Prehospital Mass Casualty Incident Response to a Fire in a Nursing Home in Milan, Italy: Actions Taken and Shortcomings.

On July 7, 2023, at 1:21 am, a fire was declared in a retirement home in Milan, Italy. The number of casualties (n = 87) according to the Simple Triage and Rapid Treatment (START) triage system was categorized as 65 green, 14 yellow, 2 red, and 6 black; 75% were women, and the mean age was 85.1 years (± 9). Most patients were unable to walk. A total of 30 basic life support (BLS) ambulances, 3 advanced cardiac life support (ACLS) teams on fast cars, 2 buses, and 1 coordination team were deployed. A scoop and run approach was adopted with patients being transported to 15 health care facilities. The event was terminated at 5:43 am. Though the local mass casualty incident (MCI) response plan was correctly applied, the evacuation of the building was difficult due to the age and comorbidities of the patients. START failed to correctly identify patients categorized as minor. Communication problems arose on site that led to the late evacuation of critical patients.

Severe Acute Respiratory Syndrome Coronavirus 2 and Medical Evacuation in Lombardy: Lessons Learned from an Unprecedented Pandemic.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerging infectious disease pandemic developed in Lombardy (northern Italy) during the last week of February 2020 with a progressive increase of patients presenting with serious clinical findings. Despite the efforts of the Central Italian Government, regional resources were rapidly at capacity. The solution was to plan the medical evacuation (MEDEVAC) of 119 critically ill patients (median age 61 years) to in-patient intensive care units in other Italian regions (77) and Germany (42). Once surviving patients were deemed suitable, the repatriation process concluded the assignment. The aim of this report is to underline the importance of a rapid organization and coordination process between different nodes of an effective national and international network during an emerging infectious disease outbreak and draw lessons learned from similar published reports.

Impact of Point-of-Care Ultrasound on Secondary Triage: A Pilot Study.

OBJECTIVES: In mass casualty scenarios, patients with apparent hemodynamic and respiratory stability might have occult life-threatening injuries. These patients could benefit from more accurate triage methods. This study assessed the impact of point-of-care ultrasound on the accuracy of secondary triage conducted at an advanced medical post to enhance the detection of patients who, despite their apparent clinically stable condition, could benefit from earlier evacuation to definitive care or immediate life-saving treatment. METHODS: A mass casualty simulated event consisting of a bomb blast in a remote area was conducted with 10 simulated casualties classified as YELLOW at the primary triage scene; patients were evaluated by 4 physicians at an advanced medical post. Three patients had, respectively, hemoperitoneum, pneumothorax, and hemothorax. Only 2 physicians had sonographic information. RESULTS: All 4 physicians were able to suspect hemoperitoneum as a possible critical condition to be managed first, but only physicians with additional sonographic information accurately detected pneumothorax and hemothorax, thus deciding to immediately evacuate or treat.

Residents working with Médecins Sans Frontières: training and pilot evaluation.

BACKGROUND: Well-prepared humanitarian workers are now more necessary than ever. Essential to the preparation process are: clearly defined learning objectives, curricula tailored to the nuances of humanitarian settings, simulation-based training, and evaluation. This manuscript describes a training program designed to prepare medical residents for their first field deployment with Médecins Sans Frontières and presents the results of a pilot assessment of its effectiveness. METHODS: The training was jointly developed by the Research Center in Emergency and Disaster Medicine- CRIMEDIM of the Università del Piemonte Orientale, Novara, Italy, and the humanitarian aid organization Médecins Sans Frontières- Italy (MSF-Italy); the following topics were covered: disaster medicine, public health, safety and security, infectious diseases, psychological support, communication, humanitarian law, leadership, and job-specific skills. It used a blended-learning approach consisting of a 3-month distance learning module; 1-week instructor-led coaching; and a field placement with MSF. We assessed its effectiveness using the first three levels of Kirkpatrick's training evaluation model. RESULTS: Eight residents took part in the evaluation. Four were residents in emergency medicine, 3 in anesthesia, and 1 in pediatrics; 3 of them were female and the median age was 31 years. Two residents were deployed in Pakistan, 1 in Afghanistan, 1 in the Democratic Republic of Congo, 1 in Iraq, 2 in Haiti and 1 on board of the MSF Mediterranean search & rescue ship. Mean deployment time was 3 months. The average median score for the overall course was 5 (excellent). There was a significant improvement in post-test multiple choice scores (p = 0.001) and in residents' overall performance scores (P = 0.000001). CONCLUSION: Residents were highly satisfied with the training program and their knowledge and skills improved as a result of participation. TRIAL REGISTRATION: This study was approved by the Institutional Ethics Committee (date 24-02-2016, study code UPO.2015.4.10).

Prone Positioning in Non-Intubated Patients With COVID-19 Outside of the Intensive Care Unit: More Evidence Needed.

The coronavirus disease (COVID-19) pandemic has brought the Italian National Health System to its knees. The abnormally high influx of patients, together with the limited resources available, has forced clinicians to make unprecedented decisions and provide compassionate treatments for which little or no evidence is yet available. This is the case for the use of noninvasive positive pressure ventilation and continuous airway pressure ventilation, combined with prone position in patients with COVID-19 and acute respiratory distress syndrome treated outside of intensive care units. In our article, we comment on the evidence available, so far, and provide a brief summary of data collected at our health institution in Piedmont, Italy.

Initial plans for a large-scale investigation into the chronic health effects of earthquakes in Italy: building on Barbara Pacelli's legacy.

Barbara Pacelli, a young Italian epidemiologist, passed away unexpectedly in September 2019. During her prolific professional life, she gave several scientific contributions to natural disaster epidemiology, particularly in relation to the medium and long-term health effects of earthquakes. In this opinion paper, we reflect on Barbara's legacy and outline potential actions that could arise from her work. Particularly, availability of electronic health records would enable a systematic and large-scale investigation into the long-term health effects of earthquakes in Italy, a country with high seismic risk. This effort would have high societal value as it would likely enable mitigation of substantial morbidity and mortality in areas affected by earthquakes. In this paper, we define scope, objectives, potential data sources, and analysis methods that could be used to systematically assess the chronic health effects of recent earthquakes in Italy. Keywords: earthquakes; chronic diseases; electronic health records; retrospective cohort; case crossover study.

Comparing Resource Management Skills in a High- versus Low-Resource Simulation Scenario: A Pilot Study.

BACKGROUND: Low-resource environments, such as those found in humanitarian crises, pose significant challenges to the provision of proper medical treatment. While the lack of training of health providers to such settings has been well-acknowledged in literature, there has yet to be any scientific evidence for this phenomenon. METHODS: This pilot study utilized a randomized crossover experimental design to examine the effects of high- versus low-resource simulated scenarios of a resuscitation of a critically ill obstetric patient on a medical doctors' performance and inter-personal skills. Ten senior residents (fifth-year post-graduate) of the Maggiore Hospital School of Medicine (Novara, NO, Italy) were included in the study. RESULTS: Overall performance score for the high-resource setting was 5.2, as opposed to only 2.3 for the low-resource setting. The mean effect size for the overall score was 2.9 (95% CI, 1.7-4.0; P <.001). The results suggest a significant decrease in both technical (medical) and non-technical skills, such as leadership, problem solving, situation awareness, resource utilization, and communication in the low-resource environment setting. The latter finding is of special important since it was yet to be reported. CONCLUSIONS: This pilot study suggests that untrained physicians in low-resource environments may experience a considerable setback not only to their professional performance, but also to their interpersonal skills, when deployed ill-prepared to humanitarian missions. Consequently, this may endanger the health of local populations.

Threat Perception and Public Preparedness for Earthquakes in Italy.

INTRODUCTION: Italy is prone to major earthquakes and has experienced several devastating earthquakes in the far and recent past. The objectives of this study were to assess the level of Italian households' preparedness for earthquakes and to measure the public's perception of the risk and its impact on preparedness behavior. HYPOTHESIS: Italian households' preparedness for earthquakes is insufficient and is influenced by different threat perception components that were assessed. METHODS: A cross-sectional study, using an online questionnaire, was conducted in early 2018. The sample included 1,093 responders from a diverse sociodemographic background. The primary outcome was the Preparedness Index (PI), a score indicating the number of preparedness actions complied-with out of 10. RESULTS: The PI's mean was 5.26 (SD = 2.17). The recommendation most complied-with was keeping a flashlight at home (87.7%) and the least was securing the kitchen cupboards (15.1%). The PI was positively correlated with a higher sense of preparedness (r = 0.426; P <.001). The PI was higher for responders residing in high-seismic-risk areas and those who experienced a major earthquake before. The predictors of PI were: gender, age, prior experience, sense of preparedness, searching for information, and threat intrusiveness (negatively). CONCLUSIONS: The findings demonstrate a medium-level of preparedness; however, this might be circumstantial. Italians perceive major earthquakes to be unlikely, yet severe if and when they do occur. A validated tool in Italian now exists and can be used in future studies.Bodas M, Giuliani F, Ripoll-Gallardo A, Caviglia M, Dell'Aringa MF, Linty M, Della Corte F, Ragazzoni L. Threat perception and public preparedness for earthquakes in Italy. Prehosp Disaster Med. 2019;34(2):114-124.

[Long-term health effects of earthquakes: outlining the features of an epidemiological surveillance system in Italy.] / Gli effetti dei terremoti sulla salute a lungo termine: quali caratteristiche per un sistema di sorveglianza in Italia?

The major earthquakes occurred in Italy in the past 10 years (L'Aquila, Emilia and Amatrice) have resulted in 679 death, displacement of more than 120,000 people and economic losses for more than 20 billion euros. In a recent review, we found that earthquakes are associated to multiple health conditions in the long term. Because of Italy's high seismic risk, it is likely that establishing a post-earthquake surveillance system would enable early detection of many deleterious effects and mitigation of damages. In this editorial, we outline the possible features of such a surveillance system. Firstly, it should be cost-effective, capitalising on routinely collected health data. Secondly, it should be coordinated centrally by a compact multidisciplinary team, to enable harmonised procedures and analysis. Thirdly, based on current evidence, it should be able to follow-up populations for least 7 years and capture both physical and mental health diseases. Finally, it should gather sufficient information to enable stratified analysis and identify at-risk subgroups that may need specific interventions.

Intra-operative low-dose ketamine does not reduce the cost of post-operative pain management after surgery: a randomized controlled trial in a low-income country.

BACKGROUND: In developing countries, post-operative pain remains underestimated and undertreated due to economic constraints, lack of awareness and limited resources. In contrast, ketamine is an effective, readily available, easy to use and inexpensive drug frequently used in poor settings. OBJECTIVES: The aim of this study was to explore the overall reduction in the medication treatment cost of acute post-operative pain by adding intra-operative low-dose ketamine to traditional intravenous morphine for surgery in a low-income country. METHODS: A double blind randomized controlled trial with placebo-controlled parallel group was performed in Mulago National Hospital (Uganda). Consenting adults scheduled for elective surgery were randomized into two study arms: Group K received ketamine 0.15mg/kg bolus at induction and a continuous infusion of 0.12 mg/kg/hour till start of skin closure; Group C (control) received normal saline. Both groups received Morphine 0.1 mg/kg IV at debulking. The total medication cost was registered. NRS pain scores and other measurements such vital signs and incidence of major and minor side effects were also recorded. RESULTS: A total of 46 patients were included. Patients' baseline characteristics were comparable in both groups. No statistically significant difference was found between the groups concerning the overall medication cost of post-operative pain management. Pain scores, patients' satisfaction in the first 24 hours after surgery and hospital length of stay were similar in both groups. CONCLUSION: Our results do not support the utilization of intra-operative low dose ketamine as a cost-saving post-operative pain treatment strategy for all types of surgery in low-resource settings.

Medium- and long-term health effects of earthquakes in high-income countries: a systematic review and meta-analysis.

Background: Accurate monitoring of population health is essential to ensure proper recovery after earthquakes. We aimed to summarize the findings and features of post-earthquake epidemiological studies conducted in high-income countries and to prompt the development of future surveillance plans. Methods: Medline, Scopus and six sources of grey literature were systematically searched. Inclusion criteria were: observational study conducted in high-income countries with at least one comparison group of unexposed participants, and measurement of health outcomes at least 1 month after the earthquake. Results: A total of 52 articles were included, assessing the effects of 13 earthquakes that occurred in eight countries. Most studies: had a time-series (33%) or cross-sectional (29%) design; included temporal comparison groups (63%); used routine data (58%); and focused on patient subgroups rather than the whole population (65%). Individuals exposed to earthquakes had: 2% higher all-cause mortality rates [95% confidence interval (CI), 1% to 3%]; 36% (95% CI, 19% to 57%) and 37% (95% CI, 29% to 46%) greater mortality rates from myocardial infarction and stroke, respectively; and 0.16 higher mean percent points of glycated haemoglobin (95% CI, 0.07% to 0.25% points). There was no evidence of earthquake effects for blood pressure, body mass index or lipid biomarkers. Conclusions: A more regular and coordinated use of large and routinely collected datasets would benefit post-earthquake epidemiological surveillance. Whenever possible, a cohort design with geographical and temporal comparison groups should be used, and both communicable and non-communicable diseases should be assessed. Post-earthquake epidemiological surveillance should also capture the impact of seismic events on the access to and use of health care services.

Yemen's Unprecedented Humanitarian Crisis: Implications for International Humanitarian Law, the Geneva Convention, and the Future of Global Health Security.

The current humanitarian crisis in Yemen is unprecedented in many ways. The Yemeni War tragedy is symptomatic of gross failures to recognize, by combatants, existing humanitarian law and the Geneva Convention that have become the new norm in unconventional armed conflicts and are increasingly replicated in Africa, Afghanistan, and other areas of the Middle East with dire consequences on aid workers and the noncombatant population. The health and humanitarian professions must take collective responsibility in calling for all belligerent parties to cease the massacre and commit to guaranteed medical assistance, humanitarian aid, and the free flow of information and respect for the humanitarian principles that protect the neutrality and impartiality of the humanitarian workforce. (Disaster Med Public Health Preparedness. 2016;page 1 of 3).

[Medium- and long-term health effects of the L'Aquila earthquake (Central Italy, 2009) and of other earthquakes in high-income Countries: a systematic review]. / Effetti sulla salute a medio e lungo termine del terremoto dell'Aquila del 2009 e di altri terremoti avvenuti in Paesi ad alto reddito: una revisione sistematica della letteratura.

OBJECTIVES: to compare the methodological characteristics of the studies investigating the middle- and long-term health effects of the L'Aquila earthquake with the features of studies conducted after other earthquakes occurred in highincome Countries. DESIGN: a systematic comparison between the studies which evaluated the health effects of the L'Aquila earthquake (Central Italy, 6th April 2009) and those conducted after other earthquakes occurred in comparable settings. METHODS: Medline, Scopus, and 6 sources of grey literature were systematically searched. Inclusion criteria comprised measurement of health outcomes at least one month after the earthquake, investigation of earthquakes occurred in high-income Countries, and presence of at least one temporal or geographical control group. RESULTS: out of 2,976 titles, 13 studies regarding the L'Aquila earthquake and 51 studies concerning other earthquakes were included. The L'Aquila and the Kobe/Hanshin- Awaji (Japan, 17th January 1995) earthquakes were the most investigated. Studies on the L'Aquila earthquake had a median sample size of 1,240 subjects, a median duration of 24 months, and used most frequently a cross sectional design (7/13). Studies on other earthquakes had a median sample size of 320 subjects, a median duration of 15 months, and used most frequently a time series design (19/51). CONCLUSIONS: the L'Aquila studies often focussed on mental health, while the earthquake effects on mortality, cardiovascular outcomes, and health systems were less frequently evaluated. A more intensive use of routine data could benefit future epidemiological surveillance in the aftermath of earthquakes.

Core Competencies in Disaster Management and Humanitarian Assistance: A Systematic Review.

Disaster response demands a large workforce covering diverse professional sectors. Throughout this article, we illustrate the results of a systematic review of peer-reviewed studies to identify existing competency sets for disaster management and humanitarian assistance that would serve as guidance for the development of a common disaster curriculum. A systematic review of English-language articles was performed on PubMed, Google Scholar, Scopus, ERIC, and Cochrane Library. Studies were included if reporting competency domains, abilities, knowledge, skills, or attitudes for professionals involved disaster relief or humanitarian assistance. Exclusion criteria included abstracts, citations, case studies, and studies not dealing with disasters or humanitarian assistance. Thirty-eight papers were analyzed. Target audience was defined in all articles. Five references (13%) reported cross-sectorial competencies. Most of the articles (81.6%) were specific to health care. Eighteen (47%) papers included competencies for at least 2 different disciplines and 18 (47%) for different professional groups. Nursing was the most widely represented cadre. Eighteen papers (47%) defined competency domains and 36 (94%) reported list of competencies. Nineteen articles (50%) adopted consensus-building to define competencies, and 12 (31%) included competencies adapted to different professional responsibility levels. This systematic review revealed that the largest number of papers were mainly focused on the health care sector and presented a lack of agreement on the terminology used for competency-based definition.

Multiple withdrawals from single-use vials: a study on sterility.

BACKGROUND: Reutilization of single-use vials containing medical drugs is still under discussion. This practice has been adopted as a standard to avoid drug wastage, particularly in developing countries and in the aftermath of disasters. Some studies have assessed sterility of medications stored in single-use vials after utilization as multiple doses; however, most of these were limited to one single drug, included a low number of samples and did not consider an intermediate transfer step from the vial to a disposable syringe. The purpose of this study was to assess microbial contamination of samples withdrawn over three days from disposable syringes prepared from single-use vials. METHODS: A prospective sterility study was conducted. A total of 600 initial samples were prepared from six-hundred 10 mL single-use vials of physiological solution into six-hundred 20 mL disposable syringes. Samples were prepared in three different standard operating rooms, on six different days and by the same operator, using basic sterile technique. All syringes were capped, placed together in a non-sterile steel container, covered with a clean drape and stored in the refrigerator at 4°C under non-sterile conditions. Using basic sterile technique, four samples were withdrawn daily and cultured from each syringe over the next 3 days. Microbial growth was examined on Sabouraud agar and chocolate agar culture media. RESULTS: A total of 7200 samples were collected and 14,400 cultures were performed. No evidence of microbial growth in any of the culture media plates was found. CONCLUSION: This study demonstrated that contents initially stored in single-use vials and subsequently transferred into disposable syringes in an operating room using sterile technique, maintain sterility after 4 withdrawals per day for a total of 3 days.

Professionalization of anesthesiologists and critical care specialists in humanitarian action: a nationwide poll among italian residents.

BACKGROUND: Over the last decades, humanitarian crises have seen a sharp upward trend. Regrettably, physicians involved in humanitarian action have often demonstrated incomplete preparation for these compelling events which have proved to be quite different from their daily work. Responders to these crises have included an unpredictable mix of beginner-level, mid-level, and expert-level providers. The quality of care has varied considerably. The international humanitarian community, in responding to international calls for improved accountability, transparency, coordination, and a registry of professionalized international responders, has recently launched a call for further professionalization within the humanitarian assistance sector, especially among academic-affiliated education and training programs. As anesthetists have been involved traditionally in medical relief operations, and recent disasters have seen a massive engagement of young physicians, the authors conducted, as a first step, a poll among residents in Anesthesia and Critical Care Medicine in Italy to evaluate their interest in participating in competency-based humanitarian assistance education and in training incorporated early in residencies. METHODS: The Directors of all the 39 accredited anesthesia/critical care training programs in Italy were contacted and asked to submit a questionnaire to their residents regarding the objectives of the poll study. After acceptance to participate, residents were enrolled and asked to complete a web-based poll. RESULTS: A total of 29 (74%) of the initial training programs participated in the poll. Out of the 1,362 questionnaires mailed to residents, 924 (68%) were fully completed and returned. Only 63(6.8%) of the respondents voiced prior participation in humanitarian missions, but up to 690 (74.7%) stated they were interested in participating in future humanitarian deployments during their residency that carried over into their professional careers. Countrywide, 896 (97%) favored prior preparation for residents before participating in humanitarian missions, while the need for a specific, formal, professionalization process of the entire humanitarian aid sector was supported by 889 (96.2%). CONCLUSIONS: In Italy, the majority of anesthesia/critical care residents, through a formal poll study, affirmed interest in participating in humanitarian assistance missions and believe that further professionalization within the humanitarian aid sector is required. These results have implications for residency training programs worldwide.

Virtual reality and live simulation: a comparison between two simulation tools for assessing mass casualty triage skills.

OBJECTIVES: This study tested the hypothesis that virtual reality simulation is equivalent to live simulation for testing naive medical students' abilities to perform mass casualty triage using the Simple Triage and Rapid Treatment (START) algorithm in a simulated disaster scenario and to detect the improvement in these skills after a teaching session. METHODS: Fifty-six students in their last year of medical school were randomized into two groups (A and B). The same scenario, a car accident, was developed identically on the two simulation methodologies: virtual reality and live simulation. On day 1, group A was exposed to the live scenario and group B was exposed to the virtual reality scenario, aiming to triage 10 victims. On day 2, all students attended a 2-h lecture on mass casualty triage, specifically the START triage method. On day 3, groups A and B were crossed over. The groups' abilities to perform mass casualty triage in terms of triage accuracy, intervention correctness, and speed in the scenarios were assessed. RESULTS: Triage and lifesaving treatment scores were assessed equally by virtual reality and live simulation on day 1 and on day 3. Both simulation methodologies detected an improvement in triage accuracy and treatment correctness from day 1 to day 3 (P<0.001). The time to complete each scenario and its decrease from day 1 to day 3 were detected equally in the two groups (P<0.05). CONCLUSION: Virtual reality simulation proved to be a valuable tool, equivalent to live simulation, to test medical students' abilities to perform mass casualty triage and to detect improvement in such skills.

Combining Dedicated Online Training and Apprenticeships in the Field to Assist in Professionalization of Humanitarian Aid Workers: a 2-year Pilot Project for Anesthesia and Intensive Care Residents Working in Resource Constrained and Low-income Countries.

INTRODUCTION: As a result of the gaps in humanitarian response highlighted by several reports, the international community called for an increased professionalization of humanitarian aid workers. This paper describes a pilot project by an Italian university and a non-profit, non-governmental organization to implement a medical apprenticeship in low-income countries during Anesthesia and Intensive Care Medicine residencies. METHODS: Before deployment, participants were required to complete a dedicated online training course about safety and security in the field, principles of anesthesia at the district hospital level, emergency and essential surgical care, essentials of medical treatment in resource-constrained environments and psychological support in emergencies. RESULTS: At the end of the program, a qualitative self-evaluation questionnaire administered to participants highlighted how the project allowed the participants to advance their professional skills when working in a low-resource environment, while also mastering their adapting skills and the ability to interact and cooperate with local healthcare personnel. The project also proved to be a means for personal growth, making these experiences a recommendation for all residents as a necessary step for the professionalization of healthcare personnel involved in humanitarian aid.

Art of disaster preparedness in European union: a survey on the health systems.

INTRODUCTION: Naturally occurring and man-made disasters have been increasing in the world, including Europe, over the past several decades. Health systems are a key part of any community disaster management system. The success of preparedness and prevention depends on the success of activities such as disaster planning, organization and training. The aim of this study is to evaluate health system preparedness for disasters in the 27 European Union member countries. METHOD: A cross-sectional analysis study was completed between June-September 2012. The checklist used for this survey was a modified from the World Health Organization toolkit for assessing health-system capacity for crisis management. Three specialists from each of the 27 European Union countries were included in the survey. Responses to each survey question were scored and the range of preparedness level was defined as 0-100%, categorized in three levels as follows: Acceptable; Transitional; or Insufficient. RESULTS: Response rate was 79.1%. The average level of disaster management preparedness in the health systems of 27 European Union member states was 68% (Acceptable). The highest level of preparedness was seen in the United Kingdom, Luxemburg, and Lithuania. Considering the elements of disaster management system, the highest level of preparedness score was at health information elements (86%), and the lowest level was for hospitals, and educational elements (54%). CONCLUSION: This survey study suggests that preparedness level of European Union countries in 2012 is at an acceptable level but could be improved. Elements such as hospitals and education and training suffer from insufficient levels of preparedness. The European Union health systems need a collective strategic plan, as well as enough resources, to establish a comprehensive and standardized disaster management strategy plan. A competency based training curriculum for managers and first responders is basic to accomplishing this goal. KEYWORDS: Disaster medicine; Disaster preparedness; Disaster epidemiology; Health systems; European Union.