Conflict and Catastrophe Medicine: A Practical Guide
Abstract
Conflict and Catastrophe Medicine - A Practical Guide provides a framework for use by health professionals visiting a resource-constrained environment. Encompassing problems brought about by local conflict or natural disasters, the book covers preparation, organisation, logistics, treatment of major trauma and medical emergencies, and the special problems of delivering medicine in a hostile environment.
Conflict and Catastrophe Medicine - A Practical Guide comprehensively tackles:
- self-preparation of health professionals to face a range of medical and related problems which occur in hostile and remote environments;
- war and disaster medicine, covering acute management, rehabilitation, reconstruction and prevention;
- bridging the fields of medicine, nursing, international relations, history, politics and economics.
The book also touches on nutrition, infection, trauma, psychiatry and psychological medicine and training.
James Ryan, Leonard Cheshire Professor of Conflict Recovery, Royal Free and University College Medical School, London, UK Peter F Mahoney, Consultant Anaesthetist and Honorary Senior Lecturer in Conflict Medicine, Leonard Cheshire Centre, Royal Free and University College Medical School, London, UK Ian Greaves, Lecturer in Conflict Medicine, Leonard Cheshire Centre, Royal Free and University College Medical School, London, UK Gavin Bowyer, Consultant in Orthopaedic Surgery, Southampton General Hospital, UK.
Chapters (24)
Confucius’s phrase “May you live in interesting times” can be interpreted equally as a blessing or a curse. When directed at a prospective humanitarian aid volunteer, eager to embark on an overseas mission in the new millennium, the phrase leans more towards the latter. This may be an unexpected introduction to a manual directed at future volunteers, but this view is becoming widespread and bears dispassionate scrutiny.
Natural disasters are a growing public health problem in the increasing number of events and the numbers of people affected. This chapter focuses on some of the background health issues behind this global trend as they apply to aid workers. Technological disasters differ in many important respects from natural disasters in their causes and health impacts, and their frequency is much lower as they are inherently preventable by engineers and government regulation. Avoiding technological disasters is more straightforward than mitigating natural hazards, but disaster workers should include both types of disaster in an all-hazards approach to planning and preparedness. Thus an earthquake may trigger the failure of a hazardous installation such as a nuclear reactor, or floodwaters may become contaminated with toxic materials. Man-made humanitarian emergencies from conflicts or political repression (complex disasters) may also be complicated by natural hazards, or responses to events such as floods in war zones can be inhibited by the threat of landmines.
The terms “refugee” and “internally displaced person” (IDP) are widely used in the literature of humanitarian assistance and require definition and distinction. Refugees are migrants who must have crossed an international frontier because of a well-founded fear of persecution. IDPs are people who have involuntarily been uprooted and displaced but still remain in their own countries. The distinction is important, as the United Nation’s High Commissioner for Refugee (UNHCR) is legally bound by international law to protect and assist refugees. While care of IDPs is undertaken by UNHCR - witness the conflict in the Balkans - the arrangement is not legally binding. Although there are distinctions under international law, humani-tarian assistance organisations make little or no distinction, and attempt to access and assist all displaced people.
EDITORS’ NOTE - Much of this chapter is written in the first person as it is a very personal account from a highly accomplished trio of doctors with a vast experience of working in remote and hostile settings. Readers will note that most of the pearls of wisdom written here are echoed in many of the sections and chapters of this work.
In this chapter, the concepts of medical intervention in the event of a catastrophe or a conflict will be examined and analysed. A convenient starting point, therefore, is an understanding of the terms involved. A medical intervention is an action taken by an agency in order to remedy a medical shortfall or problem. As such it does not neces-sarily have to be purely clinical in nature. Rather, it must simply address a medical requirement in the target population. Its delivery may be undertaken by a variety of non-medical agencies such as food-relief programmes. Similarly, a catastrophe or conflict is an event which has produced an inability to cope with the extra humani-tarian demands consequent upon the incident. Such a mismatch between demand and supply may be temporary, as in earthquake recovery in developed nations like Japan, or be long-term and seemingly intractable, as in many cases of internal conflict in Africa.
A volunteer deploying on a humanitarian mission can expect to encounter fellow aid workers from a bewildering variety of agencies. Increasingly, there will be a mix of military and non-military personnel working side by side, not always harmoniously.
When questioned, many a medical student or nursing student will profess a deep desire to work in the field of international humanitarian aid overseas at some time in their future career.
Medical students training in the United Kingdom have an opportunity in their final year to experience medicine in a setting which is different to that of their medical school and its associated satellite district general hospitals. During a period of 2–3 months, medical students may choose from an array of destinations (commonly with the clear objective of studying a specific speciality of personal interest during this time). As travel has become so much easier, with ever shortening times needed to reach far-flung destinations, so the possibility of experiencing medicine in excit-ing, sometimes hazardous and completely different situations has increased. This finding was confirmed recently by a study, which reviewed both the destinations as well as the hazards associated with the medical student elective. A nationwide survey which included medical students throughout the United Kingdom demonstrated that 97% of students choose to travel abroad, with 69% visiting developing countries, with southern Africa being the most popular [1].
Most travellers understand that “avoiding trouble” in a foreign country in which they are travelling will include issues that may affect personal safety and security, for example such obvious things as avoiding being present during a gunfight between warring factions within the country, not engaging in espionage, not being caught smuggling drugs through customs etc.
Conflicts and catastrophes, natural or otherwise, do not only visit themselves on the people living in the areas they hit. They can also have a profound effect on people who specialise in helping to sort out their aftermath.
The psychological aspects involved in the provision of medical aid in hostile environments relate to general issues and those specific to the location to which you deploy, as well as the phases of that deployment.
The biggest threats to humanitarian workers in the field are from injury and illness. People deploying from a developed society are used to being able to call for and receive help easily when they are in difficulties.
Medical aid personnel working in conflicts, catastrophes, and remote areas may be required to interface with aviation in a variety of ways. Firstly, they may be inserted, deployed and recovered by air, secondly they may be shuttled from location to location in their operational area by air, or be involved in medical reconnaissance or search and rescue utilising aircraft. Thirdly, they may be required to assist in the safe landing of medical evacuation aircraft, prepare patients for aero-medical evacuation, load them into aircraft, and occasionally act as flight medical attendants, accom-panying and supporting patients in flight, and ensuring appropriate handover and disposal on arrival.
EDITORS’ NOTE - This chapter and the following one are lengthy and detailed. This is our intention, as we believe that most medical persons are unfamiliar with this important area. Aid personnel frequently depend for their lives and safety on their ability to communicate effectively.
The range of communications modalities described in the preceding chapter give a range of capabilities around which providers can build support for an operation. As with the enabling technology, they can be divided into low-bandwidth and high-bandwidth capabilities.
The authors of this chapter include emergency physicians, primary care physicians and a surgeon. All have experience of the complex problems faced by health professionals in attempting to provide acute medical care in the face of adversity following natural and man-made disasters and in other austere settings. In this context, it is impossible to draw a line between public health medicine and acute medical care. Thirst, starvation, diarrhoea and communicable disease are all illnesses requiring management and are the lot of the acute care health professional as well as the public and community health professional. Inevitably this has lead to some overlap with other chapters and sections in this manual. We see this as reinforcement, not repetition, and perhaps it also shows an additional viewpoint. This chapter attempts to deal with a vast array of medical problems in a wide variety of conflict settings. It is not intended for the experienced senior physician, seasoned by numerous deployments. The authors recognise that readers of this manual are more likely to include elective students in medicine and professions allied to medicine, junior doctors, nurses and a range of other health professionals. The age and experience of this diverse group will also vary greatly. Therefore, the chapter does not attempt to be an exhaustive treatise on medical therapeutics. Such specialist texts already exist and are listed in the suggested reading section at the end of this chapter, and in the Resources section.
In conflict and catastrophe, women are major victims. Women experience these disasters differently to men, a phenomenon confirmed by those working in the field. This distinctive experience is related to the particular vulnerability of this group when disaster strikes, although its effects differ widely across cultures depending on the role of women in each society. Moreover, they are generally disadvantaged in terms of education and are considerably less mobile because of their traditional role in caring for others. Despite the prevailing situation, the “reproductive role” of the woman continues, and along with it the complications. Women are seen as a “sexual objects” and are often the victims of sexual assault.
In spite of the huge strides which have been made towards the improvement of health and education in developing countries, old problems are continuously confronting new generations. In addition to war, poverty, and other socio-political factors, the most vulnerable countries are also plagued by natural disasters. These disasters can strain resources and overwhelm even the most affluent of societies. However, the consequences in deprived societies can be profound, amounting to disaster in its true definition.
The authors of this chapter include emergency physicians, surgical specialists and anaesthetists with experience of working in a wide variety of hostile environments. As with earlier chapters, the aim is not to “teach grandmothers to suck eggs”. Senior surgeons with deployment experience will have their own tried and trusted methods for managing patients under austere circumstances, and some will belong to that dying breed the “general surgeon”. This chapter is not aimed at the senior and experienced old hands. Rather, the purpose is to illustrate the range and complexity of conditions covered by our chapter headings for the more junior and often specialised health professional with a surgical interest in the widest sense
The bulk of this manual is concerned with activities during the acute phase in a hostile environment, whether it is as a result of war, conflict or a natural disaster. In a sense, this is the most attractive or glamorous period. There is typically wide-spread media coverage, and a myriad of aid organisations deploy and begin their work in the full glare of TV news cameras. The immediate aim of these agencies is to drive down mortality rates in ways that have been described in earlier chapters. These activities are exciting and telegenic, and occur at a time of maximum international interest and attention. This phase passes, and along with it goes media interest. Further, many of the aid agencies which specialise in acute-phase activities depart very quickly when the situation stabilises.
This section of the handbook concludes with a chapter describing the more important pitfalls that face the health professional deployed in a hostile environment. No attempt is made to list or describe every single adverse event that might occur - that would merit a complete text in its own right. What we describe are “the big ones”! These are the problems that beset aid operations again and again. Most of these events are predictable and preventable. The other ambition in this section is to emphasise that lessons can be learnt from taking hard knocks, and these lessons need wide dissemination to the vast number of youthful and inexperienced volun-teers waiting in the wings for their first overseas deployment.
The publications listed here are over and above the references and further reading lists found at the end of many of the chapters in this handbook.
Although pre-packed kits are available (see list of companies below), many will want to personalise their medicines and equipment depending on location, local logistics, risks and length of tour. It is assumed that the organisation deploying you will provide medicines for the population at risk. Therefore, the following recommenda-tions are for personal use.
The web is a growing resource for the humanitarian volunteer and is underutilised. Most aid organisations have web sites - the problem is how to find them and use them to answer questions.
... There are a number of excellent reference texts and resources that describe the priorities and immediate actions in assessing acutely unwell patients in the hospital and general practice setting (15)(16)(17)(18)(19). The approach and techniques advocated are often equally applicable in the resource limited pre-hospital environment and during transition to hospital (1,(20)(21)(22)(23). Similarly, the ABCDE approach taught on standard life support courses is as applicable to acute medical emergencies as it is to resuscitation from cardiac arrest and the management of major trauma (3,(24)(25)(26)(27).Thus the structured approach illustrated in Figure 1 is recommended. ...
... Urgent surgical review should be arranged and the patient evacuated if necessary to achieve this. General management principles in the intervening period and during transport are listed in Box 5 (22). The practice of withholding analgesia in patients with acute abdominal pain to prevent masking of the signs necessary for diagnosis has been shown to be unfounded (57,58). ...
The pre-hospital management of acute medical emergencies can be difficult. Critically ill patients must be evaluated quickly and accurately to ensure that immediately life-threatening problems are identified and treated. Figure 1 and Box 2 provide a structured method for rapid assessment in the pre-hospital phase. Although the majority of medically unwell patients will not require an aggressive resuscitation phase during the primary survey, the use of the structured approach in all patients will ensure that 'time critical' pre-hospital medical emergencies are identified. This approach also emphasizes that once immediately correctable problems have been treated, the priority is transfer the patient to the nearest resuscitation facility.
... Subsequent contact with Page 4 of 15 the medic and their employer is minimal and access to continuing medical education is lacking leading to ill prepared medics with minimal continuing support. Ciottone (2006) and Ryan et al (2002), describe additional stressors on the remote medic including "Communicative isolation, … marriage/relationship stability (and) regular communication with dependents" being of special concern when an employee is deployed for long periods of up to a year without leave. The standard initial contract for an Indian or Filipino medic in Saudi Arabia before a vacation is permitted is twenty-four months exacerbating the innate stressors of working in remote locations. ...
A post-graduate diploma course module assignment for Remote and Offshore Medicine.
... Medical helicopters and aeromedical evacuation provided fast transportation of wounded persons at disaster sites to hospitals. 19,20 With the ability of landing at almost any location, these units functioned as flying ambulances and rescued people at sea or trapped at places that were difficult to reach using conventional first aid facilities. ...
Introduction
Natural and man-made disasters are becoming global concerns. Natural disasters appear to be growing in number and intensity due to global warming, population explosion, increased travel, and overcrowding of cities. In addition, man-made disasters do not seem to be diminishing.
At disaster sites, an immediate response is needed. National and international organizations; nongovernmental, military, and commercial organizations; and even private donors enlist to provide humanitarian and medical support and to send supplies, shelters, and temporary health care facilities to disaster zones.
Problem
The literature is sparse regarding the design of portable health care facilities intended for disaster zones and their adaptability to the tasks required and site areas.
Methods
Data were collected from peer-reviewed literature, scientific reports, magazines, and websites regarding health care facilities at rescue and salvage situations. Information was grouped according to categories of structure and properties, and relative strengths and weaknesses. Next, suggestions were made for future directions.
Results
Permanent structures and temporary constructed facilities were the two primary categories of health care facilities functioning at disaster zones. Permanent hospitals were independent functioning medical units that were moved or transported to and from disaster zones as complete units, as needed. These facilities included floating hospitals, flying (airborne) hospitals, or terrestrial mobile facilities. Thus, these hospitals self-powered and contained mobility aids within their structure using water, air, or land as transporting media.
Temporary health care facilities were transported to disaster zones as separate, nonfunctioning elements that were constructed or assembled on site and were subsequently taken apart. These facilities included the classical soft-type tents and solid containers that were organized later as hospitals in camp configurations. The strengths and weaknesses of the diverse hospital options are discussed.
Conclusions
Future directions include the use of innovative materials, advanced working methods, and integrated transportation systems. In addition, a holistic approach should be developed to improve the performance, accessibility, time required to function, sustainability, flexibility, and modularity of portable health care facilities.
Bitterman N, Zimmer Y. Portable health care facilities in disaster and rescue zones: characteristics and future suggestions. Prehosp Disaster Med.
... And finally, the surgical treatment should be conducted with the aim of minimizing blood loss and the need for blood transfusions, as well as optimizing the chances of postoperative recovery without the facilities for intensive 544 A.K. Leppäniemi care, total parenteral nutrition, and use of sophisticated and expensive medication. 1,2 Patient Characteristics in an NGO Hospital A large number of wounded patients brought to an NGO field hospital are civilians, defined as women and girls, boys (under 16 years of age), and men of 50 or more. Of the 18 877 patients injured by bullets, bombs, shells, mortars, or mines and admitted to ICRC hospitals in 1991 through 1998, about 28% were civilians. ...
Much of this is still valid, but a number of concepts in care of the ballistic casualty have changed. These include developing ideas on fluid resuscita-tion and refinement of field protocols based on operational experience. Authors, editors, and colleagues expressed the view that there was a need for a practical guide encompassing these developments, along the lines of Conflict and Catastrophe Medicine (Springer, 2002). The aim was to distill real-life practice and try to capture that which often is lost or diluted in traditional texts. With 9/11, the world changed. Since then, major conflicts have occurred in Afghanistan and Iraq, and operations are still ongoing. Many of the authors and editors deployed to these conflicts with nongovernmental orga-nizations, Aid Agencies, and the military. Others are working with these injuries on a day-to-day basis at one of the USA's busiest trauma centers. This has delayed the production of Ballistic Trauma: A Practical Guide, but means that people are writing with recent experience of managing ballistic injury. Colleagues returning from deployment have emphasized the need for clear guidance on managing ballistic injury, especially as more and more military reservists are being deployed and their day-to-day work may not include managing these types of injury. Authors have been given a relatively free hand in structuring their chapters so they would be unconstrained by the book's style and be able to pass on their lessons unhindered. Finally, our request is that this book be a "living" document. Give us feedback. Record what treatment works and what treatment does not. Use this knowledge to improve the care of the ballistic casualty.
... M ajor incidents are defined as the result of a vast ecological breakdown in the relationship between humanity and environment for which extraordinary measures, often necessitating outside or international help, are required to cope with them. 1 Preparedness involves arrangements to ensure that all resources and services that may be needed to cope with the effects of major incident can be rapidly mobilized and deployed. 2,3 It builds better coordination and cooperation between agencies within the community and improves response to the effects of a major incident by organizing the delivery of timely and effective rescue, relief, and assistance. ...
Background:
Research shows that having previous experience of major incidents has a positive impact on awareness and preparedness of organizations. We investigated the effects of major incident experience on preparedness of health organizations on future disasters in Iran.
Methods:
A qualitative study using a semistructured interview technique was conducted with 65 public health and therapeutic affairs managers. Analysis of the data was performed used the framework analysis technique, which was supported by qualitative research software.
Results:
The study found that prior experience of major incidents results in better performance, coordination, and cooperation in response to future events. There was a positive effect on policy making and resource distribution and an increase in (1) preparedness activities, (2) raising population awareness, and (3) improving knowledge. However, the preparedness actions were predominantly individual-dependent.
Conclusions:
Our findings showed that to increase system efficiency and effectiveness within health organizations, an appropriate major incident management system is needed. The new system can use lessons learned from previous major incidents to better equip health organizations to cope with similar events in the future.
... care, total parenteral nutrition, and use of sophisticated and expensive medication. 1,2 Patient Characteristics in an NGO Hospital A large number of wounded patients brought to an NGO field hospital are civilians, defined as women and girls, boys (under 16 years of age), and men of 50 or more. Of the 18 877 patients injured by bullets, bombs, shells, mortars, or mines and admitted to ICRC hospitals in 1991 through 1998, about 28% were civilians. ...
There are tens of thousands of nongovernmental organizations (NGOs) operating today in most countries, with their scope varying
from large, Northern-based charities to community-based self-help groups in the South. The World Bank defines NGOs as “private
organizations that pursue activities to relieve suffering, promote the interests of the poor, protect the environment, provide
basic social services or undertake community development.” With increasing globalization, NGOs have become more influential
in world affairs, and it has been estimated that over 15% of total overseas development aid are channeled through NGOs. These
organizations are not directly affiliated with any national government, but often have a significant impact on the social,
economic, and political activity of the country or region involved.
... 1 It is described as the result of a vast ecological breakdown in the relationship between human and environment, and requires extraordinary measures in order to cope with it, often necessitating outside or international help. 2 Preparedness incorporates arrangements to ensure that all resources and services which may be needed to cope with the effects of a major incident can be rapidly mobilised and deployed. 3 Major incident preparedness is defined as an umbrella strategy that involves forecasting and taking precautionary measures prior to an imminent threat. ...
Research shows that previous experience of major incidents has positive impacts on awareness and preparedness of organisations. This manuscript aims to examine the preparedness indicators of health organisations against major incidents in two different types of organisation: those with direct involvement in response to the Bam earthquake and other organisations.
A descriptive study was conducted, and 230 questionnaires were distributed among the health managers in both types of organisations to compare the questionnaire results between them.
A total of 114 questionnaires were returned. 85% of the respondents were male, and 15% were female. Considering the organisational factor, a significant difference between the organisations was observed. Considering the communication factor, only differences in relationship with outside stakeholders and knowing the responsibility of other organisations were significant. Rehearsal and multiagency plans for warning were considerably different in the organisations. In planning, coordination, training, business continuity and cultural factors, there were no important differences. For resource variables, only the statement of sufficient resources and tools for the employees was significantly different, and, for the policy factor, there were significant differences in two variables: incorporation of major incident issues into the service design and management of voluntary efforts in a major incident.
The findings have implications for health organisations in developing countries, especially in the Middle East. A major incident-management system re-engineering is required to bring the lessons learnt from previous major incidents into preparedness efforts and to shift individual-based activities toward systematic approaches in major incident management.
... This sound military doctrine applies no less to surgical teams on an aid mission to a natural disaster. Good preparation and planning will prevent inappropriate deployment with the ensuing embarrassment that will follow (14). The old adage is 'do not become a casualty yourself'. ...
In recent years, the concepts of sustainability and sustainable development of transport infrastructure have been examined mainly from an economic, ecological, and social perspective. However, an essential aspect of the sustainability of the Trans-European Transport Networks (TEN-T) land infrastructure is also the construction and technical parameters of critical infrastructure objects. For this reason, the aim of the article is to define recommendations for the sustainability and future development of the TEN-T land infrastructure. For this purpose, the article presents the procedure for defining and modelling typical transport situations using the TEN-T land infrastructure and the procedure for identifying critical infrastructure objects of the TEN-T land infrastructure. Attention is also paid to the digitalization of critical infrastructure objects, which categorizes infrastructure according to its suitability for excessive and oversized transport using map data. The main output of the article are recommendations for the sustainability and future development of the TEN-T land infrastructure. These recommendations are based on the systematic development of TEN-T in four basic layers, namely legislative, capatitive, construction-technical, and technological. These recommendations are intended primarily for the Ministry of Defence of the Czech Republic and the Ministry of Transport of the Czech Republic, but also for transport infrastructure operators, i.e., Road and Motorway Directorate and Railway Infrastructure Administration.
RESUMO-A abordagem da grávida traumatizada, segue a regra geral da abordagem de toda a vitima de trauma, no entanto existe uma excepção. Neste caso estamos a tratar 2 pessoas. Devemos vigiar o estado hemodinâmico da grávida, uma vez que o choque tarda em aparecer, mas quando se instala é de difícil tratamento. INTRODUÇÃO A importância do estudo do traumatismo na grávida consiste no facto da incidência de traumatismos durante este período estar a aumentar nos últimos anos, devido à crescente participação da mulher na sociedade actual, inclusive quando grávida, o que a torna mais exposta a atropelamentos, acidentes de viação, actos de violência ou qualquer outro tipo de traumatismo. O trauma apareceu como a causa mais importante de morte de etiologia não obstétrica na grávida (cerca de 22%). Apresenta uma incidência de 6 a 7% e a mortalidade fetal apresenta valores de cerca de 70%. Mais de metade dos acidentes ocorrem no último trimestre, já que neste período, devido a um útero muito volumoso, a mulher perde parte da sua agilidade física. Toda a equipa médica que assiste uma grávida traumatizada deve ter conhecimento das alterações anatomo-fisiológicas da grávida que podem influenciar o diagnóstico e a conduta terapêutica. Deve terse em conta que estamos a assistir duas vítimas, onde a principal causa de lesão do feto é a alteração da homeostase materna. Mesmo que não ocorram lesões directas sobre o feto, as alterações da homeostase materna como hipóxia e hipotensão, causam vários danos e, por isso, deve dar-se prioridade à sobrevida materna. ALTERAÇÕES MORFOLÓGICAS E FUNCIONAIS DA GRAVIDEZ Estas modificações ocorrem naturalmente durante a gravidez e são necessárias para o desenvolvimento do feto e para preparar a mãe para o parto. Contudo, se não forem bem conhecidas pela equipa, podem ser confundidas com situações patológicas, levarem a interpretações erradas dos dados diagnósticos e a condutas terapêuticas inapropriadas.
A crisis is an exceptional event that causes damage and negative impacts on organizations. For this reason, crisis management is considered as a significant action needed to follow crisis causes and consequences for preventing or avoiding these exceptional events from occurring again. Studies have devoted their efforts to proposing methods, techniques, and approaches in the crisis management direction. As a result, it is critical to provide a consolidated study that has an integrated view of proposed crisis management methods, crisis impacts, and effective response strategies. For this purpose, this paper first highlights the proposed techniques used in crisis management and presents the main objective behind each technique. Second, the risks and impacts resulting from a crisis are highlighted. Finally, crisis response strategies are discussed. The major contribution of this study is it can guide researchers to define research gaps or new directions in crisis management and choose the proper techniques that cope with their research problems or help them discover new research problems.
Resumo-Em Portugal, o Trauma é a patologia que causa mais mortes, por acidente de viação. Cerca de 30% desta mortalidade poderá ser evitada se estas vitimas receberem assistência especializada nas primeiras horas. Assim sendo, é muito importante dispor de um sistema de socorro e triagem para assistência a situações de múltiplas vítimas. Em geral, para realizarem o transporte de um doente, a equipa de saúde deve estabelecer as condições mínimas de transporte para o doente, determinando: via aérea permeável, mecânica respiratória adequada; pressão arterial média estável, imobilização cervical, dorso-lombar e pélvica, e, controlo da dor e agitação psicomotora. Factores a analisar num socorro: • Tempo de transporte • Comunicações • Triagem • Tipo de doentes • Carências hospitalares • Organização intersectorial e interinstitucional TRIAGEM EXTRA E INTRAHOSPITALAR Desastre Define-se como uma situação súbita em que os recursos existentes para a assistência dos doentes é insuficiente face às necessidades imediatas. Do ponto de vista médico, corresponde a todo o evento que provoca um número total de vítimas que superam a capacidade de assistência médica habitual de uma localidade. O mais importante perante esta situação que, em geral ocorre de uma forma imprevista, grave e imediata, é que se responda eficientemente através de uma boa planificação e organização. Classificação Os desastres podem classificar-se de acordo com a natureza que os provoca, podendo distinguir-se da seguinte forma: Naturais-Tectónicos (erupções, tempestades)-Meteorológicos (inundações, furacões)-Topológicos (avalanches, desabamentos) Provocados pelo Homem-Contaminações químicas-Intoxicações maciças (gases, explosões)
RESUMO-É imprescendivél que a equipa que utiliza qualquer que seja o meio de transporte, conheça esse transporte, conheça os conceitos principais de transporte para adoptar as medidas necessárias, evitando os efeitos nocivos a que determinados doentes são sensíveis. A equipa deve actuar segundo as normas gerais de actuação: a) estabilização antes da evacuação; b) suporte básico de vida; c) acessos venosos; d) mobilização controlada para uma correcta evacuação. INTRODUÇÃO Qualquer que seja o meio utilizado para realizar o transporte sanitário, deve reunir um mínimo de condições que facilitem a assistência e assegurem uma transferência confortável, livre de riscos que comprometam o transporte sanitário. Estes factores físicos determinam alterações fisiológicas, que não são muito significativas nas pessoas saudáveis, mas que podem ter repercussões graves nas pessoas doentes, tais como alterações hemodinâmicas e respiratórias. Também, os aparelhos de monitorização e controlo clínico podem, por vezes, ser afectados, bem como a perfusão e composição de fármacos. Estas alterações são determinadas por:-variações de velocidade: aceleração/desaceleração-vibração-ruídos-temperatura-altitude: alterações de pressão e volume dos gases; diminuição da disponibilidade de oxigénio ACELERAÇÃO / DESACELERAÇÃO O corpo humano, quando submetido a alterações de velocidade, desenvolve forças de inércia que dependem da intensidade de aceleração ou desaceleração, do sentido deste e da massa corporal, actuando sobre o organismo, segundo a postura que este adopta em relação ao movimento. Geralmente, as acelerações podem apresentar repercussões graves nas pessoas doentes, dependendo da aceleração ser positiva ou negativa (desaceleração). O sangue desloca-se no sentido cabeça/pés ou vice-versa, (se o doente se encontra em decúbito dorsal e no sentido da marcha), sendo interpretados estes deslocamentos pelos sensores orgânicos situados nas aurículas, seios carotídeos e crossa da aorta, como alterações de peso e cuja resposta nervosa é conduzida pelo nervo vago e pelo sistema nervoso simpático, aos orgãos efectores (coração e grandes vasos). Se a aceleração ou a desaceleração é constante e intensa, o sangue acumula-se em determinadas regiões, ocasionando sintomas distintos.
A balística é a ciência do movimento dos projécteis. A balística pode dividir-se em 3 categorias: 1. Balística Interna (estudo dos projécteis no interior do cano da arma. 2. Balística Externa (aborda o estudo dos projécteis durante o seu voo) 3. Balística Terminal (estuda a penetração/embate dos projécteis em sólidos). 4. Balística das Feridas (estuda a penetração dos projécteis em tecidos moles). MECÂNICA DOS FERIMENTOS POR BALA O tipo de ferimento provocado por um projéctil depende em muito da tendência de um determinado projéctil para entrar em cambalhota (perder o seu ponto de equilíbrio). Um projéctil curto e de alta velocidade é mais propicio a dar rapidamente uma cambalhota ao entrar em contacto com tecidos vivos. Tal situação provoca uma maior destruição de tecido e aumento da transferência de energia cinética (EC) do projéctil ao alvo. A longa distância uma bala mais longa e mais pesada dispõe de mais EC ao embater no alvo, mas pode penetrar de tão facilmente que abandona o alvo ainda com muita da sua restante energia cinética. Uma bala com baixo valor de EC e dispondo de um desenho tal que consiga transmitir toda a sua EC ao alvo, pode provocar uma destruição de tecido bastante significativa (o alvo tem de estar próximo). Os danos produzidos por balas em tecidos vivos podem ser dos seguintes tipos: 1. Laceração e Esmagamento-Balas de baixa velocidade, pistolas e revólveres, que viagem a menos de 330 m/Seg. provocam virtualmente os seus danos por esmagamento. 2. Cavidades-A cavidade permanente é significativa com projécteis que viajam a mais de 330 m/Seg. A cavidade permanente é provocada pela trajectória da própria bala. O diâmetro resultante da cavidade permanente varia mas é normalmente maior que o diâmetro da bala.
World perceptions of security and health threats have changed in the last decade. The terrorist attacks of September 11, 2001 ushered communities into a new paradigm of social construct and behavior. In the United States (U.S.) the heightened security measures, surveillance, and medical preparedness of the Patriot Act have had far reaching effects on various sectors of our society. Fortunately, there has not been a successful attack on U.S. soil since 9-11, but our allies in the “war on terror” have not been so fortunate (e.g. London, Madrid, Mumbai and Oslo bombings). Changes in the scope of civilian and military involvement and an expanding medical role are discussed.
A unique healthcare system
The Falklands are a British overseas territory just to the east of the southern tip of South America that came to world attention during the 1982 conflict with Argentina. The archipelago comprises two main islands and some 20 other inhabited islands and upwards of 300 smaller ones, covering an area about the size of half of Wales. Most of the population is centred in the capital, Stanley, and in the military base at Mount Pleasant. The total population, civilian and military, is some 5000, with the deep sea fishing fleets adding another 5000 or so. The islands are situated on the same latitude as Oxford, but due to the lack of the Gulf Stream are cooler than southern England—the climate being more akin to Scotland, where a significant proportion of the early settlers originated from.
The medical services are based in Stanley at the King Edward VII Memorial Hospital which was rebuilt in 1987 after a tragic fire destroyed the previous wooden building. Out of the ashes arose a modern very well equipped facility. The range of equipment and facilities often surprises medical visitors, since Stanley is really only the size of a British village. This is because the hospital is the only medical facility for a large area of the South Atlantic, with referrals coming from as far as Tristan da Cuhna, South Georgia, and Antarctica.
Before the 1982 conflict the medical services were very limited mainly due to poor state of the economy. The medical situation was third world in nature with general practitioner (GP) surgeons and GP anaesthetists doing their best with limited facilities. Referrals could be made to the UK, Argentina, or Uruguay but were difficult due to poor communications and lack of money. Overnight the recapture of the Islands brought consultant …
The purpose of this project was to define education and training requirements for hospital-based dentists to efficiently and meaningfully participate in a hospital disaster response. Eight dental faculty with hospital-based training and/or military command and CBRNE (chemical, biological, radiological, nuclear, and explosive) expertise were recruited as an expert panel. A consensus set of recommended educational objectives for hospital-based dentists was established using the following process: 1) identify assumptions supported by all expert panelists, 2) determine current advanced dental educational training requirements, and 3) conduct additional training and literature review by various panelists and discussions with other content and systems experts. Using this three-step process, educational objectives that the development group believed necessary for hospital-based dentists to be effective in treatment or management roles in times of a catastrophic event were established. These educational objectives are categorized into five thematic areas: 1) disaster systems, 2) triage/medical assessment, 3) blast and burn injuries, 4) chemical agents, and 5) biological agents. Creation of training programs to help dentists acquire these educational objectives would benefit hospital-based dental training programs and strengthen hospital surge manpower needs. The proposed educational objectives are designed to stimulate discussion and debate among dental, medical, and public health professionals about the roles of dentists in meeting hospital surge manpower needs.
To review the essential principles involved in rescue missions for natural and man-made disasters.
A description of the relief of a concentration camp in 1945 as an example of the logistics required in any major disaster or rescue.
The arrival of trained Army rescue teams on the first day and dealing systematically with priorities in salvage, treatment and nursing saved many lives, even of desperately ill patients.
A centralised administration and organisation of supplies is the first priority. Suitable intravenous and very light nutrients, and the prevention and combating of infections are more urgent than the provision of shelter and clothing.
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