To clarify the factors and reasons for the differences in the outcomes of rescue and relief efforts in Hiroshima and Nagasaki, mainly focusing on the numbers of rescue/relief staffs and casualties in the period within 72 hours of the atomic bombings in August 1945.

By retrieving the data and information from the records and reports concerning the disasters in the two cities, together with other publications as to the damages by the atomic bombings and subsequent rescue-relief activities, and restoration activities.

It seems that there was less damage in Nagasaki, where a stronger atomic bomb was used than in Hiroshima. There were crucial geographic factors that led to the different effects in terms of the numbers of victims; however, systematic organization and mobilization of rescue and relief staffs, maintenance of functional transportation, and advanced medical knowledge and public warning with regard to disaster all may have contributed to a lower death toll and increase in survivors in Nagasaki.

MatsunariY, YoshimotoN. Comparison of Rescue and Relief Activities Within 72 Hours of the Atomic Bombings in Hiroshima and Nagasaki. Prehosp Disaster Med. 2013;28(6):1-7.

On June 29, 2012, mid-Atlantic storms resulted in a large-scale power outage affecting up to three million people across multiple (US) states. Hemodialysis centers are dependent on electricity to provide dialysis care to end-stage renal disease patients. The objective of this study was to determine how the power outage impacted operations in a sample of hemodialysis centers in the impacted regions.

The sample consisted of all hemodialysis centers located in the District of Columbia and a total of five counties with the largest power losses in West Virginia, Virginia, and Maryland. A semi-structured interview guide was developed, and the charge nurse or supervisor in each facility was interviewed. The survey questions addressed whether their centers lost power, if so, for how long, where their patients received dialysis, whether their centers had backup generators, and if so, whether they had any problems operating them, and whether their center received patients from other centers if they had power.

Calls were placed to 90 dialysis centers in the sampled areas and a 90% response rate was achieved. Overall, hemodialysis operations at approximately 30% (n = 24) of the centers queried were impacted by the power outage. Of the 36 centers that lost power, 31% (n = 11) referred their patients to other dialysis centers, 22% (n = 8) accommodated their patients during a later shift or on a different day; the rest of the centers either experienced brief power outages that did not affect operations or experienced a power outage on days that the center is usually closed. Some centers in the study cohort reported receiving patients from other centers for dialysis 33% (n = 27). Thirty-two percent (n = 26) of the centers queried had backup generators on site. Eleven percent (n = 4) of the centers experiencing power outages reported that backup generators were brought in by their parent companies.

Comprehensive emergency planning for dialysis centers should include provisions for having backup generators on site, having plans in place for the timely delivery of a generator during a power outage, or having predesignated backup dialysis centers for patients to receive dialysis during emergencies. Most dialysis centers surveyed in this study were able to sustain continuity of care by implementing such pre-existing emergency plans.

AbirM, JanS, JubeltL, MerchantR, LurieN. The Impact of a Large-Scale Power Outage on Hemodialysis Center Operations. Prehosp Disaster Med. 2013;28(6):1-4.

The 2011 Great East Japan Earthquake caused major disruptions in the provision of health care, including that for patients with sleep-disordered breathing (SDB) using a nasal continuous positive airway pressure (nCPAP) device. This study investigated the ability of SDB patients to continue using the nCPAP device in the weeks immediately following the earthquake, whether inability to use the nCPAP device led to symptom relapse, and measures that should be taken to prevent disruptions in nCPAP therapy during future disasters.

If nCPAP devices cannot be used during disasters, SDB patients’ health will be affected negatively.

Within 14 days of the disaster, 1,047 SDB patients completed a questionnaire that collected data regarding ability to use, duration of inability to use, and reasons for inability to use the nCPAP device; symptom relapse while unable to use the nCPAP device; ability to use the nCPAP device use at evacuation sites; and recommendations for improvement of the nCPAP device.

Of the 1,047 patients, 966 (92.3%) had been unable to use the nCPAP device in the days immediately following the earthquake. The most common reason for inability to use the nCPAP device was power failure, followed by anxiety about sleeping at night due to fear of aftershocks, involvement in disaster-relief activities, loss of the nasal CPAP device, and fear of being unable to wake up in case of an emergency. Among the 966 patients, 242 (25.1%) had experienced relapse of symptoms, the most common of which was excessive daytime sleepiness (EDS), followed by insomnia, headache, irritability, and chest pain.

Developing strategies for the continuation of nCPAP therapy during disasters is important for providing healthy sleeping environments for SDB patients in emergency situations.

MitoF, NishijimaT, SakuraiS, KizawaT, HosokawaK, TakahashiS, SuwabeA, AkasakaH, KobayashiS. Effects of CPAP Treatment Interruption Due to Disasters: Patients with Sleep-disordered Breathing in the Great East Japan Earthquake and Tsunami Area. Prehosp Disaster Med. 2013;28(6):547-555.

Evacuation of the World Trade Center (WTC) twin towers and surrounding buildings damaged in the September 11, 2001 attacks provides a unique opportunity to study factors that affect emergency evacuation of high rise buildings.

The goal of this study is to understand the extent to which structural and behavioral barriers and limitations of personal mobility affected evacuation by occupants of affected buildings on September 11, 2001.

This analysis included 5,023 civilian, adult enrollees within the World Trade Center Health Registry who evacuated the two World Trade Center towers and over 30 other Lower Manhattan buildings that were damaged or destroyed on September 11, 2001. Multinomial logistic regression was used to predict total evacuation time (<30 to ≤60 minutes, >1 hour to <2 hours relative to ≤30 minutes) in relation to number of infrastructure barriers and number of behavioral barriers, adjusted for demographic and other factors.

A higher percentage of evacuees reported encountering at least one behavioral barrier (84.9%) than reported at least one infrastructure barrier (51.9%). This pattern was consistent in all buildings except WTC 1, the first building attacked, where >90% of evacuees reported encountering both types of barriers. Smoke and poor lighting were the most frequently-reported structural barriers. Extreme crowding, lack of communication with officials, and being surrounded by panicked crowds were the most frequently-reported behavioral barriers. Multivariate analyses showed evacuation time to be independently associated with the number of each type of barrier as well as gender (longer times for women), but not with the floor from which evacuation began. After adjustment, personal mobility impairment was not associated with increased evacuation time.

Because most high-rise buildings have unique designs, infrastructure factors tend to be less predictable than behavioral factors, but both need to be considered in developing emergency evacuation plans in order to decrease evacuation time and, consequently, risk of injury and death during an emergency evacuation.

GroegerJL, StellmanSD, KravittA, BrackbillRM. Evacuating Damaged and Destroyed Buildings on 9/11: Behavioral and Structural Barriers. Prehosp Disaster Med. 2013;28(6):1-11.

Large earthquakes can cause population displacement, critical sanitation infrastructure damage, and increased threats to water resources, potentially predisposing populations to waterborne disease epidemics such as cholera.

The risk of cholera outbreaks after earthquake disasters remains uncertain. A cross-country analysis of World Health Organization (WHO) cholera data that would contribute to this discussion has yet to be published.

A cross-country longitudinal analysis was conducted among 63 low- and middle-income countries from 1995-2009. The association between earthquake disasters of various effect sizes and a relative spike in cholera rates for a given country was assessed utilizing fixed-effects logistic regression and adjusting for gross domestic product per capita, water and sanitation level, flooding events, percent urbanization, and under-five child mortality. Also, the association between large earthquakes and cholera rate increases of various degrees was assessed.

Forty-eight of the 63 countries had at least one year with reported cholera infections during the 15-year study period. Thirty-six of these 48 countries had at least one earthquake disaster. In adjusted analyses, country-years with ≥10,000 persons affected by an earthquake had 2.26 times increased odds (95 CI, 0.89-5.72, P = .08) of having a greater than average cholera rate that year compared to country-years having <10,000 individuals affected by an earthquake. The association between large earthquake disasters and cholera infections appeared to weaken as higher levels of cholera rate increases were tested.

A trend of increased risk of greater than average cholera rates when more people were affected by an earthquake in a country-year was noted. However these findings did not reach statistical significance at traditional levels and may be due to chance. Frequent large-scale cholera outbreaks after earthquake disasters appeared to be relatively uncommon.

SumnerS, TurnerE, ThielmanN. Association Between Earthquake Events and Cholera Outbreaks: A Cross-country 15-year Longitudinal Analysis. Prehosp Disaster Med. 2013;28(6):1-6.

Planned and organized long-term rehabilitation services should be provided to victims of a disaster for social integration, economic self-sufficiency, and psychological health. There are few studies on recovery and rehabilitation issues in disaster situations. This study explores the disaster-related rehabilitation process.

This study was based on qualitative analysis. Participants included 18 individuals (eight male and ten female) with experience providing or receiving disaster health care or services. Participants were selected using purposeful sampling. Data were collected through in-depth and semi-structured interviews. All interviews were transcribed and content analysis was performed based on qualitative content analysis.

The study explored three main concepts of recovery and rehabilitation after a disaster: 1) needs for health recovery; 2) intent to delegate responsibility; and 3) desire for a wide scope of social support. The participants of this study indicated that to provide comprehensive recovery services, important basic needs should be considered, including the need for physical rehabilitation, social rehabilitation, and livelihood health; the need for continuity of mental health care; and the need for family re-unification services. Providing social activation can help reintegrate affected people into the community.

Effective rehabilitation care for disaster victims requires a clear definition of the rehabilitation process at different levels of the community. Involving a wide set of those most likely to be affected by the process provides a comprehensive, continuous, culturally sensitive, and family-centered plan.

KhankehH, NakhaeiM, MasoumiG, HosseiniM, Parsa-YektaZ, KurlandL, CastrenM. Life Recovery After Disasters: A Qualitative Study in the Iranian Context. Prehosp Disaster Med. 2013;28(6):573-579.

Research has shown that partnerships between public health agencies, service providers, and other key stakeholders can expand resources and facilitate focus on community health issues more effectively than can any agency or organization acting alone. There is, however, little empirical evidence drawn from actual public health emergency responses to support this claim. The US response to novel influenza A (H1N1) virus provided the Centers for Disease Control and Prevention (CDC) the opportunity to explore whether, and the extent to which, state, local and territorial health departments strengthened partnerships with key partner agencies and sectors.

Participants included the CDC Public Health Emergency Response (PHER) grantees comprised of 62 state, territorial and local health departments. PHER grantees completed an assessment instrument in May 2011, including questions asking them to rate their partnership strength (on a four-point ordinal scale) with six types of partners before and after the H1N1 response. Grantees additionally reported if and how PHER funding contributed to enhancing the strength of these partnerships.

Sixty-one PHER grantees (61/62, 98%) completed the assessment instrument's partnerships section. PHER grantees reported that their partnerships with retail pharmacies were most strengthened (mean increase = 1.11 (on a four-point ordinal scale), SD = .82). This was followed by schools (K-12) (mean increase = .90, SD = .58); private medical providers (mean increase = .81, SD = .68); immunization authorities (mean increase = .80, SD = .61); main education authorities (mean increase = .75, SD = .68); and businesses (mean increase = .74, SD = .61). Mean PHER grantee increases in the strength of each partner type were statistically significant for all partner types (P < .01). Grantees reported that PHER funding contributed to enhancing the strength of their partnerships with schools most frequently (46/46, 100%), and businesses least frequently (31/37, 83.8%).

This inquiry provides evidence that state, territorial, and local health department partnerships with key sectors, agencies, and programs were strengthened after the H1N1 response. It further demonstrates that the CDC's PHER funding contributed to the health departments’ reports of increased partnership strength.

KunK, ZimmermanJ, RoseD, RubelS. State, Territorial, and Local Health Departments’ Reporting of Partnership Strength Before and After the H1N1 Response. Prehosp Disaster Med. 2013;28(6):1-6.

Major adverse climatic events (MACEs) in heavily-populated areas can inflict severe damage to infrastructure, disrupting essential municipal and commercial services. Compromised health care delivery systems and limited utilities such as electricity, heating, potable water, sanitation, and housing, place populations in disaster areas at risk of toxic exposures. Hurricane Sandy made landfall on October 29, 2012 and caused severe infrastructure damage in heavily-populated areas. The prolonged electrical outage and damage to oil refineries caused a gasoline shortage and rationing unseen in the USA since the 1970s. This study explored gasoline exposures and clinical outcomes in the aftermath of Hurricane Sandy.

Prospectively collected, regional poison control center (PCC) data regarding gasoline exposure cases from October 29, 2012 (hurricane landfall) through November 28, 2012 were reviewed and compared to the previous four years. The trends of gasoline exposures, exposure type, severity of clinical outcome, and hospital referral rates were assessed.

Two-hundred and eighty-three gasoline exposures were identified, representing an 18 to 283-fold increase over the previous four years. The leading exposure route was siphoning (53.4%). Men comprised 83.0% of exposures; 91.9% were older than 20 years of age. Of 273 home-based calls, 88.7% were managed on site. Asymptomatic exposures occurred in 61.5% of the cases. However, minor and moderate toxic effects occurred in 12.4% and 3.5% of cases, respectively. Gastrointestinal (24.4%) and pulmonary (8.4%) symptoms predominated. No major outcomes or deaths were reported.

Hurricane Sandy significantly increased gasoline exposures. While the majority of exposures were managed at home with minimum clinical toxicity, some patients experienced more severe symptoms. Disaster plans should incorporate public health messaging and regional PCCs for public health promotion and toxicological surveillance.

KimH, TakematsuM, BiaryR, WilliamsN, HoffmanR, SmithS. Epidemic Gasoline Exposures Following Hurricane Sandy. Prehosp Disaster Med. 2013;28(6):1-6.

US Navy hospital ships are used as a foreign policy instrument to achieve various objectives that include building partnerships. Despite substantial resource investment by the Department of Defense (DoD) in these missions, their impact is unclear. The purpose of this study was to understand how and why hospital ship missions influence partnerships among the different participants.

An embedded case study was used and included the hospital ship Mercy's mission to Timor-Leste in 2008 and 2010 with four units of analysis: the US government, partner nation, host nation, and nongovernmental organizations. Key stakeholders representing each unit were interviewed using open-ended questions that explored the experiences of each participant and their organization. Findings were analyzed using a priori domains from a proposed partnership theoretical framework. A documentary review of key policy, guidance, and planning documents was also conducted.

Fifteen themes related to how and why hospital ship missions influence partnerships emerged from the 37 interviews and documentary review. The five most prominent included: developing relationships, developing new perspectives, sharing resources, understanding partner constraints, and developing credibility. Facilitators to joining the mission included partner nations seeking a regional presence and senior executive relationships. Enablers included historical relationships and host nation receptivity. The primary barrier to joining was the military leading the mission. Internal constraints included the short mission duration, participant resentment, and lack of personnel continuity. External constraints included low host nation and United States Agency for International Development (USAID) capacity.

The research finds the idea of building partnerships exists among most units of analysis. However, the results show a delay in downstream effects of generating action and impact among the participants. Without a common partnership definition and policy, guidance, and planning documents reinforcing these constructs, achieving the partnership goal will remain challenging. Efforts should be made to magnify the facilitators and enablers while developing mitigation strategies for the barriers and constraints. This is the first study to scientifically assess the partnership impact of hospital ship missions and could support the DoD's effort to establish, enable, and sustain meaningful partnerships. Application of the findings to improve partnerships in contexts beyond hospital ship missions may be warranted and require further analysis. This unique opportunity could bridge the rift with humanitarian actors and establish, enable, and sustain meaningful partnerships with the DoD.

LicinaD, MookherjiS, MigliaccioG, RingerC. Hospital Ships Adrift? Part 2: The Role of US Navy Hospital Ship Humanitarian Assistance Missions in Building Partnerships. Prehosp Disaster Med.2013;28(6):592-604.

Educating emergency medical staffs in triage skills is an important aspect of disaster preparedness. The aim of the study was to compare the effect of role-playing and educational video presentation on the learning and performance of the emergency medical service staffs in Khozestan, Iran

A total of 144 emergency technicians were randomly classified into two groups. A researcher trained the first group using an educational video method and the second group with a role-playing method. Data were collected before, immediately, and 15 days after training using a questionnaire covering the three domains of demographic information, triage knowledge, and triage performance. The data were analyzed using defined knowledge and performance parameters.

There was no significant difference between the two training methods on performance and immediate knowledge (P = .2), lasting knowledge (P=.05) and immediate performance (P = .35), but there was a statistical advantage for the role-playing method on lasting performance (P = .02).

The two educational methods equally increase knowledge and performance, but the role-playing method may have a more desirable and lasting effect on performance.

AghababaeianH, SedaghatS, TaheryN, Sadeghi MoghaddamA, ManieiM, BahramiN, Araghi AhvaziL. A Comparative Study of the Effect of Triage Training by Role-Playing and Educational Video on the Knowledge and Performance of Emergency Medical Service Staffs in Iran. Prehosp Disaster Med. 2013;28(6):1-5.

Heat waves pose a serious public health risk to particular patient populations, especially in urban areas. Emergency Medical Services (EMS) in many urban areas constitute the first line of regional preparation and response to major heat wave events; however, little is known on heat wave operational impact to the EMS system, such as call volume or demand.

To examine the effect of heat wave periods on overall urban EMS system call volume and transport volume as well as the nature of the call types.

Retrospective review of all emergency medical calls to an urban, two-tiered EMS system performed over a 5-year period from 2006–2010. Heat wave days (HWD) defined as two or more consecutive days of hot weather >32.2°C (90°F) were compared with similar non-heat wave days (nHWD) of the previous year to also include two calendar days prior to and after the heat wave. National Weather Service (NWS) temperature data, daily EMS call volume data, and call type codes were collected and underwent descriptive analysis.

Thirty-one HWD were identified and compared with 93 nHWD. The mean maximum temperature for HWD was 34°C (93.2°F) compared with 25.3°C (77.6°F) for nHWD (P < .001). Average daily medical emergency calls (318.4 vs 296.3, P < .001) and actual patients transported per day (247.5 vs 198.3, P < .001) were significantly higher during HWD. There was no difference in daily medical emergency call volume or EMS transports between weekdays or weekend days. No significant differences on various call types were observed between HWD and nHWD except for “heat” related calls (7.7 vs 0.5, P < .001).

Emergency Medical Services call volumes were significantly increased during heat waves, however there was minimal change in the types of calls received.

KueRC, DyerKS. The Impact of Heat Waves on Transport Volumes in an Urban Emergency Medical Services System: A Retrospective Review. Prehosp Disaster Med. 2013;28(6):1-6.

Successful oxygenation and ventilation can mean the difference between life and death in the prehospital setting. While airway challenges can be numerous within the confines of the emergency department, there are many additional confounding difficulties in the prehospital setting, which include limited access to equipment, poor lighting, extreme environments, limited personnel to assist, no immediate backup, and limited rescue airway options. The concept of an easy, reliable, and rapidly deployable alternative rescue airway device is critical, especially when considering the addition of rapid sequence intubation protocols in the prehospital setting.

The primary objective of this study was to ascertain whether paramedics can be trained to deploy this alternative airway device with an acceptable success rate in a simulated critical care airway scenario. The secondary objective was to determine whether the previously-trained paramedics were able to retain their ability to deploy the device successfully at one year.

This was a prospective, observational, single-group, descriptive cohort, educational trial. Forty paramedics were trained in the use of the Intubating Laryngeal Mask Airway (I-LMA) in a simulation medicine curriculum culminating in a simulated critical care difficult airway scenario requiring urgent oxygenation and ventilation after failed traditional endotracheal intubation. An emergency medicine physician proctor determined successful airway management. Repeat testing was then performed at approximately one year out, challenging the medics to intubate a mannequin using the I-LMA during an unrelated training session.

Of the 40 paramedics who underwent complete simulation training, 39 were able to intubate and ventilate the simulated difficult airway using the I-LMA during the critical care scenario. This yields a success rate of 97.5% (95% CI, 87.1%-99.4%). At approximately one year out, 35 out of 35 medics were able to intubate the mannequin using the I-LMA, resulting in a success rate of 100% (95% CI, 91.4%-100%).

In this study, paramedics were able to deploy the I-LMA with a high degree of success in a simulated difficult airway, with a high degree of skill retention at one year out.

ByarsD, LoB, YatesJ. Evaluation of Paramedic Utilization of the Intubating Laryngeal Mask Airway in High-Fidelity Simulated Critical Care Scenarios. Prehosp Disaster Med.2013;28(6):1-2.

Severe sepsis and septic shock are common, expensive and often fatal medical problems. The care of the critically sick and injured often begins in the prehospital setting; there is limited data available related to predictors and interventions specific to sepsis in the prehospital arena. The objective of this study was to assess the predictive effect of physiologic elements commonly reported in the out-of-hospital setting in the outcomes of patients transported with sepsis.

This was a cross-sectional descriptive study. Data from the years 2004-2006 were collected. Adult cases (≥18 years of age) transported by Emergency Medical Services to a major academic center with the diagnosis of sepsis as defined by ICD-9-CM diagnostic codes were included. Descriptive statistics and standard deviations were used to present group characteristics. Chi-square was used for statistical significance and odds ratio (OR) to assess strength of association. Statistical significance was set at the .05 level. Physiologic variables studied included mean arterial pressure (MAP), heart rate (HR), respiratory rate (RR) and shock index (SI).

Sixty-three (63) patients were included. Outcome variables included a mean hospital length of stay (HLOS) of 13.75 days (SD = 9.97), mean ventilator days of 4.93 (SD = 7.87), in-hospital mortality of 22 out of 63 (34.9%), and mean intensive care unit length-of-stay (ICU-LOS) of 7.02 days (SD = 7.98). Although SI and RR were found to predict intensive care unit (ICU) admissions, [OR 5.96 (CI, 1.49-25.78; P = .003) and OR 4.81 (CI, 1.16-21.01; P = .0116), respectively] none of the studied variables were found to predict mortality (MAP <65 mmHg: P = .39; HR >90: P = .60; RR >20 P = .11; SI >0.7 P = .35).

This study demonstrated that the out-of-hospital shock index and respiratory rate have high predictability for ICU admission. Further studies should include the development of an out-of-hospital sepsis score.

BaezAA, HanudelP, WilcoxSR. The Prehospital Sepsis Project: Out-of-Hospital Physiologic Predictors of Sepsis Outcomes. Prehosp Disaster Med. 2013;28(6):1-4.