Emergency medical assistance team response following Taiwan Chi-Chi earthquake

Establishment of disaster medical assistance team standards and evaluation of the teams' disaster preparedness: An experience from Taiwan

BACKGROUND/PURPOSE

Taiwan set up disaster medical assistance teams (DMATs) after the Chi-Chi earthquake, but these teams lack unified standards.

METHODS

This study was divided into two phases. Phase I was a Delphi study conducted in 2019 with 26 experts who were invited to establish Taiwan's DMAT standards by modifying the World Health Organization Emergency Medical Team (WHO EMT) type I fixed standards. Phase II was a cross-sectional study conducted in 2020. A questionnaire was used to evaluate the disaster preparedness of DMATs by standards set in phase I.

RESULTS

In phase I, Taiwan's DMAT standards were established after three rounds of Delphi consensus, with a response rate of 88.5%. The major departures from the WHO EMT standards were the exclusion of obstetric care, mental health, rehabilitation, and laboratory and blood transfusion standards and the addition of an ultrasound standard. During phase II, a total of 32 teams were invited, and the response rate was 96.9%. The overall standard achievement rate was 56.9%, and the three lowest achievement rates corresponded to sanitation (22.6%), medical malpractice insurance (25.8%), and pharmacy and drug supply (25.8%). The national DMATs, official DMATs, DMATs funded by government, and DMATs with ≥10 years of experience had significantly higher achievement rates for partial or overall standards.

CONCLUSION

Using localized standards to evaluate the disaster preparedness of each team, DMATs were found to have many shortcomings mainly due to the lack of unified government announcement standards, legal protection, and adequate financial support.

A 36-Hour Unplugged Full-Scale Exercise: Closing the Gaps in Interagency Collaboration between the Disaster Medical Assistance Team and Urban Search and Rescue Team in Disaster Preparedness in Taiwan

Introduction

Disaster medical assistance team (DMAT) and urban search and rescue team (USAR) need to cooperate seamlessly to save lives in disasters, but related research is limited.

Objectives

To estimate the disaster preparedness of the DMAT and the barriers affecting interagency cooperation between the DMAT and the USAR team.

Methods

This was an observational study of a full-scale exercise conducted in Taiwan from November 16 to 18, 2018. The exercise scenario simulated a magnitude 7 earthquake in Tainan City. DMATs from other counties were deployed and cooperated with local USAR teams to carry out disaster relief. Our study invited 7 experts to evaluate DMATs on disaster preparedness capabilities and the interagency collaboration between DMATs and USAR.

Results

A total of eight DMATs, consisting of 30 physicians, 65 nurses, 74 logisticians, 5 health bureau personnel, and 85 USAR teams, participated in this exercise. During the mission, 176 patients were treated. The capabilities of each team were generally consistent with the basic technical standards for type I emergency medical teams, but the compliance rates for basic local anesthesia, cold chain equipment for medication, rapid blood test tools, and sterilization devices were only 50%, 12.5%, 12.5%, and 9%, respectively. In addition, 53% of participants reported abnormal vital signs, indicating that it was a high-stress situation. Moreover, the main barriers to interagency collaboration were differing perspectives and poor mutual understanding.

Conclusion

A full-scale exercise carried out jointly with DMATs and USAR teams was valuable for disaster preparedness, particularly in terms of understanding the weaknesses of those teams and the barriers to interagency collaboration.

Indexes of Caring for Elderly in Earthquakes According to the Iranian Experience: A Qualitative Study

OBJECTIVE

The elderly are especially susceptible to death and injury in disasters. This study aimed to identify indexes of caring for elderly people in an earthquake according to the Iranian experience.

METHODS

This qualitative study was conducted during 2014-2016 by use of the content analysis technique. Data were collected through individual deep interviews with the elderly and people with experience providing services to the elderly during earthquakes in an urban area of Iran. The data were analyzed by use of the Graneheim and Lundman method.

RESULTS

Seven categories emerged: vulnerability of elderly people, physiological indexes, psychological indexes, economic indexes, religious and spiritual indexes, health indexes, and security indexes. There were 3 uncategorized issues: "There is no specific protocol for the elderly," "The need to design plans based on age care," and "Aid organizations."

CONCLUSIONS

Implementing a comprehensive plan would not only save lives but decrease suffering and enable effective use of available resources. Due to the crucial role of the prehospital care system in disasters, there is a need for further investigation based on the results of this study to develop strategies for improving the system. (Disaster Med Public Health Preparedness. 2018;12:493-501).

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.

Response to the Bam earthquake: a qualitative study on the experiences of the top and middle level health managers in Kerman, Iran

INTRODUCTION

The 2003 Bam, Iran earthquake resulted in high casualties and required international and national assistance. This study explored local top and middle level managers' disaster relief experiences in the aftermath of the Bam earthquake.

METHODS

Using qualitative interview methodology, top and middle level health managers employed during the Bam earthquake were identified. Data were collected via in-depth interviews with participants. Data were analysed using thematic analysis.

RESULTS

Results showed that the managers interviewed experienced two main problems. First, inadequacy of preparation of local health organisations, which was due to lack of familiarity of the needs, unavailability of essential needs, and also increasing demands, which were above the participants' expectations. Second, inappropriateness of delivered donations was perceived as a problem; for example, foods and sanitary materials were either poor quality or expired by date recommended for use. Participants also found international teams to be more well-equipped and organised.

CONCLUSIONS

During the disaster relief period of the response to the Bam earthquake, local health organizations were ill prepared for the event. In addition, donations delivered for relief were often poor quality or expired beyond a usable date.

Identifying Deficiencies in National and Foreign Medical Team Responses Through Expert Opinion Surveys: Implications for Education and Training

Introduction

Unacceptable practices in the delivery of international medical assistance are reported after every major international disaster; this raises concerns about the clinical competence and practice of some foreign medical teams (FMTs). The aim of this study is to explore and analyze the opinions of disaster management experts about potential deficiencies in the art and science of national and FMTs during disasters and the impact these opinions might have on competency-based education and training.

Method

This qualitative study was performed in 2013. A questionnaire-based evaluation of experts’ opinions and experiences in responding to disasters was conducted. The selection of the experts was done using the purposeful sampling method, and the sample size was considered by data saturation. Content analysis was used to explore the implications of the data.

Results

This study shows that there is a lack of competency-based training for disaster responders. Developing and performing standardized training courses is influenced by shortcomings in budget, expertise, and standards. There is a lack of both coordination and integration among teams and their activities during disasters. The participants of this study emphasized problems concerning access to relevant resources during disasters.

Conclusion

The major findings of this study suggest that teams often are not competent during the response phase because of education and training deficiencies. Foreign medical teams and medically related nongovernmental organizations (NGOs) do not always provide expected capabilities and services. Failures in leadership and in coordination among teams are also a problem. All deficiencies need to be applied to competency-based curricula.

DjalaliA, IngrassiaPL, Della CorteF, FolettiM, Ripoll GallardoA, RagazzoniL, KaptanK, LupescuO, ArculeoC, von ArnimG, FriedlT, AshkenaziM, HeselmannD, HreckovskiB, Khorrram-ManeshA, KomadinaR, LechnerK, PatruC, BurkleFMJr., FisherP. Identifying deficiencies in national and foreign medical team responses through expert opinion surveys: implications for education and training. Prehosp Disaster Med. 2014;29(4):1-5.

Confined space medicine and the medical management of complex rescues: a case series

OBJECTIVE

A variety of hazards can precipitate the full or partial collapse of occupied structures. The rescue of entrapped survivors in these situations can be complex, require a multidisciplinary approach, and last for many hours.

METHODS

The modern discipline of Urban Search and Rescue, which includes an active medical component, has evolved to address such situations. This case series spans several decades of experience and highlights the medical principles in the response to collapsed structure incidents.

RESULTS

Recurring concepts of confined space medicine include rescuer safety, inter-disciplinary coordination, patient protection, medical resuscitation in austere environments, and technical extrications.

CONCLUSION

Strategies have been developed to address the varied challenges in the medical response to collapsed structure incidents.

Pain and natural disaster

The treatment for pain in emergency medicine is a matter of increasing interest. Available data indicate that in both normal conditions and during major-emergencies, the majority of healthcare providers are culturally and professionally unprepared to adequately treat acute pain conditions. In case of natural disasters, opioid drugs are often unavailable. Moreover, no guidelines or validated protocols provide adequate indications for the treatment for pain in case of massive emergencies. Training of the medical and nursing staff, in both formal and continuing, or on-the-job education is needed to adequately face a devastating emergency. Unfortunately, there is an inadequate level of training among healthcare professionals, even in highly seismic areas, and the source of aid is frequently limited, especially in the immediate aftermath of a disaster to those already present at the scene. Pain inadequately treated may modify the characteristics of the pain itself. Pain is no longer considered just a symptom, but itself becomes an autonomous pathology heavily influencing the social life and psycho-social aspects of a person. In the disastrous situation following an earthquake, an inadequate treatment of pain was the major violation of the psycho-physical integrity of individuals and a severe violation of their rights, as human beings and patients.

Time for order in chaos! A health system framework for foreign medical teams in earthquakes

The number of reported natural disasters is increasing, as is the number of foreign medical teams (FMTs) sent to provide relief. Studies show that FMTs are not coordinated, nor are they adapted to the medical needs of victims. Another key challenge to the response has been the lack of common terminologies, definitions, and frameworks for FMTs following disasters.In this report, a conceptual health system framework that captures two essential components of health care response by FMTs after earthquakes is presented. This framework was developed using expert panels and personal experience, as well as an exhaustive literature review.The framework can facilitate decisions for deployment of FMTs, as well as facilitate coordination in disaster-affected countries. It also can be an important tool for registering agencies that send FMTs to sudden onset disasters, and ultimately for improving disaster response.

Disaster Management following the Chi-Chi Earthquake in Taiwan

The earthquake that occurred in Taiwan on 21 September 1999 killed >2,000 people and severely injured many survivors. Despite the large scale and sizeable impact of the event, a complete overview of its consequences and the causes of the inadequate rescue and treatment efforts is limited in the literature. This review examines the way different groups coped with the tragedy and points out the major mistakes made during the process. The effectiveness of Taiwan's emergency preparedness and disaster response system after the earthquake was analyzed.

Problems encountered included: (1) an ineffective command center; (2) poor communication; (3) lack of cooperation between the civil government and the military; (4) delayed prehospital care; (5) overloading of hospitals beyond capacity; (6) inadequate staffing; and (7) mismanaged public health measures.

The Taiwan Chi-Chi Earthquake experience demonstrates that precise disaster planning, the establishment of one designated central command, improved cooperation between central and local authorities, modern rescue equipment used by trained disaster specialists, rapid prehospital care, and medical personnel availability, as well earthquake-resistant buildings and infrastructure, are all necessary in order to improve disaster responses.

Current Status of International Emergency Medicine Fellowships in the United States

Objective:

A consensus panel of Emergency Physicians with experience in international health has published a recommended curriculum for a formal fellowship in International Emergency Medicine. This article reviews the current International Emergency Medicine (IEM) fellowships available to residency-trained Emergency Physicians in the United States.

Methods:

Every allopathic Emergency Medicine (EM) residency program in the United States was contacted via e-mail or telephone. Programs that reported having an IEM fellowship were asked detailed information about their program, including: (1) the number of years the program has been offered; (2) the duration of the program; (3) the number of fellows taken each year; (4) the number of fellowship graduates from each program and their current practice patterns; (5) how the fellowship is funded; and (6) whether a Masters Degree in Public Health (MPH) is offered.

Results:

All 127 allopathic EM residency programs responded. Eight (6.8%) of these programs offered IEM fellowships. Of a total of 29 graduates identified, 23 (79.3%) were employed in academic medicine. All of the fellowships offered formal public health training and were funded by a combination of clinical billing and project-specific grants and scholarships. All IEM fellowships described a curriculum that reflected the previously published recommendations.

Conclusion:

Opportunities in formal training in international health are increasing for graduates of EM residencies in the United States. The proposed curriculum for IEM fellowships seems to have been implemented and graduates of IEM fellowships seem to be applying their training in international projects.

Logistic support provided to Australian disaster medical assistance teams: results of a national survey of team members

BACKGROUND

It is likely that calls for disaster medical assistance teams (DMATs) continue in response to international disasters. As part of a national survey, the present study was designed to evaluate the Australian DMAT experience and the need for logistic support.

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 Asian Tsunami disaster.

RESULTS

The response rate for this survey was 50% (59/118). Most of the personnel had deployed to the South East Asian Tsunami affected areas. The DMAT members had significant clinical and international experience. There was unanimous support for dedicated logistic support with 80% (47/59) strongly agreeing. Only one respondent (2%) disagreed with teams being self sufficient for a minimum of 72 hours. Most felt that transport around the site was not a problem (59%; 35/59), however, 34% (20/59) felt that transport to the site itself was problematic. Only 37% (22/59) felt that pre-deployment information was accurate. Communication with local health providers and other agencies was felt to be adequate by 53% (31/59) and 47% (28/59) respectively, while only 28% (17/59) felt that documentation methods were easy to use and reliable. Less than half (47%; 28/59) felt that equipment could be moved easily between areas by team members and 37% (22/59) that packaging enabled materials to be found easily. The maximum safe container weight was felt to be between 20 and 40 kg by 58% (34/59).

CONCLUSIONS

This study emphasises the importance of dedicated logistic support for DMAT and the need for teams to be self sufficient for a minimum period of 72 hours. There is a need for accurate pre deployment information to guide resource prioritisation with clearly labelled pre packaging to assist access on site. Container weights should be restricted to between 20 and 40 kg, which would assist transport around the site, while transport to the site was seen as problematic. There was also support for training of all team members in use of basic equipment such as communications equipment, tents and shelters and water purification systems.

Cross-sectional study of craniocerebral trauma in a tertiary hospital after 2008 Sichuan earthquake: a brief report of 242 cases and experiences from West China Hospital

BACKGROUND

We aim to analyze clinical features of patients with craniocerebral trauma after 2008 Sichuan earthquake in China.

METHODS

Medical records of patients with craniocerebral trauma admitted to Department of Neurosurgery in West China Hospital within 30 days after earthquake were retrospectively analyzed. Demographic data, clinical diagnosis, treatment, and prognosis were reviewed. Patients' data from peripheral hospitals were also analyzed.

RESULTS

Two hundred forty-two patients with craniocerebral injuries were included in the study. The male to female ratio was 1.3:1, and more than half of the patients were between 20 and 60 years. Majority of patients suffered from mild to moderate injuries (88.4%). Scalp wound was the leading type, followed by skull fractures and brain contusion and laceration. Fifty patients (20.7%) underwent craniotomy. Overall mortality was 5.4% (n = 13). In survivors, 186 patients had good outcome (Glasgow Outcome Scale score ≥4, 76.9%). Staphylococcus aureus (n = 74, 44.6%), Aerobacter cloacae (n = 37, 22.3%), and Staphylococcus epidermidis (n = 33, 19.9%) were most frequently isolated bacteria in wound smear. Over 85% (n=6) of patients with infectious wound (n=7) obtained delayed first stage healing. Mortality of patients in local hospitals ranged from 3.8% to 8.9%.

CONCLUSIONS

Most patients admitted to tertiary hospitals are mildly or moderately injured. Cooperation among different departments is critical to shorten delay in emergency room. First stage wound healing or delayed first stage healing can be achieved in most patients after treatment. More than 76% of seismic injury patients in a tertiary medical center have good outcome.

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.

Taiwan's medical response to the 921 'Chi-Chi' earthquake

OBJECTIVE

The objective of this study was to identify and review literature relevant to the medical response to the 921 earthquake in order to analyse Taiwan's immediate and long-term management of the medical issues arising from the disaster.

METHODS

Pubmed and Google Scholar searches were conducted in June 2008 to identify papers relevant to the topic. These were reviewed and the findings of each collated to develop a critical review of Taiwan's response to the earthquake. Pubmed and Google Scholar searches were conducted again in March 2010 to verify the currency of the literature reviewed.

RESULTS

A total of 14 papers were identified and reviewed. Many concluded that while disaster response efforts were initiated quickly, the inexperience of the authorities, the timing and location of the earthquake, and the associated destruction of vital infrastructure, meant much of the initial rescue planning and coordination was improvised. This resulted in poor response times by emergency teams, inefficient mobilisation of military and medical resources, poor cooperation between authorities and a failure to fully utilise international assistance when it arrived.

CONCLUSION

Taiwan was unprepared for a disaster of the magnitude of the 921 earthquake. The government has since taken initiatives to ensure Taiwan is better prepared for any future large scale disaster, including the establishment of the National Institute for Disaster Management. There is a paucity of literature on the medical response to the disaster. Only one new paper of relevance to the topic has been listed on Pubmed or Google Scholar in recent years.

Improving surge capacity for biothreats: experience from Taiwan

This article discusses Taiwan's experience in managing surge needs based on recent events, including the 1999 earthquake, severe acute respiratory syndrome in 2003, airliner crashes in 1998 and 2001, and yearly typhoons and floods. Management techniques are compared and contrasted with U.S. approaches. The authors discuss Taiwan's practices of sending doctors to the scene of an event and immediately recalling off-duty hospital personnel, managing volunteers, designating specialty hospitals, and use of incident management systems. The key differences in bioevents, including the mathematical myths regarding individual versus population care, division of stockpiles, the Maginot line, and multi-jurisdictional responses, are highlighted. Several recent initiatives aimed at mitigating biothreats have begun in Taiwan, but their efficacy has not yet been tested. These include the integration of the emergency medical services and health-facility medical systems with other response systems; the use of the hospital emergency incident command system; crisis risk-communications approaches; and the use of practical, hands-on training programs. Other countries may gain valuable insights for mitigating and managing biothreats by studying Taiwan's experiences in augmenting surge capacity.

Experience of a Korean disaster medical assistance team in Sri Lanka after the South Asia tsunami

On 26 December 2004, a huge tsunami struck the coasts of South Asian countries and it resulted in 29,729 deaths and 16,665 injuries in Sri Lanka. This study characterizes the epidemiology, clinical data and time course of the medical problems seen by a Korean disaster medical assistance team (DMAT) during its deployment in Sri Lanka, from 2 to 8 January 2005. The team consisting of 20 surgical and medical personnel began to provide care 7 days after tsunami in the southern part of Sri Lanka, the Matara and Hambantota districts. During this period, a total of 2,807 patients visited our field clinics with 3,186 chief complaints. Using the triage and refer system, we performed 3,231 clinical examinations and made 3,259 diagnoses. The majority of victims had medical problems (82.4%) rather than injuries (17.6%), and most conditions (92.1%) were mild enough to be discharged after simple management. There were also substantial needs of surgical managements even in the second week following the tsunami. Our study also suggests that effective triage system, self-sufficient preparedness, and close collaboration with local authorities may be the critical points for the foreign DMAT activity.