The aim of this study was to describe an educational method teaching Disaster Medicine to American Emergency Medicine (EM) physicians and to evaluate knowledge attainment using this method.

This was an observational study using a pre-test and a post-test. A full-scale disaster exercise (FSE) was conducted at a large academic center with two hospitals in Brooklyn, New York (USA). Eighty-two EM residents (physicians in training, post medical school) participated in the study. Inclusion criteria for study participation was all EM residents training at the State University of New York (SUNY) Downstate at the time of the study. There were no exclusion criteria. The exercise was a disaster drill designed as “Olympic Games.” Participants in the exercise took a pre-test and a post-test. The primary outcome of the study was the mean difference between pre-test and post-test scores of the study participants using independent sample t-tests. Secondary outcomes of the study were percent of critical actions met by the residents and the hospitals as measured by direct observation of trained study personnel during the exercise.

Mean resident post-test scores were higher than pre-test scores to a degree that was statistically significant (62% versus 53%; P =.002). The residents’ performances ranged from 48% to 63% of objectives met. The hospitals’ performances met 50% to 100% of their objectives.

The use of an Olympic Games format was an effective model for disaster education for physicians. The model allowed for evaluation of performance and protocols of participants and hospital systems, respectively, and may be used objectively to evaluate for areas of improvement. The Disaster Olympics drill was found to improve emergency preparedness knowledge in the population studied and may constitute a novel and efficacious methodology in disaster training.

DanielP, GistR, GrockA, KohlhoffS, RoblinP, ArquillaB. Disaster Olympics: A Model for Resident Education. Prehosp Disaster Med. 2016;31(3):237–241.

The aim of disaster reduction education (DRE) is to achieve behavioral change. Over the past two decades, many efforts have been directed towards this goal, but educational activities have been developed based on unverified assumptions. Further, the literature has not identified any significant change towards disaster preparedness at the individual level. In addition, previous research suggests that change is dependent on multiple independent predictors. It is difficult to determine what specific actions DRE might result in; therefore, the preamble of such an action, which is to have discussions about it, has been chosen as the surrogate outcome measure for DRE success. This study describes the relationship of the perceived entity responsible for disaster education, disaster education per se, sex, and country-specific characteristics, with students discussing disasters with friends and family as a measure of proactive behavioral change in disaster preparedness.

A total of 3,829 final year high school students participated in an international, multi-center prospective, cross-sectional study using a validated questionnaire. Nine countries with different levels of disaster exposure risk and economic development were surveyed. Regression analyses examined the relationship between the likelihood of discussing disasters with friends and family (dependent variable) and a series of independent variables.

There was no statistically significant relationship between a single entity responsible for disaster education and discussions about potential hazards and risks with friends and/or family. While several independent predictors showed a significant main effect, DRE through school lessons in interaction with Family & Charity Organizations had the highest predictive value.

Disaster reduction education might require different delivery channels and methods and should engage with the entities with which the teenagers are more likely to collaborate.

CodreanuTA, CelenzaA, NgoH. Disaster Risk Education of Final Year High School Students Requires a Partnership with Families and Charity Organizations: An International Cross-sectional Survey. Prehosp Disaster Med. 2016;31(3):242–254.

The authors report the results of surveys on the emergency transport or evacuation status of obstetric patients conducted in Miyagi prefecture, one of the major disaster areas of the Great East Japan Earthquake and tsunami.

The surveys examined the damages to maternity institutions, evacuation status and transport of pregnant women, and prehospital childbirths and were conducted in 50 maternity institutions and 12 fire departments in Miyagi.

Two coastal institutions were destroyed completely, and four institutions were destroyed partially by the tsunami, forcing them to stop medical services. In the two-month period after the disaster, 217 pregnant women received hospital transport or gave birth after evacuation. Satisfactory perinatal outcomes were maintained. Emergency obstetric transport increased to approximately 1.4 fold the number before the disaster. Twenty-three women had prehospital childbirths, indicating a marked increase to approximately three times the number of the previous year.

In the acute phase of the tsunami disaster, maternity institutions were damaged severely and perinatal transport was not possible; as a result, pregnant women inevitably gave birth in unplanned institutions, and the number of prehospital births was increased extremely. To obtain satisfactory obstetric outcomes, it is necessary to construct a future disaster management system and to re-recognize pregnant women as people with special needs in disaster situations.

SugawaraJ , HoshiaiT , SatoK , TokunagaH , NishigoriH , AraiT , OkamuraK , YaegashiN . Impact of the Great East Japan Earthquake on Regional Obstetrical Care in Miyagi Prefecture. Prehosp Disaster Med. 2016;31(3):255–258.

The Medical Reserve Corps (MRC) is a national network of community-based volunteer groups created in 2002 by the Office of the United States Surgeon General (Rockville, Maryland USA) to augment the nation’s ability to respond to medical and public health emergencies. However, there is little evidence-based literature available to guide hospitals on the optimal use of medical volunteers and hesitancy on the part of hospitals to use them.

This study sought to determine how MRC volunteers can be used in hospital-based disasters through their participation in a full-scale exercise.

A full-scale exercise was designed as a “Disaster Olympics,” in which the Emergency Medicine residents were divided into teams tasked with completing one of the following five challenges: victim decontamination, mass casualty/decontamination tent assembly, patient triage and registration during a disaster, point of distribution (POD) site set-up and operation, and infection control management. A surge of patients potentially exposed to avian influenza was the scenario created for the latter three challenges. Some MRC volunteers were assigned clinical roles. These roles included serving as members of the suit support team for victim decontamination, distributing medications at the POD, and managing infection control. Other MRC volunteers functioned as “victim evaluators,” who portrayed the potential avian influenza victims while simultaneously evaluating various aspects of the disaster response. The MRC volunteers provided feedback on their experience and evaluators provided feedback on the performance of the MRC volunteers using evaluation tools.

Twenty-eight (90%) MRC volunteers reported that they worked well with the residents and hospital staff, felt the exercise was useful, and were assigned clearly defined roles. However, only 21 (67%) reported that their qualifications were assessed prior to role assignment. For those MRC members who functioned as “victim evaluators,” nine identified errors in aspects of the care they received and the disaster response. Of those who evaluated the MRC, nine (90%) felt that the MRC worked well with the residents and hospital staff. Ten (100%) of these evaluators recommended that MRC volunteers participate in future disaster exercises.

Through use of a full-scale exercise, this study was able to identify roles for MRC volunteers in a hospital-based disaster. This study also found MRC volunteers to be uniquely qualified to serve as “victim evaluators” in a hospital-based disaster exercise.

GistR , DanielP , GrockA , LinC , BryantC , KohlhoffS , RoblinP , ArquillaB . Use of Medical Reserve Corps Volunteers in a Hospital-based Disaster Exercise. Prehosp Disaster Med. 2016;31(3):259–262.

Karachi, Pakistan was affected by a heat wave in June 2015 during the Muslim holy month of Ramadan. Many media reports attributed the excess deaths in part to the practice of daylight fasting during Ramadan. As much of the published research reports on heat-related mortality in Europe and the United States, an exploration of the effects of extreme heat on residents of a South Asian mega-city address a gap in current disaster research.

This report investigated potential risk factors for excess mortality associated with the June 2015 heat wave in Karachi, Pakistan.

Data were obtained through manual review of death certificates at public hospitals and private clinics in Karachi, Pakistan, conducted from July 1 through July 31, 2015 by a trained physician. Demographic data for any deaths with a primary cause of death of heat-related illness were recorded in Microsoft Excel (Microsoft Corp.; Redmond, Washington USA). EpiSheet (2012; Rothman. Modern Epidemiology. Lippincott Williams & Wilkins; Philadelphia, Pennsylvania USA) was used to calculate risk differences (RD), rate ratios (RR), and 95% confidence intervals (95% CI).

Overall, residents of Karachi were approximately 17 times as likely to die of a heat-related cause of death during June 2015 (RR=17.68; 95% CI, 13.87-22.53) when compared with the reference period of June 2014. Residents with a monthly income lower than 20,000 Pakistani Rupees (US $196; RD=0.03; 95% CI, 0.01-0.05) and those with less than a fifth grade education (RD=0.03; 95% CI, 0.00-0.05) were at significantly higher risk of death during the 2015 heat wave compared to the reference period.

Fasting during Ramadan was not a significant risk factor for mortality from heat-related causes during the Karachi heat wave of June 2015. A large number of excess deaths were reported across all demographic groups, which due to the burden of record keeping in an under-resourced health system during a public health emergency, are almost certainly an underestimate.

GhummanU , HorneyJ . Characterizing the Impact of Extreme Heat on Mortality, Karachi, Pakistan, June 2015. Prehosp Disaster Med. 2016;31(3):263–266.

Inter-facility transport of critically ill patients is associated with a high risk of adverse events, and critical care transport (CCT) teams may spend considerable time at sending institutions preparing patients for transport. The effect of mode of transport and distance to be traveled on on-scene times (OSTs) has not been well-described.

Quantification of the time required to package patients and complete CCTs based on mode of transport and distance between facilities is important for hospitals and CCT teams to allocate resources effectively.

This is a retrospective review of OSTs and transport times for patients with hypoxemic respiratory failure transported from October 2009 through December 2012 from sending hospitals to three tertiary care hospitals. Differences among the OSTs and transport times based on the mode of transport (ground, rotor wing, or fixed wing), distance traveled, and intra-hospital pick-up location (emergency department [ED] vs intensive care unit [ICU]) were assessed. Correlations between OSTs and transport times were performed based on mode of transport and distance traveled.

Two hundred thirty-nine charts were identified for review. Mean OST was 42.2 (SD=18.8) minutes, and mean transport time was 35.7 (SD=19.5) minutes. On-scene time was greater than en route time for 147 patients and greater than total trip time for 91. Mean transport distance was 42.2 (SD=35.1) miles. There were no differences in the OST based on mode of transport; however, total transport time was significantly shorter for rotor versus ground, (39.9 [SD=19.9] minutes vs 54.2 [SD=24.7] minutes; P <.001) and for rotor versus fixed wing (84.3 [SD=34.2] minutes; P=0.02). On-scene time in the ED was significantly shorter than the ICU (33.5 [SD=15.7] minutes vs 45.2 [SD=18.8] minutes; P <.001). For all patients, regardless of mode of transportation, there was no correlation between OST and total miles travelled; although, there was a significant correlation between the time en route and distance, as well as total trip time and distance.

In this cohort of critically ill patients with hypoxemic respiratory failure, OST was over 40 minutes and was often longer than the total trip time. On-scene time did not correlate with mode of transport or distance traveled. These data can assist in planning inter-facility transports for both the sending and receiving hospitals, as well as CCT services.

WilcoxSR , SaiaMS , WadenH , McGahnSJ , FrakesM , WedelSK , RichardsJB . On-scene Times for Inter-facility Transport of Patients with Hypoxemic Respiratory Failure. Prehosp Disaster Med. 2016;31(3):267–271.

There is a lack of knowledge about the early phase of severe infection. This report describes the early chain of care in bacteraemia as follows: (a) compare patients who were and were not transported by the Emergency Medical Services (EMS); (b) describe various aspects of the EMS chain; and (c) describe factors of importance for the delay to the start of intravenous antibiotics. It was hypothesized that, for patients with suspected sepsis judged by the EMS clinician, the delay until the onset of antibiotic treatment would be shorter.

All patients in the Municipality of Gothenburg (Sweden) with a positive blood culture, when assessed at the Laboratory of Bacteriology in the Municipality of Gothenburg, from February 1 through April 30, 2012 took part in the survey.

In all, 696 patients fulfilled the inclusion criteria. Their mean age was 76 years and 52% were men. Of all patients, 308 (44%) had been in contact with the EMS and/or the emergency department (ED). Of these 308 patients, 232 (75%) were transported by the EMS and 188 (61%) had “true pathogens” in blood cultures. Patients who were transported by the EMS were older, included more men, and suffered from more severe symptoms and signs.

The EMS nurse suspected sepsis in only six percent of the cases. These patients had a delay from arrival at hospital until the start of antibiotics of one hour and 19 minutes versus three hours and 21 minutes among the remaining patients (P =.0006). The corresponding figures for cases with “true pathogens” were one hour and 19 minutes versus three hours and 15 minutes (P =.009).

Among patients with bacteraemia, 75% used the EMS, and these patients were older, included more men, and suffered from more severe symptoms and signs. The EMS nurse suspected sepsis in six percent of cases. Regardless of whether or not patients with true pathogens were isolated, a suspicion of sepsis by the EMS clinician at the scene was associated with a shorter delay to the start of antibiotic treatment.

AxelssonC , HerlitzJ , KarlssonA , SjöbergH , Jiménez-HerreraM , BångA , JonssonA , BremerA , AnderssonH , GellerstedtM , LjungströmL . The Early Chain of Care in Patients with Bacteraemia with the Emphasis on the Prehospital Setting. Prehosp Disaster Med. 2016;31(3):272–277.

On-scene time (OST) previously has been shown to be a significant component of Emergency Medical Services’ (EMS’) operational delay in acute stroke. Since stroke patients are managed routinely by two-person ambulance crews, increasing the number of personnel available on the scene is a possible method to improve their performance.

Using fire engine crews to support ambulances on the scene in acute stroke is hypothesized to be associated with a shorter OST.

All patients transported to hospital as thrombolysis candidates during a one-year study period were registered by the ambulance crews using a case report form that included patient characteristics and operational EMS data.

Seventy-seven patients (41 [53%] male; mean age of 68.9 years [SD=15]; mean Glasgow Coma Score [GCS] of 15 points [IQR=14-15]) were eligible for the study. Forty-five cases were managed by ambulance and fire engine crews together and 32 by the ambulance crews alone. The median ambulance response time was seven minutes (IQR=5-10) and the fire engine response time was six minutes (IQR=5-8). The number of EMS personnel on the scene was six (IQR=5-7) and two (IQR=2-2), and the OST was 21 minutes (IQR=18-26) and 24 minutes (IQR=20-32; P =.073) for the groups, respectively. In a following regression analysis, using stroke as the dispatch code was the only variable associated with short (<22 minutes) OST with an odds ratio of 3.952 (95% CI, 1.279-12.207).

Dispatching fire engine crews to support ambulances in acute stroke care was not associated with a shorter on-scene stay when compared to standard management by two-person ambulance crews alone. Using stroke as the dispatch code was the only variable that was associated independently with a short OST.

PuolakkaT , VäyrynenT , ErkkiläE-P , KuismaM . Fire Engine Support and On-scene Time in Prehospital Stroke Care – A Prospective Observational Study. Prehosp Disaster Med. 2016;31(3):278–281.

The objective of this study was to assess the accuracy and safety of two pre-defined checklists to identify prehospital post-ictal or hypoglycemic patients who could be discharged at the scene.

A retrospective cohort study of lower acuity, adult patients attended by paramedics in 2013, and who were either post-ictal or hypoglycemic, was conducted. Two self-care pathway assessment checklists (one each for post-ictal and hypoglycemia) designed as clinical decision tools for paramedics to identify patients suitable for discharge at the scene were used. The intention of the checklists was to provide paramedics with justification to not transport a patient if all checklist criteria were met. Actual patient destination (emergency department [ED] or discharge at the scene) and subsequent events (eg, ambulance requests) were compared between patients who did and did not fulfill the checklists. The performance of the checklists against the destination determined by paramedics was also assessed.

Totals of 629 post-ictal and 609 hypoglycemic patients were identified. Of these, 91 (14.5%) and 37 (6.1%) patients fulfilled the respective checklist. Among those who fulfilled the checklist, 25 (27.5%) post-ictal and 18 (48.6%) hypoglycemic patients were discharged at the scene, and 21 (23.1%) and seven (18.9%) were admitted to hospital after ED assessment. Amongst post-ictal patients, those fulfilling the checklist had more subsequent ambulance requests (P=.01) and ED attendances with seizure-related conditions (P=.04) within three days than those who did not. Amongst hypoglycemic patients, there were no significant differences in subsequent events between those who did and did not meet the criteria. Paramedics discharged five times more hypoglycemic patients at the scene than the checklist predicted with no significant differences in the rate of subsequent events. Four deaths (0.66%) occurred within seven days in the hypoglycemic cohort, and none of them were attributed directly to hypoglycemia.

The checklists did not accurately identify patients suitable for discharge at the scene within the Emergency Medical Service. Patients who fulfilled the post-ictal checklist made more subsequent health care service requests within three days than those who did not. Both checklists showed similar occurrence of subsequent events to paramedics’ decision, but the hypoglycemia checklist identified fewer patients who could be discharged at the scene than paramedics actually discharged. Reliance on these checklists may increase transportations to ED and delay initiation of appropriate treatment at a hospital.

TohiraH , FatovichD , WilliamsTA , BremnerA , ArendtsG , RogersIR , CelenzaA , MountainD , CameronP , SprivulisP , AhernT , FinnJ . Paramedic Checklists do not Accurately Identify Post-ictal or Hypoglycaemic Patients Suitable for Discharge at the Scene. Prehosp Disaster Med. 2016;31(3):282–293.

The 11th of March 2011, a magnitude 9.0 earthquake struck alongside the north-east coast of Honshu Island, Japan, causing a tsunami and a major nuclear accident. The French Institute for Public Health Surveillance (InVS) set up, within one week after the triple catastrophe, an Internet-based registry for French nationals who were in Japan at the time of the disasters. In this string of disasters, in this context of uncertainties about the nuclear risks, the aim of this registry was to facilitate the: (1) realization of further epidemiologic studies, if needed; and (2) contact of people if a medical follow-up was needed. The purpose of this report was to describe how the health registry was set up, what it was used for, and to discuss further utilization and improvements to health registries after disasters.

The conception of the questionnaire to register French nationals was based on a form developed as part of the Steering Committee for the management of the post-accident phase in the event of nuclear accident or a radiological emergency situation (CODIRPA) work. The questionnaire was available online.

The main objective was achieved since it was theoretically possible to contact again the 1,089 persons who completed the form. According to the data collected on their space-time budget, to the result of internal contamination measured by the French Institute for Radiological Protection and Nuclear Safety (IRSN) and dosimetric expertise published by the World Health Organization (WHO), it was not suitable to conduct an epidemiologic follow-up of adverse effects of exposure to ionizing radiations among them. However, this registry was used to launch a qualitative study on exposure to stress and psychosocial impact of the Great East Japan Earthquake on French nationals who were in Japan in March 2011.

Setting a registry after a disaster is a very important step in managing the various consequences of a disaster. This experience showed that it is quickly feasible and does not raise adverse side effects in involved people.

MotreffY , PirardP , LagréeC , RoudierC , Empereur-BissonnetP . Voluntary Health Registry of French Nationals after the Great East Japan Earthquake, Tsunami, and Fukushima Daiichi Nuclear Power Plant Accident: Methods, Results, Implications, and Feedback. Prehosp Disaster Med.2016;31(3):326–329.

The Great East Japan Earthquake of March 11, 2011 may have influenced the long-term health of those in the disaster area. It is important to collect current and future health information of the people living in the post-disaster area to provide appropriate health support and quality-oriented care. However, public perceptions of health and genomic studies in the Great East Japan Earthquake disaster area are still unknown.

A questionnaire survey was conducted in one town affected by the Great East Japan Earthquake and subsequent tsunami. The results of the questionnaire were tailed and the differences in responses to each question were assessed by sex and age.

In 284 eligible people (137 men, 147 women), almost all participants agreed to join a health survey investigating the adverse effects of the disaster, and over 80% of the total participants agreed to genomic analysis. Over 70% of the participants wanted to receive pharmacogenetic testing and to receive feedback on which medications were suitable or unsuitable for them.

Most people living in the disaster area are interested in health surveys. Most of the participants also showed interest in genomic analysis.

IshikuroM, NakayaN, ObaraT, SatoY, MetokiH, KikuyaM, TsuchiyaN, NakamuraT, NagamiF, KuriyamaS, HozawaA, the ToMMo Study Group. Public Attitudes toward an Epidemiological Study with Genomic Analysis in the Great East Japan Earthquake Disaster Area. Prehosp Disaster Med. 2016;31(3):330–334.

On October 29, 2012, Hurricane Sandy touched down in New York City (NYC; New York USA) causing massive destruction, paralyzing the city, and destroying lives. Research has shown that considerable damage and loss of life can be averted in at-risk areas from advanced preparation in communication procedures, evacuation planning, and resource allocation. However, research is limited in describing how natural disasters of this magnitude affect emergency departments (EDs).

The aim of this study was to identify and describe trends in patient volume and demographics, and types of conditions treated, as a result of Hurricane Sandy at Staten Island University Hospital North (SIUH-N; Staten Island, New York USA) site ED.

A retrospective chart review of patients presenting to SIUH-N in the days surrounding the storm, October 26, 2012 through November 2, 2012, was completed. Data were compared to the same week of the year prior, October 28, 2011 through November 4, 2011. Daily census, patient age, gender, admission rates, mode of arrival, and diagnoses in the days surrounding the storm were observed.

A significant decline in patient volume was found in all age ranges on the day of landfall (Day 0) with a census of 114; -55% compared to 2011. The daily volume exhibited a precipitous drop on the days preceding the storm followed by a return to usual volumes shortly after.

A notably larger percentage of patients were seen for medication refills in 2012; 5.8% versus 0.4% (P<.05). Lacerations and cold exposure also were increased substantially in 2012 at 7.6% versus 2.8% (P<.05) and 3.8% versus 0.0% (P<.05) of patient visits, respectively.

A large decline in admissions was observed in the days prior to the storm, with a nadir on Day +1 at five percent (-22%). Review of admitted patients revealed atypical admissions for home care service such as need for supplemental oxygen or ventilator.

In addition, a drop in Emergency Medical Services (EMS) utilization was seen on Days 0 and +1. The SIUH-N typically sees 18% of patients arriving via EMS. On Day +1, only two percent of patients arrived by ambulance.

The daily ED census saw a significant decline in the days preceding the storm. In addition, the type of conditions treated varied from baseline, and a considerable drop in hospital admissions was seen. Data such as these presented here can help make predictions for future scenarios.

GreensteinJ , ChackoJ , ArdolicB , BerwaldN . Impact of Hurricane Sandy on the Staten Island University Hospital Emergency Department. Prehosp Disaster Med. 2016;31(3):335–339.

Crush syndrome, of which little is known, occurs as a result of compression injury to the muscles. This syndrome is characterized by systemic manifestations such as acute kidney injury (AKI), hypovolemic shock, and hydroelectrolytic variations. This pathology presents high morbidity and mortality if not managed aggressively by prehospital care.

A 40-year-old worker was rescued after being buried underground in a ditch for 19 hours. The patient was administered early resuscitation with isotonic solutions and monitored during the entire rescue operation. Despite having increased plasma levels of total creatine kinase (CK), the patient did not develop AKI or hydroelectrolytic variations.

Aggressive early management with isotonic solutions before hospital arrival is an effective option for nephron-protection and prevention of crush syndrome.

MardonesA , ArellanoP , RojasC , GutierrezR , OliverN , BorgnaV . Prevention of Crush Syndrome through Aggressive Early Resuscitation: Clinical Case in a Buried Worker. Prehosp Disaster Med. 2016;31(3):340–342.