Post-preparedness medical disaster response in Costa Rica

Association of injury pattern and entrapment location inside damaged buildings in the 2016 Taiwan earthquake

BACKGROUND/PURPOSE

To explore the association of patient injury patterns and entrapped locations inside damaged buildings in the 2016 Taiwan earthquake.

METHODS

A retrospective analysis was conducted using the Tainan incident registry system. Residents inside nine conjunctive, 16-story (49.3 m in height) reinforced concrete buildings were categorized as non-injured, injured, and dead. Residents were classified into different groups according to their entrapped locations in height and the severity of building damage. The field triage acuity and trauma severity among groups were compared. Statistical significance was set at the level of 0.05.

RESULTS

There were 309 enrollees with 76 (24.6%) non-injured, 118 (38.2%) injured, and 115 (37.2%) dead. Residents either in the high floors (odds ratio [OR] = 2.9, 95% CI: 1.5-5.8, p = 0.003) or in the collapsed buildings (OR = 18.2, 95% CI: 7.6-43.6, p < 0.001) were more likely to be dead. Injured patients who were located in the high floors were more likely to have severe field triage acuities (adjusted OR = 14.7, 95% CI: 1.8-118.0, p = 0.012); intracranial hemorrhage (12.5%), intrathoracic injury (18.8%), or intra-abdominal damage (12.5%) (All p < 0.05); the need for emergency surgical intervention (31.3%, p = 0.035); and major trauma (18.8%, p = 0.001). Residents in the collapsed buildings were more likely to have a crush injury (80.0%, p < 0.001) or crush syndrome (80.0%, p < 0.001).

CONCLUSION

People entrapped at different heights of floors or in differently damaged buildings could have a distinct pattern of injury. Our findings may facilitate strategic approaches of patients entrapped in damaged buildings and may contribute to future training for field searches and rescues after earthquakes.

Effectiveness of Mechanisms and Models of Coordination between Organizations, Agencies and Bodies Providing or Financing Health Services in Humanitarian Crises: A Systematic Review

BACKGROUND

Effective coordination between organizations, agencies and bodies providing or financing health services in humanitarian crises is required to ensure efficiency of services, avoid duplication, and improve equity. The objective of this review was to assess how, during and after humanitarian crises, different mechanisms and models of coordination between organizations, agencies and bodies providing or financing health services compare in terms of access to health services and health outcomes.

METHODS

We registered a protocol for this review in PROSPERO International prospective register of systematic reviews under number PROSPERO2014:CRD42014009267. Eligible studies included randomized and nonrandomized designs, process evaluations and qualitative methods. We electronically searched Medline, PubMed, EMBASE, Cochrane Central Register of Controlled Trials, CINAHL, PsycINFO, and the WHO Global Health Library and websites of relevant organizations. We followed standard systematic review methodology for the selection, data abstraction, and risk of bias assessment. We assessed the quality of evidence using the GRADE approach.

RESULTS

Of 14,309 identified citations from databases and organizations' websites, we identified four eligible studies. Two studies used mixed-methods, one used quantitative methods, and one used qualitative methods. The available evidence suggests that information coordination between bodies providing health services in humanitarian crises settings may be effective in improving health systems inputs. There is additional evidence suggesting that management/directive coordination such as the cluster model may improve health system inputs in addition to access to health services. None of the included studies assessed coordination through common representation and framework coordination. The evidence was judged to be of very low quality.

CONCLUSION

This systematic review provides evidence of possible effectiveness of information coordination and management/directive coordination between organizations, agencies and bodies providing or financing health services in humanitarian crises. Our findings can inform the research agenda and highlight the need for improving conduct and reporting of research in this field.

Mortality following the Haitian earthquake of 2010: a stratified cluster survey

INTRODUCTION

Research that seeks to better understand vulnerability to earthquakes and risk factors associated with mortality in low resource settings is critical to earthquake preparedness and response efforts. This study aims to characterize mortality and associated risk factors in the 2010 Haitian earthquake.

METHODS

In January 2011, a survey of the earthquake affected Haitian population was conducted in metropolitan Port-au-Prince. A stratified 60x20 cluster design (n = 1200 households) was used with 30 clusters sampled in both camp and neighborhood locations. Households were surveyed regarding earthquake impact, current living conditions, and unmet needs.

RESULTS

Mortality was estimated at 24 deaths (confidence interval [CI]: 20-28) per 1,000 in the sample population. Using two approaches, extrapolation of the survey mortality rate to the exposed population yielded mortality estimates ranging from a low of 49,033 to a high of 86,555. No significant difference in mortality was observed by sex (p = .786); however, age was significant with adults age 50+ years facing increased mortality risk. Odds of death were not significantly higher in camps, with 27 deaths per 1,000 (CI: 22-34), compared to neighborhoods, where the death rate was 19 per 1,000 (CI: 15-25; p = 0.080). Crowding and residence in a multistory building were also associated with increased risk of death.

CONCLUSIONS

Haiti earthquake mortality estimates are widely varied, though epidemiologic surveys conducted to date suggest lower levels of mortality than officially reported figures. Strategies to mitigate future mortality burden in future earthquakes should consider improvements to the built environment that are feasible in urban resource-poor settings.

The human impact of earthquakes: a historical review of events 1980-2009 and systematic literature review

Introduction. Population growth and increasing urbanization in earthquake-prone areas suggest that earthquake impacts on human populations will increase in the coming decades. Recent large earthquakes affecting large populations in Japan, Haiti, Chile and New Zealand are evidence of this trend and also illustrate significant variations in outcomes such damage and mortality levels. The objectives of this review were to describe the impact of earthquakes on human populations in terms of mortality, injury and displacement and, to the extent possible, identify risk factors associated with these outcomes. This is one of five reviews on the human impact of natural disasters. Methods. Data on the impact of earthquakes were compiled using two methods, a historical review from 1980 to mid 2009 of earthquake events from multiple databases and a systematic literature review of publications, ending in October 2012. Analysis included descriptive statistics and bivariate tests for associations between earthquake mortality and characteristics using STATA 11. Findings. From 1980 through 2009, there were a total of 372,634 deaths (range 314,634-412,599), 995,219 injuries (range: 845,345-1,145,093), and more than 61 million people affected by earthquakes, and mortality was greatest in Asia. Inconsistent reporting across data sources suggests that the numbers injured and affected are likely underestimates. Findings from a systematic review of the literature indicate that the primary cause of earthquake-related death was trauma due to building collapse and, the very young and the elderly were at increased mortality risk, while gender was not consistently associated with mortality risk. Conclusions. Strategies to mitigate the impact of future earthquakes should include improvements to the built environment and a focus on populations most vulnerable to mortality and injury.

Resuscitation in a multiple casualty event

A major weakness in the emergency medical response to multiple casualty events continues to be the resuscitation component, which should consist of the systematic application of basic, advanced, and prolonged life support and definitive care within 24 hours. There have been major advances in emergency medical care over the last decade, including the feasibility of point-of-care ultrasound to aid in rapid assessment of injuries in the field, damage control resuscitation, and resuscitative surgery protocols, delivered by small trauma/resuscitation teams equipped with regional anesthesia capability for rapid deployment. Widespread adoption of these best practices may improve the delivery of resuscitative care in future multiple casualty events.

Epidemiologic Assessment of Mortality, Building Collapse Pattern, and Medical Response after the 1992 Earthquake in Turkey

Background:

Post-earthquake engineering and epidemiologic assessments are important for the development of injury prevention strategies. This paper describes mortality and its relationship to building collapse patterns and initial medical responses following the 1992 earthquake in Erzincan, Turkey.

Methods:

The study consisted of: 1) background data collection and review; 2) design and implementation of a field survey; and 3) site inspection of building collapse patterns. The survey included: 1) national (n = 11) and local (n = 17) officials; 2) medical and search and rescue (SAR) workers (n = 38); and 3) a geographically stratified random sample of lay survivors (n = 105). The survey instruments were designed to gather information regarding location, injuries, initial actions and prior training of survivors and responders, and the location, injuries, and management of dead and dying victims. A case-control design was constructed to assess the relationship between mortality, location, and building collapse pattern.

Results:

There was extensive structural damage throughout the region, especially in the city where mid-rise, unreinforced masonry buildings (MUMBs) incorporating a “soft” first floor design (large store windows for commercial use) and one story adobe structures were most vulnerable to collapse. Of 526 people who died in the city, 87% (n = 456) were indoors at the time of the earthquake. Of these, 92% (n = 418) died in MUMBs. Of 54 witnessed deaths, 55% (n = 28) of victims died slowly, the majority of whom (n = 26) were pinned or trapped (p <0.05). Of 42 MUMB occupants identified through the survey, those who died (n = 25) were more likely to have been occupying the ground floor when compared with survivors (n = 28) (p <0.01). Official medical and search and rescue responders arrived after most deaths had occurred. Prior first-aid or rescue training of lay, uninjured survivors was associated with a higher likelihood of rescuing and resuscitating others (p <0.001).

Conclusion:

During an earthquake, MUMBs with soft ground floor construction are highly lethal, especially for occupants on the ground floor, suggesting that this building type is inappropriate for areas of seismic risk. The vulnerability of MUMBs appears due to a lack of lateral force resistance as a result of the use of glass store fiont windows and the absence of shear walls. The prevalence of this building type in earthquake-prone regions needs to be investigated further. A large portion of victims dying in an earthquake die slowly at the scene of injury. Prior public first-aid and rescue training programs increase participation in rescue efforts in major earthquakes and may improve survival.

Perceived Preparedness for a Mass Casualty Disaster in the United States: A Survey

Introduction:

A mass casualty disaster (MCD) never has occurred in the United States, but such an event remains a fearful possibility. The purpose of this study was to establish baseline information concerning the perceptions relative to the capabilities of the United States to respond to a MCD of persons most likely to involved in the responses to such an event when it does occur.

Methods:

A survey was constructed in 1995 to query the perceptions of persons in authority in federal, state, and local agencies who would participate in the medical responses to a MCD. Participants were asked to select the most likely scenario, a hurricane or earthquake, that could generate 30,000 casualties within their respective region. The survey requested respondent's perceptions as to the timing of the federal responses and the quality and sufficiency of these responses. The survey also sought information about the availability of plans to meet such a catastrophe in the region, and the frequency with which such plans have been exercised.

Responses were grouped by phase of the responses and whether the respondents were employed by federal, state, or local agencies. Descriptive statistics were used to summarize the data. When appropriate, a one-tailed t-test was used to compare the responses of the groups. A p-value = 0.05 was considered statistically significant.

Results:

A total of 104 surveys were distributed of which 88 were completed and returned (85%). Both the federal and state respondents had considerable experienced in this area.

Overall, the federal respondents were more optimistic about the availability, utility, and timely arrival of federal resources to assist regions in meeting the medical needs. In each of the three phases of MCD responses evaluated (medical response, patient evacuation, and definitive care), there was concern that there were insufficient resources to meet the requirements. States and local respondents perceived that initially, they will be on their own for field rescue, life-supporting first-aid, and casualty evacuation. Respondents acknowledged that a combination of local, state, federal, and private resources eventually would be needed to meet the huge demand. Only 31% federal and 26% state/local respondents believed that there will be sufficient combined local, state, federal, and private resources to meet the requirements for the evacuation of casualties to definitive care facilities outside of the region, and another 50% acknowledged the resources would only partially meet these requirements. Sixty-eight percent of state/local respondents believed that there would be insufficient local, state, federal, and private definitive care resources to meet the requirements for definitive care.

Conclusion:

While three years have elapsed since the survey was conducted and there have been some improvements in preparedness and responses, concerns center around the perceived lack of resource capability or lack of ability to get the resources to the MCD scene in time to meet requirements. Such perceptions by experienced professionals warrant further review by those at all levels of government responsible for planning and responding to mass casualty disasters.

Surgery under Extreme Conditions in the Aftermath of the 2010 Haiti Earthquake: The Importance of Regional Anesthesia

The 12 January 2010 earthquake that struck Port-au-Prince, Haiti caused >200,000 deaths, thousands of injuries requiring immediate surgical interventions, and 1.5 million internally displaced survivors. The earthquake destroyed or disabled most medical facilities in the city, seriously hampering the ability to deliver immediate life- and limb-saving surgical care. A Project Medishare/University of Miami Miller School of Medicine trauma team deployed to Haiti from Miami within 24 hours of the earthquake. The team began work at a pre-existing tent facility in the United Nations (UN) compound based at the airport, where they encountered 225 critically injured patients. However, non-sterile conditions, no means to administer oxygen, the lack of surgical equipment and supplies, and no anesthetics precluded the immediate delivery of general anesthesia. Despite these limitations, resuscitative care was administered, and during the first 72 hours following the event, some amputations were performed with local anesthesia. Because of these austere conditions, an anesthesiologist, experienced and equipped to administer regional block anesthesia, was dispatched three days later to perform anesthesia for limb amputations, debridements, and wound care using single shot block anesthesia until a better equipped tent facility was established. After four weeks, the relief effort evolved into a 250-bed, multi-specialty trauma/intensive care center staffed with >200 medical, nursing, and administrative staff. Within that timeframe, the facility and its staff completed 1,000 surgeries, including spine and pediatric neurological procedures, without major complications. This experience suggests that when local emergency medical resources are completely destroyed or seriously disabled, a surgical team staffed and equipped to provide regional nerve block anesthesia and acute pain management can be dispatched rapidly to serve as a bridge to more advanced field surgical and intensive care, which takes longer to deploy and set up.

Impact of Hurricane Ivan on Pharmacies in Baldwin County Alabama

OBJECTIVE

To evaluate the impact of Hurricane Ivan, which made landfall east of Mobile, Alabama, on September 16, 2004, on pharmacies in the affected areas.

DESIGN

Retrospective cross-sectional analysis.

SETTING

Baldwin County, Alabama.

INTERVENTIONS

Pharmacy community rapid-needs-assessment survey.

PARTICIPANTS

41 hospital and community (chain and independent) pharmacies.

MAIN OUTCOME MEASURES

Posthurricane pharmacy hours of operations, prescription volumes, infrastructure damage, and prehurricane disaster planning.

RESULTS

During the week of the hurricane, both chain and independent community pharmacies within the evacuation zone worked significantly fewer hours (46% and 49%, respectively) and dispensed significantly fewer prescriptions (37% and 52%) compared with the same week of the prior year. Overall, 40% of pharmacies depleted their supplies of certain medications (e.g., anxiolytics, antihypertensives). A total of 60% of the chain and independent pharmacies outside the evacuation zone closed because of loss of electricity, but pharmacies with a generator were significantly less likely to report having turned away patients. The proportion of pharmacies that had a disaster plan but turned away patients or rationed or ran out of medications was similar to that of pharmacies without a disaster plan.

CONCLUSION

Although Hurricane Ivan primarily affected the operation of pharmacies within the evacuation zone, pharmacies in the surrounding area were also affected because of loss of power. Emergency management officials should evaluate the efficacy of specific guidelines outlined in disaster plans and identify ways to deliver essential medications to people in disaster-affected areas.

Implementation of the Hospital Emergency Incident Command System during an outbreak of severe acute respiratory syndrome (SARS) at a hospital in Taiwan, ROC

We sought to describe the implementation of the Hospital Emergency Incident Command System (HEICS) at National Cheng Kung University Hospital (NCKUH) in Taiwan, ROC during the outbreak of severe acute respiratory syndrome (SARS) in early 2003. We administered a 14-question survey via structured interviews to individuals occupying activated HEICS leadership positions at NCKUH to identify the organization, structure, and function of the HEICS units and subunits they led and the job actions they performed from 25 March to 16 June 2003 Thirty-three of 38 persons (87%) occupying 39 of 44 (89%) activated HEICS leadership positions directly participated in the survey. The participants collectively reported: 1) the creation of four new HEICS unit leader positions and corresponding units during the outbreak, including the infection control officer (administrative section) and SARS assessment, isolation, and critical care unit leaders (operations section); 2) the creation of six new HEICS subunits, including functional areas for fever screening, SARS assessment, and resuscitation outside the hospital, and SARS patient care, SARS critical care, and employee isolation inside the hospital; and 3) the performance of new job actions related to infection control by all HEICS unit leaders. HEICS provides a flexible framework that seems to have assisted NCKUH in the organization of its emergency response to the SARS outbreak in Taiwan, ROC.

Health care personnel in disaster response. Reversible roles or territorial imperatives?

Disasters frequently demand exceptional skills from medical responders. Providers work most efficiently and effectively, however, within the roles and hierarchical structures with which they are familiar. The goal of disaster medical response planners is to assign personnel to roles that are as familiar as possible and to simultaneously enhance flexibility of response to extraordinary circumstances. We have outlined the most common disaster medical response roles and the personnel types that fit most directly as a primary provider within each role. Medics excel in field operations and field care of patients, whereas the training of nurses and physicians makes them the most flexible all-around providers, if specially trained in field emergency care, and the sole providers of definitive care. None of the providers, by virtue of their basic training, is well equipped to manage the public health consequences of disasters, but nurses and physicians should be able to easily move into the role, given appropriate special training. Some of the special courses needed to make medics, nurses, and physicians capable of serving flexible roles already exist; others need to be developed or enhanced.

Management of unique clinical entities in disaster medicine

This article discusses the management of clinical problems encountered particularly in disasters. These include the principles of multiple-casualty triage, and field and hospital management of blast injury, crush syndrome, compartment syndrome, particulate inhalation, and traumatic asphyxiation. The indications for extraordinary measures, such as field amputation, are detailed. A brief review of the causes and epidemiology of these entities is provided, with emphasis on the clinical management in the disaster setting.

Disaster preparedness and response as primary health care

The need for search and rescue and medical care following a sudden impact disaster is immediate and often overwhelming. In the past, governments and international organizations have relied on external assistance for these efforts. Because the life expectancy of severely injured and trapped victims is limited, the response must come first from the impact area itself. The preponderance of disaster research demonstrates that the local populace overwhelmingly is responsible for search-and-rescue efforts. Emergency medical care, e.g., that delivered in the first 24 hours to 48 hours after a disaster, also is overwhelmingly from local or regional resources. Outside and, perhaps, even international assistance is required for medium- and long-term response, but is of limited benefit for the “emergency phase.”

Post-disaster malaria in Costa Rica

INTRODUCTION

In recent years, controversy has surrounded the issue of whether infectious disease should be considered a serious potential consequence of natural disasters. This article contributes to this debate with evidence of a significant outbreak of malaria in Costa Rica's Atlantic region after the 1991 earthquake and subsequent floods.

METHODS

This study is an epidemiologic investigation of the incidence of malaria for the periods of 22 months before the April 1991 Limón earthquake and for 13 months afterward. Data were obtained from the Costa Rican Ministry of Health's malaria control program.

RESULTS

Some of the cantons in the region experienced increases in the incidence of malaria as high as 1,600% and 4,700% above the average monthly rate for the preearthquake period (p < or = 0.01). Causal mechanisms are postulated as relating to changes in human behavior (increased exposure to mosquitoes while sleeping outside, and a temporary pause in malaria control activities), changes in the habitat that were beneficial to mosquito breeding (landslide deforestation, river damming, and rerouting), and the floods of August 1991.

CONCLUSIONS

It is recommended that there be enhanced awareness of the potential consequences of disaster-wrought environmental changes. Date of Event: 22 April 1991; Type: Earthquake, 7.4 Richter scale;

LOCATION

Costa Rica; Number of deaths and casualties: 54 deaths and 505 moderate to severe injuries.

Emergency medical services during the siege of Sarajevo, Bosnia and Herzegovina: a preliminary report

BACKGROUND

The siege of Sarajevo is a long-term, human-made, medical disaster of international significance. The delivery of emergency health care provided to the large civilian population held captive in that war zone for an extended time was studied.

METHODS

In May 1993, a humanitarian and fact-finding visit to Sarajevo was conducted. Physicians, administrators, and public health officials were interviewed; epidemiological data were acquired--the resuscitation of war casualties at the two largest hospitals were observed; and local published reports and videotaped footage on the organization and delivery of prehospital and hospital care were reviewed. The videotapes also served to document war crimes.

RESULTS

Daily bombardment and sniper fire directed at civilians have caused a steady stream of casualties (64,130, or an average of 119 killed or injured per day in 18 months). Eighty percent of the victims were civilian. Despite hazardous conditions from direct shelling, disruption of vital lifelines, and shortage of supplies, medicines, oxygen, and anesthetics, the physicians continue to provide at least a minimum standard of resuscitative care. Seventy percent of all war victims were transported to hospitals in private vehicles. Most casualties (93%) received some form of prehospital, basic first-aid from lay bystanders or first responders. From November 1992 to February 1993, 27,733 patients were treated in hospitals, resulting in 2,139 major surgical procedures. The primary cause of death in 71 of 273 victims was prolonged hemorrhagic, hypovolemic shock. Sixty-one percent of these victims died within 24 hours of injury.

CONCLUSIONS

Continuous needs assessment of a civilian population in a war zone should be accompanied by rapid delivery of outside aid. International "peacekeeping" forces should protect hospitals and their staffs, and ensure the entry of supplies and evacuation of some patients. A public trained in life-supporting first-aid, and physicians and paramedics with experience in advanced life support may have enhanced lifesaving efforts in Sarajevo.

An analysis of prehospital mortality in an earthquake. Disaster Reanimatology Study Group

INTRODUCTION

Anecdotal observations about prehospital emergency medical care in major natural and human-made disasters, such as earthquakes, have suggested that some injured victims survive the initial impact, but eventually die because of a delay in the application of life-saving medical therapy.

METHODS

A multidisciplinary, retrospective structured interview methodology to investigate injury risk factors, and causes and circumstances of prehospital death after major disasters was developed. In this study, a team of United States researchers and Costa Rican health officials conducted a survey of lay survivors and health care professionals who participated in the emergency medical response to the earthquake in Costa Rica on 22 April 1991.

RESULTS

Fifty-four deaths occurred prior to hospitalization (crude death rate = 0.4/1,000 population). Seventeen percent of these deaths (9/54) were of casualties who survived the initial impact but died at the scene or during transport. Twenty-two percent (2/9) were judged preventable if earlier emergency medical care had been available. Most injuries and deaths occurred in victims who were inside wooden buildings (p < .01) as opposed to other building types or were pinned by rubble from building collapse. Autopsies performed on a sample of victims showed crush injury to be the predominant cause of death.

CONCLUSIONS

A substantial proportion of earthquake mortality in Costa Rica was protracted. Crush injury was the principal mechanism of injury and cause of death. The rapid institution of enhanced prehospital emergency medical services may be associated with a significant life-saving potential in these events.