Introduction: Disasters and mass-casualty scenarios may overwhelm medical resources regardless of the level of preparation. Disaster response requires medical equipment, such as ventilators, that can be operated under adverse circumstances and should be able to provide respiratory support for a variety of patient populations.

Objective: The objective of this study was to evaluate the performance of three portable ventilators designed to provide ventilatory support outside the hospital setting and in mass-casualty incidents, and their adherence to the Task Force for Mass Critical Care recommendations for mass-casualty care ventilators.

Methods: Each device was evaluated at minimum and maximum respiratory rate and tidal volume settings to determine the accuracy of set versus delivered VT at lung compliance settings of 0.02, 0.08 and 0.1 L/cm H20 with corresponding resistance settings of 10, 25, and 5 cm H2O/L/sec, to simulate patients with ARDS, severe asthma, and normal lungs. Additionally, different FIO2 settings with each device (if applicable) were evaluated to determine accuracy of FIO2 delivery and evaluate the effect on delivered VT. Ventilators also were tested for duration of battery life.

Results: VT decreased with all three devices as compliance decreased. The decrease was more pronounced when the internal compressor was activated. At the 0.65 FIO2 setting on the MCV 200, the measured FIO2 varied widely depending on the set VT. Battery life range was 311-582 minutes with the 73X having the longest battery life. Delivered VT decreased toward the end of battery life with the SAVe having the largest decrease. The respiratory rate on the SAVe also decreased approaching the end of battery life.

Conclusion: The 73X and MCV 200 were the closest to satisfying the Task Force for Mass Critical Care requirements for mass casualty ventilators, although neither had the capability to provide PEEP. The 73X provided the most consistent tidal volume delivery across all compliances, had the longest battery duration and the least decline in VT at the end of battery life.

Introduction: When countermeasures are taken against an avian influenza (AI) pandemic in a hospital, it is essential to know the potential number of staff who would choose to be absent. The purpose of this study was to clarify how many medical staff would be willing to work during a pandemic, and requirements to secure adequate human resources.

Methods: From September to December 2008, a total of 3,152 questionnaires were sent to five private hospitals and one public hospital, which represent the core hospitals in the regions of Kyoto, Osaka, and Hyogo Prefectures. Participants consisted of hospital staff including: (1) physicians; (2) nurses; (3) pharmacists; (4) radiological technologists (RTs); (5) physical therapists (PTs); (6) occupational therapists (OTs); (7) clinical laboratory technologists (CLTs); (8) caregivers; (9) office clerks; and (10) others. They were queried about their attitude toward pandemics, including whether they would come to the hospital to work, treat patients, and what kinds of conditions they required in order to work.

Results: A total of 1,975 persons (62.7%) responded. A total of 204 persons (10.6%) would not come to the hospitals during a pandemic, 363 (18.8%) would perform their duties as usual, unconditionally, 504 (26.1%) would come to hospitals but not treat AI patients, and 857 (44.5%) would report to the hospital and treat AI patients with some essential conditions. These essential conditions were: (1) personal protective equipment (PPE) (80.0%); (2) receipt of workmen's compensation (69.3%); (3) receipt of anti-virus medication (58.2%); and (3) receipt of pre-pandemic vaccination (57.8%).

Conclusion: During a pandemic, all types of health professionals would be lacking, not only physicians and nurses. This study indicates that ensuring sufficient medical human resources would be difficult without the provision of adequate safety and compensation measures.

Background: Despite frequent disasters caused by natural hazards, concern has been raised regarding the effectiveness of disaster health services in disaster-prone countries such as Iran. The purpose of this study was to explore, in relation to health disaster management, the experiences and perceptions of individuals who responded or were affected by a recent Iranian earthquake disaster.

Methods: This study was conducted using grounded theory. Study participants included members of a multidisciplinary disaster response team as well as residents of the community affected by the earthquake (n = 29). Data collection included semi-structured interviews, field notes, and reviews of narratives.

Results: The findings of this study indicate that the lack of planning, inadequate organizational management of resources, insufficient coordination in the provision of health services during the disaster, and the manner of participation of international relief efforts were the most important barriers to adequate disaster healthcare services delivery during the 2003 Bam Iranian earthquake.

Conclusions: This study supports the value of health service managers coordinating the appropriate use of international aid in advance. It is suggested that this can be done by better communication with local and foreign constituents. Further, this study indicates that public education and proper pre-event planning help to bring about an effective response to providing healthcare services during a disaster.

Introduction: Radiographic findings of dengue fever have not yet been clearly elucidated in relation to clinical and serological findings, despite the fact that two-fifths of the world population lives in areas where the virus is endemic. The current study is a retrospective analyzis of ultrasonographic (USG) features of patients presenting with probable dengue fever during the outbreak of DF of 2006 in North India.

Methods: Case records of a 169 patients with probable dengue fiver were included. Ten individual sonographic parameters were reviewed vis-à-vis ascites, hepatomegaly, splenomegaly, gall bladder wall edema (GBWE), pleural effusion (right or left or both), pericardial effusion, pericholecystic collection, perinephric collection. Subjects who had GB wall thickness >3 mm as measured on ultrasound were identified as positive for GBWE. The cases were analyzed in view of their serological profile.

Results: The mean age of the subjects was 27.9 +/− 13.4 years. The mean value of the platelet count was 57.4 +/− 22.3 x 103/cmm. The most common ultrasonographic feature was ascites (126, 74.6%) followed by gall bladder wall edema (122, 72%), hepatomegaly (78, 46.2%), splenomegaly (66, 39.1%) and pericholecystic collection (63, 37.3%); 48 (28.4%) subjects demonstrated evidence of pleural effusion on the right side, while 19 (11.2%) had bilateral effusion. None of the subjects had an isolated left pleural effusion. Twenty-seven (16%) subjects reported bleeding manifestations in the form of petechiae and five (3%) developed renal dysfunction. Presence of pleural and pericardial effusions was found to be specific while ascites and GBWE were identified as highly sensitive markers for seropositive Primary DF.

Conclusions: Ultrasonographic evidence of ascites, pleuro-pericardial effusion, and gallbladder wall edema are rapidly aquired, non-invasive markers of dengue and can be helpful before serological investigations become available. These findings may indicate severity and may herald the onset of bleeding (petechiae) or predict the development of acute renal dysfunction.

Introduction: This study compares self-reported Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) status among elderly survivors of the 2003 Bam Earthquake before, two months after, and five years after the event, and explores related determinants.

Methods: A two-stage cluster survey was conducted on 210 elderly survivors in the earthquake-stricken area five years after the event.

Results: Both ADL and IADL scores decreased two months after earthquake compared to prior status (p <0.001). No differences were observed between two months and five years after the event (p >0.05). Access to medical services were not related to level of ADL or IADL (p = 0.52 and p = 0.74, respectively). Elderly survivors with lower functional capability in terms of ADL experienced more problems in access to relief items (p = 0.04), but no similar association was found for IADL (p = 0.26).

Conclusion: The Bam earthquake adversely affected functional capacity of the elderly. Disaster responders must take into account functional capacity of elders when planning for medical and relief operations.

Introduction: The environmental aspects of mass gatherings that can affect the health and safety of the crowd have been well described. Although it has been recognized that the nature of the crowd will directly impact the health and safety of the crowd, the majority of research focuses on crowd behavior in a negative context such as violence or conflict. Within the mass gathering literature, there is no agreement on what crowd behavior, crowd mood and crowd type actually mean. At the same time, these elements have a number of applications, including event management and mass gathering medicine. These questions are worthy of exploration.

Methods: This paper will report on a pilot project undertaken to evaluate how effective current crowd assessment tools are in understanding the psychosocial domain of a mass gathering event.

Results: The pilot project highlighted the need for a more consistent descriptive data set that focuses on crowd behavior.

Conclusions: The descriptive data collected in this study provide a beginning insight into the science of understanding crowds at a mass gathering event. This pilot has commenced a process of quantifying the psychosocial nature of an event. To maximize the value of this work, future research is required to understand the interplay among the three domains of mass gatherings (physical, environmental and psychological), along with the effects of each element within the domains on safety and health outcomes for participants at mass gatherings.

Introduction: Ensuring the capacity of the public health, emergency preparedness system to respond to disaster-related need for mental health services is a challenge, particularly in rural areas in which the supply of responders with relevant expertise rarely matches the surge of demand for services.

Problem: This investigation established and evaluated a systems-based partnership model for recruiting, training, and promoting official recognition of community residents as paraprofessional members of the Maryland Medical Professional Volunteer Corps. The partners were leaders of local health departments (LHDs), faith-based organizations (FBOs), and an academic health center (AHC).

Methods: A one-group, quasi-experimental research design, using both post-test only and pre-/post-test assessments, was used to determine the feasibility, effectiveness, and impact of the overall program and of a one-day workshop in Psychological First Aid (PFA) for Paraprofessionals. The training was applied to and evaluated for 178 citizens drawn from 120 Christian parishes in four local health jurisdictions in rural Maryland.

Results: Feasibility—The model was demonstrated to be practicable, as measured by specific criteria to quantify partner readiness, willingness, and ability to collaborate and accomplish project aims. Effectiveness—The majority (93–99%) of individual participants “agreed” or “strongly agreed” that, as a result of the intervention, they understood the conceptual content of PFA and were confident about (“perceived self-efficacy”) using PFA techniques with prospective disaster survivors. Impact—Following PFA training, 56 of the 178 (31.5%) participants submitted same-day applications to be paraprofessional responders in the Volunteer Corps. The formal acceptance of citizens who typically do not possess licensure in a health profession reflects a project-engendered policy change by the Maryland Department of Health and Mental Hygiene.

Conclusions: These findings are consistent with the conclusion that it is feasible to consider LHDs, FBOs, and AHCs as partners to work effectively within the span of a six-month period to design, promote, conduct, and evaluate a model of capacity/capability building for public mental health emergency response based on a professional “extender” rationale. Moreover, consistently high levels of perceived self-efficacy as PFA responders can be achieved with lay members of the community who receive a specially-designed, one-day training program in crisis intervention and referral strategies for disaster survivors.

On 12 January 2010, the fate of Haiti and its people shifted with the ground beneath them as the strongest earthquake in 200 years, and a series of powerful aftershocks demolished the capital and multiple areas throughout the southern coast in thirty seconds, leaving some 220,000 people dead, and 300,000 persons injured. On 27 February 2010, at 03:35 hours local time, an earthquake of magnitude 8.8 struck Chile. As a consequence, the tsunami generated affected a coastal strip of more than 500 kilometers. Approximately 1.5 million people were affected and thousands lost their homes and livelihoods. The emergency health response of the International Red Cross Movement to both disasters was immediate, powerful and dynamic. The IFRC deployed seven emergency response units (ERU) to Haiti: one 150-bed referral hospital, one Rapid Deployment Emergency Hospital, and five basic health care units. One surgical hospital and two Basic Health Care Units were deployed to Chile. The ERU system of the IFRC is a flexible and dynamic tool for emergency health response in shifting and challenging environments. Evaluations show that the system performs well during urban and rural disasters. Despite a very different baseline in the two contexts, the ERU system of IFRC can adapt to the local needs. As panorama of pathology in the aftermath of an earthquake changes, the ERU system adapts and continues supporting the local health care system in its recovery.

Introduction: Studies have demonstrated the presence of stress and post-traumatic stress among ambulance personnel, but no previous research has focused on the body's reaction in the form of the change in heart rate of ambulance staff in association with specific occupational stress.

Hypothesis: The purpose of this study is to investigate whether work as an ambulance professional generates prolonged physiological arousal that can be measured by heart rate in different situations.

Methods: Twenty participants carried a pulse-meter in the form of a wristwatch, which continuously measured and stored their heart rate 24 hours per day for a period of seven days. All ambulance alarms that occurred during the test period were recorded in journals, and the participants completed diaries and a questionnaire describing their experiences. The alarms were divided into different phases. Correlations between heart rate in the different phases were computed.

Results: Analysis of study data indicated a significant rise of heart rate unrelated to physical effort during an emergency alarm and response. This increased heart rate was noticed throughout the mission and it was not related to the length of experience the staff had in the ambulance profession. In addition, a non-significant trend suggested that alarms involving acutely ill children lead to an even higher increase in heart rate. In addition, this research showed that constant tension existed during sleep, while available for an emergency, indicated by a noticeable increase in heart rate during sleep at work compared to sleeping at home.

Conclusions: A rise in heart rate was experienced during all acute emergency missions, regardless of a subject's experience, education, and gender. Missions by themselves generated a rate increase that did not seem to correlate with physical effort required during an emergency response. This study shows that working on an ambulance that responds to medical emergencies is associated with a prolonged physiological arousal.

Introduction: A common reason for utilizing local paramedics and the emergency medical services is for the recognition and immediate treatment of chest pain, a complaint that has multiple possible etiologies. While many of those complaining of disease processes responsible for chest pain are benign, some will be life-threatening and will require immediate identification and treatment. The ability of paramedics to not only perform field electrocardiograms (ECGs), but to accurately diagnose various unstable cardiac rhythms has shown significant reduction in time to specific treatments. Increasing the overall accuracy of ECG interpretation by paramedics has the potential to facilitate early and appropriate treatment and decrease patient morbidity and mortality.

Methods: A convenient training device (flip book) on ambulances and in common areas in the fire station could improve field interpretation of certain cardiac rhythms. This training device consists of illustrated sample ECG tracings and their associated diagnostic criteria. The goal was to enhance the recognition and interpretation of ECGs, and thereby, reduce delays in the initiation of treatment and potential complications associated with misinterpretation.

This study was a prospective, observational study using a matched pre-test/post-test design. The study period was from November 2008 to December 2008. A total of 136 paramedics were approached to participate in this study. A pre-test consisting of 15 12-lead ECGs was given to all paramedics who agreed to participate in the study. Once the pre-tests were completed, the flip books were placed in common areas. Approximately one month after the flip books were made available to the paramedics, a post-test was administered.

Statistical comparisons were made between the pre- and post-test scores for both the global test and each type of rhythm.

Results: Using these data, there were no statistically significant improvements in the global ECG interpretation or on individual rhythm interpretations.

Conclusions: A flip book with multiple ECG rhythms and definitions without the benefit of any outside support was not effective in improving paramedic identification of ECG rhythms on a post-test. Suggestions for further research include repeating the study with a larger sample size; utilizing a lecturer to explain how to use the flip book in the most efficient manner; reiterating how to read and interpret ECGs; and answering questions. Comparing test scores of paramedic students, and newly certified paramedics as opposed to veteran paramedics also may indicate that the flip books are more suited for one group over another.

In 2001, a survey of Canadian emergency departments indicated significant deficiencies in disaster preparedness. Since then, there have been efforts on the part of Provincial governments to remedy this situation. This survey repeats the original study with minor modifications to determine if there has been improvement. The Hospital Emergency Readiness Overview study demonstrates that despite improvements, there remain gaps in Canadian healthcare facility readiness for disaster, specifically one involving contaminated patients. It also highlights the lack of any standardized assessment of healthcare facilities' chemical, biological, radiological, or nuclear readiness.

This special report was prepared as a white paper for the First World Health Organization (WHO) Consultation on Nursing and Midwifery Contributions in Emergencies held in Geneva on 22–24 November 2006. Pertinent issues related to research of nurses and midwives were identified based on prior international conferences. Using this information, gaps between the current and proposed state of preparedness research activities were identified. Global perspective recommendations were made for consideration by the WHO and other nursing organizations. Finally, possible discussion questions were posed that were used during the consultation, but could also be used in other international nursing conferences.

Introduction: In confined-space airway emergencies, prehospital personnel may need to perform cricothyrotomy when conventional airway techniques cannot be utilized or have failed. This study is a prospective, cross-over, randomized controlled trial that compares two widely-known techniques using two commercially available kits.

Methods: Twenty residents at Palmetto Health Richland Department of Emergency Medicine participated in the study. Their performance was assessed using the time required to placement and correctness of placement for each device. The residents performed the procedures on an Air-Man™ manikin that had been situated in a confined space. The residents also indicated which kit they would prefer in a confined-space, emergency airway situation.

Results: All of the devices were placed in the airway. The mean time to placement for the Melker™ and Quicktrach™ kits was 108.5 seconds and 23.9 seconds, respectively. This yielded a mean difference of 84.5 seconds, which provided a t-statistic of 8.88 (p < 0.0001). There was no evidence of a carry-over effect (p = 0.292) or a period effect (p = 0.973). All residents preferred using the Quicktrach™ kit.

Conclusions: Use of the Quicktrach™ kit resulted in the fastest time to placement, was placed correctly in the airway, and was preferred by each of the residents. Its small, simple, and sturdy design, with few parts and easy manipulation, allow the Quicktrach™ to be a valuable option in prehospital situations involving confined spaces. The Melker™ kit, with its many parts, and need for greater manipulation, is not as easily utilized or preferred in a confined space scenario.

Introduction: With at least 20% of ambulance patients reporting pain of moderate to severe intensity, pain management has become a primary function of modern ambulance services. The objective of this study was to describe the use of intravenous morphine, inhaled methoxyflurane, and intranasal fentanyl when administered in the out-of-hospital setting by paramedics within a large Australian ambulance service.

Methods: A retrospective analysis was conducted using data from ambulance patient health care records (PHCR) for all cases from 01 July 2007 through 30 June 2008 in which an analgesic agent was administered (alone or in combination).

Results: During the study period, there were 97,705 patients ≤100 years of age who received intravenous (IV) morphine, intranasal (IN) fentanyl, or inhaled methoxyflurane, either alone or in combination. Single-agent analgesia was administered in 87% of cases. Methoxyflurane was the most common agent, being administered in almost 60% of cases. Females were less likely to receive an opiate compared to males (RR = 0.83, 95% CI, 0.82–0.84, p <0.0001). Pediatric patients were less likely to receive opiate analgesia compared to adults (RR = 0.65, 95% CI, 0.63–0.67, p <0.0001). The odds of opiate analgesia (compared to pediatric patients 0–15 years) were 1.47; 2.10; 2.56 for 16–39 years, 40–59 years, and ≥60 years, respectively. Pediatric patients were more likely to receive fentanyl than morphine (RR = 1.69, 95% CI, 1.64–1.74, p < 0.0001).

Conclusion: In this ambulance service, analgesia most often is provided through the use of a single agent. The majority of patients receive non-opioid analgesia with methoxyflurane, most likely because all levels of paramedics are authorized to administer that analgesic. Females and children are less likely to receive opiate-based analgesia than their male and adult counterparts, respectively. Paramedics appear to favor intranasal opiate delivery over intravenous delivery in children with acute pain.

Introduction: In October 2005, Hurricane Stan impacted Central America, causing severe damage to Guatemala. The main objectives of this study are to report on the effects of Hurricane Stan in rural Guatemala, to assess the responses of a rural clinic during and after the storm, and to identify ways in which the clinic can better prepare for future disasters. The clinic is located in Catarina, San Marcos, Guatemala. Roughly 400–500 patients are attended to each week at the clinic.

Methods: Survey data were obtained during a two-week period using a convenience sample of people at the clinic and in the surrounding community.

Results: The major medical problems after the impact of Hurricane Stan included fungal infections, upper respiratory infections, diarrhea, and emotional problems. The most needed supplies included food, electricity, home repair, potable water, communication, and clothing. In the immediate aftermath of event, 61% of the participants could not get to a hospital; however, most did not require medical assistance.

Conclusions: Hurricane Stan had a devastating effect on the San Marcos region of Guatemala. While the clinic could have served as a resource center and a base, it was not prepared to address the community's health needs after the hurricane as there were no previous plans in place for disaster response for the clinic or for the community. Next steps include developing a preparedness plan to utilize the clinic as a local resource center , in the event that the planned national disaster responses are delayed or unable to reach the affected area.

Introduction: This is the first study using national data to evaluate transportation risks among emergency medical technicians (EMTs) and paramedics (to be referred to hereafter as “EMTs”) in the United States.

Hypothesis: This epidemiological study compares the transportation risks for EMTs to the transportation risks for all workers in the US.

Methods: The rates, relative risks, and proportions associated with the 1,050 injury cases with lost work days, and 30 fatalities resulting from transportation incidents occurring to EMTs in the US between 2006 and 2008 are described.

Results: The risk of transportation-related injury for EMTs in the US is about five times higher than the national average. Females were the victims in 53% of the cases yet females only accounted for about 27% of employment in this occupation. Twenty percent of cases resulted in 31 or more lost work days. There were 30 transportation related fatalities.

Conclusions: The US national EMS system is built on the premise of having an unlimited supply of 20 year olds interested in, and dedicated to, the provision of EMS care. Not only do we not have an unlimited supply of 20 year olds, we may be rapidly losing our current workforce through clearly preventable risks such as transportation incidents.

Emergency medical services workers face a rate of occupational injury that is much higher than the national average and transportation-related events are a significant component of that risk. Resources must be devoted to further research, and to the development and evaluation of interventions designed to mitigate these transportation-related hazards.

Introduction: Earthquake exposure has been associated with adverse consequences for coronary heart disease. However, the natural history and prognostic significance of earthquake-related, new-onset angina have not been characterized.

Objective: The objective of this study was to evaluate the association between episodes of depressive symptoms and one-year prognosis after the first admission to the hospital among adults with new-onset angina before and after the Sichuan earthquake.

Methods: One hundred forty-one first hospitalized patients with new-onset angina before and after the Sichuan earthquake underwent psychological assessments during their first admission to the hospital following the earthquake. Patients were followed for 12 months to determine survival status. The independent relationships between baseline variables and readmission risk after the earthquake were examined. Baseline somatic and psychosocial variables were collected with the aid of standard, validated questionnaires.

Results: The proportion of patients with moderate/severe depression symptom in the earthquake-related group is higher than among their counterparts (23.7% vs. 8.9%, p = 0.026). Patients with new-onset angina after the Sichuan earthquake had a higher risk of readmission (22.4% vs. 8.9%, p = 0.041) and longer total hospitalization (average of 13.4 ±6.8 vs. 10.7 ±5.5 days, p = 0.015). The risks for readmission was associated with moderate/severe depression (adjusted hazard ratio, 9.18 [95% confidence interval (CI) = 3.09–27.23, p = 0.0000]) and low ejection fraction (adjusted hazard ratio, 6.66 [95%CI = 2.131–20.781, p = 0.001]).

Conclusions: Among patients diagnosed with new-onset angina, those with first episode after the Sichuan earthquake generated more moderate/severe depressive symptoms and had a higher risk for readmission and longer hospital stay. Depressive symptoms upon admission and low ejection fractions were significant predictors of 12-month risk for readmission, which indicates that antidepressants should be prescribed.