Introduction: This paper is a report of a qualitative study of emergency and critical care nurses' perceptions of occupational response and preparedness during infectious respiratory disease outbreaks including severe acute respiratory syndrome (SARS) and influenza.

Problem: Healthcare workers, predominantly female, face occupational and personal challenges in their roles as first responders/first receivers. Exposure to SARS or other respiratory pathogens during pregnancy represents additional occupational risk for healthcare workers.

Methods: Perceptions of occupational reproductive risk during response to infectious respiratory disease outbreaks were assessed qualitatively by five focus groups comprised of 100 Canadian nurses conducted between 2005 and 2006.

Results: Occupational health and safety issues anticipated by Canadian nurses for future infectious respiratory disease outbreaks were grouped into four major themes: (1) apprehension about occupational risks to pregnant nurses; (2) unknown pregnancy risks of anti-infective therapy/prophylaxis; (3) occupational risk communication for pregnant nurses; and (4) human resource strategies required for pregnant nurses during outbreaks. The reproductive risk perceptions voiced by Canadian nurses generally were consistent with reported case reports of pregnant women infected with SARS or emerging influenza strains. Nurses' fears of fertility risks posed by exposure to infectious agents or anti-infective therapy and prophylaxis are not well supported by the literature, with the former not biologically plausible and the latter lacking sufficient data.

Conclusions: Reproductive risk assessments should be performed for each infectious respiratory disease outbreak to provide female healthcare workers and in particular pregnant women with guidelines regarding infection control and use of anti-infective therapy and prophylaxis.

During large-scale, sudden-onset disasters, resscue personnel experience severe stress due to the brief window of opportunity for saving lives. Following the earthquake in Haiti, rescue personnel worked in Port-au-Prince under harsh conditions in order to save lives and extricate bodies. Reactions to this disaster among rescue personnel were examined using self-report questionnaires. Correlations between psychosocial factors and psychological trauma (dissociation and post-traumatic stress disorder (PTSD) symptoms) were examined in a sample of 20 rescue personnel who worked in Haiti. The study indicated that negative affect and crisis of meaning were associated with higher levels of dissociative and PTSD symptoms. The results suggest that rescue personnel who are overwhelmed by the destruction and number of bodies being extricated may exhibit negative affect and loss of meaning along with dissociative and PTSD symptoms.

Today there is adequate research evidence at national and international level regarding the health and mental health consequences of disasters. The realization of the larger impact of mental health on the recovery process has been instrumental in prioritizing mental health and psychosocial well-being of affected populations in recent years. Traditionally the bio medical models were used to understand the disaster mental health outcomes, however over the last two decade a gradual change is visible in the understanding of the mental health and psychosocial consequences of disasters. It is more inclusive of varied expressions of distress and the services to address the same. A review of various disaster mental health research and interventions documented since 2001 reveals that most studies/interventions attempt to list the various mental health problems and psychosocial consequences. There are very few studies which go beyond listing of consequences, to focus on implications of disaster mental health for long term disaster recovery. There is dearth of research based literature on the concept of community trauma, factors contributing to negative emotions and emotional distress/ problems, community response (social and cultural) to disaster mental health issues, long term emotional implications of psychosocial consequences of disasters and the life course of individuals with mental health issues in the long run following disasters. The paper attempts to address the above mentioned issues in the context of 2004 tsunami. The paper is based on a study carried out in India two years after the disaster. A Case study approach was used and 177 case studies were collected from 104 villages in 14 affected districts of three states in India. The paper contributes to understanding the long term implications of disaster mental health for disaster recovery and reiterates the significance of integrating disaster mental health services within humanitarian services.

Introduction: Annual ambulance diversion hours in Boston increased more than six-fold from 1997 to 2006. Although interventions and best practices were implemented, there was no reduction in the number of diversion hours.

Objectives: A consortium of Boston teaching hospitals instituted a two-week moratorium on citywide diversion from 02 October 2006 to 15 October 2006. The hypothesis was that there would be no significant difference in measures of hospital and emergency medical services (EMS) efficiency compared with the two weeks immediately prior.

Methods: A total of nine hospitals and the municipal emergency medical services in Boston submitted data for analysis. The following mean daily hospital measures were studied: (1) emergency department volume; (2) number of emergency department admissions; (3) length of stay (LOS) for all patients; and (4) number of elopements. Mean EMS at-hospital time by destination and the percent of all Boston EMS transports to each hospital destination were calculated. The median differences (MD) were calculated as “before” minus “during” the study period and were compared with paired, Wilcoxon, non-parametric tests. Additional mean EMS measures for all destinations included: (1) to hospital time; (2) number of responses with transport initiated per day; (3) incident entry to arrival; and (4) at-hospital time.

Results: The LOS for admitted patients (MD = 0.30 hours; IQR 0.10,1.30; p = 0.03) and number of daily admissions (MD = -1.50 patients; IQR -1.50, -0.10; p = 0.04) were significantly different statistically. The results for LOS for all patients, LOS for discharged patients, ED volume, EMS time at hospital by destination, number of elopements, and percent of Boston EMS transports to each hospital revealed no statistically significant differences. The difference between the study and control periods for mean EMS to hospital time, at-hospital time, and incident entry to arrival was a maximum of 0.6 minutes. The vast majority of EMS respondents to an online survey believed that the “no diversion” policy should be made routine practice.

Conclusions: The LOS for admitted patients decreased by 18 minutes, and the number of admissions increased by 1.5 patients per day during the study period. The “no diversion” policy resulted in minimal changes in EMS efficiency and operations. Diversion was temporarily eliminated in a major city without significant detrimental changes in ED, hospital, or EMS efficiency.

Introduction: The use of wireless, electronic, medical records and communications in the prehospital and disaster field is increasing.

Objective: This study examines the role of wireless, electronic, medical records and communications technologies on the quality of patient documentation by emergency field responders during a mass-casualty exercise.

Methods: A controlled, side-to-side comparison of the quality of the field responder patient documentation between responders utilizing National Institutes of Health-funded, wireless, electronic, field, medical record system prototype (“Wireless Internet Information System for medicAl Response to Disasters” or WIISARD) versus those utilizing conventional, paper-based methods during a mass-casualty field exercise. Medical data, including basic victim identification information, acuity status, triage information using Simple Triage and Rapid Treatment (START), decontamination status, and disposition, were collected for simulated patients from all paper and electronic logs used during the exercise. The data were compared for quality of documentation and record completeness comparing WIISARD-enabled field responders and those using conventional paper methods. Statistical analysis was performed with Fisher’s Exact Testing of Proportions with differences and 95% confidence intervals reported.

Results: One hundred simulated disaster victim volunteers participated in the exercise, 50 assigned to WIISARD and 50 to the conventional pathway. Of those victims who completed the exercise and were transported to area hospitals, medical documentation of victim START components and triage acuity were significantly better for WIISARD compared to controls (overall acuity was documented for 100% vs 89.5%, respectively, difference = 10.5% [95%CI = 0.5–24.1%]). Similarly, tracking of decontamination status also was higher for the WIISARD group (decontamination status documented for 59.0% vs 0%, respectively, difference = 9.0% [95%CI = 40.9–72.0%]). Documentation of disposition and destination of victims was not different statistically (92.3% vs. 89.5%, respectively, difference = 2.8% [95%CI = -11.3–17.3%]).

Conclusions: In a simulated, mass-casualty field exercise, documentation and tracking of victim status including acuity was significantly improved when using a wireless, field electronic medical record system compared to the use of conventional paper methods.

Introduction: In the summer of 2009, British Columbia hosted the World Police and Fire Games (WPFG). The event brought together 10,599 athletes from 55 countries. In this descriptive, Canadian study, the composition of the medical team is analyzed, the unique challenges faced are discussed, and an analysis of the illness and injury rates is presented. This event occurred during a labor dispute affecting the sole provider of emergency ambulance service in the jurisdiction, which necessitated additional planning and resource allocation. As such, the context of this event as it relates to the literature on mass gathering medicine is discussed with a focus on how large-scale public events can impact emergency services for the community.

Methods: This is a case report study.

Results: There were 1,462 patient encounters. The majority involved musculo-skeletal injuries (53.8%). The patient presentation rate (PPR) was 109.40/1,000. The medical transfer rate (MTR) was 2.32/1,000. The ambulance transfer rate (ATR) for the 2009 WPFG was 0.52/1,000. In total, 31 patients were transported to the hospital, the majority for diagnostic evaluation. Only seven calls were placed to 9-1-1 for emergency ambulance service.

Conclusions: The 2009 WPFG was a mass-gathering sporting event that presented specific challenges in relation to medical support. Despite relatively high patient presentation rates, the widely spread geography of the event, and a reduced ability to depend on 9-1-1 emergency medical services, there was minimal impact on local emergency services. Adequate planning and preparation is crucial for events that have the potential to degrade existing public resources and access to emergency health services for participants and the public at large.

The provision of surgery within humanitarian crises is complex, requiring coordination and cooperation among all stakeholders. During the 2011 Humanitarian Action Summit best practice guidelines were proposed to provide greater accountability and standardization in surgical humanitarian relief efforts. Surgical humanitarian relief planning should occur early and include team selection and preparation, appropriate disaster-specific anticipatory planning, needs assessment, and an awareness of local resources and limitations of cross-cultural project management. Accurate medical record keeping and timely follow-up is important for a transient surgical population. Integration with local health systems is essential and will help facilitate longer term surgical health system strengthening.

The 2010 Haiti earthquake was one of the most catastrophic episodes in history, leaving 5% of the nation’s population killed or injured, and 19% internally displaced. The distinctive combination of earthquake hazards and vulnerabilities, extreme loss of life, and paralyzing damage to infrastructure, predicts population-wide psychological distress, debilitating psychopathology, and pervasive traumatic grief. However, mental health was not referenced in the national recovery plan. The limited MHPSS services provided in the first eight months generally lacked coordination and empirical basis.

There is a need to customize and coordinate disaster mental health assessments, interventions, and prevention efforts around the novel stressors and consequences of each traumatic event. An analysis of the key features of the 2010 Haiti earthquake was conducted, defining its “Trauma Signature” based on a synthesis of early disaster situation reports to identify the unique assortment of risk factors for post-disaster mental health consequences. This assessment suggests that multiple psychological risk factors were prominent features of the earthquake in Haiti. For rapid-onset disasters, Trauma Signature (TSIG) analysis can be performed during the post-impact/pre-deployment phase to target the MHPSS response in a manner that is evidence-based and tailored to the event-specific exposures and experiences of disaster survivors. Formalization of tools to perform TSIG analysis is needed to enhance the timeliness and accuracy of these assessments and to extend this approach to human-generated disasters and humanitarian crises.

Introduction: The geriatric population is unique in the type of traumatic injuries sustained, physiological responses to those injuries, and an overall higher mortality when compared to younger adults. No published, evidence-based, geriatric-specific field destination criteria exist as part of a statewide trauma system. The Trauma Committee of the Ohio Emergency Medical Services (EMS) Board sought to develop specific criteria for geriatric trauma victims.

Methods: A literature search was conducted for all relevant literature to determine potential, geriatric-specific, field-destination criteria. Data from the Ohio Trauma Registry were used to compare elderly patients, defined as age >70 years, to all patients between the ages of 16 to 69 years with regards to mortality risk in the following areas: (1) Glasgow Coma Scale (GCS) score; (2) systolic blood pressure (SBP); (3) falls associated with head, chest, abdominal or spinal injury; (4) mechanism of injury; (5) involvement of more than one body system as defined in the Barell matrix; and (6) co-morbidities and motor vehicle collision with one or more long bone fracture. For GCS score and SBP, those cut-off points with equal or greater risk of mortality as compared to current values were chosen as proposed triage criteria. For other measures, any criterion demonstrating a statistically significant increase in mortality risk was included in the proposed criteria.

Results: The following criteria were identified as geriatric-specific criteria: (1) GCS score <14 in the presence of known or suspected traumatic brain trauma; (2) SBP <100 mmHg; (3) fall from any height with evidence of traumatic brain injury: (4) multiple body-system injuries; (5) struck by a moving vehicle; and (6) the presence of any proximal long bone fracture following motor vehicle trauma. In addition, these data suggested that elderly patients with specific co-morbidities be given strong consideration for evaluation in a trauma center.

Conclusions: The state of Ohio is the first state to develop evidence-based geriatric-specific field-destination criteria using data from its state-mandated trauma registry. Further analysis of these criteria will help determine their effects on over-triage and under-triage of geriatric victims of traumatic injuries and the impact on the overall mortality in the elderly.

Crisis, disasters, terror attacks or any other traumatic event may cause among the survivors acute stress reaction (ASR). The main goal of the first responder in terms of mental health in the acute phase is to provide the victim the basic support that will stabilized the needed coping resources and re-establish the sense of control and safety (Kutz & Bleich, 2005). This process encourages the shift of the victim's perspective from a helpless victim to a coping survivor. The emergency mental health interventions are differentiated by the location: Location 1: The event's location: Pacing & Leading using varied communications channels. Re-establishing sequences of contingency. Regaining sense of control. Using the cognitive communication channel. Yes-set sequences. Location 2: Emergency rooms or Traumatic Stress First Aid Centers (TSFAC) Stress symptoms reduction using suggestive techniques Memory Structure Intervention (MSI). Psychological Inoculation (PI). Group interventions. Basic deferential diagnosis: ASR-PTSD Patent release decision making. The higher the number of casualties, the more likely is the need for early interventions by non-professionals. This may be particularly true for a mega-terror attack, when the numbers of survivors with ASR can flood the hospital gates. The general principles for intervention by non-professionals, adopted by the Israel Ministry of Health (2002), are: a. Establish personal contact with the survivors and provide words of comfort or supportive touch. b. Encourage survivors to verbalize their experiences. c. Provide orienting information about what happened and what is about to happen in the hospital. d. Ensure physical needs such as hydration, food, and rest when appropriate. e. Enable contact with any significant other as soon as possible through phone or personal contact. During the presentation the above subjects will be elaborated and demonstrated by case studies and short videos.

Introduction: Calls for disaster medical assistance teams (DMATs) are likely to continue in response to international disasters.

Objective: As part of a national survey, the present study was designed to evaluate the education and training of Australian DMATs.

Methods: Data were collected via an anonymous, mailed survey distributed via State and Territory representatives on the Australian Health Protection Committee, who identified team members associated with Australian DMAT deployments from the 2004 Southeast Asia tsunami disaster.

Results: The response rate for this survey was 50% (59/118). Most of the personnel had deployed to the tsunami-affected areas. The DMAT members were quite experienced, with 53% of personnel in the 45–55-year age group (31/59). Seventy-six percent of the respondents were male (44/58). While most respondents had not participated in any specific training or educational program, any kind of relevant training was regarded as important in preparing personnel for deployment. The majority of respondents had experience in disasters, ranging from hypothetical exercises (58%, 34/59) to actual military (41%, 24/49) and non-governmental organization (32%, 19/59) deployments. Only 27% of respondents felt that existing training programs had adequately prepared them for deployment. Thirty-four percent of respondents (20/59) indicated that they had not received cultural awareness training prior to deployment, and 42% (25/59) received no communication equipment training. Most respondents felt that DMAT members needed to be able to handle practical aspects of deployments, such as training as a team (68%, 40/59), use of communications equipment (93%, 55/59), ability to erect tents/shelters (90%, 53/59), and use of water purification equipment (86%, 51/59). Most respondents (85%, 50/59) felt leadership training was essential for DMAT commanders. Most (88%, 52/59) agreed that teams need to be adequately trained prior to deployment, and that a specific DMAT training program should be developed (86%, 51/59).

Conclusions: This study of Australian DMAT members suggests that more emphasis should be placed on the education and training. Prior planning is required to ensure the success of DMAT deployments and training should include practical aspects of deployment. Leadership training was seen as essential for DMAT commanders, as was team-based training. While any kind of relevant training was regarded as important for preparing personnel for deployment, Australian DMAT members, who generally are a highly experienced group of health professionals, have identified the need for specific DMAT training.

Limb amputations are frequently performed as a result of trauma inflicted during conflict or disasters. As demonstrated during the 2010 earthquake in Haiti, coordinating care of these patients in austere settings is complex. During the 2011 Humanitarian Action Summit, consensus statements were developed for international organizations providing care to limb amputation patients during disasters or humanitarian emergencies. Expanded planning is needed for a multidisciplinary surgical care team, inclusive of surgeons, anesthesiologists, rehabilitation specialists and mental health professionals. Surgical providers should approach amputation using an operative technique that optimizes limb length and prosthetic fitting. Appropriate anesthesia care involves both peri-operative and long-term pain control. Rehabilitation specialists must be involved early in treatment, ideally before amputation, and should educate the surgical team in prosthetic considerations. Mental health specialists must be included to help the patient with community reintegration. A key step in developing local health systemsis the establishment of surgical outcomes monitoring. Such monitoring can optimizepatient follow-up and foster professional accountability for the treatment of amputation patients in disaster settings and humanitarian emergencies.

Introduction: Access to the vascular system of the critically ill or injured adult patient is essential for resuscitation. Whether due to trauma or disease, vascular collapse may delay or preclude even experienced medical providers from obtaining standard intravenous (IV) access. Access to the highly vascular intramedullary space of long bones provides a direct link to central circulation. The sternum is a thin bone easily identified by external landmarks that contains well-vascularized marrow. The intraosseous (IO) route rapidly and reliably delivers fluids, blood products, and medications. Resuscitation fluids administered by IV or IO achieve similar transit times to central circulation. The FAST-1 Intraosseous Infusion System is the first FDA-approved mechanical sternal IO device. The objectives of this study were to: (1) determine the success rate of FAST-1 sternal IO device deployment in the prehospital setting; (2) compare the time of successful sternal IO device placement to published data regarding time to IV access; and (3) describe immediate complications of sternal IO use.

Methods: All paramedics in the City of Portsmouth, Virginia were trained to correctly deploy the FAST-1 sternal IO device during a mandatory education session with the study investigators. The study subjects were critically ill or injured adult patients in cardiac arrest treated by paramedics during a one-year period. When a patient was identified as meeting study criteria, the paramedic initiated standard protocols; the FAST-1 sternal IO was substituted for the peripheral IV to establish vascular access. Time to deployment was measured and successful placement was defined as insertion of the needle, with subsequent aspiration and fluid flow without infiltration.

Results: Over the one-year period, paramedics attempted 41 FAST-1 insertions in the pre-hospital setting. Thirty (73%) of these were placed successfully. The mean time to successful placement was 67 seconds for 28 attempts; three of the 31 insertions did not have times recorded by the paramedic. Paramedics listed the problems with FAST-1 insertion, including: (1) difficulty with adhesive after device placement (3 events); (2) failure of needles to retract and operator had to pull the device out of the skin (2 events); and (3) slow flow (1 event). Emergency department physicians noted two events of minor bleeding around the site of device placement.

Conclusion: This is the first study to prospectively evaluate the prehospital use of the FAST-1 sternal IO as a first-line device to obtain vascular access in the critically ill or injured patient. The FAST-1 sternal IO device can be a valuable tool in the paramedic arsenal for the treatment of the critically ill or injured patient. The device may be of particular interest to specialty disaster teams that deploy in austere environments.

Introduction: Globally, railway transport is increasing steadily. Despite the adoption of diverse safety systems, major railway incidents continue to occur. Higher speeds and increased passenger traffic are factors that influence the risk of mass-casualty incidents and make railway crashes a reality that merits extensive planning and training.

Methods: Data on railway disasters were obtained from the Centre for Research on the Epidemiology of Disasters (CRED), which maintains the Emergency Events Database (EM-DAT). This descriptive study consists of 529 railway disasters (≥10 killed and/or ≥100 non- fatally injured) from 1910 through 2009.

Results: The number of railway disasters, people killed, and non-fatally injured, has increased throughout the last hundred years—particularly during the last four decades (1970–2009), when 88% of all disasters occurred. In the mid-20th century, a shift occurred, resulting in more people being non-fatally injured than fatally injured. During 1970–2009, 74% of all railway disasters occurred in Asia, Africa, and South and Central America, combined. The remaining 26% occurred in Europe, North America, and Oceania, combined. Since 1980, railway disasters have increased, especially in Asia and Africa, while Europe has had a decrease in railway disasters. The number killed per disaster (1970–2009) was highest in Africa (n = 55), followed by South and Central America (n = 47), and Asia (n = 44). The rate was lowest in North America (n = 10) and Europe (n = 29). On average, the number of non-fatal injuries per disaster was two to three times the number of fatalities, however, in the African countries (except South Africa) the relation was closer to 1:1, which correlates to the relation found in more developed countries during the mid-20th century. The total losses (non-fatally and fatally injured) per disaster has shown a slight decreasing trend.

Conclusions: Despite extensive crash avoidance and injury reduction safety systems, railway crashes occur on all continents, indicating that this type of incident must be accounted for in disaster planning and training. Better developed safety, crashworthiness, and rescue resources in North America and Europe may be factors explaining why the number of crashes and losses has stabilized and why the average number of people killed per disaster is lowest on these continents.

Introduction: In recent years, the number of public health emergencies has increased. Improving hospital emergency management is an important challenge.

Objective: This is a pilot study intended to assess hospital emergency management in the Beijing area, make recommendations to government health authorities and hospital managers, and offer references for similar studies.

Methods: This was an observational, cross-sectional survey. Forty-five hospitals in the Beijing area were selected randomly. A self-administered questionnaire was used as a data collection tool. It comprised of three sections: (1) Section A was the introduction; (2) Section B asked for the respondent's personal information; and (3) Section C comprised the major part of the questionnaire and was intended to gather information regarding the hospital's general emergency management situation.

Results: The survey response rate was 44%, accounting for 29% of total hospitals that the study targeted. No hospital had an established emergency management department or full-time staff for emergency management. A total of 15–45% of the hospitals had established a hospital emergency management committee, performed a vulnerability analysis, or evaluated emergency management regularly. Twenty-five percent of respondents thought that the local government health authority had established an integrated hospital incident command system. A total of 40%–55% of hospitals contracted with outside institutions for supplements, backup of key functional systems and professional support.

Conclusions: After the occurrence of the 2003 severe acute respiratory syndrome (SARS) epidemic, Chinese hospital managers took many measures to improve hospital resilience. However, most of these efforts lacked the guidance of theories, concepts, principles, and methods. An integrated, standardized, operational hospital emergency management model has not been established. Although the survey response rate was relatively low, some clues for further study were discovered, and suggestions to the health authority for hospital emergency management improvement were revealed.

Introduction: This project examined the use of first aid by bystanders at road traffic crashes (RTC) and was undertaken in the context of increasing average ambulance response times to RTC throughout Australia and the potential impact of early first aid intervention on the mortality and morbidity associated with RTC. The aim of this project was to acquire knowledge about the prevalence of first aid training; the incidence of being a bystander and of providing first aid; the range of first aid skills being utilized; the motivation to intervene; and, the perceived impact of first aid training.

Methods: An Internet-based survey was distributed to a potential population of 12,500 road users and a total of 773 responded. Descriptive and comparative statistical analysis of quantitative data and thematic analysis of qualitative data were completed.

Results: Seventy-seven percent (77%) of participants had first aid training at some stage in their lives; 28% held a current first aid certificate; 11% had provided first aid at RTC; 75.3% who had provided first aid were travelling in a vehicle. Having first aid training increased the likelihood of intervention and of owning a first aid kit or pocket mask.

Conclusions: First aid training, even if it is not current, is an enabler for providing first aid at RTCs. The first aid skills most commonly used were changing posture, opening an airway, and providing comfort and reassurance. Key concerns for first aiders included a feeling of a lack of follow-up, and lack of an opportunity to debrief. Strategies to increase first aid training, to improve information and support, and to increase the knowledge of first aider’s are discussed.

Introduction: The aim of this study was to describe the current state of disaster preparedness in hospitals in the public sector in the Western Cape, South Africa with the advent of the FIFA 2010 Soccer World Cup. The objectives included the completion of a self-reported assessment of readiness at all Western Cape public sector hospitals, to identify best practice and shortfalls in these facilities, as well as putting forward recommendations for improving disaster preparedness at these hospitals.

Methods: The National Department of Health, as part of the planning for the FIFA 2010 World Cup, appointed an expert committee to coordinate improvements in disaster medicine throughout the country. This workgroup developed a Self Reported Hospital Assessment Questionnaire, which was sent to all hospitals across the country. Data only were collected from public hospitals in the Western Cape and entered onto a purpose-built database. Basic descriptive statistics were calculated. Ethical approval was obtained from the Health Sciences Faculty Research Committee of the University of Cape Town.

Results: Twenty-seven of the 41 (68%) public hospitals provided completed data on disaster planning. The study was able to ascertain what infrastructure is available and what planning already has been implemented at these institutions.

Recommendations: Most hospitals in the Western Cape have a disaster plan for their facility. Certain areas need more focus and attention; these include: (1) increasing collaborative partnerships; (2) improving HAZMAT response resources; (3) specific plans for vulnerable populations; (4) contingency plans for communication failure; (5) visitor, media and VIP dedicated areas and personnel; (6) evacuation and surge capacity plans; and (7) increased attention to training and disaster plan exercises.

Enclosed-space smoke inhalation is the fifth most common cause of all unintentional injury deaths in the United States. Increasingly, cyanide has been recognized as a significant toxicant in many cases of smoke inhalation. However, it cannot be emergently verified. Failure to recognize the possibility of cyanide toxicity may result in inadequate treatment. Findings suggestive cyanide toxicity include: (1) a history of an enclosed-space fire scene in which smoke inhalation was likely; (2) the presence of oropharyngeal soot or carbonaceous expectorations; (3) any alteration of the level of consciousness, and particularly, otherwise inexplicable hypotension (systolic blood pressure ≤90 mmHg in adults). Prehospital studies have demonstrated the feasibility and safety of empiric treatment with hydroxocobalamin for patients with suspected smoke inhalation cyanide toxicity. Although United States Food and Drug Administration (FDA)-approved since 2006, the lack of efficacy data has stymied the routine use of this potentially lifesaving antidote. Based on a literature review and on-site observation of the Paris Fire Brigade, emergency management protocols to guide empiric and early hydroxocobalamin administration in smoke inhalation victims with high-risk presentations are proposed.

Field first-aid data from the Wenchuan Earthquake in China was analyzed retrospectively in order to probe into ways to develop field first-aid operations and provide a reference for future emergency rescue. Related documents about the Wenchuan Earthquake were collected and reviewed. The state of injury and leading causes of death during the disaster were identified. The presnece of emergency medical resources on-site after the earthquake was relatively insufficient. Deaths mainly were due to cardiopulmonary arrest, severe craniocerebral injury, incurable hemorrhagic shock, and crush syndrome that caused multiple organ system dysfunction syndrome. Only by strengthening the on-site emergency medical resources, speeding-up triage, and equipping responders with professional, portable medical equipment, can field first-aid operations be delivered more efficiently.

Background: The disaster response environment in Haiti following the 2010 earthquake represented a complex healthcare challenge. This study was designed to identify challenges during the Haiti disaster response.

Methods: Qualitative and quantitative study of injured patients carried out six months after the January 2010 earthquake in Haiti to review the surgical inputs of foreign medical teams.

Results: Study findings revealed a need during the response for improved medical records and data gathering for regulation, quality assurance, coordination and resource allocation; wider adherence to standard patient referral mechanisms and protocols linking surgical service provision with appropriate hospital and community based rehabilitation services; a greater recognition of the impact of non-amputation injury, and the need for patients to have a greater say in their management and to be the keepers of their medical records. Key first steps to improving the international response are a minimum dataset and uniform reporting.

Conclusion: This study showed that challenges for emergency medical response during the Haiti Earthquake involved issues of accountability, professional ethics, standards-of-care, unmet needs, patient agency and expected outcomes for patients in such settings: