A Mega Mass-Casualty Event (MMCE) is a unique and exceptional event, that results in a very large number of casualties (500–5000) needing emergency care in the prehospital and hospital settings. This type of event usually goes beyond the capabilities of a certain region and requires reinforcement of resources from adjacent and remote regions. Due to its exceptional nature, a MMCE dictates a different organization of all emergency services and agencies involved. As a result of the recent experience, and in order to adequately prepare for such future events, a novel MMCE doctrine was developed by a committee of diverse emergency professionals. This doctrine was transferred to guidelines referring to MMCE recognition and the following series of actions that need to taken at all levels. It holds organizational, operational, and clinical aspects, as well as command and control elements. In November 2009, a large-scale drill of 1,000 mock casualties was performed in order to validate and evaluate the MMCE plan. This drill emphasized the need for the involvement of all pertinent emergency services and agencies, and their optimal collaboration and coordination, subjected to regional and national headquarters' command and control. In addition, the need for dedicated educational programs and o-going training was recognized. It was accepted that adequate planning is obligatory for better outcomes in the future.

Asian tsunami in 2004 had a tremendous impact on the health system of Sri Lanka leaving many healthcare institutions damaged in the costal provinces and destabilizing the healthcare delivery network. Immediately after the tsunami, health authorities in Sri Lanka realized, health workers should be prepared well if they are to face any future disasters successfully. In this background, the Ministry of Health set its agenda to train all levels of health cadres on disaster preparedness and mitigation whenever there are opportunities. Ministry of Health established the Tsunami Rehabilitation Unit (TRU), later renamed as Disaster Preparedness and Response Unit (DPRU) and mandated it to prepare the health sector for future disasters. During a disaster, well trained health cadre is an asset to any health manager facing the burden of the emergency at the ground level. Trained health personnel on disaster management become a human resource multiplier to fill the gaps of scarce skilled health staff in the field operations. We reviewed the Ministry of Health reports, plans, meeting minutes, reports of training institutions, routine reporting from Ministry of Health departments and reports from health sector partners to compile and then analyze to construct this case study. We provide an overview of how DPRU coordinated and used the opportunities following Tsunami 2004 and then during the humanitarian crisis at the end of 30 years of armed conflict in 2009 to train the health staff. This case study also describes how DPRU networked with government and non governmental organizations to train the different categories of government health staff.

Western Australia (WA) was one of the first states in Australia to deploy medical team members to the tsunami-stricken regions of the Maldives and Banda Aceh in 2004. This early experience led the WA Department of Health to develop and pilot these teams locally and to progress a national model for their future development, which could be implemented further by other Australian jurisdictions. Further experience with these teams in Yogyakarta after the 2006 Java earthquake, Karratha after Tropical Cyclone George in 2007, Ashmore Reef after the 2009 boat explosion, Samoa after the 2009 tsunami, and during the Pakistan floods in 2010 have signaled both the utility of the Australian Medical Assistance Teams (AUSMATs) and the commitment by the Australian Commonwealth and State Governments to utilize these teams in both domestic and international settings. This presentation will examine the implementation of the AUSMAT model in Australia over the last five years, the modifications to the original model to suit the unique geographical and resource challenges faced by Australian teams, both within and outside Australia, and the lessons learned from recent team deployments. The challenges of delivering health care over vast, sparsely populated distances, and the inherent and increasing natural and industrial disaster threats in the Asia-Pacific region, have contributed to the modification of the model to ensure that the AUSMATs are flexible, modular, and capable of responding to a variety of major incidents. The national model continues to evolve to ensure that well prepared, equipped and trained civilian AUSMATS remain able to effectively deploy to a mass casualty situation in Australia's area of interest.

Despite technological advancements, India is vulnerable to disasters. Disasters of any etiology have the common denominator of a large number of deaths in a short span of time. Thus, the Administration is saddled with the indomitable task of retrieving and recovering dead bodies, then identifying them to enable the handing over of the remains to their next-of-kin. Initial media focus is often based on the myth that dead bodies cause epidemics. Therefore, bodies often are placed in mass burials or mass cremations universally, without being identified and without preserving the individuality of the deceased. This culminates into social, psychological, emotional, economic, and legal repercussions (financial compensation, property rights, inheritance, and issues of remarriage) regarding the legacy of the deceased, thereby exacerbating the damage caused by disasters. With the paradigm shift from the erstwhile response-centric approach after the enactment of the Disaster Management Act in 2005, to the holistic management of disasters, the National Disaster Management Authority embarked on the task of formulating the guidelines on this sensitive and vital issue. These Guidelines are designed to provide not only technical information, but also dwell on administrative aspects that will support the correct approach in handling dead bodies with the highest possible quality of standards/measures, and functioning in an interdisciplinary manner to ensure positive identification of victims. Management of the dead after disasters is under the ambit of the Incident Response System being incorporated in the National, State and District “all hazard” Disaster Management Plans are intended to achieve the desired aim that no unidentified body should be laid to rest.

The first decade of the 21st century will go down in history as an era of major disasters. Disasters have occurred in all corners of the world and ranged from events such as the 11 September attack, the London bombings, the Asian Tsunami, Hurricane Katrina, earthquakes in India, Iran, Pakistan, China, and Haiti, and cyclones and floods in Bangladesh and Myanmar. The unavoidable common factor of all these disasters was the massive number of casualties and deceased witnessed within a short period. The effective intervention of governmental agencies to manage casualties during the immediate aftermath of a disaster often is restricted by many technical and circumstantial factors. However, it was observed during the last decade that during disasters, volunteer members of the affected and surrounding communities form a huge supportive force to meet most urgent tasks, including managing the dead. This was best witnessed in 2004, after the Asian tsunami disaster. The management of the dead during disasters is a multidisciplinary, multi-stage task and a medico-legal emergency that should be commenced during the immediate post-disaster period. Community first responders comprise an easily accessible, readily available task force in the field of managing the dead, especially in the recovery and transportation of dead during disasters. The first attempt to regularize the role of community first responders during disasters was made in 2005 with the post-Asian tsunami experience through a joined effort of many international organizations. Since then, south Asian countries have been more concerned about developing capacity of first responders via community-based disaster management schemes. The services of first responders could be greatly enhanced through training and integrating them into mass casualty management plans in less resourced countries as elaborated in this paper.

During the authors' recent experience in Haiti during the early aftermath of a major earthquake, it was discovered that more optimal use of field hospitals could be achieved through increased coordination across the deployed medical resources. Moreover, if it were possible to standardize both the capabilities of these resources and their inter-operational guidelines, further improvement in resource utilization could be achieved. Resolving the bottleneck particularly was crucial as the impact on mortality that specialized field hospitals may affect in disasters is observed primarily early on. Confronted with tremendous need in the face of massive devastation, a solution was improvised: For every patient requiring a higher level of care sent by a light hospital, it would have to take a patient being cared for by the authors' in exchange. This arrangement allowed the admission patients who had been screened by other health professionals as requiring an acute intervention that the authors were in a unique position to provide, and ensured that patients would remain under medical care until they were stable enough to be discharged. Additionally, senior medical staff to light hospitals to help identify which patients would most likely benefit from being transferred to the authors' facility. With the other hospital teams' cooperation, surgeons performed needed morbidity and mortality reducing operations on more patients than would have otherwise been possible. Implementing a collaborative healthcare system would help achieve more optimal use of all the medical resources available in a disaster. Further optimization could likely be achieved if participating countries and organizations adhered to a standardized classification and coordination system. Both levels of coordination, at the preparatory and deployment stages, would likely lead to decreased mortality, morbidity, and disability among the devastated population.

El programa se estableció en el año 2006 dentro de la Coordinación General de Protección Civil de la Secretaría de Gobernación e incluye un Comité Nacional de Evaluación, Diagnóstico y Certificación integrado por todas las instituciones del Sector Salud Público, Privado y Social Se han acreditado cerca de 700 evaluadores de más de 2,700 que han tomado el curso. Se han realizado más de 1,700 autoevaluaciones y se han evaluado de 205 hospitales. En el marco legal se ha integrado el Programa Hospital Seguro en la Ley General de Protección Civil, se ha incluido en la Norma Oficial Mexicana que tiene relación con instalaciones de salud, se ha logrado el acceso al Fondo de Prevención de Desastres que maneja la Secretaría de Gobernación y se ha establecido que previo a la Certificación de Calidad del Consejo de Salubridad General (que incluye los criterios internacionales de la Joint Commission) sea evaluada como Hospital Seguro. De los hospitales calificados como no seguros ya se han evacuado dos (que serán demolidos) con alternativa de construir nuevos con alto nivel de seguridad. En un gran número de hospitales se han mejorado los sistemas de detección de incendios, rutas de evacuación y escaleras de emergencias, entre otros

This proposal considers the recent events in the Gulf of Mexico during the British Petroleum MC 252 explosion and subsequent spill. It will discuss the challenges and innovative solutions applied by those involved in the Safety and Pre-hospital medical branch of the Deepwater Horizon spill response. First, it examines the logistical and practical challenges faced by emergency medicine planners working with a large temporary workforce on a HAZMAT scene for many months. It will also discuss the geographic challenges with working on dock sites that existed in local communities with mostly a rural medicine and hospital system, while also considering the potential for ambulance and further pre-hospital support. Impacts resulting from the public/private Incident Command Structure (ICS) will also be discussed liberally throughout the presentation. The author is the former Emergency Response Coordinator for one of BP's largest contractors in charge of the Vessels of Opportunity (VOO) and Near-Shore Skimming (NSS) programs. He was in charge of coordinating all emergency medicine in multiple US states throughout the response. It will analyze the multi-layered approach taken by on-site contractors in addressing these issues from a planning and operational perspective. Planners discovered that a uniform, one-size-fits-all approach applied by the Unified Area Command in New Orleans was virtually inapplicable to sites that had unique geographic and personnel characteristics. Furthermore those who involved in cleanup work in the Gulf had very different requirements than those on-shore. Therefore, site-specific personnel had to adapt to conditions while working within the framework established in New Orleans in order to satisfy ICS guidelines and ensure that emergency medicine in local communities was not overwhelmed. Lessons for future responses will be discussed, as there will be an examination of both the land-based NSS and the water-borne VOO programs.

Impacto Socioeconómico del “Huracán Karl” sobre instalaciones de salud en Veracruz, México con una población de 7 millones 600 mil habitantes en Septiembre del año 2010 Resumen. El huracán Karl, decimotercer ciclón tropical de la temporada de huracanes en el Atlántico de 2010, se originó en el mar Caribe e impactó en la península de Yucatán como una tormenta tropical fuerte, hasta emerger al golfo de México donde se reorganizó gradualmente hasta alcanzar la categoría 3 (huracán mayor) en la escala de Saffir-Simpson e impactó la costa oriental de México el 17 de septiembre del año 2010. Preparativos. El 16 de septiembre, el Gobierno Federal, la Comisión Federal de Electricidad, la Central Nuclear Laguna Verde, la Secretaría de Defensa Nacional, la Secretaría de Gobernación y de Marina desplegaron elementos humanos y materiales para el auxilio a la población. El Sector Salud igualmente se preparó tomando las medidas convenientes bajo el concepto de Hospital Seguro de la OPS/OMS. Impacto En el estado de Veracruz (más de 7 millones 600 mil habitantes), el Huracán Karl tocó tierra cerca de las 11:30 am del 17 de septiembre a 15 km al norte del puerto de Veracruz alcanzando una potencia de 195 km por hora. Las lluvias torrenciales del fenómeno inundaron las calles y avenidas del centro histórico del puerto, alcanzando el agua de 40 centímetros a 1 metro de altura, hacia el sur del Estado y en zonas periféricas llegó hasta los 2 metros de altura. Provocó serios daños desde su inicio a la infraestructura de salud, como la suspensión de electricidad pública, daño al sistema de distribución de agua potable, ruptura de ventanales e inundación de un hospital así como de varias Unidades de Medicina Familiar.

Il n'est pas d'hommes politiques ou de grands responsables qui ne souhaitent l'égalité du citoyen face aux agressions, chacun recherchant au travers d'une doctrine unique une réponse adaptée en tout point du territoire et chaque jour de l'année. Meme si les types de détresse ont évolué et le recours au centre d'appel est devenu habituel, demandant aux secouristes professionnels de s'adapter le vrai drame ou le chronomètre et les compétences sont essentiels, reste le challenge des services de secours. Mais comment, dans le panel des différentes formations techniques et des types de matériel, adapter dans une doctrine que l'on voudrait unique, une marche générale des opérations efficiente. Le secours á personnes que l'on pense réserver exclusivement aux professionnels de santé ne doit il pas être aussi la préoccupation du sauveteur citoyen. La premiùre minute reste essentielle, elle est quelque soit le type d'agression de la responsabilité du premier maillon de la chaine du premier témoin sur les lieux. Alors doctrine unique, difficile, utilisation des compétences, surement. Un code des bons gestes á effectuer au bon moment au bon endroit semble capital, un référentiel sur les responsabilités de chacun indispensable et l'égalité des chances un objectif.

La réalisation de gestes de secours adaptés par le premier témoin diminue la mortalité et réduit les séquelles pour les survivants après accident et détresse vitale. L'Académie Nationale de Médecine Française a souhaité, dans un rapport adopté en juin 2010 une systématisation des obligations de formation de la population au secourisme, soulignant le retard de la France en la matière. L'Automobile Club Médical de France (ACMF) souhaite rebondir sur la dynamique induite par ce travail afin de concevoir un programme spécifique de premiers secours aux accidentés de la route. Il souhaite une généralisation rapide de son enseignement à tous les candidats aux permis de conduire. L'objectif d'avoir lors de chaque accident du trafic un premier témoin capable de maintenir la survie des victimes en attendant l'arrivée des secours professionnels est clair. Le contenu de cet enseignement et les modalités pédagogiques sont en cours de réflexion par un groupe réuni à l'initiative de l'ACMF. Cette proposition sera soumise à l'observatoire national du secourisme en charge de la validation des contenus. La séquence de formation ainsi retenue aura vocation à devenir le module de base pour la formation des usagers de la route, à l'image du module “Alerter-Masser-Défibriller” dans le domaine de l'urgence cardiaque. Nous présenterons donc les principales causes et les statistiques estimées de morts évitables par l'intervention des premiers témoins.Puis nous décrirons les gestes réalisables par tout citoyen formé: alerte rapide et adaptée, prévention des sur-accidents, libération des voies aériennes supérieures, arrêt des saignements visibles. Ce programme sera une formation courte, pratique et gestuelle.

Infirmier Pompier L'infirmier sapeur pompier est aujourd'hui en France un maillon fort de l'organisation des secours. Originaire d'exercices très variés, il dispose d'une culture commune aux sapeurs pompiers mais aussi á ses collègues infirmiers sur l'ensemble du territoire. Doté de moyens performants il arrive en renfort de ses collègues secouristes rapidement sur les lieux des détresses mais aussi prend une part active dans l'ensemble des missions qui leurs sont confiés comme la médecine d'aptitude, le soutien sanitaire, la médecine préventive. Il est au centre d'un réseau complexe, aidé par tous les outils des nouvelles technologies de communications disponibles et l'avancée de la télémédecine. Acteur incontesté des secours de proximité, il a néanmoins mis de longues années avant de trouver sa place et n'est á ce jour que difficilement accepté. Incompréhension, méconnaissance, absence d'explications, les ë képis noirs  / voient en cet officier un parvenu qui n'a pas mérité ses galons. Mais savent ils réellement ce qu'il en est ? Comme á l'hôpital, l'infirmier doit savoir tout faire, sans faire tout. Il doit se limiter á des règles professionnelles dictées par le bon sens médical mais aussi par le corporatisme important enclin chez nous. L'infirmier, un acteur aux multiples facettes mais au seul uniforme.

La doctrine classique, en cas d'accident catastrophique en contexte chimique, consiste á confier aux sauveteurs (porteurs d'une tenue d'isolation leur permettant de ne pas Être eux-mêmes contamines) l'extraction et la décontamination d'urgence des victimes. Le médecin n'intervient alors qu'après passage des victimes dans la chaine de décontamination. Ce concept est actuellement remis en cause au vu des retours d'expérience. La plupart des accidents catastrophiques référencés sont constitués d'accidents Á effet limité, et se situent dans une dimension d'espace et de temps réduite. La présence médicale en zone d'exclusion apportera au moins les Eléments favorables suivants: •Caractérisation plus rapide du toxique sur une analyse séméiologique fine

• • Pratique de gestes de survie (exsufflation d'un pneumothorax suffocant, intubation d'un trauma crânien inconscient, remplissage d'une hypo volhémie aiguë administration précoce d'un antidote)

• • Soutien des Équipes de sauvetage

• • Anticipation Évolutive au vu de la nature du toxique en cause (décision d'administration de l'antidote, méta-triage des victimes)

• • Une présence médicale en zone d'exclusion devra Être précoce et donc susceptible d'amputer les effectifs médicaux initialement présents sur le terrain

• • La présence d'un médecin implique de sa part une discipline et une intégration parfaites au sein des Équipes de secours, soulignant la nécessité d'un entrainement régulier

• • Le travail en tenue de décontamination comporte des conséquences ergonomiques certaines, ralentissant la pratique des gestes techniques, et imposant des relèves

• • Une présence médicale implique un renfort logistique (réapprovisionnement en drogues et matériel)

• • Le médecin devra constamment garder Á l'esprit le contexte d'accident catastrophique pour ne pas ralentir le processus d'Évacuation de la zone contaminée

L'analyse du rapport favorable/défavorable concernant la présence médicale en zone d'exclusion lors d'un accident catastrophique en contexte chimique incite Á recommander cette présence, recommandation reprise dans les textes officiels récents.

Flood is one of the most common disasters and contributes to many-disaster related deaths worldwide. According to the EM-DAT database, floods account for 38.7% of all incidences, 6.2% of the deaths and every year 43% of world population is affected by flood. There are various factors which magnify the impact of flood to the community in the catchment area. The nature and extent of the flood is determined by the physical location and topography, and by the built environment. The built environment comprises of the existing political, social and economic structures inherent in a community. In the post-flood period, the risk of diarrhoea is significantly higher for those with lower educational level, living in a household with a non-concrete roof, drinking tube-well water (vs. tap water), using a distant water source and unsanitary toilets. The 1998 Bangladesh flood study confirms that low socio-economic groups and poor hygiene and sanitation groups are most vulnerable to flood-related diarrhoea (Annya et al., 2010). The Bihar flood of 2008 affected 100 villages out of which Supaul, Araria, Saharsa, Madhepura and Purnea were the most severly affected districts. Nearly 2.5 million people were affected by the floodwater. Various disease outbreaks are a common phenomenon in a post flood scenario. In Bihar, the population witnessed outbreaks of malaria, diarrhoea, measles and cholera. This paper examines the various factors causing diarrhoeal spread in the five flood affected districts of Bihar. Also, the paper analyses the above factors in terms of most contributing and least contributing factor towards diarrhoeal outbreak. The methodology used for the study is the statistical tool of Standard Multiple Regression Analyses where several independent variables will predict the dependent variable. The various independent variables have been taken all the five affected districts in Bihar floods. They are malnutrition, population density, awareness levels, socio-economic conditions, literacy, extent of flood and availability of health facilities. These independent variables will determine how much each predicts the dependent variable and as a result help in analysing the linear relationship between the dependent and independent variables.

An unprecedented cholera outbreak affected Zimbabwe from August 2008 to July 2009 with 98,592 cases and 4,288 deaths, in 54 out of 62 districts. The main strategy used to overcome the outbreak was an integrated community-based interventions package. The present work is a case study to describe the strategy and lessons learned for future humanitarian crises and preparedness. The methodology was based on the review of epidemiological reports, assessment and surveys' reports, minutes of joint Health and Water Sanitation and Hygiene (WASH) Clusters' meetings, and direct observation as Health Cluster Coordinator. Epidemiological data showed an increasing number of cases in rural areas with community deaths representing 66% of the 1,948 deaths from 61,304 cases on 31 January 2009. Risk factors identified in communities were: lack of awareness about the disease, cultural and religious behaviors, lack of potable water with weak sanitation, lack and inappropriate use of water purification tablets, and lack of soap and water containers for effective behavior change. There also was late arrival to cholera to the few treatment centers by rural populations. In addition to treatment centers, a package of interventions was implemented by multi-sectoral stakeholders. The package included: health and WASH education tools and practice sessions for healthy and hygienic behavior change and for an effective use of oral rehydration salt as first aid measure; community-based surveillance with an early warning system and response teams; and distribution of containers and water purification tablets with drilling of water points. Epidemiological data showed a significant decrease of cholera cases where the full package was implemented. This work showed that an integrated package of interventions jointly targeting risk factors can be effective on public health threats in rural communities. Community-based preparedness and response should then take into account an integrated joint intervention package to mitigate public health threats.