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Chemical weapon functional exercise--Cincinnati: observations and lessons learned from a "typical medium-sized" city's response to simulated terrorism utilizing Weapons of Mass Destruction.

In the wake of the September 11, 2001, attacks and the subsequent anthrax scare, there is growing concern about the United States' vulnerability to terrorist use of Weapons of Mass Destruction (WMD). As part of ongoing preparation for this terrible reality, many jurisdictions have been conducting simulated terrorist incidents to provide training for the public safety community, hospitals, and public health departments. As an example of this national effort to improve domestic preparedness for such events, a large scale, multi-jurisdictional chemical weapons drill was conducted in Cincinnati, Ohio, on May 20, 2000. This drill depicted the components of the early warning system for hospitals and public health departments, the prehospital medical response to terrorism. Over the course of the exercise, emergency medical services personnel decontaminated, triaged, treated, and transported eighty-five patients. Several important lessons were learned that day that have widespread applicability to health care delivery systems nationwide, especially in the areas of decontamination, triage, on-scene medical care, and victim transportation. As this training exercise helped Cincinnati to prepare for dealing with future large scale WMD incidents, such drills are invaluable preparation for all communities in a world increasingly at risk from terrorist attacks.

Ambulances↗

A diary of hurricane Hugo.

Charleston, South Carolina was the recent victim of Hurricane Hugo. This article recalls the events that occurred before, during, and after the hurricane struck. The focus is on four outpatient dialysis units in that area. It is a story from which others may learn more about emergency preparedness.

Ambulatory Care Facilities↗

Post-traumatic stress disorder in children and adolescents of the Armenian earthquake.

The impact of the Armenian earthquake of 1988 on children and adolescents screened through the National Mental Health Research Center in Spitak, Armenia, is discussed. The earthquake caused close to 20,000 deaths, almost two-thirds of which were children and adolescents. Clinical data which address advances in understanding the diagnostic indicators and resulting psychopathology in victims of the Armenian earthquake are presented. Current theory about the processing of trauma in children and adolescents is reviewed, with recommendations for future research in this area.

Adaptation, Psychological↗

An epidemiologic study of posttraumatic stress disorder in flood victims in Hunan China.

OBJECTIVE: To estimate the occurrence and to assess the determinants of posttraumatic stress disorder (PTSD) in flood victims. METHOD: We carried out a retrospective study to examine the occurrence and the determinants of PTSD in victims of flood in 1998 and 1999 in Hunan, China. We used multistage sampling to select the subjects from the flood areas, and we ascertained PTSD according to DSM-IV criteria. Data were collected in face-to-face interviews carried out by experienced research assistants using a preconstructed questionnaire. We used a multiple logistic regression model to analyze the data. RESULTS: A total of 33 340 subjects (86.0% of the selected subjects, aged 7 years or over) in the study villages were interviewed. Among them, 2875 (8.6%) had symptoms that met the diagnostic criteria for PTSD. Significant risk factors for PTSD included female sex (odds ratio [OR] 1.12; 95% confidence interval [CI], 1.04 to 1.21), older age (age 18 to 59 years OR 2.28; 95%CI, 2.02 to 2.57, and age > or = 60 years OR 2.42; 95%CI, 2.05 to 2.85), flood type (collapsed embankment OR 1.84; 95%CI, 1.64 to 2.05, and flash flood OR 3.12; 95%CI, 2.76 to 3.52), and flood severity (intermediate OR 4.05; 95%CI, 3.55 to 4.62, and severe OR 2.98; 95%CI, 2.60 to 3.41). CONCLUSIONS: PTSD is a common mental disorder in flood victims, which implies the need for improved health services, especially mental health services, for this population.

Adolescent↗

Clinical analogies for the management of toxic trauma.

The management of injuries from toxic release (HAZMAT) incidents is unfamiliar to many emergency medical responders owing to the relative rarity of such incidents. However, the risks from toxic release in both industrial and other metropolitan areas are increasing and emergency medical services (EMS) personnel should be trained to be aware of the dangers to both victims and responders alike. Many examples exist of analogies for the management of HAZMAT situations from conventional prehospital and hospital emergency medicine. Application of the lessons learned in more familiar situations will be of benefit for the preparation of an effective EMS response for HAZMAT.

Disasters↗

Lessons learned from Hurricane Mitch: a guide for holistic practice.

Hurricanes are often devastating for the victims. Although millions of dollars and hours are invested, relief efforts could be more effective. The purpose of this article is to utilize the lessons learned from Hurricane Mitch as a guide for holistic practice in both hurricane preparation and response planning.

Altruism↗

After the bomb. Oklahoma City rescuers talk about their experiences.

Rather than trying to write a second-hand description of the response to the April 19 bombing of the Federal Building in Oklahoma City, we thought we'd let some of the people who were there caring for patients and searching for victims share their experiences in their own words. Marion Angell Garza, JEMS editorial/news coordinator, spoke at length with six responders, including paramedics, the triage and treatment officer, a firefighter/EMT-1 and an emergency physician. The following excerpts are from those interviews.

Anecdotes as Topic↗

The Göteborg discothèque fire, 1998.

Findings from a study of 563 adolescents' reactions following a discotheque fire that killed 63 young people in Göteborg in October 1998 are presented. The group answered a questionnaire seven months following the disaster. The questionnaire included the Impact of Event Scale (IES) and the Birleson Depression Self-Rating Scale (DSRS). The level of trauma was found to be very high, while depression scores were less elevated. A little under a third of the students scored above a clinical cut-off point (> 35) on the IES, indicating high posttraumatic stress levels. Girls evidenced more depression and traumatic stress reactions than boys. Levels of reactions increased with more closeness (knowing victims personally) and if the adolescents were of non-Swedish origin.

Adolescent↗

Chest injury in victims of Bam earthquake.

OBJECTIVE: To analyze the data of trauma patients with thoracic injury in the earthquake of Bam admitted to hospitals of Tehran University of Medical Science (TUMS) for better understanding the type and consequence of thoracic injuries in a major earthquake. METHODS: After Bam earthquake registering 6.5 on the Richter scale, 526 trauma patients were admitted to hospitals of TUMS. Among them, 53 patients sustained thoracic injury. RESULTS: This group was composed of 21 females (39.6%) and 32 males (60.4%). Fifteen patients (28.3%) had isolated chest injuries. Rib fracture (36.4%) was the most common injury in our patients and haemo/pneumothorax (25.5%) followed. Superficial injury was the most common accompanying injury. Multiple-trauma patients with chest injury had higher injury severity score (ISS) versus patients with isolated chest injury (P=0.003). CONCLUSIONS: Chest wall injuries and haemo/pneumothorax comprise a considerable number of injuries in survival victims of earthquakes. Consequently, the majority of these patients can be treated with observation or tube thoracostomy. We should train and equip the health workers and members of rescue teams to treat and manage these patients in the field.

Adolescent↗

Nuclear terrorism: triage and medical management of radiation and combined-injury casualties.

This article addresses the medical effects of nuclear explosions and other forms of radiation exposure, assessment of radiation dose, triage of victims, definitive treatment of radiation and combined-injury casualties, and planning for emergency services after a terrorist attack involving a nuclear device. It reviews historical events of mass radiation-induced casualties and fatalities at Hiroshima, Chernobyl, and Goiania, and discusses various scenarios for nuclear terrorism.

Disaster Planning↗

Psychiatric patients' vulnerability in the wake of the September 11th terrorist attacks.

The September 11, 2001 (9/11) terrorist attacks led to speculation about the vulnerability of psychiatric patients to psychological distress following such events. This study examined the impact of national terrorist attacks on psychiatric and medical outpatients living approximately 150 to 200 miles from the attack sites (N = 308). Two to 3 weeks following 9/11, patients were given questionnaires assessing background information, healthcare service utilization, and posttraumatic stress disorder (PTSD) symptoms. Psychiatric patients (33%) were significantly more likely than medical patients (13%) to report distressing symptoms meeting criteria for PTSD (except for the duration criterion) despite no differences in learning about the attacks or personal involvement with the victims. Patients meeting PTSD criteria were more likely to schedule an appointment to speak with their physician about their reactions. Psychiatric patients not directly impacted by the 9/11 terrorist attacks are at increased risk for experiencing distressing symptoms following national terrorist attacks.

Adult↗

Managing crises and trauma in the workplace: how to respond and intervene.

1. Health care, human resource, and employee assistance provider professionals must be aware of the impact of trauma in the workplace. 2. Critical Incident Stress (CIS) refers to the work and situations that emergency service professionals face on a regular basis. Trauma in the workplace refers to a work setting, such as an industrial accident, personal injury/illness, or crime taking place in a work setting. The death or injury of an employee outside of the workplace is also considered traumatic for employees. 3. Victims of witnesses of a traumatic incident, a violent crime, physical maltreatment, or sexual abuse may experience Posttraumatic Stress Disorder (PTSD). Individuals of all ages are vulnerable to PTSD. 4. Unresolved CIS or a workplace trauma may result in PTSD for the involved individuals if not handled appropriately.

Crisis Intervention↗

A prehospital approach to multiple-victim incidents.

Although most prehospital systems have well-developed protocols for single-victim rescues and mass casualties, multiple-victim incidents falling between the two in scope have not been analyzed in detail. Forty-one audio tapes of incidents with four or more victims were evaluated for techniques and decisions that affected the runs' speed and efficiency. Common problems both in the field and at the base hospital were identified. Recommendations for management in the field and for paramedic and base station transmissions are given.

Disaster Planning↗

Are Saudi Arabian hospitals prepared for the threat of biological weapons?

The use of biological weapons has been recorded repeatedly in history. Until recently, biological terrorism had been little discussed or written about. However, events over the past 12 to 18 months have made it clear that likely perpetrators already envisage every possible scenario. Nations and dissident groups exist that have both the motivation and access to utilize biological weapons. In April 1994, a Russian biological weapons expert presented the conclusions of the Russian experts as to the agents most likely to be used: smallpox, anthrax, and plague. Health care workers in the Kingdom of Saudi Arabia (physicians, nurses, and emergency medical technicians) need to be aware of the seriousness of the threat of biological weapons, and to have an approach for the early identification, triage, and management of biological weapons victims. Clues to the occurrence of a bioterrorism attack include the abrupt onset of a large number of cases of a similar disease or syndrome, the occurrence of diseases with unusual geographic or seasonal distribution, and epidemics of non-endemic diseases. Health care workers must maintain a high index of suspicion, involve the hospital epidemiologist or infectious diseases specialist, identify a clear administrative chain-of-command to minimize confusion, and rely on existing networks such as the hospital disaster-and-safety committee to ensure a multidisciplinary response. Maximum readiness can be achieved by periodic readiness drills.

Biological Warfare↗

The Santa Monica crash: an urban multicasualty event.

Mass casualty events provide dramatic challenges for trauma centers and trauma systems. We analyzed the management of victims and assessed the response of the UCLA Healthcare System to the Santa Monica multicasualty event of July 16, 2003, when an elderly man drove his car through a crowded outdoor market and injured 73 people, 10 of whom died (eight at the scene). Of the victims, 26 were treated at UCLA (n = 15) and Santa Monica (n = 11) Medical Centers. Fourteen patients (54%) were female; average age was 41.9 years (range 7 months to 88 years). Fifteen patients were treated in the ER only, and 11 patients required admission. Of the latter, 10 (91%) had multisystem injuries, most commonly musculoskeletal, which occurred in nine patients (82%). Seven patients required immediate operations (orthopedic in six and a pericardial window in one). Three patients required delayed operations (orthopedic and plastic surgery). Most surgical and medical specialties were needed in consultation. Average LOH was 11.8 (range 2-23) days. Mean ISS was 21.2 (range 1-75). There were six complications (three early and three late) and one death from head injury. Seven patients (64%) required rehabilitation. We conclude that mass casualty victims have multisystem injuries of variable severity, which underscores the importance of trauma centers and trauma systems. The large trauma scene and particular need for orthopedic services were notable features of this event.

Accidents, Traffic↗

Hypoxia and hypercapnia during respiration into an artificial air pocket in snow: implications for avalanche survival.

Snow avalanche case reports have documented the survival of skiers apparently without permanent hypoxic sequelae, after prolonged complete burial despite there being only a small air pocket on extrication. We investigated the underlying pathophysiological changes in a prospective, randomised 2 x 2 crossover study in 12 volunteers (28 tests) breathing into an artificial air pocket (1- or 2-l volume) in snow. Peripheral SpO(2), ETCO(2), arterialised capillary blood variables, air pocket O(2) and CO(2), snow density, and snow conditions at the inner surface of the air pocket were determined. SpO(2) decreased from a median of 99% (93-100%) to 88% (71-94%; P<0.001) within 4 min of breathing into the air pocket; the reduction was greater at 1 l, than 2 l, volume air pocket (P=0.013, intention to treat P=0.003) and correlated to snow density (r=0.50, P=0.021, partial correlation coefficient). ETCO(2) rose simultaneously from median 5.07 kPa (3.47-6.93 kPa) to 6.8 kPa (5.87-8.27 kPa; P<0.001), with consequent respiratory acidosis. Despite premature interruption due to hypoxia (SpO(2)</=75%) in 17 of 28 tests (61%), a respiratory steady state prevailed in five tests until protocol completion (30 min). We conclude that the degree of hypoxia following avalanche burial is dependent on air pocket volume, snow density and unknown individual personal characteristics, yet long-term survival is possible with only a small air pocket. Hence, the definition of an air pocket, "any space surrounding mouth and nose with the proviso of free air passages" is validated as the main criterion for triage and management of avalanche victims. Our experimental model will facilitate evaluating the interrelation between volume and inner surface area of an air pocket for survival of avalanche victims, whilst the present findings have laid the basis for future investigation of possible interactions between hypoxia, hypercapnia, and hypothermia (triple H syndrome) in snow burial.

Accidents↗

Avalanche deaths in the United States: a 45-year analysis.

OBJECTIVE: To describe the demographic characteristics and patterns of death of persons killed in snow avalanches over a 45-year study period. METHODS: The national avalanche database was the source of data in this retrospective, descriptive study. RESULTS: A total of 440 victims were killed in 324 fatal avalanches, of which 87.7% were fully buried, 4.7% were partially buried, and 7.6% were not buried. The average age was 27.6 +/- 10.6 years, and 87.3% were men. Victims who died included climbers (25.5%), backcountry skiers (22.7%), out-of-bounds skiers (10.0%), snowmobilers (6.8%), in-bounds skiers (5.2%), residents (4.5%), ski patrollers (3.6%), workers (3.6%), and motorists (3.0%). Over the 45-year study period there appear to be decreases in the deaths of in-bounds skiers, highway workers, and motorists. Increasing fatalities were observed among out-of-bounds skiers, snowmobilers, ski patrollers, and backcountry skiers. Most deaths occurred in Colorado (33.0%), Washington (13.2%), and Alaska (12.0%). CONCLUSIONS: Avalanche fatalities have increased over the last 45 years. Climbers, backcountry skiers, out-of-bounds skiers, and more recently snowmobilers constitute the majority of the victims. The decrease in deaths among groups that benefit from avalanche control programs supports the benefit of avalanche prevention strategies. Further study is needed to assess the impact of avalanche safety education for individuals who travel in remote and uncontrolled terrain.

Adolescent↗