Objective: Trauma casualties caused by terror-related events and children injured as a result of trauma may be given preference in hospital emergency departments (EDs) due to their perceived importance. We investigated whether there are differences in the treatment and hospitalization of terror-related casualties compared to other types of injury events and between children and adults injured in terror-related events.

Methods: Retrospective study of 121 608 trauma patients from the Israel Trauma Registry during the period of October 2000-December 2005. Of the 10 hospitals included in the registry, 6 were level I trauma centers and 4 were regional trauma centers. Patients who were hospitalized or died in the ED or were transferred between hospitals were included in the registry.

Results: All analyses were controlled for Injury Severity Score (ISS). All patients with ISS 1-24 terror casualties had the highest frequency of intensive care unit (ICU) admissions when compared with patients after road traffic accidents (RTA) and other trauma. Among patients with terror-related casualties, children were admitted to ICU disproportionally to the severity of their injury. Logistic regression adjusted for injury severity and trauma type showed that both terror casualties and children have a higher probability of being admitted to the ICU.

Conclusions: Injured children are admitted to ICU more often than other age groups. Also, terror-related casualties are more frequently admitted to the ICU compared to those from other types of injury events. These differences were not directly related to a higher proportion of severe injuries among the preferred groups.

(Disaster Med Public Health Preparedness. 2012;6:14–19)

Objectives: Oximes such as pralidoxime (2-PAM) are essential antidotes for life-threatening organophosphate poisoning. Unfortunately, oximes are expensive, have limited use, and have short shelf lives. As such, maintaining large stockpiles in preparation for terrorist activity is not always possible. We have demonstrated that atropine is stable well beyond its labeled shelf life and that recently expired 2-PAM was clinically efficacious in a series of poisoned patients. Because 2-PAM is often dosed empirically, clinical improvement does not guarantee pharmacological stability. We therefore chose to analyze the chemical stability of expired 2-PAM.

Methods: Samples of lyophylized 2-PAM were maintained according to the manufacturer's recommendations for 20 years beyond the published shelf life. We studied 2-PAM contained in a MARK I autoinjector that was stored properly for 3 years beyond its expiration date. An Agilent LC/MSD 1100 with diode-array detector and an Agilent Sorbax SB-C-18, 4.6 × 150-mm, 5-μm column were used with the following solvent systems: water with 0.01% trifluoroacetic acid and methanol with 0.01% trifluoroacetic acid. Fresh reagent grade 2-PAM was used as a standard. Results were repeated for consistency.

Results: Lyophylized 2-PAM was a white powder that was clear and colorless in solution. Liquid chromatography was identical to the standard and resulted in 2 isolated peaks with identical mass spectra, suggesting that they are stereoisomers. The autoinjector discharged a clear, yellowish solution. In addition to the 2 peaks identified for lyophylized 2-PAM, a small third peak was identified with a mass spectra corresponding to the reported N -methyl pyridinium carboxaldehyde degradation product.

Conclusions: When properly stored, lyophylized 2-PAM appears to be chemically stable well beyond its expiration date. Although the relative amount of degradation product found in solubilized (autoinjector) 2-PAM was small, it is unclear whether this may be toxic and therefore is of concern. Further studies performed with lots of drug stored under varied conditions would be required to fully determine the stability of expired 2-PAM.

(Disaster Med Public Health Preparedness. 2012;6:20–25)

Objective: To examine the mental health effects of Hurricane Ike, the third costliest hurricane in US history, which devastated the upper Texas coast in September 2008.

Method: Structured telephone interviews assessing immediate effects of Hurricane Ike (damage, loss, displacement) and mental health diagnoses were administered via random digit-dial methods to a household probability sample of 255 Hurricane Ike–affected adults in Galveston and Chambers counties.

Results: Three-fourths of respondents evacuated the area because of Hurricane Ike and nearly 40% were displaced for at least one week. Postdisaster mental health prevalence estimates were 5.9% for posttraumatic stress disorder, 4.5% for major depressive episode, and 9.3% for generalized anxiety disorder. Bivariate analyses suggested that peritraumatic indicators of hurricane exposure severity—such as lack of adequate clean clothing, electricity, food, money, transportation, or water for at least one week—were most consistently associated with mental health problems.

Conclusions: The significant contribution of factors such as loss of housing, financial means, clothing, food, and water to the development and/or maintenance of negative mental health consequences highlights the importance of systemic postdisaster intervention resources targeted to meet basic needs in the postdisaster period.

(Disaster Med Public Health Preparedness. 2012;6:26–32)

The series of earthquakes and aftershocks that have hit Christchurch, New Zealand, for more than one year has been severe and sustained, resulting in major damage to homes, buildings, essential services, and resources in water, sewerage, food, access to health care, energy for heating and cooling, and unprecedented challenges to resiliency. Large swathes of destroyed buildings, land damage, and liquefaction have made rebuilding impossible for many. Populations have moved or report that they either wish to or plan to do so. For those who remain, a ”new normal” mindset has taken hold and serves as an objective measure for the process that defines daily life and future decisions. The new normal serves as an uncomfortable but realistic guideline by which further resiliency can be measured. A number of factors have led to the development of the new normal state for the Christchurch earthquake survivors.

(Disaster Med Public Health Preparedness. 2012;6:33-43)

Effective preparedness, response, and recovery from disasters require a well-planned, integrated effort with experienced professionals who can apply specialized knowledge and skills in critical situations. While some professionals are trained for this, others may lack the critical knowledge and experience needed to effectively perform under stressful disaster conditions. A set of clear, concise, and precise training standards that may be used to ensure workforce competency in such situations has been developed. The competency set has been defined by a broad and diverse set of leaders in the field and like-minded professionals through a series of Web-based surveys and expert working group meetings. The results may provide a useful starting point for delineating expected competency levels of health professionals in disaster medicine and public health.

(Disaster Med Public Health Preparedness. 2012;6:44–52)

Disaster diplomacy is an evolving contemporary model that examines how disaster response strategies can facilitate cooperation between parties in conflict. The concept of disaster diplomacy has emerged during the past decade to address how disaster response can be leveraged to promote peace, facilitate communication, promote human rights, and strengthen intercommunity ties in the increasingly multipolar modern world. Historically, the concept has evolved through two camps, one that focuses on the interactions between national governments in conflict and another that emphasizes the grassroots movements that can promote change. The two divergent approaches can be reconciled and disaster diplomacy further matured by contextualizing the concept within the disaster cycle, a model well established within the disaster risk management community. In particular, access to available health care, especially for the most vulnerable populations, may need to be negotiated. As such, disaster response professionals, including emergency medicine specialists, can play an important role in the development and implementation of disaster diplomacy concepts.

(Disaster Med Public Health Preparedness. 2012;6:53–59)

The close interplay between mental health and physical health makes it critical to integrate mental and behavioral health considerations into all aspects of public health and medical disaster management. Therefore, the National Biodefense Science Board (NBSB) convened the Disaster Mental Health Subcommittee to assess the progress of the US Department of Health and Human Services (HHS) in integrating mental and behavioral health into disaster and emergency preparedness and response activities. One vital opportunity to improve integration is the development of clear and directive national policy to firmly establish the role of mental and behavioral health as part of a unified public health and medical response to disasters. Integration of mental and behavioral health into disaster preparedness, response, and recovery requires it to be incorporated in assessments and services, addressed in education and training, and founded on and advanced through research. Integration must be supported in underlying policies and administration with clear lines of responsibility for formulating and implementing policy and practice.

(Disaster Med Public Health Preparedness. 2012;6:60–66)

In substantial numbers of affected populations, disasters adversely affect well-being and influence the development of emotional problems and dysfunctional behaviors. Nowhere is the integration of mental and behavioral health into broader public health and medical preparedness and response activities more crucial than in disasters such as the 2009-2010 H1N1 influenza pandemic. The National Biodefense Science Board, recognizing that the mental and behavioral health responses to H1N1 were vital to preserving safety and health for the country, requested that the Disaster Mental Health Subcommittee recommend actions for public health officials to prevent and mitigate adverse behavioral health outcomes during the H1N1 pandemic. The subcommittee's recommendations emphasized vulnerable populations and concentrated on interventions, education and training, and communication and messaging. The subcommittee's H1N1 activities and recommendations provide an approach and template for identifying and addressing future efforts related to newly emerging public health and medical emergencies. The many emotional and behavioral health implications of the crisis and the importance of psychological factors in determining the behavior of members of the public argue for a programmatic integration of behavioral health and science expertise in a comprehensive public health response.

(Disaster Med Public Health Preparedness. 2012;6:67–71)

Recent manmade and natural disasters highlight weaknesses in the public health systems designed to protect populations from harm and minimize disruption of the social and built environments. Emergency planning and response efforts have, as a result, focused largely on ensuring populations' physical well-being during and after a disaster. Many public health authorities, including the World Health Organization, have recognized the importance of addressing both mental and physical health concerns in emergency plans. Individuals with mental disorders represent a notable proportion of the overall population, and anticipating their needs is critical to comprehensive emergency planning and response efforts. Because people with serious mental disorders historically have been stigmatized, and many individuals with mental disorders may be unable to care for themselves, ethical guidance may be of assistance to those engaged in emergency planning and response. This article considers several broad categories of ethical issues that arise during emergencies for people with serious mental disorders and offers recommendations for ways in which emergency planners and other stakeholders can begin to address these ethical challenges.

(Disaster Med Public Health Preparedness. 2012;6:72–78)