Objectives: To illustrate the character, clinical course and late complications of wounds caused by high energy with severe contamination during a natural disaster, as a basis for designing principles for primary treatment under these conditions. Patients and Methods: This paper presents case reports from complicated wounds treated at a specialized unit for wound management in a hospital receiving patients after transfer from primary to definitive treatment. Results: Of the Swedish citizens evacuated from the disaster zone in Thailand after the tsunami disaster in 2004, 174 of those arriving at Stockholm Airport were referred to the Karolinska Hospital for treatment, of whom 75 were admitted. Forty of the patients admitted were seen by the surgeons at the Department of Plastic and Reconstructive Surgery because of complicated wounds requiring special treatment. Fifteen of these could be treated as ambulatory patients and 25 required hospitalization for a mean time of 10.5 days (range 1–48). The majority had multiple injuries, 93% on the lower limbs and 47% on the upper limbs. The majority had been primarily closed at primary treatment. Treatment strategies included removal of all sutures, wound excision, secondary healing (38/40, 95%), delayed primary closure (40/40, 100%), vacuum-assisted closure (VAC) (3/40, 8%), splitthickness skin grafts (23/40, 58%), pedicled perforator flap (1/40, 2%) and free flap (1/40, 2%). Amputation was requested in two cases. Aside from long-lasting psychological sequelae and varying degrees of physical disability, unusual late infections occurred with progressing and migrating abscesses. Cultures and skin biopsies from these revealed both mycobacteria and pigmented fungal hyphae. Conclusions: The patterns of injury and clinical courses in these patients illustrate the risk of complications in wounds caused by high energy, with severe contamination and which arrive late for primary treatment by staff who are not fully aware of the risk of secondary complications under these conditions. Recommendations for primary treatment should include extensive cleaning, excision of dead tissue and delayed primary closure, according to the well-established principles of management of war wounds, where the conditions are similar.
Objective: Paramedics and physicians are important components of our emergency medical system. To date, no survey has been carried out assessing physicians and paramedics regarding their preparedness for a mass casualty incident (MCI) resulting from a terrorist attack in Germany. The aim of this study was to assess the current state of preparedness of emergency physicians and paramedics for an MCI. Materials and Methods: Using an online questionnaire, we interviewed 1,707 emergency physicians and paramedics in Germany. The replies were analyzed statistically with the one-way analysis of variance (ANOVA) test and the Tukey-Kramer multiple comparisons test. Results: In all, 95% of the emergency physicians and paramedics knew their area of responsibility in the case of an MCI. However, 45% of them were unaware of injury patterns and treatment strategies in patients following nuclear, chemical or biological contamination. Of the interviewed emergency physicians and paramedics, 97% asked for further specific training for MCI/terrorism attacks. Conclusions: Emergency physicians and paramedics are still insufficiently prepared for nuclear, chemical, and biological as well as conventional terrorism attacks. The emergency training of emergency physicians and paramedics must be modified to accommodate the increased risk of catastrophes and terrorist attacks.
OBJECTIVES:To provide an overall assessment of the response to the terrorist bombings in Madrid, 11 March 2004, which were considered the deadliest terrorist attack on European soil in modern times.MATERIALS AND METHODS:Overall data on the number of victims treated at the scenes and at primary care facilities and hospitals, as well as the logistics involved, were reported by the EMS and the Health Authority of the Comunidad de Madrid local government. Data were mainly obtained by retrospective chart review, and did not include casualties who had only emotional shock, superficial bruises or transient hearing loss from barotraumas without eardrum perforation. We defined as critical any casualty with an Injury Severity Score (ISS) >15.RESULTS:Over 70,000 personnel were mobilized in the care of the victims. EMS response and total evacuation times at the four blast scenes averaged 7 and 99 min, respectively. There were around 2,000 casualties, and a typical bimodal distribution of deaths, with 177 immediate fatalities and 14 subsequent in-hospital deaths. Almost 60% of casualties were taken to the two closest hospitals. Problems related to security, identification of casualties and record-keeping were encountered at the closest hospital. Closed doors increased the immediate fatality rate in the trains. Most survivors had noncritical injuries, but 14% of the 512 casualties assessed had an ISS >15. The critical mortality rate was 19.5%. The most frequently injured body regions were the head/neck and face. In all, 124 major surgical interventions were performed on 82 victims in the first 24 h, and orthopedic trauma procedures accounted for 50% of the case load. Most patients with lung injuries from the blasts required intubation and mechanical ventilation, and their survival rate was 88.3%. Also, 35% of laparotomies were either negative or nontherapeutic.CONCLUSION:There was a rapid EMS response and evacuation, but also overtriage, uneven distribution of casualties and difficulties in communication. The sizes and resources of the closest hospitals, as well as the early hour, were probably decisive in the adequacy of the overall response.
The aim of this paper is to review the art and science underpinning the application of effective triage. The paper also attempts to cut through the fog of confusion surrounding the topic and to point a way towards a generally-agreed unified approach. Triage needs to be understood in the context of the environment in which it is applied, and the paper deals with this in some detail.
OBJECTIVE:In the Netherlands, major incidents are sparse, and so there is a general feeling of a relatively low risk. Upon evaluating multiple casualty events (MCEs) in the Netherlands over the last 60 years, it is worth noting 39 major events. Our objective was to report the experiences from a mass casualty incident in an urban area, performing a critical evaluation of the response and outcome related to the scenario in order to learn from our past and to train for the future.MATERIALS AND METHODS:In a retrospective patient record analysis we collected all of the data concerning an MCE we encountered in August 2006.RESULTS:There were 21 casualties at the scene. Of our 19 patients, 12 were seen in the crash room. The average age of the patients was 30 years (range 22-53). In all, 87 X-rays, 1 ultrasound and 15 CT scans were performed. Four patients were admitted: ten patients received definitive wound treatment in the ED. Psychological support was given to all patients. One patient died three days later.CONCLUSION:Triage supported by one person and two trauma teams worked well. The amount of over- and undertriage was in line with the literature. Numbering the patients worked well but also caused enormous problems with the supporting facilities. Centralizing the trauma care yielded certain advantages; however, we must respect our surge capacity of 20 patients. When the number of patients surpasses 20, an alternative plan must be followed. This event has been an eye-opener for our organization; it has given us new tools to prepare for a potential new disaster.
Objectives: A tsunami hit Thailand and affected 25 000 Swedish holidaymakers on December 25, 2004. The transportation home of injured Swedish citizens had to be improvised. One of the several assets used was a corporate jet put at the disposal of the Swedish foreign ministry. The aim of this study was to evaluate the improvised use of this corporate jet aircraft to support evacuation of injured citizens hit by disaster in a foreign country. Materials and methods: A Falcon 900 EX jet with capacity to carry 14 seated or 6 stretcher cases was used. Refueling and change of crew took place in Dubai. Five physicians were recruited for an assessment team with the task of locating patients and evaluating them before transport. The assessment team stayed in Thailand to locate patients for the next trip while the jet made the round trip to Sweden (32 hours). The team reported regularly to Swedish healthcare ministry officials in an improvised coordination center in Phuket. Results: Fifteen Swedish tsunami victims were transported from Thailand by the corporate jet in three round trips. Twelve additional patients were evaluated and allocated to other medical evacuation flights. In total 1500 injured Swedish citizens were transported to Sweden, most of whom were able to use regular flights as seated passengers. Conclusion: When the operation started on December 31, many injured Swedish citizens were still in Thailand because of delays in the response from the Swedish authorities and were being treated in hospitals at different locations. Due to lack of deployment of a sufficient number of assessment teams, a substantial amount of time was needed to locate patients and to evaluate whether or not they could be transported without risk. Our experience is that ground assessment teams cooperating with local resources are necessary and, if insufficient, can limit transport capacity more than air‐carrying capacity. A coordination center must handle a considerable amount of information and ID numbers are necessary to avoid duplicates; we made good use of group text messages (SMS) from cell phones to facilitate this aspect.
Dear readers, contributors and subscribers to IJDM,We are living in a world of rapid development, and that is valid also for the field of scientific publication. This journal has now been in the ma...
Objectives: In a changing climate, flood disaster may not only threaten the health of the population, but may also interfere with the function of its health providers. Few data are available about hospital evacuation in these situations. Therefore, this study evaluated the effects of the emergency evacuation of the Dresden Heart Centre in August, 2002, due to the flood disaster along the Elbe, on its 168 critically ill patients, i.e. the patients' perceptions and their psychological stress. Materials and methods: A retrospective survey was started 1 month after the evacuation (T1) and a prospective follow‐up study was carried out 6 months later (T2). The questionnaire consisted of a list of items related to the evacuation as well as standardized psychosocial tools – Hospital Anxiety and Depression Scale (HADS), Posttraumatic Symptom Scale (PTSS‐10) and Impact of Event Scale (IES‐R). A module of the Structured Clinical Interview (SCID) was applied to validate post‐traumatic stress disorder (PTSD). In all, 147 patients were eligible for the study (conscious, non‐ventilated, adequate mental status). Results: A total of 111 patients (75.5%) returned the questionnaire at T1. Of those, 72 patients completed the study after 7 months (T2); 64 patients underwent the SCID. Patients were mainly satisfied and felt safe during the evacuation. However, only 47% of them agreed with the amount of information passed on to their relatives. Anxiety and depression showed no significant alteration. PTSD and avoidance behaviour showed a higher prevalence compared with the general population (8.7% vs 6.5%, p<0.05). No correlation with cardiac diagnoses was observed. Conclusion: Emergency hospital evacuation of patients with cardiac diseases during a natural disaster such as a flood can be done safely without risking a PTSD in most of the patients independent of the underlying cardiac diagnosis. The data indicate that lack of broad information, both to the patients and their relatives in this setting, may be a relevant cause and promoter of anxiety and PTSD. Therefore special focus should be given to personalized care to prevent such apprehensive reactions. Sufficient information on the medical and current status of affected patients should be provided to both patients and their relatives in similar situations.
Objectives: Hepatitis A is an enterically transmitted disease that still remains endemic in many developing countries. In 1999, two earthquake disasters ruined the northwest region of Turkey, and particularly affected Duzce. The aim of this study was to determine seroprevalences of hepatitis A virus (HAV) infection before and after the earthquakes. Materials and methods: The study was conducted in two centres and data including 18 months before and after the earthquakes were examined. A total of 2796 patients were in the study group. Data were evaluted by seperating the groups into two age groups: group 1 (0–17.9 years; n = 1114), group 2 (>18 years; n = 1682). Serum samples were tested for anti‐HAV IgG antibodies by enzyme immunoassay (EIA). The χ2 test was used in all cases for statistical analysis. Results: The overall prevalences of HAV infection before and after the earthquakes were 71.3% and 89.4%, respectively. A significant increase in seropositivity was detected after the earthquakes (p<0.001). Seropositivity rates were not related to gender (p>0.05), but were higher in adults (p<0.05). Conclusion: People are at risk of acquiring infections transmitted by the faecal–oral route, such as HAV, in disasters, so screening programmes to determine the seroprevalence of hepatitis A should be planned, and vaccination strategies and other preventive measures must be revised.
Objectives: Victims of major disasters are at risk for development of post-traumatic stress disorder (PTSD). The aim of this study was to compare two groups of bereaved relatives from Italy and Sweden, and to examine the role of psychosocial support and psychological reactions 18 months after traumatic bereavement. Methods: In all, 153 bereaved relatives of deceased victims in the Milano/Linate aeroplane crash were assessed by a questionnaire. Reactions of psychological distress were measured by the Impact of Event Scale-Revised (IES-R). Results: In the whole group, 53.2% showed symptoms indicating that they might meet the DSM-IV criteria for PTSD. The frequency was higher among the Italian relatives (58.7%) compared with the Swedish relatives (42.6%). Females showed more signs of post-traumatic reactions compared with males in the total population, as did spouses and parents within the Italian group. The general health status, measured by subjective evaluation, was significantly affected in both groups as a result of the disaster. A significant recovery after 18 months was reported, although not to the pre-accident level. The Swedish relatives had a pattern of using more psychotherapy compared with the Italians, among whom it was more common to use medication for both anxiety and sleeping problems. The need for psychotherapy and medication was related to higher scores on IES-R. Conclusions: (1) Traumatic losses deeply affect bereaved relatives. Health is affected and a large group of these relatives develop strong symptoms of post-traumatic stress. (2) Swedish bereaved relatives seem to be more apt to ask for professional help, e.g. psychotherapy, while in Italy it is more common to rely on family, friends and medication. (3) Acute organized psychosocial support in the aftermath can possibly facilitate for victims to handle a traumatic loss but it does not prevent the development of strong post-traumatic reactions. Future investigations may show how it is possible to optimize the help with more specific interventions of support and treatment.
Objective: Ultrasound (US) is commonly used for the diagnosis of hemoperitoneum in trauma patients. The use of US in the evaluation of abdominal injury during multiple casualty incidents (MCIs) has been described, but never evaluated. The purpose of this study was to determine the accuracy of US for evaluation of the unique injury patterns associated with MICs. Patients and methods: We conducted a retrospective study of patients admitted to a Level 1 trauma center during MCIs resulting from terrorist attacks in the Tel‐Aviv area. Results: During the 4‐year study period there were 43 patients who had an US examination as part of their initial assessment. The overall accuracy of the US examination was 77%, with a sensitivity of 40%, and a specificity of 88%. The positive predictive value (PPV) was 50%, and the negative predictive value (NPV) was 83%. Conclusions: Although US examination lacks the sensitivity to be used alone in determining operative intervention in the evaluation of patients admitted in an MCI, a reasonable specificity might justify its use as a screening tool in MCIs.
Objectives: Three months after the 2005 earthquake in Pakistan, we carried out a mental health needs assessment on behalf of the World Health Organization (WHO) in one district. Here, we share our experience, to illustrate the challenges of undertaking such an assessment, under extreme circumstances and in resource‐poor settings. Materials and methods: We analysed service utilization data and conducted surveys of psychological problems in two tent villages using the GHQ‐12. In addition, we carried out a thematic analysis on data from a series of semi‐structured interviews with local people and field notes during key meetings and visits. Results: We found that, before the earthquake, mental health service provision in the district was extremely limited or non‐existent. We found evidence of considerable post‐disaster psychological distress and high service utilization. Notable themes from the interviews included lack of mental health service provision before the earthquake, and a reduction in social stigma associated with using mental health services after it. We found a readiness for participation in mental health promotion and support for integration of mental health services into primary care on the part of health care workers and community workers. Conclusion: Our findings are consistent with expectations of an increase in existing psychological morbidity post‐disaster. Results also support the integration of mental health services in primary care and the use of community‐based approaches to promote mental health. Given the extreme circumstances, our assessment was necessarily restricted; nevertheless, even such a limited exercise can yield valuable insights to inform service development.
Introduction: Events such as September 11, 2001, the 2005 tsunami in southeast Asia, and hurricane Katrina in the United States have emphasized the necessity for disaster medicine education in medical schools internationally. Society expects that physicians will be capable of planning for and managing the consequences to mankind of natural and man‐made disasters. Objective: The purpose of this systematic review was to examine articles related to disaster medicine in indexed peer‐reviewed journals, describing courses for medical students, physicians and medical military, before and after September 11, 2001. Method: This was a systematic review, from 1985 to 2006, in the English language, of four bibliographic databases (ERIC, MEDLINE, Embase, and Healthstar). Methodological quality assessment of courses described in the included articles was completed using the Learning Outcomes Inventory (LOI), which was developed to assess four key components for managing medical education: course objectives, course content, evaluation process, and target audience. Results: The initial search yielded 7595 research titles. With increasing specificity in inclusion and exclusion criteria, 54 articles (34 qualitative/20 quantitative) were retained, with 26 published before September 11, 2001 and 28 after. All articles were evaluated against the criteria from the LOI, resulting in 25 articles graded as weak, 25 as moderate, and 4 as strong. Conclusion: The body of knowledge in indexed peer‐reviewed journals concerning disaster medicine curriculum was limited in quantity and quality before September 11, 2001, but has improved dramatically since. This increase in quality and quantity of published articles is promising in view of the plethora of web‐based reports describing disaster medicine courses that have not been indexed or peer‐reviewed.
Objective: This study analyzed how effectively bacteria penetrate through a new filtering device (Muski™) aimed at providing temporary protection against hazardous air contaminants. Materials and methods: A 1.5–7×108 cfu/ml bacterial or spore suspension was aerosolized. Fragments of the Muski filter, previously sterilized by gamma rays, were placed in a sterile stainless steel Seitz filter holder, plugged into an Erlenmeyer vacuum flask connected to a vacuum pump to force the bacteria aerosol through the Muski filter. As a control the same apparatus was used without the Muski filter. To evaluate the bacteria passing through the apparatus, diluent solution was introduced in the Erlenmeyer flask, which was then subjected to mechanical shaking. Both the contents of Erlenmeyer flask and the diluent solution, used to rinse out the Erlenmeyer flask, were filtered through a membrane filtration apparatus. The filtration membrane was transferred to the surface of a Petri dish containing a suitable culture medium f...
(2006). Psychosocial issues following a natural disaster in a developing country: a qualitative longitudinal observational study. International Journal of Disaster Medicine: Vol. 4, No. 4, pp. 169-176.
This article discusses some of the lessons learned in recent disaster response efforts with regard to medical data transmission in disasters, along with various alternatives to the accomplishment of this task and their associated problem areas. One possible solution devised by the US Army and currently fielded will be discussed in detail – the BMIST‐J (Battlefield Medical Information System Tactical ‐ Joint).
Objectives: The aim of the study was to apply a mathematical model of medical disaster management to determine the medical resources for disasters in the Netherlands. Methods: Quantification of the medical management capacity requirements was based on the medical severity index model. Results: The medical rescue capacity, the medical transport capacity and the hospital treatment capacity requirements have been calculated for various numbers of mechanically injured disaster victims with three different medical severity factors (0.5, 1.0, 1.5) with a clearance time of the disaster area of 4 hours. Conclusion: The major objective of the publication is to invite researchers and managers to apply the mathematical models in order to further validate and refine the methodology.
Objectives: To investigate the possibility of delayed health effects of a natural disaster and develop insight into the circumstances where such delays may be likely, we examined the existing Haitian Health Foundation (HHF) database of children for the years surrounding the events of Hurricane Gilbert. Subjects and methods: The HHF database was limited to records of children with valid entries that were age 60 months or younger and who first entered the HHF program between the years of 1988 and 1992. This resulted in a sample of 4413 children available for the study. The outcomes for this study were malnutrition and mortality. Results: Haitian children appear to have been immediately affected by Hurricane Gilbert through increased levels of malnutrition and mortality. Even higher numbers of pediatric deaths were recorded throughout the following year, after which the number of deaths decreased and began a return toward pre‐Gilbert levels. Conclusion: Our study found substantial amounts of delayed mortality a year subsequent to Hurricane Gilbert. These findings suggest that additional planning for agricultural infrastructure support and for extended relief should be considered under certain circumstances, including situations where the affected area has food sources and infrastructure that are affected by the disaster and where the local population is highly dependent on these food sources and infrastructure.
