Background: Hurricane Katrina made landfall in August 2005 and destroyed the infrastructure of New Orleans. Mass evacuation ensued. The immediate and long-lasting impact of these events on the mental health of children have been reported in survey research. This study was done to describe the nature of mental health need of children during the four years after Hurricane Katrina using clinical data from a comprehensive healthcare program. Medical and mental health services were delivered on mobile clinics that traveled to medically underserved communities on a regular schedule beginning immediately after the hurricane. Patients were self-selected residents of New Orleans. Most had incomes below the federal poverty level and were severely affected by the hurricane.

Methods: Paper charts of pediatric mental health patients were reviewed for visits beginning with the establishment of the mental health program from 01 July 2007 through 30 June 2009 (n = 296). Demographics, referral sources, presenting problems, diagnoses, and qualitative data describing Katrina-related traumatic exposures were abstracted. Psychosocial data were abstracted from medical charts. Data were coded and processed for demographic, referral, and diagnostic trends.

Results: Mental health service needs continued unabated throughout this period (two to nearly four years post-event). In 2008, 29% of pediatric primary care patients presented with mental health or developmental/learning problems, including the need for intensive case management. The typical presentation of pediatric mental health patients was a disruptive behavior disorder with an underlying mood or anxiety disorder. Qualitative descriptive data are presented to illustrate the traumatic post-disaster experience of many children. School referrals for mental health evaluation and services were overwhelmingly made for disruptive behavior disorders. Pediatric referrals were more nuanced, reflecting underlying mood and anxiety disorders. Histories indicated that many missed opportunities for earlier identification and intervention.

Conclusions: Mental health and case management needs persisted four years after Hurricane Katrina and showed no signs of abating. Many children who received mental health services had shown signs of psychological distress prior to the hurricane, and no causal inferences are drawn between disaster experience and psychiatric disorders. Post-disaster mental health and case management services should remain available for years post-event. To ensure timely identification and intervention of child mental health needs, pediatricians and school officials may need additional training.

Introduction: In 2002, the Mount Sinai Center for Occupational and Environmental Medicine, with support from the National Institute for Occupational Safety and Health (NIOSH), began coordinating the World Trade Center (WTC) Worker and Volunteer Medical Screening Program (MSP) to monitor the health of qualified WTC responders. Enrolled participants were offered a clinical examination; interviewed to collect medical, mental health, and exposure information; and requested to complete a self-administered medical questionnaire. The objective of this study was to better understand work-related injuries and illnesses sustained on-site by WTC responders.

Methods: A descriptive analysis of select data from the MSP self-administered medical questionnaire was conducted. Data collected July 2002 through April 2004 from MSP participants enrolled at the Mount Sinai clinic were reviewed using univariate statistical techniques.

Results: Records from 7,810 participants were analyzed, with most participants associated with either the construction industry (n = 2,623, 34%) or law enforcement (n = 2,036, 26%). Approximately a third of the participants (n = 2,486, 32%) reported at least one injury or illness requiring medical treatment that was sustained during WTC work/volunteer activities. Of the total 4,768 injuries/illnesses reported by these participants, respiratory complaints were most common (n = 1,350, 28%), followed by traumatic injuries excluding eye injuries (n = 961, 20%), eye injuries/ailments (n = 709, 15%), chest pain (n = 375, 8%), headaches (n = 359, 8%), skin conditions (n = 178, 4%), and digestive system conditions (n = 163, 3%). Participants reported that 36% of injuries/illnesses were treated off-site and 29% were treated on-site, with the remaining not specifying treatment location. Off-site treatment was prevalent for respiratory complaints, psychological stress, and chest pain. On-site treatment was predominate for eye injuries/ailments and traumatic injuries excluding eye injuries.

Conclusion: Study results underscore the need for rapid deployment of personal protective equipment for disaster responders and medical care stations mobilized near disaster worksites. Additionally, the results, many of which are comparable to findings from previous WTC studies where data were collected in real-time, indicate that a screening program such as the MSP may be effective in retrospectively providing general information on disaster responder demographics and work-related injuries and illnesses.

Objective: The objective of this study was to evaluate the effects of the decision support tool (DST) on the assessment of the acutely ill or injured out-of-hospital patient.

Methods: This study included systematic reviews of randomized controlled trials (RCT) where the DST was compared to usual care in and out of the hospital setting. The databases scanned include: (1) Cochrane Reviews (up to January 2010); (2) Cochrane Controlled Clinical Trials (1979 to January 2010); (3) Cinahl (1986 to January 2010); and (4) Pubmed/Medline (1926 to January 2010). In addition, information was gathered from related magazines, prehospital home pages, databases for theses, conferences, grey literature and ongoing trials.

Results: Use of the DST in prehospital care may have the possibility to decrease “time to definitive care” and improve diagnostic accuracy among prehospital personnel, but more studies are needed.

Conclusions: The amount of data in this review is too small to be able to draw any reliable conclusions about the impact of the use of the DST on prehospital care. The research in this review indicates that there are very few RCTs that evaluate the use of the DST in prehospital care.

Introduction: Major disasters disrupt the infrastructure of communities and have lasting psychological, economic, and environmental effects on the affected areas. The psychological status and community effects of the devastating 2007 wildfires on the Peloponnese Peninsula of Greece were assessed six months following the disaster.

Methods: Adult inhabitants, 18–65 years of age, living in villages affected by the wildfires were selected randomly and compared with a demographically similar group living in neighboring villages that were unaffected by the fires. Regions were chosen based on the extent of fire damage in that area. There were 409 participants in the fire group, and 391 in the control group. Participants completed a questionnaire that included the SCL-90-R symptom checklist, a subjective perception of health status, and a series of items assessing views about current problems, personal values, and trust in different institutions.

Results: The fire group scored significantly higher on psychological distress compared to the control group. Both groups viewed their health status in the previous year as better than at the present time. There were few significant differences between groups in the designation of regional problems, attitudes, and values. In the total sample, 41.6% listed unemployment, and 15.0% listed poverty as the most important problem in their region. The Church was indicated as the most trusted institution by 36.7% of the group and the Government by 13.3%. A total of 30.2% did not have a trusted institution.

Conclusions: The hardiness and resilience of the fire-impacted group was evident. However, an improvement in economic conditions is needed to maintain the health and enhance the quality of life of the population living in the Peloponnese region. This improvement likely would have a positive effect on the attitude of trust in government institutions.

Introduction: Surveillance for health outcomes is critical for rapid responses and timely prevention of disaster-related illnesses and injuries after a disaster-causing event. The Disaster Surveillance Workgroup (DSWG) of the US Centers for Disease Control and Prevention developed a standardized, single-page, morbidity surveillance form, called the Natural Disaster Morbidity Surveillance Individual Form (Morbidity Surveillance Form), to describe the distribution of injuries and illnesses, detect outbreaks, and guide timely interventions during a disaster.

Problem: Traditional data sources can be used during a disaster; however, supplemental active surveillance may be required because traditional systems often are disrupted, and many persons will seek care outside of typical acute care settings. Generally, these alternative settings lack health surveillance and reporting protocols. The need for standardized data collection was demonstrated during Hurricane Katrina, as the multiple surveillance instruments that were developed and deployed led to varied and uncoordinated data collection methods, analyses, and morbidity data reporting. Active, post-event surveillance of affected populations is critical for rapid responses to minimize and prevent morbidity and mortality, allocate resources, and target public health messaging.

Methods: The CDC and the Georgia Department of Public Health (GDPH) conducted a study to evaluate a Morbidity Surveillance Form to determine its ability to capture clinical presentations. The form was completed for each patient evaluated in an emergency department (ED) during triage from 01 August, 2007 through 07 August, 2007. Data from the form were compared with the ED discharge diagnoses from electronic medical records, and kappa statistics were calculated to assess agreement.

Results: Nine hundred forty-nine patients were evaluated, 41% were male and 57% were Caucasian. According to the forms, the most common reasons for seeking treatment were acute illness, other (29%); pain (12%); and gastrointestinal illness (8%). The frequency of agreement between discharge diagnoses and the form ranged from 3 to 100%. Kappa values ranged from 0.23–1.0, with nine of the 12 categories having very good or good agreement.

Conclusion: With modifications to increase sensitivity for capturing certain clinical presentations, the Morbidity Surveillance Form can be a useful tool for capturing data needed to guide public health interventions during a disaster. A validated collection instrument for a post-disaster event facilitates rapid and standardized comparison and aggregation of data across multiple jurisdictions, thus, improving the coordination, timeliness, and accuracy of public health responses. The DSWG revised the Morbidity Surveillance Form based on information from this study.

Objective: The objective of this study was to evaluate initial end-tidal CO2 (EtCO2) as a predictor of survival in out-of-hospital cardiac arrest.

Methods: This was a retrospective study of all adult, non-traumatic, out-of-hospital, cardiac arrests during 2006 and 2007 in Los Angeles, California. The primary outcome variable was attaining return of spontaneous circulation (ROSC) in the field. All demographic information was reviewed and logistic regression analysis was performed to determine which variables of the cardiac arrest were significantly associated with ROSC.

Results: There were 3,121 cardiac arrests included in the study, of which 1,689 (54.4%) were witnessed, and 516 (16.9%) were primary ventricular fibrillation (VF). The mean initial EtCO2 was 18.7 (95%CI = 18.2–19.3) for all patients. Return of spontaneous circulation was achieved in 695 patients (22.4%) for which the mean initial EtCO2 was 27.6 (95%CI = 26.3–29.0). For patients who failed to achieve ROSC, the mean EtCO2 was 16.0 (95%CI = 15.5–16.5). The following variables were significantly associated with achieving ROSC: witnessed arrest (OR = 1.51; 95%CI = 1.07–2.12); initial EtCO2 >10 (OR = 4.79; 95%CI = 3.10–4.42); and EtCO2 dropping <25% during the resuscitation (OR = 2.82; 95%CI = 2.01–3.97).

The combination of male gender, lack of bystander cardiopulmonary resuscitation, unwitnessed collapse, non-vfib arrest, initial EtCO2 ≤10 and EtCO2 falling > 25% was 97% predictive of failure to achieve ROSC.

Conclusions: An initial EtCO2 >10 and the absence of a falling EtCO2 >25% from baseline were significantly associated with achieving ROSC in out-of-hospital cardiac arrest. These additional variables should be incorporated in termination of resuscitation algorithms in the prehospital setting.

Introduction: For more than a decade, conflict in the Eastern Democratic Republic of Congo (DRC) has been claiming lives. Within that conflict, sexual violence has been used by militia groups to intimidate and punish communities, and to control territory. This study aimed to: (1) investigate overall frequency in number of Eastern DRC sexual assaults from 2004 to 2008 inclusive; (2) determine if peaks in sexual violence coincide with known military campaigns in Eastern DRC; and (3) study the types of violence and types of perpetrators as a function of time.

Methods: This study was a retrospective, descriptive, registry-based evaluation of sexual violence survivors presenting to Panzi Hospital between 2004 and 2008.

Results: A total of 4,311 records were reviewed. Throughout the five-year study period, the highest number of reported sexual assaults occurred in 2004, with a steady decrease in the total number of incidents reported at Panzi Hospital from 2004 through 2008. The highest peak of reported sexual assaults coincided with a known militant attack on the city of Bukavu. A smaller sexual violence peak in April 2004 coincided with a known military clash near Bukavu. Over the five-year period, the number of sexual assaults reportedly perpetrated by armed combatants decreased by 77% (p = 0.086) and the number of assaults reportedly perpetrated by non-specified perpetrators decreased by 92% (p < 0.0001). At the same time, according to the hospital registry, the number of sexual assaults reportedly perpetrated by civilians increased 17-fold (p < 0.0001). This study was limited by its retrospective nature, by the inherent selection bias of studying only survivors presenting to Panzi Hospital, and by the use of a convenience sample within Panzi Hospital.

Conclusions: After years of military rape in South Kivu Province, civilian adoption of sexual violence may be a growing phenomenon. If this is the case, the social mechanisms that prevent sexual violence will have to be rebuilt and sexual violence laws will have to be fully enforced to bring all perpetrators to justice. Proper rehabilitation and reintegration of ex-combatants may also be an important step towards reducing civilian rape in Eastern DRC.

Introduction: A professional understanding of disasters, paired with the need for health service development, can provide opportunities for the recovery and improvement of the health sector. Investment in training capacity ranks among the top priorities of a recovering health sector. The recovery and development of primary healthcare delivery systems has been implemented by various international and local health players in the aftermath of conflicts around the world. However, human resource development in the post-conflict environment has not been evaluated and/or published appropriately in the medical literature.

Objective: In this retrospective, descriptive study, the authors describe the strategy and evaluate the effectiveness of a field-based training program for primary healthcare doctors implemented by the US-based international non-governmental organization, the International Medical Corps, after the conflict in Kosovo in 1999.

Methods: A six-month, comprehensive education and training program on primary healthcare issues was delivered to 134 Kosovar primary healthcare physicians in 10 Kosovo municipalities in 1999 and 2000. Qualitative and quantitative data were collected. The qualitative methods included open-ended, semi-structured, key informant interviews, structured focus groups, and unstructured participant observations. The quantitative method was multiple-choice knowledge tests.

Results: The education and training program proved to be culturally appropriate and well-accepted by local communities. The program met its overall objective to refresh the knowledge of primary care doctors on various primary healthcare issues and set the stage for further strengthening and development of primary health services and their required human resources in Kosovo.

Conclusions: The comprehensive education and training of primary healthcare doctors in Kosovo was a feasible, much appreciated, and effective intervention implemented in a difficult post-conflict environment. This training was one of the early steps in the modernization of primary healthcare services in Kosovo. Later, primary health care was strengthened by the introduction of a Department of Family Medicine at the university, which includes a residency program. The intervention described in this study has the potential to be reproduced in other post-disaster environments, especially in resource-poor settings with long-time troubled health sectors in developing countries.

Introduction: Disasters and mass-casualty scenarios may overwhelm medical resources regardless of the level of preparation. Disaster response requires medical equipment, such as ventilators, that can be operated under adverse circumstances and should be able to provide respiratory support for a variety of patient populations.

Objective: The objective of this study was to evaluate the performance of three portable ventilators designed to provide ventilatory support outside the hospital setting and in mass-casualty incidents, and their adherence to the Task Force for Mass Critical Care recommendations for mass-casualty care ventilators.

Methods: Each device was evaluated at minimum and maximum respiratory rate and tidal volume settings to determine the accuracy of set versus delivered VT at lung compliance settings of 0.02, 0.08 and 0.1 L/cm H20 with corresponding resistance settings of 10, 25, and 5 cm H2O/L/sec, to simulate patients with ARDS, severe asthma, and normal lungs. Additionally, different FIO2 settings with each device (if applicable) were evaluated to determine accuracy of FIO2 delivery and evaluate the effect on delivered VT. Ventilators also were tested for duration of battery life.

Results: VT decreased with all three devices as compliance decreased. The decrease was more pronounced when the internal compressor was activated. At the 0.65 FIO2 setting on the MCV 200, the measured FIO2 varied widely depending on the set VT. Battery life range was 311-582 minutes with the 73X having the longest battery life. Delivered VT decreased toward the end of battery life with the SAVe having the largest decrease. The respiratory rate on the SAVe also decreased approaching the end of battery life.

Conclusion: The 73X and MCV 200 were the closest to satisfying the Task Force for Mass Critical Care requirements for mass casualty ventilators, although neither had the capability to provide PEEP. The 73X provided the most consistent tidal volume delivery across all compliances, had the longest battery duration and the least decline in VT at the end of battery life.