Discrepancies in Mass Shootings and Access to Trauma Care Across the United States, 2014-2018.

INTRODUCTION: The United States has one of the highest rates of gun violence and mass shootings. Timely medical attention in such events is critical. The objective of this study was to assess geographic disparities in mass shootings and access to trauma centers. METHODS: Data for all Level I and II trauma centers were extracted from the American College of Surgeons and the Trauma Center Association of America registries. Mass shooting event data (4+ individuals shot at a single event) were taken from the Gun Violence Archive between 2014 and 2018. RESULTS: A total of 564 trauma centers and 1672 mass shootings were included. Ratios of the number of mass shootings vs trauma centers per state ranged from 0 to 11.0 mass shootings per trauma center. States with the greatest disparity (highest ratio) included Louisiana and New Mexico. CONCLUSION: States in the southern regions of the US experience the greatest disparity due to a high burden of mass shootings with less access to trauma centers. Interventions are needed to increase access to trauma care and reduce mass shootings in these medically underserved areas.

Assistência de urgência e emergência: desafios no atendimento a múltiplas vítimas / Urgency and emergency assistance: challenges in caring for multiple victims / Urgencias y emergencias: retos en la atención a múltiples víctimas

A urgência e emergência, por sua vez, se faz como ocorrência imprevista com ou sem risco potencial à vida, onde o indivíduo necessita de assistência e pressupõem atendimento rápido, proporcional a sua gravidade. O presente trabalho tem o objetivo de promover reflexões acerca dos desafios que surgem diante do atendimento a múltiplas vítimas nos serviços médicos de urgência e emergência. Trata-se de uma revisão integrativa da literatura. Realizou-se uma análise de materiais já publicados na literatura e artigos científicos divulgados em bases de dados: Scientific Eletronic Library Online, Medical Literature Analysis and Retrieval System Online e Localizador de informação em Saúde. Foram encontradas nas bases de dados, 25 estudos completos, após a leitura dos resumos, 21 artigos foram selecionados para análise na íntegra, sendo 17 eleitos para integrar a revisão integrativa. Diante dos resultados obtidos, observou que as equipes de atendimento pré- hospitalar vivenciam desafios para atender múltiplas vítimas, e dentro desse paradigma existem várias etapas que devem ser seguidas, que envolvem comunicação desde um protocolo de atendimento inicial ao transporte final. Portanto, observa-se a necessidade de maiores estudos e desenvolvimento de novas tecnologias que auxiliam na assistência a múltiplas vítimas, como também o prepara e atualização dos profissionais.

Urgency and emergency, in turn, is made as an unforeseen occurrence with or without potential risk to life, where the individual needs assistance and quick care, in turn, proportional to its severity. The work of emergency care and the need to respond to problems presented in urgent and emergency services. This is an integrative literature review. An analysis was performed of materials already published in the literature and articles published in databases: Scientific Electronic Library Online, Medical Literature Analysis and Retrieval System Online and Health Information Locator. All studies were complete, after reading the studies,21 articles were selected for full analysis, with 17 studies elected to integrate the integrative review. Results obtained, observed that pre care teams experience challenges to support various hospital communication protocols, and within these paradigms from initial care to transport. Therefore, there is a need for studies and development of technologies that assist in the installation of larger and more up-to-date devices, there is a need for studies and development of new technologies, as well as preparation.

La atención de urgencia y emergencia es un suceso imprevisto con o sin riesgo potencial para la vida, en el que el individuo necesita asistencia y requiere una atención rápida, proporcional a su gravedad. Este documento pretende promover la reflexión sobre los retos que surgen al tratar con múltiples víctimas en los servicios médicos de urgencia y emergencia. Se trata de una revisión bibliográfica integradora. Se ha realizado un análisis de los materiales publicados en la literatura y los artículos científicos divulgados en las bases de datos: Scientific Eletronic Library Online, Medical Literature Analysis and Retrieval System Online y Localizador de información en Salud. Se encontraron en las bases de datos, 25 estudios completos, después de leer los resúmenes, se seleccionaron 21 artículos para el análisis en su totalidad, siendo 17 elegidos para integrar la revisión integradora. A partir de los resultados obtenidos, se observa que los equipos de atención prehospitalaria viven desafíos para atender a múltiples víctimas, y dentro de este paradigma existen varias etapas que deben seguirse, que implican la comunicación desde un protocolo de atención inicial hasta el transporte final. Por lo tanto, se observa la necesidad de realizar más estudios y desarrollar nuevas tecnologías que ayuden en la asistencia a las múltiples víctimas, así como la preparación y actualización de los profesionales.

Mass casualty medicine: time for a 21st century refresh.

Mass casualty events are on the rise globally, as we face increasing pressures from scarcity of resources, population growth, systemic inequalities, geopolitical instabilities, and polarised discourse. Although they are rare events for an individual practitioner, they are going to happen to someone, somewhere, this week, this month, this year. And whilst they are often the last consideration for healthcare systems under constant pressures from daily routine work, individuals, departments, hospitals, and systems have to step up effectively in times of crisis. Failure to do so can lead to suboptimal outcomes for casualties, and even perceived failures can have crippling consequences on staff, families, and communities for years.

Coronavirus Outbreak: Is Radiology Ready? Mass Casualty Incident Planning.

On March 11, 2020, the World Health Organization declared a coronavirus disease 2019 (COVID-19) pandemic. Health care systems worldwide should be prepared for an unusually high volume of patients in the next few weeks to months. Even the most efficient radiology department will undergo tremendous stress when victims of a mass casualty flood the emergency department and in turn the radiology department. A significant increase is expected in the number of imaging studies ordered for the initial diagnosis and treatment follow-up of cases of COVID-19. Here, we highlight recommendations for developing and implementing a mass casualty incident (MCI) plan for a viral outbreak, such as the current COVID-19 infection. The MCI plan consists of several steps, including preparation, mobilization of resources, imaging chain, adjusting imaging protocols, and education, such as MCI plan simulation and in-service training. Having an MCI plan in place for a viral outbreak will protect patients and staff and ultimately decrease virus transmission. The use of simulations will help identify throughput and logistical issues.

Triage in Complex, Coordinated Terrorist Attacks.

INTRODUCTION: Terror attacks have increased in frequency, and tactics utilized have evolved. This creates significant challenges for first responders providing life-saving medical care in their immediate aftermath. The use of coordinated and multi-site attack modalities exacerbates these challenges. The use of triage is not well-validated in mass-casualty settings, and in the setting of intentional mass violence, new and innovative approaches are needed. METHODS: Literature sourced from gray and peer-reviewed sources was used to perform a comparative analysis on the application of triage during the 2011 Oslo/Utoya Island (Norway), 2015 Paris (France), and 2015 San Bernardino (California USA) terrorist attacks. A thematic narrative identifies strengths and weaknesses of current triage systems in the setting of complex, coordinated terrorist attacks (CCTAs). DISCUSSION: Triage systems were either not utilized, not available, or adapted and improvised to the tactical setting. The complexity of working with large numbers of patients, sensory deprived environments, high physiological stress, and dynamic threat profiles created significant barriers to the implementation of triage systems designed around flow charts, physiological variables, and the use of tags. Issues were identified around patient movement and "tactical triage." CONCLUSION: Current triage tools are inadequate for use in insecure environments, such as the response to CCTAs. Further research and validation are required for novel approaches that simplify tactical triage and support its effective application. Simple solutions exist in tactical triage, patient movement, and tag use, and should be considered as part of an overall triage system.

Analysis of Emergency Health Care Workforce and Service Readiness for a Mass Casualty Event in the Republic of Ireland.

OBJECTIVE: Ultimately, a country's capacity for a large-scale major emergency response will be directly related to the competence of its health care provider (HCP) workforce and communication between emergency responders and hospitals. The purpose of this study was to assess HCP preparedness and service readiness for a major emergency involving mass casualties (mass casualty event or MCE) in Ireland. METHODS: A cross-sectional study using a 53-item survey was administered to a purposive sample of emergency responders and HCPs in the Republic of Ireland. Data collection was achieved using the Qualtrics® Research Suite. Descriptive statistics and appropriate tests of comparison between professional disciplines were conducted using Stata 13. RESULTS: A total of 385 respondents, registered nurses (43.4%), paramedics (37.9%), medical doctors (10.1%), and administrators/managers (8.6%), participated in the study. In general, a level of knowledge of MCEs and knowledge of clinical response activities and self-assessed clinical competence varied drastically across many aspects of the survey. Knowledge and confidence also varied across professional disciplines (P<0.05) with nurses, in general, reporting the least knowledge and/or confidence. CONCLUSIONS: The results demonstrate that serious deficits exist in HCP knowledge, skills, and self-perceived abilities to participate in a large-scale MCE. Results also suggest a poor knowledge base of existing major emergency response plans. (Disaster Med Public Health Preparedness. 2019;13:243-255).

Operational and Financial Considerations of Using Drones for Medical Support of Mass Events in Poland.

OBJECTIVE: The implementation of drones in the medical security system requires a proper planning of the cooperation of different services, dividing the area into sectors, assessing potential risks, and other factors. This study refers to the cost analysis of using drones in the medical support of mass events. The aim of this research is to analyze the costs of unmanned aerial vehicle (UAV) implementation in the mass event medical support system. METHODS: The description includes purchase and maintenance costs of UAVs. The analysis also involves ways of raising funds for projects related to the UAV sector. Apart from the financial aspect, staff and drone operator training issues are the subjects of this analysis as well. RESULTS: This study is based on a specialist research involving drones and referring to reports on the current situation in Poland and in the world. CONCLUSIONS: The presented funds required for such projects and the way of raising these funds illustrate the range of the project and its requirements. (Disaster Med Public Health Preparedness. 2019;13:527-532).

Assessment of the disaster medical response system through an investigation of a 43-vehicle mass collision on Jung-ang expressway.

PURPOSE: It was considered the challenges of the actual response and the potential for improvement, including the activities of the disaster response system, national emergency medical center, and the regional base hospital for the treatment of multiple traffic accident victims. The purpose of this study was to analyze the accident management system through real investigating the multiple collision over 10 vehicles with mass casualty events as a disaster situation. METHODS: This study was retrospective study to analyze the disaster event with multiple collision traffic accident on the expressway in Korea. We visited five medical centers for eight days since the accident occurred and interviewed the injured patients in this accident to examine the health status and medical records. After that, we visited the sixteen car-repair shops in four cities for real investigate about damaged vehicles. According to the arrangement of the accident situation for the accident vehicles through real-world investigation, we reproduced all parts of the accident scene, which were real-world investigated, by the accident situation sketch program. The collected data were summarized by Collision Deformation Classification (CDC) codes, and the medical records of the occupants were assessed using the Injury Severity Score (ISS). RESULTS: The cause of the accident was snow freezing of the road. The information about 72 injured patients on 31 damaged vehicles was collected by phone, visit, and actual accident investigation. Of the 72 patients who were examined, 4 were severely injured and 68 were mildly injured. The accident occurred in the order of Sedan 13 (41.9%), SUV 11 (35.5%), Truck 4 (12.9%), Van 2 (6.5%) and Bus 1 (3.2%). The median value of the age [lower quartile and upper quartile] was 43 [34.5-52] years old and the patients included 25 drivers, 11 passengers, 7 back seat passengers, and 29 bus passengers. CONCLUSION: The primary cause of this mass collision accident was road surface freezing, but the more serious secondary cause was a driver's inability to avoid the accident scene after the first collision. The severely injured occupants were occurred on the roads outside and inside the vehicle. In the event of a disaster, various teams from the police team, firefighting team, DMAT, EMS, road management team are gathered, and communication and command system between each team is important in order to identify and solve the disaster situation. To do this, it is important to develop manuals and prepare for training through repeated simulations.

Evaluation of Health Care Services Provided in Political Public Meetings in Turkey: A Forgotten Detail in Politics.

BACKGROUND: Political parties in Turkey execute political public meetings (PPMs) during their election campaign for members of the parliament (MoP). A great number of people attend these meetings. No guidelines exist regarding preparation and organization of health care services provided during these meetings. Furthermore, there is no study evaluating health care problems encountered in previous PPMs. OBJECTIVE: Political parties arranged PPMs in 2015 during the election campaign for general election of MoP. The present study aimed to investigate the context of health care services, the distribution of assigned health staff, as well as the number and the symptoms of patients admitted in health care tents in these PPMs. METHODS: Two general elections for MoP were done in Turkey on June 7, 2015 and November 1, 2015. Health care services were provided by the City Emergency Medical Services Department (CEMSD) in the cities. Demographic characteristics, symptoms, comorbid conditions, treatment, discharge, and hospital transfer of the patients were obtained from patient medical registration records. Information about the distribution and the number of the assigned staff was received from local CEMSDs. The impact of variables such as the number of attendees, heat index, humidity, and the day of the week on the number of patients and the patient presentation rate (PPR) were analyzed. RESULTS: A total of 97 PPMs were analyzed. The number of total attendees was 5,265,450 people. The number of patients seeking medical help was 1,991. The PPR was 0.5 (0.23-0.91) patients per 1,000 attendees. Mean age of the patients was 40 (SD=19) years old while 1,174 (58.9%) of the patients were female. A total of 1,579 patients were treated in the tents and returned to the PPM following treatment. Two-hundred and three patients were transferred to a hospital by ambulance. Transfer-to-hospital ratio (TTHR) was 0.05 (0.0-0.13) patients per 1,000 attendees. None of the patients suffered sudden cardiac death (SCD) or cardiac arrest. Medical conditions were the main cause for admission. The most common symptoms were dizziness, low blood pressure, fatigue, and hypertension, respectively. The most commonly used medical agents included pain killers and myorelaxants. The number of attendees, heat index, and weekend days were positively correlated with the number of the patients. CONCLUSION: The majority of medical conditions encountered in PPMs are easily treatable in health care tents settled in the meeting area. The number of attendees, heat index, and weekend days are factors associated with the number of patients. CeyhanMA, DemirGG, GülerGB. Evaluation of health care services provided in political public meetings in Turkey: a forgotten detail in politics. Prehosp Disaster Med. 2018;33(6):607-613.

Determining the scope of attacks on health in four governorates of Syria in 2016: Results of a field surveillance program.

BACKGROUND: Violent attacks on and interferences with hospitals, ambulances, health workers, and patients during conflict destroy vital health services during a time when they are most needed and undermine the long-term capacity of the health system. In Syria, such attacks have been frequent and intense and represent grave violations of the Geneva Conventions, but the number reported has varied considerably. A systematic mechanism to document these attacks could assist in designing more protection strategies and play a critical role in influencing policy, promoting justice, and addressing the health needs of the population. METHODS AND FINDINGS: We developed a mobile data collection questionnaire to collect data on incidents of attacks on healthcare directly from the field. Data collectors from the Syrian American Medical Society (SAMS), using the tool or a text messaging system, recorded information on incidents across four of Syria's northern governorates (Aleppo, Idleb, Hama, and Homs) from January 1, 2016, to December 31, 2016. SAMS recorded a total of 200 attacks on healthcare in 2016, 102 of them using the mobile data collection tool. Direct attacks on health facilities comprised the majority of attacks recorded (88.0%; n = 176). One hundred and twelve healthcare staff and 185 patients were killed in these incidents. Thirty-five percent of the facilities were attacked more than once over the data collection period; hospitals were significantly more likely to be attacked more than once compared to clinics and other types of healthcare facilities. Aerial bombs were used in the overwhelming majority of cases (91.5%). We also compared the SAMS data to a separate database developed by Physicians for Human Rights (PHR) based on media reports and matched the incidents to compare the results from the two methods (this analysis was limited to incidents at health facilities). Among 90 relevant incidents verified by PHR and 177 by SAMS, there were 60 that could be matched to each other, highlighting the differences in results from the two methods. This study is limited by the complexities of data collection in a conflict setting, only partial use of the standardized reporting tool, and the fact that limited accessibility of some health facilities and workers and may be biased towards the reporting of attacks on larger or more visible health facilities. CONCLUSIONS: The use of field data collectors and use of consistent definitions can play an important role in the tracking incidents of attacks on health services. A mobile systematic data collection tool can complement other methods for tracking incidents of attacks on healthcare and ensure the collection of detailed information about each attack that may assist in better advocacy, programs, and accountability but can be practically challenging. Comparing attacks between SAMS and PHR suggests that there may have been significantly more attacks than previously captured by any one methodology. This scale of attacks suggests that targeting of healthcare in Syria is systematic and highlights the failure of condemnation by the international community and medical groups working in Syria of such attacks to stop them.

Hospital Surge Capacity: A Web-Based Simulation Tool for Emergency Planners.

The National Center for the Study of Preparedness and Catastrophic Event Response (PACER) has created a publicly available simulation tool called Surge (accessible at http://www.pacerapps.org) to estimate surge capacity for user-defined hospitals. Based on user input, a Monte Carlo simulation algorithm forecasts available hospital bed capacity over a 7-day period and iteratively assesses the ability to accommodate disaster patients. Currently, the tool can simulate bed capacity for acute mass casualty events (such as explosions) only and does not specifically simulate staff and supply inventory. Strategies to expand hospital capacity, such as (1) opening unlicensed beds, (2) canceling elective admissions, and (3) implementing reverse triage, can be interactively evaluated. In the present application of the tool, various response strategies were systematically investigated for 3 nationally representative hospital settings (large urban, midsize community, small rural). The simulation experiments estimated baseline surge capacity between 7% (large hospitals) and 22% (small hospitals) of staffed beds. Combining all response strategies simulated surge capacity between 30% and 40% of staffed beds. Response strategies were more impactful in the large urban hospital simulation owing to higher baseline occupancy and greater proportion of elective admissions. The publicly available Surge tool enables proactive assessment of hospital surge capacity to support improved decision-making for disaster response. (Disaster Med Public Health Preparedness. 2018;12:513-522).

Special Considerations for Mass Violence Events in Senior Living Facilities: A Case Report on the Pinelake Health and Rehab Center Shooting.

The 2009 Pinelake Health and Rehab Center shooting in Carthage, North Carolina, presents a unique case study for examining the specific considerations for mass violence events in senior living facilities. A variety of factors, including reduced sensory perception, reduced mobility, and cognitive decline, may increase the vulnerability of the populations of senior living facilities during mass violence events. Management of response aspects such as evacuation, relocation, and reunification also require special consideration in the context of mass violence at senior living facilities. Better awareness of these vulnerabilities and response considerations can assist facility administrators and emergency managers when preparing for potential mass violence events at senior living facilities. (Disaster Med Public Health Preparedness. 2017;11:150-152).

Conditions found among pediatric survivors during the early response to natural disaster: a prospective case study.

BACKGROUND: Major natural disasters may provoke a mass casualty situation, and children tend to represent an important proportion of the victims. The purpose of this study was to prospectively record medical conditions presented by pediatric survivors of a major natural disaster to determine the type of medical specialists most needed during the acute phase of relief response. METHODS: After the 2010 Haiti earthquake, age, sex, date of presentation, diagnosis, and treatment provided were prospectively recorded for all patients less than 18 years old treated by a medical relief team. Patients were then allocated to 1 of the 2 groups: surgical (traumatism or surgical disorder) and medical (medical disorder). Medical activity lasted for 43 days. RESULTS: Four hundred seventy-one of the 796 treated patients were less than 18 years old. Two hundred forty-four (52%) were assigned to the surgical group and 227 (48%) to the medical group. As there was a substantial decrease in the number of new surgical patients registered on day 11 of activity, we arbitrarily defined an early period (until day 10 of activity) and a late period (beginning on day 11 of activity). Data obtained from the 147 new patients registered during the early period revealed 134 (91%) surgical patients and 13 (9%) medical patients. Eighty-eight percent of patients needed specialized care for traumatic orthopaedic lesions, and procedures under anesthesia or sedation were mainly (98%) performed for traumatic conditions. Data obtained for the 324 new patients registered during the late period revealed 110 (34%) surgical patients and 214 (66%) medical patients. There was a switch from high surgical needs to more routine medical and surgical care, with less procedures (88%) for the treatment of traumatic lesions. CONCLUSIONS: Pediatric orthopaedic surgeons have a major role to play in the acute phase of relief response to potentially minimize long-term physical and psychosocial disability associated with these complex injuries in growing patients. LEVEL OF EVIDENCE: Economic or decision analyses, level II.

Children and terror casualties receive preference in ICU admissions.

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.

Effect of a mass casualty incident: clinical outcomes and hospital charges for casualty patients versus concurrent inpatients.

OBJECTIVES: A mass casualty incident (MCI) may strain a health care system beyond surge capacity, affecting patterns of care for casualties and other patients. Prior studies of MCIs have assessed clinical care for casualty patients, but have not examined outcomes or expenditures for noncasualty inpatients in the same time period. METHODS: This was a retrospective analysis of administrative hospital claims in a state where an MCI with over 200 casualties occurred; two hospitals that admitted casualties of >5% of their inpatient capacity were studied. The "surge period" was defined as 7 days after the MCI. Using diagnostic codes, patients admitted on the MCI day with diagnoses of burns or inhalation injury were included in the "MCI surge cohort." Patients admitted within a time frame of 7 days prior to 7 days after the MCI who were inpatients during the surge period were included in the "non-MCI surge cohort." The authors compared the MCI and non-MCI surge cohorts to a mutually exclusive reference cohort (all inpatients during 6 weeks prior to the MCI), regarding key outcomes of hospital length of stay (LOS) and hospital charges adjusted for age, sex, race/ethnicity, and severity of illness. RESULTS: Fifty-five patients met criteria for the MCI surge cohort, 1,369 for the non-MCI surge cohort, and 5,980 for the reference group. Compared with the reference group and adjusted for covariates, the mean (±SD) hospital LOS was 4.90 (±1.85) days longer for the MCI surge cohort (95% confidence interval [CI] = 1.67 to 8.84) and 1.34 (±0.16) days longer for the non-MCI surge cohort (95% CI = 1.00 to 1.65). The MCI cohort also had significantly longer mean hospital LOS than the non-MCI surge cohort (difference = 3.56 days; 95% CI = 0.36 to 7.36). Also adjusted for covariates, mean (±SD) total hospital charges for the MCI surge cohort were $22,349 (±$8,342) greater than for the reference group (95% CI = $8,182 to $39,485). Mean (±SD) charges for the non-MCI surge cohort were $4,028 (±$633) greater than for the reference group (95% CI = $2,792 to $5,196). The MCI cohort also had higher mean total charges than the non-MCI surge cohort (difference = $18,321; 95% CI = $4,488 to $34,980). CONCLUSIONS: When adjusted for severity of illness, casualty patients and noncasualty patients receiving concurrent hospital care have significantly longer LOS and higher charges than typical hospital patients at times unaffected by MCIs. Spillover effects from MCIs for noncasualty patients have not been previously described and have implications for clinical and hospital management in MCI and other high-surge circumstances.

Allocation of scarce resources after a nuclear detonation: setting the context.

The purpose of this article is to set the context for this special issue of Disaster Medicine and Public Health Preparedness on the allocation of scarce resources in an improvised nuclear device incident. A nuclear detonation occurs when a sufficient amount of fissile material is brought suddenly together to reach critical mass and cause an explosion. Although the chance of a nuclear detonation is thought to be small, the consequences are potentially catastrophic, so planning for an effective medical response is necessary, albeit complex. A substantial nuclear detonation will result in physical effects and a great number of casualties that will require an organized medical response to save lives. With this type of incident, the demand for resources to treat casualties will far exceed what is available. To meet the goal of providing medical care (including symptomatic/palliative care) with fairness as the underlying ethical principle, planning for allocation of scarce resources among all involved sectors needs to be integrated and practiced. With thoughtful and realistic planning, the medical response in the chaotic environment may be made more effective and efficient for both victims and medical responders.

World Trade Center disaster: assessment of responder occupations, work locations, and job tasks.

BACKGROUND: To date there have been no comprehensive reports of the work performedby 9/11 World Trade Center responders. METHODS: 18,969 responders enrolled in the WTC Medical Monitoring and Treatment Program were used to describe workers' pre-9/11 occupations, WTC work activities and locations from September 11, 2001 to June 2002. RESULTS: The most common pre-9/11 occupation was protective services (47%); other common occupations included construction, telecommunications, transportation, and support services workers. 14% served as volunteers. Almost one-half began work on 9/11 and >80% reported working on or adjacent to the ''pile'' at Ground Zero. Initially,the most common activity was search and rescue but subsequently, the activities of most responders related to their pre-9/11 occupations. Other major activities included security; personnel support; buildings and grounds cleaning; and telecommunications repair. CONCLUSIONS: The spatial, temporal, occupational, and task-related taxonomy reported here will aid the development of a job-exposure matrix, assist in assessment of disease risk, and improve planning and training for responders in future urban disasters.

Hospital referral patterns: how emergency medical care is accessed in a disaster.

BACKGROUND: A prevalent assumption in hospital emergency preparedness planning is that patient arrival from a disaster scene will occur through a coordinated system of patient distribution based on the number of victims, capabilities of the receiving hospitals, and the nature and severity of illness or injury. In spite of the strength of the emergency medical services system, case reports in the literature and major incident after-action reports have shown that most patients who present at a health care facility after a disaster or other major emergency do not necessarily arrive via ambulance. If these reports of arrival of patients outside an organized emergency medical services system are accurate, then hospitals should be planning differently for the impact of an unorganized influx of patients on the health care system. Hospitals need to consider alternative patterns of patient referral, including the mass convergence of self-referred patients, when performing major incident planning. METHODS: We conducted a retrospective review of published studies from the past 25 years to identify reports of patient care during disasters or major emergency incidents that described the patients' method of arrival at the hospital. Using a structured mechanism, we aggregated and analyzed the data. RESULTS: Detailed data on 8303 patients from more than 25 years of literature were collected. Many reports suggest that only a fraction of the patients who are treated in emergency departments following disasters arrive via ambulance, particularly in the early postincident stages of an event. Our 25 years of aggregate data suggest that only 36% of disaster victims are transported to hospitals via ambulance, whereas 63% use alternate means to seek emergency medical care. CONCLUSIONS: Hospitals should evaluate their emergency plans to consider the implications of alternate referral patterns of patients during a disaster. Additional consideration should be given to mass triage, site security, and the potential need for decontamination after a major incident.