The CDC National Pharmaceutical Stockpile Program: An Overview
A release of selected biological or chemical agents targeting the United States civilian population will require rapid access to quantities of pharmaceuticals, antidotes, vaccines, and other medical supplies. In such an event, state, local, and private stocks of medical materiel will become depleted quickly. No one can anticipate exactly where a terrorist will strike and few local governments have the resources to create sufficient stockpiles on their own.
With this in mind, the Centers for Disease Control and Prevention (CDC) have created the National Pharmaceutical Stockpile Program (NPSP). The NPSP is responsible for the purchase, storage, and deployment of pharmaceuticals, supplies, and equipment that localities will need in a chemical or biological terrorist incident. The NPSP can help bolster state and local response capacity, and be one of the keys in mitigating the results of a bioterrorist incident.
The broad role of the CDC is to ensure that federal, state, and local levels of the public health partnership coordinate efforts, and work with the medical and emergency response communities to prepare for acts of biological and chemical terrorism.
Attendees at this session will have an understanding of the role and capability of the National Pharmaceutical Stockpile Program.
Keywords: bioterrorism; CDC; emergency response; stockpile
E-mail: sgb3@CDC.gov
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An Overview of the Patients Needing Hemodialysis in the Taiwan 921 Earthquake
Emergency Department, Cheng-Ching General Hospital, Yang-Ming University, Taiwan, ROC
Introduction: The 921 earthquake was a painful and devastating event for people living in central Taiwan. The disaster medical response was challenging for local hospitals and important for all medical victims. There was a sudden increase in need for hemodialysis following the earthquake.
Methods: We retrospectively reviewed the charts during the period of the first 48 hours after the quake, and analyzed the reasons for the use of hemodialysis, time interval from the earthquake to arrival at the hospital, and types of transportation used.
Results: There were 495 patients treated in the Emergency Department (ED) within 48 hours of the earthquake. Eighty-five patients (17.2%) required hemodialysis. The majority of patients requiring hemodialysis had pre-existing, end-stage renal disease (ESRD), and only three patients were diagnosed to have rhabdomyolysis due to the crush syndrome. Fifty-nine patients came from Pu-Li Village, which is located in central zone of earthquake. Forty-eight patients (56.5%) were from another hospital in Pu-Li Village, which had a strategic affiliation with our hospital for at least 2 years. Most of patients were transported to hospital by ambulance (75%), helicopter (12%), or private cars (13%). The average time from the earthquake to arrival at this hospital was 17.5 hours. No patient received hemodialysis until 7 hours after admission. Hemodialysis of these patients increased the workload of our hemodialysis room by 37%, which was well-tolerated during this disaster management.
Conclusions: This review may provide helpful information and contribute to disaster management for hemodialysis-related illness or injuries.
Keywords: 921 earthquake; crush syndrome; disaster; hemodialysis; response; Taiwan
E-mail: er118@ms34.hinet.net
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The Remarkable Medical Supply of the 1998: Flood Fighting and Rescue Work in China
In the summer of 1998, some provinces in China suffered from severe floods, and people ran out of treatment and medicine.The People's Liberation Army (PLA) did its best to supply the needed medicines for them, thus safeguarding their lives. We used the main-channel functions of the Army's medical supply capabilities to provide a sufficient and smooth supply of medicines. With epidemic prevention as the main goal, the funds of medical supplies also were increased. To avoid supplying drug, blindly, the distribution program for the medicine funds were inspected closely. Increasing the supply of medicine was accomplished through the use of multiple channels. In addition, the special preventive drugs and emergent medicines were provided for the flood-fighting troops. In addition, using the Wuhan Rear Base as a strategic rear supply base, supplemental medicines were provided for the flood-fighting troops of different districts.
Keywords: China; epidemic; flood; medicines; prevention; supplies
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The Role of the Teaching Hospitals in the Subacute Phase 921 Earthquake in Taiwan
Introduction: At 01:47 h, 21 September1999, a quake registering 7.3 on the Richter scale, centered near Nantou (central Taiwan), affected 2.5 million people living in this area and 10 other cities and towns in the Taiwan. It killed >2,400 people, and injured approximately 9,400 persons.Three days later, there were 320,000 people (12.8%) who were staying in shelters because their houses (81,000) were totally or partly damaged. The affected areas were divided into 26 medical supporting units by teaching hospitals on 26 September.
Objective: This study could explain that teaching hospitals played a role in the subacute phase of a major earthquake. We observed and identified emergency and disaster medical services issues at the affected areas and provided an overview of the morbidity and mortality of disaster patients.
Methods: We assessed these activities retrospectively by reviewing the official reports and the medical records. From observation and site visits, we collected the information in affected areas of central Taiwan one month after the quake. The data were analyzed from affected hospitals and local health center administrations involved emergency medical relief groups and the local governments.
Results: On 22 September, we sent more than 100 physicians and nurses to the evacuation centers to survey the medical requirements. The first peak in the number of patients requiring emergency care was 2-8 hours after the earthquake. The demands for the treatment of such disaster injuries as bone fractures, crush syndrome, and other injuries were great on Day 1. From 22 to 26 September, a total of 1,724 patients were examined, and 39 were in emergency condition. The diseases most commonly were upper airway infection, minor trauma, hypertension, dermatitis, and gastroenteritis. Since 27 September, continuous medical care was established in the affected areas. For about one month 250-300 patients were treated daily. Chronic and psychiatric illness were noted.
Conclusion: In the subacute phase of the 921 earthquake, the teaching hospitals can provide medical services and support local clinics by referring patients from on-site. The continuous medical care can reduce the possibility for outbreaks of infectious diseases in affected areas.
Keywords: characteristics; disaster; earthquake; hospitals, teaching; intubation; patients; subacute; Taiwan
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The Operational and Functional Components of Hospital Buildings - The Experience in the Taiwan Ji-Ji Earthquake
Background: This study evaluated the non-structural elements of the medical capacity available following the Ji-Ji earthquake. This catastrophic earthquakes registering 7.3 on the Richter scale, struck mid-Taiwan on 21 September 1999, and took a death toll of 2,403, and injured 10,002 persons.
Methods: Four affected hospitals participated in the study. Affected hospitals were defined as those with at least 200 beds that were within the epicenter area. The damaged, non-structural elements of these evacuated hospitals were examined and scored.
Results: These hospitals suffered from only minor structural damage, but sustained extensive non-structural damage and were forced to evacuate patients from their buildings. Several major operational and functional components (OFC) that were critical to their operations were damaged: falling objects, flooding, loss of electricity, and damaged medical equipment.
Conclusion: A well-designed, disaster medical care system should include seismic considerations of these hospitals, especially those key non-structural elements evaluated. In the 1999 Taiwan Ji-Ji quake, these affected hospitals lost most of their medical capacity at a period when patients desperately needed medical attention. It is important to re-establish the advanced design code for the repaired hospitals, providing OFC seismic protection to reduce mortality in next rural temblor.
Keywords: catastrophic earthquake; functional components; non-structural elements; operational components
E-mail: chuanger@ksts.seed.net.tw
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A Template for Urban Management of Biological Exposures and Casualties
A coordinated response in a multi-jurisdictional environment is required to protect Canadians from accidental or terrorist-initiated exposure to biological agents. A template for a flexible and rapid response with multiple entry points for potential casualties of an unknown nature will be presented, and its development process described. The template acknowledges that the event initially may not be recognized and identi fies key signs, symptoms, and laboratory features that suggest exposure to a biological agent. It outlines the reporting and communications fan-out, and describes the lines of operational authority when multi-agency response and cooperation is required. The template details rapid response strategies for First Response agencies as well as measures to contain an exposure as quickly as possible. It provides lists of provincial, national, and international experts, equipment, antidotes/vaccines, and relevant literature. Resource requirements for handling exposures and casualties are identified, and a guide for a coordinated public health response including surveillance and contact tracing, is provided. It is hoped that this template will provide the stimulus and background to enable other agencies to establish their own local response force.
Keywords: biological hazards; bioterrorism; coordination; health response; preparedness; template
E-mail: pdaly@rhb.bc.ca
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Changes in pCO2 During Air-Medical Transport of Children with Closed Head Injuries
Introduction: Inappropriate management of pCO2 following head-injury can adversely affect outcome. We studied whether the optimal pCO2 level was maintained in ventilated children with closed-head injuries transported by paramedics, and whether hand-bagging or mechanical ventilation resulted in better pCO2 levels.
Methods: Hospital charts and transport records were reviewed for all head-injured children transported by a specialized paramedic team to tertiary care over a 12-month period. All of the children were intubated and mechanically or manually ventilated. Outcome measures were final pCO2 prior to transport and first pCO2 on arrival in the ICU.
Results: 29 children (age 0.6 to 16 years, median 6 years) met the criteria, 14 hand bagged (HB) and 15 mechanically ventilated (MV). 11 patients started in the target pCO2 range of 35-45 mmHg: 5 HB and 6 MV. Following transport, 1 hand-bagged patient and 9 mechanically-ventilated patients had pCO2 values within the target range. The duration of transport (range 15-200 minutes) did not contribute to final pCO2 level.
Conclusions: Mechanical ventilation is preferable to hand-bagging. Those managing head-injured patients in a disaster need to be aware that hand-bagging significantly increases the incidence of sub-optimal pCO2 levels and the risk of sub-optimal cerebral blood flow, and that monitoring of CO2 (e.g., by point-of-care testing) is desirable.
Keywords: closed head injury; CO2, monitoring of; pCO2; transport; ventilation
E-mail: amacnab@cw.bc.ca
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Methods of Self-aid and Mutual-aid of the Injured in Earthquake and Points for Attention
Self-aid and mutual-aid for the injured in an earthquake generally is carried out by the survivors and the injured before the arrival of exterior rescue teams. Such actions have great significance in lowering the mortality and alleviating the pain of the injured.
First, according to the disaster relief experiences from the 1976 Tangshang Earthquake, the procedures of self-aid and mutual-aid of the person under ruins were identified and included exposure of the head and chest first followed by the provision of food, boosting the confidence of the trapped that they will be saved and to hold on, etc.
Second, the authors introduce kinds of organization that are helpful to the provision of mutual-aid for the masses, which include mutual-aid for the family, mutual-aid for those injured located on the streets, mutual-aid among rescue units, and mutual-aid implemented by militia and the Peoples' Liberation Army (PLA).
Finally, the presentation directs attention to the course of the rescue efforts: 1) Search for the injured carefully; 2) Diagnose the condition of injury correctly; and 3) Treat the condition of injury promptly. Several examples from the activites associated with the Tangshang Earthquake are used to illustrated the views of authors. Each of these experiences should be applied in future Disaster Medicine relief.
Keywords: assistance; disaster; earthquake; initial aid; lay public; organization; plans; priorities; rescue; survivors
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Does The End-Tidal CO2 Monitoring Have Prognostic Value during Out-of-Hospital Cardiac Arrest?
Introduction: Management of cardiac arrest is made difficult by the absence of a readily available, non-invasive measurement that identifies individual patients who are likely to be resuscitated successfully. Animal and clinical studies have suggested that end-tidal CO2 (EtCO2) correlates closely with cardiac output during resuscitation efforts. To investigate further the utility of EtCO2 as a prognostic indicator of initial outcome of resuscitation and survival in patients, we conducted a prospective study of the use of EtCO2 in adult victims of out-of-hospital, non-trauma-related cardiac arrest.
Methods. We prospectively studied 238 adult (age >18years) patients in non-trauma-related, out-of hospital cardiac arrest (in from January 1998-December 1999). EtCO2 was monitored with an in-line sensor and was calibrated every 48 hours according to the manufacturer's specification (BCI 82000 Capnometer, BCI International). For each patient, the following measures were recorded: 1) age; 2) gender; 3) EtCO2 (initial, final); 4) cardiac rhythm; 5) return of spontaneous circulation ( ROSC); and 6) survival. Data were analyzed to compare patients who died (NS, NR) with those were resuscitated successfully (R), and with survival (S). Data were analyzed using the unpaired, two-tailed, Student's t-test; O2-test; p <0.05.
Results: 238 patients were included in the study (144 (61%) males, and 94 (39%) females). Survivors were younger than non-survivors( 56 ±15 vs.69 ±11 years; p <0.05). The mean values for EtCO2 are in Table 1.
Table 1
Group Number Initial EtCO2 Final EtCO2
mean SD mean SD
All (n =238)
R 68 18.8 6.2 24.1 5.1
NR 170 7.4 2.4 5.8 4.3
S 26 22.2 3.7 28.4 4.3
NS 212 8.7 2.3 7.2 4.2
Asystole (n = 132)
R 28 15.2 6.3 21.2 6.2
NR 104 6.4 2.1 5.2 3.5
S 3 17.8 3.7 22.5 4.5
NS 129 7.2 3.7 6.3 4.2
VF (n = 55)
R 22 17.2 4.5 28.6 10.3
NR 33 7.3 2.5 5.4 2.3
S 14 19.4 5.4 31.2 10.1
NS 41 8.4 4.1 7.2 3.2
VT (n = 12)
R 8 21.5 7.4 26.2 8.7
NR 4 9.8 3.9 6.2 2.2
S 6 26.2 6.3 27.8 7.5
NS 6 11.3 4.7 8.2 5.5
EMD (n = 39)
R 10 22.7 5.8 31.2 8.1
NR 29 6.3 1.9 7.1 2.3
S 3 24.3 6.5 35.2 6.3
NS 36 9.3 3.5 7.3 4.2
The initial and final EtCO2 was significantly higher in patients with ROSC than in patients without ROSC (p <0.05). The initial and final EtCO2 also was greater for those patients who survived to leave the hospital compared with those patients who died (p <0.05).
Conclusion: Data from this prospective clinical trial indicate that EtCO2 monitoring during CPR correlates with resuscitation from and survival of cardiac arrest. End-tidal CO2 monitoring has potential as a non-invasive indicator of cardiac output during resuscitation and a prognostic indicator for survival.
Keywords: cardiac arrest; EtCO2; prognosis; ROSC; survival
E-mail: zd-mb.re_ l@siol.net
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The Italian Multi-Disciplinary Approach to the Management of a Complex Emergency in Cuba: A Case Study of Dengue and Leptospirosis Control
During the last three years, major epidemics as well as a cluster of cases of dengue virus infections and leptospirosis have been recorded by the Cuban Ministry of Public Health. The most serious episode was the 1997 epidemic of dengue in Santiago de Cuba, where there were over 3,000 clinical cases in addition to 205 cases of haemorrhagic diseases (5.6% mortality rate). Leptospirosis also has been identified as having an increasing incidence during the last four years (25.6 cases per 100,000 inhabitants in 1994) throughout the island.
The Italian Co-operation (IC) has been present in Cuba since 1998. One of the first initiatives was focused on supporting the Cuban Ministry of Health in its attempts to control the spread of dengue and leptospirosis. The approach of the IC was based on a multi-disciplinary approach that focused on the following key points:
1) Education and training of populations at greater risk of exposure to the principal domestic vector, Aedes aegypti, as well as to rodents;
2) Support to the surveillance system for dengue and leptospirosis;
3) Strengthen the capacity of early clinical recognition (suspected cases) and laboratory confirmation of new cases of leptospirosis;
4) Support to the Aedes aegypti and rodent control programmes;
5) Structural/infrastructural interventions with impact on urban and rural environments, in order to limit the risk of an increase in vectors and the rodent population; and
6) Select a strict system of evaluation indicators to monitor the efficacy of the intervention.
One year following the implementation of the programme in selected areas of the island (Pinar del Rio, Ciudad Habana, Cienfuegos, and Granma), the main results are:
1) Decrease in the larval breeding index of Aedes aegypti (p <0.01, 1999 vs. 1998);
2) Decrease in the incidence of dengue cases, with no recordings of epidemics or clusters of cases;
3) Decrease in the incidence of leptospirosis (p <0.0l, 1999 vs. 1998);
4) Reduction in rodent population, with a special impact on the urban area; and
5) Increase in chemoprophylaxis and early treatment of new cases of leptospirosis.
Conclusions: The results obtained highlight the short-term efficacy of the IC approach in controlling the spread of dengue and leptospirosis in this setting. The discussion will focus on the advantages and drawbacks of this integrated strategy in order to control two diseases that traditionally have been controlled by vertical programmes. The impact of the support to the entomological, epidemiological, clinical, environmental, and educational sectors will be compared to each other and then discussed. This should allow the strong points of each component to be identified, considering that such an approach is not only a method for preventing and treating infectious diseases, but also is a path towards the creation of healthy communities.
Keywords: complex emergency; cooperation; Cuba; dengue; education; epidemics; leptospirosis; rodents; training; vectors
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Orthopaedic and Plastic Reconstructive Surgery for War Victims: The Italian Co-Operation Experience in the Ethiopian-Eritrean Conflict
Orthopaedic and reconstructive surgery for war wounds is different from the type of surgery performed for civilian injuries. Furthermore, in developing countries, additional problems often arise from the lack of an integrated approach (which includes pre- and post-operative treatment and pre- and post-operative rehabilitation) to the war wounds and related complications.
From the outbreak of the Ethiopian-Eritrean conflict, the Italian Co-operation supported this complex emergency situation by sending to the site, a surgical team consisting of an orthopaedic surgeon, a maxillo-facial and plastic surgeon, an anaesthesist specialist, a ward nurse, a scrub nurse, and a physiotherapist. The emergency surgical team, in collaboration with the local Eritrean staff, was based at the Asmara Halibet Hospital (Eritrea) from April to December 1999.
The presentation reports the results obtained during this period, and focuses on the methodological approach selected to improve the quality of the treatment of patients, and to best manage the situation in an emergency setting. 650 patients were treated according to the ICRC guidelines. The safest and cheapest peripheral anaesthesia procedures were performed in 60% of cases. On-the-job training on the integrated treatment of persons with war injuries with the resident staff was carried out daily. The integrated approach towards war wounds and the prevention of complications using the existing resources were the main objectives of the rapid response, and confirmed the efficacy of the intervention.
Keywords: Eritrean; Ethiopia; Italian Co-operation; orthopaedic; plastic; reconstruction; surgery; war; wounds
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Essential Factors in Rapid Reaction Capability of Disaster Medicine Relief Force and Practical Measures
Rapid Reaction Capability (RAC) is the response ability to cope with emergencies, wars, or disasters promptly, flexibly, and efficiently. It is one of the most important capabilities of Disaster Medicine Relief Force (DMRF).
First, in this paper, the necessity that the DMRF possesses RAC is discussed. This is because a disaster happens abruptly, and that Disaster Medicine relief differs from other tasks (e.g., it is practiced prior to others). Thus, the DMRF must possess the capabilities and emergency measures that are of great significance for lowering the incidence of disability and mortality of the injured.
Second, according to the analysis of Disaster Medicine relief procedures, the authors suggest several essential factors related to the RAC of the DMRF, such as the system of organization of Disaster Medicine relief, counter-plans, conduct, vehicles, personal mental health, material and medical makings of a DMRF member, and so on.
Lastly, practical methods to enhance the RAC of the DMRF are proposed: 1) Establish perfect organizations that are suited to work in domestic conditions; 2) Set up an automatic disaster relief system of conduct; 3) Be ready to provide Disaster Medicine relief no matter whether during peacetime or wartime; and 4) Because of suddenness and destructiveness of Disasters (wars), joint army-civilian Disaster Medicine relief must be practised. The statistics of DMRF following the Tangshang Earthquake of 1976 are presented to illustrate the viewpoints of authors.
Keywords: army; civilian; earthquake; Disaster Medicine; Disaster Medicine Relief Force (DMRF); organization; relief; response
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Organising Ophthamological Aid in Disasters and Emergencies
1) Lost of vision in emergencies is a severe mental injury;
2) Provide first aid. Eye specialists should be included in the general medical team;
3) A special kit containing medicines, bandages and instruments has been developed to provide ophthalmological first aid;
4) A colour marker card system to identify eye injuries has been developed; and
5) A list of recommendations for first aid to patients with eye injuries, including disinfectant drop instillation, application of sterile bandages and hospitalisation in a specialised eye centre, is presented.
Keywords: aid; disaster; eye; ophthamology
E-mail: zaza@caravan.ru
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Management of the Mass Casualties of Traffic Accidents in the City
The number of Chinese drivers comprise 2.2% of the total in the world. But the automobile accidents in China comprise 9%. Currently, the number of people dying from traffic accidents is about 86,000/year. Shanghai is one of the biggest cities in the world. It contains a population of 13,000,000. The average density of population is >1,000 persons/km2 and >10,000 persons/km2 in the downtown. The daily commuting population in Shanghai is >2,000,000. Statistics of the past five years show that the traffic accidents exceed the past records by 60,000 cases with 2 persons killed every day (in China, one person is killed by accidents every 6 minutes).
Table 1-Numbers of traffic accidents, injured, and deaths in Shanghai 1987-1991
Year Accidents Wounded Dead
1987 18,475 10,059 1,514
1988 20,074 9,500 1,164
1989 8,736 8,991 947
1990 7,621 4,699 607
1991 7,524 4,450 594
Total 62,430 37,699 4,826
Table 2-The number of traffic accidents, wounded, and dead in China 1987-1991
Year Accidents Wounded Dead
1987 298,147 187,399 53,439
1988 276,071 170,598 54,814
1989 258,030 159,002 50,441
1990 250,297 155,072 49,271
1991 264,817 162,019 53,292
Total 1,347,362 834,090 261,257
The data indicate: 1) 85% of all the persons killed in traffic accidents are >40 years old; 2) Prehospital mortality is 66% of the total; 3) 60% of traffic accidents are related to bicycle riders; 4) Owing to the improvement of prehospital first-aid and emergency facilities, the mortality rate and the number of wounded has decreased in recent years.
The Shanghai First-Aid Central Station (SFACS) owns 173 ambulances and employs 517 specialists. The new resuscitation ambulance, called "Movable ICU", is equipped with a cardiopulmonary monitor, ventilator, emergency drugs, and other resuscitative equipment. The ambulance also is equipped with an excellent communication system that can connect with any part of the communication network in Shanghai. A total of 110,889 persons who needed first-aid were transported by SPACS in 1991.The number of people wounded by traffic accidents and other events (such as burns, intoxication, drowning, etc.) was 26,681 with 318 persons found dead before hospitalization.
All severe trauma patients should be transported to the identified hospital in Shanghai. Every central hospital in Shanghai is setting up a Resuscitative Department to care for large numbers of critically wounded casualties. The function of Resuscitative Department is to sort out all of the critically wounded, resuscitate them, and render supportive treatment. Their functions include: 1) Cardiopulmonary resuscitation; 2) Immediate treatment of life-threatening respiratory failure, organ injuries, and the loss of blood; and 3) Initial management of fractures and injuries.
Keywords: accidents; ambulances; bicycles; cardiopulmonary resuscitation (CPR); China; deaths; equipment; hospitals; prehospital; resuscitation; Shanghai; traffic; trauma
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Vulnerability and Disaster Management in India
The Indian subcontinent has a highly diversified range of natural features. Its unique geo-climatic conditions make this region among the most vulnerable to natural disasters in the world. Disasters occur with amazing frequency and while the community at large has adapted itself to these regular occurrences, the economic and social costs continue to mount year after year. It is highly vulnerable to drought, floods, cyclones, earthquakes, landslides, volcanoes, etc. Almost all parts of India experience one or more of these events. This paper highlights the various disasters that are prevalent in India and their management.
With an increase in the perception towards spreading a culture of prevention in the disaster management scenario, considerable emphasis is being placed on research and development activities. In India, a number of Research Institutes are conducting active research in the field of disaster management. Valuable inputs in technical, social, economic as well as management areas of the field are being investigated. Research activities are being coordinated by different ministries depending on the type and level of research. An important role is played by the universities.
The National Centre for Disaster Management (NCDM) is the nodal agency for research, training, consultancy, and advocacy in the field of natural disasters in India. The NCDM has identified broad areas of research such as disaster preparedness, disaster mitigation, cost-benefit analysis of preparedness plans, environmental impact of floods, droughts, earthquakes, cyclones, and other disasters, and the behavioral aspects of disasters on the affected people. It is networking with various Central Government Ministries and concerned departments involved in disaster management as well as with various autonomous institutions. These activities are described in detail during this presentation.
Keywords: agencies; contingency; coordination;disasters; economics; India; mitigation; prevention; research; vulnerability
E-mail: alokncdm@usa.net
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Patterns of Psychosocial Coping and Adaptation Among Riverbank Erosion-Induced Displacees in Bangladesh: Implications for Development Programming
The primary purpose of this study was to identify psychosocial aspects of riverbank erosion-induced displacement in the flood plains of Bangladesh. Although considerable research has examined the social and economic impacts of such disasters in Bangladesh, there has been a general neglect of associated psychosocial implications. The specific objectives of the study were to: 1) assess hazard awareness in relation to riverbank erosion; 2) determine the magnitude of psychological distress associated with displacement; 3) examine patterns and predictors of economic and social adaptation among displacees; and 4) identify patterns of psychosocial coping and adaptation common to displaced and non-displaced poor in Bangladesh. The field survey for the study was conducted in Bangladesh during the 1998 flood season. Over 200 displacees living in urban squatter settlements in the district of Serajganj were sampled; a comparision group of 200 non-displacees was drawn from Shariakhandi district.
The results indicate that the constant threat of riverbank erosion has contributed to a substantial disaster subculture in the riverine zones of Bangladesh. Although frequent displacement was common among the floodplain residents, only 17% had perceived riverbank erosion to be a serious problem, and just 10% believed that they eventually would be displaced permanently. In most cases, displacees cope with erosion and land loss by relocating to nearby lands; the impacts of displacement become acute only when land scarcity forces displacees into urban areas, where they are both removed from their traditional rural way of life and marginalized both economically and politically.
Although displacees were found to have a significantly higher level of distress than did non-displacees, this was related primarily to socio-economic deprivation, rather than to displacement per se. The commonly hypothesized factors, such as loss of land and frequency and duration of displacement, were not found to have significant association with distress levels. Among both displacees and non-displacees, chronic survival concerns, daily hunger, and marginal living conditions were predictive factors of psychological distress. Vulnerability to economic strain and associated psychological distress was particularly high among women and the elderly.
The need to integrate disaster education and development projects within a social, cultural and psychological context is reviewed. The capacity of people to respond to environmental threats is a function not only of the physical forces that affect them, but of the way people see themselves in relation to these forces. It is important to recognize that Western conceptualizations of poverty do not always take into account social and psychological subtleties of coping and adaptation. Popular development theory usually associates low personal control with maladaptive passivity and dependency. In this study, however, displacees more often responded to their difficulties with active problem-solving efforts, with fatalism being among the least utilized forms of coping. It may be reasoned that low aspirations and self-efficacy generated by poverty may be psychologically adaptive, reducing levels of frustration and distress, but not determination and perseverance.
Rehabilitation programming may be most effective when it takes into account the psychosocial aspects of disasters, both because psychological distress impacts the capacity of people to achieve livelihoods, but also because important social and psychological processes determine the way people perceive and adapt to natural hazards. Research has shown that displacees in Bangladesh usually survive poverty and marginalization because of mutual kinfolk obligations of assistance. Rehabilitation programming in this context may have the most benefit when it assumes a socio-ecentric rather egocentric Western perspective, assisting communities to maintain and develop natural social coping mechanisms that enhance adaptive functioning and promote self-determination.
Keywords: adaptation; coping; displaced persons; erosion; floodplain; floods; vulnerability
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Analysis of Aged Patients Injured in Traffic Accidents: Counter-measures for a Senior-Laden Society
Objective: To analyze the features of aged patients injured in traffic accidents in Japan, and to propose the counter-measures for traffic accidents for a senior-laden society.
Methods: This study was designed prospectively between July and December 1999 by four tertiary emergency and critical care center in Kyusyu, Japan. The cardiopulmonary arrest patients and the patients who died in the emergency rooms were excluded. The records of 82 patients >20 years whose AIS were >3 were analyzed. Patients were categorized into 3 groups by age: A (>65 years); B (40-64 years); and C (20-39 years).
Results: l) Group A consists of 35 patients (male:female = l8:17); Group B = 26 (16:10); and Group C = 21 (16:5); 2) Many patients in Group A were pedestrians and motorcycle passengers, and those in Group B and Group C were injured while driving cars; 3)The majority of the injured in Group A had head injuries; 4) The values of ISS, AIS, and the Trauma score did not differ between the 3 groups. The values for the APACHE-II score in Group A were significantly higher than for Group B and Group C; 5) All of the severity scores were adequate to evaluate the outcomes of the 3 groups; 6) Seven patients in Group A, six in Group B, and one in Group C were died; 7) The main cause of death in Group A was brain injury, and in Group B and Group C was hemorrhagic shock.
Keywords: accident; aged patients; bicycle; cycles; head injuries; outcome; pedestrians; seniors; shock; traffic; trauma
E-mail: deptccm@med. Kurume-u.ac.jp
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Measuring Disasters for Risk Control
To speak about a disaster, and more than that, to prevent, mitigate, and control it, is not correct from a professional point of view without the knowledge of how to measure it. Therefore, in 1990-1992, the Scale of Disaster Magnitude (DIMAK) was proposed and developed. A brief description of the DIMAK scale was distributed among the participants of IDNDR Conference (Yokohama, May, 1994), and the scale was tested and improved during subsequent 5 years. Operating with the adopted basic units - "one fate" and "one loss", a logarithmic field of disasters (or plane of social and economic losses) is described. Any point of the "disaster field" is presented as a vector with a length, magnitude (Md) (characterising the degree of disaster from 0 to 5), and tangent of angle - p (relative social vulnerability index). DIMAK scale estimates (Md, p) of some recent earthquake disasters are given and analysed. The DIMAK scale provides for additional characteristics of the disaster: index of economic stability of different countries to disaster; relative score of disaster-din, etc. Thus, the DIMAK scale allows the estimation of a predicated disaster, and in turn, to decide questions about its acceptability and preventive measures on seismic risk reduction.
These questions are solved worldwide, as a rule, on the basis of a cost-benefit analysis. Such a purely economic approach is satisfactory to explain acceptable risk criteria from the point of view of private proprietors or bank-investors. However, a state has other more socially acceptable risk criteria, which are not determined only by a cost-benefit analysis. The DIMAK Scale satisfies governmental needs to measure various (both economic and social) consequences of any disaster. It helps to provide the control of disaster risk for which we stand up as for obligatory condition in the policy of sustainable development of any seismic-prone urbanisation.
Keywords: consequences; disaster; measurement; mitigation; scale
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The Effects of the Taiwan Earthquake on the Urban Emergency Health Care System
Introduction: The Taiwan earthquake measuring 7.3 on the Richter scale, struck Taipei, the capital city of Taiwan, 200 kilometers from the epicenter at 01:47 hours on 21 September, 1999. Taipei sustained only one collapsed building (12-story), but had the highest death toll among all collapsed structures in the quake.
Methods: To characterize the responsiveness of the rescue and prehospital EMS system and the hospital Emergency Departments in Taipei city, we retrieved and reviewed EMS runsheets and hospital records of all 214 injured persons from the collapsed building, to determine the utilization of our urban emergency care services and the epidemiology of the injuries.
Results: 76 victims were found dead upon extrication, the majority extricated more than 6 hours after the earthquake. 74% (102/138) of the 138 survived patients were transported by ambulance, among those only 65% (66/102) had prehospital records, and 61% (40/66) of these records were incomplete. 86% of the patients extricated alive arrived at hospitals within 3 hours after the quake. 18% of Emergency Department records did not contain the triage level and initial vital signs. Trauma and inhalation accounted for 89% and 27% of all patients. The leading injuries included lacerations (65%), contussion/abrasion (53%), and head injuries (35%). Fractures and burn constituted >5% of the injuries. 31% of the patients were admitted and only 2% patients needed intensive care. Two patients died in the hospital.
Conclusion: EMS records and Emergency Department triage were under-utilized during the disaster. Most patients sustained mild injuries and freed themselves. The small rescue team Taiwan possesses is incapable of dealing with victims buried under collapsed structures. Most patients extricated later than 6 hours after the earthquake were dead. Further improvement of the EMS system and implementation of heavy search and rescue capabilities is needed.
Keywords: collapsed structure; confined space medicine; earthquake; emergency care, epidemiology; injuries; rescue; search; urban
E-mail: timentin@ms8.hinet.net
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The "1. Schnelleinsatzgruppe (SEG) Sanität Erlangen Stadt, Bavarian Red Cross, Germany" as an Example for Modern Disaster Planning
Matthias Langhans; Hermann Schönstein
The "Schnelleinsatzgruppe, SEG" (fast operation group) is a modern form for disaster planning. Small groups that are ready for action in a few minutes, are flexible and are not only brought into action in case of disaster, but also to support the regular rescue service in periods when it is sparsely filled. In case of disaster, the different groups co-operate.
The organization, financing, and personnel structure are quite different for the various groups. A typical example is to be portrayed.
The "1. Schnelleinsatzgruppe Sanität Erlangen Stadt" is organized completely using an honorary capacity. Personnel structure and organization financing, equipment, and fleet, alert, and range of action will be presented.
Keywords: Bavarian; disaster; Red Cross; response; Schnelleinsatzgruppe Sanität Erlangen Stadt
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Ocular Emergencies in Disasters
When large groups of people are in fires, explosions, earthquakes, or wars, there can occur many ocular injuries. These can be contaminated, sterile, or chemical. The patients may not be aware of the injury or may be unconscious. Treatment begins in the field with sterile, non-pressure dressings, incident labeling, and early evacuation. Charting starts at triage with careful attention to patient identification for tracking and pictorial descriptions. Every person should be checked quickly for trauma.
Surgical care is easier with portable microscopes as eye care can follow neurosurgical or orthopedic procedures in the same room and with the same anesthetic. Roving ophthalmic follow-up assures continuity despite other treatments requiring that the patient be moved all around the hospital.
Keywords: eye; injuries; ophthalmology; surgery; trauma
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Taiwan's Problems of Disaster Management from the Viewpoint of a 500-bed Hospital Hit Hard by an Earthquake
A devastating earthquake measured 7.6 (Richter scale) struck Central Taiwan on 21 September 1999, and was responsible for mass casualties. The official data indicated that there were more than 2,400 fatalities, 10,000 injuries, and a cost of US$10 billion. A total of 468 health-care-providing units reported to absorb the various degrees of building damage of which 87 suffered collapse; 115 major damage, and the remaining, minor damage. Our 500-bed hospital was one of the few big hospitals severely damaged by the earthquake. We report our experience at managing and operating in a rather chaotic disaster situation.
A recent opinion poll indicated that >50% of the residents from the impact areas were dissatisfied with government's response to the disaster. So in order to analyze the problems associated with the relief efforts and to determine the societal impacts, we also investigated the existing literature, journalistic accounts, and official documents concerning the earthquake.
We expect relief efforts by local citizens and relevant county and city governments as well as national agencies will be improved and better coordinated with time and improved technology. Taiwan still is rebuilding following this deadly earthquake. At this time, a refined protocol and a nationwide disaster plan are being developed.
Keywords: collapse, building; disaster; earthquake; hospitals; opinion, public; relief
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Medical Aspects of the Civil Protection in Mexico City
Mexico City is settled in an area of 1,600 km2. It has a population of 7,818,383 inhabitants. Also, it is the headquarters of the governmental institutions for Mexico. On the other hand, it is the economical and financial heart of the nation.
From a civilian protection point of view, major cities have been conceptualized as human settlements that in a susceptible progressive way, can be overtaken by its regulatory systems. Because of its population number, distribution area; vital and strategic systems demand centralization of the political, economical and administrative authorities, etc. Mexico City adjusted clearly to this point of view, since the federal government headquarters are located in it and it is considered the economical and financial heart of the nation.
a) The age group 14-44 years old represents 53.2% of total population; followed by 5-14 years old (18.4%), and 45-64 years old group (13.8%). Most of the Social Security (Medic Aid) is provided by the state. This is related to the high costs of private insurance. 53.7% of the population receive some medical aid, and the rest do not have this benefit. In relation to the capacity to respond to massive numbers of ill and/or injured patients, Mexico City has different level hospitals that belong to a different medical aid or programs at the national level. The most important are those contained in IMSS and ISSSTE for workers only; and open population service of the local and federal Health Ministry.
b) The epidemiological transition derived from poverty through those typically found in industrialized countries has not been limited; other sufferings such as respiratory and gastrointestinal infections continue to be important morbidity factors. Related to the vigilance of the epidemiological and environment sanitation, international experience show that it only will be possible to have a good epidemiological, post-disaster control, when an efficient system has been established for routine situations. In this way, Mexico owns a National System for Epidemiological Surveillance that has demonstrated effectiveness. In the recent past, rains, which occurred in different states in the Center and South of the Country, left >256,000 persons homeless, but there were no signs of any epidemic. Of the 3,544 hospitals in Mexico City, none have achieved the certification given by the OMS in the Secure Hospital Program. No medical or nursing schools (except the military) teaches disaster prevention and intervention. Finally, activities for management and disaster control such as prehospital services virtually are unknown. Routinely, 502 patients are attended every hour in the Emergency Rooms in the Mexico City hospitals. To date, the Civil Protection General Direction coordinate with the local Health Ministry of Mexico City proposed the creation of a State Emergency System that contains operational, legal, and academic matters.
c) Needs
Operational - 1) Creation of a unique emergency operations center; 2) Medical and prehospital services regionalization; and 3) Logistic and administrative support to prehospital.
Legal - Law enforcement to regulate emergency medical services in Mexico City.
Academic - The creation of map that shows alternative academics in medical emergency and catastrophe medicine and civil protection.
Related to coordination among the different emergency services, the Medical Direction of the Civilian Protection General Direction has proposed in many forums, adaptation of the U.S. Incident Command System. This model has been designed to improve the responses to all kind of emergencies. We believe that the establishment of this model will allow us versatility to attend to different magnitude emergencies and variability of resources. In addition, it is compatible with more specific systems. Finally, the Civilian Protection General Direction must break through the paradigm of isolated emergency care in order to emphasize a culture of prevention through: 1) developing excellent systems for providing routine care; 2) clearing politics and procedures for routine situations; and 3) changing the capacity for routine care. We are convinced that disasters aren't natural; they are the result of natural phenomena presented over vulnerable human settlements (population), and that vulnerability can be reduced. Also, bi-directional relations, in a way that enhances the capacity of a population to respond to a disaster, will be more efficient in routine situations. And, the more efficient routine situations are managed, the less will be the impact of disasters. We understand that Medicine from Civilian Protection point of view is the science, art, and techniques to preserve humanity and to avoid the individual and social hosts.
Keywords: disaster; emergency; incident command system; development; medical care; Mexico City
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Hospital Drills: Preparations for Mass Toxicological Event (MTE) - The Israeli Experience (1997-1999)
An accidental or deliberate mass toxicological event will present an utmost challenge to the medical community. Israel Defense Force's Home Front Command assists the Ministry of Health in preparing hospitals to cope with the event. An intensive planning, instruction, and equipping process terminates with a large-scale hospital drill.
The Hospital MTE deployment scheme is outlined, areas of responsibilities, materials and methods, and inspection methods and issues are discussed. Twenty-two MTE drills took place in 20 hospitals since November 1997; half of them were not anticipated. The number of simulated casualties ranged from 5-200.
The main lessons gained concerning medical organization and quality of care included: 1) deficient relevant information disclosure to staff; 2) inefficient utilization of the decontamination facility; 3) inadequate respiratory care during patient transportation; and 4) disregard for the synergistic effects of combined injuries. Control and coordination were limited by: 1) personal protective equipment; 2) a lack of real-time assessment of the burden levels throughout admission and treatment sites; 3) difficulties maintaining law and order within hospital sites; 4) inadequate medical charting; 5) failure to maintain patient privacy; and 6) insufficient collaboration with first-responders. Most of these lessons were implemented in the subsequent drills, which became more sophisticated and realistic. Drills succeeded in building the confidence and collective memory among hospital staff and management, as well as implementing simple and feasible guidelines concerning incident diagnosis and management. Some future exercise plans are discussed.
Keywords: control and coordination; drills; exercises; hospitals; management; mass toxicological events (MTE); terrorism
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"Packing" of the Thoracic Cavity - A Technique to Treat Uncontrollable Intrathoracic Bleeding
Polytraumatized patients often suffer from additional serious thoracic injuries. Experience during the Vietnam War have demonstrated that ruptures of the liver, mainly caused by gunshots, could have been treated successfully by "packing" the injury. Until the definitive operative intervention can be accomplished, the liver is compressed by " towels" to prevent exsanguination.
Given these findings, we tried this technique in desperate cases of uncontrollable intrathoracic hemorrhage. This massive hemorrhage was the result of severe thoracic trauma in three cases, and in one case, the result of an injury caused by a failed transthoracic puncture. After "packing" the thoracic cavity, the "towels" were removed three days later. In the meantime, the circulation and coagulation ( DIC ) had been stabilizized, and PEEP-ventilation was practiced without problems. Three of the four patients survived without further complications; one died after 10 days, from a neurosurgical problem.
Conclusions: In desperate cases of severe, uncontrollable bleeding, this technique could be done by general surgeon in order to gain time for a transport to an unit with a thoracic surgeon. Therefore, we regard our method as a new useful way to treat massive hemorrhage within the thorax, when other treatment fails, no specialist is near by, or when there is a large number of patients with thoracic injuries during catastrophes.
Keywords: hemorrhage; intrathoracic bleeding; packing; trauma
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S.O.S: Prepared for the Emergency?
Introduction: This experience indicates that discoveries in medical science and psychology applied to training, especially of volunteers, helps to alleviate the effects of stress in an emergency with an objective of preventing disasters, especially as applied to managing human resources.
Objectives: Qualify persons to react in psychosocial crisis that are produced in an emergency or disaster, and to understand the extent of the psychological and multiple organic stresses on persons affected. It also sought to prepare the professionals of emergency brigades and their helpers, and to inform and motivate the population in general, to obtain an answer in cases of emergencies. It involved the training of qualified volunteers of governmental and non governmental institutions (schools, airline companies, foundations, etc.).
Methods: Thc people in charge of qualifying and some people that are qualified developed some projects in this field: 1) the control of clinical parameters has been done in a group of works that have been dedicated to medical emergencies. The daily evaluation of blood pressure and heart rate showed an increase in relation to the amount of time that has passed and the level of responsibility; 2) organization in a local emergency for floods with 39 centers for the victims of this phenomenon. Three mobile medical attention centers have been developed and used in an emergency that occurred in a city of 650,000 inhabitants, with 5,500 people located in risk zones, who had to leave their houses; and 3) The experiences of patients and medical personnel in surgical and intensive care areas were obtained.
Conclusions: 1) There is a correlation between the level of knowledge and training and the alterations in the clinical parameters observed. The emotional training in these situations, improves professional efficiency; 2) It is necessary for human and technical resources to be prepared before emergencies and disasters occur in order for them to be effective after the events; 3) This leads to the concept that natural phenomena (tornadoes, floods, etc.) are not disasters in themselves; rather, the events become disasters if people do not know how to manage them; 4) Therefore, it is of vital importance that the community, government, and non-governmental agencies coordinate their efforts; 5) There is a need to make agencies that take part in the rescue work and the general population be made aware of psychosocial support and the importance of disaster drills so that they know the steps to take in an emergency; and 6) We succeeded in justifying the need for a training programme on psychosocial support.
Keywords: disasters; drills; emergencies; events; preparedness; psychosocial; rescue; support; volunteers
E-mail: Jlicuri@intramed.net or Mari saenez@hotmail.com
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Cost-Benefit of Point-of-Care Blood Gas Analysis
Introduction: Point-of-care testing allows laboratory tests to be independent of hospital-based resources and power. We studied whether the iSTAT Portable Clinical Analyzer was cost-effective in managing ventilated pediatric patients prior to inter-hospital transport.
Methods: Data were collected prospectively: 1) when blood gas analysis was requested; 2) the need to call-in technicians; and 3) waiting times for results. Cost-efficacy calculations were based on: 1) 3 minutes to obtain a result using the iSTAT (unit cost $CDN8,000); 2) lab technician call-back; paramedic overtime; and 3) cost of charter aircraft wait time.
Results: Among 46 patients, blood gases were required on 35. Technicians were called-in for 17 (49%). Time waiting to obtain laboratory gases was 526 minutes compared with a calculated 105 minutes using point-of-care testing. Cost-saving on technician call-back ($1,530), paramedic overtime ($690), and aircraft time waiting charges ($2,000) totaled $4,220. Cost of point-of-care equipment could have been recouped in 101 patients if aircraft charges applied or 192 patients if no aircraft costs were included. In 11 cases, ventilator adjustments were made during transport, and in 6 patients, point-of-care testing would have been used to optimize transport care.
Conclusion: The present study indicates that this technology is cost-effective and can reduce stabilization times. The technology would be ideal for medical management during disasters.
Keywords: analysis; blood gases; cost; efficacy; point-of-care; savings; transport; ventilation (assisted)
E-mail: amacnab@cw.bc.ca
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Early Report on Emergency Sternal Intraosseous Infusion in Adults
Purpose: Intraosseous (IO) infusion into the adult sternum is possible with the F.A.S.T.1™ Intraosseous Infusion System (Pyng Medical Corp., Vancouver British Columbia, Canada). We are evaluating success rates, insertion times, and complications.
Method: Six emergency departments and 5 prehospital sites in Canada/US provided data on the use of the IO system. Indications included: 1) age ³18 years; 2) urgent fluid or medication need; and 3) unacceptable delay or inability to achieve standard vascular access.
Results: Success rate overall was 84%, 74%, and 95% respectively for first-time and experienced users. Of 8 insertion failures, 5 were for patients described subjectively as "very obese", 1 had had 3 previous sternotomies, and 2 had failure to penetrate the bone. Mean time-to-vascular access overall was 83, 91, and 72 seconds respectively for first-time and experienced users. Flow rates up to 80 ml/minute were reported for gravity drip, and 150 ml/minute by bolus. No complications or complaints were reported at 2 month follow-up (n = 11). Conscious patients who had IO insertion using a lidocaine protocol (n = 11) reported little or no pain during the insertion.
Conclusions: These early data indicate that sternal IO infusion using the new F.A.S.T.1 IC System provides rapid, safe, and effective vascular access, and is a useful technique to reduce unacceptable delays in the provision of emergency treatment.
Keywords: access, vascular; complications; insertion times; intraosseous infusion; fluid administration; new technology; sternum
E-mail: amacnab@cw.bc.ca
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What We Have Learned from a Disaster Drill : A Questionnaire Study for Simulated Victims and Hospital Personnel
A disaster drill was performed at the Osaka City General Hospital (OCGH) in March, 1999. The scenario was a "train crash" at the station near OCGH, where 30 student nurses were made up as victims. After the completion of the drill, a questionnaire regarding triage, routing instructions, informed consent, and mental care for the patients was done for both the simulated patients and the OCGH personnel.
Judging from the results of this questionnaire, a lack of mental care for the victims and their families predominated, albeit in a situation of a massive influx of mock patients.
We have to put this awareness to use in daily hospital activities, since the mental care support system has not been developed completely in Japanese hospitals.
Keywords: disaster drill; exercise; mental care; questionnaire; simulated victims; support system
E-mail: kazumat@msic.med.osaka-cu.ac.jp
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