Overview of evacuation and transport of patients following the 1995 Hanshin-Awaji earthquake

Placing engineering in the earthquake response and the survival chain

Earthquakes injure millions and simultaneously disrupt the infrastructure to protect them. This perspective argues that the current post-disaster investigation paradigm is insufficient to protect communities' health effectively. We propose the Earthquake Survival Chain as a framework to change the current engineering focus on infrastructure to health. This framework highlights four converging research opportunities to advance understanding of earthquake injuries, search and rescue, patient mobilizations, and medical treatment. We offer an interdisciplinary research agenda in engineering and health sciences, including artificial intelligence and virtual reality, to protect health and life from earthquakes.

Prehospital management of earthquake crush injuries: A collective review

Earthquakes are natural disasters which can destroy the rural and urban infrastructure causing a high toll of injuries and death without advanced notice. We aim to review the prehospital medical management of earthquake crush injuries in the field. PubMed was searched using general terms including rhabdomyolysis, crush injury, and earthquake in English language without time restriction. Selected articles were critically evaluated by three experts in disaster medicine, emergency medicine, and critical care. The medical response to earthquakes includes: (1) search and rescue; (2) triage and initial stabilization; (3) definitive care; and (4) evacuation. Long-term, continuous pressure on muscles causes crush injury. Ischemia-reperfusion injury following the relieving of muscle compression may cause metabolic changes and rhabdomyolysis depending on the time of extrication. Sodium and water enter the cell causing cell swelling and hypovolemia, while potassium and myoglobin are released into the circulation. This may cause sudden cardiac arrest, acute extremity compartment syndrome, and acute kidney injury. Recognizing these conditions and treating them timely and properly in the field will save many patients. Majority of emergency physicians who have worked in the field of the recent Kahramanmaraş 2023, Turkey, earthquakes, have acknowledged their lack of knowledge and experience in managing earthquake crush injuries. We hope that this collective review will cover the essential knowledge needed for properly managing seriously crushed injured patients in the earthquake field.

Multi-hazard hospital evacuation planning during disease outbreaks using agent-based modeling

As different types of hazards, including natural and man-made, can occur simultaneously, to implement an integrated and holistic risk management, a multi-hazard perspective on disaster risk management, including preparedness and planning, must be taken for a safer and more resilient society. Considering the emerging challenges that the COVID-19 pandemic has been introducing to regular hospital operations, there is a need to adapt emergency plans with the changing conditions, as well. Evacuation of patients with different mobility disabilities is a complicated process that needs planning, training, and efficient decision-making. These protocols need to be revisited for multi-hazard scenarios such as an ongoing disease outbreak during which additional infection control protocols might be in place to prevent transmission. Computational models can provide insights on optimal emergency evacuation strategies, such as the location of isolation units or alternative evacuation prioritization strategies. This study introduces a non-ICU patient classification framework developed based on available patient mobility data. An agent-based model was developed to simulate the evacuation of the emergency department at the Johns Hopkins Hospital during the COVID-19 pandemic due to a fire emergency. The results show a larger nursing team can reduce the median and upper bound of the 95% confidence interval of the evacuation time by 36% and 33%, respectively. A dedicated exit door for COVID-19 patients is relatively less effective in reducing the median time, while it can reduce the upper bound by more than 50%.

Assessment of Critical Care Surge Capacity During the COVID-19 Pandemic in Japan

Japan has the highest proportion of older adults worldwide but has fewer critical care beds than most high-income countries. Although the COVID-19 infection rate in Japan is low compared with Europe and the United States, by the end of 2020, several infected people died in ambulances because they could not find hospitals to accept them. Our study aimed to examine the Japanese healthcare system's capacity to accommodate critically ill COVID-19 patients during the pandemic. We created a model to estimate bed and staff capacity at 3 levels of pandemic response (conventional, contingency, and crisis), as defined by the US National Academy of Medicine, and the function of Japan's healthcare system at each level. We then compared our estimates of the number of COVID-19 patients requiring intensive care at peak times with the national health system capacity using expert panel data. Our findings suggest that Japan's healthcare system currently can accommodate only a limited number of critically ill COVID-19 patients. It could accommodate the surge of pandemic demands by converting nonintensive care unit beds to critical care beds and using nonintensive care unit staff for critical care. However, bed and staff capacity should not be expanded uniformly, so that the limited number of physicians and nurses are allocated efficiently and so staffing does not become the bottleneck of the expansion. Training and deploying physicians and nurses to provide immediate intensive care is essential. The key is to introduce and implement the concept and mechanism of tiered staffing in the Japanese healthcare system. More importantly, most intensive care facilities in Japanese hospitals are small-scaled and thinly distributed in each region. The government needs to introduce an efficient system for smooth dispatching of medical personnel among hospitals regardless of their founding institutions.

Orchestrating performance of healthcare networks subjected to the compound events of natural disasters and pandemic

The current COVID-19 pandemic has demonstrated the vulnerability of healthcare systems worldwide. When combined with natural disasters, pandemics can further strain an already exhausted healthcare system. To date, frameworks for quantifying the collective effect of the two events on hospitals are nonexistent. Moreover, analytical methods for capturing the dynamic spatiotemporal variability in capacity and demand of the healthcare system posed by different stressors are lacking. Here, we investigate the combined impact of wildfire and pandemic on a network of hospitals. We combine wildfire data with varying courses of the spread of COVID-19 to evaluate the effectiveness of different strategies for managing patient demand. We show that losing access to medical care is a function of the relative occurrence time between the two events and is substantial in some cases. By applying viable mitigation strategies and optimizing resource allocation, patient outcomes could be substantially improved under the combined hazards.

Post-disaster transportation of seriously injured people to hospitals

Purpose

The purpose of this paper is to deal with the transportation of a high number of injured people after a disaster in a highly populated large area. Each patient should be delivered to the hospital before the specific deadline to survive. The objective of the study is to maximize the survival rate of patients by proper assignment of existing emergency vehicles to hospitals and efficient generation of vehicle routes.

Design/methodology/approach

The concepts of non-fixed multiple depot pickup and delivery vehicle routing problem (MDPDVRP) is utilized to capture an image of the problem encountered in real life. Due to NP-hardness of the problem, a hybrid genetic algorithm (GA) is proposed as the solution method. The performance of the developed algorithm is investigated through a case study.

Findings

The proposed hybrid model outperforms the traditional GA and also is significantly superior compared to the nearest neighbor assignment. The required time for running the algorithm on a large-scale problem fits well into emergency distribution and the promptness required for humanitarian relief systems.

Originality/value

This paper investigates the efficient assignment of emergency vehicles to patients and their routing in a way that is most appropriate for the problem at hand.

The Gujarat Earthquake (2001) Experience in a Seismically Unprepared Area: Community Hospital Medical Response

Background:

At 08:53 hours on 26 January 2001, an earthquake measuring 6.9 on the Richter scale devastated a large, drought-affected area of northwestern India, the state of Gujarat. The known number killed by the earthquake is 20,005, with 166,000 injured, of whom 20,717 were “seriously” injured. About 370,000 houses were destroyed, and another 922,000 were damaged.

Methods:

A community health worker using the local language interviewed all of the patients admitted to the Gandhi-Lincoln hospital with an on-site, oral, real-time, Victim Specific Questionnaire (VSQ).

Results

The census showed a predominance of women, children, and young adults, with the average age being 28 years. The majority of the patients had other family members who were also injured (84%), but most had not experienced deaths among family members (86%). Most of the patients (91%) had traveled more than 200 kilometers using their family cars, pick-ups, trucks, or buses to reach the buffer zone hospitals. The daily hospital admission rate returned to pre-event levels five days after the event, and all of the hospital services were restored by nine days after the quake. Most of the patients (83%) received definitive treatment in the buffer zone hospitals; 7% were referred to tertiary-care centers; and 9% took discharge against medical advice.

The entrapped village folk with their traditional architecture had lesser injuries and a higher rescue rate than did the semi-urban townspeople, who were trapped in collapsed concrete masonry buildings and narrow alleys. However, at the time of crisis, aware townspeople were able to tap the available health resources better than were the poor. There was a low incidence of crush injuries. Volunteer doctors from various backgrounds teamed up to meet the medical crisis. International relief agencies working through local groups were more effective. Local relief groups needed to coordinate better. Disaster tourism by various well-meaning agencies took a toll on the providers. Many surgeries may have contributed to subsequent morbidity.

Conclusions:

The injury profile was similar to that reported for most other daytime earthquakes. Buffer zone treatment outcomes were better than were the field and damaged hospital outcomes.

Survey of Bam Earthquake Survivors' Opinions on Medical and Health Systems Services

Introduction: On 26 December 2003, a catastrophic earthquake measuring 6.6 on the Richter scale devastated large areas of the city of Bam in south-eastern Iran. More than 40,000 people died, tens of thousands were injured, and almost 20,000 homes were destroyed.

Many national and international search-and-rescue teams were dispatched to the area to provide medical and health services and assist in the evacuation of survivors to undamaged areas.

Problem: The purpose of the study was to evaluate the opinions of survivors about medical responses provided, and the process of reconstruction of health infrastructures.

Methods: This was a descriptive study performed two years after the earthquake. Stratified, two-stage area sampling was used to enroll 211 survivors into the survey. A designed questionnaire was applied to evaluate the respondents' opinions about medical and health responses. The respondents were asked to score their satisfaction on a variety of services on a five-point scale, with 1 being “very poor” and 5 being “very good”.

Results: Family members and relatives comprised the majority of first responders for those injured or trapped (127, 60.2%). Field hospitals deployed by the Red Crescent, international relief teams, and military forces were the first medical facilities for 98 (46.4%) of the casualties. As denoted by the mean values for the satisfaction scores, transportation by aircraft to the backup hospitals received the highest score (4.2), followed by international assistance (4.1), first medical care (3.5), search and rescue (3.3), primary transportation (3.1), and reconstruction and the quality of access to the infrastructures of the city (2.6). Two years after the earthquake, 151 (71.5%) respondents still were living in connexes (temporary accommodations or shelters for victims to live in; resemble a small hotel), only 33 (15.6%) had access to safe drinking water, and 44 (20.9%) did not have sufficient supplies of sanitary food.

Conclusions: In addition to reinforcing the medical and health infrastructures of a society in accordance with geographical and architectural characteristics, effective air evacuation and relief missions carried out by experienced international relief teams can play an important role in the appropriate management of approximately 30,000 casualties after a catastrophic event, such as experience with the Bam Earthquake.

Evacuation of a Tertiary Neonatal Centre: Lessons from the 2016 Kumamoto Earthquakes

BACKGROUND

Newborn infants hospitalised in the neonatal intensive care unit (NICU) are vulnerable to natural disasters. However, publications on evacuation from NICUs are sparse. The 2016 Kumamoto Earthquakes caused serious damage to Kumamoto City Hospital and its level III regional core NICU. Local/neighbour NICU teams and the disaster-communication team of a neonatal academic society cooperated to evacuate 38 newborn infants from the ward.

OBJECTIVE

The aim of this paper was to highlight potential key factors to improve emergency NICU evacuation and coordination of hospital transportation following natural disasters.

METHODS

Background variables including clinical risk scores and timing/destination of transportation were compared between infants, who subsequently were transferred to destinations outside of Kumamoto Prefecture, and their peers.

RESULTS

All but 1 of the infants were successfully evacuated from their NICU within 8 h. One very-low-birth-weight infant developed moderate hypothermia following transportation. Fourteen infants were transferred to NICUs outside of Kumamoto Prefecture, which was associated with the diagnosis of congenital heart disease, dependence on respiratory support, higher risk scores, and longer elapsed time from the decision to departure. There was difficulty in arranging helicopter transportation because the coordination office of the Disaster Medical Assistance Team had requisitioned most air/ground ambulances and only helped arrange ground transportations for 13 low-risk infants. Transportation for all 10 high-risk infants (risk scores greater than or equal to the upper quartile) was arranged by local/neighbour NICUs.

CONCLUSIONS

Although the overall evacuation process was satisfactory, potential risks of relying on the adult-based emergency transportation system were highlighted. A better system needs to be developed urgently to put appropriate priority on vulnerable infants.

Disaster Vulnerability of Hospitals: A Nationwide Surveillance in Japan

Objective

Hospital preparedness against disasters is key to achieving disaster mitigation for health. To gain a holistic view of hospitals in Japan, one of the most disaster-prone countries, a nationwide surveillance of hospital preparedness was conducted.

Methods

A cross-sectional, paper-based interview was conducted that targeted all of the 8701 registered hospitals in Japan. Preparedness was assessed with regard to local hazards, compliance to building code, and preparation of resources such as electricity, water, communication tools, and transportation tools.

Results

Answers were obtained from 6122 hospitals (response rate: 70.3%), among which 20.5% were public (national or city-run) hospitals and others were private. Eight percent were the hospitals assigned as disaster-base hospitals and the others were non-disaster-base hospitals. Overall compliance to building code, power generators, water tanks, emergency communication tools, and helicopter platforms was 90%, 84%, 95%, 43%, and 22%, respectively.

Conclusion

Major vulnerabilities in logistics in mega-cities and stockpiles required for chronic care emerged from the results of this nationwide surveillance of hospitals in Japan. To conduct further intensive surveillance to meet community health needs, appropriate sampling methods should be established on the basis of this preliminary study. Holistic vulnerability analysis of community hospitals will lead to more robust disaster mitigation at the local level. (Disaster Med Public Health Preparedness. 2015;9:614–618)

Medical Efforts and Injury Patterns of Military Hospital Patients Following the 2013 Lushan Earthquake in China: A Retrospective Study

The aim of this paper is to investigate medical efforts and injury profiles of victims of the Lushan earthquake admitted to three military hospitals. This study retrospectively investigated the clinical records of 266 admitted patients evacuated from the Lushan earthquake area. The 2005 version of the Abbreviated Injury Scale (AIS-2005) was used to identify the severity of each injury. Patient demographic data, complaints, diagnoses, injury types, prognosis, means of transportation, and cause of injury were all reviewed individually. The statistical analysis of the study was conducted primarily using descriptive statistics. Of the 266 patients, 213 (80.1%) were admitted in the first two days. A total of 521 injury diagnoses were recorded in 266 patients. Earthquake-related injuries were primarily caused by buildings collapsing (38.4%) and victims being struck by objects (33.8%); the most frequently injured anatomic sites were the lower extremities and pelvis (34.2%) and surface area of the body (17.9%). Fracture (41.5%) was the most frequent injury, followed by soft tissue injury (27.5%), but crush syndrome was relatively low (1.2%) due to the special housing structures in the Lushan area. The most commonly used procedure was suture and dressings (33.7%), followed by open reduction and internal fixation (21.9%).The results of this study help formulate recommendations to improve future disaster relief and emergency planning in remote, isolated, and rural regions of developing countries.

Evacuation of Intensive Care Units During Disaster: Learning From the Hurricane Sandy Experience

OBJECTIVE

Data on best practices for evacuating an intensive care unit (ICU) during a disaster are limited. The impact of Hurricane Sandy on New York City area hospitals provided a unique opportunity to learn from the experience of ICU providers about their preparedness, perspective, roles, and activities.

METHODS

We conducted a cross-sectional survey of nurses, respiratory therapists, and physicians who played direct roles during the Hurricane Sandy ICU evacuations.

RESULTS

Sixty-eight health care professionals from 4 evacuating hospitals completed surveys (35% ICU nurses, 21% respiratory therapists, 25% physicians-in-training, and 13% attending physicians). Only 21% had participated in an ICU evacuation drill in the past 2 years and 28% had prior training or real-life experience. Processes were inconsistent for patient prioritization, tracking, transport medications, and transport care. Respondents identified communication (43%) as the key barrier to effective evacuation. The equipment considered most helpful included flashlights (24%), transport sleds (21%), and oxygen tanks and respiratory therapy supplies (19%). An evacuation wish list included walkie-talkies/phones (26%), lighting/electricity (18%), flashlights (10%), and portable ventilators and suction (16%).

CONCLUSIONS

ICU providers who evacuated critically ill patients during Hurricane Sandy had little prior knowledge of evacuation processes or vertical evacuation experience. The weakest links in the patient evacuation process were communication and the availability of practical tools. Incorporating ICU providers into hospital evacuation planning and training, developing standard evacuation communication processes and tools, and collecting a uniform dataset among all evacuating hospitals could better inform critical care evacuation in the future.

A Sex Disparity Among Earthquake Victims

OBJECTIVE

Understanding who is most vulnerable during an earthquake will help health care responders prepare for future disasters. We analyzed the demography of casualties from the Christchurch earthquake in New Zealand.

METHODS

The demography of the total deceased, injured, and hospitalized casualties of the Christchurch earthquake was compared with that of the greater Christchurch population, the Christchurch central business district working population, and patients who presented to the single acute emergency department on the same month and day over the prior 10 years. Sex data were compared to scene of injury, context of injury, clinical characteristics of injury, and injury severity scores.

RESULTS

Significantly more females than males were injured or killed in the entire population of casualties (P20% were injured at commercial or service localities (444/2032 males [22%]; 1105/4627 females [24%]). Adults aged between 20 and 69 years (1639/2032 males [81%]; 3717/4627 females [80%]) were most frequently injured.

CONCLUSION

Where people were and what they were doing at the time of the earthquake influenced their risk of injury.

Evacuation of the ICU: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement

BACKGROUND

Despite the high risk for patient harm during unanticipated ICU evacuations, critical care providers receive little to no training on how to perform safe and effective ICU evacuations. We reviewed the pertinent published literature and offer suggestions for the critical care provider regarding ICU evacuation. The suggestions in this article are important for all who are involved in pandemics or disasters with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials.

METHODS

The Evacuation and Mobilization topic panel used the American College of Chest Physicians (CHEST) Guidelines Oversight Committee's methodology to develop seven key questions for which specific literature searches were conducted to identify studies upon which evidence-based recommendations could be made. No studies of sufficient quality were identified. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process.

RESULTS

Based on current best evidence, we provide 13 suggestions outlining a systematic approach to prepare for and execute an effective ICU evacuation during a disaster. Interhospital and intrahospital collaboration and functional ICU communication are critical for success. Pre-event planning and preparation are required for a no-notice evacuation. A Critical Care Team Leader must be designated within the Hospital Incident Command System. A three-stage ICU Evacuation Timeline, including (1) no immediate threat, (2) evacuation threat, and (3) evacuation implementation, should be used. Detailed suggestions on ICU evacuation, including regional planning, evacuation drills, patient transport preparation and equipment, patient prioritization and distribution for evacuation, patient information and tracking, and federal and international evacuation assistance systems, are also provided.

CONCLUSIONS

Successful ICU evacuation during a disaster requires active preparation, participation, communication, and leadership by critical care providers. Critical care providers have a professional obligation to become better educated, prepared, and engaged with the processes of ICU evacuation to provide a safe continuum of critical care during a disaster.

Telecommunications in Israeli field hospitals deployed to three crisis zones

A field hospital overseas requires various types of communication equipment. This study presents the communications equipment used by three Israeli field hospital delegations to earthquake sites at Adapazari, Turkey, in 1999, Port-au-Prince, Haiti, in 2010 and Minamisanriku, Japan, in 2011. The delegations to Turkey and Haiti were relatively large (105-230 personnel) and were on the site early (three to four days after each event). The 55-person delegation to Japan arrived later and was established as an outpatient community hospital. Standard military VHF radios were the only effective tool up to 5 km, until cellular coverage was regained (1-2 weeks after each event). International communication was good. While short-wave communication (telephone and Internet) was used in Turkey, a direct satellite channel was set up in Haiti. In Japan, BGAN Inmarsat provided efficient Wi-Fi for all needs. Motorola walkie talkies were not efficient beyond the immediate vicinity. This paper recommends continued use of military-specification equipment alongside newer modalities, particularly in situations where infrastructure is damaged.

Role of the French Rescue Teams in Diquini Hospital: Port-au-Prince, January 2010

On January 12, 2010, Port-au-Prince, Haiti, was shattered by a violent earthquake that killed or injured thousands of its citizens. Local emergency services became overwhelmed and international assistance was required. French relief teams were deployed to assist local hospitals in caring for the victims. The medical care activity of the team at Diquini Hospital from January 17-26 was analyzed.

Priority was given to surgery, leading to the creation of a pre- and post-operative area and a medical care unit. Special attention was required for infection prevention, pain relief, minor surgery, and pre-surgery triage. The continual influx of accompanied victims necessitated the creation of a receiving area.

In spite of the assistance from several foreign surgical teams, some patients had to be evacuated to French or American facilities, particularly children, patients with spinal cord injuries, and those needing intensive care.

Analysis of the actions undertaken highlights the importance of well-prepared and flexible medical teams and the ability to provide local and regional anesthesia, including the necessary medical supplies and equipment. Medical care activity, especially post-surgical care, was a predominant, ongoing need. The ability to provide medical care required organization and cooperation among local health care providers and other relief workers.

BennerP, StephanJ, RenardA, PetitjeanF, LargerD, PonsD, PaklepaB, DenielC, LeDreffP. Role of the French rescue teams in Diquini Hospital: Port-au-Prince, January 2010. Prehosp Disaster Med. 2012;27(6):1-5.

The great East Japan earthquake of March 11, 2011, from the vantage point of blood banking and transfusion medicine

BACKGROUND

The Great East Japan Earthquake of March 11, 2011, and subsequent tsunami took nearly 20 000 lives in Tohoku, the northeastern part of Japan's main island. Most victims were either carried away by the tsunami or drowned. The ability to collect blood was disrupted on the Pacific coast of Tohoku. Inland areas were less affected, but allogeneic blood collected in Tohoku is tested at the Miyagi Red Cross Blood Center (Miyagi Center) in the coastal city of Sendai. Miyagi Center was damaged and could not test for 2 months.

OBJECTIVES

The aims of this study are as follows: (1) to assess transfusion practice at 8 disaster response hospitals in Tohoku's Fukushima Prefecture, for equal intervals before and after March 11, 2011; (2) to report activities related to blood collection and distribution in response to the disaster; and (3) to describe the Great East Japan Earthquake in the context of other disasters.

METHODS

Data were collected through a survey of transfusion services at 8 major disaster response hospitals, communication at transfusion conferences, and literature review.

RESULTS

Transfused patients and units transfused were about 70% and 60% of normal in the surveyed hospitals because this was a disaster of mass casualty rather than mass injury, and patients requiring chronic care were evacuated out. A nationally coordinated effort allowed excess blood collected outside Tohoku to be transported in, despite infrastructure damage.

CONCLUSION

Japan's national system of blood collection and distribution responded effectively to local needs after the Great East Japan Earthquake. Disasters such as Japan's 3.11 should guide discourse about emergency preparedness and centralization of services.

The 2003 Bam Earthquake: Overview of First Aid and Transport of Victims

Introduction:

In December 2003, the residents of Bam, Iran experienced an earthquake that measured 6.6 on the Richter scale and destroyed more than 90% of the city.

Problem:

The purpose of this study was to assess the status of the rescue, evacuation, and transportation of the casualties during the early stages following the earthquake.

Methods:

A cross-sectional study of 185 casualties who were transferred to and hospitalized in the university hospital during the first week period following the earthquake was conducted. Information regarding different places of settlement after being removed from the rubble, initial medical care, and the means of transportation was obtained by reviewing medical records and interviewing the victims.

Results:

The mean value of the duration of times taken for the first rescuers to reach the scene and remove the casualties from the rubble was 1.7 ±2.7 and 0.9 ±1.1 hours, respectively. Sixty-nine (37.7%) of the patients stayed within the area immediately surrounding their home for average times of 8 ±10 hours. The majority of casualties (57.6%) were transferred manually to a first place of settlement; 45.8% were taken to a second place of settlement using blankets. Of the patients studied, 159 (85.9%) did not receive any basic medical care at the first place and intravenous fluid therapy was the most common treatment provided for 24 (13%) patients at the second place of settlement. Patients received medical care at the first place of settlement for a mean time of 16.8 ±13.5 hours after escaping the rubble.

Conclusions:

These findings indicate that the emergency medical service system in Bam was destroyed and not able to respond adequately. In order to reduce the negative effects of such disasters in the future, there is an essential need for a comprehensive disaster management plan and improvement of hospital structures, healthcare facilities, and communication between the different governmental departments for better coordination and planning.

A Fundamental, National, Medical Disaster Management Plan: An Education-Based Model

During disasters, especially following earthquakes, health systems are expected to play an essential role in reducing mortality and morbidity. The most significant naturally occurring disaster in Iran is earthquakes; they have killed <180,000 people in the last 90 years. According to the current plan in 2007, the disaster management system of Iran is composed of three main work groups: (1) Prevention and risk management, (2) Education, and (3) Operation. This organizational separation has resulted in lack of necessary training programs for experts of specialized organizations, e.g., the Ministry of Health and Medical Education (MOHME).The National Board of MOHME arranged a training program in the field of medical disaster management. A qualified training team was chosen to conduct this program in each collaborating center, based on a predefined schedule. All collaborating centers were asked to recall 5–7 experts from each member university. Working in medical disaster management field for ≤2 years was an inclusion criterion. The training programs lasted three days, consisted of all relevant aspects of medical disaster management, and were conducted over a six-month period (November 2007–April 2008). Pretest and post-tests were used to examine the participants' knowledge regarding disaster management; the mean score on the pretest was 67.1 ±11.6 and 88.1 ±6.2, respectively. All participants were asked to hold the same training course for their organizations in order to enhance knowledge of related managers, stakeholders, and workers, and build capacity at the local and provincial levels. The next step was supposed to be developing a comprehensive medical disaster management plan for the entire country. Establishing nine disaster management regional collaborating centers in the health system of Iran has provided an appropriate base for related programs to be rapidly and easily accomplished throughout the country. This tree-shaped model is recommended as a cost-benefit and rapid approach for conducting training programs and developing a disaster management plan in the health system of a developing country.

Hospital Responses to Acute-Onset Disasters: A Review

Introduction:

Hospitals the world over have been involved in disasters, both internal and external. These two types of disasters are independent, but not mutually exclusive. Internal disasters are isolated to the hospital and occur more frequently than do external disasters. External disasters affect the community as well as the hospital. This paper first focuses on common problems encountered during acute-onset disasters, with regards to hospital operations and caring for victims. Specific injury patterns commonly seen during natural disasters are reviewed. Second, lessons learned from these common problems and their application to hospital disaster plans are reviewed.

Methods:

An extensive review of the available literature was conducted using the computerized databases Medline and Healthstar from 1977 through March 1999. Articles were selected if they contained information pertaining to a hospital response to a disaster situation or data on specific disaster injury patterns. Selected articles were read, abstracted, analyzed, and compiled.

Results:

Hospitals continually have difficulties and failures in several major areas of operation during a disaster. Common problem areas identified include communication and power failures, water shortage and contamination, physical damage, hazardous material exposure, unorganized evacuations, and resource allocation shortages.

Conclusions::

Lessons learned from past disaster-related operational failures are compiled and reviewed. The importance and types of disaster planning are reviewed.

Benchmarking for Hospital Evacuation: A Critical Data Collection Tool

In events such as earthquakes or terrorist attacks, hospitals may be victims of disasters. They may need to transfer patients to outside facilities rather than continue to provide on-site care. Following the Northridge earthquake, eight hospitals in the damaged area were the foci of a United States National Science Foundation study that examined the status of the hospitals' pre-event planning, post-event evacuationdecision-making, and internal and external evacuation processes. Building on this experience, this paper offers a standardized data collection tool, which will enable researchers to record hospital evacuation information in a systematic manner so that comparable data can be accumulated, evacuation research methods can be improved, and consensus on methods can be reached. The study's principal subjects include: (1) hospital demographics; (2) description of existing disaster response plans; (3) an event's impacts on hospital operations; (4) decision-making and incident command; (5) movement of patients within the facility; (6) movement of patients to off-site institutions; and (7) hospital recovery.

Analysis of trends and emergency activities relating to critical victims of the Chuetsuoki Earthquake

INTRODUCTION

When a large-scale disaster occurs, it is necessary to use the available resources in a variety of sites and scenes as efficiently as possible. To conduct such operations efficiently, it is necessary to deploy limited resources to the places where they will be the most effective. In this study, emergency and medical response activities that occurred following the Chuetsuoki Earthquake in Japan were analyzed to assess the most efficient and effective activities.

METHODS

Records of patient transports by emergency services relating to the Niigata Chuetsuoki Earthquake, a magnitude 6.8 earthquake that struck Japan on 16 July 2007 were analyzed, and interview surveys were conducted.

RESULTS

The occurrence of serious injuries caused by this earthquake essentially was limited to the day the earthquake struck. A total of 682 patients were treated on the day of the quake, of which about 90 were hospitalized. Of the 17 patients whose conditions were life-threatening, three were rescued and transported to hospital by firefighters, three were transported by ambulance, and 11 were transported to hospital using private means. Sixteen people were subsequently transferred to other hospitals, six of these by helicopter. There was difficulty in meeting all of the requests for emergency services within 4 to 6 hours of the earthquake's occurrence. Most transports of patients whose conditions were life-threatening were between hospitals rather than from the scene of the injury. Transfers of critical patients between hospitals were efficient early on, but this does not necessarily mean that inter-hospital transfers were given higher priority than treatment at emergency scenes.

CONCLUSION

During the acute emergency period following a disaster-causing event, it is difficult to meet all requests for emergency services. In such cases, it is necessary to conduct efficient activities that target critically injured patients. Since hospital transfers are matters of great urgency, it is necessary to consider assigning resource investment priority to hospital transfers during this acute period, when ambulance services may be insufficient to meet all needs. To deal with such disasters appropriately, it is necessary to ensure effective information exchange and close collaboration between ambulance services, firefighting organizations, disaster medical assistance teams, and medical institutions.

Emergency medical rescue efforts after a major earthquake: lessons from the 2008 Wenchuan earthquake

Major earthquakes often result in incalculable environmental damage, loss of life, and threats to health. Tremendous progress has been made in response to many medical challenges resulting from earthquakes. However, emergency medical rescue is complicated, and great emphasis should be placed on its organisation to achieve the best results. The 2008 Wenchuan earthquake was one of the most devastating disasters in the past 10 years and caused more than 370,000 casualties. The lessons learnt from the medical disaster relief effort and the subsequent knowledge gained about the regulation and capabilities of medical and military back-up teams should be widely disseminated. In this Review we summarise and analyse the emergency medical rescue efforts after the Wenchuan earthquake. Establishment of a national disaster medical response system, an active and effective commanding system, successful coordination between rescue forces and government agencies, effective treatment, a moderate, timely and correct public health response, and long-term psychological support are all crucial to reduce mortality and morbidity and promote overall effectiveness of rescue efforts after a major earthquake.

Facilitators and obstacles in pre-hospital medical response to earthquakes: a qualitative study

Background

Earthquakes are renowned as being amongst the most dangerous and destructive types of natural disasters. Iran, a developing country in Asia, is prone to earthquakes and is ranked as one of the most vulnerable countries in the world in this respect. The medical response in disasters is accompanied by managerial, logistic, technical, and medical challenges being also the case in the Bam earthquake in Iran. Our objective was to explore the medical response to the Bam earthquake with specific emphasis on pre-hospital medical management during the first days.

Methods

The study was performed in 2008; an interview based qualitative study using content analysis. We conducted nineteen interviews with experts and managers responsible for responding to the Bam earthquake, including pre-hospital emergency medical services, the Red Crescent, and Universities of Medical Sciences. The selection of participants was determined by using a purposeful sampling method. Sample size was given by data saturation.

Results

The pre-hospital medical service was divided into three categories; triage, emergency medical care and transportation, each category in turn was identified into facilitators and obstacles. The obstacles identified were absence of a structured disaster plan, absence of standardized medical teams, and shortage of resources. The army and skilled medical volunteers were identified as facilitators.

Conclusions

The most compelling, and at the same time amenable obstacle, was the lack of a disaster management plan. It was evident that implementing a comprehensive plan would not only save lives but decrease suffering and enable an effective praxis of the available resources at pre-hospital and hospital levels.

ICU fire evacuation preparedness in London: a cross-sectional study

BACKGROUND

Hospital fires present a sporadic but significant threat to patients and staff. This is especially so within an intensive care unit (ICU) setting, due to the complexity of moving acutely unwell patients reliant on invasive monitoring and organ support. Despite an average of 500 in-hospital fires reported to the UK department of health per annum, causing 65 injuries and 1-2 fatalities, the readiness of ICUs for urgent evacuation has not been assessed.

METHODS

A cross-sectional survey of all 50 adult and paediatric ICUs within the London Postgraduate Deanery was conducted; neonatal units were excluded. The senior nurse at each unit was asked to complete a 90-question structured questionnaire, covering unit patient characteristics, design, equipment, training, and their evacuation plan. Thirty-five of 50 (70%) responded within 2 months of the study.

RESULTS

Significant weaknesses were reported in unit design, equipment, and planning. Unit design was compromised by inadequate fire doors (20%), ventilation cut-outs (17%), and escape routes (up to 60%). The ability to evacuate multiple patients simultaneously may be limited by a lack of portable monitoring equipment (49% of beds) and emergency drug supplies (20% of beds). Evacuation plans were often limited in their scope (96% expected to remain on their floor; 14% had plans to obtain medications after evacuation), and not rehearsed (60%). Staff training, while well provided for permanent staff, is less so for temporary staff (34%).

CONCLUSIONS

Forward planning for an urgent evacuation can be improved.

Impact on hospital functions following the 2010 Chilean earthquake

OBJECTIVE

The objective of this study was to assess the impact of the 2010 Chilean earthquake on hospital functions and services. Hospitals functioning in a post-disaster environment must provide emergency medical care related to the event, in addition to providing standard community health services. This study focused on damage to both structural and nonstructural components, as well as to utility services.

METHODS

Site visits were made to every hospital in a single province (Bio-Bio). Engineers conducted damage assessments while interviews of hospital administrators were conducted. The survey was requested by the Chilean Ministry of Health (MOH) to assess the impact of the earthquake on hospital operations and facility responses to those effects. Other important regional and hospital data were gathered from hospital administrators and the MOH.

RESULTS

Seven government hospitals were surveyed. All hospitals in the region lost communications, municipal electrical power and water for several days. All reported some physical damage although only one suffered significant structural damage. All lost some functional capacity as a result of the earthquake. The loss of telephones and cellular service was identified as the most difficult problem by administrators. An average of 3 physical areas per hospital lost some degree of functional capacity following the earthquake.

CONCLUSION

Even in an earthquake-prone and very well-prepared country such as Chile hospital functions were widely disrupted by the event. The loss of hospital functions can occur even with minimal damage to the physical structure. The loss of communications can impede or halt response efforts at all levels. Hospitals should be prepared to self-sustain following a disaster for 2-3 days regardless of the level of structural damage. Understanding the details of these impacts is essential to hospital preparedness and plans for continuing services after a disaster.

Establishing disaster medical assistance teams in Japan

INTRODUCTION

The large number casualties caused by the 1995 Great Hanshin and Awaji Earthquake created a massive demand for medical care. However, as area hospitals also were damaged by the earthquake, they were unable to perform their usual functions. Therefore, the care capacity was reduced greatly. Thus, the needs to: (1) transport a large number of injured and ill people out of the disaster-affected area; and (2) dispatch medical teams to perform such wide-area transfers were clear. The need for trained medical teams to provide medical assistance also was made clear after the Niigata-ken Chuetsu Earthquake in 2004. Therefore, the Japanese government decided to establish Disaster Medical Assistance Teams (DMATs), as "mobile, trained medical teams that rapidly can be deployed during the acute phase of a sudden-onset disaster". Disaster Medical Assistance Teams have been established in much of Japan. The provision of emergency relief and medical care and the enhancement and promotion of DMATs for wide-area deployments during disasters were incorporated formally in the Basic Plan for Disaster Prevention in its July 2005 amendment.

RESULTS

The essential points pertaining to DMATs were summarized as a set of guidelines for DMAT deployment. These were based on the results of research funded by a Health and Labour Sciences research grant from the, Labour and Welfare (MHLW) of the Ministry of Health. The guidelines define the basic procedures for DMAT activities-for example: (1) the activities are to be based on agreements concluded between prefectures and medical institutions during non-emergency times; and (2) deployment is based on requests from disaster-affected prefectures and the basic roles of prefectures and the MHLW. The guidelines also detail DMAT activities at the disaster scene of the, support from medical institutions, and transportation assistance including "wide-area" medical transport activities, such as medical treatment in staging care units and the implementation of medical treatment onboard aircraft.

CONCLUSIONS

Japan's DMATs are small-scale units that are designed to be suitable for responding to the demands of acute emergencies. Further issues to be examined in relation to DMATs include expanding their application to all prefectures, and systems to facilitate continuous education and training.

Potential roles of military-specific response to natural disasters -- analysis of the rapid deployment of a mobile surgical team to the 2007 Peruvian earthquake

The August 2007 earthquake in Peru resulted in the loss of critical health infrastructure and resource capacity. A regionally located United States Military Mobile Surgical Team was deployed and operational within 48 hours. However, a post-mission analysis confirmed a low yield from the military surgical resource. The experience of the team suggests that non-surgical medical, transportation, and logistical resources filled essential gaps in health assessment, evacuation, and essential primary care in an otherwise resource-poor surge response capability. Due to an absence of outcomes data, the true effect of the mission on population health remains unknown. Militaries should focus their disaster response efforts on employment of logistics, primary medical care, and transportation/evacuation. Future response strategies should be evidence-based and incorporate a means of quantifying outcomes.

Earthquakes and trauma: review of triage and injury-specific, immediate care

Earthquakes present a major threat to mankind. Increasing knowledge about geophysical interactions, progressing architectural technology, and improved disaster management algorithms have rendered modern populations less susceptible to earthquakes. Nevertheless, the mass casualties resulting from earthquakes in Great Kanto (Japan), Ancash (Peru), Tangshan (China), Guatemala, Armenia, and Izmit (Turkey) or the recent earthquakes in Bhuj (India), Bam (Iran), Sumatra (Indonesia) and Kashmir (Pakistan) indicate the devastating effect earthquakes can have on both individual and population health. Appropriate preparation and implementation of crisis management algorithms are of utmost importance to ensure a large-scale medical-aid response is readily available following a devastating event. In particular, efficient triage is vital to optimize the use of limited medical resources and to effectively mobilize these resources so as to maximize patient salvage. However, the main priorities of disaster rescue teams are the rescue and provision of emergency care for physical trauma. Furthermore, the establishment of transport evacuation corridors, a feature often neglected, is essential in order to provide the casualties with a chance for survival. The optimal management of victims under such settings is discussed, addressing injuries of the body and psyche by means of simple diagnostic and therapeutic procedures globally applicable and available.

Military nursing research: translation to disaster response and day-to-day critical care nursing

Where to begin? How do you identify nursing care requirements for military operations, disaster, and humanitarian response, and how do you modify care under these unique conditions? This article presents a framework for identifying areas of critical care nursing that are performed on a day-to-day basis that may also be provided during a contingency operation, and discusses how that care may be changed by the austere conditions associated with a contingency response. Examples from various disasters, military operations, and military nursing research are used to illustrate the use of this framework. Examples are presented of how the results of this military nursing research inform disaster nursing and day-to-day critical care nursing practice.

Nephrology in earthquakes: sharing experiences and information

Earthquakes are the most unpredictable natural disasters and often result in many deaths and casualties as a result in part of the collapse of buildings. To restore medical facilities and activities after a large earthquake, nephrologists play critical roles not only in the restoration of dialysis facilities for regular renal replacement therapy but also in the prevention and treatment of acute kidney injury and hyperkalemia, mainly as a result of crush syndrome. For these purposes, sufficient education and establishment of functional networks among medical facilities are certainly needed. Recently, the contribution of international task forces has become more significant, especially for large-scale natural disasters. Organized detailed action plans should be prepared among regional governments and armies considering the differences in cultures and social systems.

Predictive Model for Estimating Risk of Crush Syndrome: A Data Mining Approach

BACKGROUND

There is no standard triage method for earthquake victims with crush injuries because of a scarcity of epidemiologic and quantitative data. We conducted a retrospective cohort study to develop predictive models based on clinical data for crush injury in the Kobe earthquake.

METHODS

The medical records of 372 patients with crush injuries from the Kobe earthquake were retrospectively analyzed. Twenty-one risk factors were assessed with logistic regression analysis for three outcomes relating to crush syndrome. Two types of predictive triage models--initial evaluation in the field and secondary assessment at the hospital--were developed using logistic regression analysis. Classification accuracy, Brier score and area under the receiver operating characteristic curve (AUC) were used to evaluate the model.

RESULTS

The initial triage model, which includes pulse rate, delayed rescue, and abnormal urine color, has an AUC of 0.73. The secondary model, which includes WBC, tachycardia, abnormal urine color, and hyperkalemia, shows an AUC of 0.76.

CONCLUSIONS

These triage models may be especially useful to nondisaster experts for distinguishing earthquake victims at high risk of severe crush syndrome from those at lower risk. Application of the model may allow relief workers to better utilize limited medical and transportation resources in the aftermath of a disaster.

Surgical and psychosocial outcomes in the rural injured--a follow-up study of the 2001 earthquake victims

INTRODUCTION

After a major disaster in a developing country, the graphic media coverage of the dead and injured invariably leads to an influx of volunteering healthcare personnel to the disaster zone. Very few studies document the outcomes of the treatment rendered in this field setting, under compromised conditions. We revisited the rural victims of the 2001 Gujarat earthquake in an attempt to analyse their surgical outcome and the status of their physical/psychosocial rehabilitation, 2 years after the disaster.

METHOD

We traced displaced victims treated for earthquake-related injuries to their new homes. A community health worker interviewed patients with an oral questionnaire in the local language about injuries, the examining physician and first aid, orthopaedic implants, amputations, wounds, disability, deformity, residual pain, occupational and economic rehabilitation, post traumatic stress disorder (PTSD) and perceptions of healthcare rendered.

RESULTS

We located 133 of the 179 non-urban victims, from 11 villages. There were 10% missed injuries, 19% infection rate, restricted range of motion in 12%, non-union rate in 23% and reoperations in 30.5% patients. Fifty-one percent had resumed their previous occupation, but only 30% had recovered economically. Of 98% who had destroyed homes, 89% had their homes rebuilt. Residual sadness was the only significant PTSD symptom.

CONCLUSION

This trauma outcome study highlights the shortcomings of surgeons for disaster-related work. One-tenth of the injuries were missed, suggesting that field examination at the site of disaster was more difficult than in the comfort of the hospital emergency room. Further there were inappropriately timed, aggressive implant operations, short time commitments, a lack of follow-up and a high rate of reoperations contributing to subsequent morbidity. These pointed to a need for training in disaster medicine within the curriculum of surgical residency. On the brighter side, despite poor sterility, prolonged transport times and no prehospital care, the postoperative infection rate was lower than expected. This perhaps was due to use of potent antibiotics in a previously unexposed rural population. Good physiotherapy given in the temporary shelters, by the informal carers within the family and by voluntary groups, kept up a good range of motion and reduced the final disability. PTSD was marked 3-6 months after the event, but was minimal 2 years postquake. Sadness about the event was the only residual PTSD symptom. While there were varying perceptions of satisfactory outcome, we found good coping mechanisms in place. The simple village folks were largely happy to be alive and accepted the residual deformities and cosmetic blemishes as a "small price to pay".

The devastation of Bam: an overview of health issues 1 month after the earthquake

The appalling earthquake in the ancient city of Bam on December 27th 2003 was one of the worst disasters since the last century in Iran. Further to the chilling statistics of human loss, essential services including water supply, power, telephone, health care services, main roads, and the city's only airport were crippled. From the 'public health' and 'health emergency' perspectives, the initial priorities were to minimise avoidable further mortality and morbidity. This required prompt evacuation of the injured, defining catchment areas, establishment of efficient systems for disease control, organising a disaster management plan, out patient management, co-ordination of international aid, and re-organising the current PHC network in the district. The second stage, each department planning health delivery for the subsequent year, was rapidly initiated. This paper discusses these strategies, which were designed specifically for Bam but are likely useful in similar situations.

Intensive care in a field hospital in an urban disaster area: lessons from the August 1999 earthquake in Turkey

OBJECTIVE

To describe our experience with the implementation of intensive care in the setting of a field hospital, deployed to the site of a major urban disaster.

DESIGN

Description of our experience during mission to Turkey; conclusions regarding implementation of intensive care at disaster sites.

SETTING

Military Field Hospital at Adapazari in Turkey.

PATIENTS

Civilian patients admitted for care at the field hospital.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

On August 17, 1999 a major earthquake occurred in western Turkey, causing approximately 16,000 fatalities and leaving >44,000 injured. Approximately 66,000 buildings were severely damaged or destroyed. A medical unit of the Israeli Defense Forces Medical Corps, consisting of 23 physicians, 13 nurses, nine paramedics, 13 medics, laboratory and roentgen technicians, pharmacists, and associated support personnel, were sent to Adapazari in Turkey. The field hospital treated approximately 1,200 patients over a period of 2 wks, 70 surgical operations were performed, 20 babies were delivered, and a variety of medical, surgical, orthopedic, and pediatric/neonatal care was provided. The 12-bed intensive care unit operated by the unit, was staffed by three physicians and eight nursing/paramedic personnel. Patient mix was: a total of 63 patients, among them five with major trauma, 20 with acute cardiac disease, 15 patients with various acute medical conditions, and 11 surgical and postoperative patients. Three patients were intubated and mechanically ventilated (one cardiogenic pulmonary edema and two major trauma). The intensive care unit provided the following functions to the field hospital: care of the critically ill and injured, preparation for and implementation of transportation of such patients, pre- and postoperative care for major surgical procedures, expertise, and equipment for the care of very ill patients throughout the field hospital.

CONCLUSIONS

In suitable circumstances, an intensive care capability should be an integral part of medical expeditions to major disasters.

Crush syndrome patients after the Marmara earthquake

BACKGROUND

To assess the treatment and outcome of patients with crush injury sustained in the Marmara earthquake.

METHODS

Seven hundred eighty three patients were transferred to a university hospital and 25 of them were admitted to the intensive care unit. The medical records of 18 crush injury patients were retrospectively reviewed.

RESULTS

The major associated injuries were in the lower extremities, upper extremities, and chest. Seven patients underwent fasciotomy and six patients had amputations. Twelve patients required mechanical ventilation. Adult respiratory distress syndrome developed in four patients. Oliguria occurred in eight patients. Hyperkalaemia was seen in six patients and four of them underwent emergency haemodialysis. One patient died because of hyperkalaemia on arrival to the intensive care unit. Renal failure was treated with haemodialysis or haemoperfusion in 13 patients. Five patients died because of multiple organ failure and two patients because of sepsis.

CONCLUSION

Crush syndrome is a life threatening event. The authors believe that early transportation and immediate intensive care therapy would have improved the survival rate.

Implications of hospital evacuation after the Northridge, California, earthquake

BACKGROUND

On January 17, 1994, an earthquake with a moment magnitude (total energy release) of 6.7 occurred in Northridge, California, leading to the evacuation of patients from several hospitals. We examined the reasons for and methods of evacuation and the emergency-management strategies used. The experience in California may have implications for hospital strategies for responding to any major disaster, including an act of terrorism.

METHODS

From September 1995 to September 1996, we surveyed all acute care hospitals in Los Angeles County that reported having evacuated patients after the Northridge earthquake. Physicians, nurses, hospital administrators, and staff on duty at the hospitals during the evacuation responded to a 58-item structured questionnaire.

RESULTS

Eight of 91 acute care hospitals (9 percent) were evacuated. Six hospitals evacuated patients within 24 hours (the immediate-evacuation group), four completely and two partially. All six cited nonstructural damage such as water damage and loss of electrical power as a major reason for evacuation. Five hospitals evacuated the most seriously ill patients first, and one hospital evacuated the healthiest patients first. All hospitals used available equipment to transport patients (blankets, backboards, and gurneys) rather than specialized devices. No deaths resulted from evacuation. One hospital evacuated patients after 3 days and another after 14 days because of structural damage, even though initial inspections had shown no damage (the delayed-evacuation group). Both hospitals required demolition. Some hospitals identified destinations for their evacuated patients independently, whereas others sought the assistance of the Los Angeles County Emergency Operations Center; the two strategies were equally effective.

CONCLUSIONS

After even a moderate earthquake, hospitals are at risk for both immediate nonstructural damage that may force them to evacuate patients and the delayed discovery of structural damage resulting in permanent closure. Evacuation of large numbers of inpatients from multiple hospitals can be accomplished quickly and safely with the use of available resources and personnel.

Disaster preparation and management for the intensive care unit

The purpose of this report is to provide information regarding preparation for disaster management from the perspective of ICU physicians. Both a framework toward ICU preparation for disaster management and a guide to the relevant literature are presented. Our objective is to show that the understanding of disaster preparedness on multiple levels, including government, hospital, ICU, and clinician, may lead to optimal management in a disaster.