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PubMedDate not supplied

The spectrum of human reactions to terrorist attacks with weapons of mass destruction: early management considerations.

Residents of a community who are intentionally exposed to a hazardous biological, chemical, or radiological agent (including medical first-responders and other civil defense personnel who live in that community) will exhibit a spectrum of psychological reactions that will impact the management of the incident. These reactions will range from a variety of behaviors of normal people under abnormal circumstances that either will help or hinder efforts to contain the threatening agent, deliver medical care, and reduce the morbidity, mortality, and costs associated with the disaster, to the development of new, or exacerbation of preexisting, mental disorders. Anticipating the decisions that people will make and actions they will take as the crisis develops is hindered by the limited number of previous disasters that bear crucial similarities to a terrorist attack with a weapon of mass destruction. Such actions, therefore, could serve as models to predict community reactions. One result of a study that attempted to fill in these gaps suggested that medical first-responders and their spouses/significant others may require separately crafted information and advice to reduce the potential for disharmony within the family that could affect job performance during the crisis. For those persons who exhibit emotional lability or cognitive deficits, evaluation of their psychiatric signs and symptoms may be more difficult than imagined, especially with exposure to nerve agents. Appreciation of these difficulties, and possession of the skill to sort through them, will be required of those assigned to triage stations. The allocation and utilization of mental health resources as the incident unfolds will be the responsibility of local consequence managers; these managers should be aware of the results of a recently-held workshop that attempted to reach consensus among experts in disaster mental health, based on the peer-reviewed literature, on the efficacy and safety of various approaches to early psychological interventions for victims of mass trauma and disasters. Thus, psychological factors are likely to be significant in the management of a terrorist incident that involves an agent of mass destruction. Emergency medical workers with managerial responsibilities, whether limited in scope or community-wide, should be aware of these factors, and should train to handle them through effective risk communication as part of their planning and preparation.

Humans↗
PubMed1992

Toxicologic findings in the USS Iowa disaster.

The toxicologic results from the 47 victims of the explosion on the USS Iowa are presented. Good correlation between carboxyhemoglobin saturations and cause of death was found. There were no correlations between blood cyanide concentrations and causes of death. Volatile analysis suggested postmortem ethanol production rather than antemortem ethanol ingestion. No drugs except nicotine were detected in any of the victims.

Carbon Monoxide↗
PubMedDate not supplied

Hospital responses to acute-onset disasters: a review.

INTRODUCTION: Hospitals the world over have been involved in disasters, both internal and external. These two types of disasters are independent, but not mutually exclusive. Internal disasters are isolated to the hospital and occur more frequently than do external disasters. External disasters affect the community as well as the hospital. This paper first focuses on common problems encountered during acute-onset disasters, with regards to hospital operations and caring for victims. Specific injury patterns commonly seen during natural disasters are reviewed. Second, lessons learned from these common problems and their application to hospital disaster plans are reviewed. METHODS: An extensive review of the available literature was conducted using the computerized databases Medline and Healthstar from 1977 through March 1999. Articles were selected if they contained information pertaining to a hospital response to a disaster situation or data on specific disaster injury patterns. Selected articles were read, abstracted, analyzed, and compiled. RESULTS: Hospitals continually have difficulties and failures in several major areas of operation during a disaster. Common problem areas identified include communication and power failures, water shortage and contamination, physical damage, hazardous material exposure, unorganized evacuations, and resource allocation shortages. CONCLUSIONS: Lessons learned from past disaster-related operational failures are compiled and reviewed. The importance and types of disaster planning are reviewed.

Disaster Planning↗
PubMed2003

The Kaprun cable car fire disaster--aspects of forensic organisation following a mass fatality with 155 victims.

In November 2000, a tunnel-bound cable car in Kaprun caught fire, with the subsequent death of 155 persons. No passenger list was in existence and bodies were burnt to such an extent that morphological identification was not feasible. A full post-mortem examination was performed on all bodies. All bodies were positively identified within 19 days after the incident by DNA analysis. Cause of death was determined to be carbon monoxide poisoning in combination with suffocation due to inhalation of smoke. The organisational aspects of processing are portrayed.

Adolescent↗
PubMed1989

Disaster psychiatry and traumatic stress studies in Norway. History, current status and future.

The breakthrough of Norwegian disaster psychiatry and traumatic stress studies came when the "Board of Norwegian Doctors of 1957" carried out exceptionally thorough and comprehensive studies of former concentration camp prisoners. These studies convincingly demonstrated that chronic mental illnesses could develop in persons who had a harmonious childhood but who had been subject to extreme physical and psychological stress. During the seventies Norway became the first country in the world to have a University chair of disaster psychiatry. The scope of the field was broadened by the initiation of several studies on traumatic neurosis, industrial disaster and injuries. The support from the Joint Norwegian Armed Forces Medical Services, the University of Oslo, the Norwegian Research Council for Science and the Humanities, and later the Royal Norwegian Council for Scientific and Technical Research, was crucial for this development. Currently stress and disaster psychiatry has become an integrated part of the care of victims who have suffered individual or collective disaster. Disaster psychiatry is taught in medical schools and is part of the obligatory training for residents in psychiatry.

Adaptation, Psychological↗
PubMed2002

Renal replacement therapies in the aftermath of the catastrophic Marmara earthquake.

BACKGROUND: Renal replacement therapy is of vital importance in the treatment of crush syndrome victims, who are frequently encountered after catastrophic earthquakes. The Marmara earthquake, which struck Northwestern Turkey in August 1999, was characterized by 477 victims who needed dialysis. METHOD: Within the first week of the disaster, questionnaires containing 63 clinical and laboratory variables were sent to 35 reference hospitals that treated the victims. Information considering the features of dialyses obtained through these questionnaires was submitted to analysis. RESULTS: Overall, 639 casualties with renal complications were registered, 477 of whom (mean age 32.3 +/- 13.7 years, 269 male) needed dialysis. Among these, 452 were treated by a single dialysis modality (437 intermittent hemodialysis, 11 continuous renal replacement therapy and 4 peritoneal dialysis), while 25 victims needed more than one type of dialysis. In total, 5137 hemodialysis sessions were performed (mean 11.1 +/- 8.0 sessions per patient) and mean duration of hemodialysis support was 13.4 +/- 9.0 days; this duration was shorter in the non-survivors (7.0 +/- 8.7 vs. 10.0 +/- 9.8 days, P = 0.005). Thirty-four victims who underwent continuous renal replacement therapy had higher mortality rates (41.2 vs. 13.7%, P < 0.0001). Only eight victims were treated by peritoneal dialysis, four of whom also required hemodialysis or continuous renal replacement therapy. The mortality rate in the dialyzed victims was 17.2%, a significantly higher figure compared to the mortality rate of the non-dialyzed patients with renal problems (9.3%; P = 0.015). CONCLUSION: Substantial amounts of dialysis support may be necessary for treating the victims of mass disasters complicated with crush syndrome. Dialyzed patients are characterized by higher rates of morbidity and mortality.

Acute Kidney Injury↗
PubMed1988

Terrorist bombings. Lessons learned from Belfast to Beirut.

Experience in the management of mass casualties following a disaster is relatively sparse. The terrorist bombing serves as a timely and effective model for the analysis of patterns of injury and mortality and the determination of the factors influencing casualty survival in the wake of certain forms of disaster. For this purpose, a review of the published experience with terrorist bombings was carried out, providing a study population of 3357 casualties from 220 incidents worldwide. There were 2934 immediate survivors of these incidents (87%), of whom 881 (30%) were hospitalized. Forty deaths ultimately occurred among these survivors (1.4%), 39 of whom were among those hospitalized (4.4%). Injury severity was determined from available data for 1339 surviving casualties, 251 of whom were critically injured (18.7%). Of this population evaluable for injury severity, there were 31 late deaths, all of which occurred among those critically injured, accounting for an overall "critical mortality" rate of 12.4%. Overall triage efficiency was characterized by a mean overtriage rate (noncritically injured among those hospitalized or evacuated) of 59%, and a mean undertriage rate (critically injured among those not hospitalized or evacuated) of .05%. Multiple linear regression analysis of all major bombing incidents demonstrated a direct linear relationship between overtriage and critical mortality (r2 = .845), and an inversely proportional relationship between triage discrimination and critical mortality (r2 = 0.855). Although head injuries predominated in both immediate (71%) and late (52%) fatalities, injury to the abdomen carried the highest specific mortality rate (19%) of any single body system injury among immediate survivors. These data clearly document the importance of accurate triage as a survival determinant for critically injured casualties of these disasters. Furthermore, the data suggest that explosive force, time interval from injury to treatment, and anatomic site of injury are all factors that correlated with the ultimate outcome of terrorist bombing victims. Critical analysis of past disasters should allow for sufficient preparation so as to minimize casualty mortality in the future.

Abdominal Injuries↗
PubMed2003

The gander disaster: dental identification in a military tragedy.

The authors record the contributions of dentistry to the identification of victims of one of the most significant disasters in aviation and U.S. military history--the December 1985 crash of a DC-8 charter airliner near Gander, Newfoundland (now known as Newfoundland and Labrador), Canada, which killed 248 Army personnel and 8 crewmembers. Most of the dental records of the military victims were destroyed in the crash, and, as a result, this loss hampered dental identification. Nevertheless, dental identification was the primary means of identification for many because a very high percentage of the bodies were severely burned and fragmented. Many phases of the U.S. identification efforts have been reported, but the dental-investigation aspects have been mentioned only in passing. Therefore, this article documents the dental team's organization, methodology, and a variety of remarkable problems that the team encountered.

Accidents, Aviation↗
PubMedDate not supplied

Disaster triage: START, then SAVE--a new method of dynamic triage for victims of a catastrophic earthquake.

Triage of mass casualties in situations in which patients must remain on-scene for prolonged periods of time, such as after a catastrophic earthquake, differs from traditional triage. Often there are multiple scenes (sectors), and the infrastructure is damaged. Available medical resources are limited, and the time to definitive care is uncertain. Early evacuation is not possible, and local initial responders cannot expect significant outside assistance for at least 49-72 hours. Current triage systems are based either on a shorter time to definitive care or on a longer time to initial triage. The Medical Disaster Response (MDR) project deals with the scenario in which specially trained, local health-care providers evaluate patients immediately after the event, but cannot evacuate patients to definitive care. For this type of scenario, a dynamic triage methodology was developed that permits the triage process to evolve over hours or even days, thereby maximizing patient survival and resulting in a more efficient use of resources. This MDR system incorporates a modified version of "Simple Triage and Rapid Treatment" (START) that substitutes radial pulse for capillary refill, coupled with a system of secondary triage termed, "Secondary Assessment of Victim Endpoint" (SAVE). The SAVE triage was developed to direct limited resources to the subgroup of patients expected to benefit most from their use. The SAVE assesses survivability of patients with various injuries and, on the basis of trauma statistics, uses this information to describe the relationship between expected benefits and resources consumed. Because early transport to an intact medical system is unavailable, this information guides treatment priorities in the field to a level beyond the scope of the START methodology. Pre-existing disease and age are factored into the triage decisions. An elderly patient with burns to 70% of body surface area is unsalvageable under austere field conditions and would require the use of significant medical resources-both personnel and equipment-and would be triaged to an "expectant area." Conversely, a young adult with a Glasgow Coma Scale score of 12 who requires only airway maintenance would use few resources and would have a reasonable chance for survival with the interventions available in the field, and would be triaged to a "treatment" area. The START and SAVE triage techniques are used in situations in which triage is dynamic, occurs over many hours to days, and only limited, austere, field, advanced life support equipment is readily available. The MDR-SAVE methodology is the first systematic attempt to use triage as a tool to maximize patient benefit in the immediate aftermath of a catastrophic disaster.

Abdominal Injuries↗
PubMed2006

A myth too tough to die: the dead of disasters cause epidemics of disease.

Myths abound in the practice of health care, death, and disease. Akin to the old adage of swallowing camels and straining gnats, the myth that mass fatalities cause epidemics of disease following natural or other disasters is alive and well. Despite the findings of observers, microbiologists, epidemiologists, and other scientists, even medical doctors and public health professionals lend support to the ancient belief and rush into mass graves or mass cremations the bodies of those victims of trauma in a disaster. Putting this myth to rest depends on use of information concerning the transmission of the organisms that cause disease, the sources of those organisms, and the hosts or suspected hosts that will be receptive to those organisms to result in disease. The information provided by recent investigators of disasters in the region of the Americas and comments from those who have reviewed the literature on the subject of the myth concerning the dead and epidemics following disasters have provided the basis for some concise guidelines for placing this myth in the archives of other traditions without foundation. Education of the public and the news media are the responsibility of those who are aware of the fallacies in this belief to bring about the demise of this myth.

Cadaver↗
PubMed1994

The continuity principle: a unified approach to disaster and trauma.

The continuity principle stipulates that through all stages of disaster, management and treatment should aim at preserving and restoring functional, historical, and interpersonal continuities, at the individual, family, organization, and community levels. Two misconceptions work against this principle and lead to decisional errors: the "abnormalcy bias" which results in underestimating victims' ability to cope with disaster, and the "normalcy bias" which results in underestimating the probability or extent of expected disruption. This article clarifies these biases and details the potential contributions of the continuity principle at the different stages of the disaster.

Adaptation, Psychological↗
PubMed2003

Different medical needs between hurricane and flood victims.

OBJECTIVE: Through the review of patient records seen by the New Mexico-1 Disaster Medical Assistance Team (NM-1DMAT) after various disasters, we hoped to find patterns that might help in disaster planning. Our hypothesis was that flood and hurricane victims have different medical conditions and needs. METHODS: We conducted a retrospective review of patient records for NM-1DMAT deployments to Hurricane Andrew in Florida (August 1992) and the Houston, TX flood caused by Tropical Storm Allison (June 2001). We compared age, gender, chief complaint, medical history, diagnosis, diagnostic testing, treatment rendered, triage category, and patient disposition. RESULTS: We found several differences between the patients presenting after Hurricane Andrew and those presenting after Tropical Storm Allison. The chief complaint, diagnosis, presence of medical history, diagnostic testing, treatment rendered, triage category, and disposition all differed between the 2 disasters. The mean ages in both groups were similar. CONCLUSIONS: The needs of the patients differed in several areas between Hurricane Andrew and the Houston flood. This information should be tested in a future hurricane or flood and taken into account when planning for deployments.

Adult↗
PubMed1995

Psychological first-aid: a practical aide-memoire.

Despite advances made in recent years in medical first aid, psychiatric intervention, survival training and equipment design, many people still perish quickly during and immediately following a disastrous event. In this study, individuals and groups of survivors of life-threatening events were debriefed and the behavior of those who coped well during such a threat to life were compared with those who did not. The behaviors of those who coped well were distilled into a set of principles for psychological first aid; that is, a series of simple actions for use within a disaster which serves to recover victims to functional behavior as quickly as possible, thus increasing their chance for survival. These principles of psychological first aid have recently been introduced into basic first aid and survival training courses for both military and civilian units.

Adaptation, Psychological↗