During an earthquake, vulnerable populations, especially those with chronic conditions, are more susceptible to adverse, event-induced exacerbation of chronic conditions such as limited access to food and water, extreme weather temperatures, and injury. These circumstances merit special attention when health care facilities and organizations prepare for and respond to disasters.

This study explores the relationship between pre-earthquake burden of illness and postearthquake health-related and preparedness factors in the US. Data from a cohort of male veterans who were receiving care at the Sepulveda Veterans Affairs Medical Center (VAMC) in Los Angeles, California USA during the 1994 Northridge earthquake were analyzed.

Veterans with one or more chronic conditions were more likely to report pain lasting two or more days, severe mental/emotional stress for more than two weeks, broken/lost medical equipment, having difficulty refilling prescriptions, and being unable to get medical help following the quake compared to veterans without chronic conditions. In terms of personal emergency preparedness, however, there was no association between burden of illness and having enough food or water for at least 24 hours after the earthquake.

The relationship that exists between health care providers, including both individual providers and organizations like the US Department of Veterans Affairs (VA), and their vulnerable, chronically-ill patients affords providers the unique opportunity to deliver critical assistance that could make this vulnerable population better prepared to meet their postdisaster health-related needs. This can be accomplished through education about preparedness and the provision of easier access to medical supplies. Disaster plans for those who are burdened with chronic conditions should meet their social needs in addition to their psychological and physical needs.

Der-MartirosianC , RiopelleD , NaranjoD , YanoE , RubensteinL , DobalianA . Pre-earthquake Burden of Illness and Postearthquake Health and Preparedness in Veterans. Prehosp Disaster Med. 2014;29(3):1-7.

Although prehospital care is recognized as key in health systems development, it has been largely neglected in Haiti. The North East Department is one of the poorest areas of Haiti, and is a region where no data on out-of-hospital health care exists. This research assessed prehospital characteristics in the North East Department with the aim of providing baseline data to inform prehospital systems development.

In this observational study, data were collected from patients presenting at the Fort Liberté Hospital, the public regional referral health center in the North East Department. Data were accrued from April 2, 2012 through June 5, 2012. All patients accessing acute care at the hospital were eligible for enrollment. After obtaining consent, data on demographics, health needs, and prehospital information were gathered via a standardized questionnaire administered by hospital staff trained in study protocols.

Data were collected from 441 patient visits. The median age was 24 years, with 62% of the population being female. Medical complaints comprised 75% of visits, with fever and gastrointestinal complaints being the most common reasons for presentation. Traumatic injuries accounted for 25% of encounters, with an equal distribution of blunt and penetrating events. Extremity injuries were the most common traumatic subclassification. The majority of patients (67.2%) were transported by motorcycle taxi and paid transport fees. Trauma patients were more likely to be transported without charge (OR = 9.10; 95% CI, 2.19-37.76; P < .001). Medical patients were most commonly brought from home (78.5%) and trauma patients from a road/street setting (42.9%). Median time to presentation was 240 minutes (IQR = 120-500) and 65 minutes (IQR = 30-150) for medical and trauma complaints, respectively (P < .001). Eleven percent of patients reported receiving care prior to arrival. As compared with medical patients, trauma victims were less likely to have received prehospital care.

Assessing prehospital care in this low-income setting that lacks surveillance systems was feasible and required minimal resources. Motorcycle taxi drivers function as the primary emergency transport mechanism and may represent an access point for prehospital interventions in the North East Department of Haiti. Out-of-hospital care is nearly nonexistent in the region and its development has the potential to yield public health benefits.

AluisioAR, GoreR, DecomeI, De WulfA, BloemC. Prehospital Characteristics in the North East Department of Haiti: A Cross-sectional Study from a Low-income Setting Without Prehospital Systems. Prehosp Disaster Med. 2014;29(3):1-7.

The 2010 Haiti earthquake and Pakistan floods were similar in their massive human impact. Although the specific events were very different, the humanitarian response to disasters is supposed to achieve the same ends. This paper contrasts the disaster effects and aims to contrast the medium-term response.

In January 2011, similarly structured population-based surveys were carried out in the most affected areas using stratified cluster designs (80×20 in Pakistan and 60×20 in Haiti) with probability proportional to size sampling.

Displacement persisted in Haiti and Pakistan at 53% and 39% of households, respectively. In Pakistan, 95% of households reported damage to their homes and loss of income or livelihoods, and in Haiti, the rates were 93% and 85%, respectively. Frequency of displacement, and income or livelihood loss, were significantly higher in Pakistan, whereas disaster-related deaths or injuries were significantly more prevalent in Haiti.

Given the rise in disaster frequency and costs, and the volatility of humanitarian funding streams as a result of the recent global financial crisis, it is increasingly important to measure the impact of humanitarian response against the goal of a return to normalcy.

WeissWM , KirschTD , DoocyS , PerrinP . A Comparison of the Medium-term Impact and Recovery of the Pakistan Floods and the Haiti Earthquake: Objective and Subjective Measures. Prehosp Disaster Med. 2014;29(3):1-8.

In catastrophic events, a key to reducing health risks is to maintain functioning of local health facilities. However, little research has been conducted on what types and levels of care are the most likely to be affected by catastrophic events.

The Great East Japan Earthquake Disaster (GEJED) was one of a few “megadisasters” that have occurred in an industrialized society. This research aimed to develop an analytical framework for the holistic understanding of hospital damage due to the disaster.

Hospital damage data in Miyagi Prefecture at the time of the GEJED were collected retrospectively. Due to the low response rate of questionnaire-based surveillance (7.7%), publications of the national and local governments, medical associations, other nonprofit organizations, and home web pages of hospitals were used, as well as literature and news sources. The data included information on building damage, electricity and water supply, and functional status after the earthquake. Geographical data for hospitals, coastline, local boundaries, and the inundated areas, as well as population size and seismic intensity were collected from public databases. Logistic regression was conducted to identify the risk factors for hospitals ceasing inpatient and outpatient services. The impact was displayed on maps to show the geographical distribution of damage.

Data for 143 out of 147 hospitals in Miyagi Prefecture (97%) were obtained. Building damage was significantly associated with closure of both inpatient and outpatient wards. Hospitals offering tertiary care were more resistant to damage than those offering primary care, while those with a higher proportion of psychiatric care beds were more likely to cease functioning, even after controlling for hospital size, seismic intensity, and distance from the coastline.

Implementation of building regulations is vital for all health care facilities, irrespective of function. Additionally, securing electricity and water supplies is vital for hospitals at risk for similar events in the future. Improved data sharing on hospital viability in a future event is essential for disaster preparedness.

OchiS, NakagawaA, LewisJ, HodgsonS, MurrayV. The Great East Japan Earthquake Disaster: Distribution of Hospital Damage in Miyagi Prefecture. Prehosp Disaster Med. 2014;29(3):1-8.

Prehospital postresuscitation induced hypothermia (IH) has been shown to reduce neurological complications in comatose cardiac-arrest survivors. Retrofitting ambulances to include equipment appropriate to initiate hypothermia, such as refrigeration units for cooled saline, is expensive. The objective of this nonhuman subject research study was to determine if inexpensive, commercially available coolers could, in conjunction with five reusable ice packs, keep two 1 L bags of precooled 0.9% normal saline solution (NSS) at or below 4°C for an average shift of eight to 12 hours in a real-world environment, on board in-service Emergency Medical Service (EMS) units, over varying weather conditions in all seasons.

The coolers were chosen based on availability and affordability from two nationally available brands: The Igloo MaxxCold (Igloo Products Corp., Katy, Texas USA) and Coleman (The Coleman Company, Wichita, Kansas USA). Both are 8.5 liter (nine-quart) coolers that were chosen because they adequately held two 1 L bags of saline solution, along with the reusable ice packs designated in the study design, and were small enough for ease of placement on ambulances. Initial testing of the coolers was conducted in a controlled environment. Thereafter, each EMS unit was responsible to cool the saline to less than 4°C prior to shift. Data were collected by emergency medical technicians, paramedics, and resident physicians working in seven different ambulance squads. Data analysis was performed using repeated measurements recorded over a 12-hour period from 19 individual coolers and were summarized by individual time points using descriptive statistics.

Initial testing determined that the coolers maintained temperatures of 4°C for 12 hours in a controlled environment. On the ambulances, results based on the repeated measurements over time revealed that the saline solution samples as defined in the protocol, remained consistently below 4°C for 12 hours. Utilizing the lower bound of the 2-sided 95% exact binomial confidence intervals, there was less than a five percent chance that saline samples could not be maintained below 4°C for 12 hours, even during the summer months.

Simple, commercially available coolers can maintain two 1 L bags of 0.9% NSS at 4°C for 12 hours in ambulances in varying environmental conditions. This suggests that EMS agencies could inexpensively initiate prehospital IH in appropriate cases.

KaneKE , TomshoRJ , PheasantK , StaufferT , SchoenfeldtB , HamiltonS , KainT , KaneBG . The “ICE” Study: Feasibility of Inexpensive Commercial Coolers on Mobile EMS Units. Prehosp Disaster Med. 2014;29(3):1-8.

Approximately 1.2 million persons in Oakland County, Michigan (USA) reside less than 50 miles from the Fermi Nuclear Power Plant, Unit 2, but information is limited regarding how residents might react during a radiation emergency. Community Assessment for Public Health Emergency Response (CASPER) survey methodology has been used in disaster and nondisaster settings to collect reliable and accurate population-based public health information, but it has not been used to assess household-level emergency preparedness for a radiation emergency. To improve emergency preparedness plans in Oakland County, including how residents might respond during a radiation emergency, Oakland County Health Division (OCHD), with assistance from the Centers for Disease Control and Prevention (CDC) and the Michigan Department of Community Health (MDCH), conducted a CASPER survey.

During September 2012, a 2-stage cluster sampling design was used to select 210 representative households in Oakland County. By using in-person surveys, the proportion of households with essential needs and supplies, how residents might respond to public health authorities’ instructions, and their main source for obtaining information during a radiation emergency were assessed. Data were weighted to account for the complex sampling design.

Of the goal of 210 households, 192 (91.4%) surveys were completed: 64.7% and 85.4% of respondents indicated having 3-day supplies of water and of nonperishable food, respectively; 62.8% had a 7-day supply of prescription medication for each person who needed it. Additionally, 64.2% had a working carbon monoxide detector; 67.1% had a first-aid kit; and 52% had an alternative heat source. In response to instructions from public health officials during a radiation emergency, 93.3% of all respondents would report to a radiation screening center; 96% would evacuate; and 91.8% would shelter-in-place. During a radiation emergency, 55.8% of respondents indicated their main information source would be television, 18.4% radio, and 13.6% the Internet. The most trusted source for information would be the local public health department (36.5%), local news (23%), a physician (11.2%), and family members (11.1%). Including completed and incomplete interviews, refusals, and nonrespondents, 517 total households were contacted.

CASPER data regarding how residents might react during a radiation emergency provided objective and quantifiable information that will be used to develop Oakland County's radiation emergency preparedness plans. Survey information demonstrates the feasibility and usefulness of CASPER methodology for radiation emergency preparedness planning.

NyakuMK, WolkinAF, McFaddenJ, CollinsJ, MurtiM, SchnallA, BiesS, StanburyM, BeggsJ, BayleyegnTM. Assessing Radiation Emergency Preparedness Planning by Using Community Assessment for Public Health Emergency Response (CASPER) Methodology. Prehosp Disaster Med. 2014;29(3):1-9.

Emergency response relies on the assumption that essential health care services will continue to operate and be available to provide quality patient care during and after a patient surge. The observed successes and failures of health care systems during recent mass-casualty events and the concern that these assumptions are not evidence based prompted this review.

The aims of this systematic review were to explore the factors associated with the intention of health care personnel (HCP) to respond to uncommon events, such as a natural disaster or pandemic, determine the state of the science, and bolster evidence-based measures that have been shown to facilitate staff response.

Authors of the 70 studies (five mixed-methods, 49 quantitative, 16 qualitative) that met inclusion criteria reported a variety of variables that influenced the intent of HCP to respond. Current evidence suggests that four primary factors emerged as either facilitating or hindering the willingness of HCP to respond to an event: (1) the nature of the event; (2) competing obligations; (3) the work environment and climate; and (4) the relationship between knowledge and perceptions of efficacy.

Findings of this study could influence and strengthen policy making by emergency response planners, staffing coordinators, health educators, and health system administrators.

ConnorSB . When and Why Health Care Personnel Respond to a Disaster: The State of the Science. Prehosp Disaster Med. 2014;29(3):1-5.

An earthquake and tsunami hit the east coast of Japan on March 11, 2011. Nurses were actively involved in the health response to this disaster and, subsequently, many authors have reported on the role nurses played in these efforts in Japanese nursing professional journals.

To describe the role of nurses who assisted in the 2011 Great East Earthquake of Japan by reviewing Japanese literature and reporting the findings in English.

This research used an integrative literature review methodology. Manuscripts were obtained from the Japanese database Ichushi Ver. 5 (Japan Medical Abstracts Society, Tokyo, Japan). A total of 44 manuscripts were identified and included in a thematic analysis.

Three main themes were identified: (1) nursing roles, (2) specialized nursing roles, and (3) preparedness education. Nurses fulfilled different roles in the period after the disaster (ie, as a clinician, a communicator, a leader, and a provider of psychosocial support). Additionally, the specialized nurse role was identified, along with the need for preparedness education to support the nurse's role in a disaster.

The understanding of the role of nurses in disasters is expanding. There is a need to further explore the roles of specialized nurses in disasters. Further disaster education opportunities should be available as a part of continuing education for all nurses. Radiation aspects of disaster assistance should be included in disaster education programs where there are radio-nuclear hazards present in the environment.

KakoM , RanseJ , YamamotoA , ArbonP . What Was the Role of Nurses During the 2011 Great East Earthquake of Japan? An Integrative Review of the Japanese Literature. Prehosp Disaster Med. 2014;29(3):1-5.

In 2012, a minimum data set (MDS) was proposed to enable the standardized collection of biomedical data across various mass gatherings. However, the existing 2012 MDS could be enhanced to allow for its uptake and usability in the international context. The 2012 MDS is arguably Australian-centric and not substantially informed by the literature. As such, an MDS with contributions from the literature and application in the international settings is required.

This research used an integrative literature review design. Manuscripts were collected using keyword searches from databases and journal content pages from 2003 through 2013. Data were analyzed and categorized using the existing 2012 MDS as a framework.

In total, 19 manuscripts were identified that met the inclusion criteria. Variation in the patient presentation types was described in the literature from the mass-gathering papers reviewed. Patient presentation types identified in the literature review were compared to the 2012 MDS. As a result, 16 high-level patient presentation types were identified that were not included in the 2012 MDS.

Adding patient presentation types to the 2012 MDS ensures that the collection of biomedical data for mass-gathering health research and evaluation remains contemporary and comprehensive. This review proposes the addition of 16 high-level patient presentation categories to the 2012 MDS in the following broad areas: gastrointestinal, obstetrics and gynecology, minor illness, mental health, and patient outcomes. Additionally, a section for self-treatment has been added, which was previously not included in the 2012 MDS, but was widely reported in the literature.

RanseJ , HuttonA , TurrisSA , LundA . Enhancing the Minimum Data Set for Mass-Gathering Research and Evaluation: An Integrative Literature Review. Prehosp Disaster Med. 2014;29(3):1-10.

Disaster management is a complex and difficult undertaking that may involve limited health care resources and evaluation of multiple victims. The objectives of this study were to evaluate the feasibility of real-time ultrasound video transmission from a simulated disaster triage location via commercially available video mobile phones and assess the ability of emergency physicians to accurately interpret the transmitted video of Focused Assessment with Sonography for Trauma (FAST) ultrasound examinations.

This was a prospective, observational study that took place at a simulated disaster scene put on for an Advanced Disaster Life Support (ADLS) course. The second component occurred at a Level I academic urban emergency department (ED) with an annual census of 78,000. Nineteen subjects at a simulated disaster scene were scanned using a SonoSite Titan ultrasound system (Bothell, Washington USA). An off-the-shelf, basic, video-capable mobile phone was used to record each ultrasound examination; and then immediately transmit the videos to another mobile phone approximately 170 miles away. The transmitted video was received by three emergency physicians with hospital credentialing in emergency ultrasound. Each FAST examination video was assessed for pathology, such as free fluid. The reviewers graded the image quality and documented the overall confidence level regarding whether or not a complete and adequate examination was visualized. Spearman's rank correlation coefficient was used to examine the agreement between the reviewers and the sonologist who performed the ultrasound examinations.

A total of 19 videos were transmitted. The median time for transmission of a video was 82.5 seconds (95% CI, 67.7 seconds-97.3 seconds). No video failed to transmit correctly on the first attempt. The image quality ratings for the three reviewers were 7.7, 7.5, and 7.4 on a 10-point Likert scale. There was a moderate agreement between the reviewers and sonologist in image quality rating and overall confidence level scores (rho = 0.6).

Real-time portable ultrasound video transmission via commercially available video mobile phones from a simulated disaster triage location is feasible and emergency physicians were able to accurately interpret video of FAST ultrasound examinations.

AdhikariS , BlaivasM , LyonM , ShiverS . Transfer of Real-time Ultrasound Video of FAST Examinations from a Simulated Disaster Scene Via a Mobile Phone. Prehosp Disaster Med. 2014;29(3):1-4.

Specialized knowledge and a scientific body of literature are the foundation of the recognition of Emergency Medical Services (EMS) as a subspecialty within emergency medicine (EM). Emergency Medical Services research often is presented at national meetings and published in abstract form, but full publication occurs less frequently.

The primary goal of the study was to determine the rate at which EMS-related research presented at selected conferences went on to manuscript publication. A secondary goal was the determination of the time to manuscript publication.

A cross-sectional study of published abstracts from the 2003-2005 national meetings of the American College of Emergency Physicians (ACEP), Society for Academic Emergency Medicine (SAEM), National Association of EMS Physicians (NAEMSP), Association of Air Medical Services (AAMS), and the National Association of EMS Educators (NAEMSE) was conducted to identify EMS-related abstracts. PubMed (National Center for Biotechnology Information, Bethesda, Maryland USA) was searched using abstract title keywords and authors’ names to determine if the study had been published in a PubMed-indexed journal in the time since presentation and abstract publication.

Abstracts for the five conferences were reviewed for 2003-2005. Six hundred and thirty-five EMS-related abstracts met the inclusion criteria. The total number of EMS abstracts presented and the percent subsequently published as a manuscript were: SAEM 135, 53.3%; ACEP 128, 48.4%; NAEMSP 282, 42.9%; AAMS 66, 33.3%; and NAEMSE 24, 16.7%. The overall rate of publication was 44.3%. The average time to publication was 22.2 months (SD = 16.5 months, range = 0-94 months).

Less than half of EMS abstracts go on to manuscript publication. This may represent missed opportunities for the growth of EMS as a subspecialty.

ClemencyBM , ThompsonJJ , LindstromHA , GurienS , JaisonBA , Grates-SciarrinoAA . Frequency of Manuscript Publication Following Presentation of EMS Abstracts at National Meetings. Prehosp Disaster Med. 2014;29(3):1-5.

Penetrating junctional trauma is a leading cause of preventable death on the battlefield. Similarly challenging in civilian settings, exsanguination from the vessels of the abdomen, pelvis, and groin can occur in moments. Therefore, iliac artery or abdominal aortic compression has been recommended. Based on prior research, 120 lbs (54 kg) or 140 lbs (63 kg) of compression may be required to occlude these vessels, respectively. Whether most rescuers can generate this amount of compression is unknown.

To determine how many people in a convenience sample of 44 health care professionals can compress 120 lbs and 140 lbs.

This study simulated aortic and iliac artery compression. Consent was obtained from 44 clinicians (27 female; 17 male) from two large urban hospitals in Edmonton, Alberta, Canada. Participants compressed the abdominal model, which consisted of a medical scale and a 250 ml bag of saline, covered by a folded hospital blanket and placed on the ground. In random order, participants compressed a force they believed maintainable for 20 minutes (“maintainable effort”) and then a maximum force they could maintain for two minutes (“maximum effort”). Compression was also performed with a knee. Descriptive statistics were used to evaluate the data.

Compression was directly proportional to the clinician's body weight. Participants compressed a mean of 55% of their body weight with two hands at a maintainable effort, and 69% at a maximum effort. At maintainable manual effort, participants compressed a mean of 86 lbs (39 kg). Sixteen percent could compress over 120 lbs, but none over 140 lbs. At maximum effort, participants compressed a mean of 108 lbs (48 kg). Thirty-four percent could compress greater than 120 lbs and 11% could compress greater than 140 lbs. Using a single knee, participants compressed a mean weight of 80% of their body weight with no difference between maintainable and maximum effort.

This work suggests that bimanual compression following penetrating junctional trauma is feasible. However, it is difficult, and is not likely achievable or sustainable by a majority of rescuers. Manual compression (used to temporize until device application and operative rescue) requires a large body mass. To maintain 140 lbs of compression (for example during a lengthy transport), participants needed to weigh 255 lbs (115 kg). Alternatively, they needed to weigh 203 lbs (92 kg) to be successful during brief periods. Knee compression may be preferable, especially for lower-weight rescuers.

DoumaM , BrindleyPG . Abdominal Aortic and Iliac Artery Compression Following Penetrating Trauma: A Study of Feasibility. Prehosp Disaster Med. 2014;29(3):1-4.

The goal of an Emergency Medical Services (EMS) system is to prevent needless death or disability from time-sensitive disease processes. Despite growing evidence that these processes contribute significantly to mortality in low- and middle- income countries (LMICs), there has been little focus on the development of EMS systems in poor countries.

The objective of this study was to understand the utilization pattern of a newly-implemented EMS system in Ruhiira, Uganda.

An EMS system based on community priorities was implemented in rural Uganda in 2009. Six months of ambulance logs were reviewed. Patient, transfer, and clinical data were extracted and analyzed.

In total, 207 cases were reviewed. Out of all transfers, 66% were for chief complaints that were obstetric related, while 12% were related to malaria. Out of all activations, 77.8% were for female patients. Among men, 34% and 28% were related to malaria and trauma, respectively. The majority of emergency transfers were from district to regional hospitals, including 52% of all obstetric transfers, 65% of malaria transfers, and 62% of all trauma transfers. There was no significant difference in the call to arrival on scene time, the time to scene or the scene to treatment time during the day and night (P > .05). Cost-benefit analysis revealed a cost of $89.95 per life saved with an estimated $0.93/capita to establish the system and $0.09/capita/year to maintain the system.

Contrary to current belief, EMS systems in rural Africa can be affordable and highly utilized, particularly for life-threatening, nontrauma complaints. Construction of a simple but effective EMS system is feasible, acceptable, and an essential component to the primary health care system of LMICs.

Stewart De RamirezS , DollJ , CarleS , AnestT , AriiM , HsiehYH , OkongoM , MoreskyR , SachsSE , MillinM . Emergency Response in Resource-poor Settings: A Review of a Newly-implemented EMS System in Rural Uganda. Prehosp Disaster Med. 2014;29(3):1-6.