Lessons learned from chlorine intoxications in swimming pools: the challenge of pediatric mass toxicological events.

INTRODUCTION: The classical doctrine of mass toxicological events provides general guidelines for the management of a wide range of "chemical" events. The guidelines include provisions for the: (1) protection of medical staff with personal protective equipment; (2) simple triage of casualties; (3) airway protection and early intubation; (4) undressing and decontamination at the hospital gates; and (5) medical treatment with antidotes, as necessary. A number of toxicological incidents in Israel during the summer of 2005 involved chlorine exposure in swimming pools. In the largest event, 40 children were affected. This study analyzes its medical management, in view of the Israeli Guidelines for Mass Toxicological Events. METHODS: Data were collected from debriefings by the Israeli Home Front Command, emergency medical services (EMS), participating hospitals, and hospital chart reviews. The timetable of the event, the number and severity of casualties evacuated to each hospital, and the major medical and logistical problems encountered were analyzed according to the recently described methodology of Disastrous Incident Systematic Analysis Through-Components, Interactions, Results (DISAST-CIR). RESULTS: The first ambulance arrived on-scene seven minutes after the first call. Emergency medical services personnel provided supplemental oxygen to the victims at the scene and en route when required. Forty casualties were evacuated to four nearby hospitals. Emergency medical services classified 26 patients as mildly injured, 13 as mild-moderate, and one as moderate, suffering from pulmonary edema. Most children received bronchodilators and steroids in the emergency room; 20 were hospitalized. All were treated in pediatric emergency rooms. None of the hospitals deployed their decontamination sites. CONCLUSIONS: Event management differed from the standard Israeli toxicological doctrine. It involved EMS triage of casualties to a number of medical centers, treatment in pediatric emergency departments, lack of use of protective gear, and omission of decontamination prior to emergency department entrance. Guidelines for mass toxicological events must be tailored to unique scenarios, such as chlorine intoxications at swimming pools, and for specific patient populations, such as children. All adult emergency departments always should be prepared and equipped for taking care of pediatric patients.

Scintigraphic characteristics of non-ossifying fibroma in military recruits undergoing bone scintigraphy for suspected stress fractures and lower limb pains.

INTRODUCTION: Non-ossifying fibroma (NOF) is the most common fibrous bone lesion in children and young adults. This benign lesion is not a true neoplasm but is considered a developmental defect. Clinically, the lesion is asymptomatic and has a predilection for the long bones, particularly the femur and the tibia. NOF that ossify can show increased uptake on bone scintigraphy. Although the radiographic and histopathological findings of NOF have been well described, the scintigraphic findings of the abnormality have only been incidentally mentioned in the literature. AIM: To document the scintigraphic features of NOF in a group of military recruits undergoing bone scintigraphy for suspected stress fractures. Features to differentiate co-existent NOF and stress fractures lesions are discussed. MATERIALS AND METHODS: Eighty-three military recruits, 67 male and 16 female, aged 18 to 22 years (mean, 19.4 years), who underwent Tc-methylene diphosphonate bone scans for suspected stress fractures or because of pain of the lower limbs had 91 focal lesions on bone scan which on further evaluation demonstrated characteristic radiographic findings of NOF. We evaluated the anatomical site of the lesions, documented the intensity of uptake on bone scan and compared the findings with the radiographic description of the lesions. Comparison with the characteristic scintigraphic pattern of co-existent stress fracture lesions and with previously reported data was performed. RESULTS: A total of 91 NOF lesions were detected. Overall, 89% of NOF were located about the knee. Anatomic distribution of NOF lesions was as follows: 43 (47.3%, R=25, L=18) were located in the postero-medial aspect of the distal femur, 18 (19.8%, R=12, L=6) in the postero-medial aspect of the proximal tibia, 11 (12%, R=5, L=6) in the postero-lateral aspect of the distal femur, 10 (11%, R=4, L=6) in the postero-lateral aspect of the distal tibia, 4 (4.4%, R=2, L=2) in the postero-lateral aspect of the proximal tibia, 3 (3.3%, L=3) in the antero-central aspect of proximal tibia, 1 (1.1%, L=1) in the antero-lateral aspect of distal femur, 1 (1.1%, L=1) in the medial-central aspect of the proximal tibia. In this series NOF lesions were not found in the fibula. Eighty five of 91 (93.4%) of all NOF were located at the metaphysis of the long bones, 2/91 (2.2%) were located at the meta-diaphyseal region of the long bones and only 4/91 (4.4%) of the lesions were located at the diaphysis. All the NOF showed variable degrees of focal increased tracer uptake on bone scan. The bone scan appearance of the focal lesions was: faint uptake in 29 (31.9%), mild uptake in 27 (29.7%), moderate uptake in 28 (30.7%) and intensely increased uptake in seven (7.7%). The radiographic description of the NOF was: lucent NOF three (3.3%), mixed sclerotic and lucent 68 (74.7%) and sclerotic in 20 (22%). Most of the NOF which demonstrated moderate or intensely increased tracer uptake had mixed lucent and sclerotic radiographic appearance (healing). Most of the sclerotic lesions (healed) showed faint uptake. Co-existent stress fractures were predominantly located in the diaphysis of the long bones, characteristically in the postero-medial aspect of the mid-third of the tibia or femur. CONCLUSIONS: Military recruits undergoing bone scan for suspected stress fracture might have incidental findings which require further evaluation. Focal lesions on bone scan located about the knee in the lateral aspect of the distal femur or lateral aspect of the proximal tibia in the metaphyseal region of these bones are not compatible with the characteristic scintigraphic features of stress fracture. Such a finding should raise the suspicion for other bony lesions such as NOF, which is commonly located in this region. During the healing phase of the NOF which commonly occur in the age range of this group, the lesion shows mild-to-moderate increased tracer uptake on bone scan. Plain film radiography is usually diagnostic and patients are followed up conservatively. Some NOF lesions are still indistinguishable from stress fracture or splints on bone scan.

Characteristics of skeletal stress fractures in female military recruits of the Israel defense forces on bone scintigraphy.

AIM: Clinical surveys on stress fractures (SF) in female military recruits are scarce. The aim of this study was to characterize the scintigraphic findings and classify the distribution and pattern of SF in a group of female recruits of the Israel Defense Forces (IDF). MATERIALS AND METHODS: The bone scans of 146 female recruits (age range, 19-20.6 years) with suspected SF were assessed retrospectively. The SF lesions were classified qualitatively into 4 grades of bone response according to the classification criteria introduced by Zwas et al. SF location and distribution were analyzed, and in several cases, the abnormalities were correlated radiographically. RESULTS: One hundred forty-six female recruits were examined, of which 93 (64%) had bone scan findings of SF with a total of 247 SF. Forty-eight patients (with or without SF) had shin splints, 32 had thigh splints, and 34 had normal scans. Several SF were detected in sites that were not clinically suspected. Thirty-nine percent of the SF were located in the feet (tarsal bones 22.7%, metatarsal 16.2%), 36.8% in tibiae (predominantly in the midthird), 15.7% in femurs, 6.5% in the pubic and sacroiliac regions, and 2% in the fibula. SF in the tibiae and femurs were mainly located in the posterior aspect of the medial cortical region. Forty-nine percent of the patients had bilateral SF. The SF were classified on a 4-grade scale: 41.3% were grade I, 37.2% grade II, 15.8% grade III, and 5.7% grade IV. Thirty-three percent of the patients had one site of SF, 31% had 2 sites, 7.5% had 3 sites, 12% had 4 sites, 7.5% had 5 sites, and 9% had more than 5 sites of SF. Different grades of lesions were often found in the same patient. Sixty-five percent of the patients had SF in the feet, 59% in the tibiae, 26% in the femurs, 14% in the pubic or sacroiliac regions, and 5% in the fibula. Radiography was performed in 15% of the patients. Only one patient had a positive finding on radiography. CONCLUSIONS: This study shows that lower leg SF are not uncommon in female military recruits. We clearly distinguished between SF and shin splints, which have important clinical consequences on treatment. Most of the SF were mild (grade I and II) located in the feet and tibiae. This study supports the experience gained in other studies, and emphasizes the significant number of pubic and sacroiliac SF in female soldiers, which is significantly higher in comparison with previous reports on male soldiers.

Prehospital care of tsunami victims in Thailand: description and analysis.

INTRODUCTION: On 26 December 2004 at 09:00 h, an earthquake of 9.0 magnitude (Richter scale) struck the area off of the western coast of northern Sumatra, Indonesia, triggering a Tsunami. As of 25 January 2005, 5,388 fatalities were confirmed, 3,120 people were reported missing, and 8,457 people were wounded in Thailand alone. Little information is available in the medical literature regarding the response and restructuring of the prehospital healthcare system in dealing with major natural disasters. OBJECTIVE: The objective of the study was to analyze the prehospital medical response to the Tsunami in Thailand, and to identify possible ways of improving future preparedness and response. METHODS: The Israeli Defense Forces (IDF) Home Front Command Medical Department sent a research delegation to study the response of the Thai medical system to the 2004 earthquake and Tsunami disaster. The delegation met with Thai healthcare and military personnel, who provided medical care for and evacuated the Tsunami victims. The research instruments included questionnaires (open and closed questions), interviews, and a review of debriefing session reports held in the days following the Tsunami. RESULTS: Beginning the day after the event, primary health care in the affected provinces was expanded and extended. This included: (1) strengthening existing primary care facilities with personnel and equipment; (2) enhancing communication and transportation capabilities; (3) erecting healthcare facilities in newly constructed evacuation centers; (4) deploying mobile, medical teams to make house calls to flood refugees in affected areas; and (5) deploying ambulance crews to the affected areas to search for survivors and provide primary care triage and transportation. CONCLUSION: The restructuring of the prehospital healthcare system was crucial for optimal management of the healthcare needs of Tsunami victims and for the reduction of the patient loads on secondary medical facilities. The disaster plan of a national healthcare system should include special consideration for the restructuring and reinforcement prehospital system.

Response of Thai hospitals to the tsunami disaster.

The disaster caused by the tsunami of 26 December 2004 was one of the worst that medical systems have faced. The aim of this study was to learn about the medical response of the Thai hospitals to this disaster and to establish guidelines that will help hospitals prepare for future disasters. The Israeli Defense Forces (IDF) Home Front Command (HFC) Medical Department sent a research delegation to Thai hospitals to study: (1) pre-event hospital preparedness; (2) patient evacuation and triage; (3) personnel and equipment reinforcement; (4) modes used for alarm and recruitment of hospital personnel; (5) internal reorganization of hospitals; and (6) admission, discharge, and secondary transfer (forward management) of patients. Thai hospitals were prepared for and drilled for a general mass casualty incident (MCI) involving up to 50 casualties. However, a control system to measure the success of these drills was not identified, and Thai hospitals were not prepared to deal with the unique aspects of a tsunami or to receive thousands of victims. Modes of operation differed between provinces. In Phang Nga and Krabi, many patients were treated in the field. In Phuket, most patients were evacuated early to secondary (district) and tertiary (provincial) hospitals. Hospitals recalled staff rapidly and organized the emergency department for patient triage, treatment, and transfer if needed. Although preparedness was deficient, hospital systems performed well. Disaster management should focus on field-based first aid and triage, and rapid evacuation to secondary hospitals. Additionally, disaster management should reinforce and rely on the existing and well-trusted medical system.

Disaster healthcare system management and crisis intervention leadership in Thailand--lessons learned from the 2004 Tsunami disaster.

INTRODUCTION: Quarantelli established criteria for evaluating the effectiveness of disaster management. OBJECTIVES: The objectives of this study were to analyze the response of the healthcare system to the Tsunami disaster according to the Quarantelli principles, and to validate these principles in a scenario of a disaster due to natural hazards. METHODS: The Israeli Defense Forces (IDF) Home Front Command Medical Department sent a research team to study the response of the Thai medical system to the disaster. The analysis of the disaster management was based on Quarantelli's 10 criteria for evaluating the management of community disasters. Data were collected through personal and group interviews. RESULTS: The three most important elements for effective disaster management were: (1) the flow of information; (2) overall coordination; and (3) leadership. Although pre-event preparedness was for different and smaller scenarios, medical teams repeatedly reported a better performance in hospitals that recently conducted drills. CONCLUSIONS: In order to increase effectiveness, disaster management response should focus on: (1) the flow of information; (2) overall coordination; and (3) leadership.

Response of Thai Hospitals to the Tsunami Disaster.

The disaster caused by the Tsunami of 26 December 2004 was one of the worst that medical systems have faced. The aim of this study was to learn about the medical response of the Thai hospitals to this disaster and to establish guidelines that will help hospitals prepare for future disasters. The Israeli Defense Forces (IDF) Home Front Command (HFC) Medical Department sent a research delegation to Thai hospitals to study: (1) pre-event hospital preparedness; (2) patient evacuation and triage; (3) personnel and equipment reinforcement; (4) modes used for alarm and recruitment of hospital personnel; (5) internal reorganization of hospitals; and (6) admission, discharge, and secondary transfer (forward management) of patients. Thai hospitals were prepared for and drilled for a general mass casualty incident (MCI) involving up to 50 casualties. However, a control system to measure the success of these drills was not identified, and Thai hospitals were not prepared to deal with the unique aspects of a tsunami or to receive thousands of victims. Modes of operation differed between provinces. In Phang Nga and Krabi, many patients were treated in the field. In Phuket, most patients were evacuated early to secondary (district) and tertiary (provincial) hospitals. Hospitals recalled staff rapidly and organized the emergency department for patient triage, treatment, and transfer if needed. Although preparedness was deficient, hospital systems performed well. Disaster management should focus on field-based first aid and triage, and rapid evacuation to secondary hospitals. Additionally, disaster management should reinforce and rely on the existing and well-trusted medical system.

Lessons learned from cross-border medical response to the terrorist bombings in Tabba and Ras-el-Satan, Egypt, on 07 October 2004.

INTRODUCTION: Large-scale, terrorist attacks can happen in peripheral areas, which are located close to a country's borders and far from its main medical facilities and involve multi-national casualties and responders. The objective of this study was to analyze the terrorist suicide bombings that occurred on 07 October 2004, near the Israeli-Egyptian border, as representative of such a complex scenario. METHODS: Data from formal debriefings after the event were processed in order to learn about victim outcomes, resource utilization, critical events, and time course of the emergency response. RESULTS: A total of 185 injured survivors were repatriated: four were severely wounded, 13 were moderately injured, and 168 were mildly injured. Thirty-eight people died. A forward medical team landed at the border town's airport, which provided reinforcement in the field and in the local hospital. Israeli and Egyptian search and rescue teams collaborated at the destruction site. One-hundred sixty-eight injured patients arrived at the small border hospital that rapidly organized itself for the mass-casualty incident, operating as an evacuation "staging hospital". Twenty-three casualties secondarily were distributed to two major trauma centers in the south and the center of Israel, respectively, either by ambulance or by helicopter. CONCLUSION: Large-scale, terrorist attacks at a peripheral border zone can be handled by international collaboration, reinforcement of medical teams at the site itself and at the peripheral neighboring hospital, rapid rearrangement of an "evacuation hospital", and efficient transport to trauma centers by ambulances, helicopters, and other aircraft.

Mass medical repatriation of injured civilians after terrorist attack in Mombassa, Kenya: medical needs, resources used, and lessons learned.

INTRODUCTION: On 28 November 2002, three suicide bombers crashed their car into a hotel in Mombassa, Kenya; 12 people were killed, including three Israelis, and 80 were wounded (22 of whom were Israeli). The Israeli Defense Force Airborne Medical Evacuation Flight Teams participated in a repatriation mission to bring the wounded home. OBJECTIVES: The objectives of this study are to outline the distinctive aspects of this mission, as well as to share the experiences and lessons learned. METHODS: Israeli Army debriefing reports were used to study the composition of the crew, medical equipment taken, injury distribution, mode of operation, and mission schedule. RESULTS: A total of six fixed-wing aircraft were used--two Boeing 707s and four Hercules C-130s--with a total of 54 medical team members on board. A total of 260 Israelis were repatriated, 22 of whom were wounded, and three were dead. Of the casualties, 14 were conveyed sitting, and eight supine. The time from the first landing in Kenya to the evacuation of the last supine patient was 5.5 hours. Nurses, as well as social workers, played a central role in the mission. A forward team, including five doctors, was used for the initial organization and for gathering information on the medical status of the casualties. CONCLUSIONS: There was redundancy in the medical crew and medical equipment sent. The need for improved infrastructure on the medical aircraft was stressed. Based on this experience, a new mode for operation for similar missions in the future was formulated.