Proper management of mass-casualty incidents (MCIs) relies on triage as a critical component of the disaster plan.

The objective of this study was to assess the precision of triage in mass-casualty incidents.

The precision of decisions made by two experienced triage officers was examined in two large MCIs. These decisions were compared to the real severity of injury as defined by the Israeli Defence Forces (IDF) classification of severity of injuries and the Injury Severity Score (ISS).

Two experienced trauma physicians triaged a total of 94 casualties into 77 mild, seven moderate, and 10 severe casualties. Based on the IDF criteria, there were 74 mild, five moderate, and 15 severe casualties. Based on ISS scoring, there were 78 mild (ISS <9), five moderate (9 ≤ISS<16), and 11 severe (ISS < 16) casualties. Of 15 severely injured victims defined by the IDF classification of injury severity, the triage officers identified only seven (47%).

Primary triage, even when carried out by experienced trauma physicians, can be unreliable in a MCI.

On 04 September 2005, 1,589 Hurricane Katrina evacuees from the New Orleans area arrived in Oklahoma. The Oklahoma State Department of Health conducted a rapid needs assessment of the evacuees housed at a National Guard training facility to determine the medical and social needs of the population in order to allocate resources appropriately.

A standardized questionnaire that focused on individual and household evacuee characteristics was developed. Households from each shel-ter building were targeted for surveying, and a convenience sample was used.

Data were collected on 197 households and 373 persons. When com-pared with the population of Orleans Parish, Louisiana, the evacuees sampled were more likely to be male, black, and 45–64 years of age. They also were less likely to report receiving a high school education and being employed pre-hurricane. Of those households of <1 persons, 63% had at least one missing household member. Fifty-six percent of adults and 21% of children reported having at least one chronic disease. Adult women and non-black persons were more likely to report a pre-existing mental health condition. Fourteen percent of adult evacuees reported a mental illness that required medication pre-hur-ricane, and eight adults indicated that they either had been physically or sex-ually assaulted after the hurricane. Approximately half of adults reported that they had witnessed someone being severely injured or dead, and 10% of per-sons reported that someone close to them (family or friend) had died since the hurricane. Of the adults answering questions related to acute stress disor-der, 50% indicated that they suffered at least one symptom of the disorder.

The results from this needs assessment highlight that the evac-uees surveyed predominantly were black, of lower socio-economic status, and had substantial, pre-existing medical and mental health concerns. The evac-uees experienced multiple emotional traumas, including witnessing grotesque scenes and the disruption of social systems, and had pre-existing psy-chopathologies that predisposed this population to post-traumatic stress dis-order (Post-traumatic Stress Disorder).x When disaster populations are displaced, mental health and social service providers should be available immediately upon the arrival of the evacuees, and should be integrally coordinated with the relief response. Because the displaced population is at high risk for disaster-related mental health problems, it should be monitored closely for persons with PTSD. This displaced population will likely require a substantial re-establishment of financial, medical, and educational resources in new communities or upon their return to Louisiana.

Over-triage of patients by emergency medical services (EMS) dispatch is thought to be an acceptable alternative to under-triage, which may delay how quickly life-saving care reaches a patient. Previous studies have looked at advanced life support (ALS) misutilization in urban- and county-based EMS systems and have attempted to analyze how dispatch methods either contribute to or alleviate this problem.1–5

The purpose of this study is to assess the relationship between dispatches of a cardiac nature in a Medical Priority Dispatch (MPD) system, and the actual clinical diagnosis as determined by an emergency department physician.

Calls for emergency medical assistance in a suburban community outside of a major metropolitan area were surveyed over a three-month period. Medical Priority Dispatch protocols determined that 104 of these calls were cardiac-related. Of these emergency calls, 56 (53.8%) patients were transported to the local community hospital and treated by the emergency physician. A retrospective review of the medical records was conducted to determine whether the patient had a cardiac-related discharge diagnosis from the emergency department.

Sixteen (28.6%) of the patients in this cohort were diagnosed with a cardiac-related condition upon discharge from the emergency department. Forty (71.4%) were diagnosed with a non-cardiac-related condition. The positive, predictive value of the dispatch protocol for the detection of an actual cardiac emergency in this EMS system was 28.6%.

In this suburban community, the MPD system may over-triage emergency medical responses to cardiac emergencies. This can result in the only ALS (paramedic) unit in the community being unavailable in certain situations. Future studies should be conducted to determine what level (in any) of over-triage is appropriate in EMS systems using a MPD system.

Standardized, validated training programs for teaching administrative decision-making to healthcare professionals responding to weapons of mass destruction (weapons of mass destruction) incidents have not been available. Therefore, a multidisciplinary team designed, developed, and offered a four-day, functional exercise, competency-based course at a national training center.

This report provides a description of the development and initial evaluation of the course in changing participants' perceptions of their capabilities to respond to weapons of mass destruction events.

Course participants were healthcare professionals, including physicians, nurses, emergency medical services administrators, hospital administrators, and public health officials. Each course included three modified tabletop and/or real-time functional exercises. A total of 441 participants attended one of the eight course offerings between March and August 2003. An intervention group only, pre-post design was used to evaluate change in perceived capabilities related to administrative decision-making for weapons of mass destruction incidents. Paired evaluation data were available on 339 participants (81.9%). Self-ratings for each of 21 capability statements were compared before and after the course. A 19-item total scale score for each participant was calculated from the pre-course and post-course evaluations. Paired t-tests on pre- and postcourse total scores were conducted separately for each course.

There was consistent improvement in self-rated capabilities after course completion for all 21 capability statements. Paired t-tests of pre- and postcourse total scale scores indicated a significant increase in mean ratings for each course (all p <0.001).

The tabletop/real-time-exercise format was effective in increasing healthcare administrators' self-rated capabilities related to weapons of mass destruction disaster management and response. Integrating the competencies into training interventions designed for a specific target audience and deploying them into an interactive learning environment allowed the competency-based training objectives to be accomplished.

It is important to identify what kinds of drugs are required by disaster-affected populations so that appropriate donations are allocated. On 26 December 2003, an earthquake with an amplitude of 6.3 on the Richter scale struck southeastern Iran, decimating the city of Bam. In this study, the most frequently utilized and prescribed drugs for Bam outpatients during the first six months after the Bam Earthquake were investigated.

In this descriptive, cross-sectional study, the data were collected randomly from 3,000 prescriptions of Bam outpatients who were examined by general practitioners from Emergency Medical Assistance Teams in 12 healthcare centers during the first six months after the Bam Earthquake. The data were analyzed for: (1) patient sex; (2) number of drugs/prescriptions; (3) drug category; (4) drug name (generic or brand); (5) route of administration; (6) percent of visits where the most frequent drug categories were prescribed; and (7) the 25 most frequently prescribed drugs, using World Health Organization (WHO) indicators of drug use in health facilities.

Male patients represented 47.4% and females 52.6% of the total number of outpatients. The mean number of drugs/prescriptions was 3.5 per outpatient. Oral administration was the most frequent method of administration (81.7%), followed by injections (10.9%). Respiratory drugs were the most frequently used drugs (14.2%), followed by analgesics/non-steroidal anti-inflammatory drugs (non-steroidal anti-inflammatory drugs) (11.3%), antibacterials (11.2%), gastroinestinal (GI) drugs (9.6%), and central nervous system drugs (7%). Penicillins (6.8%), cold preparations (8%), and systemic anti-acids (ranitidine and omeprazole) were among the 25 most frequently used drugs by outpatients and inhabitants of Bam during the first six months after the Bam Earthquake.

Respiratory, analgesic, antibacterial, gastrointestinal, and psychiatric medications were among the most commonly prescribed pharmaceuticals after the catastrophic Bam Earthquake.The results of this study may help to predict the needs of patients during future disasters and prevent unnecessary donations of medicine.

On 26 December 2004, an earthquake (9.0 Richter, 10 kilometers below the sea) near Sumatra, Indonesia, triggered a tsunami, which traveled at approximately 800 km per hour to strike the Indian coastline. The disaster response at a 100-bed hospital situated on the beach front (2,028 km from the epi-center) is described.This paper underlines the benefit of the Pan-American Health Organization (PAHO)/World Health Organization (WHO) Guidelines for Natural Disasters in the Indian setting.

The demand on the healthcare system in the affected study area (50 km2, 40,000 population) was assessed in terms of preparedness, response time, casualties, personnel, and resources. Other disaster issues studied included: (1) the disposal of the dead; (2) sanitation; (3) water supply; (4) food; (5) the role of the media; and (6) rehabilitation. Two hospital paramedics administered a disaster-related questionnaire in the local language to the victims (or an accompanying person) upon arrival at the hospital. Personalinterviews with administrative officials involved in incident management, aid, volunteers, and response, also were conducted.The outreach programs consisted of medical camps, health education, re-chlorination of contaminated drinking water, and spraying bleaching powder on wet floor areas.

The total death toll in the area was 62 (with 56, four, and two bodies being recovered on Day 1, 2, and 3 respectively). There were 17 deceased males and 45 females. The bodies immediately were handed over to the relatives upon identification or sent to the mortuary. The attendance in the makeshift accident-and-emergency department on the day of the Tsunami was 219, surged to 339 patients on Day 2, and returned to baseline census on Day 7. Essentially, injuries were minor, and two children with pulmonary edema secondary to salt-water drowning recovered fully. The hospital was cleaned of debris and seaweed on Day 3 and the equipment was restored, but it remained only partially functional. This is because many staff members did not come to work because of rumors that another tsunami was imminent.There were no outbreaks of water-borne illnesses. Post-traumatic stress disorder (PTSD) symptoms such as panic attacks, nightmares, insomnia, fear of water, being startled by loud sounds, and palpitations were detected in 17% of the patients.

After an event, medical rescue personnel often are instructed by well-meaning authorities to conduct interventions and response, which have high visibility in the media. However, strictly adhering to the Pan-American Health Organization/World Health Organization guidelines proved to be cost-effective in terms of resource allocations and disaster responses in the Tsunami-affected areas. Unnecessary mass vaccinations, mass disposal of dead bodies without identification, and an influx of untrained volunteers were avoided. Inappropriate aid by developed nations often is unmindful of the victims'needs and self-esteem. The survivors demonstrated natural coping mechanisms and resilience, which only required time and psychosocial support.

Exposure to cold temperature is a serious but often neglected problem in prehospital care. It not only is an uncomfortable, subjective experience, but it also can cause severe disturbances in vital functions, gradually leading to hypothermia.

The aim of this study was to examine healthy subjects'physiological and subjective reactions to cold exposure (30 minutes at -5°C in the a climatic chamber) while they were lying in a protective covering.

Healthy volunteers (n = 20) participated in the experiment, which consisted of a 10-minute stabilization period of vital functions at room temperature (23°C), 30 minutes of cold exposure (-5°C), and a 30-minute recovery period at room temperature. Subjects lay supinely in protective covering during the entire experiment. Skin temperatures, oxygen saturation, pulse rates, pulse wave amplitude in the middle finger, and surface electromyography (EMG) activity of the major pectoral muscle were recorded continuously during the test. Before and immediately after the cold exposure, tympanic membrane temperatures were measured. In addition, subjects were asked to estimate cold using a standard scale.

During the cold exposure, the decrease in tympanic membrane temperature was not significant.The pulse wave amplitude in the finger decreased sharply upon entering the cold chamber. Skin temperatures, especially of the fingers and toes, decreased during the cold exposure.There were no clear signs of shivering in electromyographic recordings. Subjective cold feelings followed decreasing skin temperatures. Skin temperatures did not return quickly. Even 30 minutes after the exposure, all the skin temperatures still had not returnedto normal levels.However, subjective cold feeling was relieved immediately.

Cold exposure provoked immediate protective vasoconstriction in the peripheral compartment, which caused linear decreases of local skin temperatures. This probably was triggered from the unprotected face and upper respiratory areas.

Local health departments are among the first agencies to respond to disasters or other mass emergencies. However, they often lack the ability to handle large-scale events. Plans including locally developed and deployed tools may enhance local response. Simplified cluster sampling methods can be useful in assessing community needs after a sudden-onset, short duration event.

Using an adaptation of the methodology used by the World Health Organization Expanded Programme on Immunization (EPI), a Microsoft Access-based application for two-stage cluster sampling of residential addresses in Louisville/Jefferson County Metro, Kentucky was developed. The sampling frame was derived from geographically referenced data on residential addresses and political districts available through the Louisville/Jefferson County Information Consortium (LOJIC). The program randomly selected 30 clusters, defined as election precincts, from within the area of interest, and then, randomly selected 10 residential addresses from each cluster.

The program, called the Rapid Assessment Tools Package (RATP), was tested in terms of accuracy and precision using data on a dichotomous characteristic of residential addresses available from the local tax assessor database. A series of 30 samples were produced and analyzed with respect to their precision and accuracy in estimating the prevalence of the study attribute. Point estimates with 95% confidence intervals were calculated by determining the proportion of the study attribute values in each of the samples and compared with the population proportion. To estimate the design effect, corresponding simple random samples of 300 addresses were taken after each of the 30 cluster samples.

The sample proportion fell within ±10 absolute percentage points of the true proportion in 80% of the samples. In 93.3% of the samples, the point estimate fell within ±12.5%, and 96.7% fell within ±15%. All of the point estimates fell within ±20% of the true proportion. Estimates of the design effect ranged from 0.926 to 1.436 (mean = 1.157, median = 1.170) for the 30 samples.

Although prospective evaluation of its performance in field trials or a real emergency is required to confirm its utility, this study suggests that the Rapid Assessment Tools Package, a locally designed and deployed tool, may provide populationbased estimates of community needs or the extent of event-related consequences that are precise enough to serve as the basis for the initial post-event decisions regarding relief efforts.

Physicians and nurses are integral components of the public health bioterrorism surveillance system. However, most published bioterrorism preparedness surveys focus on gathering information related to selfassessed knowledge or perceived needs and abilities.

A survey of physicians and nurses in Hawaii was conducted to assess objective knowledge regarding bioterrorism agents and diseases and perceived response readiness for a bioterrorism event.

During June and July 2004, an anonymous survey was mailed up to three times to a random sample of all licensed physicians and nurses residing in Hawaii.

The response rate was 45% (115 of 255) for physicians and 53% (146 of 278) for nurses. Previous bioterrorism preparedness training associated significantly with knowledge-based test performance in both groups. Only 20% of physicians or nurses had had previous training in bioterrorism preparedness, and <15% felt able to respond effectively to a bioterrorism event. But, >70% expressed willingness to assist the state in the event of a bioterrorist attack.

Additional bioterrorism preparedness training should be made available through continuing education and also should become a component of both medical and nursing school curricula. It is important to provide the knowledge necessary for physicians and nurses to improve their ability to perform in the event of a bioterrorist attack.

Understanding ambulance utilization patterns is essential to assessing prehospital system capacity and preparedness at the national level.

To describe the characteristics of patients transported to US emergency departments (EDs) by ambulance and to determine predictors of ambulance utilization.

Data were obtained from the National Hospital Ambulatory Medical Care Survey using mode of arrival, demographic and visit information, ICD-9-CM E and V-codes, and classified reasons for the visit.

The rates for ED visits of persons conveyed by ambulence were stable between 1997 and 2003, consisting of approximately one in every seven ED visits (14%). In 2003, there were 16.2 million ED visits for which an ambulance was used in the US. However, for patients with mental health visits, nearly one in three ED presentations (31%) arrived by ambulance. Significantly higher rates of ambulance use were associated with: (1) mental health visits; (2) older age; (3) African-Americans; (4) Medicare or self-pay insurance status; (5) urban ED location; (6) US regions outside of the South; (7) presentation between 12 midnight to 0800 hours; (8) injury-related visits; (9) urgent visit status; and/or (10) those resulting in hospital admission. Among mental health patients, older age, self-pay insurance status, urban ED location, regions outside the southern US, and urgent visit classification predicted ambulance use. Ambulance usage within the mental health group was highest for suicide and lowest for mood and anxiety disorder-related visits.

Reliance on ambulance services varies by age, insurance status, geographic factors, time of day, urgency of visit, subsequent admission status, and type of mental health disorder. Even after controlling for many confounding factors, mental health problems remain an important predictor of ambulance use.