Jeffrey L. Arnold

Disaster medicine in the 21st century: future hazards, vulnerabilities, and risk.

The prediction of future disasters drives the priorities, urgencies, and perceived adequacies of disaster management, public policy, and government funding. Disasters always arise from some fundamental dysequilibrium between hazards in the environment and the vulnerabilities of human communities. Understanding the major factors that will tend to produce hazards and vulnerabilities in the future plays a key role in disaster risk assessment. The factors tending to produce hazards in the 21st Century include population growth, environmental degradation, infectious agents (including biological warfare agents), hazardous materials (industrial chemicals, chemical warfare agents, nuclear materials, and hazardous waste), economic imbalance (usually within countries), and cultural tribalism. The factors tending to generate vulnerabilities to hazardous events include population growth, aging populations, poverty, maldistribution of populations to disaster-prone areas, urbanization, marginalization of populations to informal settlements within urban areas, and structural vulnerability. An increasing global interconnectedness also will bring hazards and vulnerabilities together in unique ways to produce familiar disasters in unfamiliar forms and unfamiliar disasters in forms not yet imagined. Despite concerns about novel disasters, many of the disasters common today also will be common tomorrow. The risk of any given disaster is modifiable through its manageability. Effective disaster management has the potential to counter many of the factors tending to produce future hazards and vulnerabilities. Hazard mitigation and vulnerability reduction based on a clear understanding of the complex causal chains that comprise disasters will be critical in the complex world of the 21st Century.

Mass-Casualty, Terrorist Bombings: Implications for Emergency Department and Hospital Emergency Response (Part II)

This article reviews the implications of mass-casualty, terrorist bombings for emergency department (ED) and hospital emergency responses. Several practical issues are considered, including the performance of a preliminary needs assessment, the mobilization of human and material resources, the use of personal protective equipment, the organization and performance of triage, the management of explosion-specific injuries, the organization of patient flow through the ED, and the efficient determination of patient disposition. As long as terrorists use explosions to achieve their goals, mass-casualty, terrorist bombings remain a required focus for hospital emergency planning and preparedness.

Mass-casualty, terrorist bombings: epidemiological outcomes, resource utilization, and time course of emergency needs (Part I).

INTRODUCTION This article characterizes the epidemiological outcomes, resource utilization, and time course of emergency needs in mass-casualty, terrorist bombings producing 30 or more casualties. METHODS Eligible bombings were identified using a MEDLINE search of articles published between 1996 and October 2002 and a manual search of published references. Mortality, injury frequency, injury severity, emergency department (ED) utilization, hospital admission, and time interval data were abstracted and relevant rates were determined for each bombing. Median values for the rates and the inter-quartile ranges (IQR) were determined for bombing subgroups associated with: (1) vehicle delivery; (2) terrorist suicide; (3) confined-space setting; (4) open-air setting; (5) structural collapse sequela; and (6) structural fire sequela. RESULTS Inclusion criteria were met by 44 mass-casualty, terrorist bombings reported in 61 articles. Median values for the immediate mortality rates and IQRs were: vehicle-delivery, 4% (1-25%); terrorist-suicide, 19% (7-44%); confined-space 4% (1-11%); open-air, 1% (0-5%); structural-collapse, 18% (5-26%); structural fire 17% (1-17%); and overall, 3% (1-14%). A biphasic pattern of mortality and unique patterns of injury frequency were noted in all subgroups. Median values for the hospital admission rates and IQRs were: vehicle-delivery, 19% (14-50%); terrorist-suicide, 58% (38-77%); confined-space, 52% (36-71%); open-air, 13% (11-27%); structural-collapse, 41% (23-74%); structural-fire, 34% (25-44%); and overall, 34% (14-53%). The shortest reported time interval from detonation to the arrival of the first patient at an ED was five minutes. The shortest reported time interval from detonation to the arrival of the last patient at an ED was 15 minutes. The longest reported time interval from detonation to extrication of a live victim from a structural collapse was 36 hours. CONCLUSION Epidemiological outcomes and resource utilization in mass-casualty, terrorist bombings vary with the characteristics of the event.

Mass-Casualty Terrorist Bombings In Istanbul, Turkey, November 2003: Report of the Events and the Prehospital Emergency Response

BACKGROUND This paper describes the two mass-casualty, terrorist attacks that occurred in Istanbul, Turkey in November 2003, and the resulting pre-hospital emergency response. METHODS A complex, retrospective, descriptive study was performed, using open source reports, interviews, direct measurements of street distances, and hospital records from the American Hospital (AH) and Taksim Education and Research State Hospital (TERSH) in Istanbul. RESULTS On 15 November, improvised explosive devices (IEDs) in trucks were detonated outside the Neve Shalom and Beth Israel Synagogues, killing 30 persons and injuring an estimated additional 300. Victims were maldistributed to 16 medical facilities. For example, AH, a private hospital located six km from both synagogues, received 69 injured survivors, of which 86% had secondary blast injuries and 13% were admitted to the hospital. The TERSH, a government hospital located 1 km from both synagogues, received 48 injured survivors. On 20 November, IEDs in trucks were detonated outside the Hong Kong Shanghai Banking Corporation (HSBC) headquarters and the British Consulate (BC), killing 33 and injuring an estimated additional 450. Victims were maldistributed to 16 medical facilities. For example, TERSH, located 18 km from the HSBC site and 2 km from the the BC received 184 injured survivors, of which 93% had secondary blast injuries and 15% were hospitalized. The AH, located 9 km from the HSBC site and 6 km from the BC, received 16 victims. CONCLUSION The twin suicide truck bombings on 15 and 20 November 2003 were the two largest terrorist attacks in modern Turkish history, collectively killing 63 persons and injuring an estimated 750 others. The vast majority of victims had secondary blast injuries, which did not require hospitalization. Factors associated with the maldistribution of casualties to medical facilities appeared to include the distance from each bombing site, the type of medical facility, and the personal preference of injured survivors.

A survey of emergency medicine in 36 countries

OBJECTIVE To assess the current level of development of emergency medicine (EM) systems in the world. DESIGN Survey of EM professionals from 36 countries during a 90-day period from Aug. 25 to Nov. 24, 1998. PARTICIPANTS Thirty-six EM professionals from 36 countries and 6 continents completed the survey. Thirty-five (97%) were physicians, of whom 25 (69%) gave presentations at 1 of 4 international EM conferences during the study period. Three potential participants from 3 countries were excluded because of language barriers. Five additional participants from 5 other countries did not respond within the study period and were excluded. MEASUREMENTS Respondents completed a 103-question questionnaire about the presence of EM specialty, academic, patient care, information and management systems and the factors influencing the future of EM in their countries. RESULTS The overall response rate was 88%. Nearly all respondents (97%) stated that their countries had hospital-based emergency departments (EDs). More than 80% of respondents reported that their countries have emergency medical services (EMS), national EMS activation phone numbers and ED systems for pediatric emergency care. More than 70% stated that their countries had national EM organizations, EM research, ED systems for patient transfer and peer review and emergency physician (EP) training in Advanced Cardiac Life Support (ACLS) and the ability to perform rapid sequence intubation. More than 60% reported ED systems for trauma care and triage and EP training in Advanced Trauma Life Support (ATLS) and the ability to perform thrombolysis for acute myocardial infarction. Fifty percent reported EM residency training programs, official recognition of EM as an independent specialty, and EM journals. CONCLUSIONS Basic emergency medicine components now exist in the majority of countries surveyed. These include many specialty, academic, patient care and administrative systems. The foundation for further EM development is widely established throughout the world.

Information-Sharing in Out-of-Hospital Disaster Response: The Future Role of Information Technology

Numerous examples exist of the benefits of the timely access to information in emergencies and disasters. Information technology (IT) is playing an increasingly important role in information-sharing during emergencies and disasters. The effective use of IT in out-of-hospital (OOH) disaster response is accompanied by numerous challenges at the human, applications, communication, and security levels. Most reports of IT applications to emergencies or disasters to date, concern applications that are hospital-based or occur during non-response phases of events (i.e., mitigation, planning and preparedness, or recovery phases). Few reports address the application of IT to OOH disaster response. Wireless peer networks that involve ad hoc wireless routing networks and peer-to-peer application architectures offer a promising solution to the many challenges of information-sharing in OOH disaster response. These networks offer several services that are likely to improve information-sharing in OOH emergency response, including needs and capacity assessment databases, victim tracking, event logging, information retrieval, and overall incident management system support.

Ethical considerations in emergency planning, preparedness, and response to acts of terrorism.

Throughout the globe, healthcare providers are increasingly challenged with the specter of terrorism and the fallout from weapons of mass destruction. Preparing for and responding to such manmade emergencies, however, threatens the ethical underpinnings of routine, individualized, patient-centered, emergency healthcare. The exigency of a critical incident can instantly transform resource rich environs, to those of austerity. Healthcare workers, who only moments earlier may have been seeing two to three patients per hour, are instantly thrust into a sea of casualties and more basic lifeboat issues of quarantine, system overload and the thornier determinations of who will be given every chance to live and who will be allowed to die. Beyond the tribulations of triage, surge capacity, and the allocation of scarce resources, terrorism creates a parallel need for a host of virtues not commonly required in daily medical practice, including prudence, courage, justice, stewardship, vigilance, resilience, and charity. As a polyvalent counterpoint to the vices of apathy, cowardice, profligacy, recklessness, inflexibility, and narcissism, the virtues empower providers at all levels to vertically integrate principles of safety, public health, utility, and medical ethics at the micro, meso, and macro levels. Over time, virtuous behavior can be modeled, mentored, practiced, and institutionalized to become one of our more useful vaccines against the threat of terrorism in the new millennium.

A Proposed Universal Medical and Public Health Definition of Terrorism

The lack of a universally applicable definition of terrorism has confounded the understanding of terrorism since the term was first coined in 18th Century France. Although a myriad of definitions of terrorism have been advanced over the years, virtually all of these definitions have been crisis-centered, frequently reflecting the political perspectives of those who seek to define it. In this article, we deconstruct these previously used definitions of terrorism in order to reconstruct a definition of terrorism that is consequence-centered, medically relevant, and universally harmonized. A universal medical and public health definition of terrorism will facilitate clinical and scientific research, education, and communication about terrorism-related events or disasters. We propose the following universal medical and public definition of terrorism: The intentional use of violence--real or threatened--against one or more non-combatants and/or those services essential for or protective of their health, resulting in adverse health effects in those immediately affected and their community, ranging from a loss of well-being or security to injury, illness, or death.

Terrorism in Turkey

Over the past two decades, terrorism has exacted an enormous toll on the Republic of Turkey, a secular democracy with a 99.8% Muslim population. From 1984 to 2000, an estimated 30,000 to 35,000 Turkish citizens were killed by a nearly continuous stream of terrorism-related events. During this period, the Partiya Karekerren Kurdistan (PKK), a Kurdish separatist group (re-named KADEK in 2002), was responsible for the vast majority of terrorism-related events (and casualties), which disproportionately affected the eastern and southeastern regions of Turkey, in which the PKK has focused its activities. Most terrorist attacks over the past two decades have been bombings or shootings that produced < 10 casualties per event. From 1984 to 2003, 15 terrorist attacks produced > or = 30 casualties (eight shootings, five bombings, and two arsons). The maximum number of casualties produced by any of these events was 93 in the Hotel Madimak arson attack by the Turkish Islamic Movement in 1993. This pattern suggests that terrorist attacks in Turkey rarely required more than local systems of emergency medical response, except in rural areas where Emergency Medical Services (EMS) are routinely provided by regional military resources. The last decade has seen the development of several key systems of local emergency response in Turkey, including the establishment of the medical specialty of Emergency Medicine, the establishment of training programs for EMS providers, the spread of a generic, Turkish hospital emergency plan based on the Hospital Emergency Incident Command System, and the spread of advanced training in trauma care modeled after Advanced Trauma Life Support.

Recommended modifications and applications of the Hospital Emergency Incident Command System for hospital emergency management.

The Hospital Emergency Incident Command System (HEICS), now in its third edition, has emerged as a popular incident command system model for hospital emergency response in the United States and other countries. Since the inception of the HEICS in 1991, several events have transformed the requirements of hospital emergency management, including the 1995 Tokyo Subway sarin attack, the 2001 US anthrax letter attacks, and the 2003 Severe Acute Respiratory Syndrome (SARS) outbreaks in eastern Asia and Toronto, Canada. Several modifications of the HEICS are suggested to match the needs of hospital emergency management today, including: (1) an Incident Consultant in the Administrative Section of the HEICS to provide expert advice directly to the Incident Commander in chemical, biological, radiological, nuclear (CBRN) emergencies as needed, as well as consultation on mental health needs; (2) new unit leaders in the Operations Section to coordinate the management of contaminated or infectious patients in CBRN emergencies; (3) new unit leaders in the Operations Section to coordinate mental health support for patients, guests, healthcare workers, volunteers, and dependents in terrorism-related emergencies or events that produce significant mental health needs; (4) a new Decedent/Expectant Unit Leader in the Operations Section to coordinate the management of both types of patients together; and (5) a new Information Technology Unit Leader in the Logistics Section to coordinate the management of information technology and systems. New uses of the HEICS in hospital emergency management also are recommended, including: (1) the adoption of the HEICS as the conceptual framework for organizing all phases of hospital emergency management, including mitigation, preparedness, response, and recovery; and (2) the application of the HEICS not only to healthcare facilities, but also to healthcare systems. Finally, three levels of healthcare worker competencies in the HEICS are suggested: (1) basic understanding of the HEICS for all hospital healthcare workers; (2) advanced understanding and proficiency in the HEICS for hospital healthcare workers likely to assume leadership roles in hospital emergency response; and (3) special proficiency in constituting the HEICS ad hoc from existing healthcare workers in resource-deficient settings. The HEICS should be viewed as a work in progress that will mature as additional challenges arise and as hospitals gain further experience with its use.