Comprehensive Review
Burden of Cardiovascular Morbidity and Mortality Following Humanitarian Emergencies: A Systematic Literature Review
- Kaitlin G. Hayman, Davina Sharma, Robert D. Wardlow II, Sonal Singh
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- Published online by Cambridge University Press:
- 15 December 2014, pp. 80-88
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Background
The global burden of cardiovascular mortality is increasing, as is the number of large-scale humanitarian emergencies. The interaction between these phenomena is not well understood. This review aims to clarify the relationship between humanitarian emergencies and cardiovascular morbidity and mortality.
MethodsWith assistance from a research librarian, electronic databases (PubMed, Scopus, CINAHL, and Global Health) were searched in January 2014. Findings were supplemented by reviewing citations of included trials. Observational studies reporting the effect of natural disasters and conflict events on cardiovascular morbidity and mortality in adults since 1997 were included. Studies without a comparison group were not included. Double-data extraction was utilized to abstract information on acute coronary syndrome (ACS), acute decompensated heart failure (ADHF), and sudden cardiac death (SCD). Review Manager 5.0 (Version 5.2, The Nordic Cochrane Centre; Copenhagen Denmark,) was used to create figures for qualitative synthesis.
ResultsThe search retrieved 1,697 unique records; 24 studies were included (17 studies of natural disasters and seven studies of conflict). These studies involved 14,583 cardiac events. All studies utilized retrospective designs: four were population-based, 15 were single-center, and five were multicenter studies. Twenty-three studies utilized historical controls in the primary analysis, and one utilized primarily geographical controls.
DiscussionConflicts are associated with an increase in long-term morbidity from ACS; the short-term effects of conflict vary by study. Natural disasters exhibit heterogeneous effects, including increased occurrence of ACS, ADHF, and SCD.
ConclusionsIn certain settings, humanitarian emergencies are associated with increased cardiac morbidity and mortality that may persist for years following the event. Humanitarian aid organizations should consider morbidity from noncommunicable disease when planning relief and recuperation projects.
. ,Hayman KG ,Sharma D ,Wardlow RD II .Singh S Burden of Cardiovascular Morbidity and Mortality Following Humanitarian Emergencies: A Systematic Literature Review . Prehosp Disaster Med.2015 ;30 (1 ):1 -9
Case Report
Intra-articular Placement of an Intraosseous Catheter
- Zachary Grabel, J. Mason DePasse, Craig R. Lareau, Christopher T. Born, Alan H. Daniels
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- Published online by Cambridge University Press:
- 08 December 2014, pp. 89-92
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Gaining vascular access is essential in the resuscitation of critically ill patients. Intraosseous (IO) placement is a fundamentally important alternative to intravenous (IV) access in conditions where IV access delays resuscitation or is not possible. This case report presents a previously unreported example of prehospital misplacement of an IO catheter into the intra-articular space of the knee joint. This report serves to inform civilian and military first responders, as well as emergency medicine physicians, of intra-articular IO line placement as a potential complication of IO vascular access. Infusion of large amounts of fluid into the joint space could damage the joint and be catastrophic to a patient who needs immediate IV fluids or medications. In addition, intra-articular IO placement could result in septic arthritis of the knee.
. ,Grabel Z ,DePasse JM ,Lareau CR ,Born CT .Daniels AH Intra-articular Placement of an Intraosseous Catheter . Prehosp Disaster Med.2015 ;30 (1 ):1 -4
Original Research
Pneumonia Prevention during a Humanitarian Emergency: Cost-effectiveness of Haemophilus Influenzae Type B Conjugate Vaccine and Pneumococcal Conjugate Vaccine in Somalia
- Lisa M. Gargano, Rana Hajjeh, Susan T. Cookson
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- Published online by Cambridge University Press:
- 10 June 2015, pp. 402-411
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Background
Pneumonia is a leading cause of death among children less than five years old during humanitarian emergencies. Haemophilus influenzae type b (Hib) and Streptococcus pneumoniae are the leading causes of bacterial pneumonia. Vaccines for both of these pathogens are available to prevent pneumonia.
ProblemThis study describes an economic analysis from a publicly funded health care system perspective performed on a birth cohort in Somalia, a country that has experienced a protracted humanitarian emergency.
MethodsAn impact and cost-effectiveness analysis was performed comparing: no vaccine, Hib vaccine only, pneumococcal conjugate vaccine 10 (PCV10) only, and both together administered through supplemental immunization activities (SIAs). The main summary measure was the incremental cost per disability-adjusted life-years (DALYs) averted. One-way sensitivity analysis was conducted for uncertainty in parameter values.
ResultsEach SIA would avert a substantial number of cases and deaths. Compared with no vaccine, the DALYs averted by two SIAs for two doses of Hib vaccine was US $202.93 (lower and upper limits: $121.80-$623.52), two doses of PCV10 was US $161.51 ($107.24-$227.21), and two doses of both vaccines was US $152.42 ($101.20-$214.42). Variables that influenced the cost-effectiveness for each strategy most substantially were vaccine effectiveness, case fatality rates (CFRs), and disease burden.
ConclusionsThe World Health Organization (WHO) defines a cost-effective intervention as costing one to three times the per capita gross domestic product (GDP; in 2011, for Somalia=US $112). Based on the presented model, Hib vaccine alone, PCV10 alone, or Hib vaccine and PCV10 given together in SIAs are cost-effective interventions in Somalia. The WHO/Strategic Advisory Group of Experts decision-making factors for vaccine deployment appear to have all been met: the disease burden is large, the vaccine-related risk is low, prevention in this setting is more feasible than treatment, the vaccine duration probably is sufficient for the vulnerable period of the child’s life, cost is reasonable, and herd immunity is possible.
,Gargano LM ,Hajjeh R .Cookson ST Pneumonia Prevention during a Humanitarian Emergency: Cost-effectiveness of Haemophilus Influenzae Type B Conjugate Vaccine and Pneumococcal Conjugate Vaccine in Somalia . Prehosp Disaster Med.2015 ;30 (4 ):1 10 .
Brief Report
Water Supply Facility Damage and Water Resource Operation at Disaster Base Hospitals in Miyagi Prefecture in the Wake of the Great East Japan Earthquake
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- Takashi Matsumura, Shizuka Osaki, Daisuke Kudo, Hajime Furukawa, Atsuhiro Nakagawa, Yoshiko Abe, Satoshi Yamanouchi, Shinichi Egawa, Teiji Tominaga, Shigeki Kushimoto
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- Published online by Cambridge University Press:
- 09 February 2015, pp. 193-198
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Introduction
The aim of this study was to shed light on damage to water supply facilities and the state of water resource operation at disaster base hospitals in Miyagi Prefecture (Japan) in the wake of the Great East Japan Earthquake (2011), in order to identify issues concerning the operational continuity of hospitals in the event of a disaster.
MethodsIn addition to interview and written questionnaire surveys to 14 disaster base hospitals in Miyagi Prefecture, a number of key elements relating to the damage done to water supply facilities and the operation of water resources were identified from the chronological record of events following the Great East Japan Earthquake.
ResultsNine of the 14 hospitals experienced cuts to their water supplies, with a median value of three days (range = one to 20 days) for service recovery time. The hospitals that could utilize well water during the time that water supply was interrupted were able to obtain water in quantities similar to their normal volumes. Hospitals that could not use well water during the period of interruption, and hospitals whose water supply facilities were damaged, experienced significant disruption to dialysis, sterilization equipment, meal services, sanitation, and outpatient care services, though the extent of disruption varied considerably among hospitals. None of the hospitals had determined the amount of water used for different purposes during normal service or formulated a plan for allocation of limited water in the event of a disaster.
ConclusionThe present survey showed that it is possible to minimize the disruption and reduction of hospital functions in the event of a disaster by proper maintenance of water supply facilities and by ensuring alternative water resources, such as well water. It is also clear that it is desirable to conclude water supply agreements and formulate strategic water allocation plans in preparation for the eventuality of a long-term interruption to water services.
. ,Matsumura T ,Osaki S ,Kudo D ,Furukawa H ,Nakagawa A ,Abe Y ,Yamanouchi S ,Egawa S ,Tominaga T .Kushimoto S Water Supply Facility Damage and Water Resource Operation at Disaster Base Hospitals in Miyagi Prefecture in the Wake of the Great East Japan Earthquake . Prehosp Disaster Med.2015 ;30 (2 ):1 -5
War Wounded and Victims of Traffic Accidents in a Surgical Hospital in Africa: An Observation on Injuries
- Martin Schneider
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- Published online by Cambridge University Press:
- 21 October 2015, pp. 618-620
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Introduction
Weapon injuries in armed conflict are likely to receive medical attention. Other types of injuries, like traffic accidents, continue to occur during armed conflict.
ProblemInjuries caused by weapons and by traffic accidents require treatment, but reports and figures to help in prioritizing care are scarce.
MethodsIn a prospective observational study, all emergency patients admitted to the surgical ward in a public hospital of the Central African Republic were evaluated for the cause of their main injury. The proportion of patients injured by weapons and by traffic accidents was analyzed with respect to the level of violence.
ResultsSeventy-eight patients were included in this study. Weapon injuries accounted for 50 (64%) admissions and traffic accidents for 28 (36%). These proportions varied significantly according to the weekly level of violence (χ2=46.8; P<.001).
ConclusionPeople injured in traffic accidents are an important, but overlooked, drain on surgical resources in low-income countries with armed conflict. Their proportion in relation to weapon wounded fluctuates with the level of violence. Humanitarian medical organizations might prepare themselves not only for weapon injuries, but also for wounds caused by traffic accidents.
.Schneider M War Wounded and Victims of Traffic Accidents in a Surgical Hospital in Africa: An Observation on Injuries . Prehosp Disaster Med.2015 ;30 (6 ):618 –620 .
Comprehensive Review
Exertional Heat Illness: Emerging Concepts and Advances in Prehospital Care
- Riana R. Pryor, Ronald N. Roth, Joe Suyama, David Hostler
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- 10 April 2015, pp. 297-305
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Exertional heat illness is a classification of disease with clinical presentations that are not always diagnosed easily. Exertional heat stroke is a significant cause of death in competitive sports, and the increasing popularity of marathons races and ultra-endurance competitions will make treating many heat illnesses more common for Emergency Medical Services (EMS) providers. Although evidence is available primarily from case series and healthy volunteer studies, the consensus for treating exertional heat illness, coupled with altered mental status, is whole body rapid cooling. Cold or ice water immersion remains the most effective treatment to achieve this goal. External thermometry is unreliable in the context of heat stress and direct internal temperature measurement by rectal or esophageal probes must be used when diagnosing heat illness and during cooling. With rapid recognition and implementation of effective cooling, most patients suffering from exertional heat stroke will recover quickly and can be discharged home with instructions to rest and to avoid heat stress and exercise for a minimum of 48 hours; although, further research pertaining to return to activity is warranted.
,Pryor RR ,Roth RN ,Suyama J .Hostler D Exertional Heat Illness: Emerging Concepts and Advances in Prehospital Care . Prehosp Disaster Med.2015 ;30 (3 ):1 9 .
Brief Reports
Development of an Online Toolkit for Measuring Performance in Health Emergency Response Exercises
- Foluso Agboola, Dorothy Bernard, Elena Savoia, Paul D. Biddinger
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- Published online by Cambridge University Press:
- 15 September 2015, pp. 503-508
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Introduction
Exercises that simulate emergency scenarios are accepted widely as an essential component of a robust Emergency Preparedness program. Unfortunately, the variability in the quality of the exercises conducted, and the lack of standardized processes to measure performance, has limited the value of exercises in measuring preparedness.
MethodsIn order to help health organizations improve the quality and standardization of the performance data they collect during simulated emergencies, a model online exercise evaluation toolkit was developed using performance measures tested in over 60 Emergency Preparedness exercises. The exercise evaluation toolkit contains three major components: (1) a database of measures that can be used to assess performance during an emergency response exercise; (2) a standardized data collection tool (form); and (3) a program that populates the data collection tool with the measures that have been selected by the user from the database. The evaluation toolkit was pilot tested from January through September 2014 in collaboration with 14 partnering organizations representing 10 public health agencies and four health care agencies from eight states across the US. Exercise planners from the partnering organizations were asked to use the toolkit for their exercise evaluation process and were interviewed to provide feedback on the use of the toolkit, the generated evaluation tool, and the usefulness of the data being gathered for the development of the exercise after-action report.
ResultsNinety-three percent (93%) of exercise planners reported that they found the online database of performance measures appropriate for the creation of exercise evaluation forms, and they stated that they would use it again for future exercises. Seventy-two percent (72%) liked the exercise evaluation form that was generated from the toolkit, and 93% reported that the data collected by the use of the evaluation form were useful in gauging their organization’s performance during the exercise. Seventy-nine percent (79%) of exercise planners preferred the evaluation form generated by the toolkit to other forms of evaluations.
ConclusionResults of this project show that users found the newly developed toolkit to be user friendly and more relevant to measurement of specific public health and health care capabilities than other tools currently available. The developed toolkit may contribute to the further advancement of developing a valid approach to exercise performance measurement.
,Agboola F ,Bernard D ,Savoia E .Biddinger PD Development of an Online Toolkit for Measuring Performance in Health Emergency Response Exercises . Prehosp Disaster Med.2015 ;30 (5 ):503 –508 .
Original Research
The Development of a Humanitarian Health Ethics Analysis Tool
- Veronique Fraser, Matthew R. Hunt, Sonya de Laat, Lisa Schwartz
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- 11 June 2015, pp. 412-420
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Introduction
Health care workers (HCWs) who participate in humanitarian aid work experience a range of ethical challenges in providing care and assistance to communities affected by war, disaster, or extreme poverty. Although there is increasing discussion of ethics in humanitarian health care practice and policy, there are very few resources available for humanitarian workers seeking ethical guidance in the field. To address this knowledge gap, a Humanitarian Health Ethics Analysis Tool (HHEAT) was developed and tested as an action-oriented resource to support humanitarian workers in ethical decision making.
While ethical analysis tools increasingly have become prevalent in a variety of practice contexts over the past two decades, very few of these tools have undergone a process of empirical validation to assess their usefulness for practitioners.
MethodsA qualitative study consisting of a series of six case-analysis sessions with 16 humanitarian HCWs was conducted to evaluate and refine the HHEAT.
ResultsParticipant feedback inspired the creation of a simplified and shortened version of the tool and prompted the development of an accompanying handbook.
ConclusionThe study generated preliminary insight into the ethical deliberation processes of humanitarian health workers and highlighted different types of ethics support that humanitarian workers might find helpful in supporting the decision-making process.
,Fraser V ,Hunt MR ,de Laat S .Schwartz L The Development of a Humanitarian Health Ethics Analysis Tool . Prehosp Disaster Med.2015 ;30 (4 ):1 9 .
Comprehensive Review
Child Debriefing: A Review of the Evidence Base
- Betty Pfefferbaum, Anne K. Jacobs, Pascal Nitiéma, George S. Everly, Jr.
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- Published online by Cambridge University Press:
- 14 April 2015, pp. 306-315
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Introduction
Debriefing, a controversial crisis intervention delivered in the early aftermath of a disaster, has not been well evaluated for use with children and adolescents. This report constitutes a review of the child debriefing evidence base.
MethodsA systematic search of selected bibliographic databases (EBM Reviews, EMBASE, ERIC, Medline, Ovid, PILOTS, PubMed, and PsycINFO) was conducted in the spring of 2014 using search terms related to psychological debriefing. The search was limited to English language sources and studies of youth, aged 0 to 18 years. No time limit was placed on date of publication. The search yielded 713 references. Titles and abstracts were reviewed to select publications describing scientific studies and clinical reports. Reference sections of these publications, and of other literature known to the authors that was not generated by the search, were used to locate additional materials. Review of these materials generated 187 publications for more thorough examination; this assessment yielded a total of 91 references on debriefing in children and adolescents. Only 15 publications on debriefing in children and adolescents described empirical studies. Due to a lack of statistical analysis of effectiveness data with youth, and some articles describing the same study, only seven empirical studies described in nine papers were identified for analysis for this review. These studies were evaluated using criteria for assessment of methodological rigor in debriefing studies.
ResultsChildren and adolescents included in the seven empirical debriefing studies were survivors of motor-vehicle accidents, a maritime disaster, hostage taking, war, or peer suicides. The nine papers describing the seven studies were characterized by inconsistency in describing the interventions and populations and by a lack of information on intervention fidelity. Few of the studies used randomized design or blinded assessment. The results described in the reviewed studies were mixed in regard to debriefing’s effect on posttraumatic stress, depression, anxiety, and other outcomes. Even in studies in which debriefing appeared promising, the research was compromised by potentially confounding interventions.
ConclusionThe results highlight the small empirical evidence base for drawing conclusions about the use of debriefing with children and adolescents, and they call for further dialogue regarding challenges in evaluating debriefing and other crisis interventions in children.
,Pfefferbaum B ,Jacobs AK ,Nitiéma P Everly GS Jr. Child Debriefing: A Review of the Evidence Base . Prehosp Disaster Med.2015 ;30 (3 ):1 10 .
Brief Report
A Modified Simple Triage and Rapid Treatment Algorithm from the New York City (USA) Fire Department
- Faizan H. Arshad, Alan Williams, Glenn Asaeda, Douglas Isaacs, Bradley Kaufman, David Ben-Eli, Dario Gonzalez, John P. Freese, Joan Hillgardner, Jessica Weakley, Charles B. Hall, Mayris P. Webber, David J. Prezant
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- Published online by Cambridge University Press:
- 17 February 2015, pp. 199-204
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Introduction
The objective of this study was to determine if modification of the Simple Triage and Rapid Treatment (START) system by the addition of an Orange category, intermediate between the most critically injured (Red) and the non-critical, non-ambulatory injured (Yellow), would reduce over- and under-triage rates in a simulated mass-casualty incident (MCI) exercise.
MethodsA computer-simulation exercise of identical presentations of an MCI scenario involving a 2-train collision, with 28 case scenarios, was provided for triaging to two groups: the Fire Department of the City of New York (FDNY; n = 1,347) using modified START, and the Emergency Medical Services (EMS) providers from the Eagles 2012 EMS conference (Lafayette, Louisiana USA; n = 110) using unmodified START. Percent correct by triage category was calculated for each group. Performance was then compared between the two EMS groups on the five cases where Orange was the correct answer under the modified START system.
ResultsOverall, FDNY-EMS providers correctly triaged 91.2% of cases using FDNY-START whereas non-FDNY-Eagles providers correctly triaged 87.1% of cases using unmodified START. In analysis of the five Orange cases (chest pain or dyspnea without obvious trauma), FDNY-EMS performed significantly better using FDNY-START, correctly triaging 86.3% of cases (over-triage 1.5%; under-triage 12.2%), whereas the non-FDNY-Eagles group using unmodified START correctly triaged 81.5% of cases (over-triage 17.3%; under-triage 1.3%), a difference of 4.9% (95% CI, 1.5-8.2).
ConclusionsThe FDNY-START system may allow providers to prioritize casualties using an intermediate category (Orange) more properly aligned to meet patient needs, and as such, may reduce the rates of over-triage compared with START. The FDNY-START system decreases the variability in patient sorting while maintaining high field utility without needing computer assistance or extensive retraining. Comparison of triage algorithms at actual MCIs is needed; however, initial feedback is promising, suggesting that FDNY-START can improve triage with minimal additional training and cost.
. ,Arshad FH ,Williams A ,Asaeda G ,Isaacs D ,Kaufman B ,Ben-Eli D ,Gonzalez D ,Freese JP ,Hillgardner J ,Weakley J ,Hall CB ,Webber MP .Prezant DJ A Modified Simple Triage and Rapid Treatment Algorithm from the New York City (USA) Fire Department . Prehosp Disaster Med.2015 ;30 (2 ):1 -6
Case Report
Mass-casualty Response to the Kiss Nightclub in Santa Maria, Brazil
- Silvana T. Dal Ponte, Carlos F. D. Dornelles, Bonnie Arquilla, Christina Bloem, Patricia Roblin
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- 29 December 2014, pp. 93-96
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On January 27, 2013, a fire at the Kiss Nightclub in Santa Maria, Brazil led to a mass-casualty incident affecting hundreds of college students. A total of 234 people died on scene, 145 were hospitalized, and another 623 people received treatment throughout the first week following the incident.1 Eight of the hospitalized people later died.1 The Military Police were the first on scene, followed by the state fire department, and then the municipal Mobile Prehospital Assistance (SAMU) ambulances. The number of victims was not communicated clearly to the various units arriving on scene, leading to insufficient rescue personnel and equipment. Incident command was established on scene, but the rescuers and police were still unable to control the chaos of multiple bystanders attempting to assist in the rescue efforts. The Municipal Sports Center (CDM) was designated as the location for dead bodies, where victim identification and communication with families occurred, as well as forensic evaluation, which determined the primary cause of death to be asphyxia. A command center was established at the Hospital de Caridade Astrogildo de Azevedo (HCAA) in Santa Maria to direct where patients should be admitted, recruit staff, and procure additional supplies, as needed. The victims suffered primarily from smoke inhalation and many required endotracheal intubation and mechanical ventilation. There was a shortage of ventilators; therefore, some had to be borrowed from local hospitals, neighboring cities, and distant areas in the state. A total of 54 patients1 were transferred to hospitals in the capital city of Porto Alegre (Brazil). The main issues with the response to the fire were scene control and communication. Areas for improvement were identified, namely the establishment of a disaster-response plan, as well as regularly scheduled training in disaster preparedness/response. These activities are the first steps to improving mass-casualty responses.
. ,Dal Ponte ST ,Dornelles CFD ,Arquilla B ,Bloem C .Roblin P Mass-casualty Response to the Kiss Nightclub in Santa Maria, Brazil . Prehosp Disaster Med.2015 ;30 (1 ):1 -4
Helicopter In-flight Resuscitation with Freeze-dried Plasma of a Patient with a High-velocity Gunshot Wound to the Neck in Afghanistan – A Case Report
- Mikael Gellerfors, Joacim Linde, Dan Gryth
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- 01 September 2015, pp. 509-511
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Massive hemorrhage with coagulopathy is one of the leading causes of preventable death in the battlefield. The development of freeze-dried plasma (FDP) allows for early treatment with coagulation-optimizing resuscitation fluid in the prehospital setting. This report describes the first prehospital use of FDP in a patient with carotid artery injury due to a high-velocity gunshot wound (HVGSW) to the neck. It also describes in-flight constitution and administration of FDP in a Medevac Helicopter. Early administration of FDP may contribute to hemodynamic stabilization and reduction in trauma-induced coagulopathy and acidosis. However, large-scale studies are needed to define the prehospital use of FDP and other blood products.
,Gellerfors M ,Linde J .Gryth D Helicopter In-flight Resuscitation with Freeze-dried Plasma of a Patient with a High-velocity Gunshot Wound to the Neck in Afghanistan – A Case Report . Prehosp Disaster Med.2015 ;30 (5 ):509 –511 .
Case Reports
Mass-gathering Events: The Public Health Challenge of the Kumbh Mela 2013
- Suresh Dwivedi, Mudera P. Cariappa
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- Published online by Cambridge University Press:
- 19 October 2015, pp. 621-624
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Mass-gathering (MG) events pose challenges to the most adept of public health practitioners in ensuring the health safety of the population. These MGs can be for sporting events, musical festivals, or more commonly, have religious undertones. The Kumbh Mela 2013 at Allahabad, India may have been the largest gathering of humanity in history with nearly 120 million pilgrims having thronged the venue. The scale of the event posed a challenge to the maintenance of public health security and safety. A snapshot of the experience of managing the hygiene and sanitation aspects of this mega event is presented herein, highlighting the importance of proactive public health planning and preparedness. There having been no outbreaks of disease is vindication of the steps undertaken in planning and preparedness, notwithstanding obvious limitations of insanitary behaviors and traditional beliefs of those attending the festival. The evident flaw on post-event analyses was the failure to cater adequately for environmental mopping-up operations after the festival. Besides, a system of real-time monitoring of disease and morbidity patterns, harnessing low cost technology alternatives, should be planned for at all such future events.
,Dwivedi S .Cariappa MP Mass-gathering Events: The Public Health Challenge of the Kumbh Mela 2013 . Prehosp Disaster Med.2015 ;30 (6 ):621 –624 .
Potential Exposure to Ebola Virus from Body Fluids due to Ambulance Compartment Permeability in Sierra Leone
- Megan L. Casey, Duong T. Nguyen, Barrie Idriss, Sarah Bennett, Angela Dunn, Stephen Martin
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- Published online by Cambridge University Press:
- 28 October 2015, pp. 625-627
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Introduction
Prehospital care, including patient transport, is integral in the patient care process during the Ebola response. Transporting ill persons from the community to Ebola care facilities can stop community spread. Vehicles used for patient transport in infectious disease outbreaks should be evaluated for adequate infection prevention and control.
ProblemAn ambulance driver in Sierra Leone attributed his Ebola infection to exposure to body fluids that leaked from the patient compartment to the driver cabin of the ambulance.
MethodsA convenience sample of 14 vehicles used to transport patients with suspected or confirmed Ebola in Sierra Leone were assessed. The walls separating the patient compartment and driver cabin in these vehicles were evaluated for structural integrity and potential pathways for body fluid leakage. Ambulance drivers and other staff were asked to describe their cleaning and decontamination practices. Ambulance construction and design standards from the National Fire Protection Association, US General Services Administration, and European Committee on Standardization (CEN) were reviewed.
ResultsMany vehicles used by ambulance staff in Sierra Leone were not traditional ambulances, but were pick-up trucks or sport-utility vehicles that had been assembled or modified for patient transport. The wall separating the patient compartment and driver cabin in many vehicles did not have a waterproof seal around the edges. Staff responsible for cleaning and disinfection did not thoroughly clean bulk body fluids with disposable towels before disinfection of the patient compartment. Pressure from chlorine sprayers used in the decontamination process may have pushed body fluids from the patient compartment into the driver cabin through gaps around the wall. Ambulance design standards do not require a waterproof seal between the patient compartment and driver cabin. Sealing the wall by tightening or replacing existing bolts is recommended, followed by caulking of all seams with a sealant.
ConclusionWaterproof separation between the patient compartment and driver cabin may be essential for patient transport vehicles in infectious disease outbreaks, especially when chlorine sprayers are used for decontamination or in resource-limited settings where cleaning supplies may be limited.
,Casey ML ,Nguyen DT ,Idriss B ,Bennett S ,Dunn A .Martin S Potential Exposure to Ebola Virus from Body Fluids due to Ambulance Compartment Permeability in Sierra Leone . Prehosp Disaster Med.2015 ;30 (6 ):625 –627 .
Case Report
Maxillofacial Gunshot Wounds
- Olga Maurin, Stanislas de Régloix, Stéphane Dubourdieu, Hugues Lefort, Stéphane Boizat, Benoit Houze, Jennifer Culoma, Guillaume Burlaton, Jean-Pierre Tourtier
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- Published online by Cambridge University Press:
- 14 April 2015, pp. 316-319
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The majority of maxillofacial gunshot wounds are caused by suicide attempts. Young men are affected most often. When the lower one-third of the face is involved, airway patency (1.6% of the cases) and hemorrhage control (1.9% of the cases) are the two most urgent complications to monitor and prevent. Spinal fractures are observed with 10% of maxillary injuries and in 20% of orbital injuries. Actions to treat the facial gunshot victim need to be performed, keeping in mind spine immobilization until radiographic imaging is complete and any required spinal stabilization accomplished. Patients should be transported to a trauma center equipped to deal with maxillofacial and neurosurgery because 40% require emergency surgery. The mortality rate of maxillofacial injuries shortly after arrival at a hospital varies from 2.8% to 11.0%. Complications such as hemiparesis or cranial nerve paralysis occur in 20% of survivors. This case has been reported on a victim of four gunshot injuries. One of the gunshots was to the left mandibular ramus and became lodged in the C4 vertebral bone.
,Maurin O ,de Régloix S ,Dubourdieu S ,Lefort H ,Boizat S ,Houze B ,Culoma J ,Burlaton G .Tourtier JP Maxillofacial Gunshot Wounds . Prehosp Disaster Med.2015 ;30 (3 ):1 4 .
Maxillofacial Injury—Not Always a Difficult Airway
- John Glasheen, David Hennelly, Stephen Cusack
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- 21 May 2015, pp. 421-424
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The optimal method for securing the airway in injured patients is controversial. Maxillofacial injury has been shown to be a marker for difficult airway management; however, a delay in intubation may result in deterioration of intubating conditions due to further airway bleeding and swelling. Decisions on the timing and method of airway management depend on multiple factors, including patient characteristics, the skill set of the clinicians, and logistical considerations. This report describes the case of a multi-agency response to a motor-vehicle collision in a rural area in Ireland. One young male patient had sustained significant maxillofacial injuries, multiple limb injuries, and had a decreased level of consciousness. Further airway compromise occurred following extrication. Difficult intubation was predicted; however, abnormal jaw mobility from bilateral mandibular fractures enabled easy laryngoscopy and intubation. Although preparation must be made for difficult airway management in the setting of maxillofacial injury, appropriately trained and experienced practitioners should not be deterred from performing early intubation when indicated.
,Glasheen J ,Hennelly D .Cusack S Maxillofacial Injury—Not Always a Difficult Airway . Prehosp Disaster Med.2015 ;30 (4 ):1 –4 .
Comprehensive Review
Literature Review on Medical Incident Command
- Rune Rimstad, Geir Sverre Braut
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- Published online by Cambridge University Press:
- 09 February 2015, pp. 205-215
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Introduction
It is not known what constitutes the optimal emergency management system, nor is there a consensus on how effectiveness and efficiency in emergency response should be measured or evaluated. Literature on the role and tasks of commanders in the prehospital emergency services in the setting of mass-casualty incidents has not been summarized and published.
ProblemThis comprehensive literature review addresses some of the needs for future research in emergency management through three research questions: (1) What are the basic assumptions underlying incident command systems (ICSs)? (2) What are the tasks of ambulance and medical commanders in the field? And (3) How can field commanders’ performances be measured and assessed?
MethodsA systematic literature search in MEDLINE, PubMed, PsycINFO, Embase, Cochrane Central Register of Controlled Trials, Cochrane Library, ISI Web of Science, Scopus, International Security & Counter Terrorism Reference Center, Current Controlled Trials, and PROSPERO covering January 1, 1990 through March 1, 2014 was conducted. Reference lists of included literature were hand searched. Included papers were analyzed using Framework synthesis.
ResultsThe literature search identified 6,049 unique records, of which, 76 articles and books where included in qualitative synthesis. Most ICSs are described commonly as hierarchical, bureaucratic, and based on military principles. These assumptions are contested strongly, as is the applicability of such systems. Linking of the chains of command in cooperating agencies is a basic difficulty. Incident command systems are flexible in the sense that the organization may be expanded as needed. Commanders may command by direction, by planning, or by influence. Commanders’ tasks may be summarized as: conducting scene assessment, developing an action plan, distributing resources, monitoring operations, and making decisions. There is considerable variation between authors in nomenclature and what tasks are included or highlighted. There are no widely acknowledged measurement tools of commanders’ performances, though several performance indicators have been suggested.
ConclusionThe competence and experience of the commanders, upon which an efficient ICS has to rely, cannot be compensated significantly by plans and procedures, or even by guidance from superior organizational elements such as coordination centers. This study finds that neither a certain system or structure, or a specific set of plans, are better than others, nor can it conclude what system prerequisites are necessary or sufficient for efficient incident management. Commanders need to be sure about their authority, responsibility, and the functional demands posed upon them.
. ,Rimstad R .Braut GS Literature Review on Medical Incident Command . Prehosp Disaster Med.2015 ;30 (2 ):1 -11
Special Report
Cardiopulmonary Resuscitation in Resource-limited Health Systems–Considerations for Training and Delivery
- Jason Friesen, Dean Patterson, Kevin Munjal
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- Published online by Cambridge University Press:
- 19 November 2014, pp. 97-101
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In the past 50 years, cardiopulmonary resuscitation (CPR) has gained widespread recognition as a life-saving skill that can be taught successfully to the general public. Cardiopulmonary resuscitation can be considered a cost-effective intervention that requires minimal classroom training and low-cost equipment and supplies; it is commonly taught throughout much of the developed world. But, the simplicity of CPR training and its access for the general public may be misleading, as outcomes for patients in cardiopulmonary arrest are poor and survival is dependent upon a comprehensive “chain-of-survival,” which is something not achieved easily in resource-limited health care settings. In addition to the significant financial and physical resources needed to both train and develop basic CPR capabilities within a community, there is a range of ethical questions that should also be considered. This report describes some of the financial and ethical challenges that might result from CPR training in low- and middle-income countries (LMICs). It is determined that for many health care systems, CPR training may have financial and ethically-deleterious, unintended consequences. Evidence shows Basic Life Support (BLS) skills training in a community is an effective intervention to improve public health. But, health care systems with limited resources should include CPR training only after considering the full implications of that intervention.
. ,Friesen J ,Patterson D .Munjal K Cardiopulmonary Resuscitation in Resource-limited Health Systems–Considerations for Training and Delivery . Prehosp Disaster Med.2015 ;30 (1 ):1 -5
Special Reports
Research and Evaluations of the Health Aspects of Disasters, Part I: An Overview
- Marvin L. Birnbaum, Elaine K. Daily, Ann P. O’Rourke, Alessandro Loretti
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- Published online by Cambridge University Press:
- 09 October 2015, pp. 512-522
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The ultimate goals of conducting disaster research are to obtain information to: (1) decrease risks that a hazard will produce a disaster; (2) decrease the mortality associated with disasters; (3) decrease the morbidity associated with disasters; and (4) enhance recovery of the affected community. And decrease the risks that a hazard will produce a disaster. Two principal, but inter-related, branches of disaster research are: (1) Epidemiological; and (2) Interventional. Epidemiological research explores the relationships and occurrences that comprise a disaster from a particular event. Interventional research involves evaluations of interventions, whether they are directed at relief, recovery, hazard mitigation, capacity building, or performance. In response to the need for the discipline of Disaster Health to build its science on data that are generalizeable and comparable, a Disaster Logic Model (DLM) and a set of five Frameworks have been developed to structure the information and research of the health aspects of disasters. These Frameworks consist of the: (1) Conceptual; (2) Temporal; (3) Societal; (4) Relief/Recovery; and (5) Risk-Reduction Frameworks. The Frameworks provide a standardized format for studying and comparing the epidemiology of disasters, and with the addition of the DLM, for evaluating the interventions (responses) provided prior to, during, and following a disaster, especially as they relate to the health status of the people affected by, or at-risk for, a disaster. Critical to all five Frameworks is the inclusion of standardized definitions of the terms. The Conceptual Framework describes the progression of a hazard that becomes an event, which causes structural damage, which, in turn, results in compromised, decreased, or losses of function(s) (functional damage) that, in turn, produce needs that lead to an emergency or a disaster. The Framework incorporates a cascade of risks that lead from the presence of a hazard to the development of a disaster. Risk is the likelihood that each of the steps leading from a hazard to a disaster will take place, as well as the probabilities of consequences of each of the elements in the Conceptual Framework. The Temporal Framework describes this chronological progression as phases in order of their appearance in time; some may occur concurrently. In order to study and compare the effects of an event on the complex amalgam that constitutes a community, the essential functions of a community have been deconstructed into 13 Societal Systems that comprise the Societal Framework. These diverse, but inter-related, Societal Systems interface with each other through a 14th System, Coordination and Control. The DLM can be used to identify the effects, costs, outcomes, and impacts of any intervention. Both the Relief/Recovery and Risk-Reduction Frameworks are based on the DLM. The Relief/Recovery Framework provides the structure necessary to systematically evaluate the processes involved in interventions provided during the Relief or Recovery phases of a disaster. The Risk-Reduction Framework details the processes involved in interventions aimed at mitigating the risk that a hazard will produce a destructive event, and/or in capacity building to augment the resilience of a community to the consequences of such an event.
,Birnbaum ML ,Daily EK ,O’Rourke AP .Loretti A Research and Evaluations of the Health Aspects of Disasters, Part I: An Overview . Prehosp Disaster Med.2015 ;30 (5 ):512 –522 .
Special Report
Recent Advances in Medical Device Triage Technologies for Chemical, Biological, Radiological, and Nuclear Events
- Krystal Lansdowne, Christopher G. Scully, Loriano Galeotti, Suzanne Schwartz, David Marcozzi, David G. Strauss
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- Published online by Cambridge University Press:
- 14 April 2015, pp. 320-323
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In 2010, the US Food and Drug Administration (Silver Spring, Maryland USA) created the Medical Countermeasures Initiative with the mission of development and promoting medical countermeasures that would be needed to protect the nation from identified, high‐priority chemical, biological, radiological, or nuclear (CBRN) threats and emerging infectious diseases. The aim of this review was to promote regulatory science research of medical devices and to analyze how the devices can be employed in different CBRN scenarios. Triage in CBRN scenarios presents unique challenges for first responders because the effects of CBRN agents and the clinical presentations of casualties at each triage stage can vary. The uniqueness of a CBRN event can render standard patient monitoring medical device and conventional triage algorithms ineffective. Despite the challenges, there have been recent advances in CBRN triage technology that include: novel technologies; mobile medical applications (“medical apps”) for CBRN disasters; electronic triage tags, such as eTriage; diagnostic field devices, such as the Joint Biological Agent Identification System; and decision support systems, such as the Chemical Hazards Emergency Medical Management Intelligent Syndromes Tool (CHEMM-IST). Further research and medical device validation can help to advance prehospital triage technology for CBRN events.
,Lansdowne K ,Scully CG ,Galeotti L ,Schwartz S ,Marcozzi D .Strauss DG Recent Advances in Medical Device Triage Technologies for Chemical, Biological, Radiological, and Nuclear Events . Prehosp Disaster Med.2015 ;30 (3 ):1 -4