdm.2015.0194


Article
Modernizing stockpiles of medical countermeasures against smallpox: Benefits, risks, and knowledge gaps
Martin B. Oleksiewicz, DVM, PhD; Nina R. Steenhard, DVM, PhD; John-Erik Stig Hansen, MD, DMSc
Spring 2015; pages 109-120

Abstract
Objective: New smallpox medical countermeasures are entering the marketplace, offering the opportunity to modernize existing stockpiles. However, new smallpox countermeasures are developed under the animal rule, meaning that human efficacy data are lacking, and human safety data may be limited. Also, stockpile modernization would require prioritization of increasingly limited public funds. Approaches to address these issues are needed. Methods: Smallpox vaccine data were gathered by literature search. The financial value of vaccination in the face of an outbreak was evaluated using a threat-based cost/benefit analysis model, involving i) estimation of the efficacy of new smallpox vaccines based on available clinical data on virus-neutralizing seroconversion in vaccinees, ii) estimation of the likelihood for a smallpox outbreak in Denmark, and iii) estimation of the expected life-saving effects of postevent vaccination. Results: The authors estimated that i) the likelihood of a smallpox outbreak in Denmark is very low (one event in 200,000 years), ii) the expected efficacy of currently available and new vaccines is 95 and 75 percent, respectively, iii) the expected frequency of serious side effects from vaccination is between 100 and 10,000 fold lower for new than for existing vaccines, depending on modes of action. Conclusions: Despite the very low likelihood for a smallpox outbreak, the potentially large consequences combined with the protective effect of vaccination make maintenance of the smallpox vaccine stockpile justified and valuable. For vaccination in the face of a smallpox outbreak, a high efficacy rather than a lowered rate of adverse effects would maximize the number of lives saved. Key words: health security, medical countermeasures, smallpox, bioterrorism, risk/benefit assessment DOI:10.5055/ajdm.2015.0195


Article
The Ebola Spatial Care Path(TM): Accelerating point-of-care diagnosis, decision making, and community resilience in outbreaks
Gerald J. Kost, MD, PhD, MS, FACB; William J. Ferguson, MS; Jackie Hoe; Anh-Thu Truong; Arirat Banpavichit, MS, MBA; Surin Kongpila, MS
Spring 2015; pages 121-143

Abstract
Objectives: To present a vision where point-of-care testing (POCT) accelerates an Ebola Spatial Care Path™ (SCP) and future molecular diagnostics enable facilitated-access self-testing (FAST POC); to design an alternate care facility (ACF) for the SCP; to innovate an Ebola diagnostic center (DC); and to propel rapid POCT to the frontline to create resilience that stops future outbreaks. Design: PubMed, literature, and web searches. Centers for Disease Control and Prevention (CDC), Food and Drug Administration (FDA), Medicine Without Frontiers, and World Health Organization (WHO) document analyses. Investigations in China, the Philippines, Thailand, and the United States. Review of SE Asia, US, and West Africa isolation-treatment centers. Innovation of a SCP, ACF, and DC suitable for American and other communities. Outcomes: The authors designed an ACF and DC to integrate SCP principles for urgent Ebola care. FDA emergency use authorizations for Ebola molecular diagnostics were discovered, but no portable, handheld, or self-contained molecular POC instruments are yet available, although feasible. The WHO initiated design criteria and an acceptance protocol for testing. Financial investment in POCT will downsize Ebola outbreaks. Conclusions: POCT is facilitating global health. Now, global health problems are elevating POCT to new levels of importance for accelerating diagnosis and evidence-based decision making during disease outbreaks. Authorities concur that rapid diagnosis has potential to stop disease spread. With embedded POCT, strategic SCPs planned by communities fulfill CDC recommendations. POC devices should consolidate multiplex test clusters supporting patients with Ebola in isolation. The ultimate future solution is FAST POC. New technologies offer minimally significant risks. Diagnostic centers in ACFs and transportable formats also will optimize Ebola SCPs. Key words: alternate care facility, biosafety cabinet, diagnostic center, empowerment, facilitated-access self-testing, hemorrhagic fever, isolation, near-patient testing, needs assessment, newdemic, outbreak, personal protective equipment, persons under investigation, point-of-care culture, POC technologies, POC testing, return on investment, small-world network, treatment center DOI:10.5055/ajdm.2015.0196


Article
Proposal for a community-based disaster management curriculum for medical school undergraduates in Saudi Arabia
Nidaa Bajow, MD, MSc DM; Ahmadreza Djalali, MD, MSc DM, PhD; Pier Luigi Ingrassia, MD, MSc DM, PhD; Hussein Ageely, MD; Ibrahim Bani, MD, PhD; Francesco Della Corte, MD
Spring 2015; pages 145-152

Abstract
Objectives: Health professional preparedness is a key element of disaster response; overall there is a need for increased disaster medicine training worldwide. The objective of this study was to design and develop a curriculum in community-based disaster medicine for Saudi Arabian medical undergraduates. Methods: A structured five-step approach was used to develop a curriculum. Expert stakeholders from the Saudi Arabian and international disaster medicine communities were surveyed to determine objectives and content. Learning strategies were carefully considered to maximize participation and retention. Particular attention was paid to equipping learners with the teaching skills required to promote disaster preparedness in their local communities. Curriculum design: The course consists of 2 weeks of classroom activities followed by 8 weeks of e-learning structured within five domains of disaster medicine. The curriculum introduces core principles in emergency medicine, public health, and disaster management. Simulations, experiential activities, case studies, and role-playing activities are all used to promote higher levels of cognitive engagement. Special content addresses the adult-learning process, and students design their own community-based seminars in disaster preparedness. Conclusions: The curriculum is designed to promote learning in disaster medicine. Given the paucity of disaster medicine educators in the region, student graduates of this program would be able to improve disaster preparedness in Saudi Arabia by launching their own community-based disaster preparedness initiatives. The program could also be adapted for use throughout the Middle East. Key words: disaster medicine, medical education, community-based disaster medicine DOI:10.5055/ajdm.2015.0197


Article
Exposures and symptoms among workers after an offsite train derailment and vinyl chloride release
Jason A. Wilken, PhD; Leah Graziano, BS; Elena Vaouli, MPH; Karl Markiewicz, PhD; Robert Helverson, MSEP; Kimberly Brinker, MSN, MPH; Alice M. Shumate, PhD; Mary Anne Duncan, DVM, MPH
Spring 2015; pages 153-165

Abstract
Objective: In 2012 in New Jersey, a train derailment resulted in the puncture of a tanker car carrying liquid vinyl chloride under pressure, and a resulting airborne vinyl chloride plume drifted onto the grounds of a nearby refinery. This report details the investigation of exposures and symptoms among refinery workers. Design and setting: The investigation team met with refinery workers to discuss their experience after the derailment and provided workers a self-administered survey to document symptoms and worker responses during the incident. Associations among categorical variables and experiencing symptoms were evaluated using Fisher’s exact test. Participants: Twenty-six of 155 (17 percent) workers present at the refinery or driving on the access road the date the spill occurred completed the survey. Main outcome measure(s): Any self-reported symptom following exposure from the vinyl chloride release. Results: Fifteen workers (58 percent) reported =1 symptom, most commonly headache (12, 46 percent). Three (12 percent) reported using respiratory protection. No differences in reporting symptoms were observed by location during the incident or by the building in which workers sheltered. Workers who moved from one shelter to another during the incident (ie, broke shelter) were more likely to report symptoms (Fisher’s exact test, p = 0.03); however, there are only limited data regarding vinyl chloride concentrations in shelters versus outside. Conclusions: Breaking shelter might result in greater exposures, and managers and health and safety officers of vulnerable facilities with limited physical access should consider developing robust shelter-in-place plans and alternate emergency egress plans. Workers should consider using respiratory protection if exiting a shelter is necessary during a chemical incident. Key words: chemical hazard release, vinyl chloride, workplace DOI:10.5055/ajdm.2015.0198


Article
The simultaneous death of seven people due to the detonation of an antipersonnel landmine at the land borders of the European Union during peacetime
Pavlos Pavlidis, MD, PhD; Valeria Karakasi, MD
Spring 2015; pages 167-172

Abstract
This incident concerns the simultaneous death of seven people as a result of the accidental triggering of an antipersonnel landmine during peacetime. The victims were illegal migrants who attempted to cross the Greek-Turkish border zone and accidentally entered a demarcated minefield. This incident is presented because of its rarity and highlights the devastating consequences of the residual mines on the European Union eastern frontiers in peacetime. It also showcases the difficulties and risks that arise during the identification process in illegal migration issues. The victims’ positions at the moment of explosion are indicated by the detailed forensic examination and comparison of the injuries’ anatomical dispersion and their severity. Key words: disaster, injury, trauma, firearms and ballistics, forensic pathology, forensic science, migrants, mines, Greece, borders, minefield DOI:10.5055/ajdm.2015.0199

American Journal of Disaster Medicine
Summer 2015, Volume 10
, Number 3


Article
A benchmark system to optimize our defense against an attack on the US food supply using the Risk Reduction Effectiveness and Capabilities Assessment Program
Ofia Hodoh, MS, BS; Cham E. Dallas, PhD; Paul Williams, DVM; Andrew M. Jaine, PhD; Curt Harris, PhD
Summer 2015; pages 177-188

Abstract
Objective: A predictive system was developed and tested in a series of exercises with the objective of evaluating the preparedness and effectiveness of the multiagency response to food terrorism attacks. Design: A computerized simulation model, Risk Reduction Effectiveness and Capabilities Assessment Program (RRECAP), was developed to identify the key factors that influence the outcomes of an attack and quantify the relative reduction of such outcomes caused by each factor. Setting: The model was evaluated in a set of Tabletop and Full-Scale Exercises that simulate biological and chemical attacks on the food system. Participants: More than 300 participants representing more than 60 federal, state, local, and private sector agencies and organizations. Results: The exercises showed that agencies could use RRECAP to identify and prioritize their advance preparation to mitigate such attacks with minimal expense. RRECAP also demonstrated the relative utility and limitations of the ability of medical resources to treat patients if responders do not recognize and mitigate the attack rapidly, and the exercise results showed that proper advance preparation would reduce these deficiencies. Conclusions: Using computer simulation prediction of the medical outcomes of food supply attacks to identify optimal remediation activities and quantify the benefits of various measures provides a significant tool to agencies in both the public and private sector as they seek to prepare for such an attack. Key Words: emergency response, food terrorism, simulation, public health preparedness, intervention, food defense DOI:10.5055/ajdm.2015.0201


Article
An assessment of Chemical, Biological, Radiologic, Nuclear, and Explosive preparedness among emergency department healthcare providers in an inner city emergency department
Joseph G. Kotora, DO, MPH
Summer 2015; pages 189-204

Abstract
Introduction: Emergency healthcare providers are required to care for victims of Chemical, Biological, Radiologic, Nuclear, and Explosive (CBRNE) agents. However, US emergency departments are often ill prepared to manage CBRNE casualties. Most providers lack adequate knowledge or experience in the areas of patient decontamination, hospital-specific disaster protocols, interagency familiarization, and available supply of necessary medical equipment and medications. This study evaluated the CBRNE preparedness of physicians, nurses, and midlevel providers in an urban tertiary care emergency department. Methods: This retrospective observational survey study used a previously constructed questionnaire instrument. A total of 205 e-mail invitations were sent to 191 eligible providers through an online survey distribution tool (Survey Monkey®). Respondents were enrolled from February 1, 2014 to March 15, 2014. Simple frequencies of correct answers were used to determine the level of preparedness of each group. Cronbach’s coefficient a was used to validate the precision of the study instrument. Finally, validity coefficients and analysis of variance ANOVA were used to determine the strength of correlation between demographic variables, as well as the variation between individual responses. Results: Fifty-nine providers responded to the questionnaire (31.14 percent response rate). The overall frequency of correct answers was 66.26 percent, indicating a relatively poor level of CBRNE preparedness. The study instrument lacked precision and reliability (coefficient a 0.4050). Significant correlations were found between the frequency of correct answers and the respondents’ gender, practice experience, and previous experience with a CBRNE incident. Significant variance exists between how providers believe casualties should be decontaminated, which drugs should be administered, and the interpretation of facility-specific protocols. Conclusions: Emergency care providers are inadequately prepared to manage CBRNE incidents. Furthermore, a valid and precise instrument capable of measuring preparedness needs to be developed. Standardized educational curriculums that consider healthcare providers’ genders, occupations, and experience levels may assist in closing the knowledge gaps between providers and reinforce emergency departments’ CBRNE preparedness. Key words: disaster management, CBRNE, terrorism, decontamination DOI:10.5055/ajdm.2015.0202


Article
Intraosseous hydroxocobalamin versus intravenous hydroxocobalamin compared to intraosseous whole blood or no treatment for hemorrhagic shock in a swine model
Vikhyat S. Bebarta, MD, FACEP, FACMT; Normalynn Garrett, PhD; Susan Boudreau, RN, BSN; Maria Castaneda, MS
Summer 2015; pages 205-215

Abstract
Objective: To determine if intraosseous (IO) hydroxocobalamin can improve systolic blood pressure (SBP) in a swine model after severe hemorrhagic shock. Methods: Thirty six swine (45-55 kg) were anesthetized, intubated, and instrumented with continuous femoral and pulmonary artery pressure monitoring and then hemorrhaged such that 30 percent of their blood volume was extracted over 20 minutes. Five minutes later, animals were randomly assigned to receive 500 mL IO whole blood, 150 mg/kg IO or intravenous (IV) hydroxocobalamin in 180 mL of saline, or no treatment and then monitored for 60 minutes. A sample size of eight animals per group was based on a power of 80 percent, an alpha of 0.05, and a small effect size to detect a difference in SBP between groups. Outcome data were analyzed using repeated measures analysis of variance (RMANOVA). Results: RMANOVA outcome analysis detected a significant difference between groups (p < 0.05). IO whole blood, IO hydroxocobalamin, and IV hydroxocobalamin groups were similar to each other, but significantly different compared to controls regarding SBP, mean arterial pressure (MAP), systemic vascular resistance, and heart rate. Differences in SBP and MAP were sustained throughout the experiment. At 60 minutes, the comparison among the groups, IO whole blood, IO hydroxocobalamin, IV hydroxocobalamin, and control, was the following: SBP 78.2 versus 83.7 versus 75.1 versus 55.3 mm Hg; MAP 62.7 versus 65 versus 60 versus 43 mm Hg. There was a significant interaction by time in lactate values (p < 0.01) such that control animal lactate values increased over time (3.3 mmol/L) compared to IO whole blood, IO or IV hydroxocobalamin treated animals (1.1, 1.6, 1.3 mmol/L). Conclusions: IO hydroxocobalamin improved SBP, MAP, compared to no treatment and was similar to IO whole blood and IV hydroxocobalamin in this animal model of severe hemorrhage. Moreover, whereas serum lactate was improving in all treated groups, it was deteriorating in the control group. Key words: hydroxocobalamin, intraosseous infusion, swine, hemorrhage, resuscitation DOI:10.5055/ajdm.2015.0203


Article
The pharmacokinetics of intraosseous atropine in hypovolemic swine
Jonathan Yost, CRNA, MSN; P. Baldwin; S. Bellenger; F. Bradshaw; E. Causapin; R. Demotica; M. Livingston; C. Lee; B. Gegel; J. Burgert; A. Claessens; D. Johnson; M. Loughren
Summer 2015; pages 217-222

Abstract
Objective: Compare the pharmacokinetics of atropine administered via the intravenous (IV), intramuscular (IM), and intraosseous (IO) routes in a normovolemic and hypovolemic swine model. Design: Prospective, between subjects, experimental study. Setting: Vivarium. Subjects: Yorkshire-cross swine (N = 36). Intervention: Atropine was administered via IV, IM, or IO routes to normovolemic and hypovolemic swine. Blood samples were drawn at regular intervals after atropine administration and analyzed for plasma atropine concentration. Pharmacokinetic parameters were obtained from modeling the plasma concentrations. Main outcome measurements: Pharmacokinetic parameters, maximum concentration (Cmax) and time to maximum concentration (Tmax). Results: The IV and IO groups in both the normovolemic and hypovolemic models reached peak plasma concentration immediately and had a very rapid distribution phase with no apparent absorption phase for the IO groups. Peak plasma concentration and time to reach peak concentration were both significantly lower for the IM groups. There was a significant increase in absorption time with IM administration in the hypovolemic model compared to the normovolemic model. Conclusion: The IO route is an effective method of administering atropine and is comparable to the IV route even under conditions of significant hemorrhage. Therapeutic levels of atropine may be delayed and possibly difficult to obtain via IM injection in the presence of hypovolemic shock. Key words: intraosseous, intramuscular, atropine, nerve agent, shock, pharmacokinetics DOI:10.5055/ajdm.2015.0204


Article
Examining the importance of incorporating emergency preparedness and disaster training core competencies into allied health curricula
Tammy Curtis, PhD, RT(R)(CT)(CHES)
Summer 2015; pages 223-236

Abstract
Preparation for responding to emergency events that does not warrant outside help beyond the local community resources or responding to disaster events that is beyond the capabilities of the local community both require first responders and healthcare professionals to have interdisciplinary skills needed to function as a team for saving lives. To date, there is no core emergency preparedness and disaster planning competencies that have been standardized at all levels across the various allied health curricula disciplines. Objective: To identify if emergency preparedness and disaster training content are currently being taught in allied health program courses, to identify possible gaps within allied health curricula, and to explore the perceptions of allied health college educators for implementing emergency preparedness and disaster training core competencies into their existing curricula, if not already included. Design: A quantitative Internet-based survey was conducted in 2013. Setting: Convenient sample. Participants: Fifty-one allied health college educators completed the survey. Findings: Descriptive statistics indicated that the majority of allied health college instructors do not currently teach emergency preparedness and disaster training core competency content within their current allied health discipline; however, their perceived level of importance for inclusion of the competencies was high. The results of this study supported the need for developing and establishing a basic national set of standardized core emergency preparedness and disaster planning competencies at all levels across various allied health curricula disciplines to ensure victims receive the best patient care and have the best possible chance of survival. Key words: emergency preparedness, disaster training, core competencies, allied health curricula DOI:10.5055/ajdm.2015.0205


Article
A decision support framework for characterizing and managing dermal exposures to chemicals during Emergency Management and Operations
G. Scott Dotson, PhD, CIH; Naomi L. Hudson, DrPH; Andrew Maier, PhD, DABT, CIH
Summer 2015; pages 237-258

Abstract
Emergency Management and Operations (EMO) personnel are in need of resources and tools to assist in understanding the health risks associated with dermal exposures during chemical incidents. This article reviews available resources and presents a conceptual framework for a decision support system (DSS) that assists in characterizing and managing risk during chemical emergencies involving dermal exposures. The framework merges principles of three decision-making techniques: 1) scenario planning, 2) risk analysis, and 3) multicriteria decision analysis (MCDA). This DSS facilitates dynamic decision making during each of the distinct life cycle phases of an emergency incident (ie, preparedness, response, or recovery) and identifies EMO needs. A checklist tool provides key questions intended to guide users through the complexities of conducting a dermal risk assessment. The questions define the scope of the framework for resource identification and application to support decision-making needs. The framework consists of three primary modules: 1) resource compilation, 2) prioritization, and 3) decision. The modules systematically identify, organize, and rank relevant information resources relating to the hazards of dermal exposures to chemicals and risk management strategies. Each module is subdivided into critical elements designed to further delineate the resources based on relevant incident phase and type of information. The DSS framework provides a much needed structure based on contemporary decision analysis principles for 1) documenting key questions for EMO problem formulation and 2) a method for systematically organizing, screening, and prioritizing information resources on dermal hazards, exposures, risk characterization, and management. Key words: chemicals, decision analysis, dermal, Emergency Management and Operations, risk analysis, Hazards DOI:10.5055/ajdm.2015.0206


Article
Rodent-borne infectious disease outbreaks after flooding disasters: Epidemiology, management, and prevention
James H. Diaz, MD, DrPH
Summer 2015; pages 259-267

Abstract
Objective: To alert clinicians to the climatic conditions that can precipitate outbreaks of the rodent-borne infectious diseases most often associated with flooding disasters, leptospirosis (LS), and the Hantavirus-caused diseases, hemorrhagic fever with renal syndrome (HFRS) and Hantavirus pulmonary syndrome (HPS); to describe the epidemiology and presenting clinical manifestations and outcomes of these rodent-borne infectious diseases; and to recommend both prophylactic therapies and effective control and prevention strategies for rodent-borne infectious diseases. Design: Internet search engines, including Google®, Google Scholar®, Pub Med, Medline, and Ovid, were queried with the key words as search terms to examine the latest scientific articles on rodent-borne infectious disease outbreaks in the United States and worldwide to describe the epidemiology and presenting clinical manifestations and outcomes of LS and Hantavirus outbreaks. Setting: Not applicable. Participants: Not applicable. Interventions: Not applicable. Main outcome measure: Rodent-borne infectious disease outbreaks following heavy rainfall and flooding disasters. Results: Heavy rainfall encourages excessive wild grass seed production that supports increased outdoor rodent population densities; and flooding forces rodents from their burrows near water sources into the built environment and closer to humans. Conclusions: Healthcare providers should maintain high levels of suspicion for LS in patients developing febrile illnesses after contaminated freshwater exposures following heavy rainfall, flooding, and even freshwater recreational events; and for Hantavirus-caused infectious diseases in patients with hemorrhagic fevers that progress rapidly to respiratory or renal failure following rodent exposures. Key words: Hantavirus, New World Hantaviruses, American Hantaviruses, Sin nombre virus, Bayou virus, Black Creek Canal virus, Hantavirus pulmonary syndrome, Old World Hantaviruses, Leptospira interrogans, leptospirosis, Weil's disease, infectious disease outbreaks, climatic factors, rodent-borne DOI:10.5055/ajdm.2015.0207

American Journal of Disaster Medicine
Fall 2015, Volume 10
, Number 4


Article
Assessing American Red Cross First Aid mobile app user trends: Implications for resilience
Visanee V. Musigdilok, MPH; NE Demeter, MPH; RV Burke, PhD, MPH; E Shook, PhD; J Ajayakumar, MS; BM Berg, MPH; MD Hawkins, PhD; J Ferree, BS; BW MacAloney, II, BS; S Chung, MD; JL Pellegrino, PhD; D Tolli, MSEE; G Hansen, MA; JS Upperman, MD
Fall 2015; pages 273-283

Abstract
Objective: Disasters have devastated communities, impacted the economy, and resulted in a significant increase in injuries. As the use of mobile technology increasingly becomes a common aspect of everyday life, it is important to understand how it can be used as a resource. The authors examined the use of American Red Cross mobile apps and aimed to characterize user trends to better understand how mobile apps can help bolster individual and community preparedness, resilience, and response efforts. Design/main outcome measures: Tornado data were obtained from the National Oceanic and Atmospheric Administration and the National Weather Service. Data for the mobile apps were provided by the American Red Cross. All data were reviewed for 2013, 2014, and three specific tornado events. Data were organized in Microsoft Excel spreadsheets and then graphed or mapped using ArcMap 10.2™. Results: Between 2013 and 2014, 1,068 tornado watches and 3,682 tornado warnings were issued. Additionally, 37,957,560 Tornado app users and 1,289,676 First Aid app users were active from 2013 to 2014. Overall, there was an increase in the use of American Red Cross mobile apps during tornado occurrences. Yet the increase does not show a consistent correlation with the number of watches and warnings issued. Conclusions: Mobile apps can be a resourceful tool. This study shows that mobile app use increases during a disaster. The findings indicate that there is potential to use mobile apps for building resilience as the apps provide information to support individuals and communities in helping before, during, and after disasters. Key words: disaster, technology, tornado, mHealth DOI:10.5055/ajdm.2015.0209


Article
Checklist use in evaluating pediatric disaster training
Rita V. Burke, PhD, MPH; Kathy Lehman-Huskamp, MD; Rachel E. Whitney, MD; Gitanjli Arora, MD, DTMH; Daniel B. Park, MD; Pamela Mar, MD; Mark X. Cicero, MD
Fall 2015; pages 285-294

Abstract
Objective: Disaster preparedness training has a small but growing part in medical education. Various strategies have been used to simulate disaster scenarios to safely provide such training. However, a modality to compare their effectiveness is lacking. The authors propose the use of checklists, which have been a standard in aviation safety for decades. Design: Residents at four different academic pediatric residency programs volunteered to participate in tabletop simulation of a timed, pediatric disaster scenario. Resident teams were required to properly triage and manage simulated patients. Care intervention requests corresponding to each of the patients were recorded on a premade checklist. Results: Thirty-six teams provided a total of 1,476 possible care intervention requests for three pediatric patients: one with crush injury, one with increased intracranial pressure, and a nonverbal child. Some interventions were more likely to be omitted than others, and some teams performed extra interventions. Twenty-five entries from the checklist intervention responses were missing, affecting three of the teams. On average, teams requested 65 percent, were prompted to request 11 percent, and missed 22 percent of all checklist interventions with only 2 percent of all items not being recorded. Chi-square tests were performed for each patient scenario using R software. Categories compared included total counts of “requested,” “prompted,” and “missed” responses. Chi-square values were all statistically significant (p value < 0.05). Conclusions: In the checklist use during a tabletop disaster simulation, the authors have demonstrated that the checklist allows trainees to receive near immediate feedback. This training exercise provided them an opportunity to explore their own preparedness for a disaster scenario in a low-stress environment and allows for evaluation of such preparedness in a safe environment. Key words: checklist, disaster preparedness, disaster medicine, resident education, simulation DOI:10.5055/ajdm.2015.0210


Article
Evaluation of emergency drug releases from the Centers for Disease Control and Prevention Quarantine Stations
Shahrokh Roohi, RN, MPH; Margaret Grinnell, BS; Michelle Sandoval, MPH; Nicole J. Cohen, MD; Kimberly Crocker, BSN, RN; Christopher Allen, RPh, MPH; Cindy Dougherty, PharmD, RPh; Julian Jolly, PharmD, RPh; Nicki Pesik, MD
Fall 2015; pages 295-299

Abstract
The Centers for Disease Control and Prevention (CDC) Quarantine Stations distribute select lifesaving drug products that are not commercially available or are in limited supply in the United States for emergency treatment of certain health conditions. Following a retrospective analysis of shipment records, the authors estimated an average of 6.66 hours saved per shipment when drug products were distributed from quarantine stations compared to a hypothetical centralized site from CDC headquarters in Atlanta, GA. This evaluation supports the continued use of a decentralized model which leverages CDC’s regional presence and maximizes efficiency in the distribution of lifesaving drugs. Key words: public health, botulism, diphtheria, Malaria DOI:10.5055/ajdm.2015.0211


Article
A cross-sectional survey of patient needs in hospital evacuation
Rune Rimstad, MD; Anders Holtan, MD
Fall 2015; pages 301-307

Abstract
To aid development of contingency plans, a cross-sectional survey of inpatient needs in the event of a total hospital evacuation within a few hours was undertaken. The hospital is a part of a tertiary care facility with a mixed surgical and medical population and a relatively large load of emergency medicine. A doctor or nurse on each ward registered patients' physical mobility, special needs complicating transportation (intensive care, labor, isolation, etc), and the lowest acceptable level of care after evacuation. Of the 760 included patients, 57.8 percent could walk, 20.0 percent needed wheelchair, and 22.2 percent needed transport on stretcher. Special needs were registered for 18.2 percent of patients. Only 49.7 percent of patients needed to be evacuated to another hospital to continue care on an acceptable level, while 37.6 percent could be discharged to their own home, and 12.6 percent could be evacuated to a nursing home. Patients in psychiatric wards and high dependency units had distinctly different needs than patients in ordinary somatic wards. The differences between patients in surgical and nonsurgical wards were minor. Patient discharge seems to be a considerable capacity buffer in a hospital crisis situation. Key words: hospitals, evacuation, needs assessment, continuity of patient care, disaster planning DOI:10.5055/ajdm.2015.0212


Article
Description of blast injuries and predictors of admission to hospital in blast victims in an urban civilian setting
Mazen J. El Sayed, MD, MPH, FAAEM, FACEP; Hady Zgheib, MD; Rana Bachir, MPH; Hussein Abou Ghaddara, MD
Fall 2015; pages 309-315

Abstract
Introduction: Blast injuries characteristics and outcomes are not well described in urban civilian settings. Objectives: To describe blast injuries characteristics and to identify predictors of hospital admission after sustaining a blast injury. Methods: Retrospective chart review study of blast victims who presented to the Emergency Department (ED) of a tertiary care center in Beirut, Lebanon, over 8 years. The authors conducted a descriptive analysis, followed by a multivariate analysis to identify predictors. Results: A total of 59 patients were included. They were mostly males (81.4 percent) with a mean age of 35.4 ( ± 15) years with high rate of admission to the hospital (71.2 percent). Surface injury (mainly open wounds) was most common (91.5 percent). Injuries involved mainly the face (45.8 percent) and thigh/knee (33.9 percent). Significant associations were identified between different injury locations. Significant predictors of hospital admission in blast victims were internal injury (odds ratio [OR] = 11.6, 95% confidence interval [CI; 1.7, 79.9]), orthopedic injury (OR = 41.1, 95% CI [3.4, 496.2]), and undergoing a chest X-ray in the ED (OR = 14.3, 95% CI [2.2, 93.3]). Conclusion: Blasts in a civilian setting result in a wide range of injuries. Facial injuries were most common in our setting with close associations between injuries of different organ systems. Identified predictors of hospital admission can help guide disposition decision for blast victims in the ED. Key words: blast injury, civilian, predictors, hospital admission, Lebanon DOI:10.5055/ajdm.2015.0213


Article
Laboratory evaluation of airborne particulate control treatments for simulated aircraft crash recovery operations involving carbon fiber composite materials
Matthew Ferreri, MS, CIH; Jeremy Slagley, PhD, CIH, CSP; Daniel Felker, PhD
Fall 2015; pages 316-324

Abstract
Objective: This study compared four treatment protocols to reduce airborne composite fiber particulates during simulated aircraft crash recovery operations. Design: Four different treatments were applied to determine effectiveness in reducing airborne composite fiber particulates as compared to a “no treatment” protocol. Both “gold standard” gravimetric methods and real-time instruments were used to describe mass per volume concentration, particle size distribution, and surface area. The treatment protocols were applying water, wetted water, wax, or aqueous film-forming foam (AFFF) to both burnt and intact tickets of aircraft composite skin panels. The tickets were then cut using a small high-speed rotary tool to simulate crash recovery operations. Setting: Aerosol test chamber. Subjects, participants: None. Interventions: Airborne particulate control treatments. Main outcome measures: Measures included concentration units of milligrams per cubic meter of air, particle size distribution as described by both count median diameter and mass median diameter and geometric standard deviation of particles in micrometers, and surface area concentration in units of square micrometers per cubic centimeter. Finally, a Monte Carlo simulation was run on the particle size distribution results. Comparison was made via one-way analysis of variance. Results: A significant difference (p < 0.0001) in idealized particle size distribution was found between the water and wetted water treatments as compared to the other treatments for burnt tickets. Conclusions: Emergency crash recovery operations should include a treatment of the debris with water or wetted water. The resulting increase in particle size will make respiratory protection more effective in protecting the response crews. Key words: composite materials, aircraft crash recovery, dust control DOI:10.5055/ajdm.2015.0214


Article
A scrutiny of tools used for assessment of hospital disaster preparedness in Iran
Esmail Heidaranlu, BSN, MSN; Abbas Ebadi, PhD; Ali Ardalan, MD, PhD; Hamidreza Khankeh, PhD
Fall 2015; pages 325-338

Abstract
Introduction: In emergencies and disasters, hospitals are among the first and most vital organizations involved. To determine preparedness of a hospital to deal with crisis, health system requires tools compatible with the type of crisis. The present study aimed to evaluate the accuracy of tools used for assessment of hospitals preparedness for major emergencies and disasters in Iran. Method: In this review study, all studies conducted on hospital preparedness to deal with disasters in Iran in the interim 2000-2015 were examined. The World Health Organization (WHO) criteria were used to assess focus of studies for entry in this study. Results: Of the 36 articles obtained, 28 articles that met inclusion criteria were analyzed. In accordance with the WHO standards, focus of tools used was examined in three areas (structural, nonstructural, and functional). In nonstructural area, the most focus of preparation tools was on medical gases, and the least focus on office and storeroom furnishings and equipment. In the functional area, the most focus was on operational plan, and the least on business continuity. Half of the tools in domestic studies considered structural safety as indicator of hospital preparedness. Conclusion: The present study showed that tools used contain a few indicators approved by the WHO, especially in the functional area. Moreover, a lack of a standard indigenous tool was evident, especially in the functional area. Thus, to assess hospital disaster preparedness, the national health system requires new tools compatible with scientific tool design principles, to enable a more accurate prediction of hospital preparedness in disasters before they occur. Key words: disasters, hospital preparedness, Iran DOI:10.5055/ajdm.2015.0215


Article
The impact of Hurricane Sandy on the mental health of New York area residents
Rebecca M. Schwartz, PhD; Cristina Sison, PhD; Samantha M. Kerath, MS; Lisa Murphy, BA; Trista Breil, MA; Daniel Sikavi; Emanuela Taioli, MD, PhD
Fall 2015; pages 339-346

Abstract
Objective: To evaluate the long-term psychological impact of Hurricane Sandy on New York residents. Design: Prospective, cross-sectional study. Setting: Community-based study. Participants: From October 2013 to February 2015, 669 adults in Long Island, Queens, and Staten Island completed a survey on their behavioral and psychological health, demographics, and hurricane impact (ie, exposure). Main outcome measures: Depression, anxiety, and post-traumatic stress disorder (PTSD). Results: Using multivariable logistic regression models, the relationships between Hurricane Sandy exposure and depression, anxiety, and PTSD were examined. Participants experienced an average of 3.9 exposures to Hurricane Sandy, most of which were related to property damage/loss. Probable depression was reported in 33.4 percent of participants, probable anxiety in 46 percent, and probable PTSD in 21.1 percent. Increased exposure to Hurricane Sandy was significantly associated with a greater likelihood of depression (odds ratio [OR] = 1.09, 95% confidence interval [CI]: 1.04-1.14), anxiety (OR = 1.08, 95% CI: 1.03-1.13), and probable PTSD (OR = 1.32, 95% CI: 1.23-1.40), even after controlling for demographic factors known to increase susceptibility to mental health issues. Conclusions: Individuals affected by Hurricane Sandy reported high levels of mental health issues and were at an increased risk of depression, anxiety, and PTSD in the years following the storm. Recovery and prevention efforts should focus on mental health issues in affected populations. Key words: Hurricane Sandy, mental health, New York residents DOI:10.5055/ajdm.2015.0216


Article
Public health incident management: Logistical and operational aspects of the 2009 initial outbreak of H1N1 influenza in Mexico
Miguel A. Cruz, PhD
Fall 2015; pages 347-353

Abstract
Hosting an international outbreak response team can pose a challenge to jurisdictions not familiar with incident management frameworks. Basic principles of team forming, organizing, and executing mission critical activities require simple and flexible communication that can be easily understood by the host country’s public health leadership and international support agencies. Familiarity with incident command system principles before a public health emergency could save time and effort during the initial phases of the response and aid in operationalizing and sustaining complex field activities throughout the response. The 2009 initial outbreak of H1N1 in Mexico highlighted the importance of adequately organizing and managing limited resources and expertise using incident management principles. This case study describes logistical and operational aspects of the response and highlights challenges faced during this response that may be relevant to the organization of public health responses and incidents requiring international assistance and cooperation. Key words: emergency management, outbreaks, incident command system, international agencies, public health DOI:10.5055/ajdm.2015.0217


Article
Letter to the editor. Modernizing smallpox vaccine stockpiles; Author's reply
Erik Heegaard, MD, PhD, DMSc; Martin B. Oleksiewicz, DVM, PhD; Nina R. Steenhard, DVM, PhD; John-Erik S. Hansen, MD, DMSc
Fall 2015; pages 354-366

Abstract
DOI:10.5055/ajdm.2015.0218