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Major disaster management in chemical warfare.

A disaster is internationally defined as: 'a catastrophic event which, relative to the manpower and resources available, overwhelms a healthcare facility and usually occurs in a short period of time'. War produces such events following every major engagement, resulting in continuous streams of casualties with injuries reflecting the type of campaign being fought and weapons used. Chemical weapons are designed more to injure than to kill, as has been demonstrated in conflicts that have involved the use of such weapons where mortality has been 3-5%. However, the use of such weapons when overlaid on conventional injury cause added medical problems along with a massive tactical contamination problem. It is therefore essential that disaster planning and training takes account of these hazards in areas where such a threat exists, in order to save the maximum number of lives and prevent secondary casualties among hospital and rescue staff. The principles outlined in this paper apply equally well to civilian disasters involving the many hazardous materials of industry being transported daily on roads, railways and in the air. This paper will give an overview of the nature of chemical weapons and of some of the medical/tactical problems when disaster involves chemical warfare agents.

Chemical Warfare↗

The importance of estimating selection bias on prevalence estimates shortly after a disaster.

PURPOSE: The aim was to study selective participation and its effect on prevalence estimates in a health survey of affected residents 3 weeks after a man-made disaster in The Netherlands (May 13, 2000). METHODS: All affected adult residents were invited to participate. Survey (questionnaire) data were combined with electronic medical records of residents' general practitioners (GPs). Data for demographics, relocation, utilization, and morbidity 1 year predisaster and 1 year postdisaster were used. RESULTS: The survey participation rate was 26% (N = 1171). Women (odds ratio [OR], 1.46; 95% confidence interval [CI], 1.28-1.67), those living with a partner (OR, 2.00; 95% CI, 1.72-2.33), those aged 45 to 64 years (OR, 2.00; 95% CI, 1.59-2.52), and immigrants (OR, 1.50; 95% CI, 1.30-1.74) were more likely to participate. Participation rate was not affected by relocation because of the disaster. Participants in the survey consulted their GPs for health problems in the year before and after the disaster more often than nonparticipants. Although there was selective participation, multiple imputation barely affected prevalence estimates of health problems in the survey 3 weeks postdisaster. CONCLUSIONS: Estimating actual selection bias in disaster studies gives better information about the study representativeness. This is important for policy making and providing effective health care.

Adolescent↗

CCATT: a military model for civilian disaster management.

When major disasters incapacitate hospitals and definitive care facilities-as Hurricane Katrina did in 2005-a crisis point is rapidly reached. Critical care services are often the first to be overwhelmed. Personal experiences and regional disaster plans were examined in the wake of Hurricane Katrina to uncover shortfalls in delivery of care and resources. A search was undertaken for a viable model for delivering critical care services in the immediate post-disaster period. Such a model already exists in the US Air Force's (USAF) Critical Care Air Transport Teams (CCATT). These teams have functioned well during recent military conflicts by providing both ground critical care and transport of high-risk, severely injured patients. The need for augmented critical care and transport resources in the face of overwhelming casualties in the civilian environment does not require a de novo construct. The USAF's CCATT model should be easily adaptable to the civilian disaster scenario.

Disaster Planning↗

Elevated frequency of sister chromatid exchanges of lymphocytes in sarin-exposed victims of the Tokyo sarin disaster 3 years after the event.

We previously reported that the frequency of sister chromatid exchanges (SCEs) among victims of the Tokyo subway sarin disaster was significantly higher than that of controls 2-3 months after the disaster. It has been reported that the victims were also exposed to the by-products generated during sarin synthesis, i.e., diisopropyl methylphosphonate (DIMP), diethyl methylphosphonate (DEMP) and N,N-diethylaniline (DEA) during the disaster and we previously found that DIMP, DEMP and DEA induced a significant SCE increase in human lymphocytes in vitro. To monitor the genetic aftereffects of the sarin exposure, SCEs of peripheral blood lymphocytes were measured in fire fighters and police officers involved in the disaster 3 years after the event. We found that the frequency of SCEs was still significantly higher in the exposed subjects than the controls, suggesting a risk of the genetic aftereffects of the sarin exposure. We further found a significant positive correlation between the frequency of SCEs and the inhibition of serum cholinesterase activity in the exposed subjects, suggesting that the elevated frequency of SCEs is related to the sarin exposure. On the other hand, there was no significant difference in natural killer activity between the exposed and the controls.

Adult↗

Disaster medicine training in France.

We describe the disaster medicine training program that has been developed in France by the anesthesia-reanimation specialists who provide emergency medical services. The diploma course is presented twice yearly over a two-week period to physicians of all disciplines. The 71-hour didactic program covers the background of disasters, various plans and strategies, tactics and logistics, techniques, and victim assessment and treatment. This is followed by a field exercise. Graduates then participate in a full-scale mock disaster exercise that lasts two days to one week. The development of such a course illustrates the attention that nations worldwide are giving to specialized physician training in disaster preparedness.

Curriculum↗

Managing disasters involving hazardous substances in Canada: technical and sociopolitical issues.

This article focuses on the management lessons learned from disasters involving hazardous materials, which occurred in Quebec, Canada, between 1988 and 1995. The findings of the previous case studies of Canadian and some other disasters are considered as well. Both technical and sociopolitical issues on the disaster management are contemplated from the viewpoint of complexity and uncertainty. A distinction is made between the two concepts through specific examples. In addition, two types of uncertainty, first and second-level, are differentiated. The relationship between technical and sociopolitical issues of such management are then illustrated, and the salience of efficient disaster risk communication between technical specialists and the public for bridging the gap existing between these two types of issues is shown.

Canada↗

Health care personnel in disaster response. Reversible roles or territorial imperatives?

Disasters frequently demand exceptional skills from medical responders. Providers work most efficiently and effectively, however, within the roles and hierarchical structures with which they are familiar. The goal of disaster medical response planners is to assign personnel to roles that are as familiar as possible and to simultaneously enhance flexibility of response to extraordinary circumstances. We have outlined the most common disaster medical response roles and the personnel types that fit most directly as a primary provider within each role. Medics excel in field operations and field care of patients, whereas the training of nurses and physicians makes them the most flexible all-around providers, if specially trained in field emergency care, and the sole providers of definitive care. None of the providers, by virtue of their basic training, is well equipped to manage the public health consequences of disasters, but nurses and physicians should be able to easily move into the role, given appropriate special training. Some of the special courses needed to make medics, nurses, and physicians capable of serving flexible roles already exist; others need to be developed or enhanced.

Disasters↗

Hazardous materials. Disaster medical planning and response.

Hazardous materials offer a variety of unique challenges to emergency personnel. These agents have immense economic impact, but when mishandled, they become notorious for turning contained accidents into disasters involving the entire community. During a hazmat accident, the victims often ignore the rules of the disaster plan by seeking out the nearest hospital for medical care, regardless of that institution's capabilities. Health care workers rushing to the aid of contaminated individuals, without taking appropriate precautions (i.e., donning PPE), potentially make themselves victims. Disaster preparedness requires planning, policy, and procedure development, hazard analysis, training, and the availability of personal protective equipment for all responding personnel. Presently, the level of hazmat preparedness varies greatly among different hospitals, EMS and fire services, and disaster response teams. These differences in hazmat preparedness can be linked to a variety of factors (lack of awareness, funding, and support) and controversies (types of PPE and level of training required) which have prevented the establishment of a national hazmat policy for most of these organizations. Despite these difficulties, emergency departments continue to be the primary provider of care to contaminated individuals. As a result, emergency physicians must work with their hospital to implement a hazmat decontamination program in order to appropriately care for these individuals. The appendix to this article presents a list of recommendations for hospital hazmat preparedness. It is modeled after existing CDC and OSHA guidelines.

Decontamination↗

A paradigm for multidisciplinary disaster research: the Oklahoma City experience.

The objective of this article is to describe the creation and operation of a multidisciplinary group to examine the Oklahoma City (OKC) bombing. The OKC bombing presented an opportunity to study a major disaster within 2 days of the incident. The Disaster Health Studies Group (DHSG) was created to facilitate this effort. The creation, organization, and operation of the DHSG is outlined. In addition the mission statement, participants, communications, political empowerment, data preservation and collection, data ownership, patient rights, threats to the DHSG, media interactions, funding, the institutional review board process, and results reporting will be detailed. The 22 projects of the DHSG are listed. In conclusion, four main findings are examined: 1) A multidisciplinary disaster study group is feasible and can be rapidly organized; 2) certain organizations and institutions form a core group for facilitation of the research effort; 3) specific issues must be addressed in order for the group to succeed; and 4) the group leader should have disaster expertise and be committed to the multidisciplinary process.

Communication↗

A disaster drill in Hong Kong.

This case report relates the course of a disaster drill held on 19 August 1994 in a regional acute hospital (Pamela Youde Nethersole Eastern Hospital) in Hong Kong. The Hospital Civil Disaster Contingency Plan (the Plan) was put to trial on that day. Volunteers were invited to become simulated casualties in the exercise. Briefing seminars had been conducted with clinicians of the Accident and Emergency department (A & E) and other departments of the hospital. The scenario was a man-made type disaster. A double-decker bus turned over and injured 19 people in that afternoon. All the victims were sent to A & E by ambulance. The Plan was activated and relevant units were mobilized according to the Plan. It took 45 minutes to complete the disaster exercise. Debriefing sessions reviewed difficulties encountered throughout the drill and possible remedies.

Disaster Planning↗

Frail elderly as disaster victims: emergency management strategies.

PURPOSE: To identify the vulnerabilities of elderly to disasters, and to develop strategies to address these vulnerabilities. METHODS: A relevant literature search of journal articles, government training materials, news reports, and materials from senior organizations was conducted. RESULTS: The vulnerability of the elderly to disasters is related to their impaired physical mobility, diminished sensory awareness, chronic health conditions, and social and economic limitations that prevent adequate preparation for disasters, and hinder their adaptability during disasters. Frail elderly, those with serious physical, cognitive, economic, and psycho-social problems, are at especially high risk. CONCLUSIONS: This segment of the population is growing rapidly. Therefore, it is important that emergency management recognize the frail elderly as a special needs population, and develop targeted strategies that meet their needs. Several management strategies are presented and recommendations for further action are proposed.

Aged↗

Overview of the psychosocial impact of disasters.

The psychosocial sequelae can be intense and of long duration in the aftermath of natural and technological disasters, as well as terrorist attacks. Post-traumatic stress symptoms and full syndrome disorder, depression, anxiety, somatic complaints, and excessive alcohol use have been demonstrated consistently, particularly following large-scale disasters. This paper examines the psychological research conducted at various intervals after extensive natural disasters, the Three Mile Island and Chernobyl technological accidents, and recent terrorist events in the United States. Factors predictive of the emergence of emotional distress and psychological and physical problems following a disaster also are discussed.

Disasters↗

Disaster and terrorism: Cognitive-Behavioral interventions.

The mental health effects of disaster and terrorism have moved to the forefront in the recent past following the events of 11 September 2001 in the United States. Although there has been a protracted history by mental health researchers and practitioners to study, understand, prevent, and treat mental health problems arising as a result of disasters and terrorism, there still is much to learn about the effects and treatment of trauma. Continued communication among disaster workers, first-response medical personnel, and mental health professionals is part of this process. This paper outlines current knowledge regarding the psychological effects of trauma and best cognitive-behavioral practices used to treat trauma reactions. More specifically, the information presented is a summary of Cognitive-Behavioral Therapy (CBT) interventions that are relevant for responding to and dealing with the aftermath of disasters.

Bereavement↗

Realities of rural emergency medical services disaster preparedness.

INTRODUCTION: Disaster preparedness is an area of major concern for the medical community that has been reinforced by recent world events. The emergency healthcare system must respond to all types of disasters, whether the incidents occur in urban or rural settings. Although the barriers and challenges are different in the rural setting, common areas of preparedness must be explored. PROBLEM: This study sought to answer several questions, including: (1) What are rural emergency medical services (EMS) organizations training for, compared to what they actually have seen during the last two years?; (2) What scale and types of events do they believe they are prepared to cope with?; and (3) What do they feel are priority areas for training and preparedness? METHODS: Data were gathered through a multi-region survey of 1801 EMS organizations in the US to describe EMS response experiences during specific incidents as well as the frequency with which these events occur. Respondents were asked a number of questions about local priorities. RESULTS: A total of 768 completed surveys were returned (43%). Over the past few years, training for commonly occurring types of crises and emergencies has declined in favor of terrorism preparedness. Many rural EMS organizations reported that events with 10 or fewer victims would overload them. Low priority was placed on interacting with other non-EMS disaster response agencies, and high priority was placed on basic staff training and retention. CONCLUSION: Maintaining viable, rural, emergency response capabilities and developing a community-wide response to natural or man-made events is crucial to mitigate long-term effects of disasters on a local healthcare system. The assessment of preparedness activities accomplished in this study will help to identify common themes to better prioritize preparedness activities and maximize the response capabilities of an EMS organization.

Disaster Planning↗

Disaster coordination and management: summary and action plans.

INTRODUCTION: Disaster is a collective responsibility requiring coordinated response from all parts of society. This theme focused on coordination and management issues in a diverse range of scenarios. METHODS: Details of the methods used are provided in the preceding paper. The chairs moderated all presentations and produced a summary that was presented to an assembly of all of the delegates. Although the main points developed in Themes 1 and 4 were different from each other (as reported in the Results section), their implementation was similar. Therefore, the chairs of both groups presided over one workshop that resulted in the generation of a set of Action Plans that then were reported to the collective group of all delegates. RESULTS: The main points developed during the presentations and discussions included: (1) the need for evidence-based assessments and planning, (2) the need for a shift in focus to health-sector readiness, (3) empowerment of survivors, (4) provision of relief for the caregivers, (5) address the incentives and disincentives to attain readiness, (6) engage in joint preparation, response, and training, (7) focus on prevention and mitigation of the damage from events, and (8) improve media relations. There exists a need for institutionalization of processes for learning from experiences obtained from disasters. DISCUSSION: Action plans presented include: (1) creation of an Information and Data Clearinghouse on Disaster Management, (2) identification of incentives and disincentives for readiness and develop strategies and interventions, and (3) act on lessons learned from evidence-based research and practical experience. CONCLUSIONS: There is an urgent need to proactively establish coordination and management procedures in advance of any crisis. A number of important insights for improvement in coordination and management during disasters emerged.

Continuity of Patient Care↗

Sharing international experiences in disasters: summary and action plan.

INTRODUCTION: The discussions in this theme provided an opportunity to share specific experiences with disasters that occurred outside of the Asia-Pacific Rim. METHODS: Details of the methods used are provided in the preceding paper. The chairs moderated all presentations and produced a summary that was presented to an assembly of all of the delegates. Since the findings from the Theme 7 and Theme 3 groups were similar, the chairs of both groups presided over one workshop that resulted in the generation of a set of action plans that then were reported to the collective group of all delegates. RESULTS: The main points developed during the presentations and discussion included: (1) disaster response planning, (2) predetermined command and organizational structure, (3) rapid response capability, (4) mitigation, and (5) communications and alternatives. DISCUSSION: The action plans presented are in common with those presented by Theme 3, and include: (1) plan disaster responses including the different types, identification of hazards, training based on experiences, and provision of public education; (2) improving coordination and control; (3) maintaining communications assuming infrastructure breakdown; (4) maximizing mitigation through standardized evaluations, creation of a legal framework, and recognition of advocacy and public participation; and (5) providing resources and knowledge through access to existing therapies, using the media, and increasing decentralization of hospital inventories. CONCLUSIONS: Most of the problems that occurred outside the Asia-Pacific rim relative to disaster management are similar to those experienced within it. They should be addressed in common with the rest of the world.

Communication↗

Education issues in disaster medicine: summary and action plan.

INTRODUCTION: Change must begin with education. Theme 8 explored issues that need attention in Disaster Medicine education. METHODS: Details of the methods used are provided in the introductory paper. The chairs moderated all presentations and produced a summary that was presented to an assembly of all of the delegates. The chairs then presided over a workshop that resulted in the generation of a set of action plans that then were reported to the collective group of all delegates. RESULTS: Main points developed during the presentations and discussion included: (1) formal education, (2) standardized definitions, (3) integration, (4) evaluation of programs and interventions, (5) international cooperation, (6) identifying the psychosocial consequences of disaster, (7) meaningful research, and (8) hazard, impact, risk and vulnerability analysis. DISCUSSION: Three main components of the action plans were identified as evaluation, research, and education. The action plans recommended that: (1) education on disasters should be formalized, (2) evaluation of education and interventions must be improved, and (3) meaningful research should be promulgated and published for use at multiple levels and that applied research techniques be the subject of future conferences. CONCLUSIONS: The one unanimous conclusion was that we need more and better education on the disaster phenomenon, both in its impacts and in our response to them. Such education must be increasingly evidence-based.

Clinical Competence↗

The need for a global health disaster network.

When a disaster occurs, a major difficulty is knowing where to find accurate information, and how to help coordinate efforts to share accurate information in a quick and organized manner. The establishment of a global information network, that is in place before a disaster occurs, could link all the communication efforts for relief. We propose that a Global Health Unit for Disaster and Relief Coordination be set up as part of the Global Health Network, utilizing the Internet as its backbone. This Unit would establish the links for the disaster information mosaic.

Computer Communication Networks↗