Effective Medical Response Research Articles

Determining optimal treatment rate after a disaster

From the standpoint of medical services, a disaster is a calamitous event resulting in an unexpected number of casualties that exceeds the therapeutic capacities of medical services. In these situations, effective medical response plays a crucial role in saving life. To model medical rescue activities, a two-priority non-preemptive S-server, and a finite capacity queueing system is considered. After constructing Chapman–Kolmogorov differential equations, Pontryagin's minimum principle is used to calculate optimal treatment rates for each priority class. The performance criterion is to minimize both the expected value of the square of the difference between the number of servers and the number of patients in the system, and also the cost of serving these patients over a determined time period. The performance criterion also includes a final time cost related to deviations from the determined value of the desired queue length. The two point boundary value problem is numerically solved for different arrival rate patterns and selected parameters.

ORGANIZATION OF AN EFFECTIVE MEDICAL RESPONSE FOR MORBIDITY AND MORTALITY IMMEDIATE REDUCTION AFTER AN EARTHQUAKE

This article presents the important issues of an effective medical response to catastrophic earthquakes, in conditions of international aid delay or to be insufficient. For that the local response system must ensure the primary medical assistance to disaster casualties until arrival and install of external aid. This work presents the most useful triage model of disaster casualties and the way to hospital arrival of casualties. Key words: Organization, efficient medical response, catastrophic disasters, triage, casualty’s evacuation and hospital admittance.

Descriptive analysis and lessons learned from the disaster medical response to an urban building collapse

An effective disaster medical response plan is imperative for any established emergency medicine program. Here we describe the response to an urban building collapse in Dar es Salaam, Tanzania, including a description of the event, type and severity of casualties, and lessons learned. We interviewed members of the medical response team and reviewed the treatment records and the results of the investigation. Several local hospitals sent personnel to assist at the site. The Muhimbili National Hospital Emergency Department (ED) sent staff to establish triage and provide stabilizing medical care, while another team remained in the ED and prepared to treat survivors. Of fifty nine casualties, 37 were dead at the scene. The most common injuries among the survivors were musculoskeletal and soft tissue trauma, including fractures, lacerations, and degloving injuries. All were stabilized on-site prior to transport to the hospital. The search and rescue efforts were hampered by a lack of resources. Heavy machinery, sufficient to clear the rubble and facilitate rescue efforts, was not immediately available. Private engineering companies later provided this equipment. Protective gear, such as hard hats, gloves, and boots were not available, thus some responders were injured while clearing the rubble and three were bitten by police dogs. Family members gathered at the scene to await news of survivors and some developed respiratory distress due to the dusty environment while others syncopized. The investigation revealed that the building was licensed for 10 floors, but construction continued illegally to 16 floors. Structural factors contributing to the collapse included poorly mixed concrete and substandard steel bars. This event highlights the importance of a well-developed disaster response plan, including coordination of medical and rescue workers. Additional policy and advocacy issues identified include the need for building safety code enforcement and available rescue supplies, equipment, and machinery.

Wind disasters: A comprehensive review of current management strategies

Wind disasters are responsible for tremendous physical destruction, injury, loss of life and economic damage. In this review, we discuss disaster preparedness and effective medical response to wind disasters. The epidemiology of disease and injury patterns observed in the early and late phases of wind disasters are reviewed. The authors highlight the importance of advance planning and adequate preparation as well as prompt and well-organized response to potential damage involving healthcare infrastructure and the associated consequences to the medical response system. Ways to minimize both the extent of infrastructure damage and its effects on the healthcare system are discussed, focusing on lessons learned from recent major wind disasters around the globe. Finally, aspects of healthcare delivery in disaster zones are reviewed.

Injury epidemiology after the 2001 Gujarat earthquake in India: a retrospective analysis of injuries treated at a rural hospital in the Kutch district immediately after the disaster

BackgroundThe number of injured far exceeds those dead and the average injury to mortality ratio in earthquakes stands at 3:1. Immediate effective medical response significantly influences injury outcomes and thus the overall health impact of earthquakes. Inadequate or mismanagement of injuries may lead to disabilities. The lack of precise data from immediate aftermath is seen as a remarkable weak point in disaster epidemiology and warrants evidence generation.ObjectiveTo analyze the epidemiology of injuries and the treatment imparted at a secondary rural hospital in the Kutch district, Gujarat, India following the January 26, 2001 earthquake.Design/MethodsDischarge reports of patients admitted to the hospital over 10 weeks were analyzed retrospectively for earthquake-related injuries.ResultsOrthopedic injuries, (particularly fractures of the lower limbs) were predominant and serious injuries like head, chest, abdominal, and crush syndrome were minimal. Wound infections were reported in almost 20% of the admitted cases. Surgical procedures were more common than conservative treatment. The most frequently performed surgical procedures were open reduction with internal fixation and cleaning and debridement of contaminated wounds. Four secondary deaths and 102 transfers to tertiary care due to complications were reported.ConclusionThe injury epidemiology reported in this study is in general agreement with most other studies reporting injury epidemiology except higher incidence of distal orthopedic injuries particularly to the lower extremities. We also found that young males were more prone to sustaining injuries. These results warrant further research. Inconsistent data reporting procedures against the backdrop of inherent disaster data incompleteness calls for urgent standardization of reporting earthquake injuries for evidence-based response policy planning.

Physically-based biodosimetry using in vivo EPR of teeth in patients undergoing total body irradiation

Purpose: The ability to estimate individual exposures to radiation following a large attack or incident has been identified as a necessity for rational and effective emergency medical response. In vivo electron paramagnetic resonance (EPR) spectroscopy of tooth enamel has been developed to meet this need.Materials and methods: A novel transportable EPR spectrometer, developed to facilitate tooth dosimetry in an emergency response setting, was used to measure upper incisors in a model system, in unirradiated subjects, and in patients who had received total body doses of 2 Gy.Results: A linear dose response was observed in the model system. A statistically significant increase in the intensity of the radiation-induced EPR signal was observed in irradiated versus unirradiated subjects, with an estimated standard error of dose prediction of 0.9 ± 0.3 Gy.Conclusions: These results demonstrate the current ability of in vivo EPR tooth dosimetry to distinguish between subjects who have not been irradiated and those who have received exposures that place them at risk for acute radiation syndrome. Procedural and technical developments to further increase the precision of dose estimation and ensure reliable operation in the emergency setting are underway. With these developments EPR tooth dosimetry is likely to be a valuable resource for triage following potential radiation exposure of a large population.

(A24) An Disaster Education Framework to Bridge Natural Disaster Medical Response and Primary Care Development in Developing Countries

IntroductionNatural disasters cannot be prevented but their human impact can be mitigated. Effective medical and public health mitigation and responses require multidisciplinary efforts and appropriate training. Whilst Asia is currently ranked as the most natural disaster prone area globally, limited disaster medical and public health response training opportunities are available in the region. Our paper reports efforts to identify the training gaps and ways to fill them to prepare frontline practitioners and academic researchers in disaster and medical humanitarian emergency relief efforts in Asia.MethodsGrounded on the disciplinary principles of academic training in public health, emergency & disaster medicine and primary care, our paper reviews the current disaster related academic training offered in these disciplines and maps out the training and knowledge gaps in disaster mitigation and response for frontline practitioners and academic researchers. We suggest ways to fill such gaps.ResultsA two-dimensional (clinical versus non-clinical), three-tier education training framework (Entrant level, Continuous medical education needs and Expertise level) is developed. Experiences and key training needs in Asia are highlighted.ConclusionThe proposed framework identifies areas for comprehensive training for medical and public health practitioners who are interested to engage in medical disaster relief. The proposed framework also aims to strengthen mitigation and response capacities in health systems.

(A282) Comparison of Safety Index in Iranian Hospitals

IntroductionHospitals are highly complex facilities that play a key role in the medical response to disasters. However, they are susceptible to the impact of disasters with respect to their structural, non-structural and functional elements. Many hospitals have collapsed or been damaged and rendered nonfunctional as a consequence of disasters. The resilience of a hospital along with the capability of effective medical response to disasters is a key part of a community based disaster plan.ObjectiveThe objective of this study was to evaluate and compare hospitals in Iran with respect to safety.MethodsThis study was performed as a survey in four hospitals in Iran. The Hospital Safety Index package from WHO was used as an evaluation tool. The evaluation team consisted of: a PhD in structural engineering, an architect with a Master's degree, a specialist in electrical and mechanical maintenance, a medical doctor, a specialist in disaster management, and an expert in health care planning. The hospitals were evaluated in three elements; structural, non-structural, and organizational. The hospital safety calculator was used.ResultsThe most important hazard for these hospitals was earthquakes. The structural safety at three hospitals was inadequate or at risk; and consequently needs intervention in a near future. Also, the administrative and organizational element of these hospitals was inadequate or at risk. All hospitals need intervention in the near future due to non-structural safety being inadequate. The overall safety index at one hospital was A (functional); in two hospitals B (at risk); and in one hospital C (inadequate).ConclusionsThe Iranian hospitals which had been assessed were on the whole unsafe. Also, these hospitals do not have a disaster management plan. Implementing a comprehensive disaster plan, including mitigation and a preparedness plan, would most likely enhance the safety of these hospitals.

Allocation of Scarce Resources After a Nuclear Detonation: Setting the Context

The purpose of this article is to set the context for this special issue of Disaster Medicine and Public Health Preparedness on the allocation of scarce resources in an improvised nuclear device incident. A nuclear detonation occurs when a sufficient amount of fissile material is brought suddenly together to reach critical mass and cause an explosion. Although the chance of a nuclear detonation is thought to be small, the consequences are potentially catastrophic, so planning for an effective medical response is necessary, albeit complex. A substantial nuclear detonation will result in physical effects and a great number of casualties that will require an organized medical response to save lives. With this type of incident, the demand for resources to treat casualties will far exceed what is available. To meet the goal of providing medical care (including symptomatic/palliative care) with fairness as the underlying ethical principle, planning for allocation of scarce resources among all involved sectors needs to be integrated and practiced. With thoughtful and realistic planning, the medical response in the chaotic environment may be made more effective and efficient for both victims and medical responders.

Medical Response to a Nuclear Detonation: Creating a Playbook for State and Local Planners and Responders

For efficient and effective medical responses to mass casualty events, detailed advanced planning is required. For federal responders, this is an ongoing responsibility. The US Department of Health and Human Services (DHHS) prepares playbooks with formal, written plans that are reviewed, updated, and exercised regularly. Recognizing that state and local responders with fewer resources may be helped in creating their own event-specific response plans, subject matter experts from the range of sectors comprising the Scarce Resources for a Nuclear Detonation Project, provided for this first time a state and local planner's playbook template for responding to a nuclear detonation. The playbook elements are adapted from DHHS playbooks with appropriate modification for state and local planners. Individualization by venue is expected, reflecting specific assets, populations, geography, preferences, and expertise. This playbook template is designed to be a practical tool with sufficient background information and options for step-by-step individualized planning and response.

Beyond the signaling effect role of amyloid-β 42 on the processing of APP, and its clinical implications

Alzheimer's disease (AD) currently has over 6 million victims in the USA, alone. The recently FDA approved drugs for AD only provide mild, transient relief for symptoms without addressing underlying mechanisms to a significant extent. Basic understanding of the activities of the amyloid β peptide (Aβ) and associated proteins such as β-site APP-cleaving enzyme 1 (BACE1) is necessary to develop effective medical responses to AD. Recently (Exper. Neurol. 2010. 221, 18–25), Tabaton et al. have presented a model of both non-pathological and pathological Aβ activities and suggest potential therapeutic pathways based on their proposed framework of Aβ acting as the signal that induces a kinase cascade, ultimately stimulating transcription factors that upregulate genes such as BACE1. We respond by presenting evidence of Aβ's other activities, including protection against metal-induced reactive oxidizing species (ROS), modification of cholesterol transport, and potential activity as a transcription factor in its own right. We touch upon clinical implications of each of these functions and highlight the currently unexplored implications of our suggested novel function of Aβ as a transcription factor. Aβ appears to be a highly multi-functional peptide, and any or all of the pathways it engages in is a likely candidate for antiAD drug development.

Predicting the Magnitude and Spatial Distribution of Potentially Exposed Populations during IND or RDD Terrorism Incidents

ABSTRACT Rapid delineation of the population potentially at risk from terrorist incidents involving an Improvised Nuclear Device (IND) or Radiological Dispersion Device (RDD) is necessary for effective medical response and incident management as part of the recovery process. The spatial interaction modeling framework presented estimates population magnitude and distribution at a geographical scale relevant for accurately estimating risk isopleths moving away from the detonation point for a 10KT IND and a 3.7 × 1013 Bq 241Am RDD. The methodology is applied to a set of illustrative release scenarios with varying meteorological parameters for wind speed, wind direction, and atmospheric stability. The analytical framework allocates population data for a representative urban area (≈1M people; 40 × 40 km area) within potential effects zones on a spatial basis for daytime and nighttime release scenarios.

Predicting Individual Radiation Sensitivity: Current and Evolving Technologies

In 2005, the National Institute of Allergy and Infectious Diseases (NIAID) of the U.S. National Institutes of Health established a Radiation/Nuclear Program to develop radioprotectors, mitigators and therapeutic agents to facilitate an effective medical response against radiological and nuclear threats. This program also supports development of biomarker/biodosimetry techniques and devices for rapid triage and treatment of radiation exposed individuals after any radiological event. In support of this program, NIAID in collaboration with the Columbia University Medical Center organized a workshop entitled Predicting Individual Radiation Sensitivity: Current and Evolving Technologies. The meeting was held at Columbia University in New York on March 17-18, 2008, and was attended by 86 participants from eight countries. The background to the Workshop relates to the need for mass biodosimetry and mitigation/therapy after a large-scale radiological event, both in regard to short-term sequelae and also in terms of long-term end points such as carcinogenesis and heart disease. While retrospective dose estimates provide information about average risks, it is known from studies of higher-dose radiotherapy that there is considerable person-to-person variability in response to a given radiation dose. Thus the goals of this Workshop were to assess the significance of interindividual radiation sensitivity in terms of the aftermath of a large-scale radiological event and to assess whether the approaches used at clinical doses can be translated to lower doses or whether different approaches will be needed. Session themes were:

Optimising the role of the public health community in planning and implementing large-scale evacuations

The public health community must advocate for the design and administration of plans and regulations that protect public health, promote effective medical response in evacuations, and require active participation by public health officials in evacuation planning. The public health response during recent natural disasters has highlighted the inadequacies of meeting the needs of complex populations of vulnerable individuals. Critical issues in the emergency management and public health systems with regard to the evaluation of a population are delineated, and potential solutions are suggested.

Public Health Response to An Anthrax Attack: An Evaluation of Vaccination Policy Options

A discrete-time, deterministic, compartmental model was developed and analyzed to provide insight into how the use of anthrax vaccine before or after a large-scale attack can reduce casualties. The model accounts for important response and protection factors such as antibiotic and vaccine efficacy, the protective effects of buildings, the timing of emergency response, and antibiotic adherence and vaccine coverage in the population prior to the attack. The relative benefit of pre- versus post-exposure vaccination is influenced by the timing of the post-exposure antibiotic distribution campaign as well as assumptions of antibiotic adherence. The results indicate that, regardless of which vaccination policy is adopted, a rapid and effective post-attack medical response has a large impact on the number of lives that can be saved by a post-exposure prophylaxis (PEP) campaign. A sensitivity analysis of the model indicates that uncertainty in medical efficacy and the time to initiate a PEP campaign are the model parameters that have the greatest impact on the number of predicted deaths. It is shown that for each day that a mass prophylaxis campaign is delayed, more casualties and deaths result than for each day that the completion of the campaign is delayed.

Characteristics of Medical Surge Capacity Demand for Sudden‐impact Disasters

To describe the characteristics of the demand for medical care during sudden-impact disasters, focusing on local U.S. communities and the initial phases of sudden-impact disasters. Established databases and published reports were used as data sources. Data were obtained to describe the baseline capacity of the U.S. medical system. Information for the initial phases of a sudden-impact disaster was sought to allow for characterization of the length of time before a U.S. community can expect arrival of outside assistance, the expected types of medical surge demands, the expected time for the peak in medical-care demand, and the expected health system access points. The earliest that outside assistance arrived for a community subject to a sudden-impact disaster was 24 hours, with a range from 24 to 96 hours. After sudden-impact disasters, 84% to 90% of health care demand was for conditions that were managed on an ambulatory basis. Emergency departments (EDs) were the access point for care, with peak demand time occurring within 24 hours. The U.S. emergency care system was functioning at relatively full capacity on the basis of data collected for the study that showed that annually, 90% of EDs were boarding admitted inpatients, and 75% were diverting ambulances. As part of planning for sudden-impact disasters, communities should be expected to sustain medical services for 24 hours, and up to 96, before arrival of external resources. For effective medical surge-capacity response during sudden-impact disasters, there should be a priority for emergency medical care with a focus on ambulatory injuries and illnesses.

Public health issues in disasters

This article outlines a number of important areas in which public health can contribute to making overall disaster management more effective. This article discusses health effects of some of the more important sudden impact natural disasters and potential future threats (e.g., intentional or deliberately released biologic agents) and outlines the requirements for effective emergency medical and public health response to these events. All natural disasters are unique in that each affected region of the world has different social, economic, and health backgrounds. Some similarities exist, however, among the health effects of different natural disasters, which if recognized, can ensure that health and emergency medical relief and limited resources are well managed.

Syndromic surveillance for infectious disease outbreaks using chief complaint data

Study objectives: Although the ubiquitous threat of biochemical terrorism has spurred newfound interest in disease surveillance, the current set of systems has limited ability to rapidly detect and report an outbreak. By focusing on real-time analysis of patient chief complaint data, this investigation seeks to eliminate the inherent delay in current surveillance systems. The objective is to compare a real-time computerized tracking system to rapid laboratory testing for disease surveillance using influenza as a model. Methods: All patients presenting to the adult and pediatric emergency departments (EDs) of a university teaching hospital with chief complaints of and flu-like illness from October 2004 through December 2004 were included. Using a computerized patient tracking system, patient age, sex, chief complaint, and ZIP code were collected and correlated with the documented outbreak of the 2003 to 2004 influenza season as indicated by the total daily number of positive rapid influenza tests. Determinations of an increase in the number of chief complaints of concern were based on the CUSUM statistic. In addition, these surveillance data were also compared with chief complaint data collected from many EDs within the Nashville area by the Metropolitan Nashville Health Department. Results: It was found that, although chief complaints of flu or fever effectively mirrored flu diagnosis, our surveillance system did not appreciably improve use of rapid influenza testing. The real-time nature of this investigation, however, yielded a novel use for this system in its predictive ability concerning the course of the outbreak and subsequent allowance for improved hospital response time through informed staffing decisions. Conclusion: Although our findings indicate that syndromic surveillance from a single institution may not result in a more effective influenza outbreak detection in a moderate-sized city, they also suggest that real-time analysis of this evolving outbreak would prove valuable in mounting an effective medical response.

Implications of pandemic influenza for bioterrorism response.

The 1918-1919 influenza pandemic (Spanish flu) had catastrophic effects upon urban populations in the United States. Large numbers of frightened, critically ill people overwhelmed health care providers. Mortuaries and cemeteries were severely strained by rapid accumulation of corpses of flu victims. Understanding of the outbreak's extent and effectiveness of containment measures was obscured by the swiftness of the disease and an inadequate health reporting system. Epidemic controls such as closing public gathering places elicited both community support and resistance, and fear of contagion incited social and ethnic tensions. Review of this infamous outbreak is intended to advance discussions among health professionals and policymakers about an effective medical and public health response to bioterrorism, an infectious disease crisis of increasing likelihood. Elements of an adequate response include building capacity to care for mass casualties, providing emergency burials that respect social mores, properly characterizing the outbreak, earning public confidence in epidemic containment measures, protecting against social discrimination, and fairly allocating health resources.

The role of the emergency physician in the management of Jehovah's Witnesses

Patients presenting to the emergency department who refuse recommended treatment present substantial management and medicolegal problems for the emergency physician. Members of the Jehovah's Witness religion, who number approximately 700,000 in the United States, create specific medical, ethical, and legal challenges when they require but refuse necessary blood component therapy. Appropriate management involves timely medical intervention, an awareness of the religious rights and beliefs of Jehovah's Witnesses and a sound understanding of the ramifications of their emergency care. A protocol is presented for responding to opposition to transfusions by Jehovah's Witnesses. The protocol should increase the likelihood of an effective medical and ethical response by emergency physicians and should help to protect against potential legal actions.