Steven J. Rottman

The role of public health in disaster preparedness, mitigation, response, and recovery.

1. Research Director, Center for Public Health and Disaster Relief, University of California-Los Angeles 2. Director, Center for Public Health and Disaster Relief, University of CaliforniaLos Angeles and President, World Association for Disaster and Emergency Medicine Correspondence: Kimberly Shoaf, Dr.PH Center for Public Health and Disaster Relief University of California-Los Angeles Los Angeles, California 90024 USA

Development of a Training Curriculum for Public Health Preparedness

We describe the development of a 2-day training curriculum in emergency public health to improve the competency of public health personnel to prepare for, and respond to, both natural and human-caused disaster hazards. The training is conducted in a face-to-face setting and content is mapped to recognized emergency preparedness competencies for public health workers. The training materials are uniquely structured to the specific hazards, demographics, resources, and local emergency response agencies for each jurisdiction. This training program incorporates a series of challenging interactive scenarios that reinforce decision making in a public health emergency. Pretesting and posttesting are used to evaluate knowledge gained by participants. This interactive approach aligns with the principles of adult learning, and training evaluations indicate that this method is an effective integration of process and content.

Education issues in disaster medicine: summary and action plan

INTRODUCTION Change must begin with education. Theme 8 explored issues that need attention in Disaster Medicine education. METHODS Details of the methods used are provided in the introductory paper. The chairs moderated all presentations and produced a summary that was presented to an assembly of all of the delegates. The chairs then presided over a workshop that resulted in the generation of a set of action plans that then were reported to the collective group of all delegates. RESULTS Main points developed during the presentations and discussion included: (1) formal education, (2) standardized definitions, (3) integration, (4) evaluation of programs and interventions, (5) international cooperation, (6) identifying the psychosocial consequences of disaster, (7) meaningful research, and (8) hazard, impact, risk and vulnerability analysis. DISCUSSION Three main components of the action plans were identified as evaluation, research, and education. The action plans recommended that: (1) education on disasters should be formalized, (2) evaluation of education and interventions must be improved, and (3) meaningful research should be promulgated and published for use at multiple levels and that applied research techniques be the subject of future conferences. CONCLUSIONS The one unanimous conclusion was that we need more and better education on the disaster phenomenon, both in its impacts and in our response to them. Such education must be increasingly evidence-based.

Prehospital use of heparin locks: A cost-effective method for intravenous access

Intravenous (IV) infusions were ordered in nearly 95% of paramedic runs called into a busy base station hospital. Most of the patients received IV lines for either prophylactic access or administration of single or multiple bolus medications. In this group of patients, the application of a heparin lock injection port directly to the IV catheter, followed by the injection of 10 units of heparin, was evaluated. Of 102 consecutive patients treated in the field, 98 (97%) were treated with heparin locks only. The total number of patients requiring an IV infusion drip (either by paramedics or in the emergency department of the receiving hospital) was 20 (20%). If all 102 patients had received conventional IV drip infusions, the total patient equipment charges would have been

Pandemic influenza triage in the clinical setting.

4,610.40. The actual charges for all patients in this series, either with heparin locks or IV infusion sets, was

Low-level carbon-monoxide poisoning: inability of neuropsychological testing to identify patients who benefit from hyperbaric oxygen therapy.

1,846.14--a 60% savings. The results of the study indicate that the heparin lock is a safe, convenient, and cost-effective method for maintaining IV access in the prehospital environment.

Examining Self-Perceived First-aid Abilities After the Northridge Earthquake

INTRODUCTION There has been much federal and local health planning for an influenza pandemic in the United States, but little is known about the ability of the clinical community to deal quickly and effectively with a potentially overwhelming surge of pandemic influenza patients. PROBLEM The attitudes and expectations of emergency physicians, emergency nurses, hospital nursing supervisors, hospital administrators, and infection control personnel concerning clinical care in a pandemic were assessed. METHODS Key informant structured interviews of 46 respondents from 34 randomly selected emergency receiving hospitals in Los Angeles County were conducted using an Institutional Review Board-approved protocol. The interview asked about supplies/resources, triage, quality of care, and decision-making. At the conclusion of each interview, the informant was asked to provide the contact information for at least two others within their respective professional group. Interviews were transcribed and coded for key themes using qualitative analytical software. RESULTS There was little salience that an influx of variably ill patients with influenza would force stratified healthcare decision-making. There also was a general lack of preparation to address the ethics and practices of triaging patients in the clinical setting of a pandemic. CONCLUSIONS Guidelines must be developed in concert with public health, medical society, and legislative authorities to help clinicians define, adopt, and communicate to the public those practice standards that will be followed in a mass population, infectious disease emergency.

Comparison of inhaled metaproterenol via metered-dose and hand-held nebulization in prehospital treatment of bronchospasm.

INTRODUCTION Although major sequelae of carbon-monoxide (CO) poisoning and its treatment with hyperbaric oxygen (HBO) are well-documented, a syndrome of low-level CO poisoning has received relatively little attention. Subtle symptoms of poor concentration, language difficulty, problems with calculations, and memory loss were noted after an acute exposure of 131 dormitory residents to low levels of CO. The CO Neuropsychological Screening Battery (CONSB), a series of tests reported by others as useful to identify victims of CO poisoning, was performed on a subset of 46 victims. It was hypothesized that their test scores would improve after treatment with HBO. METHODS Testing was performed both before and after HBO on 35 CO-exposed victims. A control group of 20 students residing on the same college campus, but not involved with the CO incident, also were tested on two separate occasions to assess the ability of the test to identify selectively victims of low-level CO poisoning, as well as to evaluate its validity when administered serially. RESULTS Both CO-exposed and control subjects demonstrated significant performance improvement when completing the testing for the second time. In addition, the baseline test scores were not significantly different for either the CO-exposed or the control groups. Nonetheless, all CO-exposed victims reported immediate subjective improvement of their symptoms after HBO therapy. CONCLUSION These observations and a review of the literature suggest that there might exist a syndrome of subtle neurological disturbances in victims of low-level CO poisoning. Whether this is permanent or might regress spontaneously over time is unknown. As a diagnostic adjunct, the CONSB does not appear to be as useful in low-level CO poisoning.

A Graduate Curriculum in Emergency Public Health

INTRODUCTION This study examines those factors predictive of self-perceived first-aid abilities among a community-based sample after the 1994 Northridge earthquake. METHODS A probabilities-proportionate-to-size (pps) sample of residents of Los Angeles Country and 11 pre-selected zip codes from southeastern Ventura County was selected using computer-generated random digit-dialing (rdd) procedures 7-11 months after the earthquake. Data were collected from 506 individuals in 45 minute interviews. A unidimensional scale of self-perceived first-aid ability was created and represents the dependent variable in a causal path model. RESULTS In a causal path model, standardized path coefficients suggested that while reports of taking first-aid courses were the most influential factors in predicting higher self-perceived first-aid abilities, other factors including being white, younger, speaking English in the home, and lower income also predicted higher self-perceived first-aid abilities that were independent from taking formal first-aid courses. CONCLUSIONS First-aid training should be directed towards target segments of the population that are not likely to have had instruction in these basic skills. Those individuals who self-report high first-aid proficiency, independent of formal first-aid training, should be evaluated to assess their abilities to perform these skills.

Prehospital Fluid Administration in Trauma

INTRODUCTION Although the efficacy of the administration of beta-adrenergic bronchodilators has been demonstrated, the best method available for the delivery of these drugs in the prehospital setting has not been defined. This paper compares the effects of administration of metaproterenol when administered by paramedics using either a metered-dose inhaler (MDI) or a hand-held nebulizer (HHN). HYPOTHESIS There is no difference in the effects produced in patients suffering from smooth bronchiolar muscle spasm by metaproterenol when delivered either by a standard metered-dose inhaler or with a hand-held nebulizer. PARTICIPANTS Consecutive prehospital patients complaining of difficulty breathing with clinical evidence of bronchospasm and with a history of asthma, chronic obstructive pulmonary disease, or emphysema who were not in extremis. METHODS Prior to the administration of metaproterenol, a peak expiratory flow rate (PEFR) was obtained. This measurement was repeated five minutes following the conclusion of the administration of metaproterenol. Patients in Burbank, California, received the treatment using a standard metered-dose inhaler, and those in Madison, Wisconsin, received the drug using a hand-held nebulizer. Peak expiratory flow rates were compared using Students t-tests with Bonferronis correction. Statistical significance was set at p < 0.05. RESULTS Data were collected from 36 consecutive patients by the paramedics of the Burbank Fire Department and from 32 consecutive patients by the paramedics of the Madison Fire Department. For the metered-dose inhaler group, the mean value for peak expiratory flow rate for the pre-treatment test was 95.4 +/- 88.1 l/min, and after treatment was 109.4 +/- 89.3 l/min (p < 0.001). For the hand-held nebulizer group, the mean value for peak expiratory flow rate before the administration of the metaproterenol was 96.1 +/- 76.3 l/min and following the treatment was 149.1 +/- 92.9 l/min (p < 0.001). The mean values for the differences between the control peak expiratory flow rate and the post-treatment peak expiratory flow rate for the metered-dose inhaler group was + 140.0 +/- 27.4 l/min, and for the hand-held nebulizer group was + 53.0 +/- 69.1 l/min (p < 0.003). CONCLUSIONS In the prehospital setting, the administration of metaproterenol using a hand-held nebulizer is more effective than delivering the drug using a metered-dose inhaler. The hand-held nebulizer is easier to use and delivers a higher dose of the drug than is convenient using the metered-dose inhaler.