Preparing hospitals for toxicological mass casualties events

Surgical Science and the Evolution of Critical Care Medicine

Surgical science has driven innovation and inquiry across adult and pediatric disciplines that provide critical care regardless of location. Surgically originated but broadly applicable knowledge has been globally shared within the pages Critical Care Medicine over the last 50 years.

Disaster Exercises to Prepare Hospitals for Mass-Casualty Incidents: Does it Contribute to Preparedness or is it Ritualism?

IntroductionThe central question this study sought to answer was whether the team members of Strategic Crisis Teams (SCTs) participating in mass-casualty incident (MCI) exercises in the Netherlands learn from their participation.

METHODS

Evaluation reports of exercises that took place at two different times were collected and analyzed against a theoretical model with several dimensions, looking at both the quality of the evaluation methodology (three criteria: objectives described, link between objective and items for improvement, and data-collection method) and the learning effect of the exercise (one criterion: the change in number of items for improvement).

RESULTS

Of all 32 evaluation reports, 81% described exercise objectives; 30% of the items for improvement in the reports were linked to these objectives, and 22% of the 32 evaluation reports used a structured template to describe the items for improvement. In six evaluation categories, the number of items for improvement increased between the first (T1) and the last (T2) evaluation report submitted by hospitals. The number of items remained equal for two evaluation categories and decreased in six evaluation categories.

CONCLUSION

The evaluation reports do not support the ideal-typical disaster exercise process. The authors could not establish that team members participating in MCI exercises in the Netherlands learn from their participation. More time and effort must be spent on the development of a validated evaluation system for these simulations, and more research into the role of the evaluator is needed.Verheul MLMI, Dückers MLA, Visser BB, Beerens RJJ, Bierens JJLM. Disaster exercises to prepare hospitals for mass-casualty incidents: does it contribute to preparedness or is it ritualism? Prehosp Disaster Med. 2018;33(4):387-393.

Are Dutch Hospitals Prepared for Chemical, Biological, or Radionuclear Incidents? A Survey Study

Introduction Being one of Europe's most densely populated countries, and having multiple nuclear installations, a heavy petrochemical industry, and terrorist targets, the Netherlands is at-risk for chemical, biological, or radionuclear (CBRN) incidents. Recent world and continental events show that this threat is real and that authorities may be underprepared. Hypothesis The hypothesis of this study is that Dutch hospitals are underprepared to deal with these incidents.

METHODS

A descriptive, cross-sectional study was performed. All 93 Dutch hospitals with an emergency department (ED) were sent a link to an online survey on different aspects of CBRN preparedness. Besides specific hospital information, information was obtained on the hospital's disaster planning; risk perception; and availability of decontamination units, personal protective equipment (PPE), antidotes, radiation detection, infectiologists, isolation measures, and staff training.

RESULTS

Response rate was 67%. Sixty-two percent of participating hospitals were estimated to be at-risk for CBRN incidents. Only 40% had decontamination facilities and 32% had appropriate PPE available for triage and decontamination teams. Atropine was available in high doses in all hospitals, but specific antidotes that could be used for treating victims of CBRN incidents, such as hydroxycobolamine, thiosulphate, Prussian blue, Diethylenetriaminepentaacetic acid (DTPA), or pralidoxime, were less frequently available (74%, 65%, 18%, 14%, and 42%, respectively). Six percent of hospitals had radioactive detection equipment with an alarm function and 22.5% had a nuclear specialist available 24/7 in case of disasters. Infectiologists were continuously available in 60% of the hospitals. Collective isolation facilities were present in 15% of the hospitals.

CONCLUSION

There is a serious lack of hospital preparedness for CBRN incidents in The Netherlands. Mortelmans LJM , Gaakeer MI , Dieltiens G , Anseeuw K , Sabbe MB . Are Dutch hospitals prepared for chemical, biological, or radionuclear incidents? A survey study. Prehosp Disaster Med. 2017;32(5):483-491.

Managing mass casualties and decontamination

Careful planning and regular exercising of capabilities is the key to implementing an effective response following the release of hazardous materials, although ad hoc changes may be inevitable. Critical actions which require immediate implementation at an incident are evacuation, followed by disrobing (removal of clothes) and decontamination. The latter can be achieved through bespoke response facilities or various interim methods which may utilise water or readily available (dry, absorbent) materials. Following transfer to a safe holding area, each casualty's personal details should be recorded to facilitate a health surveillance programme, should it become apparent that the original contaminant has chronic health effects.

What a Disaster?! Assessing Utility of Simulated Disaster Exercise and Educational Process for Improving Hospital Preparedness

Introduction:

Recent events have brought disaster medicine into the public focus. Both the government and communities expect hospitals to be prepared to cope with all types of emergencies. Disaster simulations are the traditional method of testing hospital disaster plans, but a recent, comprehensive, literature review failed to find any substantial scientific data proving the benefit of these resource and time-consuming exercises.

Objectives:

The objective of this study was to test the hypothesis that an audiovisual presentation of the hospital disaster plans followed by a simulated disaster exercise and debriefing improved staff knowledge, confidence, and hospital preparedness for disasters.

Methods:

A survey of 50 members of the medical, nursing, and administrative staff were chosen from a pool of approximately 170 people likely to be in a position of responsibility in the event of a disaster.The pre-intervention survey tested factual knowledge as well as perceptions about individual and departmental preparedness. Post-intervention, the same 50 staff members were asked to repeat the survey, which included additional questions establishing their involvement in the exercise.

Results:

There were 50 pre-intervention tests and 42 post-intervention tests. The intervention resulted in a significant improvement in test pass rate: preintervention pass rate 9/50 (18%, 95% confidence interval ((CI) = 16.1–19.9%) versus post-intervention pass rate 21/42 (50%, 95% CI = 42.4–57.6%; X2 test, p = 0.002). Emergency department (ED) staff had a stronger baseline knowledge than non-ED staff: ED pre-test mean value for scores = 12.1 versus nonED scores of 6.2 (difference 5.9, 95% CI = 3.3–8.4); t-test, p <0.001. Those that attended >1 component had a greater increase in mean scores: increase in mean attendees was 5.6, versus the scores of non-attendees of 2.7 (difference 2.9, 95% CI = 1.0–4.9); t-test, p = 0.004. There was no significant increase in the general perception of preparedness. However, the majority of those surveyed described the exercise of benefit to themselves (53.7%,95% CI = 45.5–61.8%) and their department (63.2%, 95% CI = 53.5–72.8%).

Conclusions:

The disaster exercise and educational process had the greatest benefit for individuals and departments involved directly. The intervention also prompted enterprise-wide review, and an upgrade of disaster plans at departmental levels. Pre-intervention knowledge scores were poor. Post-intervention knowledge base remained suboptimal, despite a statistically significant improvement. This study supports the widely held belief that disaster simulation is a worthwhile exercise, but more must be done. More time and resources must be dedicated to the increasingly important field of hospital disaster preparedness.

What Should We Learn from Recent Earthquakes in Asia?

This keynote on lessons to be learned from the recent natural disasters in Asiawill complement and elaborate further on the points already made eloquently by the first two keynote speakers during this session: Dr. M. Gilbert on building local resilience and competencies, and the call from Prof. E. Rahardjo towards a more efficient, multi-national work on rescue and aid to disasters.

Both speakers stressed the importance of strengthening external aid rather than substituting the national- or community-level capacity. I share the concern of the Indonesian medical professionals feeling marginalized in their own country, as said by Prof. Rahardjo. I also agree with Dr. Gilbert on our duty to build on the remarkable resilience and abilities of local communities. It is feasible, as he clearly demonstrated in local projects.

Effectiveness of Hospital Staff Mass-Casualty Incident Training Methods: A Systematic Literature Review

Introduction:

Recently, mass-casualty incident (MCI) preparedness and training has received increasing attention at the hospital level.

Objectives:

To review the existing evidence on the effectiveness of disaster drills, technology-based interventions and tabletop exercises in training hospital staff to respond to an MCI.

Methods:

A systematic, evidence-based process was conducted incorporating expert panel input and a literature review with the key terms: “mass casualty”, “disaster”, “disaster planning”, and “drill”. Paired investigators reviewed citation abstracts to identify articles that included evaluation of disaster training for hospital staff. Data were abstracted from the studies (e.g., MCI type, training intervention, staff targeted, objectives, evaluation methods, and results). Study quality was reviewed using standardized criteria.

Results:

Of 243 potentially relevant citations, twenty-one met the defined criteria. Studies varied in terms of targeted staff, learning objectives, outcomes, and evaluation methods. Most were characterized by significant limitations in design and evaluation methods. Seventeen addressed the effectiveness of disaster drills in training hospital staff in responding to an MCI, four addressed technology-based interventions, and none addressed tabletop exercises. The existing evidence suggests that hospital disaster drills are effective in allowing hospital employees to become familiar with disaster procedures, identify problems in different components of response (e.g., incident command, communications, triage, patient flow, materials and resources, and security) and provide the opportunity to apply lessons learned to disaster response. The strength of evidence on other training methods is insufficient to draw valid recommendations.

Conclusions:

Current evidence on the effectiveness of MCI training for hospital staff is limited. A number of studies suggest that disaster drills can be effective in training hospital staff. However, more attention should be directed to evaluating the effectiveness of disaster training activities in a scientifically rigorous manner.

Editorial Comments—Mental Health Problems following Earthquake in Kashmir: Findings of Community Run Clinics

The article by Chadda et al is particularly deserving in that it describes a universal, social imperative to address the mental health and well-being of affected populations following a horrendous disaster caused by natural hazards. The inclusion of mental health workers, psychologists, and psychiatrists in postdisaster recovery and response efforts is not always feasible, but in recent years the importance of recognizing these professionals as “front line responders” has been gaining currency. By addressing the extent and typology of mental health needs of survivor populations (e.g., adjustment disorders, depression, and stress reactions, such as post-traumatic stress disorder (PTSD) symptoms), the business of recovery and reconstruction can begin. This paper sufficiently captures the extent of psychiatric morbidity in the affected Kashmiri populations following the October 2005 earthquake in India.The authors visited >30 rural and remote sites and met with >300 survivors who had lost their homes, loved ones, and who also had suffered physical injury and mental health trauma. It is a remarkable testament to human resiliency that the vast majority of the earthquake survivors described in this paper, including those who live in an ongoing state of civil unrest due to political conflict, did not present full PTSD mental health disorders. Prehospital and Disaster Medicine deserves praise for supporting the work of our colleagues in the south. Thanks to the WADEM for the inclusion of this empirically based study, as it contributes to our understanding of human resiliency following disasters caused by natural hazards in a meaningful way.

Development of an “All-Hazards” Hospital Disaster Preparedness Training Course Utilizing Multi-Modality Teaching

Objectives:

The objectives of the study were to develop and evaluate an “all-hazards” hospital disaster preparedness training course that utilizes a combi-nation of classroom lectures, skills sessions, tabletop sessions, and disaster exercises to teach the principles of hospital disaster preparedness to hospital-based employees.

Methods:

Participants attended a two-day, 16-hour course, entitled Hospital Disaster Life Support (HDLS). The course was designed to address seven core competencies of disaster training for healthcare workers. Specific disaster situations addressed during HDLS included: (1) biological; (2) conventional; (3) radiological; and (4) chemical mass-casualty incidents. The primary goal of HDLS was not only to teach patient care for a disaster, but more important-ly, to teach hospital personnel how to manage the disaster itself. Knowledge gained from the HDLS course was assessed by pre- and post-test evaluations. Additionally, participants completed a course evaluation survey at the conclu-sion of HDLS to assess their attitudes about the course.

Results:

Participants included 11 physicians, 40 nurses, 23 administrators/direc-tors, and 10 other personnel (n = 84). The average score on the pre-test was 69.1 ±12.8 for all positions, and the post-test score was 89.5 ±6.7, an improve-ment of 20.4 points (p <0.0001, 17.2–23.5).Participants felt HDLS was edu-cational (4.2/5), relevant (4.3/5) and organized (4.3/5).

Conclusions:

Identifying an effective means of teaching hospital disaster pre-paredness to hospital-based employees is an important task. However, the opti-mal strategy for implementing such education still is under debate.The HDLS course was designed to utilize multiple teaching modalities to train hospital-based employees on the principles of disaster preparedness. Participants of HDLS showed an increase in knowledge gained and reported high satisfaction from their experiences at HDLS. These results suggest that HDLS is an effec-tive way to train hospital-based employees in the area of disaster preparedness.

Preparedness lessons from modern disasters and wars

Disasters come in all shapes and forms, and in varying magnitudes and intensities. Nevertheless, they offer many of the same lessons for critical care practitioners and responders. Among these, the most important is that well thought out risk assessment and focused planning are vital. Such assessment and planning require proper training for providers to recognize and treat injury from disaster, while maintaining safety for themselves and others. This article discusses risk assessment and planning in the context of disasters. The article also elaborates on the progress toward the creation of portable, credible, sustainable, and sophisticated critical care outside the walls of an intensive care unit. Finally, the article summarizes yields from military-civilian collaboration in disaster planning and response.

Establishing a high level of knowledge regarding bioterrorist threats in emergency department physicians: methodology and the results of a national bio-preparedness project

INTRODUCTION

Medical systems worldwide are facing the new threat of morbidity associated with the deliberate dispersal of microbiological agents by terrorists. Rapid diagnosis and containment of this type of unannounced attack is based on the knowledge and capabilities of medical staff. In 2004, the knowledge of emergency department physicians of anthrax was tested. The average test score was 58%. Consequently, a national project on bioterrorism preparedness was developed. The aim of this article is to present the project in which medical knowledge was enhanced regarding a variety of bioterrorist threats, including cutaneous and pulmonary anthrax, botulinum, and smallpox.

METHODS

In 2005, military physicians and experts on bioterrorism conducted special seminars and lectures for the staff of the hospital emergency department and internal medicine wards. Later, emergency department senior physicians were drilled using one of the scenarios.

RESULTS

Twenty-nine lectures and 29 drills were performed in 2005. The average drill score was 81.7%. The average score of physicians who attended the lecture was 86%, while those who did not attend the lectures averaged 78.3% (NS).

CONCLUSIONS

Emergency department physicians were found to be highly knowledgeable in nearly all medical and logistical aspects of the response to different bioterrorist threats. Intensive and versatile preparedness modalities, such as lectures, drills, and posters, given to a carefully selected group of clinicians, can increase their knowledge, and hopefully improve their response to a bioterrorist attack.

Guidelines for treating cardiac manifestations of organophosphates poisoning with special emphasis on long QT and Torsades De Pointes

Organophosphate poisoning may precipitate complex ventricular arrhythmias, a frequently overlooked and potentially lethal aspect of this condition. Acute effects consist of electrocardiographic ST-T segment changes and AV conduction disturbances of varying degrees, while long-lasting cardiac changes include QT prolongation, polymorphic tachycardia ("Torsades de Pointes"), and sudden cardiac death. Cardiac monitoring of organophosphate intoxicated patients for relatively long periods after the poisoning and early aggressive treatment of arrhythmias may be the clue to better survival. We present here a review of the literature with a focus on late cardiac arrhythmias (mainly "Torsades de pointes"), possible mechanisms, and treatment modalities, with special emphasis on postpoisoning monitoring for development of arrhythmias.

Lessons learned from clinical anthrax drills: evaluation of knowledge and preparedness for a bioterrorist threat in Israeli emergency departments

STUDY OBJECTIVE

Emergency department (ED) physicians and nurses are considered critical sentinels of a bioterrorist attack. We designed a special hospital drill to test EDs' response to inhalational anthrax and assess the level of preparedness for anthrax bioterrorism. We hypothesized that the occurrence of such a drill in an ED would improve the knowledge of its physicians, even those who had not actually participated in the drill.

METHODS

We conducted 23 drills at all Israeli general hospitals' EDs. An actor entered the walk-in triage area, simulating a febrile patient with lower respiratory complaints. A chest radiograph with mediastinal widening, as can be seen in early anthrax disease, was planted in the hospital's imaging results system. Patients were instructed to give additional epidemiologic clues, such as having a few friends with a similar syndrome. Either before or after the drills, we distributed multiple choice tests about diagnosis and management of anthrax to the 115 senior emergency physicians at these hospitals.

RESULTS

In 91% of EDs, a decision to admit the patient was made. Sixty-one percent included anthrax in the differential diagnosis and activated the appropriate protocols. Only 43% contacted all relevant officials. Average score on the anthrax tests was 58 (of 100). Physicians who were tested before the drill (in their institution) achieved a mean score of 54.5, whereas those who were tested after their ED had been exercised achieved a mean score of 59.3.

CONCLUSION

A national framework of drills on bioterrorism can help estimate and potentially augment national preparedness for bioterrorist threats. It is not, on its own, an effective educational tool. More emphasis should be given to formal accredited continuing medical education programs on bioterrorism, especially for emergency physicians and ED nurses, who will be in the front line of a bioterrorist attack.

Role of the anaesthetist in developing and implementing readiness of hospital to mass casualty incidents

PURPOSE OF REVIEW

A mass casualty incident is usually short and resolves itself. To minimize the risks to patients during mass casualty incidents, planning is essential. We hereby provide our experience with a recent literature review of the steps to provide the hospital with an efficient plan to overcome mass casualty situations of a traumatic nature, with special implications for the anaesthetist's role.

RECENT FINDINGS

Preparation of the hospital starts with an accepting master plan and guidelines for creating local standing orders for this scenario. The hospital should work step by step in adjusting the master plan to its local requirements and infrastructure. During this work, one will find that it is not only technical or logistic but should address medical issues, with pertinent information from clinicians of different specialities. After authorization of the preparedness plan, it should be tested in limited scale drills, and then implemented in the hope that it will never need to be used. Periodic adjustments according to threats and new concepts and equipment should be made.

SUMMARY

As a result of recent events, a major effort is considered to improve the preparedness plan of the hospital for mass casualty incidents. However, common surveyors report their unease with the current ability to cope with disasters. The involvement of medical teams in the process is mandatory to lessen the effects of the first wave of casualties and to be able to cope with the second wave.

Defining bioterrorism preparedness for nurses: concept analysis

AIM

This paper reports a concept analysis to define the concept of nursing bioterrorism preparedness.

BACKGROUND

Nursing bioterrorism preparedness is necessary, yet no theoretical or operational definition exists. The concept is often misinterpreted as being synonymous with organizational preparedness or confused with the bioterrorism preparedness needs of other professions, such as medicine. There is no standardized definition of the concept that is specific to the profession of nursing.

METHODS

A concept analysis was conducted using a systematic literature review; the Cumulative Index to Nursing and Allied Health Literature, Psych Info and Medline databases for years 1966-2005 were used. One hundred and eighteen references were identified, 41 of which were deemed relevant. Data from the 41 relevant articles were analysed and synthesized to develop a theoretical definition, defining attributes, antecedents, consequences and related concepts.

FINDINGS

Nursing bioterrorism preparedness is the continual process of nurses becoming better prepared to recognize and respond to a bioterrorism attack. Nurses, regardless of their level of education, areas of expertise or practice settings must participate in at least one educational session and one exercise each year to meet the minimum requirements of engaging in the bioterrorism preparedness process. The antecedents are acceptance and readiness to change. Defining attributes include gaining knowledge, planning, practising response behaviours and evaluating knowledge level and content of response plan. Consequences include recognition of an event and implementation of appropriate response actions.

CONCLUSION

Nursing bioterrorism preparedness is essential. To assess nurses' level of preparedness, a definition is needed of what bioterrorism preparedness means to the profession. The theoretical definition developed in this paper needs to be further refined and operationalized.

Realities of Disaster Preparedness in Rural Hospitals

Disaster preparedness has always been an area of major concern for the medical community, but recent world events have prompted an increased interest. The health care system must respond to disasters of all types, whether the incidents occur in urban or rural settings. Although the barriers and challenges are different in the rural setting, common areas of preparedness must be explored. This study examines the experiences of rural hospital emergency departments with threat preparedness. Data were gathered through a nationwide survey to describe emergency department experience with specific incidents, as well as the frequency of occurrence of these events. Expanding surge capacity of hospitals and developing a community-wide response to natural or human-made incidents is crucial in mitigating long-term effects on the health care system. Analysis of preparedness activities will help identify common themes to better prioritize preparedness activities and maximize a hospital's response capabilities.

Truth hurts - hard lessons from Australia's largest mass casualty exercise with contaminated patients

In response to the increasing threat of a mass casualty incident involving chemical, biological or radiological agents, and concern over the preparedness of our hospital system to cope with patients from such an incident, we conducted the largest hospital-based field exercise involving contaminated patients that has been held in Australia. In the present paper, we outline the background to, and methodology of, Exercise Supreme Truth, and the efforts made to increase its realism. We focus our discussion on three issues highlighted by the exercise, which we believe have enormous implications for the development of hospital chemical, biological or radiological plans and the likelihood of their success--hospital security, crowd control and decontamination.

Is the Australian hospital system adequately prepared for terrorism?

Australian hospitals need to be prepared to deal with mass casualties from terrorist strikes, including bomb blasts and chemical, biological and radiation injury. Injuries from bomb explosions are more severe than those commonly seen in Australian hospitals. In disasters involving mass casualties in urban areas, many of the injured make their own way to hospital, often arriving before the more seriously injured casualties. Major hospitals in Australia should plan for large numbers of undifferentiated and potentially contaminated casualties arriving with minimal warning. It is critical that experienced and trained senior medical officers perform the triage of casualties in emergency departments, with frequent reassessment to detect missed injuries (especially pulmonary blast injury). Hospitals require well developed standard operating procedures for mass casualty events, reinforced by regular drills. Preparing for a major event includes training staff in major incident management, setting up an operational/control unit, nominating key personnel, ensuring there is an efficient intra-hospital communication system, and enhancing links with other emergency services and hospitals.

Mass casualty triage in the chemical, biological, radiological, or nuclear environment

Field trauma triage systems currently used by emergency responders at mass casualty incidents and disasters do not adequately account for the possibility of contamination of patients with chemical, biological, radiological, or nuclear material. Following a discussion of background issues regarding mass casualty triage schemes, this paper proposes chemical, biological, radiological, or nuclear-compatible trauma triage algorithms, based on a review of the literature and the input of recognized content experts. A basic trauma triage template is first proposed, with patient assessment limited to ability to walk, presence of breathing, and ability to follow commands. This template is then modified for use in chemical, biological, and radiation/nuclear situations in which the exposed or contaminated victims have also sustained conventional trauma. The proposed algorithms will need further refinement and testing.

Toxicological aspects of preparedness and aftercare for chemical-incidents

The threat of using chemical warfare agents still exists despite the 1993 Chemical Weapons Convention. Preparedness for attacks with chemical agents has become an important issue of national security programs. It can be anticipated that toxicologists will be increasingly involved in preparedness programs of their institutions and of the government, no matter whether they work in agencies, industry or universities. Toxicologists must get prepared to give fast and reliable advice in the case of an attack, a sabotage or an accident with release of toxic chemicals. They should be familiar with the principles of hazard management and with incident command structures and cooperate with first responders of other organizations involved such as fire department and medical emergency teams already in the planning phase. In the emergency planning phase, toxicologists are expected to help identifying possible hazards. Moreover, they consult public health services with regard to toxicosurveillance and advice hospitals regarding antidotes, decontamination procedures and shelters. They may be involved in the procurement of antidotes and of protective equipment and will support qualified analytical laboratories. In the response phase, toxicologists must be ready to gain and to interpret analytical data, to support the medical care of poisoned victims and to provide repeated risk assessment reports. This requires an on-scene access to databases and registries. The aftercare phase includes the identification of exposed persons, mapping of contaminated areas, organization of decontamination measures and the release of areas. A medical study may be initiated to observe long-term health effects. Good cooperation between regulatory and clinical toxicologists, specific education of toxicologist in the field of chemical emergencies and regular trainings are essential elements of good preparedness.

The incident command system in disasters: evaluation methods for a hospital-based exercise

OBJECTIVES

No universally accepted methods for objective evaluation of the function of the Incident Command System (ICS) in disaster exercises currently exist. An ICS evaluation method for disaster simulations was derived and piloted.

METHODS

A comprehensive variable list for ICS function was created and four distinct ICS evaluation methods (quantitative and qualitative) were derived and piloted prospectively during an exercise. Delay times for key provider-victim interactions were recorded through a system of data collection using participant- and observer-based instruments. Two different post-exercise surveys (commanders, other participants) were used to assess knowledge and perceptions of assigned roles, organization, and communications. Direct observation by trained observers and a structured debriefing session also were employed.

RESULTS

A total of 45 volunteers participated in the exercise that included 20 mock victims. First, mean, and last victim delay times (from exercise initiation) were 2.1, 4.0, and 9.3 minutes (min) until triage, and 5.2, 11.9, and 22.0 min for scene evacuation, respectively. First, mean, and last victim delay times to definitive treatment were 6.0, 14.5, and 25.0 min. Mean time to triage (and range) for scene Zones I (nearest entrance), II (intermediate) and III (ground zero) were 2.9 (2.0-4.0), 4.1 (3.0-5.0) and 5.2 (3.0-9.0) min, respectively. The lowest acuity level (Green) victims had the shortest mean times for triage (3.5 min), evacuation (4.0 min), and treatment (10.0 min) while the highest acuity level (Red) victims had the longest mean times for all measures; patterns consistent with independent rather than ICS-directed rescuer activities. Specific ICS problem areas were identified.

CONCLUSIONS

A structured, objective, quantitative evaluation of ICS function can identify deficiencies that can become the focus for subsequent improvement efforts.

Hazardous substances releases causing fatalities and/or people transported to hospitals: rural/agricultural vs. other areas

INTRODUCTION

Mass-casualty and hospital preparedness has been analyzed widely. However, information regarding the types of areas where these events occur is limited. Therefore, the characteristics of acute hazardous substances releases resulting in death/multiple-victim events occuring in rural/agricultural areas and in all other areas were studied and compared.

METHODS

Data reported to the Hazardous Substances Emergency Events Surveillance (HSEES) system from 16 state health departments during 1993-2000 were used to examine factors associated with events with death/multiple victims involving acute release of hazardous substances. A death/multiple-victim event is defined as any event resulting in a death and/or at least five people being transported to a hospital.

RESULTS

Of a total of 43,133 events, 6661 occurred in rural/agricultural areas. Of these, 107 were death/multiple-victim events with 632 victims, of whom 91 died and 77 were hospitalized. All other areas had 472 death/multiple-victim events with 7981 victims, of whom 116 died and 413 were hospitalized. Death/multiple-victim events in rural/agricultural areas were more likely to be associated with transportation (Proportional Ratio (PR) = 4.1, 95% CI = 3.1-5.4) and fires and/or explosions (PR = 1.4, 95% CI = 0.95-2.0) than were death/multiple-victim events in all other areas. Among transportation-related events in rural/agricultural areas, 19 were associated with air transport--mainly crop dusters--and resulted in 18 deaths. Responders were three times more likely to be injured in rural/agricultural areas. Of responders, volunteer firefighters constituted 52% compared with 6.7% in all other areas. The most frequently released chemicals in rural/agricultural areas were ammonia, chlorine, and pesticides. In all other areas, ammonia, chlorine, hydrochloric acid, carbon monoxide, and 0-chlorobenzylidene malononitrile, a tearing agent often associated with an illegal or unauthorized act, were released most frequently.

CONCLUSIONS

Findings from this analysis suggest that remedial actions should address safety measures in both transportation and fixed facilities containing acute hazardous substances. These include regular maintenance of equipment, education of workers about the substances used in their facility, rigorous training and licensing of drivers and crop duster operators, and education and training of employees and first responders in the use of protective equipment. These activities may reduce the number of events, casualties, and costs associated with hazardous substance events.

Practicality of performing medical procedures in chemical protective ensembles

OBJECTIVE

To determine whether certain life saving medical procedures can be successfully performed while wearing different levels of personal protective equipment (PPE), and whether these procedures can be performed in a clinically useful time frame.

METHODS

We assessed the capability of eight medical personnel to perform airway maintenance and antidote administration procedures on manikins, in all four described levels of PPE. The levels are: Level A--a fully encapsulated chemically resistant suit; Level B--a chemically resistant suit, gloves and boots with a full-faced positive pressure supplied air respirator; Level C--a chemically resistant splash suit, boots and gloves with an air-purifying positive or negative pressure respirator; Level D--a work uniform. Time in seconds to inflate the lungs of the manikin with bag-valve-mask, laryngeal mask airway (LMA) and endotracheal tube (ETT) were determined, as was the time to secure LMAs and ETTs with either tape or linen ties. Time to insert a cannula in a manikin was also determined.

RESULTS

There was a significant difference in time taken to perform procedures in differing levels of personal protective equipment (F21,72 = 1.75, P = 0.04). Significant differences were found in: time to lung inflation using an endotracheal tube (A vs. C mean difference and standard error 75.6 +/- 23.9 s, P = 0.03; A vs. D mean difference and standard error 78.6 +/- 23.9 s, P = 0.03); time to insert a cannula (A vs. D mean difference and standard error 63.6 +/- 11.1 s, P < 0.001; C vs. D mean difference and standard error 40.0 +/- 11.1 s, P = 0.01).

CONCLUSIONS

A significantly greater time to complete procedures was documented in Level A PPE (fully encapsulated suits) compared with Levels C and D. There was however, no significant difference in times between Level B and Level C. The common practice of equipping hospital and medical staff with only Level C protection should be re-evaluated.

Combined external and internal hospital disaster: Impact and response in a Houston trauma center intensive care unit*

OBJECTIVE

To increase awareness of specific risks to healthcare systems during a natural or civil disaster. We describe the catastrophic disruption of essential services and the point-by-point response to the crisis in a major medical center.

DESIGN

Case report, review of the literature, and discussion.

SETTING

A 28-bed intensive care unit in a level I trauma center in the largest medical center in the world.

CASE

In June 2001, tropical storm Allison caused >3 feet of rainfall and catastrophic flooding in Houston, TX. Memorial Hermann Hospital, one of only two level I trauma centers in the community, lost electrical power, communications systems, running water, and internal transportation. All essential hospital services were rendered nonfunctional. Life-saving equipment such as ventilators, infusion pumps, and monitors became useless. Patients were triaged to other medical facilities based on acuity using ground and air ambulances. No patients died as result of the internal disaster.

CONCLUSION

Adequate training, teamwork, communication, coordination with other healthcare professionals, and strong leadership are essential during a crisis. Electricity is vital when delivering care in today's healthcare system, which depends on advanced technology. It is imperative that hospitals take the necessary measures to preserve electrical power at all times. Hospitals should have battery-operated internal and external communication systems readily available in the event of a widespread disaster and communication outage. Critical services such as pharmacy, laboratories, blood bank, and central supply rooms should be located at sites more secure than the ground floors, and these services should be prepared for more extensive performances. Contingency plans to maintain protected water supplies and available emergency kits with batteries, flashlights, two-way radios, and a nonelectronic emergency system for patient identification are also very important. Rapid adaptation to unexpected adverse conditions is critical to the successful implementation of any disaster plan.

Application of a cuirass and institution of biphasic extra-thoracic ventilation by gear-protected physicians

OBJECTIVES

To evaluate the speed by which cuirass application, followed by biphasic extra-thoracic ventilation, can be instituted by full anti-chemical protective gear-wearing physicians.

MATERIALS AND METHODS

Ten physicians of variable subspecialties applied a cuirass on an adult volunteer and instituted biphasic extra-thoracic ventilation, using the RTX respirator (Medivent, London, UK). Endotracheal (ET) intubation and manual ventilation of a mannequin and its ventilation was comparatively assessed. Performances were conducted in a prospective, crossover, randomized manner. Times to successful applications as well as failure rates were recorded.

RESULTS

Cuirass application was performed more rapidly (102 +/- 9 s, 177 +/- 31 s, respectively, P <.01) and with a slightly lower failure rate than ET intubation.

CONCLUSIONS

Physicians wearing full anti-chemical protective gear applied the cuirass and instituted biphasic extra-thoracic ventilation faster than ET intubation and manual positive pressure ventilation. Extra-thoracic ventilation should be further evaluated as an option for emergent respiratory support during toxic mass casualty events.

Chemical-biological-radiological (CBR) response: a template for hospital emergency departments

Chemical, biological and radiological (CBR) incidents have the potential to shut down emergency departments that do not have an adequate CBR response. Secondary contamination also poses a threat to the safety and wellbeing of staff and other patients. On activation of a CBR response, "clean" and "contaminated" areas should be clearly marked, and all patients decontaminated before being allowed into the emergency department or outpatients department. Personal protective equipment (PPE) is needed for all staff. Staff using PPE must be monitored for signs of heat illness. Stocks of coveralls, bags for contaminated clothes, plastic sheeting for radiological incidents, barriers for crowd control, and selected drugs should be obtained. Staff required include medical, nursing, security, clerical, orderlies, patient care assistants and other staff, depending on the type of threat. An on-call roster that allows regular rotation of staff is needed. All hospital personnel should understand the response plan, and recognise that the emergency department and hospital is a community asset that requires protection.

Future challenges in preparing for and responding to bioterrorism events

The future success of our preparations for bioterrorism depends on many issues as presented in this article. If these issues are properly addressed, the resulting improvements in bioterrorism preparations will allow us to better deter and mitigate a bioterrorism incident and will also provide us with the added benefit of improvements in early detection, diagnosis, and treatment of natural disease outbreaks. Emergency physicians must take an active leading role in working with the various disciplines to produce a better-prepared community.

Perioperative care of children with nerve agent intoxication

Nerve agents (NA) present a major threat to civilian populations. When a ballistic system is used for spreading poison, multiple trauma, as well as toxic trauma could be caused. Children are more susceptible, due to their smaller physiological reserve. Urgent surgical intervention for combined intoxication in the multiple-traumatized child could be a tremendous task in view of the background of physiological instability. Nerve agents affect the autonomic, as well as the central nervous system, leading occasionally to unexpected interactions with agents normally used for resuscitation. This can cause additional instability, and possibly systemic collapse. This review presents and emphasizes points concerning treatment of a child who suffers from combined multiple and toxic traumas. The review is based on scant knowledge of a database of similar cases of pesticide organophosphate poisoning in children since these compounds are alike. We also extrapolated data from reports concerning episodic civilian exposure to NA.

Hydroxocobalamin: improved public health readiness for cyanide disasters

The United States is under the constant threat of a mass casualty cyanide disaster from industrial accidents, hazardous material transportation incidents, and deliberate terrorist attacks. The current readiness for cyanide disaster by the emergency medical system in the United States is abysmal. We, as a nation, are simply not prepared for a significant cyanide-related event. The standard of care for cyanide intoxication is the cyanide antidote kit, which is based on the use of nitrites to induce methemoglobinemia. This kit is both expensive and ill suited for out-of-hospital use. It also has its own inherent toxicity that prevents rapid administration. Furthermore, our hospitals frequently fail to stock this life-saving antidote or decline to stock more than one. Hydroxocobalamin is well recognized as an efficacious, safe, and easily administered cyanide antidote. Because of its extremely low adverse effect profile, it is ideal for out-of-hospital use in suspected cyanide intoxication. To effectively prepare for a cyanide disaster, the United States must investigate, adopt, manufacture, and stockpile hydroxocobalamin to prevent needless morbidity and mortality.