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Does START Triage Work? An Outcomes Assessment After a Disaster• DISASTER MEDICINE/ORIGINAL RESEARCH Available online 06 February 2009
Christopher A. Kahn, Carl H. Schultz, Ken T. Miller, Craig L. Anderson Annals of Emergency Medicine
DOI: 10.1016/j.annemergmed.2008.12.035
Study objective
The mass casualty triage system known as simple triage and rapid treatment (START) has been widely used in the United States since the 1980s. However, no outcomes assessment has been conducted after a disaster to determine whether assigned triage levels match patients’ actual clinical status. Researchers hypothesize that START achieves at least 90% sensitivity and specificity for each triage level and ensures that the most critical patients are transported first to area hospitals.
Methods
The performance of START was evaluated at a train crash disaster in 2003. Patient field triage categories and scene times were obtained from county reports. Patient medical records were then reviewed at all receiving hospitals. Victim arrival times were obtained and correct triage categories determined a priori using a combination of the modified Baxt criteria and hospital admission. Field and outcomes-based triage categories were compared, defining the appropriateness of each triage assignment.
Results
Investigators reviewed 148 records at 14 receiving hospitals. Field triage designations comprised 22 red (immediate), 68 yellow (delayed), and 58 green (minor) patients. Outcomes-based designations found 2 red, 26 yellow, and 120 green patients. Seventy-nine patients were overtriaged, 3 were undertriaged, and 66 patients’ outcomes matched their triage level. No triage level met both the 90% sensitivity and 90% specificity requirement set forth in the hypothesis, although red was 100% sensitive (95% confidence interval [CI] 16% to 100%) and green was 89.3% specific (95% CI 72% to 98%). The Obuchowski statistic was 0.81, meaning that victims from a higher-acuity outcome group had an 81% chance of assignment to a higher-acuity triage category. The median arrival time for red patients was more than 1 hour earlier than the other patients.
Conclusion
This analysis demonstrates poor agreement between triage levels assigned by START at a train crash and a priori outcomes criteria for each level. START ensured acceptable levels of undertriage (100% red sensitivity and 89% green specificity) but incorporated a substantial amount of overtriage. START proved useful in prioritizing transport of the most critical patients to area hospitals first.
The Association Between Roofing Material and Head Injuries During the 2008 Wenchuan Earthquake in China• DISASTER MEDICINE/BRIEF RESEARCH REPORT Available online 27 April 2009
Lei Wang, De-lin Lei, Li-sheng He, Yan-pu Liu, Yong Long, Jian Cao, Meng Cao, Jian-hua Wei, Yi-min Zhao Annals of Emergency Medicine
DOI: 10.1016/j.annemergmed.2009.03.028
Study objective
We analyze the spectrum of earthquake-related head injuries resulting in hospitalization and arising from the 2008 Wenchuan Earthquake in China. An additional objective is to assess injury patterns associated with 2 types of roofing structures found in this region of China.
Methods
This descriptive study included data on trauma patients at 8 hospitals in Jiangyou for the 14 days immediately after the earthquake. The patients were either from Jiangyou County, which experienced a modified Mercalli intensity level of VIII, or from Beichuan County (Mercalli intensity level of X). Of the 5,775 earthquake-related injuries, 1,484 (25.7%) involved the head and were classified into 4 categories. Seven injury mechanisms were also analyzed to determine the association with the 4 types of head injuries.
Results
Scalp injuries (43%) were the most common type of head injuries, followed by facial injuries, 482 (32%), intracranial injuries, 218 (15%), and skull fractures, 117 (8%). Differences in injury type and cause were apparent, with scalp injuries being more common (49%) in Jiangyou than in Beichuan (30%) and falling clay tiles contributing more (40%) to this injury in the former city than the latter (6%). In contrast, precast concrete plank roofing caused 20% of scalp injuries in Beichuan compared with 3% in Jiangyou.
Conclusion
Scalp injuries were the most common head injury type. Falling clay roofing tiles and precast concrete plank roofs are important injury mechanisms, and their contribution may reflect differences in building construction.
Chávez Seeks Tighter Grip on Military By SIMON ROMERO of the NY Times, 5/30/09
“The Venezuelan leader’s efforts to strengthen his hold on the armed forces have led to high-profile arrests and a wave of reassignments.”
Barack Obama to Nancy Pelosi and Harry Reid: “Hey guys, any lessons we can take from Hugo and use in Detroit and Wall Street?”
Sheng-lang Zhu, Jiu-hong Li, Lu Chen, Zhong-xian Bao, Long-jiang Zhang, Jia-ping Li, Jie-hui Chen, and Kun-mei Ji
Pediatrics 2009; 123: e1099-e1102.
OBJECTIVE. In this article we report our experience with thediagnostic screening and management of children with melamine-inducednephrolithiasis.
METHODS. A total of 1091 children younger than 4 years who hadbeen exposed to melamine-contaminated formula from September17 to October 12, 2008, were screened for nephrolithiasis atthe department of pediatrics at Shenzhen Nanshan Hospital inChina. During the clinical examination, each patient’s demographiccharacteristics were recorded together with the details of hisor her milk-consumption profile during the contamination scareand any clinical signs of poisoning. Urinary stones were detectedby B-ultrasonography, and renal status was examined by a routineurine test panel and a renal function test. When urinary stoneswere detected, patients were ordered to cease consumption ofthe suspected formula, and a conservative treatment course wasadopted, including infusion of fluids, urinary alkalinization,increased water consumption, and diuresis.
RESULTS. Of the 1091 children screened, 12 (1.1%) were diagnosedwith kidney stones. They had been exposed to the contaminatedmilk from 1 to 24 months. Eleven (91.7%) of these 12 patientshad consumed milk with a high level of melamine content (955–2563ppm); 1 patient (8.3%) had consumed milk with a low-level melaminecontent (6.2–17.0 ppm). Six patients exhibited dysuria;the remaining 6 patients were asymptomatic. All 12 patientshad normal renal function, although 4 had proteinuria, and 1had hematuria. The kidney stones were resolved within 3 to 5days of commencing treatment in all 12 cases.
CONCLUSIONS. Nephrolithiasis was associated with high melamine-exposurelevels. A combination of B-ultrasonography and urinalysis issuitable for screening for pediatric nephrolithiasis causedby melamine poisoning. The condition can be resolved with aconservative treatment approach in patients without seriousclinical symptoms who have normal kidney function.
Caroline E. Fife, Latisha A. Smith, Erik A. Maus, James J. McCarthy, Michelle Z. Koehler, Trina Hawkins, and Neil B. Hampson
Pediatrics 2009; 123: e1035-e1038.
BACKGROUND. Carbon monoxide (CO) poisoning is common after majorstorms because of loss of electrical power and use of alternatefuel sources for heat and electricity. In past epidemics ofhurricane-related CO poisoning, the source has typically beengasoline-powered electrical generators. Although it is typicallybelieved that generators were used to power air conditioningand refrigeration, this report demonstrates an unsuspected reasonfor their use.
PATIENTS AND METHODS. After Hurricane Ike’s landfall in September2008, major power outages were associated with an epidemic ofCO poisoning from electrical generators, as expected. Staffat Memorial Hermann Hospital-Texas Medical Center treated ortelephone-triaged cases from the Houston area. A review of thedetails of those cases forms the basis of this report.
RESULTS. Memorial Hermann Hospital-Texas Medical Center stafftreated or triaged 37 individuals exposed to CO from gasoline-poweredelectrical generators in 13 incidents in the first 36 hoursafter landfall of the hurricane. Notably, 54% (20 of 37) ofthe patients were under the age of 18 years. Symptoms rangedfrom mild to severe, with 1 child dying at the scene. Elevenpatients were treated with hyperbaric oxygen. Among 9 incidentsin which the reason for generator use was determined, 5 weredue to generators powering video games or televisions to watchmovies or programs. These 5 incidents in which video games werebeing powered accounted for 75% (15 of 20) of the pediatricpoisonings.
CONCLUSIONS. Generator-related CO poisoning is indeed commonduring power outages after hurricanes. However, generators arecommonly being used to provide electricity to power entertainmentdevices for children, such as video games. Additional publiceducation about CO risk is needed, perhaps directed at olderchildren and teenagers through the schools in regions susceptibleto hurricanes.
The Egyptian Health Ministry confirmed on Saturday [30 May 2009] the 77th
infection with H5N1 virus. A baby girl, aged 14 months, contracted the
highly pathogenic [avian A (H5N1) influenza] virus because she was in
contact with domestic birds in a village located in Daqahliya, north Cairo,
the ministry’s spokesman Dr Abdulrahman Shahin said in a press briefing.
The baby was hospitalized 5 days ago suffering from bird-flu-like symptoms
including high temperature, running nose, and respiratory disorder. She was
diagnosed as H5N1-positive, so she has been treated with the antiviral drug
Tamiflu [oseltamivir], Dr Shahin revealed. The patient is being relocated
to Manshiyat Al-Bakri Hospital, Cairo for further medication, he added.
The case pushed to 77 Egypt’s national tally of the fatal disease, with the
death toll amounting to 27 since the outbreak of the highly contagious
virus in February 2006. The National Higher Commission against Bird Flu has
adopted a new preventive methodology to control the spread of H5N1, a
subtype of the influenza A virus commonly known as bird flu, which can
cause illness in humans. The methodology involves the medical and municipal
authorities as well as the mass media.
TEHRAN, Iran (AP) — An Iranian airliner was forced to return to a southern airport minutes after takeoff when a homemade bomb was found aboard, said state television, in an incident a security official called a "sabotage operation."
The report said the bomb was found in a toilet, but gave no other details on the device. The incident took place late Saturday night.
As Iran prepares for its June 12 presidential election, there have been a number of violent incidents. A bombing Thursday at a mosque in another southern city of Zahedan killed 25 people and wounded 80. A day later, a shooting at President Mahmoud Ahmadinejad’s campaign office in the same city injured three people.
Air guards chief Mohammad Hasan Kazemi, speaking to the official IRNA news agency, left open the possibility of a link between those two incidents and the package on the airliner. He said "enemies" were trying to create a sense of hopelessness among Iranians before the election.
The plane, carrying 140 passengers, returned to an airport in the southwestern city of Ahvaz 15 minutes after takeoff Saturday after a passenger reported a suspicious package. The plane belongs to one of Iran’s commercial airlines, Kish Air.
The flight was from Ahvaz to the capital, Tehran, about 500 miles (800 kilometers) to the northeast
Fifty-five whales that beached themselves in South Africa have died or been euthanized after efforts to save them were not successful.
South African marine authorities shot about 40 of the whales on Saturday, while the rest died of exhaustion and stress.
The whales had stranded themselves on the beach near Cape Town earlier in the day.
Rescue teams tried to push the whales back to the ocean using earth-moving equipment. But heavy surf pushed the giant mammals back to the beach.
Scientists plan to take samples from the carcasses to try to determine why the whales came ashore.
The animals, originally identified as pilot whales, turned out to be false killer whales.
False killer whales look like their close relative, the killer whale, but are smaller and darker in color. They can grow to nearly six meters in length.
IOM is deploying two Rapid Response Teams to assess and respond to the needs of families displaced by military operations in Swat, Buner and Dir in Pakistan and who are living in out-of-camp settlements.
According to authorities, only 20 percent of displaced families are living in camps with the remaining 80 per cent living with relatives or friends, in public or private buildings, community guesthouses, rental accommodation or in spontaneous informal settlements.
The teams, which will be deployed early next week, will carry out need assessments, provide technical assistance for shelter support, collect and coordinate information with humanitarian partners and help distribute relief goods to vulnerable displaced families.
"Learning from our past experience following the 2005 earthquake, the Rapid Response Teams will, by working on the ground among the displaced, provide a clearer picture on how best to respond to urgent needs of the displaced. This will not only benefit our work, but also that of other humanitarian partners responding to this enormous displacement crisis," says IOM Head of Emergency and Stabilization Programme in Pakistan, Brian Kelly. "But we need to have many more of these teams and for that, we need funds."
IOM is appealing for US$ 14.7 million to carry out projects on healthcare, psychosocial support, security awareness, shelter and non-food items (NFIs), infrastructure and rehabilitation support, and awareness-raising on human trafficking in areas affected by the conflict.
Eleven IOM Rapid Response Teams, which started operations in earthquake-affected areas of Pakistan in 2006, saved a number of lives in emergencies, trained thousands of villagers and volunteers in disaster preparedness, provided risk assessments for 1,200 remote and high altitude villages, and distributed relief items to vulnerable families.
For those families living in 26 camps in Mardan, Charsadda, Peshawar, Nowshera, Lower Dir and Malakand districts in North West Frontier Province set up for people recently displaced, IOM has so far contributed 141 truckloads of non-food relief supplies. These include 800 tents, 20,000 fleece blankets, 40,000 quilts, 57,500 sleeping mats, 30,000 jerry cans, 20,000 mosquito nets, 20,000 plastic buckets, 8,000 kitchen sets and 20,000 kgs of soap.
According to NWFP authorities, the number of newly registered internally displaced people has increased to 2.5 million. This is in addition to another 553,916 people registered displaced in the Federally Administered Tribal Areas (FATA), bringing the total number to more than three million since August 2008.
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