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Emergency medical services for treatment of mass casualties.

The French emergency medical system (EMS) is the Service d'Aide Médicale Urgente (SAMU). In case of mass casualties, involving 100 simultaneous victims, SAMU has developed a disaster plan, "The White Plan." This plan is closely correlated to the Red Plan of the Fire Department, to provide advanced life support (ALS) at the incident site, followed in a continuum by medical transport and hospitalization in the appropriate services. To obtain the best chance of survival and recovery, there must be optimal coordination among all rescuers. This objective was approached by adopting a formal protocol designed for each city. In France, the medical organization for the treatment of casualties is operated by anesthesiologists who are qualified to perform ALS, preanesthetic evaluation en route, anesthesia for the multitrauma patient, and postanesthetic resuscitation in a continuum from the accident scene to the ICU.

Disaster Planning↗

Increased coronary heart disease mortality after the Hanshin-Awaji earthquake among the older community on Awaji Island. Tsuna Medical Association.

OBJECTIVES: To investigate the characteristics of earthquake (EQ)-induced coronary heart disease (CHD) deaths. SETTING AND PARTICIPANTS: On January 17, 1995, the south part of Hyogo Prefecture in Japan was struck by a major EQ (Hanshin-Awaji EQ) measuring 7.2 on the Richter scale. We investigated the characteristics of EQ-induced CHD deaths (myocardial infarction and sudden death) in the Tsuna region, which is a community with a large older population (31% of the total of 64,000 residents are 60 years of age or older) and includes the epicenter and one of the most heavily damaged areas. MEASUREMENTS: EQ-related CHD mortality on the basis of direct access to records of physicians who were able to continue services for the EQ victims without interruption by this disaster situation. RESULTS: Coronary heart disease deaths increased for a few months after the EQ, and the total number from January 17 to April 30, 1995, was 45, which was significantly (1.5 times) higher than the 31 deaths during the same period of the previous year (1994). The CHD deaths after the EQ all occurred in individuals more than 60 years of age and had a positive correlation with EQ-induced damages. Concerning the onset time, CHD deaths occurred 1.8 times more often (P < .05) in the nighttime (11 PM to 5 AM) and 1.4 times as often during the morning (5 AM to 11 AM), whereas their occurrence did not vary during a 12-hour period from 11 AM to 11 PM. CONCLUSION: Deaths of older individuals from CHD persisted for a few months after the EQ and were especially prominent during the nighttime and morning. Reduction of stress and related coronary risk factors in this period may suppress CHD deaths after a major EQ.

Aged↗

Post-traumatic stress disorder, depression and generalised anxiety disorder in adolescents after a natural disaster: a study of comorbidity.

BACKGROUND: Information on mental health sequel in adolescents following natural disasters from developing countries is scant. METHOD: Around one year after a super-cyclone, proportion of adolescents exhibiting post-traumatic psychiatric symptoms, prevalence of post-traumatic stress disorder (PTSD), major depression and generalized anxiety disorder, comorbidity and impairment of performance in school were studied in Orissa, India. Mini International Neuropsychiatric Interview for children and adolescents was used for evaluation and diagnosis. The criteria for diagnoses were based on Diagnostic and Statistical Manual of Mental Disorders-IV. RESULTS: Post-disaster psychiatric presentation in adolescents was a conglomeration of PTSD, depression and anxiety symptoms. The prevalences of PTSD, major depressive disorder and generalised anxiety disorder were 26.9%, 17.6% and 12.0% respectively. Proportion of adolescents with any diagnosis was 37.9%. Comorbidity was found in 39.0% of adolescents with a psychiatric diagnosis. Adolescents from middle socioeconomic status were more affected. There were gender differences in the presentation of the symptoms rather than on the prevalence of diagnoses. Prolonged periods of helplessness and lack of adequate post-disaster psychological support were perceived as probable influencing factors, as well as the severity of the disaster. CONCLUSION: The findings of the study highlight the continuing need for identification and intervention for post-disaster psychiatric morbidities in adolescent victims in developing countries.

Journal Article↗

The use of cadaver dogs in locating scattered, scavenged human remains: preliminary field test results.

Specially trained air scent detection canines (Canis familiaris) are commonly used by law enforcement to detect narcotics, explosives or contraband, and by fire investigators to detect the presence of accelerants. Dogs are also used by police, military, and civilian groups to locate lost or missing persons, as well as victims of natural or mass disasters. A further subspecialty is "cadaver" searching, or the use of canines to locate buried or concealed human remains. Recent forensic investigations in central Alberta demonstrated that the use of cadaver dogs could be expanded to include locating partial, scattered human remains dispersed by repeated animal scavenging. Eight dog-and-handler teams participated in a two-month training program using human and animal remains in various stages of decay as scent sources. Ten blind field tests were then conducted which simulated actual search conditions. Recovery rates ranged between 57% and 100%, indicating that properly trained cadaver dogs can make significant contributions in the location and recovery of scattered human remains.

Animals↗

Posttraumatic stress disorder: a review.

In this article, I have reviewed posttraumatic stress disorder with Vietnam veterans, soldiers in other wars, and in victims of natural and civilian disasters. A discussion of measurement and therapy approaches is included.

Combat Disorders↗

Identification of victims of catastrophes: introduction to the role of forensic odontology.

There are many ways of identifying victims of catastrophes but in disasters where most soft tissue has been lost, the hard tissues of teeth can be used. This article describes the important role that forensic odontology can play in these cases. This role has not been recognised in most countries, particularly developing countries, where forensic odontology has been restricted to legal affairs.

Age Determination by Teeth↗

Early mental health intervention in combat situations: the USS Stark.

The United States Army Europe Stress Management Team (USAREUR SMT) is designed to assist victims of hostage, terrorist, and disaster situations. Early intervention is intended to prevent the development of chronic posttraumatic stress disorder. This paper describes the operation of the SMT following the missile attack on the USS Stark in the Persian Gulf. Therapeutic approaches as well as some observation on the group process are described. The therapeutic principles and organizational flexibility necessary for early mental health intervention in disaster situations are illustrated.

Humans↗

Recommendations for Life-Supporting First-Aid training of the lay public for disaster preparedness.

In catastrophic disasters such as major earthquakes in densely populated regions, effective Life-Supporting First-Aid (LSFA) and basic rescue can be administered to the injured by previously trained, uninjured survivors (co-victims). Administration of LSFA immediately after disaster strikes can add to the overall medical response and help to diminish the morbidity and mortality that result from these events. Widespread training of the lay public also may improve bystander responses in everyday emergencies. However, for this scheme to be effective, a significant percentage of the lay population must learn in eight basic steps of LSFA. These have been developed by the International Resuscitation Research Center in collaboration with the World Association for Emergency and Disaster Medicine, the City of Pittsburgh Department of Public Safety, and the American Red Cross (Pennsylvania chapter). They include: 1) scene survey; 2) airway control; 3) rescue breathing (mouth-to-mouth); 4) circulation (chest compressions; may be omitted for disasters, but should be retained for everyday bystander response); 5) abdominal thrusts for choking (may be omitted for disasters, but retained for everyday bystander response); 6) control of external bleeding; 7) positioning for shock; and 8) call for help.

Cardiopulmonary Resuscitation↗

[Mental disorders during and after natural disasters and catastrophies].

Analysis is made of mental disorders seen in 3431 victims followed up by psychiatrists in 11 large-scale catastrophies and natural disasters. Three periods of the development of the life-threatening situation were distinguished, during which one can see different states of mental disadaptation and morbid disorders. The clinical picture of such disorders is provided.

Accidents↗

Critical analysis of injuries sustained in the TWA flight 800 midair disaster.

BACKGROUND: Previous reports of commercial airline disasters have reviewed incidents occurring at takeoff and landing. The purpose of the present study, which represents the first analysis of aviation injuries incurred during a midflight incident, was to examine the injuries sustained by the victims of the TWA Flight 800 disaster and to determine any correlation of injuries with structural damage and seat location. METHODS: Complete autopsy records, toxicology screening, and forensic analysis were reviewed. Injuries were assessed by anatomic region and severity by using the Abbreviated Injury Scale. The National Transportation Safety Board report of the investigation was applied to correlate individual injuries with seat location and structural damage. A comparison was performed against injury data from takeoff and landing incidents. RESULTS: All 230 passengers of TWA Flight 800 were recovered as fatalities. Head, thoracic, and abdominal injuries were multiple and severe, contributing to the mortality of the occupants. Analysis revealed that the severity of injury and anatomic injury pattern did not generally correlate with seating position or structural damage. A comparison of these injuries with those of takeoff and landing crashes showed differences in injury pattern and severity. CONCLUSION: Passengers of Flight 800 sustained instantaneous fatal blunt force injury. Analysis of the data revealed no global correlation between seat position and pattern of injury. In contrast to injuries incurred during crashes at takeoff and landing, these midflight injuries were too extreme to warrant a reappraisal of current passenger protective safety measures or standards.

Abbreviated Injury Scale↗

Early post-traumatic stress disorder in relation to acute stress reaction: an ICD-10 study among help seekers following an earthquake.

Disaster research related to earthquakes has almost exclusively dealt with their long-term psychosocial impact; besides, diagnoses were previously based only on DSM criteria. Therefore, it is pertinent to assess stress-related reactions of earthquake victims during the early post-disaster period through the application of ICD-10 criteria. For the first 3 weeks following an earthquake, 102 help-seekers were assessed based on a checklist of sociodemographic variables and a semi-structured interview for the detection of acute stress reaction (ASR) and posttraumatic stress disorder (PTSD) according to ICD-10. Forty-four subjects (43%) fulfilled the ICD-10 criteria for PTSD; all but one of them had suffered ASR. Moreover, among a series of potential predictors for PTSD, ASR was found to be the only significant one; this indicates a definite association between ASR and early development of PTSD. Logistic regression to predict group membership (PTSD/no PTSD) based on specific ASR symptoms showed that accelerated heart rate and feelings of derealization were the only significant predictors for early PTSD. Individuals who fulfill the ICD-10 diagnostic criteria for ASR following an earthquake are at high risk for subsequent occurrence of early PTSD. Increased heart rate and feelings of derealization within the first 48 h after the traumatic event appear to be the principal factors associated with the development of early PTSD. In addition to their potential value for timely prevention and treatment, these findings raise important nosological issues pertaining to the current diagnostic classification of stress-related disorders (ICD-10 versus DSM-IV).

Adolescent↗

Disaster training for emergency physicians in the United States: a systems approach.

Disaster strikes more frequently and with greater impact than ever before, and the demand for improved community disaster preparedness rises. The American College of Emergency Physicians (ACEP), in collaboration with the Federal Emergency Management Agency (FEMA), has responded by developing a 16-hour course that prepares emergency physicians and other emergency providers to serve as knowledgeable members of their community's disaster team. The course was developed using a standard instructional design system to cover the basic components of disaster planning and emergency medical operations, including: disaster elements, general planning and organization, victim flow, communication, evacuation modalities, field and hospital management, documentation, public relations, and application to the local community. The 35 national faculty members present the course on a geographic basis across the United States. Further considerations for emergency medicine in the disaster domain include questions of education, research and the formation of a network to coordinate with other medical, health, and nonhealth care sectors nationally and internationally.

Curriculum↗

Disaster management and government intervention in PNG: the case of Lae.

This paper describes government intervention in two flood disasters in Lae before and after the establishment of the Papua New Guinea disaster management body. It first describes the objectives behind the establishment of this, and second, it examines the organisational response to the 1983 and 1992 disasters in Lae. Disaster response in terms of relief operations is generally prompt and spontaneous but can at best be described as haphazard, unsystematic and often uncoordinated. Both national and provincial disaster committees are, in many aspects, ill equipped in terms of capabilities, skills and resources. Many disaster operations are unable to ensure an immediate return of the victim's lives to normality--the ultimate objective of any disaster management.

Disaster Planning↗

Posttraumatic stress disorder and identification in disaster workers.

OBJECTIVE: Disaster workers who work with deceased victims are at increased risk of posttraumatic stress disorder (PTSD). Identification with the deceased has been proposed as one of the mechanisms in this stress-illness relationship. To examine this hypothesis, this study investigated three types of identification with the dead in a group of disaster workers: identification with the deceased as oneself, identification with the deceased as a friend, and identification with the deceased as a family member. METHOD: Fifty-four volunteer disaster workers who worked with the dead following an explosion on the USS Iowa naval ship were assessed 1, 4, and 13 months after the disaster. PTSD symptoms (measured with the DSMPTSD-IV scale), intrusive and avoidant disaster-related symptoms (measured with the Impact of Event Scale), somatization and general distress (measured with the SCL-90-R), and health care utilization were assessed. RESULTS: Disaster workers who reported identification with the deceased as a friend were more likely than those who did not to have PTSD, more intrusive and avoidant symptoms, and greater levels of other posttraumatic symptoms including somatization. Disaster workers who reported identification with the deceased as a family member had greater intrusive symptoms 1 month after the disaster than those who did not. There were no differences between those who did and did not identify with the deceased as self. Health care utilization was not associated with identification. CONCLUSIONS: Identification with the deceased is a risk factor for PTSD and posttraumatic symptoms in disaster workers exposed to the dead. Identification with the dead as a friend is specifically associated with higher risk for these workers.

Adult↗

Fasciotomy in crush injury resulting from prolonged pressure in an earthquake in Turkey.

OBJECTIVES: The authors report on the patients treated in a clinic who were injured in the earthquake that took place in north western part of Turkey in 1999 and was reported to be measured at 7.4 on the Richter scale. This catastrophe killed over 16 000 people while injuring more than 23 000 people. The type of housing was varied and entrapment occurred in single, two or more storey buildings. METHODS: 35 patients were admitted to the plastic surgery department after the earthquake. The hospital is about 400 km from the disaster site. Although all the transported victims had intravenous lines, few had adequate volume replacement. Sixteen had an urgent fasciotomy at the time of admission. The procedures were performed between 8 and 21 hours after extrication. After fasciotomy, all non-viable muscle content was removed but an attempt was made to retain as much viable muscle as possible. RESULTS: Amputation was required on four patients (25%). Fasciotomy incisions were closed with skin grafting in eight cases, and with primary closure in four cases. CONCLUSION: Prompt fasciotomy in earthquake victims will be both life saving and can prevent some of the severe and dangerous complications after crush syndrome.

Adolescent↗

The European Task Force for Disaster Relief: a multi-disciplinary team approach.

After the earthquake in Armenia, the International Society of Nephrology (ISN) Commission on Acute Renal failure, in cooperation with the United States National Kidney Foundation, has created a Disaster Relief Task Force to deal with post-disaster nephrology assistance to the affected victims (1). Its main purpose is to prevent and treat crush injury-induced ARF that occurs following traumatic rhabdomyolysis.

Acute Kidney Injury↗

Chemical or biological terrorist attacks: an analysis of the preparedness of hospitals for managing victims affected by chemical or biological weapons of mass destruction.

The possibility of a terrorist attack employing the use of chemical or biological weapons of mass destruction (WMD) on American soil is no longer an empty threat, it has become a reality. A WMD is defined as any weapon with the capacity to inflict death and destruction on such a massive scale that its very presence in the hands of hostile forces is a grievous threat. Events of the past few years including the bombing of the World Trade Center in 1993, the Murrah Federal Building in Oklahoma City in 1995 and the use of planes as guided missiles directed into the Pentagon and New York's Twin Towers in 2001 (9/11) and the tragic incidents involving twentythree people who were infected and five who died as a result of contact with anthrax-laced mail in the Fall of 2001, have well established that the United States can be attacked by both domestic and international terrorists without warning or provocation. In light of these actions, hospitals have been working vigorously to ensure that they would be "ready" in the event of another terrorist attack to provide appropriate medical care to victims. However, according to a recent United States General Accounting Office (GAO) nationwide survey, our nation's hospitals still are not prepared to manage mass causalities resulting from chemical or biological WMD. Therefore, there is a clear need for information about current hospital preparedness in order to provide a foundation for systematic planning and broader discussions about relative cost, probable effectiveness, environmental impact and overall societal priorities. Hence, the aim of this research was to examine the current preparedness of hospitals in the State of Mississippi to manage victims of terrorist attacks involving chemical or biological WMD. All acute care hospitals in the State were selected for inclusion in this study. Both quantitative and qualitative methods were utilized for data collection and analysis. Six hypotheses were tested. Using a questionnaire survey, the availability of functional preparedness plans, specific preparedness education/training, decontamination facilities, surge capacity, pharmaceutical supplies, and laboratory diagnostic capabilities of hospitals were examined. The findings revealed that a majority (89.2%) of hospitals in the State of Mississippi have documented preparedness plans, provided specific preparedness education/training (89.2%), have dedicated facilities for decontamination (75.7%), and pharmaceutical plans and supplies (56.8%) for the treatment of victims in the event of a disaster involving chemical or biological WMD. However, over half (59.5%) of the hospitals could not increase surge capacity (supplies, equipment, staff, patient beds, etc.) and lack appropriate laboratory diagnostic services (91.9%) capable of analyzing and identifying WMD. In general, hospitals in the State of Mississippi, like a number of hospitals throughout the United States, are still not adequately prepared to manage victims of terrorist attacks involving chemical or biological WMD which consequently may result in the loss of hundreds or even thousands of lives. Therefore, hospitals continue to require substantial resources at the local, State, and national levels in order to be "truly" prepared.

Biological Warfare↗

[Collective oxygen therapy and disaster medicine].

The distribution of oxygen to many victims can be necessary all along the medical help chain: operations of extraction, stand up, recovery, transport, life supporting care, surviving and transportation in mobile processing formations installed to proximity of the site, evacuations by road or by fly. Moreover, hospital in situation of crisis has an increased oxygen consumption (especially for ventilators). An estimable need calculation, a census of stocking and distribution ways have to allow to adapt resources to needs. Proposed solutions are the strengthening of vehicles in oxygen tanks, utilization of liquid oxygen tanks in large mobile formations and particular procedures to supply hospital crisis situation.

Administration, Inhalation↗