When the earth trembles in the Americas: the experience of Haiti and Chile 2010

Critical Care in the Austere Environment

Practice of critical care in austere settings involves navigating rapidly evolving environments, where physical resources, provider availability, and healthcare capacity are constrained. Austere Critical Care focuses on maintaining the highest standard of care possible for patients while also identifying resource limitations, responding to patient surges, and adhering to proper triage practices at the austere site. This includes transferring the patient when able and necessary. This article describes the current practice of critical care medicine in the austere environment, using recent natural disasters, pandemics, and conflicts as case studies.

Disasters and kidney care: pitfalls and solutions

Patients with kidney disease, especially those with kidney failure, are particularly susceptible to the adverse effects of disasters because their survival depends on functional infrastructure, advanced technology, the availability of specific drugs and well-trained medical personnel. The risk of poor outcomes across the entire spectrum of patients with kidney diseases (acute kidney injury, chronic kidney disease and kidney failure on dialysis or with a functioning transplant) increases as a result of disaster-related logistical challenges. Patients who are displaced face even more complex problems owing to additional threats that arise during travel and after reaching their new location. Overall, risks may be mitigated by pre-disaster preparedness and training. Emergency kidney disaster responses depend on the type and severity of the disaster and include medical and/or surgical treatment of injuries, treatment of mental health conditions, appropriate diet and logistical interventions. After a disaster, patients should be evaluated for problems that were not detected during the event, including those that may have developed as a result of the disaster. A retrospective review of the disaster response is vital to prevent future mistakes. Important ethical concerns include fair distribution of limited resources and limiting harm. Patients with kidney disease, their care-givers, health-care providers and authorities should be trained to respond to the medical and logistical problems that occur during disasters to improve outcomes.

Crush injury and syndrome: A review for emergency clinicians

INTRODUCTION

Primary disasters may result in mass casualty events with serious injuries, including crush injury and crush syndrome.

OBJECTIVE

This narrative review provides a focused overview of crush injury and crush syndrome for emergency clinicians.

DISCUSSION

Millions of people worldwide annually face natural or human-made disasters, which may lead to mass casualty events and severe medical issues including crush injury and syndrome. Crush injury is due to direct physical trauma and compression of the human body, most commonly involving the lower extremities. It may result in asphyxia, severe orthopedic injury, compartment syndrome, hypotension, and organ injury (including acute kidney injury). Crush syndrome is the systemic manifestation of severe, traumatic muscle injury. Emergency clinicians are at the forefront of the evaluation and treatment of these patients. Care at the incident scene is essential and focuses on treating life-threatening injuries, extrication, triage, fluid resuscitation, and transport. Care at the healthcare facility includes initial stabilization and trauma evaluation as well as treatment of any complication (e.g., compartment syndrome, hyperkalemia, rhabdomyolysis, acute kidney injury).

CONCLUSIONS

Crush injury and crush syndrome are common in natural and human-made disasters. Emergency clinicians must understand the pathophysiology, evaluation, and management of these conditions to optimize patient care.

Armed conflicts and kidney patients: a consensus statement from the Renal Disaster Relief Task Force of the ERA

During conflicts, people with kidney disease, either those remaining in the affected zones or those who are displaced, may be exposed to additional threats because of medical and logistical challenges. Acute kidney injury developing on the battlefield, in field hospitals or in higher-level hospital settings is characterized by poor outcomes. People with chronic kidney disease may experience treatment interruptions, contributing to worsening kidney function. Patients living on dialysis or with a functioning graft may experience limitations of dialysis possibilities or availability of immunosuppressive medications, increasing the risk of severe complications including death. When patients must flee, these threats are compounded by unhealthy and insecure conditions both during displacement and/or at their destination. Measures to attenuate these risks may only be partially effective. Local preparedness for overall and medical/kidney-related disaster response is essential. Due to limitations in supply, adjustments in dialysis frequency or dose, switching between hemodialysis and peritoneal dialysis and changes in immunosuppressive regimens may be required. Telemedicine (if possible) may be useful to support inexperienced local physicians in managing medical and logistical challenges. Limited treatment possibilities during warfare may necessitate referral of patients to distant higher-level hospitals, once urgent care has been initiated. Preparation for disasters should occur ahead of time. Inclusion of disaster nephrology in medical and nursing curricula and training of patients, families and others on self-care and medical practice in austere settings may enhance awareness and preparedness, support best practices adapted to the demanding circumstances and prepare non-professionals to lend support.

A review of temperature-related challenges and solutions for the Abbott i-STAT and Siemens Healthineers epoc devices

The Abbott i-STAT and Siemens Healthineers epoc are commonly used in the provision of care during emergency medical services calls and other settings. Maintaining these systems within manufacturer's temperature claims in these settings poses challenges across the world. This review summarizes solutions that have been reported in the peer-reviewed literature and proposes additional strategies to further address these challenges. A literature search was performed with Clarivate's Web of Science from inception to August 3, 2022. Search terms included i-STAT, epoc, temperature, cold, hot, heat, freeze, frozen, prehospital, disaster, POCT, point of care, blood gas, helicopter, airplane, and ambulance. One author also reviewed manually every issue of the Journal of Paramedic Practice. The search identified 17 solutions for addressing temperature-related challenges with the i-STAT device, nine solutions for i-STAT cartridges, one solution for the epoc device, and one solution for the epoc test card. The majority of solutions were highly portable and consisted of widely available, inexpensive components. The solutions demonstrated only partial or entirely questionable effectiveness in achieving temperature control. The search also identified five reports on the impact of storage temperatures on cartridges and test cards. The reports suggested that these reagents may be able to withstand storage at temperatures outside of manufacturer's claims with only minimal deterioration in performance. The heterogeneity of solutions and the paucity of evidence on their effectiveness suggest that additional strategies are needed to better understand and further address temperature-related challenges with these systems. A collaborative approach and shared decision making are recommended.

Mass Disasters and Burnout in Nephrology Personnel: From Earthquakes and Hurricanes to COVID-19 Pandemic

Mass disasters result in extensive health problems and make health care delivery problematic, as has been the case during the COVID-19 pandemic. Although COVID-19 was initially considered a pulmonary problem, it soon became clear that various other organs were involved. Thus, many care providers, including kidney health personnel, were overwhelmed or developed burnout. This review aims to describe the spectrum of burnout in mass disasters and suggests solutions specifically for nephrology personnel by extending previous experience to the COVID-19 pandemic. Burnout (a psychologic response to work-related stress) is already a frequent part of routine nephrology practice and, not surprisingly, is even more common during mass disasters due to increased workload and specific conditions, in addition to individual factors. Avoiding burnout is essential to prevent psychologic and somatic health problems in personnel as well as malpractice, understaffing, and inadequate health care delivery, all of which increase the health care burden of disasters. Burnout may be prevented by predisaster organizational measures, which include developing an overarching plan and optimizing health care infrastructure, and ad hoc disaster-specific measures that encompass both organizational and individual measures. Organizational measures include increasing safety, decreasing workload and fear of malpractice, optimizing medical staffing and material supplies, motivating personnel, providing mental health support, and enabling flexibility in working circumstances. Individual measures include training on coping with stress and problematic conditions, minimizing the stigma of emotional distress, and maintaining physical health. If these measures fall short, asking for external help is mandatory to avoid an inefficient disaster health care response. Minimizing burnout by applying these measures will improve health care provision, thus saving as many lives as possible.

Kidney problems in disaster situations

Mass disasters, particularly earthquakes, cause many medical problems, including kidney problems, but an organized approach to cope with them was initiated only at the end of previous century, subsequent to the Armenian Spitak earthquake in 1988. Originally, interventions were focused on acute kidney injury (AKI) following crush injury and rhabdomyolysis in victims who had been trapped under the debris of collapsed buildings. However, similar problems were also registered in the context of other catastrophic events, especially man-made disasters like wars and torture. Other kidney-related problems, such as the preservation of treatment continuity in chronic kidney disease (CKD), especially in maintenance dialysis patients, deserved attention as well. Specific therapeutic principles apply to disaster-related kidney problems and these may differ from usual day-to-day clinical practice. Those approaches have been formulated in global and specific country-related guidelines and recommendations. It is clear that a well-conceived and organized management of kidney diseases in disasters benefits outcomes. Furthermore, it may be useful if the model and philosophy that were applied over the last three decades could be adapted by broadening the scope of disasters leading to intervention. Actions should be guided and coordinated by a panel of experts steering ad hoc interventions, rather than applying the "old" static model where a single coordinating center instructs and uses volunteers listed long before a potential event occurs.

Point-of-Care Testing Practices, Failure Modes, and Risk-Mitigation Strategies in Emergency Medical Services Programs in the Canadian Province of Alberta

CONTEXT.—

Emergency medical services (EMS) programs have been using point-of-care testing (POCT) for more than 20 years. However, only a handful of reports have been published in all of that time on POCT practices in field settings.

OBJECTIVE.—

To provide an overview of POCT practices and failure modes in 3 of Alberta's EMS programs, and to propose risk-mitigation strategies for reducing or eliminating these failure modes.

DESIGN.—

Details about POCT practices, failure modes, and risk-mitigation strategies were gathered through (1) conversations with personnel, (2) in-person tours of EMS bases, (3) accompaniment of EMS personnel on missions, (4) internet searches for publicly available information, and (5) a review of laboratory documents.

RESULTS.—

Practices were most standardized and robust in the community paramedicine program (single service provider, full laboratory oversight), and least standardized and robust in the air ambulance program (4 service providers, limited laboratory oversight). Common failure modes across all 3 programs included device inoperability due to cold weather, analytical validation procedures that failed to consider the unique challenges of EMS settings, and a lack of real-time electronic transmission of results into the health care record.

CONCLUSIONS.—

A provincial framework for POCT in EMS programs is desirable. Such a framework should include appropriate funding models, laboratory oversight of POCT, and relevant expertise on POCT in EMS settings. The framework should also incorporate specific guidance on quality standards that are needed to address the unique challenges of performing POCT in field settings.

Renal Crisis in Children during Armed Conflict

Armed conflicts continue to occur in some regions of the globe, mostly in developing countries. These man-made disasters affect all segments of the population; however, some groups are more vulnerable and suffer more seriously from the unfavorable consequences of such conflicts. Among these, the pediatric population deserves special attention because they cannot protect themselves, and hence carry a higher threat of injuries and probability of death during conflicts. In addition, children who do survive the disaster are more prone to exploitation. Pediatric victims, including those who sustain acute kidney injury or those suffering from chronic kidney disease before armed conflicts, face higher risks of morbidity and mortality as a result of treatment problems, specifically limited dialysis options. Displaced children, forced to flee their homes as a result of armed conflicts, are also at risk for various health problems because they may not find ideal circumstances for disease treatment. Making preparations in anticipation of armed conflicts, such as disaster-relief scenarios and action plans, may be useful to decrease the death toll in these children, who are dependent on their caregivers for survival. Adopting principles of disaster nephrology may contribute to improved survival chances of pediatric kidney patients in chaotic circumstances.

Acute Kidney Injury in Active Wars and Other Man-Made Disasters

Acute kidney injury (AKI) is frequent during wars and other man-made disasters, and contributes significantly to the overall death toll. War-related AKI may develop as a result of polytrauma, traumatic bleeding and hypovolemia, chemical and airborne toxin exposure, and crush syndrome. Thus, prerenal, intrinsic renal, or postrenal AKI may develop at the battlefield, in field hospitals, or tertiary care centers, resulting not only from traumatic, but also nontraumatic, etiologies. The prognosis usually is unfavorable because of systemic and polytrauma-related complications and suboptimal therapeutic interventions. Measures for decreasing the risk of AKI include making preparations for foreseeable disasters, and early management of polytrauma-related complications, hypovolemia, and other pathogenetic mechanisms. Transporting casualties initially to field hospitals, and afterward to higher-level health care facilities at the earliest convenience, is critical. Other man-made disasters also may cause AKI; however, the number of patients is mostly lower and treatment possibilities are broader than in war. If there is no alternative other than prolonged field care, the medical community must be prepared to offer health care and even perform dialysis in austere conditions, which in that case, is the only option to decrease the death toll resulting from AKI.

Improvised Field Expedient Method for Renal Replacement Therapy in a Porcine Model of Acute Kidney Injury

OBJECTIVE

Dialysis patients may not have access to conventional renal replacement therapy (RRT) following disasters. We hypothesized that improvised renal replacement therapy (ImpRRT) would be comparable to continuous renal replacement therapy (CRRT) in a porcine acute kidney injury model.

METHODS

Following bilateral nephrectomies and 2 hours of caudal aortic occlusion, 12 pigs were randomized to 4 hours of ImpRRT or CRRT. In the ImpRRT group, blood was circulated through a dialysis filter using a rapid infuser to collect the ultrafiltrate. Improvised replacement fluid, made with stock solutions, was infused pre-pump. In the CRRT group, commercial replacement fluid was used. During RRT, animals received isotonic crystalloids and norepinephrine.

RESULTS

There were no differences in serum creatinine, calcium, magnesium, or phosphorus concentrations. While there was a difference between groups in serum potassium concentration over time (P < 0.001), significance was lost in pairwise comparison at specific time points. Replacement fluids or ultrafiltrate flows did not differ between groups. There were no differences in lactate concentration, isotonic crystalloid requirement, or norepinephrine doses. No difference was found in electrolyte concentrations between the commercial and improvised replacement solutions.

CONCLUSION

The ImpRRT system achieved similar performance to CRRT and may represent a potential option for temporary RRT following disasters.

Emergency Preparedness in Ambulatory Surgery Centers and Office-Based Anesthesia Practices

Natural or manmade disasters, mass causality events, and other emergencies can disrupt healthcare delivery and change the demand for healthcare services. In order to protect patients, staff, and facilities it is essential that healthcare facilities be prepared for such emergency events. Ambulatory surgery centers (ASC) and Office Based Anesthesia (OBA) practices are unique healthcare settings that necessitate specific emergency planning since they typically do not have rapid response or code teams on site. In addition, they typically operate with fewer personnel and have staff members who often perform multiple functions. Previously there has been variability in the emergency preparedness amongst ASCs and OBA practices. The Centers for Medicare & Medicaid Services (CMS) has recently identified three requirements for maintaining healthcare services during an emergency. These are 1) safeguarding human resources, 2) maintaining business operations, and 3) protecting physical resources. In 2016 CMS issued new rules establishing national emergency preparedness requirements for Medicare and Medicaid participating providers in the United States. In addition there are requirements specifically for ASCs and OBAs. The first step in emergency preparedness is performing a risk assessment for a practice using an “all-hazards” approach. In this approach, the practice attempts to identify all hazards that could potentially affect the practice as well as evaluating the likelihood of such hazards. This risk assessment is then incorporated into an emergency plan for the facility. In addition to reviewing specific components of an emergency plan for ASCs and OBAs, the need to test the plan and create a subsequent corrective action plan is reviewed. It is important that healthcare providers at all ambulatory surgery centers and office based anesthesia practices are aware of regulations for emergency preparedness and work to ensure that patients, staff and physical resources are protected during natural disasters and other emergencies.

The dual discourse of urban resilience: robust city and self-organised neighbourhoods

Resilience has become a dominant disaster governance discourse. It has been criticised for insufficiently addressing systemic vulnerabilities while urging the vulnerable to self-organise. The urban resilience discourse involves a particular disconnect: it evokes 'robustness' and unaffectedness at the city scale on the one hand, and self-organisation of disaster-affected people and neighbourhoods on the other. This paper explains and illustrates the dual discourse through a case study on the reconstruction of informal and low-income settlements in the aftermath of the fire in Valparaíso, Chile, in 2014, focusing on the communication contents of two non-governmental organisations (NGOs). These NGOs deployed the discourse differently, yet both called for affected neighbourhoods to build a more robust city through self-organisation, and both suggested their work as the missing link between self-organisation and robustness. A danger in deploying the dual discourse is that it requires people who live in informal and low-income settlements to earn their right to the robust city through 'better' self-organisation based on fragmented visions.

Provision of Care for Critically Ill Children in Disasters

Children are affected by all types of disasters disproportionately compared with adults. Despite this, planning and readiness to care for children in disasters is suboptimal locally, nationally, and internationally. These planning gaps increase the likelihood that a disaster will have a greater negative impact on children when compared with adults. New voluntary regional coalitions have been developed to fill this gap. Some are pediatric focused or have pediatrics well integrated into the greater coalition. This article discusses key points of pediatric disaster planning, specific vulnerabilities, and the care of children in general and in specific disaster situations.

Systemic Inflammatory Response and Multiple Organ Dysfunctions Following Crush Injury: a New Experimental Model in Rabbits

In this study, we aim to develop a new, reproducible crush injury (CI) model in rabbits. Anesthetized rabbits were compressed on both hind limbs using a special instrument for 6 h followed by 3 h of reperfusion. Blood samples and injured muscles were collected for biochemical analysis and morphological evaluation. Survival observation lasted for 72 h. Bilateral compressions with 10 kg/kg body weight (BW), but not with 5 kg/kg BW, reduced serious systemic impairment. Bilateral compressions with 10 kg/kg BW resulted in severe lactic acidosis; increased serum K⁺, creatine phosphokinase, aspartate transaminase, alanine transaminase, blood urea nitrogen, and creatinine levels; and a sharply decreased mean arterial blood pressure after compression release. Serious tissue edema and inflammation were observed in the damaged muscles. The mortality rates in compression groups were 20% (5 kg/kg BW) and 60% (10 kg/kg BW). There was a significant increase in plasma concentrations of TNF-α and IL-1β after compression. Plasma IL-1β levels returned to control levels at 6 h after compression release, whereas TNF-α peaked at 12 h following reperfusion. Furthermore, antiinflammatory cytokines, including IL-4 and IL-10, were also increased after compression, and these two cytokines peaked at 12 h after compression release. Our data suggested that bilateral compression with 10 kg/kg BW on rabbits' hind limbs is a reproducible CI model, and we also reported the CI-induced systemic inflammatory responses and changes of cytokines over time.

Impact of Nepal Earthquake on Patients Presenting for Emergency Care at Patan Hospital

Objective

Natural disasters have a significant impact on the health sector. On April 25, 2015, Nepal was struck by a 7.8 magnitude earthquake. The aim of the study was to compare patient volumes and clinical conditions presenting to the emergency department pre- and post-earthquake.

Methods

A retrospective study was done at Patan Hospital Emergency Department in Kathmandu, Nepal. Volume, demographics, and patient diagnoses were collected for 4 months post-disaster and compared with cases seen the same months the year before the disaster to control for seasonal variations.

Results

After the 2015 Nepal earthquake, 12,180 patients were seen in the emergency department. This was a significant decrease in patient volume compared with the 14,971 patients seen during the same months in 2014 (P=0.04). Of those, 5496 patients (4093 pre-disaster and 1433 post-disaster) had a chief complaint or diagnosis recorded for analysis. An increase in cardiovascular and respiratory cases was seen as well as an increase in psychiatric cases (mostly alcohol related) and cases of anemia. There was a decrease in the number of obstetrics/gynecology, infectious disease, and poisoning cases post-earthquake.

Conclusions

Understanding emergency department utilization after the earthquake has the potential to give further insight into improving disaster preparedness plans for post-disaster health needs. (Disaster Med Public Health Preparedness. 2019;13:211–216).

More harm than good? The questionable ethics of medical volunteering and international student placements

It has been argued that much of international medical volunteering is done for the wrong reasons, in that local people serve as a means to meet volunteers’ needs, or for the right reasons but ignorance and ill-preparedness harm the intended beneficiaries, often without volunteers’ grasp of the damage caused. The literature on ethical concerns in medical volunteering has grown tremendously over the last years highlighting the need for appropriate guidelines. These same concerns, however, and an appreciation of the reasons why current aid paradigms are flawed, can serve as indicators on how to change existing practices to ensure a better outcome for those who are in need of help. Such paradigm change envisages medical assistance in the spirit of solidarity, social justice, equality, and collegial collaboration.

Disaster nephrology: a new concept for an old problem

Natural and man-made mass disasters directly or indirectly affect huge populations, who need basic infrastructural help and support to survive. However, despite the potentially negative impact on survival chances, these health care issues are often neglected by the authorities.

Treatment of both acute and chronic kidney diseases (CKDs) is especially problematic after disasters, because they almost always require complex technology and equipment, whereas specific drugs may be difficult to acquire for the treatment of the chronic kidney patients. Since many crush victims in spite of being rescued alive from under the rubble die afterward due to lack of dialysis possibilities, the terminology of ‘renal disaster’ was introduced after the Armenian earthquake. It should be remembered that apart from crush syndrome, multiple aetiologies of acute kidney injury (AKI) may be at play in disaster circumstances.

The term ‘seismonephrology’ (or earthquake nephrology) was introduced to describe the need to treat not only a large number of AKI cases, but the management of patients with CKD not yet on renal replacement, as well as of patients on haemodialysis or peritoneal dialysis and transplanted patients. This wording was later replaced by ‘disaster nephrology’, because besides earthquakes, many other disasters such as hurricanes, tsunamis or wars may have a negative impact on the ultimate outcome of kidney patients.

Disaster nephrology describes the handling of the many medical and logistic problems in treating kidney patients in difficult circumstances and also to avoid post-disaster chaos, which can be made possible by preparing medical and logistic scenarios. Learning and applying the basic principles of disaster nephrology is vital to minimize the risk of death both in AKI and CKD patients.

Surge capacity logistics: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement

BACKGROUND

Successful management of a pandemic or disaster requires implementation of preexisting plans to minimize loss of life and maintain control. Managing the expected surges in intensive care capacity requires strategic planning from a systems perspective and includes focused intensive care abilities and requirements as well as all individuals and organizations involved in hospital and regional planning. The suggestions in this article are important for all involved in a large-scale disaster or pandemic, including front-line clinicians, hospital administrators, and public health or government officials. Specifically, this article focuses on surge logistics-those elements that provide the capability to deliver mass critical care.

METHODS

The Surge Capacity topic panel developed 23 key questions focused on the following domains: systems issues; equipment, supplies, and pharmaceuticals; staffing; and informatics. Literature searches were conducted to identify studies upon which evidence-based recommendations could be made. The results were reviewed for relevance to the topic, and the articles were screened by two topic editors for placement within one of the surge domains noted previously. Most reports were small scale, were observational, or used flawed modeling; hence, the level of evidence on which to base recommendations was poor and did not permit the development of evidence-based recommendations. The Surge Capacity topic panel subsequently followed the American College of Chest Physicians (CHEST) Guidelines Oversight Committee's methodology to develop suggestion based on expert opinion using a modified Delphi process.

RESULTS

This article presents 22 suggestions pertaining to surge capacity mass critical care, including requirements for equipment, supplies, and pharmaceuticals; staff preparation and organization; methods of mitigating overwhelming patient loads; the role of deployable critical care services; and the use of transportation assets to support the surge response.

CONCLUSIONS

Critical care response to a disaster relies on careful planning for staff and resource augmentation and involves many agencies. Maximizing the use of regional resources, including staff, equipment, and supplies, extends critical care capabilities. Regional coalitions should be established to facilitate agreements, outline operational plans, and coordinate hospital efforts to achieve predetermined goals. Specialized physician oversight is necessary and if not available on site, may be provided through remote consultation. Triage by experienced providers, reverse triage, and service deescalation may be used to minimize ICU resource consumption. During a temporary loss of infrastructure or overwhelmed hospital resources, deployable critical care services should be considered.

System-level planning, coordination, and communication: care of the critically ill and injured during pandemics and disasters: CHEST consensus statement

BACKGROUND

System-level planning involves uniting hospitals and health systems, local/regional government agencies, emergency medical services, and other health-care entities involved in coordinating and enabling care in a major disaster. We reviewed the literature and sought expert opinions concerning system-level planning and engagement for mass critical care due to disasters or pandemics and offer suggestions for system-planning, coordination, communication, and response. The suggestions in this chapter are important for all of those involved in a pandemic or disaster with multiple critically ill or injured patients, including front-line clinicians, hospital administrators, and public health or government officials.

METHODS

The American College of Chest Physicians (CHEST) consensus statement development process was followed in developing suggestions. Task Force members met in person to develop nine key questions believed to be most relevant for system-planning, coordination, and communication. A systematic literature review was then performed for relevant articles and documents, reports, and other publications reported since 1993. No studies of sufficient quality were identified upon which to make evidence-based recommendations. Therefore, the panel developed expert opinion-based suggestions using a modified Delphi process.

RESULTS

Suggestions were developed and grouped according to the following thematic elements: (1) national government support of health-care coalitions/regional health authorities (HC/RHAs), (2) teamwork within HC/RHAs, (3) system-level communication, (4) system-level surge capacity and capability, (5) pediatric patients and special populations, (6) HC/RHAs and networks, (7) models of advanced regional care systems, and (8) the use of simulation for preparedness and planning.

CONCLUSIONS

System-level planning is essential to provide care for large numbers of critically ill patients because of disaster or pandemic. It also entails a departure from the routine, independent system and involves all levels from health-care institutions to regional health authorities. National government support is critical, as are robust communication systems and advanced planning supported by realistic exercises.

Kidney care in Haiti--the role of partnerships

Establishing a programme for the prevention and treatment of acute kidney injury, chronic kidney disease and end-stage renal disease in a developing country involves unique challenges. We became involved in a collaborative effort to improve nephrology care in Haiti after participating in the emergency response to the 2010 earthquake. The focus of this ongoing project is overcoming barriers to implementation with the goal of improving training and resources for Haitian health-care workers and developing programmes for renal disease prevention and treatment in a setting of limited resources. Here, we offer practical advice for nephrologists who would like to help to advance medical care in developing countries. Rather than technical issues related to the prevention and treatment of renal disease, we focus on collaboration, education and the building of partnerships.

Vulnerability of point-of-care test reagents and instruments to environmental stresses: implications for health professionals and developers

Strategic integration of point-of-care (POC) diagnostic tools during crisis response can accelerate triage and improve management of victims. Timely differential diagnosis is essential wherever care is provided to rule out or rule in disease, expedite life-saving treatment, and improve utilization of limited resources. POC testing needs to be accurate in any environment in which it is used. Devices are exposed to potentially adverse storage and operating conditions, such as high/low temperature and humidity during emergencies and field rescues. Therefore, characterizing environmental conditions allows technology developers, operators, and responders to understand the broad operational requirements of test reagents, instruments, and equipment in order to improve the quality and delivery of care in complex emergencies, disasters, and austere environmental settings. This review aims to describe the effects of environmental stress on POC testing performance and its impact on decision-making, to describe how to study the effects, and to summarize ways to mitigate the effects of environmental stresses through good laboratory practice, development of robust reagents, and novel thermal packaging solutions.

Effects of humidity on foil and vial packaging to preserve glucose and lactate test strips for disaster readiness

OBJECTIVE

Efficient emergency and disaster response is challenged by environmental conditions exceeding test reagent storage and operating specifications. We assessed the effectiveness of vial and foil packaging in preserving point-of-care (POC) glucose and lactate test strip performance in humid conditions.

METHODS

Glucose and lactate test strips in both packaging were exposed to mean relative humidity of 97.0 ± 1.1% in an environmental chamber for up to 168 hours. At defined time points, stressed strips were removed and tested in pairs with unstressed strips using whole blood samples spiked to glucose concentrations of 60, 100, and 250 mg/dL (n = 20 paired measurements per level). A Wilcoxon signed rank test was used to compare stressed and unstressed test strip measurements.

RESULTS

Stressed glucose and lactate test strip measurements differed significantly from unstressed strips, and were inconsistent between experimental trials. Median glucose paired difference was as high as 12.5 mg/dL at the high glucose test concentration. Median lactate bias was -0.2 mmol/L. Stressed strips from vial (3) and foil (7) packaging failed to produce results.

CONCLUSIONS

Both packaging designs appeared to protect glucose and lactate test strips for at least 1 week of high humidity stress. Documented strip failures revealed the need for improved manufacturing process.

Dynamic Temperature and Humidity Environmental Profiles: Impact for Future Emergency and Disaster Preparedness and Response

Introduction

During disasters and complex emergencies, environmental conditions can adversely affect the performance of point-of-care (POC) testing. Knowledge of these conditions can help device developers and operators understand the significance of temperature and humidity limits necessary for use of POC devices. First responders will benefit from improved performance for on-site decision making.

Objective

To create dynamic temperature and humidity profiles that can be used to assess the environmental robustness of POC devices, reagents, and other resources (eg, drugs), and thereby, to improve preparedness.

Methods

Surface temperature and humidity data from the National Climatic Data Center (Asheville, North Carolina USA) was obtained, median hourly temperature and humidity were calculated, and then mathematically stretched profiles were created to include extreme highs and lows. Profiles were created for: (1) Banda Aceh, Indonesia at the time of the 2004 Tsunami; (2) New Orleans, Louisiana USA just before and after Hurricane Katrina made landfall in 2005; (3) Springfield, Massachusetts USA for an ambulance call during the month of January 2009; (4) Port-au-Prince, Haiti following the 2010 earthquake; (5) Sendai, Japan for the March 2011 earthquake and tsunami with comparison to the colder month of January 2011; (6) New York, New York USA after Hurricane Sandy made landfall in 2012; and (7) a 24-hour rescue from Hawaii USA to the Marshall Islands. Profiles were validated by randomly selecting 10 days and determining if (1) temperature and humidity points fell inside and (2) daily variations were encompassed. Mean kinetic temperatures (MKT) were also assessed for each profile.

Results

Profiles accurately modeled conditions during emergency and disaster events and enclosed 100% of maximum and minimum temperature and humidity points. Daily variations also were represented well with 88.6% (62/70) of temperature readings and 71.1% (54/70) of relative humidity readings falling within diurnal patterns. Days not represented well primarily had continuously high humidity. Mean kinetic temperature was useful for severity ranking.

Conclusions

Simulating temperature and humidity conditions clearly reveals operational challenges encountered during disasters and emergencies. Understanding of environmental stresses and MKT leads to insights regarding operational robustness necessary for safe and accurate use of POC devices and reagents. Rescue personnel should understand these principles before performing POC testing in adverse environments.

FergusonWJ, LouieRF, TangCS, Paw UKT, KostGJ. Dynamic temperature and humidity environmental profiles: impact for future emergency and disaster preparedness and response. Prehosp Disaster Med. 2014;29(1):1-8.

Crush syndrome: a case report and review of the literature

BACKGROUND

Crush trauma to the extremities, even if not involving vital organs, can be life threatening. Crush syndrome, the systemic manifestation of the breakdown of muscle cells with release of contents into the circulation, leads to metabolic derangement and acute kidney injury. Although common in disaster scenarios, emergency physicians also see the syndrome in patients after motor-vehicle collisions and patients "found down" due to intoxication.

OBJECTIVE

The objectives of this review are to discuss the pathophysiology of crush syndrome, report on prehospital and emergency department treatment, and discuss the relationship between crush syndrome and compartment syndrome.

DISCUSSION

We present the case of a young man found down after an episode of intoxication, with compartment syndrome of his lower extremity and crush syndrome. Although he eventually required an amputation, aggressive fluid resuscitation prevented further kidney injury and metabolic derangement.

CONCLUSIONS

Early, aggressive resuscitation in the prehospital setting, before extrication if possible, is recommended to reduce the complications of crush syndrome. Providers must be aware of the risk of hyperkalemia shortly after extrication. Ongoing resuscitation with i.v. fluids is the mainstay of treatment. Compartment syndrome is a common complication, and prompt fasciotomies should be performed when compartment syndrome is present.

Early fluid resuscitation with hypertonic solution in a rat crush injury model

AIM OF THE STUDY

The aim of the study was to evaluate the effects of bolus infusion of hypertonic hydroxyethyl starches (HHESs) and continuous infusion of hypertonic saline (HTS) in the early resuscitation in crush syndrome.

METHODS

A rat model of crush injury was established. Rats were randomly divided into five groups: (1) HHES group, (2) HTS group, (3) volume resuscitation group, (4) normal resuscitation (NR) group, and (5) sham group. Blood samples were collected 6 h after the crush period for biochemical evaluation. Blood pressure was monitored throughout this experiment. Muscles and kidneys were evaluated morphologically 24 h after reperfusion. Twenty rats in each group were taken for survival observation for 72 h.

RESULTS

Compared with the NR and HTS groups, the HHES group had significantly increased the survival rate 72 h after release (P < 0.05). In the first 2 h after release, mean arterial blood pressure in the HHES group was significantly higher than in HTS, volume resuscitation, and NR groups (respectively, P < 0.05). Animals that received HHES infusion showed a better acid-base balance and renal function. However, there was no significant difference in survival rate between the HTS and NR groups. Furthermore, animals in the HTS group showed a bad acid-base balance and a higher serum sodium level.

CONCLUSIONS

Bolus infusion of HHES combined with normal saline could be an effective therapy for crush syndrome in the early resuscitation period. However, continuous HTS injection was not seemed to be a suitable choice particularly in the absence of monitoring equipment for serum irons or blood gases (institutional protocol no. ZN5R20110016).

Disaster nephrology: crush injury and beyond

Disasters result in a substantial number of renal challenges, either by the creation of crush injury in victims trapped in collapsed buildings or by the destruction of existing dialysis facilities, leaving chronic dialysis patients without access to their dialysis units, medications, or medical care. Over the past two decades, lessons have been learned from the response to a number of major natural disasters that have impacted significantly on crush-related acute kidney injury and chronic dialysis patients. In this paper we review the pathophysiology and treatment of the crush syndrome, as summarized in recent clinical recommendations for the management of crush syndrome. The importance of early fluid resuscitation in preventing acute kidney injury is stressed, logistic difficulties in disaster conditions are described, and the need for an implementation of a renal disaster relief preparedness program is underlined. The role of the Renal Disaster Relief Task Force in providing emergency disaster relief and the logistical support required is outlined. In addition, the importance of detailed education of chronic dialysis patients and renal unit staff in the advance planning for such disasters and the impact of displacement by disasters of chronic dialysis patients are discussed.

Delayed family reunification of pediatric disaster survivors increases mortality and inpatient hospital costs: a simulation study

BACKGROUND

Disasters occur randomly and can severely tax the health care delivery system of affected and surrounding regions. A significant proportion of disaster survivors are children, who have unique medical, psychosocial, and logistical needs after a mass casualty event. Children are often transported to specialty centers after disasters for a higher level of pediatric care, but this can also lead to separation of these survivors from their families. In a recent theoretical article, we showed that the availability of a pediatric trauma center after a mass casualty event would decrease the time needed to definitively treat the pediatric survivor cohort and decrease pediatric mortality. However, we also found that if the pediatric center was too slow in admitting and discharging patients, these benefits were at risk of being lost as children became "trapped" in the slow center. We hypothesized that this effect could result in further increased mortality and greater costs.

METHODS

Here, we expand on these ideas to test this hypothesis via mathematical simulation. We examine how a delay in discharge of part of the pediatric cohort is predicted to affect mortality and the cost of inpatient care in the setting of our model.

RESULTS

We find that mortality would increase slightly (from 14.2%-16.1%), and the cost of inpatient care increases dramatically (by a factor of 21) if children are discharged at rates consistent with reported delays to reunification after a disaster from the literature.

CONCLUSIONS

Our results argue for the ongoing improvement of identification technology and logistics for rapid reunification of pediatric survivors with their families after mass casualty events.

Do currently available blood glucose monitors meet regulatory standards? 1-day public meeting in Arlington, Virginia

Blood glucose monitors (BGMs) are approved by regulatory agencies based on their performance during strict testing conducted by their manufacturers. However, after approval, there is uncertainty whether BGMs maintain the accuracy levels that were achieved in the initial data. The availability of inaccurate BGM systems pose a public health problem because their readings serve as a basis for treatment decisions that can be incorrect. Several articles have concluded that BGMs in the marketplace may not consistently provide accurate results in accordance with the regulatory standards that led to approval. To address this growing concern, Diabetes Technology Society organized and conducted a 1-day public meeting on May 21, 2013, in Arlington, VA, presided by its president, David Klonoff, M.D., FACP, Fellow AIMBE, to determine whether BGMs on the market meet regulatory standards. The meeting consisted of four sessions in which Food and Drug Administration diabetes experts as well as leading academic clinicians and clinical chemists participated: (1) How is BGM performance determined? (2) Do approved BGMs perform according to International Organization for Standardization standards? (3) How do approved BGMs perform when used by patients and health care professionals? (4) What could be the consequence of poor BGM performance?

Effects of dynamic temperature and humidity stresses on point-of-care glucose testing for disaster care

OBJECTIVE

To characterize the performance of glucose meter test strips using simulated dynamic temperature and humidity disaster conditions.

METHODS

Glucose oxidase- and glucose dehydrogenase-based test strips were dynamically stressed for up to 680 hours using an environmental chamber to simulate conditions during Hurricane Katrina. Paired measurements vs control were obtained using 3 aqueous reagent levels for GMS1 and 2 for GMS2.

RESULTS

Stress affected the performance of GMS1 at level 1 (P < .01); and GMS2 at both levels (P < .001), lowering GMS1 results but elevating GMS2 results. Glucose median-paired differences were elevated at both levels on GMS2 after 72 hours. Median-paired differences (stress minus control) were as much as -10 mg/dL (range, -65 to 33) at level 3 with GMS1, with errors as large as 21.9%. Glucose median-paired differences were as high as 5 mg/dL (range, -1 to 10) for level 1 on GMS2, with absolute errors up to 24.4%.

CONCLUSIONS

The duration of dynamic stress affected the performance of both GMS1 and GMS2 glucose test strips. Therefore, proper monitoring, handling, and storage of point-of-care (POC) reagents are needed to ensure their integrity and quality of actionable results, thereby minimizing treatment errors in emergency and disaster settings.

Resuscitation in a multiple casualty event

A major weakness in the emergency medical response to multiple casualty events continues to be the resuscitation component, which should consist of the systematic application of basic, advanced, and prolonged life support and definitive care within 24 hours. There have been major advances in emergency medical care over the last decade, including the feasibility of point-of-care ultrasound to aid in rapid assessment of injuries in the field, damage control resuscitation, and resuscitative surgery protocols, delivered by small trauma/resuscitation teams equipped with regional anesthesia capability for rapid deployment. Widespread adoption of these best practices may improve the delivery of resuscitative care in future multiple casualty events.

Management of crush victims in mass disasters: highlights from recently published recommendations

Crush syndrome is the second most common cause of death after earthquakes (the first most common is direct trauma). Many logistic problems with the treatment of patients with crush syndrome are due to chaotic disaster circumstances; consequently, medical and logistic recommendations on the treatment of crush victims are needed. In a joint initiative of the Renal Disaster Relief Task Force of the International Society of Nephrology and European Renal Best Practice, a work group of nephrologists, intensivists, surgeons, and logisticians with disaster experience or experts in guideline preparation collaborated to provide comprehensive information and recommendations on the management of crush casualties considering their occurrence with "epidemic" dimensions after mass disasters. The result is the monograph "Recommendations for the Management of Crush Victims in Mass Disasters", which may help provide effective health care to disaster victims with renal problems. This article discusses medical and logistic principles of the treatment of crush victims, both at the disaster field and on admission to hospitals, and guidance is described. The importance of early fluid administration even before extrication of the victims and avoidance of potassium-containing solutions during the treatment of crush victims is underlined. Also, the logistic problems in treating crush casualties are emphasized. The most important aspects of the recently published recommendations are highlighted.

Acute kidney injury and ESRD management in austere environments

Current knowledge about managing acute kidney injury in disaster situations stems mostly from lessons learned while taking care of crush syndrome patients during major earthquakes. More recently, there has been a greater focus on emergency preparedness for ESRD management. Natural or man-made disasters create an "austere environment," wherein resources to administer standard of care are limited. Advance planning and timely coordinated intervention during disasters are paramount to administer effective therapies and save lives. This article reviews the presentation and management of disaster victims with acute kidney injury and those requiring renal replacement therapies. Major contributions of some key national and international organizations in the field of disaster nephrology are highlighted. The article intends to increase awareness about nephrology care of disaster victims, among nephrology and non-nephrology providers alike.

Enhancing crisis standards of care using innovative point-of-care testing

OBJECTIVE

To identify strategies with tactics that enable point-of-care (POC) testing (medical testing at or near the site of care) to effectively improve outcomes in emergencies, disasters, and public health crises, especially where community infrastructure is compromised.

DESIGN

Logic model-critical path-feedback identified needs for improving practices. Reverse stress analysis showed POC should be integrated, responders should be properly trained, and devices should be staged in small-world networks (SWNs). First responder POC resources were summarized, test clusters were strategized, assay environmental vulnerabilities were assessed, and tactics useful for SWNs, alternate care facilities, shelters, point-of-distribution centers, and community hospitals were designed. PARTICIPANTS AND ENVIRONMENT: Emergency-disaster needs assessment survey respondents and Center experience.

OUTCOMES

Important tactics are as follows: a) develop training/education courses and '"just-in-time" on-line web resources to ensure the competency of POC coordinators and high-quality testing performance; b) protect equipment from environmental extremes by sealing reagents, by controlling temperature and humidity to which they are exposed, and by establishing near-patient testing in defined environments that operate within current Food and Drug Administration licensing claims (illustrated with human immunodeficiency virus-1/2 tests); c) position testing in defined sites within SWNs and other environments; d) harden POC devices and reagents to withstand wider ranges of environmental extremes in field applications; e) promote new POC technologies for pathogen detection and other assays, per needs assessment results; and f) select tests according to mission objectives and value propositions.

CONCLUSIONS

Careful implementation of POC testing will facilitate evidence-based triage, diagnosis, treatment, and monitoring of victims and patients, while advancing standards of care in emergencies and disasters, as well as public health crises.

Renal replacement therapy in austere environments

Myoglobinuric renal failure is the classically described acute renal event occurring in disaster environments-commonly after an earthquake-which most tests the ingenuity and flexibility of local and regional nephrology resources. In recent decades, several nephrology organizations have developed response teams and planning protocols to address disaster events, largely focusing on patients at risk for, or with, acute kidney injury (AKI). In this paper we briefly review the epidemiology and outcomes of patients with dialysis-requiring AKI after such events, while providing greater focus on the management of the end-stage renal disease population after a disaster which incapacitates a pre-existing nephrologic infrastructure (if it existed at all). "Austere" dialysis, as such, is defined as the provision of renal replacement therapy in any setting in which traditional, first-world therapies and resources are limited, incapacitated, or nonexistent.