Upon arrival of the SUNY Downstate Medical Center team for their disaster relief mission in Port au Prince, Haiti, it was observed that obstacles to patient care were directly related to difficulty in locating supplies and medications in a timely manner. In addition, staffing schedules had not been correlated to patient flow patterns.

A survey was conducted at L'Hôpital de l'Université d'Etat d'Haïti (HUEH) in Port au Prince, Haiti by Emergency physicians and nurses from SUNY Downstate Medical Center. The following variables were obtained to assess existing resources: number and types of providers available, provider staffing schedules, medication/supply inventories and management systems. Basic ED operation and supply system flow maps were created.

The assessment revealed a large volume of patients presenting in the early morning. Night shifts were inconsistently staffed with ED physicians. Although medications and supplies were reported to be available on-site, they were not tracked, inventoried, or centrally managed. As a result, this increased time to treatment and practitioner fatigue. Process improvements included: (1) Institution of swing and night shifts accommodated peak patient volumes, decreased waiting times, provided care for critical patients during off-peak hours, and decreased physician fatigue. (2) Identification and labeling of existing medications/supplies facilitated more accurate management of inventories and decreased time to treatment and disposition.

Process improvement through systematic analysis led to better disaster resource utilization in this tent hospital.

Following the devastating earthquake in Haiti last January, the International Fund for Animal Welfare (IFAW) and the World Society for the Protection of Animals (WSPA) developed the Animal Relief Coalition of Haiti (ARCH). 19 animal welfare agencies from around the world joined IFAW and WSPA to provide a $1.04M managed fund to the Minstery of Agriculture, Natural Rescources, and Rural Development (MARNDR).

The relief and recovery efforts were based around six objectives: 1. Mobile veterinary clinic 2. Public Outreach emphasizing disaster preparedness, disease prevention, and animal welfare 3. Educational outreach to include an animal welfare curriculum for school-aged children 4. Cold-chain: to provide solar-powered refer/freezer units in remote sections of Haiti to keep vaccines cold 5. Dog and cat survey in Port-au-Prince 6. Rebuilding of the National Laboratory The purpose of this presentation will be to discuss how ARCH was developed and Best Practices and Lessons Learned from a collaborative approach to animal relief and recovery.

The January 12 2010 7.0 magnitude earthquake's epicenter hit just 10 miles west of Port-au-Prince and its 2 million inhabitants at 4:53 pm. Estimates of dead 222,517 at the time of writing, with thousands missing and hundreds of thousands living in tent cities. Haiti is the poorest country in the Western Hemisphere with approximately 80% of the population living under the poverty line. There is a lack of seismic risk perception and planning at the national level. As a result in many areas there are no, or poorly followed, road, highway or bridge building codes.

Although assistance arrived to major ports and cities from all corners of the globe, access from rural and remote areas to centralized hospitals remained difficult. Our group, a mobile medical team able to negotiate difficult terrain by foot with vehicle support in close proximity, deployed to these remote areas. EMS systems were poor in rural areas prior to the earthquake and now are nonexistent, in areas where no access to phones or even addresses (tent cities) to respond to. We found many injured without access to transportation even a month after the earthquake. No family or friends had access to vehicles to transport them. Many knew help was available, but did not know where or how to access. They waited in situ for help not knowing if it was coming. Limb threatening injuries were left to get necrotic and infected, no doubt adding to the morbidity and mortality. Our groups identified patients requiring transport and arranged for drivers, many times using paid locals from cities.

Implementation of a disaster plan for International NGOs to provide organized EMS transport for remote victims without access. Coordination with local community leaders and OCHA to identify areas in need of this service.

Injury and trauma are major causes of premature deaths worldwide. At present, Haiti does not have an existing emergency medical system. Basic first responders training was developed for lay people and medical professionals in rural Haiti.

The training was conducted in Terrier Rouge, Haiti. Participants included medical professionals, laborers, health professionals, teachers, students, and truck drivers from six towns in northeastern Haiti. A three-day training course taught by U.S. board certified emergency medicine physicians was instituted. Basic life support (BLS), first aid, and BLS/first aid instructors courses were taught based on the American and Canadian Heart Associations curriculum. The BLS/first aid instructors course was limited to health professionals, whereas the first aid course was open to all members of the community. The program included the development of local teaching tools and manuals translated to local languages. Twelve newly trained local Haitian instructors assisted in the final day of training.

The course was well received by participants. A total of 54 people completed the BLS course, 67 completed the first aid course, and 12 participants completed the BLS/first aid instructors course. Ninty-five program participants completed the end of course survey. Forty-four of the participants were male, 49 were female, and 2 did not answer. Forty-one participants had no prior BLS/first aid training or exposure. The ages of participants ranged from 13 to 52 years. The course participants included two physicians, 22 students, eight nursing students, seven nurses, 20 teachers, 12 health workers, five drivers, and 14 laborers. Of those surveyed, 92 stated they would recommend this course to a friend. Eighty-eight participants stated that hands on learning helped them better learn the course material.

This sustainable, locally controlled training model increased local skill level for basic first responders in rural Haiti.

In the Indonesian earthquake a total 21 USAR teams comprising upward of 688 rescue personnel and 67 dogs. The cost of which was estimated at tens of millions of dollars did not succeed in extricating any trappers. In Haiti, there were around 350000 casualties and 250000 dead. In this disaster 43 international USAR missions comprising over 1700 rescuers were deployed. These teams succeeded in rescuing approximately 134 trapped people, an average of about 3 trapped people per mission. During this period one field hospital treated a total of 1,111 people, 737 of these patients were hospitalized, 243 surgical procedures were carried out, of which at least 200 were life-saving procedures. In addition many other life-saving procedures that were not directly related to the injuries inflicted as a result of the earthquake were also carried out. Without the resources of the field hospital it is very possible that most of the trappers would not have survived. It mean; One field hospital (personal: 120 people) was able to save more people than 43 USAR teams, all of the highly dedicated and professional, who worked day and night to extricate people trapped.ngs. It seems that there is no need to carry out a complex economic analysis in order to determine the cost benefits and understand the significance of providing field hospitals and clinics as soon as possible after the occurrence of a disaster stemming from an earthquake. A consensus/brainstorming conference is needed.

To formulate a logical and balanced approach to configuring and dispatching rescue and medical missions. The major goal of the conference would be to establish the guidelines for rescue missions that will result in the rescue of the maximum number of people, and to provide guidelines for the provision humanitarian aid in parallel to the rescue missions.

Training Agricultural Emergency Responders by Paula L. Cowen, D.V.M., Director, Professional Development Staff, Veterinary Services, Animal Plant Health Inspection Service, United States Department of Agriculture

Background Emergency Response is a critical component of our Animal Agriculture infrastructure. The ability to deploy trained personnel to handle any kind of emergency is key to quickly containing any disaster and mitigating the effects. This training is provided by a number of federal agencies, universities as well as at the state and local level. Body Several training strategies are employed by a number of different entities. Training is available on-line, in the classroom, with wet labs using live animals, through exercises and case studies. An overview of training and education of Agricultural Emergency Response personnel across the United States will be covered with a more in depth look at the training provided by the Animal Plant Health Inspection Service.

The Professional Development Staff provides technical training in disease identification and control, emergency response, import/export, and other topics as needed. Protecting and promoting American Animal Agriculture is our core mission. Veterinary Services provides leadership at the intersection of Animal and Public Health concerns.

An activity or situation that produces conditions which are not real, but have the appearance of being real, used especially for testing something. Longman Dictionary of Contemporary English. Simulation has evolved over the centuries but has not been applied to medicine until the 20th century with the introduction of virtual reality and computers. Prior to the 20th century simulation took the forms of physical models and cadavers. With the introduction of flight simulation there was an effort to move similar approaches into medicine. This was pushed by the demands of minimally invasive surgery and the introduction of robotics in surgery. In the 21st century in addition to cognitive task analysis tools we are beginning to see the migration of advanced intelligence tools to simulation. We are just at the beginning of how we will use adversarial reasoning in the medical environment and in high risk time constrained situations like Emergency Medicine. The practitioner of emergency medicine is at high risk for errors because of multiple factors including high decision density, high levels of diagnostic uncertainty, high patient acuity, and frequent distractions. Some authors have suggested that instructing physicians in “cognitive forcing strategies” or “metacognition” will help reduce the amount of cognitive error in medical practice. It has been said ‘‘[There is an] ethical obligation to make all efforts to expose health professionals to clinical challenges that can be reasonably well simulated prior to allowing them to encounter and be responsible for similar real-life challenges.’' TYPES OF SIMULATION • Verbal • Tactile • Visual • Situational • Environmental TYPES OF SIMULATION TRAINING • Standardized patients (role play) • Basic models (partial task trainers) • Simple level • Higher level • Mannequins • Low fidelity • High fidelity • Virtual patients • Screen-based; computer-based • COMBINATIONS • Augmented sp encounters with technology • Crises management HUMAN PATIENT SIMULATION • Realistic • Suitable for all levels • Safe • Wide variety of training programs • Expensive ADVANTAGES OF SIMULATION • Patients are never at risk • Serious but infrequent events, in predictable times and places • Errors can be allowed to occur, and play-out • Rehearsal, repetition, mastery • Crisis management simulation, planning • Reduces institutional liability • Increases operational confidence • Produces rapid results • Allows team training • Increases institutional prestige The use of high fidelity simulations to train multidisciplinary teams in critical environments is well established.

Nurses play an essential role in disaster response. All health care responders, including nurses, must have knowledge of the key principles of disaster medicine. The International Trauma and Disaster Institute (ITDI) at Massachusetts General Hospital has developed a core curriculum for Mass Casualty Incident (MCI) management. The curriculum provides all members of the multidisciplinary disaster team with the fundamentals of the MCI response. The proposed concurrent session will report on understanding of the fundamental knowledge in disaster medicine and preparedness for nurses in local and international disaster responses.

Disasters follow no rules. Traditionally, medical providers have held the erroneous belief that all disasters are different, especially those involving terrorism. In reality, all disasters, regardless of etiology, have similar medical and public health consequences. A consistent medical approach to disasters, based on an understanding of their common features and the response they require, is becoming the accepted practice throughout the world. This strategy, called the MCI response, has the primary objective of reducing the mortality/morbidity caused by the disaster. The Advanced Disaster Medical Response (ADMR) Course, available in eight languages, including Chinese, is designed to train nurses in the ABC's of basic medical and public health disaster care. The delivery of optimal care in a disaster relies on a common understanding of each health professional's role and common mastery of defined essentials of disaster response such as the Incident Command System, field triage, decontamination, care of specific injuries, environmental considerations, psychological response to disasters, and care of the dead and their families. Understanding key principles and training in medical disaster response will guide nurses in disaster preparedness and response to future disasters.

A 2006 survey showed that 27% of training institutions used computer-based training in disaster medicine and an additional 23% indicated that they will use it in the near feature(1). Victim descriptions are an important element of simulation exercises. Currently, the victim data utilized in computerized simulation exercises cannot be used in an interchangeable way.

The European Master in Disaster Medicine (EMDM) Academy, recognizing the need for access to reliable disaster victim data, initiated the Victim Base project in order to improve the availability and quality of disaster victim profiles for use in simulation, training and research. A standardized victim template was developed through a review of primary and secondary survey requirements with consultation from an international consortium of training experts in disaster medical management during two workshops.

The victim template is composed of a description of the victim profile, a set of clinical conditions and triggers (time and interventions) to move from one clinical state to another. The parameters of a casualty condition are organized in sub-templates and arranged in the way the victim would most likely be assessed. Victim profiles can be delivered in different output formats on request of the users.

In order to evaluate the effectiveness or outcome of disaster response exercises or test operational plans, victim data must be robust, reliable and of high quality. Moreover, the data must be interchangeable in order to make comparisons between different response systems, regions or countries. VictimBase as an online library of disaster victims will contribute to achieve these objectives. 1. Delooz H, Debacker M, Moens G, Johannik K. and the ISEE Partnership. European survey on training objectives in disaster medicine. Eur J Emerg Med 2007;14:25-31.

Disasters and incidents with hundreds, thousands, or tens of thousands of casualties are not generally addressed in hospital disaster plans. Nevertheless, they may occur, and recent disasters around the globe suggest that it would be prudent for hospitals to improve their preparedness for a mass casualty incident. Disaster, large or small, natural or man-made can strike in many ways and can put the hospital services in danger. Hospitals, because of their emergency services and 24 hour a day operation, will be seen by the public as a vital resource for diagnosis, treatment, and follow up for both physical and psychological care.

Develop a hospital-based disaster and emergency preparedness plan. Consider how a disaster may pose various challenges to hospital disaster response. Formulate a disaster plan for different medical facility response. Assess the need for further changes in existing plans.

The author uses literature review and his own experience to develop step-by-step logistic approach to hospital disaster planning. The author presents a model for hospital disaster preparedness that produces a living document that contains guidelines for review, testing, education, training and update. The model provides the method to develop the base plan, functional annexes and hazard specific annexes.

The possibility of natural disasters and public health emergencies coupled with the possibility of terrorism support the need to incorporate emergency preparedness into the curricula for every health professional school. Methods: A survey methodology was employed to assess both attitudes towards and knowledge of emergency preparedness amongst health professions students which included the schools of medicine, nursing, dentistry and public health. The survey was piloted to graduating students and then administered prior to institution of a emergency preparedness curriculum and then repeated as an annual survey.

The survey found that 51.8% had been present at a disaster as non-responder while only 12.1% had ever been present as a responder. With regard to baseline class room exposure over 50% reported no exposure to such key concepts as incident command, triage, all-hazards planning, surge and aspects of terrorism. In addition at baseline most students felt they had no competency in emergency preparedness. As an example only 10% of students felt competent with personal protective equipment. While exposure both as a responder and student was low, 82.5% of students felt that emergency preparedness should be a mandatory topic in their education. Lastly, with a minimal curriculum change students showed statistically significant increases on knowledge testing.

While exposure was low for emergency preparedness topics and most did not recognize how information they had been taught might be applicable to emergency preparedness, there was a strong desire for additional training. In addition simple curricular adjustments can lead to significant improvements in knowledge.

Developing alternative systems to deliver emergency health services during a pandemic or public health emergency is essential to preserving the operation of acute care hospitals and the overall health care infrastructure. Alternate care sites which can serve as areas for primary screening and triage or short-term medical treatment, can assist in diverting non-acute patients from hospital emergency departments and manage non-life threatening illnesses in a systematic and efficient manner. Maintaining consistent standards of care in these settings is essential to a uniform approach to the medical management of a public health emergency.

Subject matter experts in emergency and disaster medicine, public health, pediatrics, and various other medical specialties were convened at regular intervals over an 18-month period. Through a consensus-based process this working group created a universal standard of care along with model clinical protocols to manage patients in an out-of-hospital setting using medical and non-medical personnel.

These protocols were designed to allow the mild to moderately ill patient to be managed in a non-acute care hospital or community-based care setting for a limited period of time and then return to their homes for convalescence. Of particular importance are that these protocols applicable to all public health emergencies and do not rely on the active presence of physicians at the alternate care site to render care.

The development of consistent standards of care and the ability to care for patients in an out-of-hospital setting during a pandemic or public health emergency is essential to preserve the sustained operation of acute care hospitals and the entire healthcare system. Diverting patients to a community- based alternate care site or encouraging the early discharge of patients to these locations can assist in managing the large numbers of casualties anticipated during a pandemic or public health crisis.

1. To hear the types of ethical challenges foreign health care workers (HCWs) experience while providing health care in conditions of disaster and deprivation. 2. To hear how they responded 3. To understand the kinds of resources that may have been helpful to support HCWs in these ethical dilemmas.

Qualitative study, loosely grounded theory. Canadian trained HCWs (n = 20, mean age 39) who have worked in disaster response, conflict, post disaster.

Ethical dilemmas emerged from 4 main sources: resource scarcity, historical/political/social structures, aid agency policies/agendas, HCWs norms roles/interactions. Participants described little preparation to deal with ethical dilemmas, and the value in pre-departure training. Clinicians are nurtured in western ethics- mostly formed on autonomy, beneficence, non-maleficence and justice. New realities for many were related to community oriented Public Health Ethics. Early discussion has emerged about the possibility of developing a simple, practical, hand held decision-making model (toolkit) to be used in the field to help guide reflection about ethical dilemmas for HCWs in disaster settings.

To examine how did Hyogo prefecture renovate disaster medical services system from the lessons of the Great Hanshin -Awaji Earthquake.

Countermeasures after the experience of the Earthquake were 1. Establishment of disaster-related medical information network which was introduced to each of various institutions to collect and disseminate medical information at the time of disaster. 2. Designation of sixteen hospitals as Disaster Medical Centers, which were expected to play leading role in disaster management,and to receive many patients at a time of disasters. 3. Construction of Hyogo Emergency Medical Center which was designated as a main Disaster Medical Center to train medical staffs, to operate the Emergency Medical Information Control Center.

We have several training courses for medical staffs. The most important training course is the DMAT (Disaster Medical Assistant Team)training course. DMAT trainigs held at two main Disaster Medical Centers, east National Disaster Medical Center, west Hyogo Emergency Medical Center. More than three hundreds teams have been cultivated now. We experienced five disasters in Hyogo prefecture in these seven years. 2 were natural disasters by the typhoon. 3 were a collision of the ship, the collision of the truck, train derailments each. A big JR train accident occurred in Amagasaki city of Hyogo on April 25,2005. Hyogo Emergency Medical Center worked as the emergency information control center, dispatched doctor attended ambulance, performed on-site triage and first aid, dispatched second team by helicopter, received four severe cases by helicopters, dispatched third team in the evening and provided confined space medicine, and took initiative of surveillance study of the casualties.

Disaster medical services system from the lessons of the Earthqukake functioned at the time of the JR Train accident.