On 08 October 2005, an earthquake measuring 7.6 on the Richter scale, struck Pakistan's autonomous state of Kashmir and part of Indian-administrated Kashmir. The official death toll in Pakistan was 79,000, and nearly 1,400 in Kashmir. This study reports the findings of a three-week health needs assessment to understand the needs of rural, older people post-earthquake. This study was conducted in February 2006 in the Neelum Valley of Kashmir, Pakistan, four months after the earthquake.

During emergency relief, the vulnerability and health needs of older people in rural settings are different than are those in of urban areas.

A comparative, descriptive study was performed using health information to compare the differences between rural and urban health needs and the utilization of services of older people after the earthquake. Semi-structured interviews were conducted to collect information regarding demographic background, medical and drug history, self-reported health status, healthcare access and utilization, and social/financial concerns. Clinical records were reviewed and physical indicators for older patients also were collected on-site.

The health profile, access to health care, service availability, and prevalence of non-communicable diseases differ between urban and rural settings. The greatest gap in health services at all sites was that non-communicable disease management was inadequate during non-acute, post-earthquake medical care. Health service utilization varied by gender, as in conservative rural areas, older, traditional women were less likely to receive medical services while older men were less likely to access psychological services in all sites.

This is the first study to compare the post-earthquake healthcare needs of older people in urban and rural settings. Findings highlight specific health needs and issues related to long-term, chronic disease management. Given the global pattern of aging of the population, it is important to strengthen the capacity to respond appropriately to medical disasters, which includes preparedness for treating the health needs of older people.

Good staff procedure skills in a management group during incidents and disasters are believed to be a prerequisite for good management of the situation. However, this has not been demonstrated scientifically. Templates for evaluation results from performance indicators during simulation exercises have previously been tested. The aim of this study was to demonstrate the possibility that these indicators can be used as a tool for studying the relationship between good management skills and good staff procedure skills.

Good and structured work (staff procedure skills) in a hospital management group during simulation exercises in disaster medicine is related to good and timely decisions (good management skills).

Results from 29 consecutive simulation exercises in which staff procedure skills and management skills were evaluated using quantitative measurements were included. The statistical analysis method used was simple linear regression with staff procedure skills as the response variable and management skills as the predictor variable.

An overall significant relationship was identified between staff pro-cedure skills and management skills (p ≤0.05).

This study suggests that there is a relationship between staff procedure skills and management skills in the educational setting used. Future studies are needed to demonstrate if this also can be observed during actual incidents.

In Maryland, there have been no military/civilian training exercises of the Medical Mutual Aid Agreement for >20 years. The aims of this paper are to describe the National Disaster Medical System (NDMS), to coordinate military and civilian medical mutual aid in response to arrival of overseas mass casualties, and to evaluate the mass-casualty reception and bed “urge” capacity of Maryland NDMS Hospitals.

Three tabletop exercises and a functional exercise were performed using a simulated, overseas, military mass-casualty event. The first tabletop exercise was with military and civilian NMDS partners.The second tested the revised NDMS activation plan. The third exercised the Authorities of State Emergency Medical System and Walter Reed Army Medical Center Directors of Emergency Medicine over Maryland NDMS hospitals, and their Medical Mutual Aid Agreement.The functional exercise used Homeland Security Exercise Evaluation Program tools to evaluate reception, triage, staging, and transportation of 160 notional patients (including 20 live, moulaged “patients”) and one canine.

The first tabletop exercise identified deficiencies in operational protocols for military/civilian mass-casualty reception, triage, treatment, and problems with sharing a Unified Command. The second found improvements in the revised NDMS activation plan.The third informed expectations for NDMS hospitals. In the functional exercise, all notional patients were received, triaged, dispatched, and accounted in military and five civilian hospitals within two hours. The canine revealed deficiencies in companion/military animal reception, holding, treatment, and evacuation. Three working groups were suggested: (1) to ensure 100% compliance with triage tags, patient accountability, and return of equipment used in mass casualty events and exercises; (2) to investigate making information tech-nology and imaging networks available for Emergency Operation Centers and Incident Command; and (3) to establish NDMS training, education, and evaluation to further integrate and support civil-military operations.

The exercises facilitated military/state inter-agency coopera-tion, resulting in revisions to the Maryland Emergency Operations Plan across all key state emergency response agencies. The recommendations from these exercises likely apply to the vast majority of NDMS activities in the US.

The military conflict that occurred between Lebanon and Israel in July and August of 2006 was characterized by the heavy bombardment of specific geographic regions in Israel, resulting in considerable civilian casualties and property damage.

Israeli civilians directly and indirectly exposed to bombardment were compared on exposure to the recent bombardment, trauma history, perceived life threat and peritraumatic dissociation during the recent bombardment, and current post-traumatic stress disorder (PTSD) symptom severity.

Following the conflict, data were collected by telephone from 317 Israeli residents randomly selected from two towns that were subject to differing levels of exposure to the bombardment.

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Exposure to trauma during the Second Lebanon War, prior trauma exposure, PTSD symptom severity, perceived life threat, and peri-traumatic dissociation.

The residents directly affected by the bombardment (Kiryat Shmona; KS) endorsed more trauma exposure, (p <0.01); more prior trauma, (p <0.01); more life threat, (p <0.01); and greater PTSD symptomatology (12 % of KY participants and 38% of KS participants had probable PTSD), compared to residents in the comparison town (Kfar Yona; KY). Both groups reported a similar degree of peri-event dissociation (KS: M = 7.2 ±3.7; KY: M = 7.3 ±3.0). Perceived life threat mediated the relationship between exposure to bombardment and PTSD symptomatology. Time spent in bomb shelters was not associated with PTSD symptom severity. Prior shelling-related trauma negatively predicted PTSD.

The terror of bombardment is a risk factor for PTSD among civil-ians. Although there is considerable resilience in chronically threatened commu-nities, it is prudent to develop and implement public health approaches to prevent those most distressed during and after attacks from developing PTSD. Because, to a small degree, prior trauma exposure buffers the response to bombardment, interventions should consider leveraging citizens' past successful coping.

Bag-valve-mask ventilation is a key component of life support, but only one handheld resuscitator is designed to operate in contaminated or toxic atmospheres.

After Institutional Review Board approval, the efficacy of this device was evaluated. The distal trachea of a LaerdalTM Airway Management Trainer was connected to a mechanical Draeger Volumeter 3000TM to enable determination of the minute volume delivered by BVM ventilation. Nineteen paramedics wearing chemical, biological, radiological, or nuclear (CBRN) protective equipment were asked to ventilate this modified airway trainer, either with or without a CBRN filter attached to the inlet filtration system of the AMBUTM Mark III Resuscitator. The maximum levels of minute ventila-tion achieved were compared. Values are given as mean ±SD. A paired t-test was used to detect any differences between the two groups, p-values of <0.05 were defined to show statistical significance.

The described model allowed a reproducible and reliable measurement of the delivered minute ventilation. All paramedics were able to operate the device without prior CBRN training. The maximum minute volume achieved without the filter was 9.5 ±2.7 l/min. Use of the inlet CBRN filtra-tion system reduced the maximum minute volume to 6.3 ±2.0 l/min, reduction: 23%. The achieved maximum minute volumes ranged from 15 to 4.9 l/min in the controls and from 9.8 to 1.4 l/min in the CBRN group. Four paramedics were unable to achieve a minute volume >5 l/min in the CBRN group, one participant failed to achieve that value in the control group. The inherent breathing resistance of the CBRN filter appears to reduce the inflow of air into the self-inflatable bag. This delay in refilling may have resulted in a reduced achievable minute volume.

The range of maximum minute volumes observed in both groups highlights the need for continuous BVM ventilator training.

The objective of this study was to evaluate the rapid training of medical students and their ability to provide effective manual ventilation using the bag-valve-mask technique.

A rapid training session highlighting essential aspects of the correct bag-valve-mask technique was given to 31 medical students.This was followed by a simulated experience with a certified respiratory therapist, monitored according to a checklist of essential bag-valve-mask (BVM) competency requirements. Pretest and post-test surveys assessed the medical students' knowledge and ability to provide adequate BVM technique.

Thirty-one students participated. Presurvey results demonstrated a clear identification of the potential risk for a disaster (pandemic, natural, bioterrorist) with 55% of students responding that a definite risk did exist. Their usefulness in such an event also was ascertained with 55% of students replying they would assist with basic medical tasks, assist doctors, or assist with cardiopulmonary resuscitation. Post-survey results administered after a 30-minute didactic session on the basic features of resuscitation equipment and the essential components of BVM technique demonstrated that a majority of students knew the proper head positioning maneuvers in cases not involving trauma (93%) and in cases involving trauma (72%). All students completed and passed the competency checklist.

Medical students can be rapidly trained and be utilized as a potential resource to carry out the potentially lifesaving task of manual ventilation using the BVM technique in a disaster situation in which the availability of mechanical ventilators and respiratory therapists may be limited.

In a cold, wet, or windy environment, cold exposure can be considerable for an injured or ill person. The subsequent autonomous stress response initially will increase circulatory and respiratory demands, and as body core temperature declines, the patient's condition might deteriorate. Therefore, the application of adequate insulation to reduce cold exposure and prevent body core cooling is an important part of prehospital primary care, but recommendations for what should be used in the field mostly depend on tradition and experience, not on scientific evidence.

The objective of this study was to evaluate the thermal insulation properties in different wind conditions of 12 different blankets and rescue bags commonly used by prehospital rescue and ambulance services.

The thermal manikin and the selected insulation ensembles were setup inside a climatic chamber in accordance to the modified European Standard for assessing requirements of sleeping bags. Fans were adjusted to provide low (< 0.5 m/s), moderate (2–3 m/s) and high (8–9 m/s) wind condi-tions. During steady state thermal transfer, the total resultant insulation value, Itr (m2 °C/Wclo; where °C = degrees Celcius, and W = watts), was calculated from ambient air temperature (°C), manikin surface temperature (°C), and heat flux (W/m2).

In the low wind condition, thermal insulation of the evaluated ensembles correlated to thickness of the ensembles, ranging from 2.0 to 6.0 clo (1 clo = 0.155 m2 °C/W), except for the reflective metallic foil blankets that had higher values than expected. In moderate and high wind conditions, thermal insulation was best preserved for ensembles that were windproof and resistant to the compressive effect of the wind, with insulation reductions down to about 60–80% of the original insulation capacity, whereas wind permeable and/or lighter materials were reduced down to about 30–50% of original insulation capacity.

The evaluated insulation ensembles might all be used for prehospital protection against cold, either as single blankets or in multiple layer combinations, depending on ambient temperatures. However, with extended outdoor, on-scene durations, such as during prolonged extrications or in mul-tiple casualty situations, the results of this study emphasize the importance of using a windproof and compression resistant outer ensemble to maintain adequate insulation capacity.

The majority of research that has explored workplace violence has focused on establishing the prevalence of violence in different settings. In general, there is a paucity of research that explores factors that may predict or increase the risk of experiencing violence in the workplace.

The aim of this research was to determine predictors of violence for paramedics.

A questionnaire was developed that focused on paramedics' experi-ences with six forms of violence: verbal abuse, property damage/theft, intimi-dation, physical abuse, sexual harassment, and sexual assault.The questionnaire was distributed randomly to paramedics throughout rural Victoria and metropolitan South Australia, and completed and returned anonymously.

Predictors emerged for verbal abuse, intimidation, sexual harassment, and sexual abuse. Specifically, gender was the only predictor of intimidation, sexual harassment, and sexual assault. Paramedic qualifications, how they responded to a call-out, and hours per week in direct patient contact emerged as a predictor of verbal abuse.

Certain factors predict or predispose paramedics to workplace violence. The need for workplace violence education and training is impera-tive for the prevention of violence, as well as for its management.

During a medical emergency, the American public often relies on the expertise of emergency medical technicians (EMTs). These professionals face a number of occupational hazards, and the literature suggests that EMTs are at a greater risk of developing physical and mental stress-related disorders. The purpose of this paper is to systematically examine gaps in the extant literature and to present a theoretically driven conceptual model to serve as a basis for future intervention and research efforts.

A systematic review of the literature was conducted utilizing rele-vant databases (e.g., PsychInfo, Medline). All empirical articles regarding emergency medical responders were reviewed, but given the limited research available, relevant theoretical and conceptual literature on the constructs of interest in other, related populations also were included. Based on this extensive review, a modification of the stress process model is suggested to explain the relationships among occupational stress exposure, post-traumatic stress disorder (PTSD), and high-risk alcohol and other drug use.

Exposure to traumatic events was reported to be between 80% and 100% among EMTs, and rates of PTSD are >20%. High-risk alcohol and drug use rates among other emergency response professionals were reported to be as high as 40%. The proposed model suggests direct linkages between occupationally related stress exposure, including chronic and critical incident stress, PTSD, and high-risk alcohol and other drug use. Social support and personal resources (e.g., coping, locus of control) are proposed to have mediating and moderating influences on the three main constructs, and cohesion is introduced as an important, idiosyncratic influence in this population. The moderating influences of gender, age, ethnicity, marital status, and socioeconomic status, level of training, and years of service are included in the proposed model.

High-risk alcohol and other drug use and post-traumatic symptomatology pose substantial risks for EMTs, and consequently, for the patients they serve. It is imperative that researchers develop and test a theoretically grounded model of risk and protective factors that will guide intervention development and future study. The model suggested in this paper, based on a comprehensive literature review and development of theory, represents a critical first step in the intervention research process.

The effect of immediate exposure to traumatic events and gender differences is under-studied in the literature. Most studies focus on acute stress disorder (ASD) and post-traumatic stress disorder (PTSD) phases in order to measure gender differences, and tend to neglect the immediate expo-sure to the disaster.

The main hypothesis was that female rescue personnel would exhibit higher levels of acute stress symptoms, dissociation, and depressive symptoms in the 24 hours following a traumatic event.

Twenty-three rescue personnel participated in a search and rescue operation at the Bet-Yehoshua train crash in Israel. The rescue personnel group was divided based on gender. Each participant completed a demographic questionnaire including questions that assessed psychological symptoms and issues such as perceived threat to life, the Impact of Event Scale Revised (IES-R), the Dissociative Experience Scale (DES), and the Center of Epidemiologic Studies Depression questionnaire (CES-D). Statistical inferences were calculated using t-tests and chi-square tests, along with testing of covariance (MANCOVA) in order to indentify which factors are related to psychiatric symptomatology following the immediate exposure to disaster.

The results suggest that among rescue personnel, women did not differ in their levels of acute stress, dissociation, and depressive symptoms from men.

These results suggest the possibility that the gender differences in reactions to traumatic events do not emerge in the acute stress reactions (ASR) phase (up to 24 hours after the event), but later on when people have time to process the trauma. Another possibility that may explain the discrepancy between this study and the common knowledge in the literature is that women rescue personnel are considered a highly selected group, which does not reflect on the general population of women. More studies are needed in order to substantiate these results.

An environment in which traffic regulations are not strictly enforced often is characterized by carnage from motor vehicular crashes resulting in severe injuries with unacceptably high mortality. The descriptive demographics and injury characteristics of pedestrian road crash victims presenting to a tertiary medical center in southwestern Nigeria are presented in order to provide baseline epidemiology as a first step in determining areas of potential mitigation for care of unintentional injuries.

Consecutive pedestrian road traffic crash patients treated in the Accident and Emergency Department of a tertiary hospital were prospective-ly reviewed from March 2007 to February 2008 to determine baseline demo-graphics and clinical outcomes.

A total of 184 patients with a mean value of the ages of 31.4 years were studied; 27% of the patients were <11 years of age. The male to female ratio was 1.6:1. Fifty-four percent of the victims were struck by automobiles and 29% were struck by motorcycles. Sixty-five percent were struck while crossing common thoroughfares. Head injury was sustained in 61% of patients. The mortality rate was 31.0% (n = 57). The clinical course leading to death showed 22.8% of the patients who died initially experienced hemorrhagic shock, 17.5% suffered a severe head injury, and 17.5% suffered aspiration. Autopsy confirmed brainstem herniation in 28.1% of the patients who died. The average interval between injury and death was 5.5 ±13.6 days (range: 0–77 days). In this setting, three out of every ten patients experienc-ing pedestrian vehicular trauma will die before leaving the hospital.The elder-ly are most at risk, with two-thirds of victims dying from injuries sustained.

This raises serious questions about the prehospitaland hospi-tal-based emergency services for vehicular road crash victims in this environ-ment, and confirms the World Health Organization findings that Africa has the highest rate overall for unintentional injury deaths. A system-wide program must be put in place that addresses proven prevention measures across all sectors of the community.

On 26 December 2003, at 05:26 hours, an earthquake of magnitude 6.6 (Richter scale) caused a disaster in the Bam region of Southeastern Iran, which had a population of approximately 102,000. In this study, the clinical and laboratory features and therapeutic interventions in pediatric (three months to 14 years) crush victims were analyzed. Determination of the type and amount of fluid therapy for prevention of acute renal failure (ARF) was the main aim of this study.

The clinical and laboratory data and therapeutic interventions provided to 31 pediatric crush victims were collected. Early and vigorous fluid resuscitation was immediately performed. Resuscitation of the children from hypovolemic shock was initiated by interavenous (IV) administration of normal saline until the signs and symptoms of shock disappeared. For victims with crush injuries, an alkaline intravenous solution, up to 3 to 5 times more than maintenance doses was provided. In this study, there were two groups with decreasing severity of injury: (1) crush injury (CI), with or without ARF; and (2) non-crush injury (Non-CI). According to the above mentioned classification, there were 15 and 16 patients in group I and II, respectively.

The mean time spent under the rubble was 2.2 ±2.5 hours and 0.5 ±0.5 hours in Groups I and II, respectively. Seventy-five percent of ARF patients (n = 8), were admitted to the hospital the day of the earthquake (Day 0) and the day after earthquake (Day 1). In non-ARF patients (n = 7), 85.7% of the victims were admitted on Day 0 and Day 1. In Group II (ARF and non-ARF), all patients were admitted within three days after the earthquake. Although ARF did not develop in any of the children without CI, it was observed in eight of 15 patients with CI. There was no significant difference between CI with ARF (n = 8) and CI without ARF (n = 7) patients, in terms of the admission date, time of admission, hospitalization duration, and time under the rubble (TUR). Admission SGOTs were significantly different between these two groups. The ratio of the amount of delivered IV fluid (DL) to expected (EX) was based on weight of children was the only fluid therapy parameter in which there was a statistically significant difference between ARF and non-ARF groups. It was 3.6 ±0.99 in ARF and 4.8 ±0.74 in Nnon-ARF group (p = 0.01).

Early intravenous volume replacement may prevent both ARF and dialysis need that may develop on the basis of rhabdomyolysis. In adults, six liters or 12–14 liters of fluids for prophylaxis of ARF in crush syndrome, were suggest-ed. In children, it seems that DL/EX ratio (delivered to expected ratio) is the best marker for evolution of IV fluid therapy in pediatric patients. In children with crush injuries, DL/EX ratio of >4.8 was sufficient for the prevention of ARF.

An earthquake measuring 6.6 on the Richter scale on 23 December 2003 devastated the city of Bam in southeastern Iran. During the response and recovery phases, considerable shortcomings were discovered. The dire situation in the affected area, a variety of urgently required interventions, and the large number of aid organizations involved brought about difficulties in management, coordination, and communication among authorities and aid organizations. This article highlights flaws in management in the var-ious aspects of this disaster in order to assess what was done, and what should be done to overcome these shortcomings in future disasters.

A retrospective review of the various aspects of management related to the Bam disaster was done via the assessment of files, multi-center studies, governmental data, and available literature from 2003–2008.

A review of the available data relevant to search and rescue (S&R) operations and short-term aid provision revealed flaws in different aspects of disaster management including personnel, the transfer of the injured, availability medical supplies, treatment planning, problems concerning the composition of treatment forces dispatched to the region, distribution of tasks among treatment workers, transferring of equipment, availability of facilities, and lack of coordination among the organizations responsible for the management of the disaster. Most of the aforementioned issues have been addressed.

A comprehensive disaster management plan must not be limited only to the response phase, but rather must include: preparedness, recovery with optimal legislation and budgeting, improvement of healthcare facilities, and organized communication channels between the different governmental departments. This important issue has been addressed, and a disaster management organization under the supervision of the President has been established, developing a national S&R strategy and protocol for unified managerial organization, an alert system, an international disaster command system (under which S&R and emergency medical service teams can be deployed, increasing the efficacy and coordination of the arrival of foreign teams and the con-struction field hospitals), and developing a flowchart to coordinate international agencies and the domestic authorities in charge. Continuous education, training of the general population, conducting periodic exercise drills, and provision for prepared task force mobilization in disaster management all are important aspects of the management of disasters due to natural hazards.

A scoping exercise to establish how common hospital evacuations are, identify hospital evacuation policies and review case studies to identify trig-gers, processes and challenges involved in the evacuation of hospitals globally.

A systematic search of PubMed and disaster agency online resources, search of grey literature and media reports.

This study showed that hospitals are vulnerable to both natural and man made disasters and that hospital evacuations do occur globally. It highlighted the paucity of published data and policy on hospital evacuation and emphasised the vital need to collect data on triggers, reasons for evacuation, sheltering facilities and the process of evacuation.

This study recommends the collection of case studies and the development of a database to assist with the research and development of well tailored hospital evacuation plans. These recommendations reflect and support the 2008-2009 World Disaster Reduction Campaign on Hospitals Safe from Disasters and the timely 2009 Global Platform priority that, ‘Critical services and infrastructure such as health facilities and schools must be safe from disasters.