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Handbook for Pandemic and Mass-Casualty Planning and Response [1 ed.]
 9781614991359, 9781614991342

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Copyright © 2012. IOS Press, Incorporated. All rights reserved.

HANDBOOK FOR PANDEMIC AND MASS-CASUALTY PLANNING AND RESPONSE

Handbook for Pandemic and Mass-Casualty Planning and Response, IOS Press, Incorporated, 2012. ProQuest Ebook Central,

NATO Science for Peace and Security Series This Series presents the results of scientific meetings supported under the NATO Programme: Science for Peace and Security (SPS). The NATO SPS Programme supports meetings in the following Key Priority areas: (1) Defence Against Terrorism; (2) Countering other Threats to Security and (3) NATO, Partner and Mediterranean Dialogue Country Priorities. The types of meeting supported are generally “Advanced Study Institutes” and “Advanced Research Workshops”. The NATO SPS Series collects together the results of these meetings. The meetings are co-organized by scientists from NATO countries and scientists from NATO’s “Partner” or “Mediterranean Dialogue” countries. The observations and recommendations made at the meetings, as well as the contents of the volumes in the Series, reflect those of participants and contributors only; they should not necessarily be regarded as reflecting NATO views or policy. Advanced Study Institutes (ASI) are high-level tutorial courses to convey the latest developments in a subject to an advanced-level audience. Advanced Research Workshops (ARW) are expert meetings where an intense but informal exchange of views at the frontiers of a subject aims at identifying directions for future action. Following a transformation of the programme in 2006 the Series has been re-named and reorganised. Recent volumes on topics not related to security, which result from meetings supported under the programme earlier, may be found in the NATO Science Series. The Series is published by IOS Press, Amsterdam, and Springer Science and Business Media, Dordrecht, in conjunction with the NATO Emerging Security Challenges Division.

Copyright © 2012. IOS Press, Incorporated. All rights reserved.

Sub-Series A. B. C. D. E.

Chemistry and Biology Physics and Biophysics Environmental Security Information and Communication Security Human and Societal Dynamics

Springer Science and Business Media Springer Science and Business Media Springer Science and Business Media IOS Press IOS Press

http://www.nato.int/science http://www.springer.com http://www.iospress.nl

Sub-Series E: Human and Societal Dynamics – Vol. 100 ISSN 1874-6276 (print) ISSN 1879-8268 (online) Handbook for Pandemic and Mass-Casualty Planning and Response, IOS Press, Incorporated, 2012. ProQuest Ebook Central,

Handbook for Pandemic and Mass-Casualty Planning and Response

Edited by

Elin Gursky, M.Sc., Sc.D. Corporate Fellow and Principal Deputy for Biodefense, Analytic Services Inc., Arlington, Virginia, USA and Boris Hrekovski, M.D., F.I.C.S.

Copyright © 2012. IOS Press, Incorporated. All rights reserved.

General surgery and trauma care specialist at General Hospital Dr. Josip Benevi, Slavonski Brod, Croatia

Published in cooperation with NATO Emerging Security Challenges Division

Handbook for Pandemic and Mass-Casualty Planning and Response, IOS Press, Incorporated, 2012. ProQuest Ebook Central,

Proceedings of the NATO Advanced Study Institute on Applying Lessons Learned and Sharing Best Practices in Addressing Pandemics and Catastrophic Health Events Slavonski Brod, Croatia 27 November - 8 December 2011

© 2012 The authors and IOS Press. All rights reserved. No part of this book may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without prior written permission from the publisher. ISBN 978-1-61499-134-2 (print) ISBN 978-1-61499-135-9 (online) Library of Congress Control Number: 2012947886

Copyright © 2012. IOS Press, Incorporated. All rights reserved.

Publisher IOS Press BV Nieuwe Hemweg 6B 1013 BG Amsterdam Netherlands fax: +31 20 687 0019 e-mail: [email protected]

Distributor in the USA and Canada IOS Press, Inc. 4502 Rachael Manor Drive Fairfax, VA 22032 USA fax: +1 703 323 3668 e-mail: [email protected]

LEGAL NOTICE The publisher is not responsible for the use which might be made of the following information. PRINTED IN THE NETHERLANDS Handbook for Pandemic and Mass-Casualty Planning and Response, IOS Press, Incorporated, 2012. ProQuest Ebook Central,

Handbook for Pandemic and Mass-Casualty Planning and Response E. Gursky and B. Hrečkovski (Eds.) IOS Press, 2012 © 2012 The authors and IOS Press. All rights reserved.

v

Dedication a

Elin GURSKYa Analytic Services Inc.

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It is with great sadness that I dedicate this book to a friend and colleague, Colonel John H. Sandrock, U.S. Air Force, retired, and Principal Analyst, Analytic Services Inc. I had the pleasure of working with John for almost five years at Analytic Services. John, a 25-year career officer in the Air Force, filled many high-level posts in Europe and Asia and served in a senior position in the Atlantic Council. Through extensive discussion in the planning stages of this Advanced Study Institute, it was John who suggested the rich opportunities of holding this meeting in Croatia. His leaving us before his 70th birthday created a void for many of us who valued his scholarly approach, his immense multicultural knowledge, and his expertise in diplomacy. He will be greatly missed. We hope to carry on his spirit by transcending the cultural and language barriers that artificially separate us in our mutual goals of creating a safer world.

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Acknowledgements

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a

Elin GURSKYa Analytic Services Inc.

This book represents the efforts, expertise, and initiative of many people who supported a year long process of convening a 12-day, multi-country meeting and thereafter capturing some of the most relevant teachings, reflected between these covers. There are many people I would like to acknowledge in this effort, concluding with the publication of the Handbook for Pandemic and Mass-Casualty Planning and Response. Let me first thank the NATO Science for Peace and Security Programme for its confidence in this project and supporting what resulted in a very excellent and robust Advanced Study Institute. I have had the honor of participating in two previous ASIs, and it has become obvious that these meetings establish ongoing professional relationships that grow stronger and contribute to the principles and vision of the program. Such is the case of the ASI “Applying Lessons Learned and Sharing Best Practices in Addressing Pandemics and Catastrophic Health Events,” held in Slavonski Brod, Croatia, 27 November through 8 December 2011. To my friends and colleagues who composed the travel team from Russia, Ukraine, Italy, Georgia, and the United States, I extend my profound thanks for your years of friendship and for the valuable information you have shared at these ASIs. To our new friends from the host team in Croatia and their colleagues from Slovenia, BosniaHerzegovina, Germany, and England, and all other faculty, you are now and forever part of an ASI family linked by efforts and passions to improve health and health security across the NATO countries. Vesna Bosanac, M.D., Director of General Hospital Vukovar; Ismet Gavrankapetanovi, M.D., Head of the Orthopaedic and Traumatology Clinic of the Clinical Center, University of Sarajevo; and Professor Dusko Vasic, Director-Principal, General Hospital St. Apostol Luka, Doboj; shared their time, memories, and hopes as a reminder that ensuring the health security and protection of a population is in no small measure linked to the vision and courage of physicians and health professionals. We honor your dedication. Sincere thanks to Analytic Services Inc. in the United States and its leadership team, including Ruth David, Ph.D., President and Chief Executive Officer; James Player, Vice President, National Strategies Support; Steve Bull, Director, Global Threats and Intelligence; and Mandy Mader, Manager, Decision Support Division. Our profound gratitude to the European Society for Trauma and Emergency Surgery and the Croatian Urgent Medicine and Surgery Association for supporting this NATO ASI and for your leadership internationally in disaster medicine. Our great thanks to the many sponsors of our meeting, including the Crisis Headquarters Ministry of Health and Social Welfare of Croatia, the Institute of Public Health Brod-Posavina, General Hospital Dr. Josip Benevi, the County of Brod-Posavina, the City of Slavonski Brod, the Mechanical Engineering Faculty of Slavonski Brod, the City Library of Slavonski Brod, uro akovi Holding d.d., the Music School of Slavonski Brod, and Lima O.I. doo–Orthopedic Motion.

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Copyright © 2012. IOS Press, Incorporated. All rights reserved.

Many thanks to Ms. Marijana Tolic, who helped coordinate this ASI from Croatia, identifying sites for lodging and meetings and arranging travel. Julie Frost, an intern at Analytic Services Inc., served as the coordinator of this ASI. Without her energy, effortless joy, indefatigable spirit, and incredible attention to detail this meeting would not have taken place. Thank you, Julie. You are amazing! Warmest thanks to Josip Samardži, M.D., Vice Principal of General Hospital Dr. Josip Benevi, Slavonski Brod. Dr. Samardži played a critical role in supporting this ASI. We appreciate his medical leadership and friendship. Three people on the Media Services Team at Analytic Services put their professional efforts into the conference and book: Stephen Dunham, our excellent copy editor, worked tirelessly to ensure that our strong voices were captured articulately as one voice. We are most appreciative, Steve. Michael Bowers directed the preparation of many of the conference materials, and Cynthia Nordean created the timeline graphics for the chapter “Mass-casualty planning and response.” And finally, my profound gratitude to my coeditor and friend, Boris Hrekovski, M.D., who accepted the large responsibility of codirecting this ASI—a job that included all local planning; inviting key medical, hospital, and government leader participants; identifying sponsors and support; and arranging incredible field trips and opportunities to learn from many local leaders. Dr. Hrekovski extended every courtesy for the travel team to see and experience Croatia’s history and natural beauty and to appreciate the challenges it has overcome during the past two decades. His leadership in disaster medicine in and outside of his country is outstanding. Dr. Hrekovski is a strong and visionary surgeon and professional, and we are most grateful for the wonderful learning experience he provided to us. As our days in Slavonski Brod drew to a close, we all recognized that we were experiencing a beginning, not an ending, in our mutual efforts. Thank you, Boris.

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About the Authors Asja Ajdinovi, M.D. (Croatia) Dr. Ajdinovi graduated from the Medical Faculty University of Zagreb in 1995 and passed the state exam in 1997. She started her residency in the department of anesthesiology, reanimation, and intensive care at General Hospital Dr. Josip Benevi in Slavonski Brod and has worked there since. In 2002, she finished her postgraduate studies in anesthesiology, reanimatology, and intensive medicine at the University of Zagreb. In 2001, she became a specialist in anesthesiology, reanimatology, and intensive medicine. In 2010, she became a subspecialist of intensive medicine. Her postgraduate training in continuous education was in the fields of cardiopulmonary resuscitation, bronchoscopy, mechanical ventilation, hemodynamics problems and monitoring, and anesthesiology. Her postgraduate scientific education includes biomedicine and health at the medical faculty, University Osijek. From 2008 to 2010, Dr. Ajdinovi received further education in intensive medicine at Clinical Hospital Dubrava, Zagreb. In 2010, she became a subspecialist of intensive medicine. She also participated in the 17th Annual Congress of the European Society of Intensive Care Medicine, Berlin.

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Lela Bakanidze, Ph.D. (Georgia) Dr. Bakanidze has worked at the National Center for Disease Control and Public Health in Tbilisi (the former Georgian Anti-Plague Station) with especially dangerous pathogens for about 30 years. She started work at the laboratory of Especially Dangerous Viral Infections as an electron microscopist, and her Ph.D. thesis was on morphogenesis of toga- and retroviruses in mixed infections. Later, Dr. Bakanidze was the Head of the Department of Biosafety and Bioterrorism Threat Reduction and Deputy Head of the Department of Especially Dangerous Infections. Her postgraduate studies included bioterrorism at the Summer School at Johns Hopkins University; general management and public administration at Open University, Belfast, UK; and public health management in Malmo, Sweden. For about 15 years, Dr. Bakanidze was the leader of the group that was drafting new biosafety and biosecurity regulations in Georgia after the collapse of the Soviet Union. For the past 7 years she has been the national point of contact for the Biological and Toxin Weapons Convention in Georgia; she took part in the convention’s 6th Review Conference and participated in all of the convention’s Meetings of Experts and Meetings of States Parties for the 2007-2010 Work Program. Dr. Bakanidze is President of the Georgian Biosafety Association.

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Bore Bakota, M.D. (Croatia) Dr. Bakota graduated from the Medical School, University of Zagreb, in 1998. In January of 2000, he passed the Croatian license exam and began practice. He enrolled in scientific postgraduate study in the biomedical field at the Medical School, University of Zagreb, in 1999. During 2000, he participated in laboratory experiments on rats at the Pharmacology Department, Medical School, University of Zagreb, studying liver transplantation surgery. He started his surgery residency at General Hospital Karlovac, Croatia. In 2004, he completed scientific postgraduate study in the biomedical field. In 2006, he passed the examination for Surgery Specialist at the University Hospital Merkur, Zagreb, Croatia. Dr. Bakota was elected chairman of the newly founded AO (Arbeitsgemeinschaft für Osteosynthesefragen [Work Group on Osteosynthesis Issues]) Alumni Association– Croatian Chapter and is one of its founders. His current post is Specialist Surgeon at the Traumatology Department, General Hospital Karlovac.

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Ivica Balen, M.D. (Croatia) Dr. Balen studied medicine at the Medical School at Zagreb University and graduated in 1967. He began internship training in 1968 at the Medical Center Slavonski Brod and afterwards was employed as a general practice physician in the nearby village of Sikirevci from 1969 to 1971. His residency in the field of internal medicine was completed in 1975 at the Internal Clinic Rebro in Zagreb. His postgraduate studies were in gastroenterology and hepatology. Dr. Balen has been on the Medical Faculty in Zagreb since 1977. From 1975 to 1990, he worked at the Internal Department of General Hospital in Slavonski Brod; by 1979 he was head of the Department of Gastroenterology and Hepatology, and from 1989 to 1990 was head of the Department of Internal Medicine. In 1988 Dr. Balen acquired a master of science degree and became a primarius in internal medicine. From 1990 through 2002, he was director of General Hospital in Slavonski Brod, and from 2002 to 2006 he was deputy director of the hospital. From 2006 until retirement in late 2008, he worked again in the Internal Department as a subspecialist in the field of gastroenterology and hepatology. In the spring of 2000, he became a doctor of science and then started to teach internal medicine at the Higher School of Medicine in Požega. He joined the Medical Faculty in Osijek in 2003 as an assistant professor in the Department of Internal Medicine. He later became an associate professor in 2008 and retired in autumn 2009.

Branka Bardak, M.D. (Croatia) Dr. Bardak serves as chief of the Emergency Department in Slavonski Brod. Dr. Bardak received medical education from the University of Zagreb and is an Advanced Life Support provider, International Trauma Life Support provider, European Pediatric Life Support provider, and Medical Response to Major Incidents instructor and specializes in family medicine.

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Marijan Baši (Croatia) Marijan Baši is a bachelor of medical technology. He works in prehospital emergency medical service in Slavonski Brod, Croatia, and is engaged in postgraduate study for nurses in Osijek. He is an Advanced Life Support and European Paediatric Life Support provider and instructor in the Medical Response to Major Incidents and International Trauma Life Support courses.

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Frederick “Skip” M. Burkle, Jr., M.D., MPH, DTM, FAAP, FACEP (USA) Dr. Burkle is a Senior Fellow and Scientist with the Harvard Humanitarian Initiative, Harvard School of Public Health; Senior International Public Policy Scholar at the Woodrow Wilson Center for International Scholars in Washington, DC; and Senior Associate Faculty, Department of International Health and the Center for Refugee & Disaster Response, Johns Hopkins University Medical Institutes. In 2007 he was elected to the prestigious Institute of Medicine of the National Academy of Sciences and received the William Crawford Gorgas “Yellow Fever” Medal for “distinguished work in preventive medicine, groundbreaking work in disaster management and humanitarian assistance and the training of an entire generation of United States and international personnel.” Dr. Burkle has worked in and consulted on numerous wars, conflicts, humanitarian emergencies, and large-scale international disasters in Asia, Africa, the Middle East, and Eastern Europe for major nongovernmental associations, the Red Cross Movement, the World Health Organization, and the military. He served as Deputy Assistant Administrator for the Bureau of Global Health at the Agency for International Development, United States Department of State, and as the Interim Minister of Health in Iraq. He holds degrees from Saint Michael’s College, the University of Vermont College of Medicine, Yale University, Harvard University, the University of California at Berkeley, and Dartmouth College. He is qualified in emergency medicine, pediatrics, pediatric emergency medicine, and psychiatry; holds a master’s degree in Public Health, a Diploma in Tropical Medicine from the Royal College of Surgeons in Dublin, and a Diploma in Health Emergencies in Large Populations from the University of Geneva. He has published over 200 peer-reviewed articles, abstracts, and book chapters, along with four books, three on disaster medicine. He is a retired combatdecorated Naval Reserve captain who served with the Marines in Viet Nam, Somalia, the Persian Gulf War, and Iraq. He is a member of the Board of Directors of the International Rescue Committee, is a member of the Science Advisory Board of the American Red Cross, and served as the elected Chair of the American Medical Association’s National Disaster Life Support Consortium for the last 4 years.

Antonio Caruso (Italy) Antonio Caruso is the Vice General Prosecutor of the Italian Court of Auditors– Regional Prosecutor of Lombardy District. He obtained his degree in law in 1976 from the University of Catania. He also received a specialism in European Law in 1984 from the Institute of European Studies “Alcide de Gasperi” in Rome. He also served as an Assistant Research Fellow at the Post-graduate School of European Studies of Istituto

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di Studi Europei “Alcide de Gasperi” during academic years 1984, 1985, and 1986. He was a member, from 1984 until 1988, of the Editorial Board of the journal La Funzione Amministrativa (The Administrative Work), collaborating on the publishing of several original works. He was also an external faculty member at the University of Milan (“The New State and Regional Budgeting”) in academic year 2005 and at the University of Turin (“Counseling and Other Forms of Collaboration of the Regional Control Sections of the Italian Court of Auditors”) in academic years 2006, 2007, 2008, and 2009. Finally, he was an external faculty member at the Public Administration School Scuola Superiore della Pubblica Amministrazione in Bologna (“Control over Local Governments”) in academic year 2008. He is the author of 30 articles in national and international journals. He is working on the Lombardy Healthcare Financial Statement Control as Investigating Magistrate of the report, responsible for the control of documents subject to ex ante legitimacy control of the state peripherical offices operating within the Region of Lombardy. He is a subject expert in human rights and international law, disaster medicine, maxiemergency, and terrorism. He is Chairman of the Board of Auditors of the University of Catania (2010-2014) and has been Delegate to the Control on the Financial Management of public insurance services Concessionaire since 2007. He has attended various international conferences on disaster medicine and international terrorism, including three NATO Advanced Study Institute Science for Peace Projects held in Lithuania, Macedonia, and Italy between 2005 and 2009. His languages include English (good), French (fluent), Arabic (basic), and German (basic). He has also received the honor of Grand Officer of the Order of Merit of the Italian Republic.

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Ante Cvitkovi, M.D. (Croatia) Dr. Cvitkovi of the Croatian Department of Epidemiology is Principal of the Public Health Institute of Brodsko-Posavska County. He received his education from Medical Faculty, University of Zagreb, 1989-1995, with an epidemiology specialization from 2001 to 2003. His work experience includes general practice from 1998 to 2000, the Department of Epidemiology from 2000 to 2007, and Director of the Institute of Public Health Brod Posavina County.

Robert “Bob” Dobson (United Kingdom) Bob Dobson served in the British Army from 1973 to 1976, including active service in Northern Ireland from 1973 to 1975. He has worked for the London Ambulance Service since 1976. He was a Senior Training Officer, engaged in training with the Education Department for the London Ambulance Service staff and outside agencies, including Special Operations and Special Forces. In 1988-1989, he became one of the first paramedics in the UK. He undertook the (then) new Paramedic Instructors Course at the Regional Training Centre at Banstead. In 1989, he became a founding member of the London Ambulance Service team, setting up the National Paramedic Course. He was also responsible for training the first 180 paramedics in London. He is currently working as a consultant with FMP Protection UK, Skybridge Security UK, and Hanover Associates UK. He is employed as part of the medical team at Queens Park Rangers Football Club, a Premiership team from London. He is

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studying to get his Certificate of Education from Greenwich University, London. Additionally, he is working towards receiving a Certificate of Terrorism Studies from St. Andrews University, Scotland.

Philipp Fischer, M.D. (Germany) Dr. Fischer received professional training as a paramedic from 1993 to 1995. He was a member of the Paramedic German Red Cross from 1995 to 1999. He studied medicine in Bonn, Germany, in 1999. In 2004-2005, he participated in Clinical Electives in Tel Aviv, Israel; Los Angeles; Zürich, Switzerland; and Nizza, Italy. In 2006, he had an internship at the University Clinics Bonn. In 2007, he took the State examination at University Bonn. In 2007, he studied resident orthopedics and traumatology at University Clinics Bonn. In 2008, he became the National representative from Germany in the Section Disaster Medicine, European Society of Trauma and Emergency Surgery (ESTES). He is the coordinator of the scientific project sponsored by the federal Ministry of Education and Research “Rescue and Protection of People.” In 2011, he served as the coordinator for a scientific project sponsored by the European Union in the Security FP7 Programme, “Development of a Curriculum for International Crisis Management.” Also in 2011, he was the subproject leader of a European Union FP7 Programme Research Project about chemical, biological, radiological, and nuclear preparedness.

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Fernando Galindo, J.D. (Spain) Fernando Galindo is a full professor in philosophy of law at the University of Zaragoza, Spain. Since 1999 he has been coordinator of the Legal Network for the Information Society (LEFIS), a network with interdisciplinary partners located in Europe, the USA, Russia, and South America; he is coordinator of the LEFIS Series. Since 2003 he has coordinated the Observatory of E Government located in Zaragoza and in Florianopolis, Brazil. He has been the responsible persona and juridical advisor in research on access to the legal databases (since 1984), electronic signature (since 1996), and personal data protection (since 2002). He is the author of 140 articles and books on research topics. Since 1981 he has taught philosophy of law, electronic government, and ethics and legislation for engineers.

Andrey Govorkov (Russian Federation) Andrey Govorkov is an analyst in the Programme Development Office of Irkutsk State Technical University, Irkutsk, Russia. He completed postgraduate work at the university in 2011, and studies with the university’s Faculty of Cybernetics in 2006. Since 2004 he has been an analyst, manager, and principal researcher on numerous international, national, and local projects on information sharing, information security policy, and information management. From 2006 through 2008 he was the leading specialist in the Information Technology Division of the Russian Standard Bank.

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His specialties are main field information management, project management, and information network architectures for science project management. His other fields of interest are construction of databases, website development, and technical support and consultation. His current research interests are models of university management; network models for information sharing; information-sharing policies of huge, complex, international, and multidisciplinary projects; information-sharing policies at regional levels; and simulation of information processes during disasters and emergencies. He has had five papers published in refereed journals and presented six communications to scientific meetings.

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Matteo Guidotti, D.Sc. Dr. Guidotti has been a permanent research scientist at the Institute of Molecular Sciences and Technology of the Italian National Research Council in Milan since 2001. He received a degree in chemistry at the University of Milan in 1997 and a doctorate in industrial chemistry at the university in 2000. He has done research at the Centre for Studies on Synthesis of Complexes of Transition Metals in Low Oxidation States in Milan and has been a visiting researcher at the Laboratory of Catalysis in Organic Chemistry, University of Poitiers, France; the Boreskov Institute of Catalysis in Novosibirsk, Russian Federation; the Institute of Materials Sciences of Aragon, University of Zaragoza, Spain; and the Technical University of Delft, Netherlands. Dr. Guidotti is author or coauthor of 70 scientific publications in national and international journals and books and of some 90 communications at international congresses. His current research topics are design of porous heterogeneous catalysts for the selective transformation of fine chemicals, use of nanostructured catalysts for the selective oxidation of fatty acids and terpenes derived from natural vegetable raw materials, and synthesis of metal nanoparticles and deposition onto inorganic oxides for oxidation in the presence of sustainable oxidants. He is President of the Governing Board of the Foundation for Scientific and Technical Education and Culture, Milan, and has served as Treasurer and Secretary of the Governing Board of the Lombardy Section of the Italian Chemical Society and a Member of the Organizing Committee of the NATO Advanced Study Institute BioHazaMilan 2008. He received the IX National Prize Federchimica of the Italian Industrial Chemistry Association “Per un futuro intelligente” in 1996 and the ENMIX 2011 Paper Award of the European Nanoporous Materials Institute of Excellence, Vatnahalsen, Norway.

Elin Gursky, M.Sc., Sc.D. (USA) Dr. Gursky is a Corporate Fellow and Principal Deputy for Biodefense at Analytic Services Inc., a fifty-year-old not-for-profit research institute in Arlington, Virginia, USA, serving the nation’s interests in homeland defense and national security. She leads the Global Health Security Strategy portfolio for ANSER, one of Analytic Services’ operating units. For three years she served as Senior Advisor to the Assistant Secretary for Preparedness and Response, U.S. Department of Health and Human

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Services, where she focused on policy and strategy for dispensing medical countermeasures. An epidemiologist, Dr. Gursky has held senior positions in local and state governmental public health agencies. She has served as a vice president for a system of 10 acute-care hospitals. Dr. Gursky has held faculty positions at Johns Hopkins University and has developed graduate courses and lectured on biosecurity at numerous academic institutions. Dr. Gursky has given over 50 invited lectures domestically and internationally. She has served as core faculty for two previous NATO Advanced Study Institutes. In 20052007 she served on the American Association for the Advancement of Science Global Security Fellowship Selection Committee. She also served on the Institute of Medicine Committee on the Effectiveness of National Biosurveillance Systems: BioWatch and the Public Health System. Dr. Gursky was selected as a Fulbright Senior Advisor in 2006. She has published over 35 peer-reviewed articles and nine book chapters. She is coauthor of a recently released book by the American Medical Association press, Death in Large Numbers: The Science, Policy and Management of Mass Fatality Events.

Simon Herman, M.D. (Slovenia)

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Dr. Herman is a senior surgeon in the Department of Traumatology, University Clinical Centre, in Ljubljana, Slovenia. He graduated in 1991 and became a traumatology surgeon in 1998. During 1999-2003 he completed various fellowships and trainings in Switzerland, Japan, and the United States, among other places. He has organized two or three local courses, especially AO courses, every year since 1999 and was a member of the organizing committee of the European Trauma Congress in 2006 in Ljubljana. In 2010 he was appointed by the Ministry of Health to a special task force for Medical Response to Major Incidents; he is also chairman of the MRMI courses in Slovenia.

Boris Hrekovski, M.D., F.I.C.S. (Croatia) Dr. Hrekovski is a general surgery and trauma care specialist at General Hospital Dr. Josip Benevi, Slavonski Brod. He attended Badin High School, Hamilton, Ohio, USA, and in 1989 went to Medical Faculty, University of Zagreb, receiving his general surgery specialization in 1996 and traumatology specialization in 2007. He was certified to be an Advanced International Trauma Life Support course instructor in 2008 and forensic medicine expert in 1997. He has taught sport medicine education basic and advanced courses; he became a Medical Response to Major Incidents course instructor in 2009; he became an AO instructor in 2010 and has taught advanced and basic AO courses, the Trauma Scoring System Course, Basic Life Support, and more. His work experience includes general practice and ambulance service, 1989-1990; Croatian Armed Forces, chief of the medical corps in an armor-machinery brigade during the war in Croatia and Bosnia, 1991-1994; Reserve major in the Croatian Army; Department of Surgery, traumatology unit, General Hospital Slavonski Brod, since 1994; chief of the traumatology unit, General Hospital Slavonski Brod, since 2008; vice-chief of the Surgery Department, General Hospital Slavonski Brod, since 2010; and President of the Slavonski Brod Branch of the Croatian Medical Association, 2005-

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2009. He was Vice-president of the International College of Surgeons 2011-2012 and Chairman of the European Society for Trauma and Emergency Surgery (ESTES) Section for Education and Training 2011-2013. He also serves as President of the Croatian Urgent Medicine and Surgery Association, President of the Croatian Section of the International College of Surgeons, national delegate on the ESTES Board of Directors, board member of the ESTES Section for Disaster & Military Surgery, senior faculty member of the Medical Response to Major Incidents Organization, President of the Brodskoposavska County Branch of the Homeland War Physician Association, and Vice-president of the Croatian Boxing Medical Commission.

Radek Hubac, M.D. (Czech Republic)

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Colonel Radek Hubac is Chief of the Interoperability branch of the NATO Centre of Excellence for Military Medicine in Budapest, Hungary. He graduated from Charles University Medical Faculty and Purkyne Military Medical Academy, both in Hradec Králové, Czech Republic, in 1998 and completed specialization in public health (2001, 2008). He participated in numerous courses related to the military medical field (medical planners’ courses, the Medical Intelligence course); the NATO School, Oberammergau, Germany; Law of Armed Conflicts, Switzerland; a medical evaluation course and emergency management of battlefield injuries at the Centre of Excellence for Military Medicine; Advanced Trauma Life Support at the Purkyne Military Medical Academy, Czech Republic; and conferences such as the 2nd World Conference on Vaccination and Immunization, Liege, Belgium; and the NATO Health Surveillance conference, Munich, Germany. He is a medical manager and public health specialist; he has worked as Deputy Chief of Public Health of the Czech Armed Forces (2006-2009 and again beginning 1 August 2012). He has been working on NATO medical standardization during his NATO assignment (2009-2012); he developed the concept of NATO Medical Terminology Standardization.

Igor Ivic-Hofman, M.D. (Croatia) Dr. Ivic-Hofman is a specialist epidemiologist at the Public Health Institute of BrodskoPosavska County. He worked as medical faculty at the University of Osijek from 1998 to 2005. He earned a specialization in epidemiology in 2007-2010. He also studied the Immediate Life Support Course. He has worked in the Department of Epidemiology since 2007.

Katy Jackson (USA) Katy Jackson is a student at Washington College, majoring in International Studies with a double concentration in Peace & Conflict Resolution and Middle Eastern Studies. At the college, she is a part of the Presidential Fellows Honors program, an active senator in the Student Government Association, and a member of the Alpha Omicron Pi fraternity. She is also a recipient of the Hodson Trust Merit Scholarship. Ms. Jackson graduated from Hereford High School, Parkton, Maryland, USA, in 2009;

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she was a member of the National Honor Society, Music Honor Society, and Art Honor Society and was a Maryland Distinguished Scholar, Advanced Placement Scholar, and winner of the United States Institute of Peace 2009 Essay Contest for the state of Maryland. Ms. Jackson is also an accomplished violist who studied at the Peabody Conservatory in Baltimore, Maryland, USA.

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James James, M.D., DrPH, MHA (USA) Dr. James is Director of the American Medical Association Center for Public Health Preparedness and Disaster Response and is Editor-in-Chief of Disaster Medicine and Public Health Preparedness, a peer-reviewed, Medline-indexed publication of the association. In less than five years, this center has received over $3 million in grant funding, has overseen the development and deployment of the National Disaster Life Support suite of courses, and has expanded to 10 personnel. Dr. James brings over 30 years of experience in the public and private health care sectors—as a clinician, researcher, professional personnel manager, and program director—to this challenging and critical undertaking. He is board certified in general preventive medicine; he earned a doctorate in medicine at the Cincinnati College of Medicine, a doctorate in public health from the University of California–Los Angeles School of Public Health, and a master’s in health care administration from Baylor University. Dr. James served 26 years with the U.S. Army Medical Department in a multitude of capacities. From 1999 through 2002, Dr. James served as Director of the Miami–Dade County Health Department. There he was responsible for the oversight and supervision of public health programs throughout the county. He was charged with the management of a $60 million budget and the supervision of approximately 1,000 employees. In 2011, Dr. James was appointed to numerous boards, commissions, and committees addressing national policy and operational issues around preparedness and response. He serves as a constant and active participant in several Institute of Medicine forums and roundtables. He is the chair of the National Disaster Life Support Foundation Board of Directors and co-chair of the National Disaster Life Support Education Consortium executive committee. In 2007 he was appointed to the National Biodefense Science Board and in 2008 to the Defense Health Board.

Josip Jankovic, M.D. (Croatia) Dr. Jankovic works in the Department of Surgery, General Hospital Slavonski Brod. He started medical school at Medical University Zagreb in 1998 and finished in 2004. After his exam in 2010, he got a general surgeon degree; since then he has been working in the Traumatology Department. He is also a Medical Response to Major Incidents instructor.

Darko Juriši, M.D. (Croatia) Dr. Juriši is a General and Plastic Surgeon in the Department of Traumatology, General Hospital Dr. Josip Benevi, Slavonski Brod, Croatia. He graduated from the

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School of Medicine, University of Zagreb, in 1998. The following year, during his obligatory military service, he was a physician in military medicine with the rank of reserve first lieutenant. In 2000, he became a physician in Emergency Medical Service in Slavonski Brod; in 2001, he began his specialization in general surgery; in 2005, he became a specialist in general surgery, and in 2009 a specialist in plastic surgery. He is a member of the Croatian Urgent Medicine and Surgery Association; the Croatian Society of Plastic, Reconstructive and Aesthetic Surgery; and the European Society for Trauma and Emergency Surgery. Dr. Juriši is author or coauthor of 11 papers indexed internationally and of over 20 papers at conferences and various national and international congresses. He has participated in 15 training courses in trauma and plastic surgery in Croatia and abroad. Since 2009 he has held a Trauma Fellowship at the Emergency and Trauma Center, Rashid Hospital, Dubai, United Arab Emirates, and a Fellowship in Orthopaedic Trauma Surgery, Trauma Center Murnau, Department of Orthopaedic & Trauma Surgery, Murnau, Germany.

Matija Jurjevi, M.D. (Croatia)

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Dr. Jurjevi attended Matija Mesi High School, in Slavonski Brod, graduating in 1996. He then attended the University of Zagreb, School of Medicine, until 2003. He started working at General Hospital Dr. Josip Benevi in 2003 and became a specialist in anesthesiology, reanimatology, and intensive care in 2009. He took an Advanced International Trauma Life Support Course in 2006, as well as the European Resuscitation Council Advanced Life Support course in 2004 and the council’s Advanced Pediatric Life Support Course in 2005. In 2007 he became a full instructor for the Advanced Life Support Course as well as instructor candidate for the Advanced Pediatric Life Support Course, and in 2011 a Medical Response to Major Incidents course instructor. He is also a Basic Life Support and Intermediate Life Support instructor. His fields of interest include intensive-care units, hemodynamic monitoring, and regional anesthesia.

Radko Komadina, M.D. (Croatia) Dr. Komadina received a degree in general medicine at the Medical Faculty in Ljubljana in 1981. After the compulsory two-year residential work at the Celje Health Centre, he started working in the Department of Traumatology at General Hospital Celje, where he has been since 1989. In 1989 he participated in a postgraduate course in surgery at the Medical Faculty in Ljubljana. In 1990 he became a specialist in general surgery, receiving a master’s degree at the Medical Faculty in Ljubljana in 1993 and a Ph.D. in 1995. As a university student he won the Prešeren award for the students of Medical Faculty for research of histomorphometric methods. In 1989 he studied functional conservative treatment of fractures in Pisa, Italy, as Prof. Diara’s guest. In 1990 and in 1994 he was a participant in AO Fortgeschrittemen Kurs in Davos, Switzerland. In 1991 he won an international AO scholarship, which enabled him to study spinal injuries and polytrauma with Prof. Bötl in Bochum, Germany. In 1991 he practiced surgery in Switzerland. In 1993 he visited Royal University Hospital in Liverpool, England, for a study of partial hip prosthesis. In 1995 he visited Baylor College of Medicine in Houston, USA. He studied organization of modern trauma centers with Prof. Mattox

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and at the Adams Cowley Shock Trauma Center in Baltimore in 1996. Since 1996 he has worked as secretary general of the Slovenian Society of Trauma Surgeons. Since 1997 he has organized regional biennial Celjski dnevi symposia of traumatologists, orthopedic surgeons, and physiatricians.

Jasminka Kopi (Croatia)

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Dr. Kopi is a specialist in anesthesiology and intensive care and chief of the intensivecare unit of General Hospital Slavonski Brod. Jasminka Kopi attended Faculty of Medicine, University of Zagreb, 1977-1982 and earned her anesthesiology, reanimatology, and intensive-care medicine specialization 1986-1990. She completed her postgraduate study in clinical pharmacology, Faculty of Medicine, University of Zagreb, 1989-1990. She also took a postgraduate course in intensive care medicine there in 1996. She received her Master of Biomedical Sciences degree in 2000 and Doctor of Biomedical Sciences degree in 2008. She received a subspecialty in intensive-care medicine in 2009. She is certified by the Advanced Life Support Group (Manchester, England) as an Advanced Pediatric Life Support instructor. Jasminka served as the assistant at the Department of Anesthesiology, Reanimatology and Intensive Care Medicine at the Faculty of Medicine, University of Osijek, in 2010. She has been a lecturer at Nursing School at Slavonski Brod since 2000; lecturer at C.E.E.A. courses in Croatia in 2008 and 2010; and lecturer in a postgraduate course, “Good Clinical Praxis in Transfusion Medicine,” Faculty of Medicine, University of Zagreb, in 2011. Her work experience includes general practice and ambulance service, 1982-1986; Department of Anesthesiology, Reanimatology and Intensive Care Medicine, General Hospital Slavonski Brod, 1986; and Chief of the Department of Anesthesiology, Reanimatology and Intensive Care, General Hospital Slavonski Brod, 2009. She has also been a member of the hospital infection team since 1999.

Mario Kopljar, M.D., Ph.D., FICS (Croatia) Dr. Kopljar is a general and abdominal surgeon at Clinical Hospital Dubrava Zagreb. He graduated in 1997 at Faculty of Medicine, University of Zagreb, then worked as a scientific novice at the Department of Surgery, University Hospital Sestre Milosrdnice until 2002. He finished residency in general surgery in 2007 and subspecialization in abdominal surgery in 2009 at University Hospital Dubtava, Zagreb, Croatia. His teaching experience at the Medical School of the University of Zagreb includes a module on emergency medicine, 2004-2005; postgraduate doctoral study in medical sciences—surgery of the pancreas and surgical treatment of gastric cancer, and biological processes in wound healing—2004-2010. Since 2002 he has been an assistant lecturer at the undergraduate and postgraduate levels. He has also been an instructor of International Trauma Life Support courses in prehospital patient management since 2008 and Medical Response to Major Incidents courses since 2010.

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Ronald LaPorte, Ph.D. (USA) Dr. LaPorte is a cognitive psychologist turned epidemiologist. His primary interest is the application of Internet technology to the prevention of disease, using the Supercourse, which has over 65,000 faculty worldwide. He has a bachelor’s degree in psychology from the State University of New York at Buffalo, master’s and doctoral degrees in psychology from the University of Pittsburgh, and a master’s degree in epidemiology from the University of Pittsburgh. He is the author of numerous publications and recipient of more than a dozen awards and honors.

Faina Linkov, Ph.D., MPH (USA) Dr. Linkov is assistant professor of Ob/Gyn and Reproductive Sciences, Magee Women’s Research Institute, University of Pittsburgh School of Medicine, USA. Dr. Linkov has published over 70 papers in the areas of Internet-based education and cancer epidemiology. Since 2000, she has been one of the key developers of the Global Health Network Supercourse project, a library of online lectures targeting educators and a network of nearly 50,000 scientists around the world.

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Mark Loades (United Kingdom) Mark Loades is a former British Army noncommissioned officer. After forging an exemplary career he left and was engaged within the Metropolitan Police Specialist Operations Command, specializing in personal protection duties with the British Royal Family, foreign royals, and visiting heads of state. He is an active faculty member of the Croatian Urgent Medical Association and the Medical Response to Major Incidents initiative, as well as a coordinator for MACSIM®. He is a Fellow of the Royal Geographical Society and member of the United States Special Operations Medical Association, where he has been a distinguished conference speaker. He is now a successful security consultant and Director of FMP Protection Services, an international VIP security solutions provider.

Zvonimir Lovri, M.D., Ph.D. (Croatia) Dr. Lovri is Professor of General Surgery, trauma care specialist, and Medical Response to Major Incidents instructor at Clinical Hospital Dubrava Zagreb. He received his education from Medical Faculty, Zagreb University (1973-1979). He did his postgraduate study in biomechanics in 1979-1980. He received his General Surgery Specialization training from 1983 to 1989. His work experience includes general practice (1979-1983); Department of Surgery, Osijek General Hospital (1983-1995); Plastic Surgery Division, Department of Surgery, Osijek General Hospital (1989-1995); Chief-surgeon of the Plastic Surgery Division, Osijek University Hospital (1992-1995); Trauma Surgery Division, Department of Surgery, University Hospital Dubrava Zagreb (1995 to present); and Chief-

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surgeon of the Trauma Surgery Division, Department of Surgery, University Hospital Dubrava Zagreb (2010 to present).

Jim Lyznicki, M.S., MPH (USA) Jim Lyznicki is the director of funding portfolios for the Health Outcomes and Quality Group at the American Medical Association (AMA). Prior to that position, he was the associate director of the AMA Center for Public Health Preparedness and Disaster Response. He holds a master of science degree in medical microbiology from the University of Minnesota in Minneapolis–St. Paul and a Master of Public Health degree in the environmental and occupational health sciences from the School of Public Health at the University of Illinois at Chicago. Prior to the AMA, he spent 10 years as a clinical microbiology laboratory supervisor at the University of Chicago Medical Center and the Rush Medical Center in Chicago and 2 years as an environmental health scientist at the University of Illinois School of Public Health. During his career, he has published and edited more than 75 articles and chapters on various issues affecting clinical practice and public health.

Ivo Mati, Ph.D., M.D. (Croatia)

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Dr. Mati has worked in general practice for Dr. Josip Benevi General Hospital, Slavonski Brod, and now works in the Department of Anesthesiology, Resuscitation and Intensive Care. His main activities and responsibilities include anesthesiology, reanimatology, and intensive care. He graduated in 1988 from the School of Medicine, University of Sarajevo, and received a master of science degree and Ph.D. in biomedicine and health from the School of Medicine, University of Osijek.

Kristina Lennquist Montán, RN (Sweden) Kristina Lennquist Montán is a lecturer and instructor in disaster medicine at the Center for Prehospital and Disaster Medicine, Gothenburg, Sweden. She holds a bachelor of science degree in nursing and a master of laws degree. She is a Hospital Major Incident Medical Management & Support instructor and faculty and board member of the Medical Response to Major Incidents courses. She is a Ph.D. candidate in the Department of Surgery, University of Gothenburg, and responsible for the project of scientific evaluation of the MACSIM system (used in the MRMI courses) as a tool for evaluation and development of methodology, education, training, and testing of preparedness in disaster medicine.

Nicolás Padilla-Raygoza, M.D. (Mexico) Dr. Padilla-Raygoza is a full-time professor Titular A, Department of Nursing and Obstetrics, Division of Health Sciences and Engineering, Coordinator of Support to Research and Postgrade, Campus Celaya Salvatierra, University of Guanajuato,

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Mexico. He received his doctorate in medicine from the University Autonomous of Guadalajara 1984, was certified a pediatrician by the Mexican Council of Certification on Pediatrics in 1986, received a postgraduate diploma in epidemiology principles and practice from the University of London in 2001, and M.Sc. and D.Sc. diplomas in epidemiology from AIU in 2006. He has been a developer of the Supercourse on Epidemiology, Internet and Global Health since 2008 and is coordinator of the Latin American Supercourse on Epidemiology, Internet and Global Health. He is a member of the academic body Healthy Lifestyle and Chronicity, the International Association on Epidemiology, the Mexican Academy of Pediatrics, and the National Researcher System, Level 1, CoNaCyT, Mexico. He has had 40 articles published and 6 chapters in books. He has been an assessor of five theses of masters of science in nursing.

Ivana Paji-Penavi, M.D. (Croatia)

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Dr. Paji-Penavi graduated from the medical school at the University of Zagreb in 1996; in 1997 she took the state exam for medicine; in 2003 she took a specialization in ear, nose, and throat and head and neck surgery; and in 2011 took a subspecialization in plastic surgery of the head and neck. She has worked at General Hospital Dr. Josip Benevi in Slavonski Brod, Croatia, since 1996. In 2005 she became an assistant at Medical University Josip Juraj Strossmayer in Osijek, in 2009 received a Ph.D. diploma, and in 2011 became a senior ear, nose, and throat assistant at Medical University Josip Juraj Strossmayer in Osijek. She has participated in more than 30 national and 10 international conferences as lecturer or conferee, and she has completed 16 postgraduate courses in medicine. She is a member of the Croatian Medical Association, the Croatian Ear, Nose and Throat Society, the Croatian Rhinology Society, the European Rhinology Society, the Society of Maxillofacial Surgery, and the Society for Thyroid Gland.

Igor Pavliško (Croatia) Igor Pavliško is currently an undergraduate student in Zagreb, Croatia. He is studying for a bachelor’s degree in business and is the information manager of the Association for the International Exchange of Students in Economics and Commerce, Zagreb. Currently he is working as the president of the Young Entrepreneurs in Croatia organizational committee.

Massimo Ranghieri (Italy) Capt. Massimo C. Ranghieri is Staff Officer at the 1° Field Hospital Unit of the Italian Army Auxiliary Corps of Sovereign Military Order of Malta, located in Milano. He is Vice Commander of the 1° Field Unit. His education includes a doctorate in Pharmaceutical Chemistry from Milano, State University, Faculty of Pharmacy, in 1975. He also received a diploma in Industrial Technology in Organic Chemistry at Milano Polytechnic Institute of Industrial Organic Chemistry E. Molinari in 1970. From 1983 to 1985, he studied at the International Management Centre Bruxelles. He is trained in

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management of human resources, planning of commercial enterprises, and effective presentation. He has been a researcher at Farmitalia Carlo Erba Pharma Research Institute, in Milano, working on drug metabolism of antitumoral drugs, and in development of instrumental analytical methods for pharmacokinetics. He has been export manager in Germany for American companies dealing in scientific instruments, with direct managing responsibilities of Eastern and Northern European Territories (SpectraPhysics GmbH, Darmstadt, Germany). He has also been general manager of Italian offices of American companies dealing in scientific instruments (Thermo Instruments Inc., Milano). His last civilian work was in an oil refinery addressing all risk analysis and security of the plant.

Damir Rosko, M.D. (Croatia)

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Dr. Rosko is a general and plastic surgeon in the Department of Traumatology at General Hospital Dr. Josip Benevi in Slavonski Brod, Croatia. He graduated from the School of Medicine at the University of Zagreb in 1998. In 2000 he became a physician at Emergency Medical Aid in Slavonski Brod. He received his specialization in general surgery in 2001. He became a specialist in general surgery in 2005 and a specialist in plastic surgery in 2009. He is a member of the Croatian Urgent Medicine and Surgery Association; the Croatian Society of Plastic, Reconstructive and Aesthetic Surgery; and the European Society for Trauma and Emergency Surgery. He has been the official physician of the Croatian national basketball team since 2007. He is the author or coauthor of three internationally indexed papers (two of which are indexed in Current Contents) and over 10 papers at conferences and various national and international congresses. He has participated in 12 training courses in trauma and plastic surgery in Croatia and abroad.

Alessandra Rossodivita, M.D., EMDM (Italy) Dr. Rossodivita is head of Semi-Intensive Cardiac Surgery, Department of Cardiothoracic and Vascular Diseases, and a member of the Maxi-Emergency Committee, San Raffaele Hospital Scientific Foundation. She has worked as a physician at the foundation and University of Medicine “VitaSalute” since 2002. The Maxi-Emergency Committee is one of the main referral centers for maxi-emergency and mass casualties in the Lombardia district. In 2005 Dr. Rossodivita attended the V European Master in Disaster Medicine, promoted by the University of Piemonte Orientale-A.Avogadro (Novara), represented by the Department of Anaesthesiology and Intensive Care, and the Free University Brussels, represented by the Department of Critical Care. She has been a member of the World Association for Disaster and Emergency Medicine since 2007 and is a member of the CBRNE (chemical, biological, radiological, nuclear, and explosives) Task Force. She is member of the public organization International Informatization Academy of Moscow, in general consultative status with the United Nations since 1995. She cooperates with the Italian Association for Solidarity Among People. She was directly involved in the organization and medical management of a maxi-gathering event and establishment of a field hospital with an Italian Regional Association of

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Emergency during the visit of Pope Benedetto XVI with more than 500,000 young Italian people in 2007. She was a member of the faculty of the NATO Advanced Study Institute on Strengthening National Public Health Preparedness and Response for Chemical, Biological, and Radiological Agent Threats in 2006. In 2008 she won a NATO Science for Peace grant for a project with the Russian Federation Partnership, and jointly with Prof. Andrey Trufanov from the Russian Federation she organized an international course on biological threats and pandemics. In addition, she is author or co-author of three NATO Science for Peace and Security books on disaster medicine hot topics: CBRNE incidents and pandemics. She cooperates with ANA, the Sovereign Military Hospitaller Order of St. John of Jerusalem of Rhodes, in maxi-emergencies and CBRNE preparedness and teaching activity. She is a Medical Response to Major Incidents instructor and AIACE member.

Josip Samardži, M.D., FICS (Croatia)

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Dr. Samardži is a general and abdominal surgeon, International Trauma Life Support and Medical Response to Major Incidents instructor, and Vice-principal of General Hospital Slavonski Brod. He completed his education at Medical Faculty, University of Zagreb, in 1991. He received his general surgery specialization in 1998, abdominal surgery specialization in 2009, Advanced International Trauma Life Support course instructor certification in 2007, and Medical Response to Major Incidents course instructor certification in 2011. He teaches sport medicine education (basic and advanced courses), the Trauma Scoring System course, Basic Life Support, and more. Dr. Samardži has worked in the Department of Surgery, General Hospital Slavonski Brod, since 1994. He has served as chief of the abdominal unit in General Hospital Slavonski Brod since 2003. He has also served as chief of the surgery department, General Hospital Slavonski Brod, since 2005. He was President of the Slavonski Brod Branch of the Croatian Medical Association 2001-2005.

Eugene Shubnikov, M.D. (Russian Federation) Dr. Shubnikov has been a research scientist of the laboratory of clinical, population, and prevention studies of therapeutic and endocrine diseases, Institute of Internal Medicine, Novosibirsk, Russia, since 1986. He graduated from Novosibirsk Medical Institute in 1985. He has been a member of the European Association for the Study of Diabetes since 1992. He visited the University of Pittsburgh (USA), Graduate School of Public Health, Department of Epidemiology, from February to June 2000 as a fellow of Professor LaPorte under the U.S. State Department Freedom Support Act Fellowship program. He has been a moderator of the prevention program for former Soviet Union countries in the frame of the Supercourse Global Library Project in Public Health, Epidemiology and Internet since 2000. He is a developer of the Global Free Library of Lectures at the online Supercourse project.

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Elisaveta “Jasna” Stikova, M.D., Ph.D. (Macedonia) Dr. Stikova is a professor on the medical faculty at the University of Saints Cyril and Methodius–Public Health Institute of the Republic of Macedonia, professor at Medical Faculty Skopje–Department for Occupational Medicine, and policy advisor at the National Public Health Institute. She completed her medical studies—master of science and Ph.D. in occupational medicine—at the University of Saints Cyril and Methodius. She has taught courses on occupational medicine, public health, hygiene, medical ecology, occupational safety and health, and biostatistics at five faculties of that university. She is the first Fulbright alumna in the field of public health from Macedonia and has served as a visiting professor in global public health at Sheffield University (England), Jagelonian University in Krakow (Poland), and University of Pittsburgh (USA). She is the president of the first Macedonian Association of Industrial Hygiene and Occupational Health. She co-directed NATO’s Advanced Study Institute for Public Health Preparedness and Response for Chemical, Biological, and Radiological Agent Threats in 2006 and was a member of the Scientific Committee of the NATO Advanced Study Institute for Preparing Regional Leaders with the Knowledge, Training and Instruments for Information Sharing and Decision-Making against Biological Threats and Pandemics in 2008. She is the principal investigator of the scientific project “Quality Management in Radiology with Special Focus on Radiation Protection in Macedonia” and lecturer in the Central European Network exchange program for university studies “Image Processing, Information Engineering & Interdisciplinary Knowledge Exchange.” Prof. Stikova is author and editor of five books and of more than 200 papers and presentations.

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Andrej J. Strahovnik, M.D. (Slovenia) Dr. Strahovnik is a trauma surgeon in the Department of Traumatology, General and Teaching Hospital, Celje, Slovenia. He graduated from the University of Ljubljana Slovenia Medical Faculty in 1994 and obtained his specialization in surgery in 2003. He has completed Synthes AO courses and the Advanced Trauma Life Support course and is a licensed instructor for the Medical Response to Major Incidents course. He is a member of the Slovenian Society for Emergency Medicine, the American Austrian Foundation of Medicine, the Slovenian Traumatology Association, the Slovenian Chamber of Medical Doctors, and the European Society for Trauma and Emergency Medicine. He has worked in Madagascar as a volunteer doctor and for NATO in Afghanistan as a trauma surgeon.

Alexei Tikhomirov (Russian Federation) Alexei Tikhomirov is a well-known senior United Nations expert on governance, knowledge management, and development strategies who has worked at increasing levels of responsibility. He joined the United Nations in 1989 and was promoted from a first officer to a senior one and then to a principal officer, occupying positions of Chief of the Asia and Transition Economies section, acting Chief of the Knowledge Manage-

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ment Branch, and an Interregional Adviser at the Division of Public Administration and Development Management. He has provided technical advice to heads of state and government, ministers, governors, mayors, and other high-level governmental officials in transition economies and developing countries. He designed, supervised, and backstopped a whole range of international programs, including projects devoted to public programming, modeling, and governance for development. In addition to his direct functions, he served as a member of the Headquarters Contract Committee (20082011).

Andrey Trufanov, Ph.D. (Russian Federation) Dr. Trufanov is a professor at the Institute of Engineering and Transportation, Irkutsk State Technical University, Russia. He teaches for the Automated Systems Department, Cybernetics; Mechanical Engineering Technologies Department, Institute of Engineering and Transportation; Geophysics and Geoinformatics Department, Faculty of Geology, Geoecology and Geoinformatics. He got his Ph.D. in nuclear physics in 1980 at St. Petersburg State Polytechnic University, Russia. Since 1982 he has worked as supervisor, manager, and principal researcher on numerous international, national, and local projects on information sharing, information security policy, and information management. He is an active member of the International Informatization Academy, a nongovernmental organization in general consultative status with the Economic and Social Council of the UN since 1995.

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Rustem Umerov (Ukraine) Rustem Umerov is chairman of Terra Tavrida, NGO, Simferopol, Autonomous Republic of Crimea, Ukraine. He got his master’s degree in informatics at Simferopol State University in 1994. He focuses on management of complex networks, quality management and configurations, information systems, innovation technologies and multimedia technologies as tools for effective education, managing university educational systems, preparation of audiovisual materials for teachers, and mapping and instruments of visualization in information security. He is initiator and leader of the structured cabling network that covers pedagogical schools and universities in five cities in Ukraine and developed the strategic 5-year Education Area program for the Autonomous Republic of Crimea in 2008. He was a principal member of the Ukrainian National Scientific-educational network URAN 2009-2010; a member of the organizing committee for video conferences of universities and public organizations in Turkey, Romania, and Russia, in 2010; and developer of technical capacity of SCS graphics and desktop software, National Aviation University, Information and Diagnostic Systems Institute, Information Technology Security Department, 2011. He is certified with CERT-CSIRT, Ukraine; is coordinator of the Tempus, Jean Monnet, and Erasmus Mundus projects at Crimean Engineering and Pedagogical University; and is an active participant in the Black Sea Universities Network. Mr. Umerov is active in Arkadash, Crimean Human Right Association.

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Natalia Vynograd, DMS (Ukraine)

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Dr. Vynograd, Full Professor, is Chief of the Epidemiology Department of Danylo Halytski Lviv National Medical University, Lviv, Ukraine. She graduated from Lviv Medical Institute in 1979 and completed a special course in the Division of Interferon of the Research Scientific Institute of Epidemiology & Microbiology, Moscow, in 1988-1990. She is an interdisciplinary specialist of epidemiology (1979), microbiology (1981), virology (1981), and general medicine (1998). She participated in 29 training courses in microbiology, virology, immunology, epidemiology, bioterrorism, commissioning for containment, biosafety, biosecurity, and modern laboratory diagnostics. She worked in government during the severe acute respiratory syndrome, avian flu, and pandemic flu emergencies as a Senior Epidemiologist of the Ministry of Health and Advisor to the Minister, Ministry of Emergency Situation of Ukraine. She has been a member of the Immunobiological Committee Ministry of Health of Ukraine (20022009), Special Scientific Committee for maintaining the scientific dissertation in National Medical University, Kiev (2004-present), and Scientific Research Institute of Epidemiology and Infectious diseases, Kiev (2005-present).

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Preface

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a

Elin GURSKYa Analytic Services Inc.

The past two decades have evidenced that natural and political forces challenge us to prepare our medical and public health capabilities to respond to a spectrum of horrific events. Wars, tsunamis, terrorist attacks, pandemics, and ecological changes are but some of the events that have and will continue to place our populations at risk and our responders in harm’s way. This text, the Handbook for Pandemic and Mass-Casualty Planning and Response, has captured the lectures and teachings of an extraordinary 12-day NATO Advanced Study Institute held in Slavonski Brod, Croatia, in late 2011, the purpose of which was to address the medical and public health response to disasters. The intent of this handbook is to offer the disaster medicine professional community writ large the information and tools to better prepare, individually and collaboratively, to mitigate mortality and morbidity when catastrophe occurs. The book is divided into three sections. Section One, The Context of Catastrophic Health Planning, begins with chapters and case studies on curriculum and methods of preparing the disaster response. It introduces MRMI—Medical Response to Major Incidents—an interactive and standardized postgraduate course developed by an international group of experts within the European Society for Trauma and Emergency Surgery. This and subsequent chapters provide a context that emphasizes both rigorous and standardized cross-disciplinary training, which is critical as global disasters necessitate a surge in response from multiple regions and countries and require swift, efficient, and aggregate capabilities as catastrophes unfold. Moreover, despite the disruption associated with mass-casualty events, we are reminded that governments and health professionals must ensure that medical and humanitarian efforts are guided by ethical principles and that risk communication and trustworthy information can result in an empowered and resilient population in the period after the disaster. Section Two, Principles of Response to Catastrophes with Mass Casualties, offers chapters addressing specific treatment guidelines as well as medical and surgical practices. It presents information on amputation and on burn and blast injuries; it provides triage guidelines, treatment algorithms, and principles of mass-casualty planning. Charts and images are effective adjuncts to the textual material in these chapters. Section Three, Communication and Information Sharing, provides both practical and theoretical treatises on the issue of communication. Aggregating an effective response requires more than real-time data streaming. More essential is the need to identify and correctly position—in advance—the networks and collaborative structures that must work together and share capabilities. This important teaching effectively loops us back to the beginning section: for us to be effective we must work together seamlessly. It is in this spirit of the NATO Science for Peace and Security Programme that we offer this book, the Handbook for Pandemic and Mass-Casualty Planning and Response.

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Contents Dedication

v

Acknowledgements

vii

About the Authors

ix

Preface

xxix

Section 1: The Context of Catastrophic Health Planning Medical Response to Major Incidents: A Standardized Postgraduate Course in Management and Performance in Major Incidents & Disasters Boris Hrekovski, Kristina Lennquist Montán and Bob Dobson

3

Development of a European Training Curriculum for International Crisis Management (DITAC/European Research Project): One European Training Curriculum for Each Disaster—Necessary or Impossible? 12 Philipp Fischer, Boris Hrekovski and Bob Dobson

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Pandemic Planning & Response Natalia Vynograd, Lela Bakanidze, Ante Cvitkovi and Igor Ivic-Hofman

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Mass-Casualty Preparedness—How to Upgrade from Below: Our Experiences in Slovenia 59 Simon Herman Education and Training for Major Incidents and Disasters: Croatia Case Study Zvonimir Lovri, Boris Hrekovski and Josip Samardži

62

Cross-Disciplinary Competency and Professionalization in Disaster Medicine and Public Health 72 Frederick M. Burkle, James M. Lyznicki and James J. James Complex Humanitarian Emergencies—An Overview: Controversies and Future Perspectives 84 Alessandra Rossodivita, Massimo Ranghieri, Matteo Guidotti, Elisaveta Stikova and Antonio Caruso The Hospital as the Weakest Link in Mass-Casualty Incidents Radko Komadina, Andrej Strahovnik, Miha Simoniti and Simon Herman

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Ethics and Medicine in Disasters and Mass-Casualty Incidents Ivica Balen

95

Croatia’s State and Medical Authority for Health System Organizations Ante Cvitkovi

98

Croatia: Community, Empowerment, Resiliency Katy Jackson and Elin Gursky

101

Section 2: Principles of Response to Catastrophes with Mass Casualties Basics of Terror Medicine Boris Hrekovski, Bob Dobson, Philipp Fischer and Mark Loades

107

Mass-Casualty Planning and Response Robert (Bob) Dobson

119

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Interoperability Within Military Medical Forces in Contemporary NATO Operations Radek Hubac

126

The Complete Protection of a Combat Soldier Mark Loades, Boris Hrekovski, Philipp Fischer and Robert Dobson

134

Experience from Past Conflicts Boris Hrekovski, Mark Loades, Bob Dobson and Philipp Fischer

142

Triage Protocols for Critical-Care Patients in Disaster Conditions Asja Ajdinovi, Matija Jurjevi, Jasminka Kopi and Boris Hrekovski

152

Development of Standards of Care for Polytrauma in Multiple-Casualty Incidents Mario Kopljar and Bore Bakota Treatment Algorithms and Hospital Triage in Mass-Casualty Incidents Matija Jurjevi, Asja Ajdinovi, Boris Hrekovski, Jasminka Kopi, Zvonimir Lovri, Mario Kopljar and Bore Bakota Guidelines for Limb Amputation and Reconstruction in Mass-Casualty Incidents Bore Bakota, Mario Kopljar and Boris Hrekovski Burn Injuries During Mass-Casualty Incidents Darko Juriši, Boris Hrekovski, Josip Jankovic, Damir Rosko and Matija Jurjevi

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Blast Injuries 181 Matija Jurjevi, Ivo Mati, Asja Ajdinovi, Boris Hrekovski, Ivana Paji-Penavi Josip Samardži and Zvonimir Lovri

Section 3: Communication and Information Sharing Information Sharing in Practice and for Practice: Mass-Casualty Cases Boris Hrekovski, Mark Loades and Bob Dobson Communication Between Emergency Medical Services and Media During Mass-Casualty Events in Croatia Branka Bardak, Marijan Baši and Igor Pavliško Just-in-Time Information Eugene Shubnikov, Andrey Trufanov, Faina Linkov, Nicolas Padilla and Ronald LaPorte

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193

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Collaboration Topologies for Interdisciplinary and Interlevel Information Exchange 202 Fernando Galindo, Ron LaPorte, Faina Linkov, Alessandra Rossodivita, Eugene Shubnikov, Elisaveta Stikova, Andrey Trufanov and Natalia Vynograd

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Networks and their Role in Counteracting Contemporary Global Threats: A New Model Alexei Tikhomirov, Andrey Trufanov, Antonio Caruso, Alessandra Rossodivita, Eugene Shubnikov and Rustem Umerov

217

Architecture of R&D Project Management Systems at Medical Institutions Andrey Govorkov, Alessandra Rossodivita and Andrey Trufanov

226

Lessons Learned Elin Gursky and Boris Hrekovski

235

Subject Index

241

Author Index

243

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Section 1: The Context of Catastrophic Health Planning

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Handbook for Pandemic and Mass-Casualty Planning and Response E. Gursky and B. Hrečkovski (Eds.) IOS Press, 2012 © 2012 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-61499-135-9-3

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Medical Response to Major Incidents: A Standardized Postgraduate Course in Management and Performance in Major Incidents & Disasters a

Boris HREKOVSKIa, Kristina Lennquist MONTÁNb, and Bob DOBSONc Department of Surgery, General Hospital Slavonski Brod, Croatian Urgent Medicine and Surgery Association b Center for Prehospital & Disaster Medicine, University of Gothenburg, Sweden c Hanover Associates London, Croatian Urgent Medicine and Surgery Association

Abstract. Medical Response to Major Incidents (MRMI) is a standardized postgraduate course developed by an international group of experts within the European Society for Trauma and Emergency Surgery. It is entirely interactive, with all participants training in their routine positions. It covers the whole chain of management—scene, transport, hospitals, command and communication, management of individual patients—and thereby permits training in the important coordinating between different units, which often is the weak point in real incidents. The scenarios are based on real injuries from terrorist incidents. The training is done in real time using actual simulated resources, thereby providing a measurable result of the response as a base for further development and training.

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Keywords. Major incident, disaster, mass-casualty incident, interactive training, simulation models, terror actions

Background The risk of major incidents and disasters has grown significantly during recent years in parallel to the development of an increasingly complex world. It has been clearly shown that training all involved staff is the most effective way to achieve an optimal response with respect to preservation of life and health. The incident or disaster is no place for training, and training based only on lectures is not efficient. Practical field exercises also have limitations; they are very expensive if intended to offer accurate feedback regarding decision making across the chain of management. The remaining alternative for achieving efficient training at reasonable cost is to use accurate and realistic simulation models. The interest in such models has, as a consequence of this, significantly increased in recent years.

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1. Demands on simulation models The key component in major incident response is decision making on all levels, from the level of coordination and command down to treatment of the individual patient: What should be done with this specific injury under these specific conditions? How should it be done, and with what priority? Training for such decisions requires x Accurate and complete input data on available resources given a variety of geographic conditions and casualties. x Accurate and complete output data as consequences of decisions: outcomes with regard to mortality and complications, preventable mortality and complications, and efficiency in utilization of resources. In addition, a simulation model should permit x Training the whole chain of management simultaneously: scene, transport, hospitals, coordination, command and communication; it is the coordination between units that is vulnerable to failure. Training can be achieved only if the entire chain is trained simultaneously. x Interactive participation of all participants in a course (“What I hear I forget, what I see I remember, but only what I have done can I do”). There are today very few simulation models meeting these demands.

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2. Development of the MRMI training program This program was developed by an international group of experts within the section of Disaster & Military Surgery of the European Society for Trauma & Emergency[1], a multidisciplinary society and one of the biggest societies in the field of medicine. This training is now run as a strictly standardized three-day course under the name MRMI and under the responsibility of a noncommercial international association of experts aimed at promoting this training. The course is based on an advanced simulation system, originally developed for scientific evaluation of methodology in disaster medicine, MACSIM® (Mass Casualty Simulation). The system can be studied on the MACSIM website[2]. It is used scientifically for evaluating and developing different methods, as an instrument to test preparedness and skills in an existing organization, and for education and training as in the MRMI courses. The design of the MRMI course is also described on the website. The system can be used for all kinds of training, from basic to advanced.

3. Design of the MRMI course The standardized MRMI course covers three full days, and the program is strictly standardized. The first day starts with a few short introductory lectures followed by practical training in groups: x Training in triage and primary treatment based on patient cards with injury descriptions x Instructions and training in the position the trainee will have during the simulation exercises

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x x

5

Rotations to all other positions assure that all trainees have an overview of the complete chain of management Preparation for the exercises in groups under guidance of the instructors

The second and third days are devoted to two full-day simulation exercises covering the whole chain of response: scene, transport, hospital, coordination, communication, and command on all levels. Every trainee participates actively in his or her normal function. The exercises are run with x Real consumption of time: Evacuation, transports, and every indicated treatment, prehospital and in hospital, takes the time it should have taken in reality. x Real consumption of resources: Every resource (staff, transport facilities, hospital facilities, and supplies) is provided in detail, and every measure performed consumes the resources it would have consumed in reality.

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In the MRMI courses organized so far, the scenarios have been terrorist attacks with large numbers of injured and dead, mainly blast and fragment injuries but also blunt trauma and burns. Other scenarios are under development: hazardous material, missile injuries. The casualties are presented on casualty cards based on injuries from real incidents. The cards give a complete description of injuries and the physiological condition of the patient, based on the Advanced Trauma Life Support criteria (see figure 1).

Figure 1a. The MACSIM patient card, used in the MRMI course. The card shows age, sex, and initial position of the patient; describes the patient’s condition according to the Advanced Trauma Life Support terminology (airway, breathing, circulation, disability); and finally describes the injuries (exposure) with a system of symbols. The patient’s condition can be changed by the instructor according to the time passed since the injury and according to treatments performed or not performed. MACSIM photo, used with permission[3].

Figure 1b. Tags indicating priority and treatment can be applied on the card. The tags can be removed and reused. Times needed for treatment (based on tests under field conditions) are indicated on the tags. Treatment labels are available for all kinds of scenarios. MACSIM photo, used with permission[3].

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For every patient, the instructors have information on x Complete definitive diagnosis x Times within which certain treatments have to be performed to avoid mortality and complications x The result if the patient is optimally treated (to identify avoidable death and/or complications) x Times for required surgery x Need for a ventilator x Revised Trauma Score and Injury Severity Score

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Priority is indicated on the patient cards with tags (standard colors) that can be changed to permit continuous reevaluation of triage (figure 1b). Every treatment is indicated with a treatment tag attached to the patient card showing the treatment and the time it would actually take. If the trainee decides to perform a certain treatment, the trainee and “patient” are not allowed to move until this time has passed. Priority and treatment tags are on scene and in hospitals according to the supplies that are actually available. The same is true for staff of all categories, transport facilities, and hospital facilities (figures 4-8). The resources in the standardized MRMI course are based on an example from a region where all these resources are described in detail (“Anyland,” which can be any region in Europe). Standardized disaster plans and action cards are used. When applying the training to a real region or country, these data can easily be replaced by data from the region where the training or testing takes place.

Figure 2. The first ambulance has arrived shortly after the incident. In the background is a model of a building inside which a bomb has exploded. The tasks of the first responders on the scene are to give an immediate window-report back to the alarm center and organize the work together with rescue and police commanders. MACSIM photo, used with permission[3].

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Figure 3. The first responders now have access inside the building, with the task of deciding the priority in which the patients should be evacuated. Trapped casualties are indicated with orange strips, also giving the time needed for extrication. Lifesaving treatment on site may be necessary for some of these patients and will consume time and resources. MACSIM photo, used with permission[3].

Figure 4. Ambulance crews and prehospital teams work with secondary triage in parallel lines, applying treatment tags on the cards and reevaluating the primary triage. Every treatment delays further transfer; on the other hand, not doing necessary treatments may lead to mortality and complications, which makes this rigorous but realistic training in decision making. To the right is a board for patients waiting for transport; to the left is a board for ambulance and helicopter transports. MACSIM photo, used with permission[3].

Figure 5. Every transport is done in real time. The ambulance loading officer communicates by radio with the Regional Medical Command Center, which, in contact with the involved hospitals, decides the distribution of patients among hospital units. Today’s limited reserve capacity in hospitals makes this distribution very important. At the calculated time for arrival, the casualty cards are delivered to the hospitals. MACSIM photo, used with permission[3].

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Figure 6. The exercise can be performed with an unlimited number of hospital units. The figure shows how a hospital is built up, from left to right: Receiving casualties and primary triage in the hospital, emergency department with resuscitation teams, preoperative care, surgery, and intensive care. Labeled plastic pockets along the bottom line represent the wards. Staff of different categories are present in proportion to their availability in an actual emergency. The critical limiting factors for the hospital’s surge capacity are access to operating theaters and ventilators. MACSIM photo, used with permission[3].

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Figure 7. Also in the hospital, all investigations and treatments are done with real consumption of time and resources, which means high demands for correct decisions regarding priority and the use of simplified methods. The dialogue between the instructors and the trainee is also very good training in primary trauma management. Figure 7a. Emergency department with the major incident resuscitation teams. MACSIM photo, used with permission[3].

Figure 7b. Surgery, illustrating the need for sufficient staff for surgical procedures, as well as the benefit of referring minor surgery to improvised theaters for local or regional anesthesia (green labels). MACSIM photo, used with permission[3].

Figure 8. Access to ventilators may be the most critical limiting factor for the hospital’s capacity. Patients already in the hospital at the time of the alert are indicated with special patient cards, and the intensive-care unit is here almost totally filled with such patients, which is a very common situation in today’s civilian hospitals and reflects high demands on setting priorities. MACSIM photo, used with permission[3].

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Figure 9. The Regional Medical Command Center (in the civilian organization often located together with the Rescue and Police Command Centers) communicates by radio with the scene and by telephone (when possible) with the hospital command centers. MACSIM photo, used with permission [3].

The exercises continue until all casualties are primarily treated in the hospitals. They are followed by a careful evaluation where the outcome of the response is given according to the data listed below. All calculated preventable deaths are analyzed and discussed.

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4. Presentation of the result of the response Standardized protocols are used for calculation of the result of the response, both as an overall result and the results from the different components in the chain of management: x Efficiency in alert and response x Efficiency in reporting x Efficiency of triage (over- and under-triage) x Efficiency in transport (waiting times for staffed ambulances and helicopters, distribution of patients between hospitals) x Efficiency in utilization of resources (under- or over-utilization?) x Limiting factors for surge capacity in hospitals x Preventable deaths related to trauma score

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Figure 10. All patients dead after the arrival of medical staff are carefully registered using preprinted labels attached to the patient cards and analyzed with regard to the reason of death and whether it was preventable, based on the information for each patient described above. Preventable deaths are related to trauma score and constitute one of the indicators on the outcome of the response[4].

Based on the standardized scenarios and resources, the results of the response can be reproduced and used as a numerical measure of the quality of the response, which can be improved by x x x

Further training Addition or redistribution of resources Adjustment of planning and organization

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5. Validation of the accuracy of the training Since their start in 2009, through March 2012, nine courses were organized in five countries with a total of more than 450 participants from all parts of the world. The courses have been carefully evaluated by x Course evaluations x Validation by pre- and post-course surveys of knowledge and skills x Validation by practical triage, testing the participants’ pre- and post-course knowledge The results, which have been scientifically documented and are under publication, have shown significant improvements on all points, and the model has been evaluated as highly accurate by the participants. (See the MACSIM website for references.)

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Conclusions A number of factors make the MRMI course unique: x It covers the whole chain of management, including management of individual casualties, which is a prerequisite for obtaining an outcome of the response x It gives all participants the opportunity to train interactively in their own positions x It gives a numerical result of the response, making it possible to register improvements by adjusting the organization or by additional training x It is scientifically validated with regard to accuracy of the training

References [1] See the ESTES website at www.estesonline.org. [2] See the MACSIM website www.macsim.se. [3] From S. Lennquist, ed., Medical Response to Major Incidents, Springer, New York, 2012, with permission. [4] Picture from MACSIM, with permission.

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Additional sources [1] S. Lennquist: Education and training in disaster medicine—Time for a scientific approach, International Journal of Disaster Medicine 1 (2003), 9-12. [2] S. Lennquist: Education and training in disaster medicine, Scandinavian Journal of Surgery 94 (2005), 300-310. [3] S. Lennquist: Management of major accidents and disasters: An important responsibility for the trauma surgeon, Journal of Trauma 62 (2007), 1321-1329. [4] S. Lennquist (ed.), Medical Response to Major Incidents and Disasters: A Practical Guide for All Medical Staff, Springer, Berlin, 2012. [5] K. Lennquist Montán, M. Bemelman, B. Dobson, B. Hrekovski, P. Fischer, A. Khorram-Manesh, C. Montán, P. Örtenwall, and S. Lennquist, ESTES postgraduate training in medical response to major incidents (MRMI): Experiences from the first five courses, European Journal of Trauma and Emergency Surgery (2011), supp. 1. [6] Medical Response to Major Incidents website: www.mrmi.org. [7] Croatian Urgent Medicine and Surgery Association website: www.croumsa.com.

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Handbook for Pandemic and Mass-Casualty Planning and Response E. Gursky and B. Hrečkovski (Eds.) IOS Press, 2012 © 2012 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-61499-135-9-12

Development of a European Training Curriculum for International Crisis Management (DITAC/European Research Project): One European Training Curriculum for Each Disaster—Necessary or Impossible? Philipp FISCHERa, Boris HREKOVSKIb, and Bob DOBSONc Department of Orthopaedic and Trauma Surgery, University Clinic Bonn, Germany b Department of Surgery, General Hospital Slavonski Brod, Croatian Urgent Medicine and Surgery Association c Hanover Associates London, Croatian Urgent Medicine and Surgery Association

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a

Abstract. When the scale of an emergency overwhelms national response capacities, a disaster-stricken country can benefit from civil protection means or teams in other EU countries. However, there is no common, standardized approach for all relief workers. There are two major incident training systems being used across Europe: The British Major Incident Medical Management and Support (MIMMS) system and the European-based and Swedish-led Medical Response to Major Incidents and Disasters (MRMI) course. The DITAC Project proposes to develop a holistic training curriculum for first responders and managers dealing strategically with international crises. Keywords. DITAC Project, training, curriculum, international crises

Introduction The DITAC (Disaster Training Curriculum) Project proposes to develop a holistic training curriculum for first responders and managers dealing strategically with international crises. The curriculum will address the key challenges for managing disasters. We will develop a standardized strong, comprehensive, and efficient EU-wide approach to crises and disasters to feature the value added by EU coordinated actions in the field of crisis response. The curriculum will improve the preparedness and availability of trained personnel by providing a common language, common objectives, and common tools, leading to better results in the protection and assistance of people confronting large-scale crises. The focus is on international crisis management, but the benefit of a standardized training program in crisis and disaster response can also be used to increase Europe’s resilience in facing disasters and crises within the European Union. Establishing a curricular training on how to respond to an international crisis and making it accessible to pertinent organizations throughout the EU will be a first step

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towards building a European Emergency Response Centre. Specialists in disaster response, as experts in the field of international crisis management, will collaborate with local, regional, and international authorities; nongovernmental organizations; training institutes; scientific societies; research institutes; and experts in logistics, knowledge management, collaborative network development, conflict analysis, security challenges, and medical, psychological, and technical emergency assistance to create synergies towards improved disaster response capacity in the European Union. The DITAC Project will x Analyze concepts, methods, and doctrines of crisis response and identify the relevant European competences of crisis management x Analyze existing initiatives to generate curricula for crisis management x Identify the requirements of the local actors in crisis management education x Identify the needs of relevant actors and the resulting stakeholder requirements for significant improvement of training in international disaster response and crisis management x Develop a didactic concept to transmit common standards for crisis management education, using state-of-the-art methods for teaching and training x Organize a pilot study course for suitable participants from European countries x Develop an evaluation tool for the course The DITAC Project will use open sources for dissemination during the project period in order to get continuous feedback, and it will organize public meetings and congresses to reach a consensus about the curriculum’s content. The improvement of the preparation of trained personnel will be evaluated in a pilot study. The information from the pilot study will serve to validate the curriculum and provide feedback. Preand post-tests will allow us to compare the progress of the participants in and between programs worldwide. An external panel will be assembled to fine-tune the program.

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1. The need for the reality Reality demonstrates that the number of large-scale crises and disasters is increasing. Recent history shows on the one hand that natural disasters, such as in Haiti and Pakistan in 2010, can cause hundreds or many thousands of civilian casualties. On the other, they show a lack of a common standardized approach by all relief workers. The difficulties of dealing effectively with large-scale crises are manifold: x Fragmentation—many different organizations need to be involved and coordinated. The current approaches and systems are fragmented due to the multiplicity of players and organizational setups as well as the lack of effective shared operational pictures and commonly shared information. The inconsistencies among the roles, responsibilities, operational procedures, systems, and equipment of the different organizations involved (health providers, first responders, rescue workers, municipalities, etc.) severely limit the effectiveness of the overall response to a disaster. Different protocols for different scenarios add even more complexity. x Communication—the heterogeneity of the preparation of the different first responders and strategic crisis managers as well as the lack of effective communication among all organizations and training institutes makes it very difficult to educate all actors for a professional crisis response.

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x

x x

x

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x

x

x

Incongruity—the insights that are produced at the planning stage from threat analysis and scenario development are not readily available during the operational crisis. High-level plans and scenarios do not necessarily connect with the standard operating procedures used for managing response to a disaster. The strategy and tactics do not connect. Information waste—much information is theoretically available but not used. Human factors—psychological and societal aspects (both individual and population behavior) are complicated to deal with, especially when there is a lack of trust in public authority. That can be an obstacle to effective communication with the public. One particularly important aspect will be communication with the public to induce—as far as it is possible, reasonable, and ethical—appropriate population behavior in the case of a large-scale crisis in order to limit the impact. Psychological and societal aspects—often different from one culture to another—are also critical for addressing effectively the issues of preparedness for large-scale crises. Current means of communication are insufficient for creating awareness of the reality of threats and for educating responders, the general public, and policy makers to both the appropriate preventive measures and behavior in case of natural disasters or other crises. As a result, fear is high and the overall preparedness low, which is critical when it comes to managing the population in a large-scale crisis. Holistic situation assessment—the complexity of a large-scale crisis makes it difficult to maintain an overall picture and assessment of the situation at hand, integrating in real time the information coming from multiple heterogeneous sources (organizations, agencies, population, interactive media). Investment—the rarity of large-scale crises in Europe makes it more difficult to convince political decision makers to commit the necessary investments. Proposed solutions must hence include a convincing cost-benefit analysis. The lack of coordination among the member states of the European Union can also be a source of significant gaps and inconsistencies. Training—the scarcity of effective simulators and the lack of comprehensive awareness material for the different stakeholders (even in highly exposed countries, such as developing countries) is a major obstacle to preparedness and resilience. Real exercises for disaster preparedness are complex and costly, but they can have a significant positive impact on public perception. Also, as large-scale disasters in Europe are rare, education and awareness need regular repetition. Time—in contrast to other mass-casualty incidents, large-scale disasters are more difficult to handle because it can take hours or even days for responders to arrive, assess the situation, and help in the disaster area. After the disaster, the need for humanitarian help can remain high for a prolonged period. In the case of Haiti, mechanical injuries such as broken bones had to be mended first; then, months later, infectious diseases such as cholera accompanied by violent attacks against UN staff created new challenges.

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2. Concept of the DITAC training program 2.1. The challenge for the right combination of existing concepts DITAC recognizes that many concepts, methods, and doctrines for international crisis management exist: standard operating procedures, emergency management systems, training programs, etc. These different elements, however, need to be pulled together in an overall approach to a professional crisis response and resilience that x Addresses the overall effectiveness and performance of the response and not just of the individual agencies x Can be adapted to different geopolitical, organizational, and geographic settings x Creates an environment supporting progressive learning and enrichment, even beyond the scope of the project DITAC proposes a comprehensive holistic approach. To achieve this objective, the DITAC Consortium has pulled together stakeholders, end users, and scientific experts to allow for a huge step in preparedness and resilience to large-scale crises. Furthermore, by achieving this objective DITAC will also x Support effective collaboration and dialogue between EU member states and beyond x Define and develop educational tools for preparing and responding to major disasters in general

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3. The disasters we are dealing with The EU and neighboring countries are periodically affected by natural and manmade disasters, such as earthquakes, floods, forest fires, and terrorist attacks. In 2010 alone there were fatal large-scale disasters in Europe (floods in Central Europe, storms in Western Europe) and outside it (the Haiti earthquake, the Pakistan floods). The impact of these disasters has also increased: over the past 20 years, documented disasters in Europe alone have killed almost 90,000 people, affected more than 29 million people, and caused €211 billion in economic losses[1]. The primary responsibility for dealing with the immediate effects of a disaster lies with the country where it has occurred. Nevertheless, when the scale of the emergency overwhelms national response capacities, a disaster-stricken country can benefit from civil protection means or teams in other EU countries. Hence we are very strongly taking into account the European Community Civil Protection Mechanism (the Community Mechanism) to support the mobilization of emergency assistance from participating states in the event of major emergencies. The 31 participating states of the Community Mechanism are all member states, the European economic area countries (Liechtenstein, Norway, and Iceland), and Croatia in its capacity as a candidate country. By pooling the civil protection capabilities of the participating countries, the Community Mechanism can ensure even greater protection of people, property, and the environment. The training program will be an essential part of the Community Mechanism. It is crucial in preparing experts for international civil protection assistance interventions in the European Union, as well as outside it. It also provides an excellent platform for experience sharing and networking among national experts from participating countries. The program will involve training courses and

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joint simulation exercises where experts can learn firsthand about similar responsibilities under different national systems. The target group is wide, opening the training program to many categories of actors. These can range from assessment and coordination experts to specialists in fields such as marine pollution, the environment (landslides, waste management, dam stability, etc.), geohazards, or logistics in emergency operations, as well as medical staff, security forces, and experts in conflict settlement. These experts make up our Consortium. They also are experienced trainers and are available to teach the curriculum. The project will largely involve the end-user community. The DITAC project will benefit from the existing close contacts that all partners have with end users due to their involvement in past disaster relief operations and other projects with end-user organizations[1-6]. The significance of a common response was mentioned by the European Commission in a letter to the EU Parliament, setting out a strategy to respond to disasters: “Improved EU capacity in this area has multiple benefits—most importantly, saving lives and helping recovery.… The disaster response strategy is based on making the most effective use of existing instruments rather than establishing new overarching structures”[7]. With all of the above facts in mind, the challenge for the DITAC project is to develop an overall curriculum that can realize a European standard of humanitarian aid: an efficient, rapid, flexible response and a sustainable outcome after the disaster to significantly reduce the loss of lives. To reach this goal we will incorporate the available training programs for national technical, coordination, and assessment experts, as well as for personnel involved in the civil protection modules. DITAC takes into account the weaknesses of the existing approaches and identifies the requirements for an appropriate training program that can respond to all the identified gaps. Crucial for this is a holistic approach that covers all the fields of the disaster cycle. These fields will be introduced briefly in this section. They include transport and the delivery of food, shelter, water filters, etc. (Logistics); the observation of disaster impact and data collection (Observation and Data Collection); the coordination, administration, management, and public relations of the humanitarian intervention (Coordination, Administration, Management and Public Relations); the medical requirements and assistance (Medical Assistance) the security environment and the social interaction between local actors and relief workers in the disaster area, along with the prevention of post-disaster conflicts (Security, Social Interaction, Prevention of Post-disaster Conflicts). Each field presentation starts with an analysis of the weaknesses and gaps in current training and preparation courses and then identifies the requirements and educational objectives for appropriate training programs. Based on this analysis, a didactic concept is outlined (Didactic Concept). 3.1. Examples 3.1.1. Logistics, observation, and data collection Nowadays Earth observation sensors, global navigation systems, and various Internet portals provide critical operational information relevant for mission success of the humanitarian relief community. Satellite imagery and geographic information are key elements for crisis management and response logistics, since large areas can be remotely monitored in nearly real time[1]. Satellites pass over a location on Earth at regular intervals, and the rapid and extreme changes can be considered when analyzing multi-

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temporal data. Furthermore, ground-based logistics can be supported by navigation systems as well as real-time fleet management and supply chain optimization tools. According to this concept, an appropriate training program for crisis management should encompass modules on how to get access to the satellite information and other technologies, how to trigger certain mechanisms, how to best use the up-to-date geographic information, and how to interpret the satellite-derived maps and images properly so they can be integrated into the workflow of an organization’s and European or international processes. For example, the European Global Monitoring for Environment and Security program with its Emergency Response Services will be a prominent mechanism to be addressed and reflected in the curricula to be designed. Work will be built on concepts and experience gained during the many European Commission exercises or within the commission’s training cycle—e.g., the Assessment Mission Course series on Cyprus[8-12].

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3.1.1.1. Observation and data collection In recent years, the EU has further developed and improved its instruments for crisis management—e.g., the Civil Protection Mechanism (EC 2005/12 OJL6/7)[13] by which the European Commission can coordinate contributions of member states to emergency rescue assistance. To become as effective as possible, these instruments have to be supported by geospatial data and information being made available as needed for decision support[1]. A first essential step in the case of an extreme event is to provide timely and accurate information about the extent of the event, the infrastructure affected, and the people involved. Suitable data to generate this kind of information has to be x collected in a timely and reliable way x transferred, processed, and integrated in a common operational picture The common operational picture has to provide suitable information products to support situation awareness, decision making, and response operations. Accordingly, resulting information products have to be communicated to decision makers and relief forces in the field. Another crucial requisite for generating proper situation awareness and effective decision support in any given critical situation is an appropriate knowledge and understanding of the risks involved in the situation. This means assessment, quantification, and mapping of relevant hazards, of exposure and susceptibility of the population and infrastructure, and of available coping capacities. Major challenges regarding support of European crisis management instruments and mechanisms through geospatial data and information have been identified to be related to issues such as threat prevention and preparedness, decision support in the response phase, and recovery and reconstruction monitoring, emphasizing the potential of Earth observation satellites[1]. Satellites provide reliable and rapid communication, observation, and positioning tools, especially when crucial infrastructure on the ground is damaged. In the predisaster phases of the disaster management cycle, issues such as risk assessment, disaster mitigation, and prevention also benefit greatly from space-based data. Images from Earth-observing satellites are used to produce maps of disaster areas for overview information and damage assessment, and to provide specific data layers for applications of geographic information systems—e.g., for early warning and risk and vulnerability mapping. Satellite communication serves to warn people at risk in remote areas and to connect a disaster area to the outside world, providing medical information (telemedicine) or geographic information and data to support mapping

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activities. Global Navigation Satellite Systems provide positional information on disaster-related events and objects and support relief forces in the field. Nevertheless, potential users worldwide still face questions about the existence, availability, accessibility, methodology, quality, costs, and timeliness of space-based information[14]. Apparently, there is still a widespread need for an information gateway to spacebased information for disaster management support. Where mechanisms for providing Earth observation data for disaster management are already in place, they are restricted to supporting response measures in the immediate aftermath of a disaster, not covering pre-disaster activities such as mitigation and early warning, or monitoring slow-onset disasters. Building on known risks, the integrated observation, quantification, and characterization of a given incident or situation depend on the optimized fusion of spatial data differing in type of source, data format, and spatial and temporal resolution. Data fusion has long been dealt with in remote sensing and other technical domains, where different types of sensors provide complementary data sets that have to be integrated into a common information extraction scheme[14, 15]. A holistic approach is required in view of this situation characterized by casespecific requirements, a differentiated potential of coping technology, and complex integration needs. Accordingly, the curriculum will cover and address topics such as x Human aspects (health, critical infrastructure, humanitarian aid, security) x Disaster types (earthquake, tsunami, volcano, mass movement, severe storm, flood, fire, drought, extreme temperature, epidemic, insect infestation, pollution) x Disaster management cycle phases (mitigation, preparedness, relief and response, recovery and reconstruction) x Mechanisms for data access x Characterization and availability of mapping products to support disaster management x Data fusion of in situ and remotely sensed data 3.1.1.2. Coordination, administration, management, and public relations While a few years ago, crisis information for civil protection and humanitarian purposes was provided by only a few expert centers worldwide, this situation is changing rapidly. Various national, governmental, nongovernmental, regional, and global actors and networks have been formed and are increasingly engaging in preparedness and response activities before or after major crises. They come from research and academia, industry, public bodies, UN organizations, etc. They operate at different scales and through different communities. With all these initiatives and the multitude of actors in this field, the awareness and availability of information and training resources in disaster management have increased significantly. Data access has and will continue to become easier and easier. Furthermore, the response time of existing systems has noticeably improved. Yet these positive developments have led to a significant drawback when it comes to a global coordination of efforts during extraordinary disasters or crises, when large numbers of organizations and relief actors are engaging in the relief work. The aftermath of the Haiti earthquake in 2010, for example, has shown clearly that the huge number of analysis products provided, such as assessment maps, the sometimes severe inconsistencies (thematically and graphically), and the diversity of the

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hundreds of products led to confusion, irritation, and discouragement of those who were supposed to be supported by maps, satellite-based analysis products, and other types of information. The need for specific capacities—educational, scientific, technological, and institutional—is a key factor for effective disaster management contributing to the entire disaster management cycle. The requirements capacities range from individual human capacities to organizational and institutional ones. Training in these fields should lead to a common understanding and a common practice of how to manage European crisis response and preparedness. This needs to be in line with existing procedures in the Community Mechanism, which facilitates cooperation in assistance interventions in major emergencies. The curriculum that is to be developed will take into account existing national training and exercises as well as the training program established by the Community Mechanism, including the “Exchange of Experts” platform. Courses in member states need to be aligned with the courses offered by the Community Mechanism’s training program. A European training curriculum should aim at x Raising awareness about existing opportunities in crisis management and preparing stakeholders to draw upon and work with these existing opportunities x Enabling stakeholders to communicate with one another and to coordinate their activities to make best use of existing national, international, and regional capacities x Strengthening existing European and international mechanisms and the way they are accessed, as well as the use of the services of the Monitoring and Information Center x Enabling stakeholders to communicate with the media about disaster management topics professionally x Making use of public communication channels for raising awareness among the public covering all phases of the disaster management cycle x Dealing with public information services—i.e., the media and different publication platforms—and making best use of them for both preparation and response measures Networking and information sharing need to be formal aspects of stakeholders’ capacity-building processes. Coordinating among crisis management actors must be an integral part of and internalized in the working routines and therefore in the training as well. Awareness of existing initiatives is needed in order to respond and plan appropriately[16, 17, 18]. 3.1.1.3. Medical assistance Experiences from major incidents and disasters during recent years have clearly illustrated that planning and equipment are not sufficient for an optimal medical response—training of all involved medical staff is an equally important, or even more important, component of preparedness. Training of staff for major incidents and disasters is very demanding. Contrary to most other fields of management, the real situation (during an incident) is not a good place for training. Therefore, training requires different kinds of simulations, and these must be realistic to increase the trainees’ preparedness to perform accurately in these very difficult situations.

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The most common weak points of existing training programs are x Practical field exercises where too much effort is focused on turning them into spectacular dramatic events, but too little effort emphasizes the objective evaluation of the trainees’ performance. x Insufficient analysis of the outcome with regard to mortality and complications as a result of the decisions made (utilization of available resources, triage, and treatment). x Training sessions with insufficient input data as a base for decisions, making it difficult or impossible to evaluate the decisions made. x Insufficient output data to evaluate the result of the decisions (what would have happened to this specific citizen in this specific situation as a consequence of the decisions made, and could another decision have changed this?). x Training sessions for only part of the management. This makes it difficult or impossible to evaluate the overall outcome, since all components depend on one another, and the possibly most important components—communication and coordination—cannot be practiced. x Lacking validation of training models. Results from training are often presented as evaluations from the trainees, but a good course evaluation does not guarantee that the knowledge and skills learned really have increased the trainees’ ability to perform accurately in a major incident or disaster. The problem is that the majority of available training programs today have at least some or all of these weaknesses. Since the weaknesses are easily identified by the trained staff, it reduces the motivation both for trainees to attend the programs and for decision makers to send staff to them. The need for better training programs is a wellidentified global problem[19-22]. An accurate training program in this field has to be based on simulation systems. Such systems have to fulfil certain criteria: x Make it possible to train people in or illustrate decision making in all components of the management chain simultaneously: pre-hospital organization and performance, transport, in-hospital organization and performance, command, coordination and communication, and individual patient management such as triage and treatment—what to do with this specific citizen in this specific situation, with which priority and with which methodology? x Give complete and realistic input data as a base for all decisions in training: a detailed description of all available resources with realistic times for access, real times for transport, and detailed and accurate description of injuries (based on real scenarios). x Give complete output data with regard to consequences of the decisions: consumption of time (real), consumption of all kinds of resources, outcome expressed as preventable mortality, and complications related to trauma or illness scores, including utilization of available resources. x Give a training result that is reproducible and can be numerically expressed so that it can be improved by training and/or by modification of the planning and organization. x Priority should be given to developing training systems that fulfill the criteria. The gap between programs fulfilling these criteria and the majority of the programs available today is apparent. Priority should be given to developing training systems Handbook for Pandemic and Mass-Casualty Planning and Response, IOS Press, Incorporated, 2012. ProQuest Ebook Central,

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fulfilling the criteria. The defined overall objectives for the science of disaster medicine and crisis management are to “reduce or eliminate loss of health and life, and physiological and psychological suffering, consequent to major incidents and disaster”[23]. These goals should be reached by (a) research and scientific development of methodology and (b) education and training. Based on these overall objectives, detailed standards should and can be defined for all kinds of education and training in this field, depending on level of training and category of staff. It is important that these standards be internationally uniform, and it is the task for international societies to come to agreement on such standards. Support for such activities is one way to promote this development[24-27]. 3.1.1.4. Security, social interaction, prevention of post-disaster conflicts The training curriculum is intended to address the requirements for disaster management in its whole context. Therefore, it must consider the following: x Usually a certain part of a society is affected by a disaster, and this part of the society has a particular social structure—its own values, institutions, rituals, culture, political structure, and economy—with inequalities and different ambitions and links to the larger society. Hence it forms an ethnographic field that relief workers have to be made familiar with in order to do no harm during their intervention[28, 29]. x Local actors must not only be seen as victims, but also have a crucial role in tackling emergencies caused by disasters. Parallel to the efforts of humanitarian agencies, medical doctors, and the technical apparatus that is mobilized for assistance, there are the efforts of the local social actors affected by the disaster. Relief workers have to be aware that the local actors primarily act and respond to the emergency within their own social field, which has its own weaknesses, imbalances, discriminations, power relations, and inequalities[19, 30]. x Social change occurs due to both the disaster itself and the intervention from humanitarian agencies. Humanitarian agencies and local social actors are at a critical interface that causes demands and expectations and can provoke open or latent conflict[12, 31]. Hence the DITAC curriculum must address awareness raising, skills provision, and ability to interface with local actors. x Awareness raising—about the social and ethnographic field in which a disaster occurred; about the efforts of local social actors to survive and tackle the disaster; that the approaches of the affected social groups must be taken at least as seriously as those of the humanitarian agencies themselves in order to facilitate cooperation and significantly enhance the effectiveness and sustainability of assistance; of the damage that exaggerated expectations can cause, and the role of the relief workers and humanitarian assistance in this; about the mutual shaping of local practice by humanitarian intervention and vice versa; about the dilemmas of dominance and subordination, superiority behavior and resistance, compliance and sabotage, with potentials for corruption, violence, resentment, and radicalization of existing splits in society; and methods to avoid, face, and make transparent such clashes.

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x x

Skills provision—to communicate with local representatives immediately and translate or explain to these representatives the humanitarian activities by external actors. Ability to interface with local actors—show entry points of the professional humanitarian response system to local actors’ involvement, contribution, cooperation, and decisions; train professionals to make use of these entry points, to cooperate in a respectful way with local medical staff and existing social associations, and to incorporate local rituals, values, and customs; clarify how an approach of subsidiarity in the control and organization of humanitarian assistance can be applied that gives priority to local self-help approaches; build capacity towards management and organizational skills that address waste, sewage, water, and other hygiene-related demands as well as appropriate supply with food, shelter, and other basic needs, guided by the principle of subsidiarity and utmost use of existing approaches, structures, and local actors’ ideas, suggestions, and their own organizational capacities.

Methods for training will range from intercultural communication exercises to case studies and role playing, including meta-planning and brainstorming, creative exercises, and simulations. The DITAC curriculum combines theory and field experience with international guidelines and standard operating procedures. It contains practical exercises (field and tabletop) based on different emergency scenarios where participants get the opportunity to practice their skills in a realistic setting[31-34].

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3.2. Didactic concept By our definition, a curriculum is a structured frame of a learning and teaching process, which includes topic-related objectives and methods, trainee composition, a schedule of modules, and evaluation schemes. Such modules are self-contained training packages, including the description of training activities and all materials necessary for trainer and trainees, all forms of media, trainers’ and trainees’ suggestions, and ancillary documents. The DITAC training will be based on a curriculum for international crisis management, structured around two critical points: potential disaster scenarios, which are to be analyzed for similarities and differences, and which will determine approaches, actors, and outcomes; and the trainees, what they bring into the course, and what they need to take home. The approach of the DITAC curriculum is based on several systematic frames, according to which training should endow interdisciplinary teams with skills that can be deployed in the field, allow trainees to engage in incremental self-improvement, provide self-improvement through rehearsal of expected scenarios, exploit the skills already present within any trainee group to the degree possible, and supplement training (hands-on practice) with teaching (lectures and presentations) only where knowledge gaps have been clearly identified. This implies that the emphasis in the curriculum must be on a supervised and managed experience that always reflects practical needs and potential scenarios. This also implies that, to a large degree, groups of trainees will be training themselves and one another. The curriculum will be set up for people from various sociocultural backgrounds, working as professionals in several fields of crisis management with defined standard competencies for admission.

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It is expected that trainees will be professionals with a great deal of experience in their fields. This is an often overlooked resource in training systems. In this project, we expect trainees to provide input from their professional perspective, serving as resource persons, and directing discussions of specific areas of expertise and experience. To facilitate this, registration for any course will include mining potentially useful knowledge among trainees. Trainees will then be requested to prepare presentations or other forms of input to the course. Expert input will be provided to supplement the scenarios, as well as to provide state-of-the-art and ancillary skills input. Resource persons will provide lectures, presentations, practical demonstrations, and question-and-answer sessions. The project will maintain and update a roster of resource persons available for shorter or longer engagement with relevant courses. A suitable teaching methodology is the critical success factor of the program. The core of the DITAC proposal is the development of a set of simulations in which all elements of an emergency response team for a particular scenario will be brought into play. This may be done segmentally (single elements of a scenario, then the entire scenario) and run for a part of or a full training session. Such simulations have been a successful feature of training in peacekeeping. A set of scenario tools for both European and other crises will be made available, including all ancillary material (documentation, trainer manual, game management rules, and evaluation system). The scenarios will have built-in update-and-improve structures to reflect changes in actual practice. Scenarios will be developed for in-class, remote (telephone or tabletop simulation), and practical (field) simulations[1]. The material will be available in electronic form, to provide replicability and rapid updating. Modules will include media files, text documents, activities, forms, and associated official documents. The training curriculum will thus consist of three central elements: a core of simulations evolved from data about categories of disasters and the responses to them (scenarios); input by highly experienced experts in various forms (lectures and presentations, critiques of scenario activities, question-and-answer sessions); and mining and presenting participant knowledge. To ensure that the curriculum and the modules are constantly updated, a library of older, even obsolete, modules and curricula and designer notes will be maintained and made available to future designers through the portal. Simulation models fulfilling the requirements for accurate training programs can be used to test both the preparedness of an organization and individual knowledge and skills oriented to a standard setup. In this respect and to ensure the utility of the training later on, we will include a robust process of evaluation and assessment, also available for the pilot study course. These will be built into the training regime as a whole (assessment) and every course (evaluation). Assessment is intended to measure the efficacy of the training for actual field activities. It will have two main tools: (1) occasional structured feedback from all course graduates on the utility of training in emergency- and disaster-related activities and (2) systematic feedback during (if possible) and after actual deployment of trained teams and actors in case of a real disaster. Structured data collection, analysis, and dissemination will be carried out through the portal. The objective of evaluation is improvement and steerage within each course. A secondary objective is incremental improvement between successive courses. Evaluation will consist of feedback from trainees, resource persons, and trainers.

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Different mechanisms could be used in each course for on-time steering. This will include evaluation discussions and a suggestion box through the web portal, to be accessed by course staff. Structured course evaluation will also be included. The results of this feedback will be returned to all stakeholders in raw analyzed formats, with appropriate personal data safeguards. In addition, some resource persons will serve as external evaluators of, e.g., practical exercises. This will ensure that the training will be responsive to real needs from the field and to changing strategic perceptions at all times—e.g., the Bonn International Center for Conversion has successfully developed and deployed several long-term (multiday) simulations such as Carana for training disarmament, demobilization, and reintegration implementers, and MRMI has a tabletop training exercise established through the ESTES Section of Military and Disaster Medicine.

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4. Comparison of MRMI with MIMMS and other systems History: For a better understanding, here’s a quick comparison of systems. There are two major incident training systems being used across Europe: The British Major Incident Medical Management and Support (MIMMS) system and the European-based and Swedish-led Medical Response to Major Incidents (MRMI) course. The MIMMS course develops an understanding of the roles of key players and the command and control structure. It deals with issues such as equipment and functions within the health system and how outside organizations such as the police, fire and rescue services, local authorities, and other government agencies work together at the scene of an incident. It is a well-established system that has been tried and tested for many years within the UK, but it differs from what is used in the rest of Europe. The MRMI course is more focused on the clinical outcome of each patient and concerned with the complete medical chain from the incident scene to surgery and beyond. It compares the outcome of each individual patient, scientifically assessed using the Injury Severity Score. Treatment can also be assessed to test whether the patient was given the best possible chance of survival considering the available resources, using the database of patients’ actual injuries from the bombing outrage in Madrid in 2004. It is a real-time exercise that analyzes resources at the precise moment of the incident. For example: x At 9 am or 9 pm, the actual number of available ambulances x The actual number of operations in progress or about to commence, including the number of doctors, nurses, and technicians involved x The number of operating theaters not in use x The number of ventilators available With hospitals using computerized systems to maximize the efficiency of staff and equipment, the MRMI course raises issues about decisions that have to be made. For example, who should use the ventilator: the elderly patient who has little chance of survival or the young person who has multiple injuries?

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4.1.1. Weaknesses The MRMI course does touch on the key roles of the Major Incident Command Silver (tactical) level, but not to the extent that MIMMS does. MIMMS does touch on the principles of triage but does not test the clinical outcomes of the patients—a key feature of the MRMI course. 4.1.2. Conclusions The MIMMS and MRMI courses complement each other well. If the participants might undertake a management role at the scene of a major incident, then it is highly recommended that they complete MIMMS before attending an MRMI course. If their role does not require them to be in a management position on scene, then the MRMI course would be more appropriate. To ensure that training can be of the highest quality, the project will outline a trainer management system, including an adumbration of a trainer-to-trainer course[35-41].

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5. Summary: The DITAC key innovations and implementation DITAC will integrate existing courses and training institutes to improve and coordinate operational reaction following an international crisis and will develop an international crisis management training curriculum to specific audiences envisaged before (preparedness) and after the event (response). DITAC proposes a comprehensive approach to international crisis preparedness and resilience, encompassing the different stages and stakeholders. It integrates their procedures, institutes, courses, plans, operational assets, etc. It provides senior decision makers with the information to coordinate effective planning, response, and recovery for all types of events. DITAC will x Provide these capabilities in an open knowledge portal and common curriculum that can be adapted to the specific requirements, organizational structures, and systems already used across Europe and be flexible enough to accommodate significant changes and upgrades. x Develop guidelines, a curriculum course, and simulation to train specific audiences. The security theme aims at increasing the security for Europe’s citizens and simultaneously improving Europe’s global competitiveness. It can reach its objective only if its outcome is eventually applied by the relevant stakeholder communities. x Address the needs and requirements of all stakeholders, taking cultural, societal, and psychological factors into account. x Pay special attention to communication with the general public, which is addressed at all levels of development of the DITAC concept. While duly taking into account the legal and political background, the action will lead to a common training curriculum to be used by the EU. It should lead to an integrated European approach to international crisis and should provide and demonstrate significant improvements with the existing fragmented situation and significantly improve the resilience of the European Union.

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The DITAC approach brings several key benefits here: x DITAC complements rather than replaces what exists. Thus DITAC can provide a complete knowledge portal and curriculum to support the EU in teaching crisis management. x It can deal with most complex issues. This will create the conditions for effective sharing of knowledge and best practices. x By covering the entire disaster and crisis life cycle and all aspects of natural or manmade incidents and by looking holistically at the needs, DITAC will be a major asset in addressing the fragmented situation without creating preconditions, which would contradict the principle of subsidiarity. DITAC will be designed to leverage existing training courses and knowledge into an integrated curriculum, enabling maximum effectiveness while minimizing organizational resistance. 5.1. What’s the issue? x x

x

Although EU disaster response is usually effective and swift—as illustrated by the 2010 floods in Pakistan and the earthquake in Haiti—there is room for further improvement in its effectiveness, efficiency, coherence, and visibility. Through the EU Civil Protection Mechanism, Europe supplies teams and equipment (in-kind assistance) to disaster-stricken countries worldwide. However, this is based on ad hoc offers by individual countries, so it is not possible to foresee what type of and how much assistance would be offered in response to a given disaster. The Commission has issued a communication proposing a range of measures in the areas of civil protection and humanitarian aid, as well as military support to civilian relief efforts.

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5.2. Who would benefit and how? Victims of disasters inside the EU and around the world would benefit, as European aid would be delivered with a common standard and cover the most important needs. EU national authorities and institutions would benefit, as the response would be better planned and prepared, ensuring more cost-effective assistance. Citizens would see a visible expression of European solidarity and evidence of what the EU is doing to protect them and to help others in need. 5.3. Why does the action have to be taken by the EU? When a major disaster occurs and national capacities are overwhelmed, a common European response is more effective than individual countries acting alone. 5.4. What exactly will change? The European Curriculum for International Crisis Management will accumulate all the experience and all the knowledge of the various specialized actors in crisis management. The didactic principles will follow the requirements as they will be figured out by the DITAC project in the system of methods and competencies of a crisis management Handbook for Pandemic and Mass-Casualty Planning and Response, IOS Press, Incorporated, 2012. ProQuest Ebook Central,

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concept. Proceeding from this concept, a set of modules will be designed that explains the trainees’ standardized level of performance that is expected after successfully completing the training and education. In real crises or disasters, the trained actors will be on a European-wide standardized level, ready to give a coordinated and efficient response. A European Emergency Response Capacity—a voluntary pool of pre-identified EU countries’ teams and equipment (e.g., field hospitals, forest fire–fighting airplanes, water-pumping units for floods)—would be on standby for EU operations. Countries providing assets to the pool would make them available for joint operations whenever called for except when they are needed at home. This response capacity would work hand in hand with EU humanitarian aid provided as financial assistance to our partners (the United Nations, the Red Cross family, and nongovernmental organizations). All European in-kind assistance would be coordinated by the European Emergency Response Centre. There would be closer coordination with other actors involved in disaster response: x The military x The United Nations x The European External Action Service The DITAC Project provides a unique opportunity to address this situation by facilitating research and development leading to major innovations: x A curriculum for a comprehensive and integrated international crisis management system (such a curriculum simply does not exist) x A basis for cooperation and collaboration of different countries and agencies x Practical training and advice for first responders, strategic crisis managers, and decision makers x Maximal flexibility for adaptations to the specific environments, societal contexts, and organizations of operational procedures, models, algorithms, scenarios, and plans, while providing templates and general requirements for these, as well as best-practice samples x A focus on the entire spectrum of disasters, crises, conflicts x A holistic situational awareness approach x A platform for  Efficient knowledge exchange between different agencies and countries  Efficient dissemination of academic achievements in the field (standards, concepts, methods, and doctrines) via the knowledge portal  Simulation and training, resulting in constant enrichment of the underlying knowledge base  Managing field exercises and simulations besides general guides and strategies x New training components to address the response in case of an international crisis and the identification of new perspectives for future treatments DITAC by no means discards any of the achievements of the existing curricula and training formats, but rather builds on them and adopts them whenever possible. The already implemented and proven standards, concepts, methods, and doctrines will be readily hosted by the DITAC Knowledge Portal.

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5.5. The overall strategy of the work plan—the solution for success DITAC will establish a base through which it will pursue several distinct yet interrelated strands necessary for creating an exemplary learning process. The central fulcrum of the DITAC platform will be the establishment of an open dialogue on international crisis management between stakeholders (both among the project team members and by creating a large dedicated user advisory group) and renowned experts in disaster management. This will lead to a holistically deeper understanding of all the issues at stake and will play a crucial role in influencing the developments of a standardized curriculum. DITAC, by design, will be open to collaboration with third parties for mutual benefit. DITAC expects to have progressive access to a broad range of relevant information and data in return for access to the DITAC Knowledge Portal, which will serve several aspects: x Support for simulation and training exercises x Access to a strong basis for validation, testing, dissemination, and future exploitation of results x A continuous stream of dialogue with the stakeholder community The main result of the DITAC initiative will be the implementation of the first standardized European curriculum for international crisis management that we foresee becoming a fundamental certification criterion for a new progeny of aspiring disaster management professionals—it is necessary and not impossible.

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References [1] D.H.A. Al-Khudhairy, Geo-spatial information and technologies in support of EU crisis management, International Journal of Digital Earth 3 (2010), 16-30. [2] European Commission, Towards a stronger European disaster response: The role of civil protection and humanitarian assistance. Communication from the Commission to the European Parliament and the Council (2010). [3] Ibid., text with EEA relevance, 600 final. [4] European Commission, The European Community Civil Protection Mechanism Training Programme (2009). [5] D. Stevens and J. Szarzynski, Space-based solutions for disaster and emergency medicine, Prehospital and Disaster Medicine 24, supplement 1 (2009), S79. [6] On-Site Operations Coordination Centre Guideline, United Nations Office for the Coordination of Humanitarian Affairs. [7] European Union @ United Nations, EU Commission proposes to improve European disaster response, 26 October 2010, www.eu-un.europa.eu/articles/en/article_10263_en.htm. [8] Bonn International Center for Conversion, Gesellschaft für Technische Zusammenarbeit, ECOWAS Small Arms Unit, and Kofi Annan International Peacekeeping Training Centre, SALW [Small Arms and Light Weapons] Control Training Manual for West Africa. [9] Bonn International Center for Conversion, 15 training modules on arms control, esp. small arms and light weapons. The modules come in two versions: the advanced module for trainers and the basic module for trainees. [10] H. Compaore, J.M.H. Hendrickx, et al., Evaporation mapping at two scales using optical imagery in the White Volta Basin, Upper East Ghana, Physics and Chemistry of the Earth, Parts A/B/C 33 (2008), 127-140. [11] Dorothea Hilhorst, Dennis Dijkzeul, and Joost Herman, The social dynamics of humanitarian action, Disasters 34, special issue, supplement 2 (2010), S127-S273. [12] Norman Long, Handlung, Struktur und Schnittstelle: Theoretische Reflektionen, in Thomas Bierschenk, et al., eds., Entwicklungshilfe und ihre Folgen, Campus Verlag, Frankfurt am Main, Germany, 1993. [13] Civil Protection Mechanism (European Council 2005/12 OJL6/7).

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[14] R. Backhaus, L. Czaran, et al., Support from space: The United Nations Platform for Space-based Information for Disaster Management and Emergency Response (UN-SPIDER), in O. Altan, R. Backhaus, Piero Boccardo, and Sisi Zlatanova, eds., Geoinformation for Disaster and Risk Management: Examples and best practices, Joint Board of Geospatial Information Societies–United Nations Office for Outer Space Affairs, 2010, www.un-spider.org/about/portfolio/publications/jbgisunoosa-booklet. [15] R. Backhaus and J. Szarzynski, Das SPIDER Programm der Vereinten Nationen, in DLR e.V., eds., Deutsches Zentrum für Luft- und Raumfahrt—Ein Portrait, Rheinbreitbach, NDV-Verlag, 2008, 93-95. [16] L. Guesnet, Marie Müller, and Jolien Schure, Natural resources in Côte d’Ivoire: Fostering crisis or peace? The cocoa, diamond, gold and oil sectors, Bonn International Center for Conversion, Brief 40, December 2009. [17] International Search and Rescue Advisory Group, INSARAG Guidelines and Methodology, United Nations Office for the Coordination of Humanitarian Affairs, Field Coordination Support Section (INSARAG Secretariat), 2007. [18] Arjen Boin and Mark Rhinard, Managing transboundary crises: What role for the European Union? International Studies Review 10 (2008), 1-26. [19] Dorothea Hilhorst and Maliana Serrano, The humanitarian arena in Angola, 1975-2008, Disasters 34, special issue (2010), S183-S201. [20] P.L. Ingrassia, F. Prato, F. Della Corte, et al., Evaluation of medical management during a mass casualty incident exercise—an objective assessment tool to enhance direct observation, Journal of Emergency Medicine 39 (2010), 629-36. [21] A. Khorram-Manesh, et al., Prehospital triage, discrepancy in priority-setting between emergency medical dispatch centre and ambulance crews, European Journal of Trauma and Emergency Surgery 37 (2011), 73-78, www.springerlink.com/content/n260l70380m154t6/?MUD=MP. [22] A. Khorram-Manesh, et al., Estimation of healthcare resources at sporting events, Prehospital and Disaster Medicine 25 (2010), 449-455. [23] Sten Lennquist, Education and training in disaster medicine, Scandinavian Journal of Surgery 94 (2005), 300-310. [24] R. Arafat, H. Askitopoulou, F. Della Corte, et al., Core curriculum in emergency medicine, European Journal of Anaesthesiology 25 (2008), 690-1. [25] A. Khorram-Manesh and B. Pourseidi, Management of traumatic liver injuries without a valid trauma system, Prehospital and Disaster Medicine 24 (2009), 349-355. [26] A. Khorram-Manesh, et al., Regional coordination in medical emergencies and major incidents; plan, execute and teach, Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 17 (2009), 32. [27] A. Khorram-Manesh, et al. Hospital-related incidents; causes and its impact on disaster preparedness and prehospital organisations, Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 17 (2009), 26. [28] Paul Richards, The social dynamics of humanitarian action, Disasters 34, supplement S2 (2010), S138S146. [29] E. W. Anderson, Geopolitics: International boundaries as fighting places, Journal of Strategic Studies 22 (1999), 125-136. [30] P. Bourdieu, La force du droit, Actes de la recherche en sciences sociales 64 (1986), 3-19. [31] Alex de Waal, The humanitarians’ tragedy: Escapable and inescapable cruelties, Disasters 34 special issue (2010), S130-S137. [32] E. Teruel, G. Franceschinis, and M. De Pierro, Well-defined generalized stochastic Petri nets: A netlevel method to specify priorities, IEEE Transactions on Software Engineering 29 (2003), 962-973. [33] L. Tia, J. Szarzynski, and P. Vlek, Ecological modeling of tree patterns and diversity as a means of classifying savanna landscapes: Remote sensing and GIS-based mapping, Geophysical Research Abstracts 9 (2007). [34] United Nations Disaster Assessment and Coordination Handbook, 2006. [35] H.J. Bail and S. Ruchholtz, Katastrophenmedizin in der Bundesrepublik Deutschland: Das Netzwerk Katastrophenmedizin der DGU, Trauma und Berufskrankheit 9 (2007), 279-283. [36] G.E. Cummings, F. Della Corte, and G.G. Cummings, Disaster medicine education in Canadian medical schools before and after September 11, 2001, Canadian Journal of Emergency Medicine 7 (2005), 399-405. [37] B.D. Domres, H. Peter, et al., European survey on decontamination in mass casualty incidents, American Journal of Disaster Medicine 4 (2009), 147-52. [38] P. Fischer, C. Burger, et al., Preparedness of German paramedics and emergency physicians for a mass casualty incident: A national survey, European Journal of Trauma Emergency Surgery 34 (2008), 443-50.

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[39] J.M. Franc Law, P.L. Ingrassia, L. Ragazzoni, and F. Della Corte, The effectiveness of training with an emergency department simulator on medical student performance in a simulated disaster, Canadian Journal of Emergency Medicine 12 (2010), 27-32. [40] Elke Grawert, The aid business in South Sudan after the Comprehensive Peace Agreement, in HansHeinrich Bass, et al., eds., Economic Systems in a Changing World Economy, Lit Verlag, Berlin, 2007, 387-402. [41] Elke Grawert, Cross-border dynamics of violent conflict: The case of Sudan and Chad, Journal of Asian and African Studies 43 (2008), 595-614.

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Handbook for Pandemic and Mass-Casualty Planning and Response E. Gursky and B. Hrečkovski (Eds.) IOS Press, 2012 © 2012 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-61499-135-9-31

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Pandemic Planning & Response Natalia VYNOGRADa, Lela BAKANIDZEb, Ante CVITKOVIc, Igor IVIC-HOFMANd a Professor, DMS, Chief of Epidemiology Department, Danylo Halytskiy Lviv National Medical University, Ukraine b Ph.D., Georgian Biosafety Association, Tbilisi, Georgia c Director of Institute of Public Health Brod Posavina County, Slavonski Brod, Croatia d Spec. Epidemiologist, Institute of Public Health Brod Posavina County, Slavonski Brod, Croatia

Abstract. There is a real potential for highly pathogenic and novel strains of pandemic influenza. In this chapter, new data on influenza and on the clinical and epidemiological characteristics of subtypes of viruses (H1N1)pdm09 and HPAI H5N1 are presented. Modern standards of organizing epidemiological surveillance on influenza, corresponding to International Health Regulations (2005) requirements across the pre-pandemic period, phases of pandemics, and post-pandemic period, are shown. Keywords. Influenza, (H1N1)pdm09, HPAI H5N1, epidemiology, clinic, treatment, pandemics, preparedness & response, surveillance, monitoring

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Introduction Influenza remains a global problem in the 21st century, in spite of scientific achievements and efforts of the scientific community worldwide focused on reducing its threat. International cooperation is critical to reducing the burden of flu epidemics and pandemics on the public and depends upon the control of, prognosis of, and response to epidemiological complications related to new and unknown varieties of flu virus[1, 2, 3]. According to the World Health Organization (WHO) and 2005 International Health Regulations recommendations, new, previously unknown variations of virus have penetrated the human population—a situation considered an emergency of international importance in public health[4]. The medical and social importance of flu, along with the economic burden from both seasonal outbreaks and the unpredictable emergence of virus, reveals the urgency of the issue. During seasonal epidemics, about 5% to 20% of the global population is infected, while in comparison, during pandemics the rates of morbidity and mortality increase 3 to 5 times. During seasonal epidemics, most flu cases have mild clinical manifestation, and moderate and severe presentations of illness are seen primarily in children, the elderly, and people with chronic diseases. During pandemics, the number of severe occurrences increases in lethality, and risk groups are altered. Among known subtypes of flu A virus, H1N1 and H5N1 are of the most concern and represent probable strains with high epidemiological potential for causing pandemics[1, 5].

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Three conditions are necessary for emerging pandemics: x High susceptibility of the population to the new subtype of the A flu virus (absence of herd immunity in the population) x Ability of the virus to reproduce in the human organism and high potential of pathogenicity x Easy transmission of the causative agent from human to human

1. Flu as a planetary problem

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Influenza viruses belong to the family Orthmyxoviridae and, according to different specific nucleoproteid antigens, are divided into three types: influenza viruses A, , and . The morphology of all three types is similar: these are round or oval particles with a diameter of 80 to 120 nm, although in some cases it can be changed. The main antigens of the influenza A virus are surface glycoproteins: hemagglutinin (16 subtypes) and neuraminidase (9 subtypes), antibodies to which secure protective immunity. The most important for humans are three main hemagglutinins (1, 2, and 3) and two neuraminidases (N1 and N2), though 2011 saw infection of humans with subtypes with hemagglutinins 5, 7, H9, and 11. Influenza  viruses are not divided by subtypes, though they are variable as well, and they circulate efficiently among humans. Influenza  viruses do not cause epidemic implications of significant levels and affect mainly children. The ecology of influenza A viruses is quite fully studied. Influenza A viruses circulate among many mammals (horses, pigs, dogs, etc.) and birds, and they are a source of the causative agents for humans; birds, especially waterfowl, are a natural reservoir.

1

5

Figure 1. Ecological relations of influenza A viruses.

Interspecies transfer stimulates rapid evolution of the influenza A virus, which manifests itself in changes in the level of pathogenicity and antigenic features as a result of mutations or reassortment of genes. Some authors assume that actual epidemic and pandemic strains are formed in the countries of Southeast Asia, where the density of birds is high and the conditions necessary for passing viruses through mammals (pigs) are prevalent. Continuous transfer of different subtypes of the virus by birds during seasonal migration by 14 stable migration routes also facilitates this process.

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Different subtypes of viruses are introduced by the same transcontinental and inland routes, and among these subtypes highly pathogenic strains of influenza AH5N1 (HPAI H5N1) are of the biggest concern. Epidemic variations of influenza A virus are formed as a result of point mutational processes or reassortment of genes. Some authors promote the theory of cyclicity of pandemics, as evidenced by the return of some subtypes of influenza A virus every 60 years. Flu epidemics occur every 2 to 3 years, while epidemics occur every 10 to 50 years. Figure 2 shows that pandemics occurred on the planet in the 19th through 21st centuries, caused by subtypes of viruses, and that new subtypes of influenza A virus penetrated the human population during recent years. Each time, flu pandemics were caused by new subtypes of influenza virus, formed in the process of genetic transformation: in 1957 and 1968 as a result of reassortment, and in 1918 by direct transfer from birds to humans. After the pandemics, the viruses were still circulating as seasonal strains. Each pandemic had novel attributes: severity of the illness, lethality (case-fatality ratio), reproductive number (R0), attributable excess mortality worldwide, and age groups most affected (simulated attack rates). H2N2

H2N2

H1N1

H1N1 H3N8 1895 1905

1889 Russian influenza H2N2

1915

Pandemic

H1N1

H3N2 1925

1900 Old Hong Kong influenza H3N8

1955

1918 Spanish influenza H1N1

1965

1957 Asian influenza H2N2

1975

1985

1995

New human subtypes discovered

H5 Copyright © 2012. IOS Press, Incorporated. All rights reserved.

2010

2015

H9* 1999 H7 1980

1955

2005

2009 Pandemic influenza H1N1

1968 Hong Kong influenza H3N2

1965

1975

1985

1997 2003 1996

1995

2002

2005

Reproduced and adapted (2009) with permission of Dr Masato Tashiro, Director, Center for Influenza Virus Research, National Institute of Infectious Diseases (NIID), Japan.

Figure 2. Flu pandemics in the 19th to 21st centuries and subtypes of virus causing them.

The flu pandemic of 1918-1920 (“Spanish flu”) was caused by influenza A virus H1N1. According to different investigators, more than 500 million people were affected worldwide, mainly the young population, among whom 20 million to 50 million died. The case fatality ratio was 2% to 3%, and the reproductive number (R0) was 1.54 to 1.83[6]. In 1957-1958 about 20% to 50% of the global population was affected by “Asian flu,” though this time significantly fewer people died (1 million to 4 million), and other indices were lower compared to previous pandemics: the case fatality ratio was < 0.2%, the R0 was 1.5, and mainly children got ill. In 1968-1969, a pandemic spread globally, and all age groups were affected; 1 million to 4 million people died (the case-fatality ratio was < 0.2%, and the R0 was 1.28 to 1.56). Virus H3N2, which caused this pandemic, still circulates.

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In 1977-1978 the virus H1N1 returned, but its morbidity and spread did not reach pandemic indices. The virus still circulates and, according to the results of typing, four types are still circulating: one endemic for humans, one avian, and two swine. Infection of humans with HPAI H5N1 (“avian flu”), with high rates of mortality, is of biggest concern, especially its rapid spread in 67 countries of Asia, Europe, and Africa, where it still circulates in spite of strict preventive measures, as the strain is considered a potential pandemic one if the readiness of transfer between humans increases[7]. In March 2009, a flu virus started circulating in the territory of Mexico[8]. It initially was called “swine flu,” and later “flu  virus (H1N1)2009,” but beginning in October 2011 its recommended abbreviation was (H1N1)pdm09[9]. Circulation of the new virus was confirmed on 18 March, and on 13 April the first lethal case of this virus was registered. This was the dawn of a new pandemic, and it was announced by WHO on 11 June 2009. It is present in six WHO regions and has spread globally[10]. By October 2010, 214 countries had reported laboratory-confirmed human cases of pandemic flu  (H1N1)pdm09. The pandemic strain was the fourfold reassortant of flu A virus, containing fragments of genomes of classic swine flu strain of the North American line (HA, NS, NP), avian flu virus H5N1 of the North American line (PB2, PA), human seasonal flu virus H3N2 (PB1), and swine flu virus of the Eurasian line (NA, MP). The prototype strain was flu virus A/California/04/2009[11]. WHO had accepted a two-step case definition: confirmed and probable. A confirmed case was flu-like illness (increased body temperature + shortness of breath or dyspnea) with laboratory verification by rRT-PCR or virus isolation. A probable case was flu-like illness with confirmed flu A, but negative for human H1 and H3 in rRTPCR[12]. Once hyperendemic levels of infection became prevalent across populations, laboratory verification of each case halted; laboratory investigation was limited to studying the features of the circulating strains, not to confirm or rule out infection. The absence of laboratory-confirmed verification limited understanding of the true scope of the disease burden.

2. Epidemiological and clinical peculiarities of flu  (H1N1)pdm09 and HPAI H5N1 2.1. Epidemiological peculiarities of pandemic flu  (H1N1)pdm09 The source of flu  (H1N1)pdm09 is humans infected with the virus, with or without clinical manifestation of the illness. The period of human infectiousness is determined by period of virus release: it starts 1 day prior to manifestation of symptoms of the illness and can continue up to 7 days, but some individuals—especially small children and people with immunodeficiency—shed the virus longer. The greatest release of virus is in the beginning of clinical manifestation (2 to 3 days) and correlates with the length of fever[13, 14]. Like other flu viruses, the pandemic strain had high potential for variability, requiring continual monitoring of isolated strains to determine changes in virulence and resistance to standard antiviral preparations (such as oseltamivir). “Norwegian-type”

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mutations in neuraminidase (H276Y) were found in August 2009. Later, other mutations of pandemic strains were detected in hemagglutinine (D222G, D222E, D203T, T504C, P297S, G155E) and polymerase 2 (K340N). It was shown that resistance to oseltamivir, determined by mutation H276Y, was seen in 0.33% to 5.5% of patients. From analysis of 264 strains with mutation H276Y, it was determined that 25% of them occurred as a result of treatment with oseltamivir, 6% occurred while patients were getting the medicine for prophylaxis, 22% were associated with the patient’s severe immunodeficiency, in 7% causes were not found, and in 40% investigations are still ongoing[15, 16]. The virus is transmitted by airborne mode (large-drops and small-drops versions of transfer) and by contact with contaminated objects. In both ways the portal for the virus is the mucous membranes of the eyes, nose, mouth, and nasopharynx. In the first scenario, viruses were spread by droplets created during breathing, talking, sneezing, coughing, and aerosol-generation procedures. In these cases, small dispersed “core” particles spread via turbulent air. In the contact household mode, infected objects— such as medical supplies, mobiles, hands, and horizontal surfaces—transmitted viruses[17]. The period of virus survival on hard surfaces was about 72 hours; on soft surfaces and furniture, up to 24 hours; on hands, about 5 minutes. The causative agent was inactivated with detergents, and by standard disinfectants containing alcohol and chlorine in 30 seconds. Susceptibility of the population to the pandemic strain correlated with racial features and age; in addition, there were groups at medical risk of emerging severe clinical forms and complications[18]. As with severe acute respiratory syndrome, medical workers were the group associated with professional risk. Local ethnic groups from the far north, Australia, and other territories were found to be at special risk[19, 20, 21]. The age group at greatest risk were persons of 5 to 29 years, while people older than 65 years showed the lowest morbidity indices. About a third of people older than 65 years, not belonging to the risk group for infection with (H1N1)pdm09, had antibodies to H1N1, and that maybe can explain lower indices of infection with the pandemic strain[22]. Among patients, persons of young age predominated (figure 3). Two specific groups were, for the first time, at medical risk from H1N1: pregnant women (especially in the third trimester) and people with obesity.

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22.9

26.7

25 20 15 6.97

10

3.92

5

1.3

0

04

524

2549

5064

> 65

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Figure 3. Distribution of patients with flu  (H1N1) 2009 by age.

The mean age of patients with laboratory-confirmed cases was 12 to 28 years; inpatients, 20 to 36 years; and patients in intensive-care units (ICUs), 36 to 46 years. Lethal cases occurred among patients of 35 to 51 years of age. Lethality among children was higher in boys, but in adults a statistically significant difference in sex was not found; only in the elderly was this index higher among women. Among lethal cases 2.3% were children, and 4.0% were over 65 years[23]. A special group demonstrated by high indices of lethality from pneumonia were children under 2 years. Groups at increased risk of infection were patients with chronic respiratory diseases, chronic cardiovascular diseases, chronic metabolic diseases (especially diabetes), chronic renal and hepatic diseases, immunodeficiency (inherent or acquired), respiratory diseases, neurological or neuromuscular situations, other situations with later immunity disorders, respiratory dysfunction (asthma), affected locomotor apparatus (arthritis), and obesity, as well as pregnant women[18, 24, 25]. The index of focality in families was 7% to 13%, while in organized children’s communities (schools) on average about 2.4 new cases arose from one person. In the first and second waves in different countries, 7.8% to 16.9% of the population was involved[26]; in Ukraine this index was 16.7%. The mean duration of the second wave of the pandemic was about 7 to 9 weeks; in Ukraine it lasted from October till December (figure 4).

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Figure 4. Dynamics of flu morbidity and acute respiratory viral infections in Ukraine, fall 2009. Handbook for Pandemic and Mass-Casualty Planning and Response, IOS Press, Incorporated, 2012. ProQuest Ebook Central,

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In Georgia the number of flu cases increased significantly compared with previous years. The number of hospitalized cases increased twice from 2008; 76% of cases were children under 17 years of age (table 1). Table 1. Hospitalized cases of flu-like disease by age groups

Years 2005 2007 2008 2009

Total 469 5,098 7,005 13,656

40 kg and adults: 75 mg 2 times per day An alternative medicine was zanamivir (Relenza)[31]. A very important component of treatment is oxygen therapy. Lethality was reduced and quicker recovery was seen when light phasic ventilation with small breathing volumes under blood saturation control was applied, along with short-term mechanical ventilation, limited consumption of liquids, perfect oxygenation, inhalation of nitrogen oxide, and extracorporeal membranous oxygenation. Complex therapy was carried out using angiostabilizing preparations, sphygmic therapy, corticosteroids (by life evidence), nonsteroid antiinflammatory preparations, antibiotics, antihistamines, and diuretics according to treatment protocols.

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The first case of HPAI H5N1 human-to-human transmission in family foci was detected in Thailand in January 2004. Cases were found later in other countries of Southeast Asia too (Indonesia, China, Afghanistan, etc.)[36, 37]. This was the reason for announcing pandemic phase 3, taking into consideration the etiological agents for the next pandemic[38]. By March 1, 2012, 590 human cases of avian flu were documented in 15 countries; 349 of the cases were lethal. Most of the infected people were detected in Indonesia (186 cases), Egypt (163 cases), and Vietnam (121 cases)[39]. In most cases the source of infection for humans was diseased or dead poultry. In 2006, the first group human cases occurred, when the sources of infection were humans infected with HPAI H5N1. Transmission of HPAI H5N1 to humans was seen through oral-fecal, direct contact, and air routes. Factors of transmission can be water, chicken meat or eggs, insufficiently thermally processed food, equipment, and clothes. Feces of diseased or clinically healthy birds are of high potential danger, as are the fluff or feather of waterfowl or moorfowl. Chickens in incubators can be infected if contaminated eggs are damaged[40]. Disease cases are registered during the year, and in cold seasons their number increases, which correlates with outbreaks of epizootics among birds. Group cases of the disease cover 2 or 3 up to 8 persons; predominantly these are family foci. The peculiarity of avian flu is that it predominantly affects children and young people: the mean age is 15 years, more than half of patients were under 12 years, and about 4% were under 40 years. The highest lethality was observed in the age group 10 to 19 years; the lowest indices were in persons over 50 years. The infectious period starts the day before clinical manifestation of the illness, lasts through the whole period of clinical manifestation, and can continue in the period of convalescence. The probability of infecting humans correlates with the length of contact with contaminated objects and the dose of pathogen. Risk groups during the period of epizootics are local populations, professional groups (medical staff, veterinarians, biologists, ecologists), and hunters. 2.3. Epidemiology of HPAI H5N1 The incubation period on average is 7 days or less, mostly 3 to 5 days. The last figure was characteristic for cases of human-to-human transition, though in one focus an incubation period of 8 to 9 days was established. At present the ratio of mild, moderate, and severe clinical forms in human population is not clearly defined[41]. According to WHO experts’ data, the initial period of illness during HPAI H5N1 infection clinically is similar to one during infection with A flu viruses with hemagglutinins H1-H3. Syndromic complex during avian flu includes[42] x Increase of body temperature to 38 and higher (98%) x Symptoms affecting the respiratory tract: cough (88%), dyspnea (68%), rhinorrhea (55%), pharyngitis (52%) x Symptoms affecting the gastrointestinal tract: diarrhea (39%), abdominal pain (23%), vomiting (31%) x General intoxication symptoms: headache (28%), myalgia (29%)

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As opposed to seasonal flu, primary flu-related pneumonia and polyorgan affections appear, which is the reason for high lethality. A high percentage of lethality in groups of patients with severe forms is established, and it varies from 30% to 100%. By March 2012, according to WHO data, lethality on average was 59.15%. The duration of the disease with lethal outcome was 9 to 10 days. Temporary recommendations were determined for diagnosing “avian flu,” aiming to standardize reporting the disease cases to WHO. Diagnosis considers staging with definitions of suspected probable and confirmed cases by clinical, epidemiological, and laboratory diagnosing data[43]. Suspected case of infection with HPAI H5N1 virus (corresponds to stage 3 according to WHO classification): x Clinical finding: severe respiratory illness (SRI) of the lower respiratory tract of unknown etiology with increased temperature > 38, with cough or dyspnea x Epidemiological criteria: 7 days before disease manifestation, contact within 1 meter with a person with a suspected, probable, or confirmed case of virus  HPAI H5N1 infection:  Contact with domestic or wild birds, their remains, or an environment contaminated with their feces in regions with confirmed or suspected cases of infection of animals or humans with  HPAI H5N1 virus during the last month  Consuming raw or insufficiently thermally processed products of aviculture in regions with confirmed or suspected cases of infection of animals or humans with  HPAI H5N1 virus during the last month  Close contact with animals with confirmed infection with  HPAI H5N1 virus  Working in a laboratory or other place with samples possibly contaminated with  HPAI H5N1 virus Probable case of infecting with HPAI H5N1 virus (subject to reporting to WHO): A person corresponding to the criteria of a suspected case and one of following additional criteria: x Infiltrates or signs of acute pneumonia in an X-ray with symptoms of respiratory impairment (hypoxia, accelerated respiratory rate) x Laboratory-confirmed existence of flu A infection, or insufficient evidence for laboratory confirmation of HPAI H5N1 infection x Dead from unknown acute respiratory infection that is epidemiologically connected in time, place, or contact with probable or confirmed flu  HPAI H5N1 Probable case of HPAI H5N1 virus (subject to reporting to WHO): A person correlating to the criteria of a probable or suspected case with positive results from a laboratory at a national, regional, or international level, the results of which WHO accepts as positive: x Virus isolation from clinical samples from a patient in chicken embryos of 9 to 11 days with further identification in hemagglutinin inhibition reaction (HAIR) and/or immuneprecipitation in agar, and/or identification of a virus subtype in microneutralization reaction using monospecific antisera, studying pathogenicity of isolates by intravenous inoculation in chicken 4 to 8 weeks old, calculating intravenous index of pathogenicity (IIP). For highly pathogenic strains, IIP up to 8 days must be 75% and higher.

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x x x

Detection of HPAI H5N1 virus RNA in rRT-PCR using two different PCR targets. Fourfold and higher increase of HPAI H5N1 neutralizing antibodies titres in paired blood sera. Titre of neutralizing antibodies in blood serum in the convalescence period must be 1:80 and higher. Titre of antibodies to HPAI H5N1 in a microneutralization reaction 1:80 and higher unpaired blood serum, sampled on the 14th day of the disease or later and positive result using other serological method, e.g., HAIR with equine erythrocytes with titre 1:160 and higher, or positive result in 5-specific western blot[44, 45].

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In- and outpatients must be investigated in these cases: x Detection of a suspected or probable flu  HPAI H5N1 case x Unknown death from SRI (pneumonias or respiratory diseases with acute onset) x Two or more cases of SRI with onset of the disease within 14 days among persons living together x Registration of SRI among health care system workers, taking care of or treating other patients with SRI For diagnosis verification, blood sera; bronchoalveolar washouts; washouts from nasopharynx, phlegm, pleural fluid, whole blood; and autopsy material are used. Samples to be investigated are transported to laboratories at –20°, maintaining biosafety requirements for risk group III[46]. It was established that the antiviral preparations amantadine, remantadine, oseltamivir, and zanamivir can be used for prophylaxis and treatment of A avian flu. But in 2004 some HPAI H5N1 strains were isolated that were resistant to amantadine and remantadine[47]. Pathologicoanatomic investigation data showed that death of patients from avian flu was determined by primary polysystemic and polyorgan destructions, and not by secondary ones, as happens during seasonal A flu. In a pandemic caused by HPAI H5N1, if the virus still has pathogenicity potential, predictive lethality among persons with severe forms of the illness will vary from 15% to 85%, which in absolute figures will equal from 7.4 million to 40 million lives. All these gave specialists a basis to draw a parallel between the 1918 Spanish flu pandemic and a possible HPAI H5N1 pandemic.

3. Influenza surveillance 3.1. WHO Global Influenza Surveillance Network One main strategic goal in global health care is prevention and control of flu pandemics and annual flu epidemics. In 1948, the first Global Center for Flu Control was established at the Communicable Disease Center (later the Centers for Disease Control and Prevention) in Atlanta, USA. This was a prototype of the modern WHO Global Influenza Surveillance Network, consisting of 131 National Influenza Centers in 105 countries globally, five highly specialized global reference centers (WHO Collaborating Centres), and three national agencies for licensing (Essential Regulatory Laboratories)[48].

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The main goal of surveillance is continuous clinical, virological, and global epidemiological tracking and detecting urgent flu strains, which is important for x Prognosing development of epidemiological trends x Developing and producing vaccine for the forthcoming epidemiological season x Ensuring early detection of pandemic variants of the causative agent and affected territories[49] National Influenza Centers sample, identify, and analyze circulating strains isolated from clinical samples and transfer unusual isolates of viruses to WHO Collaborating Centres for detailed characterization. National Influenza Centers using FluNet also submit weekly reports on flu’s geographic spread and the intensity of epidemiological processes, taking into account threshold levels in control centers of population in each country[50]. 3.2. Periods and phases of influenza pandemic

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According to WHO recommendations[51, 52], activities including preparedness, communication, epidemiological surveillance, detection, response, and control of pandemic flu are reasonable to consider in three-hour intervals: x Before the beginning of the pandemic (1-4 phases) x Pandemic period (5-6 phases) x Period of decline and subsiding of the pandemic (decline and post-pandemic) According to recommendations, three periods and six main phases are characteristic of new flu pandemics. For all of them criteria are determined. The first period, interepidemiological, has two phases. In the first, new subtypes of the flu virus do not circulate in human and/or bird populations, but the subtype of flu virus causing disease among humans, animals, or birds can circulate. In such cases it is considered that the risk of getting the disease or infecting humans is low. During the second phase, there are new subtypes of flu virus among humans, but the subtype circulating among animals can carry risk of causing the disease among humans. The second period, the pandemic threat period, is divided into three phases. The third phase (following the two phases in the first period) is characterized by a flu case (or cases) in humans, caused by a subtype of A flu virus, but its human-to-human transition is absent, though sometimes it’s possible, particularly in case of close contacts. The fourth phase is connected with the formation of small (by number of persons) groups (clusters) and limited spread of the virus from human to human. The fifth phase is characterized by progressive increase (by number) of groups (clusters) of infected persons, but the circulation of the virus is limited, though its ability to spread among humans increases (creating a significant risk of pandemic). Third period, pandemic, has only one phase. This sixth phase is characterized by pandemic features—intense spread and maintenance at high levels of morbidity among the population of the region, some countries, a continent, or globally. According to WHO, the leading counterepidemic measures in pandemic prevention in each country must be an effective system of epidemiological and epizootological surveillance, virological monitoring, and introducing large-scale programs of flu immunoprophylaxis, chemoprophylaxis, and chemotherapy[22].

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Assuming that pandemics cannot be prevented, it is necessary in each country to assure preparedness for reducing their rate of development, lethality, and social and economic losses.

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3.3. National plans of pandemic preparedness WHO, aiming to be prepared for new flu pandemics, initiated the establishment of National Pandemic Plans in each state and their implementation. The plans enable organization of adequate measures for reducing the burden of losses for the system of health care, society, and the economy as a whole[2, 3, 53]. Here the important element is to enhance national epidemiological, surveillance and laboratory capacities, along with early reporting of outbreaks of human or zoonotic flu. The system of response must ensure methods for preventing and controlling virus penetration in the country, early detection and identification of influenza that has pandemic potential, and timely development and production of flu vaccine from the pandemic flu virus strain. Higher priority is given to qualified and operative virological (laboratory) surveillance of the circulation of seasonal strains of flu virus, which allows timely detection of virus variants with pandemic potential[54]. Another important element is acquiring the stock of prophylactic and treatment preparations, personal protective and ancillary equipment, materials, and diagnostic kits; to sustain these efforts the source and speed of financing must be clearly defined. The stock must include x A strategy for the systemic prophylaxis for large groups of population and categories of professional risk x Drugs for urgent influenza prophylaxis in infection foci and early specific flu therapy (specific immunoglobulins and antiviral preparations, such as oseltamivir) x Drugs for patients in the acute phase of the disease x Drugs for patients with symptoms of dyspnea and life-endangering complications x Drugs for symptomatic treatment: antipyretics, vasodilatings, drugs for normalizing angienchyma, anticonvulsives, diuretics, and drugs for preventing hemorrhagic syndrome x Antibiotics Optimization of the monitoring system must assure continuous monitoring of the trends and level of morbidity in order to institute immediate preventive and antiepidemic measures in the most affected subgroups of the population. The approaches must be unified by general principles of immunoprophylaxis. Efforts to reduce morbidity through timely and effective prophylaxis and early treatment must be supported through diagnostic and treatment protocols. It is necessary to anticipate the capabilities of the services responsible for life sustenance in the territory and population during epidemiological complications of significant scope, with timely gathering and submitting of the information. It is important to calculate the manpower, among them medical staff, taking into account the relevant morbidity of the whole population and persons needing hospitalization, including those in ICUs, using single-lung ventilation systems. Interagency coordination must assure maximal control of pandemic spread and reduce social and economic losses.

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Inter-pandemic periods are the time to reach full regional and national preparedness for flu pandemics at levels: x Establishing functioning interagency committees for combating flu and preventing pandemics x Assessing predictable levels of pandemic severity x Calculating possible expenditures and losses x Enhancing the flu epidemiological surveillance system among humans and animals (birds) x Determining territories at risk of importing pandemic flu strains x Monitoring circulating strains x Establishing national and regional stocks of necessary material resources, among them antiviral preparations; algorithms of decision making on their use must be drawn x Increasing coverage of the population with immunoprophylaxis using seasonal flu vaccines x Determining groups of increased risk x Preparing the personnel (clinicians, epidemiologists, laboratory staff) and population in the issues of pandemic response

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After developing and finalizing plans, it is important to frequently check their implementation and status. The system of epidemiological and epizootological surveillance of avian flu, as well as preventive and counter-epidemiological measures, is continuously improved by experts at WHO, the UN Food and Agriculture Organization, and the World Organisation for Animal Health (Office International des Épizooties, or OIE). These international organizations have established a global system of early notification and containment measures for transborder diseases in animals. Also very important in inter-pandemic periods are scientific studies aiming to prepare new generations of vaccines, along with certification of regulations for faster registration and permitting their application in case of pandemics. Another important area is the search for new, effective antiviral preparations and disinfectants. 3.4. Epidemiologic and disease control strategies during pandemic periods These are the basics of infection control: x Early and rapid detection of patients with flu x Maintaining standard measures of protection of personnel while taking care of patients x Maintaining special measures while taking care of patients with suspected or probable flu diagnosis x Establishing infrastructure for infection control in health care facilities x Supporting measures of infection control During a pandemic, independently from the intensity of the epidemiologic process, the government of the country must lead and coordinate the activities of all governmental, nongovernmental, and private-sector organizations involved in reducing morbidity and mortality, supporting the effectiveness of the health care system, and reducing the negative impact of pandemics on society and the economy[55, 56]. During the period of pandemic threat (phase 5), measures must be directed towards early isolation of the new flu virus strain, investigating its antigenic properties and

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resistance to chemopreparations and environmental factors, with confirmation in WHO reference laboratories; timely investigation of flu cases; and carrying out measures for preventing new cases of human infection. During the pandemic period, the activity of all governmental and nongovernmental institutions and the private sector, independently from their departmental subordination, is directed towards minimizing the consequences of flu spread by means of introducing organizational epidemiological and other disease mitigation measures for social protection of the population: x Identify the issue of setting emergency limits (quarantine) x Forecast an operative prognosis of trends in the pandemic flow x Estimate losses x Determine needs for additional resources x Predict potential development of further waves of the pandemic x Correct existing plans x Assure continuous virological monitoring x Carry out retrospective operative analysis x Adjust institutions’ personnel and material provisions in accordance with reality

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To optimize and standardize operative analysis of pandemic development and sufficient response in different countries and regions, WHO has recommended the following indices[55, 57]: x The number of diseased people who seek medical care for flu-like disease (the tendency of increase in disease cases) x The number of hospitalized persons with pneumonia; the number of deaths due to pneumonia, among them pediatric x Geographic spread x The antigenic structure of viruses and assessment of their sensitivity to antiviral preparations Enhanced epidemiological surveillance implies daily monitoring of pandemic activity in administrative territories using these indices. In assessing the real epidemiological situation, standardized qualitative indices are recommended by WHO[22]: x Geographic spread refers to the number and distribution of sites reporting influenza activity:  No activity: no laboratory-confirmed case(s) of influenza or evidence of increased or unusual respiratory disease activity  Localized: limited to one administrative unit of the country (or reporting site) only  Regional: appearing in multiple but fewer than 50% of the administrative units of the country (or reporting sites)  Widespread: appearing in at least 50% of the administrative units of the country (or reporting sites)  No information available for the previous 1-week period

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x

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x

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Trend refers to changes in the level of respiratory disease activity compared with the previous week.  Increasing: evidence that the level of respiratory disease activity is increasing compared with the previous week  Unchanged: evidence that the level of respiratory disease activity is unchanged compared with the previous week  Decreasing: evidence that the level of respiratory disease activity is decreasing compared with the previous week  No information available The intensity indicator is an estimate of the proportion of the population with acute respiratory disease, covering the spectrum of disease from influenza-like illness to pneumonia.  Low or moderate: a normal or slightly increased proportion of the population is currently affected by respiratory illness  High: a large proportion of the population is currently affected by respiratory illness  Very high: a very large proportion of the population is currently affected by respiratory illness  No information available Impact refers to the degree of disruption of health-care services as a result of acute respiratory disease.  Low: demands on health-care services are not above usual levels  Moderate: demands on health-care services are above the usual demand levels but still below the maximum capacity of those services

For monitoring it is important to have high-quality data on the dynamics of the process in the population, its severity, and features of circulating strains. At the stage of mass infection of the population with the pandemic strain, it is recommended to halt laboratory verification of each case of disease and limit laboratory investigations to studying the features of circulating strains. The diagnosis can, instead, be based on clinical data and epidemiological links between cases[26]. At R0 > 2 and higher it is most reasonable to calculate a pandemic severity index by mortality indices (case fatality rate) using algorithms worked out by the CDC: category 1 = < 0.1%; category 2 = > 0.1% but < 0.5%, category 3 = > 0.5% but < 1.0%; category 4 = > 1.0% but < 2.0%; category 5 = > 2.0% [48]. Interruption of routine social networks should be instituted according to the pandemic severity index, presented in figure 8.

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Figure 8. Strategies of social interference according to the Pandemic Severity Index of the U.S. Centers for Disease Control and Prevention[58]. Handbook for Pandemic and Mass-Casualty Planning and Response, IOS Press, Incorporated, 2012. ProQuest Ebook Central,

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The most effective measure of influence on the epidemiological process is limitation—isolation in social groups of the population[59]. Quarantine in affected administrative territories includes halting studies at schools and other educational institutions; stopping work at preschool and children’s care units (limited attendance), and prohibiting mass gatherings at public events—at sports arenas and movie theaters, for example. The population is given the recommendation to limit movement and avoid crowded areas[60, 61]. 3.5. Antiepidemic measures Antiepidemic measures from the moment of threat and beginning of the pandemic contain three important blocks: x Information supply x Prevention and alleviation x Epidemiological surveillance

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3.5.1. Information supply Information supply is an important part of preventing exposure of target risk groups (medical workers) and of total population and for preventing panic and fear in emergencies[62]. It is reasonable to exploit all types of mass media (TV, radio, printed sources, postcards) for spreading information about actions taken to reduce the rate of virus transmission among the population. The population must be given brief information on the key facts and means of individual protection: cover the nose and mouth with a handkerchief or facial tissue while coughing or sneezing; wash hands; don’t touch eyes or nose; stay at home if you are sick; avoid close contacts (up to 1.5 m) with persons having signs of respiratory illness. Medical workers are given additional instructions: x Use personal respiratory protective equipment (a respirator with 95% protection) or surgical mask, as well as protection for the eyes (glasses, shields) and hands (disposable gloves) x Wash hands using soap and use alcohol-containing disinfectants x Use personal protective clothing while evacuating patients and in admission rooms, ICUs, infectious disease hospitals, therapeutic departments, pediatrics, morbid anatomy units, and forensics departments x Maintain an enhanced antiepidemic regime with wet cleaning, aeration, and use of 1% to 3% chlorine solutions x At the first manifestation of disease signs, start specific chemotherapy with oseltamivir (Tamiflu) If an active pandemic flu vaccine exists, it would be appropriate to carry out immunoprophylaxis with priority groups at professional and medical risk. Chemoprophylaxis using oseltamivir is impractical because of resistance to the medicine[63]. In crowded public places (transport, shopping centers, etc.) twofold wet cleaning using chemical disinfectants is recommended. Medical institutions should shift to a strict regime of enhanced antiepidemic measures. Starting isolation of patients and introducing quarantine for persons contacting them can result in chaos in the society. Patients with mild clinical forms can be treated and cared for at home, whenever possible. Supportive care includes bed rest, taking

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liquids, following an antibiotic regime, and sufficient feeding. Patients from risk groups or patients with a severe form of the disease must be hospitalized. It is important to institute timely isolation of diseased people and limit their movement[51]. 3.5.2. Prevention and alleviation

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Prevention and alleviation of pandemic flu in communities with limited resources: To prevent infection of medical and supporting staff, patients, visitors, volunteers, medical students, etc., having direct contact with patients in health care facilities, and to prohibit exposure of the causative agent from these institutions, it is necessary to establish sufficient control measures[64, 65]. Maintaining infection control is obligatory at all levels and stages of providing hospital care to the population: transportation of patients, admission rooms, ICUs, etc. Infection control must include these priority measures: reducing the number of potential sources of the infection-causing agent, technical control, administrative control, and personal protective equipment (PPE). Reducing the number of potential sources of the infection-causing agent is the first among antiepidemic measures. This category includes x Minimizing visits to health care facilities by persons having a mild clinical course of the disease and not belonging to any risk group by virtue of complications x Ceasing planned visits to ambulatories and polyclinics by persons with suspected or confirmed flu cases until they stop releasing virus into the environment x Prohibiting the presence of visitors with signs of acute respiratory viral infections in health care facilities Technical controls, including control of the environment in health care facilities, is second among these measures, as they reduce or eliminate contact with the source of infection and can be implemented without a human factor. Technical control elements protect personnel as well as patients: x Arranging barriers at the stage of triage and other public places to reduce exposure x Using a closed exhaust system during intubation of patients Administrative control consists of measures for ensuring activities and policy for reducing and blocking risks. As the administration and staff of a health care facility can significantly affect efficiency, administrative controls are third among measures of infectious control: x Support in conducting vaccination x Control of the health of personnel and prohibiting work by persons with signs of acute respiratory viral infection x Introducing respiratory hygiene and etiquette while coughing x Separate waiting areas for diseased persons with flu signs in admission rooms and ICUs x Managing patient flow x Appointing persons responsible for infection control x Holding training in infection control x Reducing the number of personnel taking care of patients with confirmed flu cases

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Methods of personal protection are the last line in protecting the body from the threat of exposure if the threat cannot be controlled or eliminated by some other way. Effectiveness of PPE depends on several factors, particularly continuous and proper use. Standard measures to prevent infection of personnel are the use of PPE for respiratory organs (protective medical masks or N95 filtering facepiece respirators [8612F, 8670F]); choosing them depends on the potential risks of aerosol production, particularly the type of procedures planned. Use of anti-aerosol respirators is warranted during procedures that produce small dispersed aerosols: bronchoscopy, sampling phlegm, trachea intubation and extubation, bronchi content suction, sampling lavage, other procedures that cause coughing (atomism of medicines, oxygen flows), cardiopulmonary resuscitation, and autopsy[66]. At the same time it is important to use methods for protecting the eyes (glasses, shields). Standard measures of protection, including PPE, are necessary after the death of a patient too. It is important to ensure a safe environment in a health care facility by means of x Maintaining hygiene of surfaces x Maintaining an effective ventilation system x Airing the premises x Reducing turbulent airflows x Using highly effective filters (HEPA) on mechanical and chamber ventilators x Using local exhaust ventilation (if it exists) while carrying out procedures that generate aerosols, to be held at safety boxes for respiratory infections x Using closed suction units during patient intubation x Using biosafety cabinets for laboratory work generating infectious aerosols Algorithms for cleaning and disinfecting waste, laboratory materials, and used bedding must be strictly followed. Early and rapid detection of persons with pandemic flu among health care facility personnel implies their awareness of illness symptoms and requires reporting any symptoms to their direct supervisor. If the HPAI H5N1 epidemiological or epizootological situation becomes more complicated, monitoring groups at high professional risk of infection is introduced for[67, 68] x Persons engaged in slaughtering infected or potentially infected poultry x Farmers contacting potentially infected poultry x Medical staff taking care of patients with suspected or confirmed HPAI H5N1 infection x Laboratory personnel working with clinical samples from patients with suspected or confirmed HPAI H5N1 infection x Morgue staff contacting corpses of persons dead from suspected or confirmed HPAI H5N1 infection Persons in professional risk groups must be notified of the disease symptoms and must stay under medical control during the whole period of work and seven days after.

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In case of epizootologic complications related to HPAI H5N1 flu in birds, it is necessary to carry out active epidemiological surveillance for identifying disease cases in target groups of the population[69]: x Persons living in villages where probable cases of HPAI H5N1 had occurred in domestic and wild birds x Persons involved in investigating HPAI H5N1 cases among birds and holding sufficient measures, medical workers x Staff, salespersons, and consumers at fairs that have live birds and animals x Persons engaged in slaughtering poultry x Workers on fowl and pig farms x Veterinarians x Hunters x Traders of wild and exotic birds x Zoo personnel

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3.5.3. Epidemiological investigation Epidemiological investigation in an HPAI H5N1 outbreak must be held within 24 hours from the moment of getting the information and implies gathering a case history from the patient and detailed information on the case and contact persons; sampling material for laboratory investigations, medical observation, final disinfection, and other measures for eliminating animals that are a source of infection; and hospitalization of patients, using sufficient PPE[70]. Enhanced epidemiological surveillance for early detection of cases and their treatment is set for affected territories, and immunoprophylaxis is implemented[71]; introducing quarantine and chemoprophylaxis is possible. Analysis of obtained data consists of disease description: x Clinical picture, demographic information, profession x Percentage of patients needing hospitalization x Clinical outcome and mortality percentages x Estimates of incubation period x Mechanisms and factors of transmission x Models of HPAI H5N1 virus transmission The last point facilitates evaluating trends in pandemic characteristics of the HPAI H5N1 virus, the evidence of which can be x An increase in the number of human cases of the disease, in spite of preventive measures x Cases without confirmed contact with birds or animals x Group cases with a tendency toward increased numbers in the groups x Expanding geographic spread x Changes in epidemiological features and manifestation (age, shorter incubation period, more severe course of the disease, etc.) The vertical report must contain a detailed characterization of the case. 3.6. Postpandemic period In August 2010 WHO announced the end of the first 21st-century pandemic. However, flu virus  (H1N1)pdm09 continues circulating globally as seasonal flu, and predicting Handbook for Pandemic and Mass-Casualty Planning and Response, IOS Press, Incorporated, 2012. ProQuest Ebook Central,

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its potential is impossible. Sporadic as well as clustered cases will occur, and robust response to the situation will be needed[49]. The groups at risk of infection, as well as the risk of severe complications and lethal outcome, remain the same, but quantitative indices will be reduced. Generalized experience from a pandemic is given as WHO recommendations for epidemiological and virological monitoring, for vaccination, and for following cases of the disease[51]. It is appropriate to monitor the activity of respiratory diseases: x Monitoring unusual events, such as group cases and deaths due to severe respiratory diseases x Investigating severe and unusual cases of diseases, group cases, and outbreaks of disease to rapidly detect important changes in epidemiology or the level of severity of flu x Implementing regular epidemiological surveillance of flu-like diseases and cases of severe acute respiratory viral infections x Continuously exploiting regular means, such as FluID, FluNet, and EuroFlu, for transferring data obtained in regular epidemiological surveillance of respiratory diseases x Immediate reporting to WHO (according to International Health Regulations) the detection of any listed changes:  Stable transmission of  (H1N1)pdm09 flu resistant to antiviral medical countermeasures  Cases of human infection with a flu virus that is not circulating at that moment among humans  Any significant changes in the level of severity or other epidemiological or clinical characteristics of the  (H1N1)pdm09 virus, including changes in distribution by age groups, clinical manifestation and cases, the need for intensive care, or an unexpected increase in the number of disease cases x Monitoring flu virus  (H1N1)pdm09, aiming to detect important genetic, antigenic, and functional changes, such as sensitivity to antiviral preparations Vaccination remains an important measure for reducing morbidity and mortality related to flu viruses. WHO recommends vaccination of people in high-risk groups in countries having flu vaccines, using both seasonal and monovaccines. Clinical treatment of patients with seasonal flu is given in WHO recommendations and at present is without changes. A high level of preparedness in affected countries at the moment a new flu strain began circulating in March 2009 allowed detection of it within two weeks of the first human cases. New standards in response, among them introducing quarantine or other emergency measures, allowed a reduction in the rate of increase of new cases and, ipso facto, reduced the intensity of the response process. For the first time, registration of disease cases was carried out by laboratory-confirmed cases, which does not allow proper assessment of the real scope of the pandemic, especially in countries where sufficient laboratory practice is absent. New standards of medical care (stage of triage, hospitalization, infection control) were developed and implemented, among them new approaches in therapy (oxygen therapy, oseltamivir), that minimized losses during the new pandemic.

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References [1] WHO Comment on the importance of global monitoring of variant influenza viruses, 19 December 2011, www.who.int/influenza/human_animal_interface/avian_influenza/h5n1-2011_12_19/en/index.html. [2] WHO Africa, Epidemic and pandemic alert and response, www.afro.who.int/en/clusters-a-programmes/ dpc/epidemic-a-pandemic-alert-and-response.html. [3] WHO, Influenza, Pandemic influenza preparedness and response, www.who.int/influenza/resources/ documents/pandemic_guidance_04_2009/en/index.html. [4] WHO, International Health Regulations (2005): Areas of work for implementation, www.who.int/entity/ ihr/finalversion9Nov07.pdf. [5] WHO, Avian influenza: assessing the pandemic threat, www.who.int/influenza/resources/documents/ h5n1_assessing_pandemic_threat/en/index.html. [6] N.P. Johnson and J. Mueller, Updating the accounts: global mortality of the 1918-1920 “Spanish” influenza pandemic, Bulletin of the History of Medicine 76 (2002), 105-115. [7] WHO, Influenza, Assessing and minimizing public health risks, www.who.int/influenza/human_ animal_interface/assessing_risks/en/index.html. [8] R. Perez-Padilla, D. de la Rosa-Zamboni, S. Ponce de Leon, M. Hernandez, F. Quiñones-Falconi, E. Bautista, et al., Pneumonia and respiratory failure from swine-origin influenza A (H1N1) in Mexico, New England Journal of Medicine 361 (2009), 680-9, www.nejm.org/doi/full/10.1056/NEJMoa0904252. [9] WHO, Standardization of terminology of the pandemic A(H1N1)2009 virus, 18 October 2011, www.who.int/influenza/gisrs_laboratory/terminology_ah1n1pdm09/en/index.html. [10] D. Gatherer, The 2009 H1N1 influenza outbreak in its historical context, Journal of Clinical Virology 45 (2009), 174-8, www.journalofclinicalvirology.com/article/S1386-6532(09)00253-4/abstract. [11] R.J. Garten, C.T. Davis, C.A. Russell, B. Shu, S. Lindstrom, A. Balish, et al., Antigenic and genetic characteristics of swine-origin 2009 A(H1N1) influenza viruses circulating in humans, Science 325 (2009), 197-201, www.sciencemag.org/content/325/5937/197. [12] U.S. Centers for Disease Control and Prevention, Interim guidance on case definitions to be used for investigations of swine influenza A (H1N1) cases, 26 April 2009. [13] N. Lee, P.K.S. Chan, D.S.C. Hui, T.H. Rainer, E. Wong, K.-W. Choi, et al., Viral loads and duration of viral shedding in adult patients hospitalized with influenza, Journal of Infectious Diseases 200 (2009), 492-500, http://jid.oxfordjournals.org/content/200/4/492. [14] K.K.W. To, K.-H. Chan, I.W.S. Li, T.-Y. Tsang, H. Tse, J.F.W. Chan, et al., Viral load in patients infected with pandemic H1N1 2009 influenza A virus, Journal of Medical Virology 82 (2010), 1-7, http://onlinelibrary.wiley.com/doi/10.1002/jmv.21664/abstract;jsessionid=ECF330E5334D585CDD02 ED05A794255F.d01t03 . [15] WHO, Weekly update on oseltamivir resistance to pandemic influenza A (H1N1) 2009 viruses, 14 April 2010, www.who.int/csr/disease/swineflu/oseltamivirresistant20100416.pdf. [16] A. Kilander, R. Rykkvin, S.G. Dudman, O. Hungnes, Observed association between the HA1 mutation D222G in the 2009 pandemic influenza A(H1N1) virus and severe clinical outcome, Norway 20092010, Euro Surveillance 15 (2010), www.ncbi.nlm.nih.gov/pubmed/20214869?dopt=Abstract. [17] WHO, Global Influenza Programme, Global surveillance during an influenza pandemic, version 1, updated draft April 2009, www.who.int/csr/disease/swineflu/global_pandemic_influenza_surveilance_apr09.pdf. [18] WHO Working Group for Risk Factors for Severe H1N1pdm Infection, Risk factors for severe outcomes following 2009 influenza A (H1N1) infection: A global pooled analysis, Public Library of Science Medicine, 2011, www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1001053. [19] European Centre for Disease Prevention and Control, Risk Assessment, 2009 influenza A(H1N1) pandemic, 17 December 2009. [20] A.V. Groom, C. Jim, M. Laroque, C. Mason, J. McLaughlin, et al., Pandemic influenza preparedness and vulnerable populations in tribal communities, American Journal of Public Health 99 (2009) Suppl 2: S271-278, http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2008.157453. [21] G. La Ruche, A. Tarantola, P. Barboza, L. Vaillant, J. Gueguen, et al., for the epidemic intelligence team at InVS, The 2009 pandemic H1N1 influenza and indigenous populations of the Americas and the Pacific, Eurosurveillance 14 (2009), www.eurosurveillance.org/ViewArticle.aspx?ArticleId=19366. [22] WHO, Interim guidance for the surveillance of human infection with A(H1N1) virus. [23] E. Plessa, P. Diakakis, J. Gardelis, A. Thirios, P. Koletsi, et al., Clinical features, risk factors, and complications among pediatric patients with pandemic influenza A (H1N1), Clinical Pediatrics 49 (2010), 777-781. [24] O.W. Morgan, A. Bramley, A. Fowlkes, D.S. Freedman, T.H. Taylor, et al., Morbid obesity as a risk factor for hospitalization and death due to 2009 pandemic influenza A(H1N1) disease, Public Library of Science One 5 (2010), www.plosone.org/article/info:doi/10.1371/journal.pone.0009694.

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[25] A.M. Siston, S.A. Rasmussen, M.A. Honein, A.M. Fry, K. Seib, et al., Pandemic 2009 influenza A(H1N1) virus illness among pregnant women in the United States, Journal of the American Medical Assn. 303 (2010), 1517-1525. [26] European Centre for Disease Prevention and Control, Risk Assessment, Pandemic H1N1 2009, version 6, 6 November 2009, http://ecdc.europa.eu/en/healthtopics/H1N1/Documents/1001_RA_091106.pdf. [27] J.L. Lockman, W.A. Fischer, T.M. Perl, A. Valsamakis, and D.G. Nichols, The critically ill child with novel H1N1 influenza A: A case series, Pediatric Critical Care Medicine 11 (2010), 173-8. [28] G. Chowell, S.M. Bertozzi, M.A. Colchero, H. Lopez-Gatell, C. Alpuche-Aranda, M. Hernandez, and M.A. Miller, Severe respiratory disease concurrent with the circulation of H1N1 influenza, New England Journal of Medicine 361 (2009), 674-9. [29] T. Garske, J. Legrand, C.A. Donnelly, H. Ward, S. Cauchemez, C. Fraser, et al., Assessing the severity of the novel influenza A/H1N1 pandemic, British Medical Journal 339 (2009), www.bmj.com/content/ 339/bmj.b2840. [30] T. Hanslik, P.-Y. Boelle, and A. Flahault, Preliminary estimation of risk factors for admission to intensive care units and for death in patients infected with A(H1N1)2009 influenza virus, France, 20092010, Public Library of Science Currents (2010). [31] D.M. Hartley, N.P. Nelson, and E.N. Perencevich, Antiviral drugs for treatment of patients with pandemic (H1N1) 2009 virus [letter], Emerging Infectious Diseases 15 (2009), www.cdc.gov/EID/ content/15/11/1851.htm. [32] I. Capua and D.J. Alexander, Ecology, epidemiology and human health implications of avian influenza viruses: Why do we need to share genetic data? Zoonoses and Public Health 55 (2008), 2-15. [33] WHO, Stop the Spread—Measures to Stop the Spread of Highly Pathogenic Bird Flu at Its Source, 2006, www.searo.who.int/en/Section23/Section1001/Section1110_11580.htm. [34] D. van Riel, V.J. Munster, E. de Wit, G.F. Rimmelzwaan, R.A. Fouchier, A.D. Osterhaus, et al., Human and avian influenza viruses target different cells in the lower respiratory tract of humans and other mammals, American Journal of Pathology, 171 (2007), 1215-23. [35] WHO, International Food Safety Authorities Network, note 2/04: Highly Pathogenic Avian Influenza H5N1 outbreaks in poultry and in humans: Food safety implications, 17 December 2004. [36] WHO, Human cases of influenza A(H5N1) infection, in eastern Turkey, December 2005–January 2006 Weekly Epidemiological Record 81, 27 October 2006, 410. [37] WHO, Human avian influenza in Azerbaijan, February-March 2006, May 2006. [38] WHO, Current WHO phase of pandemic alert (avian influenza H5N1), www.who.int/influenza/ preparedness/pandemic/h5n1phase/en/index.html. [39] WHO, Cumulative number of confirmed human cases of avian influenza A(H5N1) reported to WHO, 20032011, www.who.int/influenza/human_animal_interface/EN_GIP_LatestCumulativeNumberH5N1cases.pdf. [40] WHO, Review of latest available evidence on risks to human health through potential transmission of avian influenza (H5N1) through water and sewage, 2007, www.who.int/water_sanitation_health/ emerging/avianflu/en/index.html. [41] WHO, Clinical management of human infection with avian influenza A (H5N1) virus, 15 August 2007, www.who.int/influenza/resources/documents/clinical_management_h5n1_15_08_2007/en/index.html. [42] WHO, Summary of the second WHO consultation on clinical aspects of human infection with avian influenza A(H5N1) virus, 19-21 March 2007, Antalya, Turkey, www.who.int/influenza/human_ animal_interface/epidemiology_clinical/clinical_meeting_h5n1_19_03_2007/en/index.html. [43] WHO case definitions for human infections with influenza A(H5N1) virus, 29 August 2006, www.who.int/influenza/resources/documents/case_definition2006_08_29/en/index.html. [44] WHO criteria for accepting positive results of H5N1 infection in humans from national reference laboratories, www.cueid.org/component/option,com_docman/task,doc_download/gid,287/. [45] WHO, Recommendations and laboratory procedures for detection of avian influenza A(H5N1) virus in specimens from suspected human cases, revised August 2007, www.who.int/influenza/resources/ documents/h5n1_laboratory_procedures/en/index.html. [46] WHO, Collecting, preserving and shipping specimens for the diagnosis of avian influenza A(H5N1) virus infection, October 2006, www.who.int/csr/resources/publications/surveillance/WHO_CDS_ EPR_ARO_2006_1/en/. [47] WHO rapid advice guidelines on pharmacological management of humans infected with avian influenza A (H5N1) virus, 2006, www.who.int/medicines/publications/WHO_PSM_PAR_2006.6.pdf. [48] L. Finelli, CDC Influenza Surveillance, 2009. [49] WHO global technical consultation: global standards and tools for influenza surveillance, Geneva, Switzerland, 8-10 March 2011, http://whqlibdoc.who.int/hq/2011/WHO_HSE_GIP_2011.1_eng.pdf. [50] WHO, FluNet, www.who.int/influenza/gisrs_laboratory/flunet/en/. [51] WHO, Global Influenza Programme, Aide-Memoire: WHO pandemic phase descriptions and main actions by phase, http://new.paho.org/hq/index.php?option=com_docman&task=doc_download&gid=1379.

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[52] WHO, Surveillance recommendations for Member States in the post-pandemic period, 12 August 2010, www.who.int/csr/resources/publications/swineflu/surveillance_post_pandemic_20100812/en/index.html. [53] WHO, The FAO-OIE-WHO Collaboration: Tripartite Concept Note—Sharing responsibilities and coordinating global activities to address health risks at the animal-human-ecosystems interfaces, 2010, www.who.int/influenza/resources/documents/tripartite_concept_note_hanoi/en/index.html. [54] WHO, Responding to the avian influenza pandemic threat: Recommended strategic actions, 2005, http://www.who.int/influenza/resources/documents/h5n1_strategic_actions/en/index.html. [55] WHO, Global surveillance during an influenza pandemic, 28 April 2009, www.who.int/csr/resources/ publications/swineflu/surveillance/en/index.html. [56] WHO pandemic influenza draft protocol for rapid response and containment, 2006. [57] Surveillance for pediatric deaths associated with 2009 pandemic influenza A (H1N1) virus infection— United States, April-August 2009, Morbidity and Mortality Weekly Report, 58 (2009), 941-7, www.ncbi.nlm.nih.gov/pubmed/19730406?dopt=Abstract. [58] Community strategies by pandemic flu severity, U.S. Centers for Disease Control and Prevention, 2007, www.cdc.gov/media/pdf/MitigationSlides.pdf. [59] WHO, Behavioural interventions for reducing the transmission and impact of influenza A(H1N1) virus: a framework for communication strategies, June 2009, www.who.int/csr/resources/publications/ swineflu/framework/en/index.html. [60] WHO, Reducing transmission of pandemic (H1N1) 2009 in school settings, September 2009, www.who.int/csr/resources/publications/swineflu/reducing_transmission_h1n1_2009/en/index.html. [61] WHO, Case management of influenza A(H1N1) in air transport, 18 May 2009, www.who.int/csr/ resources/publications/swineflu/air_transport/en/index.html. [62] WHO Outbreak Communication Planning Guide, 2008, www.who.int/ihr/elibrary/ WHOOutbreakCommsPlanngGuide.pdf. [63] U.S. Centers for Disease Control and Prevention, Updated interim recommendations for the use of antiviral medications in the treatment and prevention of influenza for the 2009–2010 seasons, www.cdc.gov/h1n1flu/recommendations.htm. [64] WHO, Avian influenza, including influenza A (H5N1), in humans: WHO interim infection control guideline for health care facilities, 9 February 2006, http://pandemicflu.utah.gov/docs/ HCInfectionControlAIinhumansWHOInterimGuidelinesfor.pdf. [65] WHO, Infection prevention and control in health care for confirmed or suspected cases of pandemic (H1N1) 2009 and influenza-like illnesses, 16 December 2009, www.who.int/csr/resources/publications/ swineflu/swineinfinfcont/en/index.html. [66] U.S. Centers for Disease Control and Prevention. Interim Recommendations for facemask and respirator use to reduce novel influenza A (H1N1) virus transmission, 24 September 2009, www.cdc.gov/h1n1flu/masks.htm. [67] WHO guidance on public health measures in countries experiencing their first outbreaks of H5N1 avian influenza, October 2005, www.who.int/influenza/resources/documents/guidance_ publichealthmeasures_h5n1_10_2005/en/index.html. [68] WHO, Protection of individuals with high poultry contact in areas affected by avian influenza H5N1: Consolidation of pre-existing guidance, February 2008, www.who.int/influenza/resources/documents/ guidance_protection_h5n1_02_2008/en/index.html. [69] Approaches to Controlling, Preventing and Eliminating H5N1 Highly Pathogenic Avian Influenza in Endemic Countries, United Nations Food and Agriculture Organization, Rome, 2011, www.fao.org/ docrep/014/i2150e/i2150e00.htm. [70] WHO guidelines for investigation of human cases of avian influenza A(H5N1), 2007, www.who.int/ influenza/resources/documents/h5n1_investigations/en/index.html. [71] WHO, Availability of a new A(H5N1) candidate vaccine virus (clade 2.3.2.1), 16 January 2012, www.who.int/influenza/vaccines/virus/candidates_reagents/a_h5n1_idcdc-rg-30/en/index.html.

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Handbook for Pandemic and Mass-Casualty Planning and Response E. Gursky and B. Hrečkovski (Eds.) IOS Press, 2012 © 2012 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-61499-135-9-59

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Mass-Casualty Preparedness—How to Upgrade From Below: Our Experiences in Slovenia a

Simon HERMANa Dept. of Traumatology, University Clinical Centre Ljubljana

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Abstract: Slovenia is a country of 2 million residents at the tip of the Adriatic Sea. Until the 1990s it was part of Yugoslavia, which declared itself socialist but was never part of the Warsaw Pact. As a country between the eastern and western blocs, it cherished the idea of people’s resistance. The ideal was that the whole society would act as a defensive force, the prevalent part being involved in civil defense. The concept also called for regular training. After Slovenia’s secession from Yugoslavia, the principle of profit precluded most of the training. Industrial policy of maintaining minimum stocks of supplies at hospitals resulted in reduced reserves for response to any mass-casualty disaster. Only recently, thanks to effortless popularization of preparedness for Medical Response to Major Incidents (MRMI), was the European Society for Trauma and Emergency Surgery prompted to urge local medical societies to introduce necessary planning and training. Slovenia started (after 20 years) again to prepare courses for training a swift and correct response in case a of mass-casualty disaster. The introductory symposium was in March 2009, and in February 2010 the first true MRMI course was organized. To reduce costs, give instructors more training, and yield as much as possible from the available equipment, we renewed contacts with the Croatian medical society and worked together in organizing national MRMI courses. Keywords: Mass-casualty, preparedness, medical response, major incidents, MRMI

Introduction Slovenia’s landscape is mostly mountainous, although there are also flat lowlands in the northeast part of the country and a small southwest coastal region (42 km of the coast). One possibility of natural disaster is earthquake: Flooding is routine but not catastrophic: in more than 95% of the area, the temperature varies within a maximum 35 degrees C. in summer and –15 at night in winter. There are floods once every decade, but they are limited to small regions. Therefore, on the climatic side there is occasional flooding but a small probability of mass-casualty disasters. Yet there is a history of earthquakes. The most recent one devastated today’s capital, Ljubljana, at the end of the 19th century. In the last 40 years, there were two earthquakes with substantial structural damage in the affected region. One possibility of manmade disaster comes from Slovenia’s being a transit country. Many hazmat transports go through every day, and in summer tens of thousands of motorized tourists travel to or from their destinations. Recently, in less than 12 months,

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there were four smaller transport incidents with up to 60 persons involved, among them two bus incidents and a crash of two trains. Slovenia also has a nuclear power plant, a research reactor, and many medical and other sources of radioactive material. Chemical hazmat incidents happen every few years, with a few dead and some injured. And there was a short war for independence 20 years ago, followed later by prolonged conflicts in the vicinity (Croatia, Bosnia, Macedonia, Kosovo).

1. History Since the 1990s, civil defense has had a lot of political support, and there was never lack of resources or sponsorships for rescue training and disaster preparedness. After the dissolution of Yugoslavia in 1991, Slovenia became a multiparty democracy. Before that, most of the economy was government owned; afterwards, most of the business was privatized. This meant substantial change in funding military, police, civil defense, and other government-sponsored affairs. Disaster preparedness resorted mostly to planning, and if there was training at all, it was highly compartmentalized. The generations of colleagues educated in the former system became frustrated and apathetic. Only after 2005 did a new generation set things in motion again.

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2. Establishing a new paradigm We all knew that there is a need for disaster preparedness and training, but the realization that we had to do it from within the healthcare system (from the bottom to the top), and not to expect it to happen by the efforts of government officials, took some time. We had our hits and misses, but here is a compressed view of our efforts. Our experience shows that, before committing to disaster medicine organization and training, everybody should consider the following: x Disasters are rare events, and their possibility of striking in the near future is low, and therefore preparing for them is considered low priority x When budget cuts were the fashion of the day, the low-priority areas were first to be cut x In the profit-oriented focus on the year’s (or even quarterly) trade balances, there is remote possibility of industrial sponsorship for long-term goals x Elected politicians change every 4 years and are short-term oriented x Our own colleagues in the healthcare system are overburdened with daily issues and will cooperate only if paid or if advances in research or gains in their academic career can be expected However, if we are committed to preparedness, these obstacles should not pose a deterrent. There are other ways to reach the objective: x Contact the military surgeons, for they are usually at least basically trained in mass-casualty disaster preparedness (but this does not apply in Slovenia, which has no military surgeons) x The middle-level government officials are more in touch with real life and do appreciate good incentives x There are always colleagues who are willing to volunteer

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x x

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Every mass public event (such as sports championships) can be used to raise interest in disaster preparedness Incidents of smaller proportions provide good leverage to press government for better disaster preparedness; however, such opportunities have to be exploited quickly, so advance preparation is needed

Before 2007, there were sporadic voices calling for better disaster preparedness. Due to the army’s small size, it has no surgeons. However, it has a few surgeons in reserve; most of the time they work in the civil healthcare system. So the committed MRMI group had to persistently work its way through government channels in the Ministry of Health. Fortunately, the European Union issued directives for preparedness in the case of hazmat incidents, prompting the Ministry of Health to finally get under way and start to listen. The new wave in medical disaster preparedness started in 2009, when the first generation of healthcare workers attended the MRMI course in Split, Croatia. Their attendance was sponsored by the Ministry of Health. In 2010 it was possible to organize a symposium on the subject in Slovenia, and in February 2011 the first Slovenian MRMI course was organized, followed by the second in 2012. The Ministry of Health also created the task group that prepared the harmonized prehospital and hospital directives for new disaster plans in every healthcare facility.

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3. Basics The MRMI courses are now established European Society for Trauma and Emergency Surgery postgraduate courses. At the core is the MACSIM (Mass Casualty Simulation) with its introduction of theoretical insight for disaster preparedness and response. These fundamentals are employed for all courses, training, and response: x All healthcare professionals are linked, especially doctors and nurses x Connection of prehospital and hospital settings is essential x Simplicity is the key feature of the working plan

4. Current issues The hospital and prehospital professionals quickly started to value joint efforts. Not so the other services of the first responders (firefighters, police, civil defense). Civil defense is still lacking awareness that the hospitals are fundamentally linked to the whole chain of the disaster response and that the rescue work isn’t finished when all the living victims are evacuated from the scene. The prehospital and hospital healthcare providers are yet to be invited to plan the combined exercises and are still waiting to become a partner in evaluating real incidents.

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Handbook for Pandemic and Mass-Casualty Planning and Response E. Gursky and B. Hrečkovski (Eds.) IOS Press, 2012 © 2012 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-61499-135-9-62

Education and Training for Major Incidents and Disasters: Croatia Case Study Zvonimir LOVRIa, Boris HREKOVSKIb, and Josip SAMARDŽIc Trauma Department, University Hospital Dubrava, Zagreb, Croatian Urgent Medicine and Surgery Association b Trauma Department, General Hospital Slavonski Brod, Croatian Urgent Medicine and Surgery Association b Surgery Department, General Hospital Slavonski Brod, Croatian Urgent Medicine and Surgery Association a

Abstract. Education and training for major incidents and disasters started in Croatia 20 years ago during the Homeland War, 1991-1995. In the beginning of the war in Croatia, all medical institutions were receiving orders and instructions for crisis preparation from the Crisis Headquarters of the Ministry of Health. The integrated health system had been established in which civilian and military systems were mutual. Proper planning and preparedness resulted in excellent medical care performed by civilian and military organizations; 20 years later we started education and training in Croatia based on Medical Response to Major Incidents courses. Keywords. Education and training, major incidents, war, conflicts

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Introduction Education and training for major incidents and disasters started in Croatia 20 years ago during the Homeland War, 1991-1995. Croatia is a young state (formerly part of the republic of Yugoslavia) that declared independence in June 1991 but had to fight a 4-year war to achieve it. By the end of 1991, one-third of Croatian territory was occupied. On 15 January 1992, Croatia gained diplomatic recognition by members of the European Community and the United Nations. The Croatian War of Independence finished with a decisive victory by Croatia in August of 1995. In the beginning of the Homeland War, all medical institutions were receiving orders and instructions for crisis preparation from the Crisis Headquarters of the Ministry of Health. The integrated health system had been established in which civilian and military systems were mutual. Proper planning and preparedness resulted in excellent medical care performed by civilian and military organizations. More than 30,000 wounded casualties (civilians and military) were treated in Croatian hospitals during the Homeland War. The average age of wounded males was 31.3 years, females 41.4 years. More than 70% of the casualties got hit in open space, and wounds from explosions dominated at 48%. Many Croatian towns were under direct enemy fire, and some of them were completely destroyed, such as Vukovar city and hospital.

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Table 1. The distribution of casualties during 1991-1995 in the top ten Croatian hospitals that treated major numbers of patient with war wounds; 58 Croatian civil medical institutions were involved in caring for casualties during the Croatian Homeland War.

Hospital General Hospital Sl. Brod University Hospital Split Clinical Hospital Osijek General Hospital Vukovar General Hospital Vinkovci Clinical Hospital Dubrava Zagreb University Hospital Zagreb Clinical Hospital Šalata Zagreb War Hospital akovo University Hospital Rijeka

Patients with war wounds treated 20.09% 11.85% 7.82% 7.35% 7.18% 5.44% 4.91% 4.79% 3.69% 2.95%

Figure 1. Vukovar hospital and the center of the town, November 1991.

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Civilian hospitals were completely shifted towards war hospital organization in many parts of Croatia. The pre-event phase of the war was relatively short, but with clear and precise instructions from the Ministry of Health Crisis Headquarters on what to do in a crisis. Patients, operating theaters, and intensive-care units (ICUs) were moved into basements and additionally protected from artillery shells and sniper fire.

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Most elective surgery patients and departments such as psychiatry, internal medicine, infectology, epidemiology, and pediatrics were moved to other improvised places for the security of non-trauma patients. Security of in-hospital patients and medical personnel was a common concern during 1991-1995. A lot had to be done in a short period to achieve some kind of protection in basements of the hospitals for secure work in improvised space. Previously, most of the surgical departments and ICUs were on the top floors of the Croatian hospitals, a position that was completely insecure for working under war conditions.

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Figure 3. Protection of the surgical department, General Hospital Slavonski Brod, 1991.

Parallel with conversion of civil hospitals to work under war conditions and protocols, another task was to form medical units for the Croatian Army. A majority of the civilian medical personnel volunteered in Croatian Army units with strong motivation because it was a war for the homeland. Organization of the military medics started from zero and concluded with great efficiencies. Special forces of the Croatian Army and police were followed by forward surgical teams (surgeon, anesthesiologist, surgical and anesthesiologist technician, driver) on missions. Reserve Croatian Army medical units were organized according to NATO concepts and had good connections and coordination with civil hospitals. Another important task that put pressure on medical personnel and other agencies was caring for more than 700,000 refugees from Croatia and some parts of Bosnia during 1991-1995. War in this territory in the middle of Europe was brutal, with many cases of basic human rights violations and many cases of war crimes and mass shootings.

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Figure 4. Mass grave, Ovcara–Vukovar, during investigation.

After the war 13,000 square kilometers of Croatian territory was contaminated by land mines, and the process of cleaning is ongoing. Many casualties were treated after the war due to accidents from landmines.

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1. Civilian hospitals during the war—Osijek’s experience A major incident in a situation with no preexisting plan, no previous education or training, no resources to be alerted, no reserve systems prepared, and an uncertain communication system was our situation in 1991 in the beginning of the Homeland War in Croatia. Osijek is a city with 120,000 inhabitants and is the capital of the northeastern part of Croatia, with a county population of 450,000. The hospital’s department of surgery had 230 beds and 35 surgeons working in seven subspecialties. The staff had no education or previous experience in war surgery. The war activities in the surrounding area started on 2 May 1991. They disrupted the normal life of the hospital. The urgent conversion from peacetime to wartime surgery had to be performed. Everything in the hospital had to be adjusted to the needs of war and working under war conditions. With no disaster (or similar) plans in place, in order to prepare and implement great changes, what we needed first was a few determined and capable people. A hospital crisis management committee was established to coordinate all actions on the hospital level, cooperating with the city crisis committee. The main surgeon is an obligatory member of the hospital crisis committee, and surgery was the first thing that needed to adapt. Surgery was the department through which all war trauma was going to be managed, whereas all other departments were to gradually decrease their activities. During the first eight months of the siege of the city of Osijek, more than 10,000 various explosive devices hit the city. On 3 January 1992, alone, 5,000 were counted. During those eight months, 268 mortar and tank shells, aerial bombs, and missiles hit the hospital buildings. The nearest battle line was no more than 2.5 km away.

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Figure 5. Osijek surgical facilities after shelling.

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1.1. Patients From 2 May 1991 to 1 November 1992, 4,545 patients from the city and municipality of Osijek who had war injuries were admitted and managed at the Department of Surgery. The causes of injuries were explosive devices in 56.0% (2,544) of cases; bullets in 17.8% (808), and blunt objects and other causes in 26.3% (1,194) cases; 1,777 patients (39.1%) were hospitalized, whereas 2,768 patients (63.3%) were treated and released; 6,216 primary operative interventions and 1,056 secondary operative interventions were performed. When brought to the hospital, 29.9% (1,359) were immobile and 70.1% (3,186) mobile; 9.1% (414) were admitted in a state of shock. In the very beginning of the fighting, evacuation and transportation of wounded from the site of injury were not efficiently organized, yet 40% of the wounded arrived at the hospital during the first hour after wounding, and another 46% during the second hour. New beds were made available through early discharge (the average hospital stay was 14.1 days) or evacuation to other hospitals away from battle lines: 710 patients (15.6%) were evacuated after primary surgical treatment. Overall postoperative mortality was 2.95% (134 patients): 55% of all deceased died in the first 24 postoperative hours, another 23% in the next 24 hours, 5% in the first six days, and 2% afterwards.

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Figure 6. Osijek Hospital: temporary ICU in the main valve tract in the hospital basement.

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1.2. Organization Achieving the transformation of a civilian hospital into a “civilian war hospital” was fulfilled through our so-called “ten commandments”: 1. Organize and set up the concept of admission, triage, and management of an unknown and undefined number of wounded for an unknown time in a defined location and limited area with a limited number of staff 2. Constantly maintain in the highest degree of preparedness a sufficient number of specialized medical and other professionals associated in a working team 3. Constantly recruit staff to offset a 30% estimated loss of personnel 4. Take care of the patients’ and staff’s psychological condition, morale, and spirit, while carrying out maximal security measures 5. Defer all other medical activities to the needs of surgery 6. Maintain a sufficient number of spare beds 7. Determine routes of evacuation for patients, staff, and equipment in several variations 8. Provide an optimal supply of medical and surgical material 9. Maintain the integrity and functioning of all technical systems in the hospital 10. Establish an absolute hierarchy for giving and executing commands 1.3. Notes on the hospital’s ten commandments 1.3.1. Adapting to the war emergency Unfortunately, no civilian hospital has an ideal area for specific war surgery technologies, so compromises have to be made. We used the traumatology ward admittance rooms for the triage and acceptance of the injured: it was about 600 sq m, with 20 trolleys, 40 stretchers, and 6 persons for carriers. The most experienced surgeon (triage officer) was in charge, with two surgical teams (surgeon, anesthesiologist, anesthetist, and two surgical nurses).

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The injured were classified into two groups: blue and red. The red line comprised injured of the first and second categories; these were usually hospitalized. Blue line casualties of the third category were the lightly injured. Casualties of the first category, those with life-threatening injuries, were admitted to the resuscitative-operative ward after an orientational survey. The second-category casualties, after an orientational survey, were sent to the trauma station for basic clinical and radiological diagnostics, securing vein lines, laboratory findings, starting parenteral therapy (infusions, antibiotics if indicated), wound coverage, temporary immobilization, and paperwork. Lasting 15 to 20 minutes, this was followed by transfer to the operating theaters area (about 500 sq m), where they were on a waiting list for surgery. The order of operations was further assessed by the triage officer. In the resuscitative-operating ward, up to eight teams (anesthesiologists, anesthetists, scrub nurses) were available on eight possible operating tables. An extra two resuscitation teams were available. Postoperatively, patients were transferred to the ICU. The disadvantage of our surgical arrangement was the dislocation of the areas: triage and the trauma station were in the basement, operating theaters on the ground floor. The ICU in the basement dislocated about 300 sq m and four stationary wards with 160 beds in the basement, which were partially under construction when the war started. One ward was placed in the underground corridors. We had 100 additional beds in reserve. The wards were brought downstairs on 12 September 1991. The blue line casualties stayed in the trauma station and were surgically defined, then assigned to one of three operating tables or the casting room. These patients were discharged from the hospital: sent home or to an improvised military ward outside the hospital. The intake of casualties was irregular. Our experience ranged from 1 in 24 hours to 146 in 24 hours. In the first 260 days (the most intensive period of the war), the mean intake was 12.4 injured per 24 hours.

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1.3.2. Maintaining sufficient staff Constantly maintaining a sufficient number of professionals in the highest degree of preparedness was provided by way of “elastic organization.” In the first days of the fighting, we had 5 surgeons spread over 24 hours in the hospital, plus 3 on call. When walking through the city streets grew hazardous, we changed the number to 10 surgeons (24 hours on board, 48 hours free). In the end we had two teams with 16 surgeons in the hospital (48 hours on board, 48 hours free). The last option with all surgeons on board working in three shifts (16 hours on board, 8 hours free) was not applied. Physicians of other operative professions (ear, nose, and throat; facial surgeons; urologists; gynecologists) participated in response to demand assessment by the main surgeon. Other physicians (internists, etc.) were on standby. 1.3.3. Staff turnover Anticipated loss of staff was replaced from other departments, since the extent of their interventions declined about 70%.

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1.3.4. Morale To diminish the risk from grenades on the way from home to the hospital we introduced secure common rest rooms (with TV, billiards, table tennis, etc.), and the morale and spirit of the staff were excellent. 1.3.5. Giving preference to surgery All diagnostic wards and staff (radiology, laboratory, transfusiology, hospital pharmacy) were subject to surgical needs. 1.3.6. Maintaining sufficient spare beds and determining evacuation routes Managing the available beds was a roulette. To keep them in play, patient discharge or evacuation as early as possible was critical. Our first evacuation base was a hotel 20 km from Osijek with 60 convalescent and 20 internal medicine beds. After this hotel was bombed, we moved the facilities 40 km to the west, where we had 120 beds. Many injured were evacuated to other distant cities and hospitals that did not suffer direct attacks. 1.3.7. Maintaining medical supplies Thanks to our friends from abroad and in our homeland, we did not suffer lack of anything, mainly because the communications were not cut. We kept a four-month reserve of medical supplies, food, and clothing. 1.3.8. Keeping the hospital functioning

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For a short period, we had an energy breakdown when the hospital was heavily bombed. The food was prepared in a hotel, and laundry was done by citizens and some institutions in the city. The biggest problem was with heating. After these experiences, the hospital got independent electric and water supplies. 1.3.9. Chain of command Hierarchy in these conditions had to be military-like. At the top of the system was the main surgeon, followed by the hospital crisis committee. The possibility of accord and consultation did not include disobedience. 1.4. Conclusion The principle of getting surgery near to the wounded was reversed in Osijek: the casualties approached surgery from the first lines of the city defense and city streets. In this position, civilian surgery had to be transformed quickly and with quality. In peacetime, education and training facilitate potential transformation of a civilian hospital even in an eventual war situation.

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2. Present education and training for mass-casualty incidents in Croatia Present education and training for mass-casualty incidents in Croatia are connected to the organization of Medical Response to Major Incidents (MRMI) courses. Under the auspices of the Croatian Ministry of Health, the first pilot Basic and Instructor MRMI course was organized in Croatia on the island of Pag in April 2009. Sten Lennquist and an international group of experts (surgeons, paramedics, ambulance physicians) developed the MRMI course within the Disaster & Military Surgery section of the European Society for Trauma and Emergency. The second Basic and Instructor MRMI course was organized in November 2009 in Split, the third in March 2011 in Slavonski Brod.

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Figure 7. MRMI course faculty: S. Lennquist of Sweden and H. Hancock of the USA, Split, 2009.

The MRMI course was chosen for education and training because the whole chain of response (field, transport, hospital management, coordination, and command) is trained simultaneously, including triage and treatment of individual casualties. The exercises are run with real time and resources consumption, giving effective training in decision making on all levels.

Figure 8. Details from the MRMI course scene and hospitals.

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in disaster medicine. The MRMI course consists of lectures, workshops, two simulation exercises, evaluation, and triage tests. The Basic MRMI course is made for all participants from different agencies involved in the chain of the major incidents organization. The Instructor MRMI course is only for the instructor candidates who successfully finished the Basic MRMI course and satisfied criteria set by the MRMI board (see more details on the MRMI course in the first chapter). The Croatian Urgent Medicine and Surgery Association (CROUMSA) has approval from the MRMI Board of faculty to organize Basic and Instructor MRMI courses, and this means that Croatia fulfilled the criteria for the “centre of excellence” for this kind of education. CROUMSA MRMI instructors developed a good partnership with the Slovenian Surgery Association, Slovenian Society of Trauma Surgeons, Slovenian Professional Group of Health Rescue Workers, and Slovenian Ministry of Health for continuous organization of Medical Response to Major Incidents courses and with a vision to improve education and training for crises.

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Conclusion Croatian medical personnel gained huge experience through their work during the Homeland War 1991-1995. Many hospitals worked in yellow or red alert for long periods, especially during 1991-92. The organizational demands and results of such reorganization with no preexisting plans or education are presented in this chapter. Hospitals close to the battle lines experienced infrastructure damage, and some of them were completely destroyed. The principles of surgical care improved through the years and raised the quality of Croatian medicine. The war experience was unique, and the system of integral health care completely fulfilled all the hard tasks during wartime. Twenty years later we work in an economic model of a health system with reduced reserve capacities. We continue education and training with MRMI courses. Yet some lessons learned during the Homeland War present a milestone for the organization of Croatian medical response in a possible major incident and might be instructive for other areas of the world.

References [1] K. Janoši and Z. Lovri, War surgery in Osijek during 1991/92 War in Croatia, Croatian Medical Journal 36 (1995), 104-107. [2] K. Glavina, A. Tucak, K. Janoši, et al., Deliberate military destruction of the general hospital in the city of Osijek, Croatian Medical Journal 33 (War suppl. 1, 1992), 61-70. [3] Z. Lovri, B. Wertheimer, K. andrli, H. Kuveždi, I. Lovri, D. Medari, and K. Janoši, War injuries of major extremity vessels, Journal of Trauma 36 (1994), 248-51. [4] Z. Lovri, B. Wertheimer, K. andrli, V. Lehner, and O. Rubin, Reconstruction of the popliteal artery after war injury, Unfallchirurg 97 (1994), 375-377. [5] D. Kova i, Z. Lovri, and G. Kondža, War injuries of the colon and rectum, Unfallchirurg 97 (1994), 378-381. [6] Z. Lovri, H. Kuveždi, D. Prli, B. Wertheimer, and K. andrli, Ballistic trauma in 1991/92 war in Osijek, Croatia: shell fragments versus bullets, Journal of the Royal Army Medical Corps, 143 (1997), 26-30. [7] Z. Lovri, and Lj. Lovri, Wounds caused by low-velocity hand grenade spheres, National Medical Journal of India 16 (2003), 40-1. [8] A. Hebrang, I sur. Analiza u inkovitosti ratnog zdravstva, UHLD 1990-1991, Zagreb, 2007. [9] S. Lennquist, Medical Response to Major Incidents and Disasters, Springer, New York, 2012.

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Handbook for Pandemic and Mass-Casualty Planning and Response E. Gursky and B. Hrečkovski (Eds.) IOS Press, 2012 © 2012 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-61499-135-9-72

Cross-Disciplinary Competency and Professionalization in Disaster Medicine and Public Health Frederick M. BURKLE, Jr.a, James M. LYZNICKIb, and James J. JAMESb Harvard Humanitarian Initiative, Harvard University, Cambridge, Massachusetts, USA, and Woodrow Wilson International Center for Scholars, Washington, DC b Center for Public Health Preparedness and Disaster Response, American Medical Association, Chicago

a

Abstract. Unfortunately, the response to humanitarian crises and large-scale natural disasters worldwide has shown consistent failures in coordination, intervention, and documentation of impact outcomes. The response to the Haitian earthquake of 2010 prompted the international community to address these shortcomings and requirements for greater accountability, stringent quality performance oversights, documentation and reporting, and a recognized process leading to professionalization of the humanitarian community. Evidenced-based studies indicate the need to use a cross- or multi-disciplinary approach to developing competencies leading to curricula and course development and to eventual certification and registry of providers. This chapter discusses the current processes by which these issues are being addressed.

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Keywords. Disaster medicine; humanitarian assistance; training and education; competency, professionalization

Introduction The demand for better coordination and control is heard during and after every major large-scale national disaster and international humanitarian crisis[1]. Recent large-scale disasters, such as the 2010 earthquake in Haiti and the Asian tsunami that directly impacted 12 Indian Ocean countries, have revealed “unacceptable practices in the delivery of emergency medical humanitarian assistance”[2]. In particular, questions concerning competencies among some of the deployed foreign medical teams (FMTs) have been raised, including current guidelines that were found to be “limited in scope” in meeting demands expected of them[2]. These findings have prompted the international community to call for “greater accountability, more stringent oversight and better coordination of their work,” especially in health services[3]. Further post-crisis discussions among international stakeholders led the United Nations’ Inter-Agency Standing Committee and their Global Health Cluster Policy and Strategy Group to call for immediate debate and action focusing on unmet needs and concerns[3]. Additionally, the committee addressed the need to develop an international register of FMT provider organizations that would include detailed information on the composition of FMTs and the types of services they provide[3]. Separately, the international humanitarian health workforce community has launched a concerted effort to develop a blueprint for

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professionalizing humanitarian health care assistance and certification of individual health care providers based on disaster-specific professional health-related skills and cross- and multidisciplinary humanitarian health core competencies[4]. This section discusses evolving efforts to improve the internal quality performance initiatives of FMTs and to develop competency-based education and training leading to professionalization of providers practicing disaster medicine, public health preparedness, and humanitarian health care in crises. Both civilian and military providers of disaster and humanitarian crisis response—along with the nongovernmental organizations (NGOs), private governmental organizations, military-led civil action units, and international organizations that represent them—share in the responsibility to ensure that cross-disciplinary, competency-based knowledge and field-related tasks are practiced with the highest standards of care.

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1. Improving quality performance of foreign medical teams It is recognized that FMTs represent the primary focus of organized health care during major disasters and humanitarian crises. These medical and surgical teams, while collectively referred to as FMTs or foreign field hospitals, in reality arise from both national and foreign health care assets. Until recently, the responsibility for and monitoring of the internal quality performance of the FMTs were left to the teams themselves. For the most part, quality performance is not routinely monitored by FMTs, although highly established teams such as those fielded by Médecins Sans Frontières (MSF) or “Doctors Without Borders,” the International Committee of the Red Cross (ICRC), and the International Medical Corps, to name but a few, all enjoy robust internal monitoring, standards-of-care protocols, and data-gathering capacity. The 2010 Haiti earthquake response provides a pertinent backdrop for discussion of FMT response issues. Data from the Health Cluster Bulletin in Haiti reported that in the health sector alone, 390 “actors, including NGOs, international, and bilateral teams,” mostly international, were registered with the Health Cluster, which served as the external coordinating mechanism. Admittedly many health providers did not register[5]. The quality of these teams varied greatly, as did that of individual health care providers. Additionally, concerns surfaced that many providers of humanitarian services were mostly under age 30, and this was their first disaster experience. This being said, the response to the Haiti earthquake was fairly typical of what is experienced during other worldwide disaster events. Anecdotally, more than 70 FMTs were said to have participated in care but actually only 44 were identified as having deployed in the first month[6]. The World Health Organization (WHO)/Pan American Health Organization (PAHO) guidelines emphasize that the FMT’s primary role from days 3 to 15 is to fill the gaps in emergency medical assistance resulting from the large number of casualties or the inability of the local health services to respond to normal emergencies[7]. Essential requirements of the FMTs are to[8] x Be fully operational within 3 to 5 days x Be self-sufficient with minimal need for support from the local communities x Have basic knowledge of the health situation and language and respect for the culture x Include health professionals in selected specialties x Ensure capacity for sustainability, including appropriate technology

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x

Ensure a detailed agreement between recipient and donor as to responsibility for all costs

Of the 44 FMTs, only “25% adhered to essential deployment requirements and none followed the full requirements of WHO/PAHO”[6]. Due to the lack of data and transparency, it proved “impossible to determine to what extent the first wave of FMTs did any good”[6]. Such findings are not uncommon. Increasingly, there are calls for internal scrutiny of all providers, both those who arrive alone and those deployed in established or nascent medical teams. Lessons learned from the Haiti earthquake experience, and other crises, suggest that the process to ensure quality improvements of health services and standards of performance should be undertaken immediately within the teams and by professional individuals that compose these teams. It was observed that the Haitian “system was fragmented, under-resourced, and failed to provide access to basic health services in the years before the earthquake. The disaster, itself, compounded these effects resulting in a massive humanitarian crisis on a scale previously unseen by even seasoned humanitarian workers”[9]. In addition, “many of the providers of health assistance—both Haitian and international—provided excellent care under very difficult situations, though there was an absence of a transparent system to link these different providers, or to be able to move patients from one service to another. For instance, to move patients who had [undergone] amputation to a provider who could organize for rehabilitation or prosthesis fitting”[9]. Internal health care requirements that demand attention for FMTs include, at a minimum[10]: x Ensuring professional and ethical standards x Accelerating deployment capability and capacity x Matching services with supply and demand x Creating a register of FMT provider organizations x Establishing teams by specialty, experience, services, and bed capacity x Standardizing data collection and reporting x Ensuring that procedures are performed only by those licensed to do so in their own country x Ensuring that FMTs are staffed by personnel with experience in humanitarian settings x Implementing processes to supervise less-experienced personnel A recent study of emergency surgery care in developing countries identified 185 studies listed in Pubmed/Medline/Embase, but in only 11 was the data collection adequate for peer-review documentation. Understanding the outcome impact of procedures and adapting to standard documentation of data formats to show evidence of their outcomes is essential for all FMTs, and the information that must be forwarded to the Health Cluster[11].

2. Professionalization of the humanitarian health workforce When the above internal FMT requirements are addressed or accomplished, collective attention naturally shifts to the larger and more critical issue of professionalization, which has been debated for decades within the community of humanitarian health providers. Because of the recurrent service problems encountered in these crises, it is understood by the humanitarian community that a system of “accountability, quality

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control, reporting, certification, and coordination is inevitable”[4]. Both the humanitarian community and the practitioners of humanitarian aid have this moral and ethical obligation to the beneficiaries of care. What we provide to citizens in the countries where we practice should not be any different in quality performance than what we guarantee to those in need in disaster and humanitarian crisis events. Granted, providers will practice in very resource-poor settings—but this does not alter the fact that all practitioners must follow accepted standards of care. We are fortunate to have guidance available through peer-reviewed publications on standards of care[12, 13, 14]. A legitimate question is “Why professionalization now?” About 3 decades ago, an informal survey of NGOs suggested that only 2% to 4% of aid workers desired professionalization[4]. Over the ensuing years, humanitarian assistance has become more complex and demanding, and humanitarian workers have increasingly sought more education and training in all aspects of relief, but especially in public health, development, human rights, and security—with acceptance that humanitarian assistance for many has become a profession or discipline of its own. Today, 92% of humanitarian workers serving NGOs favor professionalization[4]. A decade ago about 100,000 people in the aid community considered themselves career humanitarian professionals; today this number has risen to more than 220,000, with an annual rate of increase exceeding 6%[4, 15]. Both the humanitarian community and those institutions involved in higher education and training have responded with the support and resources needed to ensure the professionalization process. Within the humanitarian aid community, strong efforts are under way to provide global and regional blueprints for professionalizing humanitarian assistance and its workforce[16]. This multidisciplinary process has gained considerable interest and is moving forward rapidly based on specific obligations for quality performance, education and training, and standards-of-care discipline. FMTs, like other project teams (e.g., water, sanitation, and sheltering projects), have specific skills obtained by competency-based education and training that qualify them in each discipline. Health care workers such as physicians, nurses, dentists, allied health professionals, and laboratory technicians also come to the humanitarian community with specific health care degrees and post-degree specialty training. What defines a humanitarian health professional is the combination of these two competency sets (see figure 1):

Sharedcorehumanitarian competencies

Individualskillspecific competencies

Humanitarianprofessional

Figure 1. A “humanitarian health professional” can be defined by the combination of individual skill-specific competencies such as those obtained by a medical or nursing degree and the completion of shared core competencies that all humanitarian professionals—such as logisticians, project managers, security personnel, human rights lawyers, and health care workers—must possess[17].

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3. Multidisciplinary education and training In any health emergency, a rapid response by competent physicians and other health professionals is essential. All health professionals in multiple settings (e.g., hospitals, private practices, public health, community health centers, skilled nursing facilities) have a responsibility to ensure they are prepared to serve their communities in the event of a disaster. To be effective, education and training require consensus on a set of shared competencies, learning objectives, and performance metrics, with course curricula based on a well-defined and testable body of knowledge and skills[16]. Minimizing adverse health outcomes requires cooperative efforts that cross traditional boundaries of health specialties, professions, and nationalities. To respond effectively, health professionals, regardless of specialty or area of expertise, require a fundamental understanding of the disaster management system and the ways in which various health-related roles are integrated to protect health and respond to disease or injury. Proficiency requires knowledge and skills beyond those typically acquired in clinical and public health training and practice, and it must encompass unique competencies. The delivery of optimal care in a disaster relies on both clinical and public health expertise, and it depends on a common understanding of each health professional’s role in the broader emergency management system. All health professionals should be knowledgeable about the range of illnesses and injuries that may arise in a disaster or humanitarian crisis and how their particular expertise facilitates effective response[16]. In addition, all must be able to recognize the general features of disasters and public health emergencies and be knowledgeable about their impact on the population, how to report a potential public health event, and where to access pertinent information as required. The authors suggest that the following elements should be considered essential components in any disaster training program for health professionals: x Personal and family preparedness is crucial to ensure that health professionals will report to work when needed in a disaster. This is most effective when implemented on a systems basis so that all employees understand roles and responsibilities that fit into a larger framework. x Health professions training should use an all-hazards approach, which is systems-oriented and sustainable. x In response to all hazards, affected populations are best served by a multidisciplinary approach to policy, planning, and practice. All health professions and disciplines should be represented in formulating policy and planning and be trained to function as integrated teams. x All-hazards response requires integration and cooperation across all sectors, including public health agencies, academic and health professions institutions, emergency management services, community health and service organizations, practitioners, and volunteers. x For training programs to assure that health professionals can perform effectively in a disaster or public health emergency, curricula need to be standardized and based upon a consensus set of core competencies with learning objectives related to those competencies. x All-hazards training for health professionals must anticipate the particular needs of underserved and other vulnerable populations in disasters with locally relevant and socially and culturally sensitive planning and practices.

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x x x x

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To engage health professionals in all-hazards training, the training must be accessible, acceptable, adaptable, time-efficient, cost-effective, evidence-based, and customized to the needs of learners and the communities they serve. Education and training in disaster preparedness should be flexible and convenient, which requires a variety of learning modalities (e.g., classroom, web based, exercises, drills). To encourage participation of health professionals in all-hazards training programs, incentives such as continuing education credits or professional certifications are desirable. Systematic evaluation of program effectiveness is needed regularly, with modification of training approaches as needed to achieve successful process measures and outcomes.

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4. Disaster and crisis-specific competencies Humanitarian health workers are integrated under shared core humanitarian competencies with education and training for general health care providers. Core humanitarian competency education and training are traditionally provided by established nongovernmental agencies (e.g., MSF, ICRC) as well as established academic affiliated training centers throughout the world. For example, North America (the USA and Canada) is fortunate to have 12 such centers that have offered competency-based training for 3 to 17 years. All of these programs regularly train both civilian and military students. Similar opportunities exist or are being developed worldwide[16]. Core competencies provide the fundamental basis of collective learning, and they help ensure consistent application and translation of knowledge into practice. In 2007, recognizing the need to better integrate competencies across all health specialties and professions, an expert stakeholder group was convened to develop a consensus-based educational framework and competency set from which educators could devise learning objectives and curricula in disaster medicine and public health[18]. This competency set, adopted by the National Disaster Life Support Education Consortium™ in 2008, served as the basis for an extensive revision of the National Disaster Life Support™ training courses[19]. In 2012, the published results of a similar process focused on the integration of crosscutting competencies applicable to most, if not all, potential health system responders[20]. This effort delineated core competencies and associated subcompetencies on which to create a standard, baseline core curriculum for all potential health system responders. Additionally, separate subdiscipline-specific competencies (e.g., emergency surgery, tropical medicine, anesthesia, critical care, pediatrics, mental health in resource-poor countries) and courses are available both regionally and internationally (e.g., MSF and ICRC Emergency Surgery courses, American Academy of Pediatrics–sponsored “Children & Disasters” training program for use internationally, including developing countries). Existing centers of learning and practitioners of aid have collaborated to develop competencies that form the foundation of curriculum and course development (see tables 1 and 2). While all published competencies are similar in many areas, they may differ in emphasis on specific disciplines or professional skill requirements. As such, competencies exist for skills related to disaster medicine, nursing, and emergency medical services professionals for single-event disasters at a national level; others focus

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primarily on public health emergencies and preparedness, whereas others strictly focus on international humanitarian crises in resource-poor countries. Core humanitarian competencies typically emphasize multidisciplinary team requirements for all professionals, not just those in the health care workforce. Table 1. Representative competency sets[16].

Examples of competency sets that can be used by academically affiliated training centers, NGOs, and private governmental organizations in developing curricula and courses. Completion of competency-based training leads to certification of the providers. All potential health system responders: x Core Competencies for Disaster Medicine and Public Health[20] All health professionals: x A Consensus-Based Educational Framework and Competency Set for the Discipline of Disaster Medicine and Public Health Preparedness[18] Clinicians and emergency medical services professionals x National Standardized All-Hazard Disaster Core Competencies for Acute Care Physicians, Nurses, and EMS Professionals[21] Public health professionals: x Public Health Preparedness and Response Core Competency Model[22] x Association of Schools of Public Health, Global Health Competency Model, Final Version 1.1[23] Humanitarian assistance professionals: x Core Humanitarian Competencies Framework[24] x Network on Humanitarian Assistance, International Association of Universities, professional profiles and competencies[25]

Table 2. Consensus-derived core competencies for all potential health system responders[20]

Core Competency Demonstrate personal and family preparedness for disasters and public health emergencies. 2.0 Demonstrate knowledge of one’s expected role(s) in organizational and community response plans activated during a disaster or public health emergency. 3.0 Demonstrate situational awareness of actual or potential health hazards before, during, and after a disaster or public health emergency. 4.0 Communicate effectively with others in a disaster or public health emergency. 5.0 Demonstrate knowledge of personal safety measures that can be implemented in a disaster or public health emergency. 6.0 Demonstrate knowledge of surge capacity assets, consistent with one’s role in organizational, agency, and/or community response plans. 7.0 Demonstrate knowledge of principles and practices for the clinical management of all ages and populations affected by disasters and public health emergencies, in accordance with professional scope of practice. 8.0 Demonstrate knowledge of public health principles and practices for the management of all ages and populations affected by disasters and public health emergencies. 9.0 Demonstrate knowledge of ethical principles to protect the health and safety of all ages, populations, and communities affected by a disaster or public health emergency. 10.0 Demonstrate knowledge of legal principles to protect the health and safety of all ages, populations, and communities affected by a disaster or public health emergency. 11.0 Demonstrate knowledge of short- and long-term considerations for recovery of all ages, populations, and communities affected by a disaster or public health emergency.

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1.0

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Figure 2 depicts four proficiency levels of health professionals in disaster medicine and public health as correlated with their expected role in a disaster. The baseline or floor-level competencies are intended to serve as the foundation for the more specific competencies developed by other entities. Second-level competencies are those required by the institutions, organizations, and agencies in which health professionals work each day. Third-level competencies apply to some—but not all—members of the health disciplines and professions that require more specialized knowledge and skills in disaster-related medicine and public health (e.g., emergency medical and nursing personnel). The tip of the pyramid contains the very specific competencies expected of health personnel who compose various disaster response teams, including FMTs. As depicted in figure 2, competencies become more specialized as an individual moves up the pyramid, but everyone starts at the same base level of proficiency.

Highly specialized competencies Highlyspecialized andintegrated competenciesforregularly deployedresponders

• NationalDisasterMedical SystemTeams(DMAT/DMORT) • U.S.PublicHealthServiceteams • Foreignmedicalteams • DoctorsWithoutBorders (MédecinsSansFrontières) • Clinicalfellowships

Discipline andprofessionspecific competencies Membersofthehealthdisciplinesandprofessions thatrequiremorespecializedknowledgeandskills indisasterrelatedmedicineandpublichealth

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Role,function,andcategoryspecificcompetencies •Hospitalworkers•Healthcareworkers •MedicalReserveCorps•Healthprofessionstudents •Humanitarianaidworkers•Publichealthworkers Additionalcompetenciesrequiredforexpectedrolesinthehealthcarefacility, publichealthagency,orotherpracticeorcommunityresponseorganization

Corecompetenciesforallpotentialhealthsystemresponders Figure 2. Defining the audience: A multitiered and multidisciplinary learning framework (adapted from Subbarao, et al.[20]).

5. Global support networks Several sector-wide networks have developed over recent years—for example, the Active Learning Network for Accountability and Performance, made up of international humanitarian organizations, promotes successful means to enhance quality performance among NGOs. A network called Enhancing Learning and Research for Humanitarian Assistance (ELRHA) is a new collaborative dedicated to supporting partnerships between institutions of higher education and humanitarian organizations and partners around the world[4]. The ELRHA Project moves the professionalization of the humanitarian aid workforce from “a position of discussion to one of action”[26].

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The ELRHA network consists of regional hubs (currently active are those in East Africa, Europe, the United Kingdom, and North America[27]; see figure 3).

RegionalHubs Latin America

Europe UK Middle East ELRHA

Africa

USA

Australasia

Asia

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Figure 3. The ELRHA hub network: One hub site has been allocated per active hub. Adapted from ELRHA[27].

Within these hubs are educational and training projects and programs to professionalize not only health providers but also logisticians, security managers, humanitarian law experts, human resources professionals, and many others who support lifesaving assistance projects in water, sanitation, health, shelter, food, and energy. Worldwide actions are being encouraged between existing hub training centers in developed countries and those struggling to sustain such expertise in developing countries, the goal being to ensure regionally appropriate and culturally sensitive education and training curricula and courses leading to certification in humanitarian assistance on all continents. The process of organizing education and training centers within regional hubs should consider the following[28]: 1. Expectations are that each discipline—such as medicine, law, logistics, and security—would determine and demonstrate discipline-specific competencybased education and training. This would be completed based on regional and cultural standards as global hubs. 2. The hubs would establish recognized certified training programs and work with members, academics, and training institutions to devise certification criteria for entry-, mid-level, and higher levels of members obtaining the training. 3. The regional hubs would provide accredited trainers from accredited academic affiliated training centers. Trainers would become accredited via their training institutions and/or by supervised experience in humanitarian missions and a track record of teaching the competency-based curriculum content and courses. 4. After creating a list of competencies, both core humanitarian competencies (that all humanitarian workers need to know) and discipline-specific ones (required by the professional specialty), the regional hubs would devise the routes for certification of the people they trained. This most commonly comes from individuals completing a specified curriculum or demonstrating competency through examination or experience, and from experienced workers who provide a portfolio or passport to document the acquisition of competencies through previously completed FMT services.

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5. Ideally, accredited training centers regionally would organize themselves under professional associations of accredited academic training centers in humanitarian health (or emergency surgery, tropical medicine, humanitarian pediatrics, mental health, etc.) to ensure timely and accurate updates in educational advances, share relevant information, determine common data impact documentation and reporting standards, devise commonly accepted competencies to meet new education challenges, and provide advocacy efforts worldwide.

6. Registry of certified humanitarian health providers

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As the professionalization process matures, a registry of certified providers needs to be developed. Regional hub-accredited training centers would seek recognition from the humanitarian stakeholders (NGOs, international organizations, donors, etc.) whose interest is to recognize and support the professionalization of the FMTs and accept the certification it provides[26]. The process leading to recognized academic associations for individual professional disciplines is summarized thus[28]: x Organize independent discipline-specific professionals regionally x Establish a forum for developing core humanitarian and core discipline-specific competencies x Set professional and ethical standards x Accredit training centers and trainers x Establish discipline-specific routes to certification x Promote research agendas to build curriculum content and standards of care x Internationalize the field (among like-minded regional hubs) Individual volunteers to humanitarian missions as well as those organized under NGO health services delivery organizations (e.g., ICRC, MSF, and the International Medical Corps) would benefit equally under this format of professionalization. It should be clear that the obligation that all health care providers have is to ensure they have the competencies to do what they are expected to do.

7. Closing comment Sustained efforts, including those described in this paper, are needed to establish and maintain a humanitarian health workforce that possesses the knowledge, skills, and abilities to support all health-related aspects of disaster management. Formal education and training can enhance the ability of all potential health system responders to be useful in an emergency as volunteers or as members of well-established organizations with significant disaster expertise. Additional research is necessary to identify the extent to which these efforts are integrated into current academic and professional development programs within the health sciences, what gaps exist in achieving these standards within current curricula, and what mechanisms exist or need to be developed to fill identified gaps. Future collaborative efforts to create and refine education and training curricula in disaster-related medicine and public health should integrate the multitiered and multidisciplinary learning framework proposed here, together with foundational core competencies as a global standard.

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References [1] F.M. Burkle Jr., A.D. Redmond, and D.F. McArdle, An authority for crisis coordination and accountability, Lancet (Epub ahead of print) (2011). [2] Inter-Agency Standing Committee, Global Health Cluster, Concept paper: foreign medical teams, 17 May 2011, www.who.int/hac/global_health_cluster/about/policy_strategy/fmt_concept_paper_16may11.pdf. [3] Global Health Cluster, Coordination and registration of providers of foreign medical teams in the humanitarian response to sudden-onset disasters: A Health Cluster Concept Paper, World Health Organization, Inter-Agency Standing Committee, Geneva, Switzerland, 2010, www.who.int/hac/ global_health_cluster/about/policy_strategy/fmt_concept_paper_27_May.pdf. [4] P. Walker, K. Hein, C. Russ, G. Bertleff, and D. Caspersz, A blueprint for professionalizing humanitarian assistance, Health Affairs 29 (2010), 2223-30. [5] Pan American Health Organization, The health cluster: Successes and obstacles in Haiti, Disasters: Preparedness and Mitigation in the Americas 113 (2010), http://new.paho.org/disasters/newsletter/ index.php?option=com_content&view=article&id=113%3Athe-health-cluster-successes-and-obstaclesin-haiti&catid=80%3Aissue-113-may-2010-member-countries&Itemid=124&lang=en. [6] M. Gerdin, A. Wladis, and J. von Schreeb, Foreign field hospitals after the 2010 Haiti earthquake: How good were we? Emergency Medicine Journal (Epub ahead of print) (2012). [7] J. von Schreeb, L. Riddez, H. Sammnegård, and H. Rosling, Foreign field hospitals in the recent suddenonset disasters in Iran, Haiti, Indonesia, and Pakistan, Prehospital and Disaster Medicine 23 (2008), 144-151. [8] WHO-PAHO guidelines for the use of foreign field hospitals in the aftermath of sudden-impact disasters, international meeting, Hospitals in disasters—handle with care, San Salvador, El Salvador, 8-10 July 2003, www.who.int/hac/techguidance/pht/FieldHospitalsFolleto.pdf. [9] J. Nickerson, Surgery in humanitarian emergencies: Lessons learned from recent disasters. GlobaHealthHub.org: Keeping up with global health & development (2012), www.globalhealthhub.org/ 2012/05/23/surgery-in-humanitarian-emergencies-lessons-learned-from-recent-disasters/. [10] A.D. Redmond, S. Mardel, B. Taithe, T. Calvot, J. Gosney, A. Duttine, and S. Girois, A qualitative and quantitative study of the surgical and rehabilitation response to the earthquake in Haiti, January 2010, Prehospital and Disaster Medicine 26 (2011), 449-56. [11] J.W. Nickerson, S. Chackungal, L. Knowlton, K. McQueen, and F.M. Burkle Jr., Surgical care during humanitarian crises: A systematic review of published surgical caseload data from foreign medical teams, Prehospital and Disaster Medicine 27 (2012), 1-6 (Epub ahead of print). [12] L.M. Knowlton, J.E. Gosney, S. Chackungal, E. Altschuler, L. Black, F.M. Burkle Jr., et al., Consensus statements regarding the multidisciplinary care of limb amputation patients in disasters or humanitarian emergencies: Report of the 2011 Humanitarian Action Summit Surgical Working Group on Amputations Following Disasters or Conflict, Prehospital and Disaster Medicine 26 (2011), 438-48. [13] S. Chackungal, J.W. Nickerson, L.M. Knowlton, L. Black, F.M. Burkle Jr., et al., Best practice guidelines on surgical response in disasters and humanitarian emergencies: Report of the 2011 Humanitarian Action Summit Working Group on Surgical Issues within the Humanitarian Space, Prehospital and Disaster Medicine 26 (2011), 429-37. [14] A. Faroog, J.E. Gosney, J.D. Reinhardt, A.J. Haig, J. Li, and J.A. DeLisa, Medical rehabilitation after natural disasters: Why, when and how? Archives of Physical Medicine and Rehabilitation (2012) (Epub ahead of print). [15] F.M. Burkle Jr., Future humanitarian crises: Challenges for practice, policy, and public health, Prehospital and Disaster Medicine 25 (2010), 191-9. [16] F.M. Burkle Jr., The development of multidisciplinary core competencies: The first step in the professionalization of disaster medicine and public health preparedness on a global scale, Disaster Medicine and Public Health Preparedness 6 (2012), 10-2. [17] Concept and design of figure 1 by F.M. Burkle Jr., Harvard Humanitarian Initiative, Harvard University, Cambridge, Massachusetts, USA, 2012. [18] I. Subbarao, J.M. Lyznicki, E.B. Hsu, K.M. Gebbie, D. Markenson, B. Barzansky, J.H. Armstrong, E.G. Cassimatis, P.L. Coule, C.E. Dallas, R.V. King, L. Rubinson, R. Sattin, R.E. Swienton, S. Lillibridge, F.M. Burkle Jr., R.B. Schwartz, and J.J. James, A consensus-based educational framework and competency set for the discipline of disaster medicine and public health preparedness, Disaster Medicine and Public Health Preparedness 2 (2008), 57-68. [19] National Disaster Life Support Foundation training courses, www.ndlsf.org. [20] L. Walsh, I. Subbarao, K. Gebbie, K.W. Schor, J. Lyznicki, K. Strauss-Riggs, A. Cooper, E.B. Hsu, R.V. King, J.A. Mitas II, J. Hick, R. Zukowski, B.A. Altman, R.A. Steinbrecher, and J.J. James, Core competencies for disaster medicine and public health, Disaster Medicine and Public Health Preparedness 6 (2012), 44-52.

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[21] C.H. Schultz, K.L. Koenig, M. Whiteside, and R. Murray, Development of national standardized allhazard disaster core competencies for acute care physicians, nurses, and EMS professionals, Annals of Emergency Medicine 59 (2012), 196-209. [22] Public Health Preparedness and Response Core Competency Model, Centers for Disease Control and Prevention and the Association of Schools of Public Health, Final Model Version 1.0, 17 December 2010, www.asph.org/userfiles/PreparednessCompetencyModelWorkforce-Version1.0.pdf. [23] Association of Schools of Public Health, Global Health Competency Model, Final Version 1.1, 31 October 2011, www.asph.org/userfiles/Narrative&GraphicGHCompsVersion1.1FINAL.pdf. [24] Core Humanitarian Competencies Framework, Consortium of British Humanitarian Agencies, 2010, www.thecbha.org/media/website/file/CBHA_Competency_Frameworks.pdf. [25] Network on Humanitarian Assistance, International Association of Universities, www.nohanet.org/ noha-master-programme/professional-profiles-and-competencies-.html. [26] Enhancing Learning and Research for Humanitarian Assistance, Professionalizing the humanitarian sector: A scoping study, www.elrha.org/uploads/Professionalising_the_humanitarian_sector.pdf. [27] ELRHA, Hubs, www.elrha.org/work/professionalisation/hubs. [28] F.M. Burkle Jr., Accountability & accreditation of emergency surgery providers, Global Risk Forum, Davos, Switzerland, video PowerPoint presentation, December 2011, http://vimeo.com/ user9671977/videos.

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Handbook for Pandemic and Mass-Casualty Planning and Response E. Gursky and B. Hrečkovski (Eds.) IOS Press, 2012 © 2012 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-61499-135-9-84

Complex Humanitarian Emergencies— An Overview: Controversies and Future Perspectives Alessandra ROSSODIVITAa1, Massimo RANGHIERIb, Matteo GUIDOTTIb, Elisaveta STIKOVAc, and Antonio CARUSOd a San Raffaele Hospital Scientific Foundation, University of Medicine of San Raffaele Life and Health, Milan, Italy b E.I.-S.M.O.M. Military Corps, Milan, Italy c University of Saints Cyril and Methodius, Skopje, Macedonia d Italian Court of Auditors, Milan, Italy

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Abstract. Globalization, migration of the population, climate change, and war and other conflicts throughout the world have created an increasingly complex environment for humanitarian aid and international response and relations. In the past two decades, wars and other conflicts have increasingly become an internal problem for fragile nation-states, and these disrupted states often suffer from inequalities in social, economic, and political development, exacerbated by long-term ethnic, religious, and minority conflicts and by the fierce competition for existing resources. In the meantime, these animosities become an international problem to solve. The humanitarian response to war-related crises and disasters has gradually evolved from charitable but uncoordinated efforts into more systematized interventions. Large, multinational organizations have developed significant technical and logistical capacity in responding to the public health needs of large vulnerable populations. The authors analyze the current controversies and future prospects in complex humanitarian emergencies management. Keywords: Complex humanitarian emergencies, disasters, wars, conflicts, vulnerable people, future crisis, global health, humanitarian crises, public health emergency.

“History shows that most of the positive or beneficial developments in human society have occurred as the result of care and compassion.” Dalai Lama, Ancient Wisdom, Modern World (Boston, Massachusetts, USA, Little Brown, 1999)

Introduction After more than three decades of responding to wars and internal political conflicts, the humanitarian community has now the opportunity to reevaluate which crises will dominate both policy and practice in the future. Sometimes the political solutions offered so far have been nation-state–centric and have missed opportunities to provide what must be global solutions. 1

Corresponding author: [email protected].

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Crises requiring a humanitarian response represent a major public health concern, with excess or indirect mortality and morbidity, for entire populations[1, 2, 3]. In 1991 Zwi and Ugalde defined complex emergencies as “situations in which the capacity to sustain livelihood and life are threatened primarily by political factors and, in particular, by high levels of violence”[4]. In the 1990s, at least 38 conflicts, including events in Northern Iraq, Somalia, Rwanda, the Congo, former Yugoslavia, Kosovo, and East Timor, were classified as complex emergencies. Common characteristics of complex emergencies are failure or disruption of a state’s essential public health infrastructure, associated with the violation of human rights and forced migration of a massive number of civilians, as either internally displaced populations or refugees in a neighboring country. The disruption of a society by complex emergencies may have catastrophic consequences for a nation’s public health. Civilians are the primary victims of these conflicts—particularly the vulnerable population: children, adolescents, and women, who are at greatest risk of not receiving proper food or education and of being abused, harassed, raped, or killed[1, 2, 3]. The international community sometimes still remains impotent and unable to manage proper interventions or decide to force some humanitarian interventions, and its response may be limited in scope and defined primarily by political factors or the restrictions of the existing laws. For such reasons health care providers have become the major humanitarian actors in complex emergencies by offering assistance to vulnerable groups who otherwise are denied access to basic health care protections and other human rights. Vulnerable populations or groups are defined as sections “of the population, specially infants, pregnant and lactating mothers, the elderly, the homeless, who are particularly prone to sickness and nutritional deficiencies. They are likely to suffer most in a disaster”[5]. Public health emergencies are defined as crises that “adversely impact the public health system and its protective infrastructure related to water, sanitation, shelter, food and health”[2]. An increasingly common threat, public health emergencies permeated and often dominated the consequences brought on by wars, other conflicts, and large-scale disasters in the last third of the 20th century. Public health emergencies occur when the public health protective threshold is destroyed (for example, during a war), overwhelmed (for example, during a large-scale disaster such as an earthquake), not recovered or maintained, or access to it denied (for example, in war or in ethnic or religious discrimination)[2]. In developed countries public health protections are considered invisible to the populations who take them for granted. Public health protection or lack of it is what distinguishes the have and have-not populations of the world. Wars and large-scale disasters such as earthquakes and tornadoes are defined by the direct deaths and injuries they produce, which may be a measure of public health protection[1, 2, 3]. Unfortunately, complex emergencies and public health emergencies have proven dangerous, long-lasting, and widespread, necessitating long-term commitments to vulnerable populations throughout extended emergency, recovery, and rehabilitation phases. These commitments are performed with difficulty. Providing health care in those situations requires professional skills and understanding of the broad international system and how it functions. This includes a working knowledge of the major participants in complex emergencies, international humanitarian law, assessment and

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epidemiology, malnutrition and communicable diseases, gender and reproductive issues, public health infrastructure, logistics and transportation, communication, security, negotiations and mediation, and critical psychosocial and cross-cultural issues. Initial humanitarian requirements call for a massive logistical response to meet the needs for water, food, shelter, and medical and public health care and to provide civil order and security. Yet there have been few investments in public health infrastructures around the world.

1. Major Participants

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1.1. The United Nations and UN Agencies No agency or organization has all the resources needed to counteract the effects of complex emergencies and public health emergencies. The major participants, all of which have a crucial role to play, include the UN and UN agencies, nongovernmental organizations (NGOs) and the International Committee of the Red Cross[3]. The United Nations functions as a treaty with an administration. It comprises institutions that have roles and responsibilities in complex emergencies: the Security Council, the General Assembly, and the UN agencies[6]. The UN is limited in its actions and its ability to respond in intrastate conflict, due to the sovereignty provisions in its charter. Because the country in conflict is usually a member of the UN, the offices of the Secretary General provide a means of negotiations and conveying the pressure of international diplomacy. Peacekeeping operations include the use of observers and civilian personnel to monitor an accord or agreement and the deployment of peacekeeping troops or civil police under a Security Council resolution. Unfortunately, peacekeeping forces have enjoyed only limited success in controlling the fragile process of peace in states with conflicts before a formal agreement is signed. Intervention has evolved from a purely humanitarian response into a system that recognizes human population needs with the support of a political solution, which may also require military security and protection. The UN forces’ duties are usually limited in providing security because they are in charge of supplying the international relief system in logistics, engineering, airfield operations, public health infrastructure repair, and emergency health and food during times of conflict. In this context a certain degree of civilian-military coordination and information sharing in the name of peacekeeping and security-keeping activities is needed. This may be a problem for the NGOs, which must maintain the operational neutrality and impartiality required under international law[3]. The UN strategy is to use open and transparent lateral organizations: Humanitarian Operation Centers at the operational level for coordinating policy issues and relief and Civil-Military Coordination Centers at the field level for security. The UN agencies are independent of the Secretary General and the General Assembly, and they act under mandates to meet humanitarian needs under existing international laws[3, 6]. The UN High Commissioner for Refugees is represented in over 100 countries and has the mandate to protect, repatriate, and resettle refugees. The Commissioner is responsible for coordinating assistance programs for the large number of internally displaced persons (14.9 million in 2011)[7].

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The World Food Program is the food aid arm of the UN, with the mission of providing emergency aid and long-term development assistance. The UN Children’s Fund (UNICEF) provides assistance in health, nutrition, and education for children and women and all victims of disasters. The emergency responsibilities of these UN agencies have been expanded greatly in past years due to complex emergencies. The initial lack of operational experience, the inability to coordinate functions, and inadequate budgetary support affected their activities. Under recent UN reforms, the Office of the Coordinator of Humanitarian Affairs was created and organized to coordinate the UN humanitarian response. In addition, an Emergency Relief Coordinator is designated to lead the role of UN agencies, represent them, and coordinate their activity with other international institutions, committees, NGOs, and the Red Cross[3]. 1.2. NGOs

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The term nongovernmental organization encompasses many types of organizations: international charities such as Oxfam “and Save the Children, research institutes, churches, community-based organizations, lobby groups, and professional associations,” according to the American Psychological Association[8]. NGOs are usually “value-based organizations that depend in whole or in part, on charitable donations and voluntary service”[8]. The UN defines an NGO as “a not-for-profit group, principally independent from government, which is organized on a local, national or international level to address issues in support of the public good. Task-oriented and made up of people with a common interest, NGOs perform a variety of services and humanitarian functions, bring public concerns to governments, monitor policy and programme implementation, and encourage participation of civil society stakeholders at the community level”[9]. In wider usage, an NGO can be described as any non-profit organization that is independent of government. NGOs have become increasingly influential in world affairs, and the World Bank estimates that over 15 percent of total overseas development aid is channeled through NGOs … There are two general categories of NGOs: (1) operational NGOs, whose primary purpose is the design and implementation of developmentrelated projects, and (2) advocacy NGOs, whose primary purpose is to defend or promote a specific cause and who seek to influence the policies and practices of [intergovernmental organizations]. Statistics about the number of NGOs worldwide are incomplete, but according to the United Nations Development Program, there are approximately 40,000 non-governmental organizations in the world in addition to the community-based organizations which number in the hundreds of thousands[8].

One important characteristic of NGOs’ work is that, in the pure sense, they provide services based solely upon need, without political, ethnic, religious, or other considerations or implications. NGOs vary according to size, mission, and capability. With the growing number of complex emergencies, a great number of NGOs specializing in humanitarian relief are emerging, with specialties such as water and sanitation, food and shelter, medical care, and activities on behalf of specific vulnerable groups (for example, protective services

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and therapeutic feeding for children). “Services provided by international health NGOs include direct health care, community potable water, vitamin supplementation, and mitigation of endemic and epidemic infectious diseases and malnutrition,” according to Wikipedia[10]. “Examples of NGOs dedicated to international health”: Médecins Sans Frontières, the International Medical Corps, Save the Children, the International Rescue Committee, and Care International[10]. 1.3. The International Committee of the Red Cross The International Committee of the Red Cross is “an all-Swiss private institution mandated to respond, under international law (Geneva Conventions), to victims of war and” other conflicts[3]. The committee “is the largest and the oldest of all humanitarian organizations and will be involved wherever internal” or international civil conflict is found[3]. The International Committee of the Red Cross “functions under the authority of the Geneva Conventions as a neutral intermediary to protect all victims”[3]. With its neutrality, impartiality and independence[11] (for example, it is separate from all NGOs and other humanitarian organizations), the International Committee of the Red Cross “has a unique mandate to monitor the treatment of prisoners and to assist in finding, tracing, and protecting those missing because of conflict”[3]. The International Committee of the Red Cross Medical Unit is internationally well recognized and well respected for its capabilities in fielding hospitals during conflicts or disasters. The Red Cross symbol is globally recognized and is easy to spot in the chaos of war[3, 11].

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2. The Sphere Project “The genocide in Rwanda in 1994” and “the challenges encountered in providing quality humanitarian assistance to the refugee populations in Goma, Zaire and Ngara, Tanzania prompted the humanitarian aid community to address issues of humanitarian norms and standards”[12]. The need to provide effective aid during crises in wars or disasters focused the attention and the work of NGOs on creating a framework of common response, developing new codes, and introducing “a formal system for accountability and self-monitoring”[12]. The Sphere Project, established in 1997, is a result of this collaborative intent[12, 13]. The Sphere Project is an attempt to bring human rights principles into the international response to complex emergencies. It is based on the principle that “it is not sufficient simply to ‘do good’ by providing humanitarian aid, but that the aid provided must be ‘good enough’”[14]. Before the “Sphere Era,” humanitarian aid had integrated with human rights marginally, operating under the mandates of international humanitarian law, but without a strong adherence to human rights norms and standards as now recommended. The “common ideology on humanitarian aid … is that it is needs-based, rather than rightsbased. While a needs–based approach provides the minimum, basic resources for victims to survive, a rights-based approach challenges those providing the aid that supports beneficiaries to live lives with dignity. In addition to providing essential aid, incorporating human rights in humanitarian emergencies addresses the underlying discrimination, marginalization, and lack of accountability that may perpetuate humanitarian crises[12].

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The Sphere Project and the Sphere Handbooks represented the first integration of human rights and their principles as a tool and code of conduct to improve the practice of humanitarian assistance in the field, particularly in the health sector, with the idea of translating human rights into action, in order to achieve more effective standards in humanitarian response. The Sphere Project and the Sphere Humanitarian Charter are based on the principles coming from the Universal Declaration of Human Rights[16, 17]. The Humanitarian Charter is based on three main principles: “(1) the right to life with dignity; (2) the distinction between combatants versus non-combatants; and (3) the right of non-refoulement”[12]. Of these three principles, “only the right to life with dignity is recognized legally as a ‘human right’, and it is the overarching principle of the Sphere Project that justifies the standards within the handbook”[12]. But most experiences of humanitarian aid relief in the field show how the Sphere Handbook had some limitations and how “most aid workers” have not been able to fully utilize this tool and “were unaware of its Humanitarian Charter or of any relationship between the technical standards and human rights”[12]. But

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the Sphere Project is revolutionary not only for attempting to articulate the value of human rights for humanitarian aid, but because it places the responsibility of realizing these rights on the shoulders of the responding NGOs in addition to the traditional, state-based responders. This is especially important in conflict settings to which NGOs [are] called to respond, but are too politically complex or sensitive for other actors to engage. In addition, during humanitarian crises, especially in conflict-afflicted zones, the “government” in control may be a rogue or even failed state. A human rightsbased approach ultimately would help confront the patterns of inequality that facilitated the emergence of the humanitarian crises, and challenge relief organizations to address some of those underlying patterns. A rights-based approach to aid would allow beneficiaries to be participants in transparent decision-making processes, thereby supporting their ability to be active stakeholders in the assistance process[12].

3. A “Rights-Based Approach to Health in a Humanitarian Space”[12] The Sphere Project and “the fundamental components of a rights-based approach”[12] in a humanitarian response are based on the following concepts and philosophy: 1. “Adherence to the Triple AQ: availability, accessibility, acceptability, and quality” 2. “Participation of affected communities, including those who are most vulnerable” 3. “Non-discrimination in providing humanitarian assistance, with attention to those who are most vulnerable” 4. “Transparency of decision-making processes and assistance” 5. “Accountability with respect to all beneficiaries, partners, and donors” “ … The Triple AQ approach is crucial to the delivery of any health services”[12]. Availability refers to the concept that all health services and health interventions “must exist and be offered to all”—for example, “clean water and safe and adequate food”[12] for all: these are essential services that should be delivered by NGOs. And it is fundamental that all NGOs involved in humanitarian crises work in strict collaboration to achieve common results for all in respect for human rights.

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Accessibility. All medical services should “be physically and financially accessible to”[12] the whole population, including vulnerable people, ethnic minorities, women, the elderly, the disabled, and people suffering from HIV/AIDS, following the principle of non-discrimination and non-marginalization. Acceptability. It is fundamental that all health “services and goods delivered … must be acceptable to”[12] the local population, in respect for cultural and gender dissimilarity. It should be sensible to involve the local population, in particular vulnerable groups, to participate “in the planning and implementation of health care services” and in the decision-making process “from the outset”[17]. The role of NGOs should be to ensure acceptability of the health services delivered in the affected community. Quality. It is important to ensure the quality of the services delivered in accord with some quality indicators as shown in the Sphere Handbook, in order to monitor and evaluate a transparent process of release. In the meantime, health services must be distributed among all beneficiaries, avoiding any form of discrimination, including, for example, discrimination against ethnic minorities or women on health care staff, aiming rather to reflect the percentage of those in the general affected population who will be attending the clinics, in order “to ensure that vulnerable groups are not under-represented”[17]. “The planning and implementation of” health “services must be transparent”[12] in respect for patients’ rights, “and the health services offered ought to be made clear and easily understandable to the local community”[12]. NGOs should be active in disseminating all useful information for the access to these services and in organizing education programs for the affected population. “Privacy, confidentiality and informed consent”[17] should be included as fundamental components of the health services in respect for human rights principles and should be ensured during any planning and decision-making process[12, 13, 16, 17].

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4. Conclusions and Future Perspectives Accountability for the entire process should be ensured through an effective monitoring and evaluation system based on human rights. NGOs and international agencies have the hard duty to guarantee and protect the entire process in respect for human rights and dignity, in order to act in a way good enough for all. The cultural, political, and security climate during complex emergencies creates an environment that threatens human rights on multiple levels. This results in two effects: (1) the difficulty in meeting technical standards when operating in a non-conducive, socio-political, and economic environment; and (2) the further inaction by responsible parties toward correcting this environment[12].

Our hope for the future lies in “establishing accountability for the technical provision of” medical care “services and the promotion of human rights in complex humanitarian” crises[12], and that these proposals do not remain just rhetorical ideas and actions but should become the cornerstone of all humanitarian future projects. Future crises are appearing on the horizon, and the international community and the scientific community should be able to cope with them, although sometimes they fail to operate effectively and are reluctant to enter political disputes, but they have the duty to interpret and manage the public health consequences derived from complex emergencies and public health emergencies.

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War, other conflicts, post-conflict periods, biodiversity crises, climate change, large-scale national disasters, globalization, urbanization, epidemics, pandemics, and emergencies of scarcity will impact policy and public health. Humanitarian assistance has begun to move from the local level to a globalized concept, focusing attention on the new basis of health education and human rights as priorities, because public health must take precedence over politics and not be driven by political motives. Public health emergencies and public health concerns should be redefined as the fundamental infrastructure and system of the entire society necessary to allow communities, urban settings, and nation-states to provide physical and social protection to their populations, especially vulnerable populations. It has become a global responsibility to ensure multidisciplinary cross-sectional interaction among all disciplines and actors from medicine, law, the social sciences, economics, engineering, research, and politics.

5. Acknowledgments A. Rossodivita wishes to thank Ms. Maryam Romagnoli for her help in the English review of this article.

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References [1] E.S. Yim, D.W. Callaway, S. Fares, and G.R. Ciottone, Disaster diplomacy: Current controversies and future prospects, Prehospital and Disaster Medicine 24 (2009), 291-293. [2] F.M. Burkle Jr., Future humanitarian crises: Challenges for practice, policy, and public health, Prehospital and Disaster Medicine 25 (2010), 191-198. [3] F.M. Burkle Jr., Complex humanitarian emergencies, in D.E. Hogan and J.L. Burstein, eds., Disaster Medicine, Lippincott Williams & Wilkins, Philadelphia, 2002. [4] A. Zwi and A. Ugalde, Political violence in the Third World: A public health issue, Health Policy and Planning 6 (1991), 203-217. [5] S.W.A. Gunn, Multilingual Dictionary of Disaster Medicine and International Relief, Kluwer Academic Publishers, Dordrecht, Netherlands, 1990, 87. [6] A.S. Natsios, The international humanitarian response system, Parameters XXV (1995), spring, 68-81. [7] Internal Displacement Monitoring Centre, www.internal-displacement.org/. [8] American Psychological Association, NGOs, the UN and APA, www.apa.org/international/united-nations/ publications.aspx. [9] United Nations Rule of Law, Non-governmental organizations, www.unrol.org/article.aspx?article_id=23. [10] Wikipedia, International health, http://en.wikipedia.org/wiki/International_health. [11] Denise Plattner, [International Committee of the Red Cross] neutrality and neutrality in humanitarian assistance, International Committee of the Red Cross Resource Centre, www.icrc.org/eng/resources/ documents/misc/57jn2z.htm. [12] H. Ouyang, M. VanRooyen, and S. Gruskin, The Sphere Project: Next steps in moving toward a rightsbased approach to humanitarian assistance, Prehospital and Disaster Medicine 24 (2009), 147-152, www.hsph.harvard.edu/faculty/sofia-gruskin/files/The_Sphere_Project.pdf. [13] P. Walker and S.L. Purdin, Birthing Sphere, Disasters 28 (2004), 100-111, www.hapinternational.org/ pool/files/birthing-sphere.pdf. [14] H. Ouyang, et al., citing C. Dufour, et al., Rights, standards and quality in a complex humanitarian space: Is Sphere the right tool? Disasters 28 (2004), 124-14. [15] H. Ouyang, et al., citing J. Darcy, Locating responsibility: The Sphere Humanitarian Charter and its rationale, Disasters 28 (2004), 112–123. [16] Universal Declaration of Human Rights: UN General Assembly Resolution 217 A (III), 10 Dec 1948, 25 Human Rights Documents, New York Center for the Study of Human Rights, Columbia University, 5-8. [17] Sphere Handbook: Humanitarian Charter and Minimum Standards in Humanitarian Response, Sphere Project, Geneva, Switzerland, 2004, www.sphereproject.org/handbook/.

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Handbook for Pandemic and Mass-Casualty Planning and Response E. Gursky and B. Hrečkovski (Eds.) IOS Press, 2012 © 2012 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-61499-135-9-92

The Hospital as the Weakest Link in MassCasualty Incidents Radko KOMADINA, M.D., Ph.D.a, Andrej STRAHOVNIK, M.D.a, Miha SIMONITIb, and Simon HERMAN, M.D., M.Sc.c a Dept. of Traumatology, General and Teaching Hospital, Celje, Slovenia b Medical Faculty, University of Ljubljana, Slovenia c Dept. of Traumatology, University Medical Centre Ljubljana, Slovenia

Abstract. The hospital is part of the chain of first responders in case of a disaster. The vulnerability of the modern hospital is growing despite scientific and technological advancement. Throughout disaster management, health professionals with broad surgical knowledge are needed, despite the existing range of subspecialists. Modern hospitals act without having enough available operating rooms, medical teams in reserve, supply reserves, etc., in case of a disaster. Every day, the hospital management is forced into permanent cost-reduction activities involving logistical supply. The dual-wave phenomenon threatens to overburden hospital capabilities, with the lightly injured patients arriving first and the more heavily injured coming in later. Volunteers, “freelancers,” relatives, and friends can overcrowd the hospital and compromise the health providers’ safety. Hazardous materials and radiological, chemical, and biological pollution, along with hostile activity by terrorists, represent an additional safety threat.

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Keywords. Hospital preparedness, disasters, reserves, dual-wave phenomenon

1. The most vulnerable link Modern hospitals generally don’t have the reserve capacity to treat an unexpectedly large number of ill or injured people. Because of extremely high operational costs under normal conditions, their capacity is used for a precise number of planned procedures, with no room to spare for reserves. During a catastrophe, all normal activities of the hospital are suspended, which makes managing mass-casualty incidents even more demanding for the staff and management personnel. The system of healthcare and hospital ownership does not affect this. It’s the same with hospitals in the USA, Canada, the EU, or the Far East. Patients in hospitals expect to be provided with everything they need to regain their health. The first part of the catastrophe cycle, which demands sufficient preparedness and planning of capacities needed to manage a disaster with a rapid influx of an unexpectedly large number of injured or acutely ill people, is therefore inadequate. When planning hospital activity in disaster medicine, we have to consider the fact that hospitals are already extremely vulnerable because of their complicated configuration: various wards with a diverse nature of work; nonfunctional architecture with previous expansions; poor horizontal and vertical transport routes; connections to the communal drinking water sources; dependency on public electricity and fuel systems;

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the usually limited stock of materials, food, and drugs, which are sufficient for only a few days (because of cost-cutting); the demanding system of collecting waste with different levels of contamination (biological, chemical, radioactive); etc. When planning for disasters, hospitals need to account for different scenarios and make arrangements for their management with a strategic, operative, and tactical plan, with crisis handling (disaster management), constantly analyzing possible threats (hazard vulnerability analysis), and preparing theoretical and practical exercises for disasters (innovative planning). It is unwise to think that our institutions cannot be hit by disaster. It is more useful to have various plans and imagine the unimaginable. Plans have to account for the safety of health providers, expect the disaster to turn in an unexpected direction, and accordingly prepare a swiftly responsive system. Everything planned and carried out has to be recorded for final analysis and future improvement, as required by the cycle of catastrophe. When planning for managing a large number of ill and injured people, complications with logistics, power failure, mental distress, and radioactive, chemical, or biological contamination all have to be anticipated. The disaster plan needs to be straightforward (“Simplicity is the key,” said Sten Lennquist, president of the Disaster and Military Surgery committee at ESTES, the European Society for Trauma and Emergency Surgery). But a complex group of experts (head surgeon, head nurse, security, architect, director …) has to be involved in making the plan. Overly extensive prehospital and hospital disaster plans have often been shown to be infeasible and caused additional confusion. They were about as effective as no plans at all. Despite all the difficulty, it’s logical that people will seek medical attention where they expect to receive it—in their local hospital. However, with the patients themselves come their relatives and friends, as well as volunteers and the media, all of whom inevitably contribute to the chaos. The dual-wave phenomenon can deceive us: lightly injured patients are the first to arrive at the hospital (in the first 15 to 30 minutes after the disaster), and only after that do the heavily injured patients reach the hospital in the second wave. The only solution is for each hospital to prepare its own disaster plan with designated persons in charge, experienced with adjusting to unexpected events in disasters. Because the hospitals in different regions vary in size, it is necessary, in the framework of multistage treatment of the heavily injured, to provide a system of interhospital connections, so that help with equipment, materials, and staff can be given to the affected hospital. For planning, different ministries (health, defense) cooperate with agencies and services for civil protection and disaster relief, nongovernmental organizations such as the Red Cross, professional and expert associations, etc.

2. Education for the health providers MRMI (Medical Response to Major Incidents) is a generic educational tool of ESTES for hospital preparedness planning and drilling, educating health providers, and providing them with algorithms for use in mass-casualty incidents. Sten Lennquist is the author. Unlike similar educational courses, MRMI has the participants (head physicians, head nurses, medical management) train in a tabletop exercise how to plan and act during a mass-casualty incident: the emergency number (112) to call, activity of the public health unit on the scene of the disaster, coordination, command, communication with the dispatch center, and transport all the way to the hospital. With the help of a

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card system they train on hundreds of patient cases (based on real disaster victims’ cases). On the operative level of planning and carrying out a medical response to a disaster, they direct real-time patient management in parallel. The hospital is the weakest link among first responders. MRMI shows how to prepare hospitals to react with as few unnecessary mistakes as possible during a disaster.

References

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[1] G.R. Ciottone, et al., Disaster Medicine, Elsevier-Mosby, Philadelphia, Pennsylvania, USA, 2006. [2] S. Lennquist, ed., Medical Response to Major Incidents and Disasters, Springer Verlag, Berlin Heidelberg, 2012. [3] R. Komadina and V. Smrkolj, et al., eds., Osnove medicine v izrednih razmerah s kirurškega vidika, Medicinska fakulteta Univerze v Ljubljani, Društvo travmatologov Slovenije, 2009.

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Handbook for Pandemic and Mass-Casualty Planning and Response E. Gursky and B. Hrečkovski (Eds.) IOS Press, 2012 © 2012 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-61499-135-9-95

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Ethics and Medicine in Disasters and MassCasualty Incidents a

Ivica Balena Retired associate professor, Medical Faculty, Department of Internal Medicine, University of Osijek.

Abstract. Triage in mass-casualty incidents must be based on the principle of maximum benefit for the majority of victims. To accomplish this ethically requires people who are wise and courageous, but also cautious, just, resourceful, compassionate, willing to make sacrifices, and, last but not least, communicative. Keywords. Triage, ethics, character

Introduction

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“Calamitis virtutis occasio est” (Calamity is virtue’s opportunity)

The ancient Greeks built the foundations of medical ethics and in time it adapted to the development of medicine and society. Ethical and legal norms that regulate the relations between people during various catastrophes have been developing through thousands of years. The 1859 Geneva Convention has already been modified several times. Legal norms are constantly being improved, and the neutral international war crimes tribunals were introduced. The Nuremberg process started that revolution, but the problem there was that the winning party tried the defeated party; as a result, no one answered for the crimes of the winners. In an attempt to try to correct that today, equal rules are being introduced for the winners and the defeated, but obviously a lot of time will be needed for the legal norms to be harmonized with ethics and justice. Nowadays we mostly manage to try the criminals who were the “servants of war,” while the masters of war, as well as those who had the power to stop the war from happening, still cannot be tried. Why is that so? First of all, because no one is perfect. For example, someone can be highly moral in private life with family, while being an amoral politician; or a very moral and good doctor can have problems with the basic norms of family life. Norwegian author J. Gaarder says: “Even in the world of today we can see how mighty powers can come apart at the seams when confronted with simple demands for peace, love, food for the poor, and amnesty for the enemies of the state.” Such a thing would be goodness without interest, and no one “smart” cares about that. The result is that on the international scale, the smallest interest of a big nation outweighs the biggest interest of a small nation. It is human nature to with ease be kind to those we need, and to easily refuse kindness towards those who need us. The story of ethics must first of all be understood as the need to make people understand the importance of ethics in all areas of human activity. Although the vast majority of people are familiar with most ethical principles, it is still difficult to explain

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to them that behaving ethically brings unexpected beauty, a better outcome, and less misfortune.

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1. Main ethical dilemmas in calamities and disasters One of the major factors that affect ethical principles is speed. In major calamities there usually isn’t a lot of time to make decisions or consult others and reach agreements. So at the very beginning we can be put into the position to violate every person’s right to equal treatment in a medical emergency. We can respect the right of equality only if the capacity of a health service allows us to take care of everyone injured, which is usually not the case when disasters happen. Therefore triage in mass-casualty incidents must be based on the principle of maximum benefit for the majority of victims. And how is that done? Those who are evidently likely to die are abandoned to their fate; those who are not seriously injured and are also able to move must wait for help; and those who are seriously injured but have a chance of survival must become a priority. Such a utilitarian principle has its reasons, but from a humanistic point of view it is not always easy to follow through. For example, the Croatian health care system functioned very well during the war because it was excellently organized from top to bottom. A joint military and civilian medical corps was the foundation, and the Ministry of Health and its Crisis Medical Committee were always at everyone’s disposal with their logistics, expendable supplies, and staff. In 6 months during 1992, our town hospital treated more than 5,000 wounded people. I know there were days when we admitted over a hundred wounded patients, as well as days when more than 350 blood units were used in one day. An average consumption of blood in those six months was about 54 units a day. Due to sufficient time for preparation and good organization, there wasn’t a moment of delay or waiting for diagnostics, therapy, or resuscitation. Otherwise we would have found ourselves in a very difficult situation, forced to follow rigid utilitarian principles of triage: among the wounded there were a lot of our friends, children, their crying parents, and our employees’ family members, and we do not have a Spartan spirit, nor are we an especially disciplined nation that would put principles above emotions and humanism. Partly because of that, a big earthquake or a terrorist attack would probably cause real chaos initially. One might expect that only resuscitation and surgical skills would be at a satisfactory level, while there would probably be a lot of misunderstandings and inadequate reactions when it comes to organization. When helping in mass-casualty situations, which characteristics should one have? According to most opinions, one should be wise and courageous, but also cautious, just, resourceful, compassionate, willing to make sacrifices, and, last but not least, communicative. Individuals possessing all such traits are rare, if they even exist, which means they are the exception that proves the rule. Let’s start with wisdom. Wisdom is relatively rare, and it is not solely the privilege of the educated. It is possible for an uneducated person to be wise, as it is for an educated person not to have wisdom. We can safely say that it is important for team and system leaders to be wise, because that will influence their subordinates to make wiser decisions too. The problem is that in human relationships it is easier to evaluate competence than wisdom, so we begin to see the wisdom of one’s decisions only after we analyze past events.

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Courage is very important; no one is brave at all times, just as no one is always a coward. There is a certain character predisposition for courage, but it depends on the motive before all. The right motive and good management make people brave. Therefore the old Latins said that calamity is virtue’s opportunity. To be cautious means that even when one is brave, one should avoid unnecessary and pointless risks. I believe that caution is mostly written in our genes, which makes it a common quality. If there is a category of people who are brave but lack caution, then those are definitely young male drivers. Fairness, as well as veracity, might be the most desirable human quality. Doctors and other staff working with the wounded must be fair when approaching the wounded, respecting above all medical ethics and the need for assistance, regardless of age, gender, race, religion, nationality, or social status. To be able to do that, they must be free of commonly present political pressures—a task that belongs to the leaders of teams and institutions. That is possible only in societies where the criteria of a profession are above political criteria and where staff is chosen based on ability rather than political suitability. I can only suppose that in the majority of countries in transition that is still not the case. When the majority of the staff is chosen based on political criteria, fairness is put to serious risk, because politics will always be pragmatic and not ideal, and an individual who owes his job to politics will usually carry out decisions made by the politics and not the profession. Resourcefulness and flexibility are very desirable qualities because in all calamities and disasters unexpected circumstances appear. Resourceful people quickly adjust to changes and find new solutions. Such people usually have a good sense of humor and bring an air of cheerfulness. They try to see the funny side of the tragedy—not because they are not aware of its greatness, but because that way they give extra emotional strength and courage to those around them. Compassion and willingness to make sacrifices are tightly connected. Only someone who loves people and sympathizes with them can be generous. That is why the profession of teacher, priest, or doctor should be a calling rather than just a job. Maybe in the future, society will have psychological tests to choose people for these professions, because without compassion and generosity we cannot meet the demands of these jobs under normal circumstances, let alone in great disasters. Generosity usually includes kindness, willingness to help a colleague and a victim, perseverance, and persistence. No matter how hopeless things look, one must do the best one can. Good communication with associates and the people around us is the key to success. There is never enough time for too much talk, so it is very important for communication to be short and clear. One must take into account that in times of action one must lead by example, because nonverbal communication can sometimes be more important than verbal. These are in short the most important characters and moral traits that a person helping the injured must have. Therefore it is very important for team and institution leaders—those who organize and lead people—to have as many of these characteristics as possible. Only moral and capable individuals can lead by example and increase people’s emotional energy that is needed to fight calamities and disasters.

References [1] Jostien Gaarder, Sophie’s World, New York, Berkley Books, 1996. Handbook for Pandemic and Mass-Casualty Planning and Response, IOS Press, Incorporated, 2012. ProQuest Ebook Central,

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Croatia’s State and Medical Authority for Health System Organizations a

Ante Cvitkovia Institute of Public Health Brod-Posavina County, Croatia

Abstract. Information sharing in disasters and emergencies is a challenge in conditions where a rapid alert system does not exist. The role of institutes of public health must be emphasized. The major institute in Croatia is the national one, and it coordinates the work of the second-level (county) institutes. In our paper we will closely describe the organization scheme.

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Keywords. Croatia, health organization, public health

Health service organization as well as the organization of all society is of great importance in catastrophes and emergencies: earthquakes, floods, etc. Every mass accident or epidemic has a large number of casualties as a result. All of them need immediate help; thus major resources and great knowledge are required. When an epidemic happens, for example, the physician acts without a real hypothesis when the urgent protection of people is necessary and the public interest is enormous[1, 2, 3]. In such cases, the organized system is needed in order to reduce the inevitable damage. In the state of chaos, rumors and unverified information can spread, and that leads to even bigger problems in organizing the response. Every country or local community must have a prearranged scenario for such cases. Every individual, as well as the institution, must get accurate and timely information. Croatia had some cases in the past (sudden death on hemodialysis, epidemics) when everyone wondered whether everything had been carried out well enough and fast enough[4, 5]. The lapses in organization and information cause a higher number of casualties. Today Croatia’s health system organization, where infectious diseases and epidemic are concerned, is a good way of managing information flow. Public health in Croatia is organized through the institutes of public health, and the whole procedure of notification of disease or death from infectious disease is regulated by law. There are 21 Institutes of Public Health in Croatia, one in each county, and the head institute, the Croatian National Institute of Public Health in Zagreb, coordinates their mutual professional work. Every institute consists of the Epidemiology Service (for infectious and noninfectious diseases); Human Microbiology Service; School Medicine Service; Service for Public Health, Mental Health, Prevention and Addiction Treatment; and Health Ecology Service. Each institute’s Epidemiology Service consists of epidemiological teams. Every team has a doctor-epidemiologist, sanitary engineer, and nurse. The teams are equipped for field work. Besides that, each institute has at least one branch office, usually in another town in the county. In case of an epidemic or unusual contagion, the law requires that the branch office phone or fax the county institute and inform the epidemiologist. All physicians are obliged to inform the Institute of Public Health immediately when

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contagious disease is discovered, but no later than 24 hours after a death or the appearance of the disease. Every institute is obliged to inform the Croatian National Institute of Public Health at once. The county institutes and the national institute are obliged to inform the Ministry of Health, as well as the Sanitary Inspection Department, which issues a legally binding decision, on the recommendation of the epidemiologist. It is of great importance to inform everybody involved, because epidemics can cross county borders and thus require management by the Croatian National Institute of Public Health. All the institutes staff their Epidemiology Service around the clock. When something exceptional happens (for example, anthrax or pandemic flu), the epidemiologist must issue the “zero report.” The experience with the sudden deaths on hemodialysis in 2003 showed that quick reaction is essential, prompting the Ministry of Health regulation requiring that all uncommon health events be reported to it and to the Sanitary Inspection Department. The Sanitary Inspection Department controls the execution of actions to protect public health, especially implementing the Law on the Protection of the Population from Infectious Diseases; the actions it orders have the force of law. The Sanitary Inspection Department controls the health surveillance of international passengers, germ carriers, certain categories of employees, physicians, hospitalizations, isolations, and quarantine.

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CroatianNationalInstituteofPublicHealth

CountyInstituteofPublicHealth

MinistryofHealth

Hygienicepidemiologicalbranchoffices

SanitaryInspection

Doctors,healthcareprofessionals,population Figure 1. Information sharing in Croatia (outbreak).

When sudden and unexpected mass accidents happen, the Protection and Rescue Headquarters (which exists in every county) is activated according to a thorough plan. County authorities have the responsibility to create their own rescue plan. The county Protection and Rescue Headquarters includes the head of the community, the chief of civil protection, the police chief, the fire chief, directors of health facilities, the director of the center for social welfare, the director of the Red Cross, the director of the electric supply, members of the mountain rescue service, the director of the water supply, veterinarians, the agricultural extension service, and directors of health institutes. Thanks to such organization, immediate reaction is possible. All members of Protection and Rescue Headquarters are linked through the 112 emergency phone service. In extraordinary cases, information sharing is important in order to avoid unnecessary

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casualties and panic. Communication with the media is important too. The control of a crisis is of great significance and requires knowledge and resources. Organization and reaction rate are the mirror of society.

References

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[1] D. Coburn, State authority, medical dominance, and trends in the regulation of the health professions: The Ontario case, Social Science and Medicine 37 (1993), 841-50. [2] N.L. Grier, G.G. Homish, D.W. Rowe, and C. Barrick, Promoting information sharing for multijurisdictional public health emergency preparedness, Journal of Public Health Management and Practice 17 (2011), 84-9. [3] F.M. Burkle Jr., Mass casualty management of a large-scale bioterrorist event: An epidemiological approach that shapes triage decisions, Emergency Medicine Clinics of North America 20 (2002), 409-36. [4] A. Cvitkovi, M. Mileti-Medved, and I. Gjenero-Margan, An epidemic of trichinellosis in autumn 2004 in Slavonski Brod, Acta Medica Croatica 61 (2007), 215-8. [5] I. Gjenero-Margan, V. Hrabak-Zerjavi, B. Aleraj, V. Kralj, B. Kai, and V. Gasparovi, Role of epidemiologic information system in sudden death prevention among Croatia’s haemodialysis patients, European Journal of Epidemiology 18 (2003), 299-303.

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Croatia: Community, Empowerment, Resiliency a

Katy JACKSONa and Elin GURSKYb Intern, Analytic Services Inc., Arlington, Virginia, USA b Analytic Services Inc., Arlington, Virginia, USA

Abstract. Emerging from a quasi-socialist economy and civil war, Croatia has demonstrated a community resilience that, along with Croatia’s membership in the European Union, bodes well for the future of its public health system. Keywords. Croatia, community, resilience, public health

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1. Evolving demographics Croatia (capital, Zagreb) is a crescent-shaped country with an extensive coastline along the Adriatic Sea. Between 1961 and 1981 Croatia’s annual population growth was largely the same as that of most developed countries (.95 percent)[1]. In 1953, its population was approximately 3.12 million, and in 1971 its population was approximately 3.51 million[1]. In many respects, Yugoslavia was a model for how to successfully build a multinational or multiethnic state. The communist republic was composed of over 20 ethnic groups—Orthodox Serbs, Catholic Croats, and Muslim Bosniaks having the largest population distribution—and six separate republics: Croatia, Macedonia, Montenegro, Serbia, Croatia, and Bosnia-Herzegovina. The demographic history of Croatia has been largely characterized by mass migration. By the 1940s and 50s, much of the German and Italian populations displaced from Croatia after World War II were absorbed by Bosnia-Herzegovina, Serbia, and Montenegro. In the 1960s and 70s, another wave of migrants left Croatia in search of economic opportunities in the west (Canada, Western Europe, and the United States)[2]. Despite the migrations, Croatia remained relatively uniform. In 1953, Croats constituted 79.6 percent of the population, while Serbs accounted for 15 percent and Bosniaks and/or Muslims just 0.4 percent. Similarly, in 1961 Croats constituted 80.3 percent of the population, while Serbs again accounted for 15 percent, and Bosniaks and/or Muslims accounted for 0.1 percent[1]. Nationalist sentiment within Croatia can largely be attributed to the insubstantial variances in ethnic distribution.

2. Economic and health indicators The constitution of Yugoslavia emphasized both market socialism and universal health care. All citizens were entitled to basic health services and quasi-monopsonistic health insurance[3]. Males born in 1960 were expected to live to approximately 63, women to approximately 69. In 1980, male life expectancy was approximately 67, while female

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life expectancy was approximately 75[4]. Life expectancy was significantly higher under Tito’s regime, primarily due to a decrease in infant mortality rates (118.6 deaths for every thousand births in 1950 versus 26.2 deaths per thousand in 1987). Between 1951 and 1980, the number of live births dramatically decreased from 87,564 in 1951 to 68,220 in 1980[4]. Furthermore, after World War II, the mortality rate in Yugoslavia abruptly declined. In 1948, Croatia had a mortality rate of about 22.1 per thousand, while the mortality rate in 1984 of 9.3 per thousand was miniscule in comparison[1].

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3. Socialism’s “shared community” Following the collapse of Austria-Hungary in 1918, Croatia joined Slovenia, Serbia, and Montenegro to form the kingdom of Serbs, Croats, and Slovenes (the name was changed to Yugoslavia in 1929). By the end of World War II, Yugoslavia’s name was changed once more to the Federal People’s Republic of Yugoslavia. Under the communist leader Marshal Tito, all political parties and ethnic divisions were abandoned and parliamentary government was suspended. The system in Yugoslavia provided for “a new interpretation of the federation as one national community”[4]. Life was meant to develop in terms of Yugoslav dimensions rather than cultural dimensions. Under Josip Tito, the new constitution was based upon self-management federalism, emphasizing a shared single language and culture, rather than self-determination socialism that could lead to competition, the breaking of friendships, and the spreading of hatred among peoples[4]. Tito espoused a carefully engineered policy to control the national ambitions of Serbs and Croats. No single ethnicity was given the opportunity to wield more political power than the other, and nationalist sentiments were promptly suppressed[5]. During the 1950s and early 60s, ethnic tensions among rival nations (especially between Croatia and Serbia) began to rise, and in 1963, the constitution was altered to refer to Yugoslavia as a “community of nations,” in which Croatia and its neighbors were given “greater freedom to regulate their own internal constitutional and organizational structures”[6]. It remained thereafter, until the death of Josip Tito in 1980, that each nation was to independently govern its internal affairs in line with federal Yugoslavian guidelines. Croatia was one of the wealthiest of the Yugoslav republics. Even still, the economy of the socialist Yugoslavia was much different than those of its eastern European communist counterparts. Though markets and businesses were ultimately owned by the state, the employees wielded unprecedented collective management powers (as compared to complete socialist markets in other communist countries). Furthermore, basic organizations of associated labor—small companies in which “the right to decision-making and a share in profits of worker-run companies was based upon the investment of labor”—were applied to health and education to ensure that all employees had the same access to decision-making as everyone else[6]. Private property was nationalized and public works projects were created to combat unemployment. During the 1960s and 70s, Croatia underwent intensive industrialization, increasing industrial output, health services, and education tenfold. In lieu of Croatia’s progress (as well as the progress of the other republics) Yugoslavia perpetuated three objectives: social ownership of a self-managing provider organization, a commitment to primary health care and education, and a continuous expansion and improvement of social and public services.

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4. Turmoil and community resiliency “Community resiliency” has been used with growing frequency over the past decade to describe the physical and psychological agility seen in communities that successfully emerge from public health emergencies—naturally occurring, intentionally introduced, or accidental. Often ascribed to the ability of civic leaders, citizens, and families that are educated and empowered to mitigate their own (and others’) risk, this resiliency, in turn, minimizes the need for significant outside response resources or assistance[7]. Community resiliency also mitigates the so-called “secondary disaster fear” wherein the public devolves into hysteria or violence to gain access to medical countermeasure products[8]. Recent experience in the United States has demonstrated that building community resilience is no easy task. For example, to build collective resilience, communities must first strive to reduce risk and resource inequities[9]. Communities must be educated and trained—this includes gaining familiarity with local public health and medical systems—to prepare for or respond to public health threats. Empowered communities also depend upon established organizational and social linkages or networks to fall back upon. Furthermore, trusted and established sources of information, capable of functioning in a variety of contexts, are also critical. Recent research has shown that communities with an ingrained social identity and set of “communal stories” appear most prepared to account for complex problems during public health emergencies[10]. A collective physical or emotional trauma has been shown to unite communities in such a way, so long as the conflict does not undermine ingrained social structures[11]. In this vein, the Kosovo conflict and Croatia’s subsequent independence serve as an important case study in postwar community resilience capabilities.

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5. Croatia today Today, Croatia’s economy, functioning under an open-market policy, competes globally. Much of Croatia’s economic activity has centered upon restructuring large companies previously owned by the state in order to increase competition within Croatia and outside of its borders in the global economy. During the 1991-1995 Croatian War of Independence, the former Yugoslavian economy severely suffered. Resources in all spectrums (medical, industrial, human, etc.) were exhausted, and the region entered an alarming postwar depression. However, led by a rebound in tourism and credit-driven consumer spending, Croatia saw “moderate but steady” growth in its gross domestic product from 2000 to 2007[12]. Croatia’s recent accession to the European Union has incredibly positive implications for the future of the economic and political system within the country. The EU grants membership to any European country that is democratically stable, willing “to take on the obligations of membership,” and operating under a functioning market economy[6]. With these requirements in mind, it is important to take heed of Croatia’s rapid developments. Before 1991, Croatia was part of a socialist regime with quasi-communist policy. Just over 30 years later the country has become a nation emphasizing previously rejected Western ideals, structures, and systems. Accession to

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the EU has led to greater foreign investment, export growth, political stability, and public funding within Croatia. The political and economic expansions and improvements within Croatia can be no less than beneficial for the country’s public health system. The EU has taken a strong stance on the importance of its members’ public health systems: the transformative potential of health policy simply cannot be overlooked.

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References [1] Photius Coutsoukis, Yugoslavia (former) population, republished from the Library of Congress Country Studies and the CIA World Factbook, 2004, www.photius.com/countries/croatia/society/yugoslavia_ former_society_population.html. [2] United Nations Development Programme, Globalization with a human face, Human Development Report 1999, Oxford University Press, New York. [3] UN Security Council, Items relating to the situation in the former Yugoslavia: Initial proceedings, 1991, www.un.org/en/sc/repertoire/89-92/Chapter%208/EUROPE/item%2020_Yugoslavia_.pdf. [4] Ana Trbovich, A Legal Geography of Yugoslavia’s Disintegration, Oxford University Press, New York, 2008, 147-188. [5] Shirley Scott, International Law in World Politics: An Introduction, Lynne Rienner, Boulder, Colorado, USA, 2010, 124-129. [6] Margaret Karns and Karen Mingst, International Organizations: The Politics and Processes of Global Governance, Lynne Rienner, Boulder, Colorado, USA, 2010, 485-486. [7] Homeland Security Presidential Directive 21, National strategy for public health and medical preparedness, October 2007. [8] M. Schoch-Spana, Community resilience for catastrophic health events, editorial, Biosecurity and Bioterrorism: Biodefense Strategy, Practice, and Science 6 (2008). “In hypothetical scenarios and tabletop exercises, members of the public appeared as mass casualties or hysteria-driven mobs that selfevacuated affected areas or resorted to violence to gain access to scarce, life-saving drugs and vaccines. According to extensive social research into disasters, however, people rarely fall apart and put themselves first.” [9] F. Norris, S. Stevens, B. Pfefferbaum, et al., Community resilience as a metaphor, theory, set of capacities, and strategy for disaster readiness, American Journal of Community Psychology 41 (2008), 127-150. [10] D.D. Brown, J.C. Kulig, The concept of resiliency: Theoretical lessons from community research, Health and Canadian Society 4 (1996-97), 29-52. [11] Arlene Audergon, The War Hotel: Psychological Dynamics in Violent Conflict, Whurr-Wiley, London, 2005, 173-207. [12] Index Mundi, Croatia Economy Profile 2012, www.indexmundi.com/croatia/economy_profile.html.

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Section 2: Principles of Response to Catastrophes with Mass Casualties

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Basics of Terror Medicine Boris HREKOVSKIa, Bob DOBSONb, Philipp FISCHERc, and Mark LOADESd Department of Surgery, General Hospital Slavonski Brod, Croatian Urgent Medicine and Surgery Association b Hanover Associates London, United Kingdom, Croatian Urgent Medicine and Surgery Association c Department of Surgery, University Clinic Bonn, Germany d FMP Protection London, Croatian Urgent Medicine and Surgery Association a

Abstract. One of society’s biggest challenges is to prevent terrorist attacks. Good intelligence will assist with identifying the risks, the terrorist capabilities, and current trends, but it is inevitable that some attacks will succeed. This considered, the need for planning has never been greater—in fact it is essential. Based on this, those involved have a responsibility to plan for numerous potential situations; the planning should include preparedness, response, and recovery activities. After a terrorist attack where there are casualties or mass casualties, in almost all situations we have to deal with the victims. Dealing with mass-casualty incidents is not a daily occurrence for those who would be involved in the chain of survival, and therefore it requires specific organization and protocols. Terror medicine includes medical management from the scene to post-hospital care, as well as a multiagency approach. Keywords. Terrorism, major incidents, terror medicine

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1. Terrorism in the civilian environment Global proliferation of terrorism is part of today’s world. It is a condition (fact) that we have to live with, and we have to fight it together. The word terrorism originates from the Greek word therares, which means “to terrify.” The first modern use of the term was in the 18th century during the French Revolution, when it was used to describe the actions of Jacobins during the Reign of Terror. The 21st century started with the global war on terrorism after the 9/11 terrorist attacks. To be more effective in the combat against terrorism, Western countries formed an antiterrorist alliance, but at the same time on the opposite side we can see the transformation of different terrorist groups or organizations in the global terrorist movement. More than 100 definitions of terrorism exist in today’s world, with 22 different definitional elements, and they vary from country to country. It is hard to have a complete definition of terrorism because different types of terrorist activity exist. United Nations Secretary-General Kofi Annan in 2005 described terrorism as “any action … intended to cause death or serious bodily harm to civilians and noncombatants with the purpose of intimidating a population or compelling a Government or international organization to do or abstain from doing an act”[1]. The European Union defines terrorism in Article 1 of the Framework Decision on Combating Terrorism as “intentional acts, defined as offences under national law,

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which, given their nature or context, may seriously damage a country or an international organisation where committed with the aim of: x seriously intimidating a population, or x unduly compelling a Government or international organisation to perform or abstain from performing any act, or x seriously destabilizing or destroying the fundamental political, constitutional, economic or social structures of a country or an international organisation”[2] No matter which definition we use to describe terrorism, three main factors are usually constant: 1. Acts or threats of violence to the civilian population 2. Fear inspired in an audience beyond the immediate victim 3. Political, economic, or religious aims by the perpetrator(s)

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2. Terrorist strategy The incidence of terrorist attacks is increasing. New technologies and rapid and easy information sharing mean that global knowledge is doubled every 3 to 4 years, so the new assets are available to everyone and are easily distributed, and in the era of globalization they can be used by the global terrorist movement for its purposes. It is written in an al-Qaeda training manual: “By using public sources openly and without resorting to illegal means, it is possible to gather at least 80% of all information required about the enemy”[3]. Terrorist websites for online training, recruiting new members, collecting intelligence, and sending encrypted messages have increased more than 500% in the last decade. The Internet helps terrorists promote their methods, suggest potential targets, glorify people who commit terrorist attacks, and develop a worldwide network based on personal relationships. Terrorists use violence to raise fear in a population and to create a condition that may lead to political and/or social changes. They use mass media like a weapon to spread their messages of fear or intimidation to the public. Fear is one of the most potent factors that can lead to public reactions, forcing a government to make social or political changes. There are different types of terrorist groups, including nationalist, ideological, religio-political, state sponsored, and single issue. The secretive cell is the main type of terrorist organization, usually consisting of two to five members with its own logistics. The commander of the cell is the only person who communicates with higher levels and other cells. The single terrorist lone wolf is something else, very hard to understand, prevent, and/or detect, as a 2011 terrorist attack by A.B. Breivik in Norway demonstrated. Preparing a terrorist attack consists of four stages: 1. Target selection—studies of the vulnerability of protective systems in the target area 2. Collection of material (slowly to avoid attention) 3. Preparation of the material such as an improvised explosive device (IED)— somewhere in a hidden place 4. Preparation for the attack—the shortest stage

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IEDs are the most common weapon used by terrorists today; these weapons are simple to make and easy to hide, with enormous potential to destroy. Terrorist doctrine is to bring the right explosive to the right place and detonate it at the right time—tactics commonly used by a suicide bomber (a sophisticated smart bomb). The main components of IEDs: 1. Batteries for a power supply 2. A trigger, which can be a radio signal; the most popular remote trigger is a cell phone 3. A detonator, usually electrical 4. A primary explosive, usually from unexploded landmines 5. Additional components such as nails, fire-starting chemicals, or even toxic materials 6. An envelope, a container, or camouflage for hiding the IED

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Terrorists sometimes use a bomber vest—a combination of explosives packed with nails and screws to produce small high-velocity shrapnel.

Figure 1. A suicide bomber vest (courtesy of Police Unit Brodsko-Posavska, Croatia).

Basic methods of using an IED: 1. Vehicle-borne: a car or truck filled with camouflaged explosives, parked at or driven to a designated area 2. Pedestrian-borne: a suicide bomber (male, female, or handicapped child) 3. Packaged: camouflaged in, for example, an envelope or dead animal Main factors that influence energy transfer to the human body after the explosion: 1. The power of the explosive device 2. The medium in which the explosion occurs 3. The distance of the human body from the center of the explosion

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Immediate deaths on the scene correlate much more with the medium in which the explosion occurs than with the magnitude of the explosion. Closed or semi-closed spaces do not need a large amount of explosives to produce deadly effects, compared to open space.

Figure 2. An explosion threw half a victim’s body into a tree: the effect of the blast from an antipersonnel land mine in combination with an antitank land mine.

Some terrorist groups use tactics to produce as many victims as they can, with the purpose of creating conditions that may lead to some political or social changes based on public and government reactions to the particular attack (Beirut 1983, Madrid 2004). A 2011 terrorist attack at a Moscow airport demonstrated what damage can be done by a relatively small amount of explosives in an enclosed space. The 1995 Oklahoma City bombing used a vehicle-borne IED parked in front of a building and caused it to collapse; many casualties were trapped and suffered crush injuries.

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3. Basics of terror medicine Global proliferation of terrorism establishes the need for a new discipline—terror medicine—as a special part of disaster medicine. Terror medicine will enable us to prepare for, respond to, and recover from possible terrorist attacks. It consists of four main parts: 1. Preparedness—a special epidemiology of terror threats and injuries, along with prevention measures 2. Incident management—a specific management and multiagency approach 3. Management of specific injuries 4. Epidemiology and management of psychological consequences 3.1. Preparedness Preparedness includes a multiagency approach and developing standard operative procedures for a possible crisis. It considers planning, education and training, and evaluating and monitoring activities needed to enable effective coordination and the work of the agencies involved in preventing, protecting against, responding to, and recovering from terrorist incidents. We need to be ready in advance to react promptly and effectively. Advance planning will reduce possible confusion and improve decision making.

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Preparedness consists of 1. Risk analyses: what is the possible threat and what could it do? What are the vulnerabilities of our system and standard operative procedures according to this (terrorist) threat? 2. Communication protocols for easily understandable terminology. 3. Standard operative protocols for multiagency emergency personnel. 4. Interactive education and training of the whole chain of management—scene, transport, hospitals, command and control, and communication—in their positions. 5. Preparation of reserve systems for electricity, water, food, communication, computer support, and medical supplies for mass-casualty management based on risk analysis. 6. Information sharing between organizations involved in emergency management.

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Many lessons could be learned from experience of terrorist attacks. No matter where there are casualties or mass casualties, in almost all situations we have to deal with the victims, with large variations in profiles: children, males, females, the elderly. Dealing with mass-casualty incidents is not a daily occurrence for those who would be involved in the chain of survival, and therefore it requires specific organization and protocols. The mechanism and distribution of injuries caused by terrorist attacks are different from what we see in victims that we deal with in everyday practice (mostly blunt trauma), with some similarity to war injuries. It is important to know two basic facts that all medical and other emergency personnel have to consider: 1. No war starts without warning—we usually have enough time to prepare, because the pre-event phase is long with clear signs. 2. A terrorist attack starts without any warning signs—the majority of terrorist attacks occur with a very short pre-event phase carefully hidden to leave no time for us to prepare.

Figure 3. Explosion wounds at a mass-casualty incident in a soccer stadium, Slavonski Brod, Croatia, 1992. Two 155 mm artillery shells exploded among refugees from Bosnia, producing 108 casualties.

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Terrorist attacks will strike the unprepared civilian population in their everyday living environment, suddenly, unexpectedly, with prevalent blast injuries. To deal with the consequences of terrorist attacks, we should prepare for response and recovery. In terror medicine that includes the whole spectrum from preparedness and medical treatment of injuries to psychological care of victims. Modern trauma care starts on the scene but also should include an injury-prevention phase. This is complicated by the fact that terrorist activity is not easily recognized in the pre-event phase, in contrast to natural disasters such as hurricanes and volcanic eruptions. Furthermore, societies react differently to major incidents caused by terrorism than to those caused by nature. Prevention of terrorist activity is the duty of intelligence work, but appropriate education and training of all agencies involved in the emergency response could benefit the whole society. They also require an adequate information-sharing process (see section 3). A multiagency approach should be a part of terrorist incident management and consider the coordination and collaboration of three main emergency services: police, fire brigade, and ambulances and medics.

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Figure 4a. Multiagency training exercise for a terrorist scenario—police, medics, and the London Ambulance Service. Medics step in once the police control the scene.

Figure 4b. London Ambulance Service personnel discuss possible conditions that could be expected in a terrorist scenario, Slavonski Brod, Croatia, 2008.

Rapid response with multiagency units will minimize the impact of terrorist attacks. Proper planning and preparedness are important but cannot replace education and training. Skills, knowledge, and organizational protocols have to be tested with accurate, correct, interactive training models.

Figure 5 (a, b). The Medical Response to Major Incidents Course uses a simulation model for education and training. Details from the hospital and incident scene—working positions in the exercise based on a terrorist incident scenario, Slavonski Brod, Croatia, 2011. Handbook for Pandemic and Mass-Casualty Planning and Response, IOS Press, Incorporated, 2012. ProQuest Ebook Central,

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3.1.1. Incident management A multiagency approach and information-sharing process need to be adopted in civilian mass-casualty management. The decision-making process is crucial during major incident management, much different than in daily work routine, and requires proper education and training. One wrong or late decision during a mass-casualty response could produce more casualties, as we see in examples from the past when a major incident was declared too late. From the viewpoint of incident management, a terrorist incident may start like a major incident or become a major incident later. Multiagency work (police, firefighters, medics) during mass-casualty management needs a unified command organization at the top level. A unified command structure enables 1. A collective approach to strategy 2. Better information sharing among agencies 3. Agencies’ tactical plans and actions to be known by everyone involved in the management process 4. The efforts of all agencies to be optimized and cost effective

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On-scene medical personnel have to work in coordination with police and firefighters and establish a check or rendezvous point fast. Recent terrorist attacks show us the intention to produce more damage with a secondary hit on emergency personnel either on the scene or in hospitals. All emergency personnel have to be educated about possible secondary devices. Lessons learned from past terrorist attacks point to two similar tactics: a) A smaller bomb will be activated to bring emergency personnel to the place of the incident. A larger and stronger bomb will be activated later to produce more casualties that include emergency personnel. b) A terrorist will activate a bomb or even simulate a threat of it to start the evacuation process and then activate IEDs in evacuation assembly areas. Medical personnel will manage casualties on the scene when they get information and permission from police and firefighters that it is reasonably safe to do it. A multiagency approach considers that all those involved in managing a major incident know their duties and responsibilities and will avoid duplication of functions and decisions. Personal protection equipment, triage cards, and action cards for the medical incident commander, triage officer, and ambulance loading officer should be supplied to all medical personnel on scene. Action Card for the Medical Incident Commander[4] 1. 2.

3.

Deliver a window report to the alarm center (a rough estimate of the number of casualties and need for transport and medical care on scene). Confirm a major incident. If a major incident is not already declared but apparent on arrival, inform the alarm center and act according to major incident plans until contact from the regional medical center. Park the ambulance and put on tabards for the medical incident commander, triage officer, and other crew members.

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4.

5. 6. 7.

8. 9.

10.

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11.

12. 13.

14. 15.

Contact the rescue incident commander and police incident commander (if arrived) direct or by channel. x Require information about  Estimated number of injured and dead  Risk zones (hot, warm) and other risks on scene  Those in most urgent need of care  Required and expected resources from the rescue service x Decide together with the rescue incident commander the location of casualty clearing and ambulance loading zones Decide whether incoming ambulance crews should be kept on scene for medical support, and if so how many and for which tasks. Dispatch the triage officer to start primary triage according to the action card. Make a quick survey of the scene and x Estimate again the number and severity of casualties x Identify the need for support in the injury zone (people trapped?). Identify urgent needs! Decide the appropriate level of major incident as a guideline for medical work; inform all staff and reevaluate this level continuously. Contact the regional medical center channel (if there is no contact with the regional medical center, contact the alarm center) and x Deliver a second report based on the information above x Request that prehospital teams be sent to the scene if needed x Request helicopters if needed and not already alerted x Request a distribution key for transports to the hospital Start transport of patients triaged by the triage officer. Until the distribution key is given, start to send the severely injured (those in potential need of immediate surgery and/or ventilator) to available hospitals. The more severely injured should not be sent until the distribution key is received. Organize casualty clearing and ambulance loading zones for primary and secondary triage and dispatch teams to those zones; also dispatch teams when needed to the injury zone (but not into the risk zone without first communicating with the rescue incident commander). Appoint an ambulance loading officer for transport coordination. Repeat contacts with the regional medical center, update reports from the scene, request updated distribution keys, and request additional support and equipment when needed. Maintain contact with the rescue incident commander and police incident commander; in large incidents, establish a command post. Cancel the major incident status on scene in agreement with the regional medical center once all the injured are evacuated. Inform the rescue incident commander, police incident commander, and all medical staff on scene. Lead a debriefing for all medical staff before their departure from the scene.

Countries that have experience and good preparedness for possible terrorist attacks usually use special communication codes for specific types of terrorist incidents. For medical personnel it is crucial to establish contact with police, establishing where the rendezvous point is and by what route to approach it.

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An appendix for an action card in a case of a terrorist incident will be 1. Is this a coded attack or response? 2. Where is the designated rendezvous point? 3. Confirm whether a stop has been called 4. Consider appointing a safety officer 5. Consider a press liaison officer Lessons learned from the Mumbai incident show us how terrorists carefully plan their actions and how simultaneous attacks on two or more positions could make problems for emergency agencies managing a crisis. The strategy for medical treatment on scene in a majority of mass-casualty incidents is Load and go. Sometimes the tactical situation on scene with long and delayed transport to the hospitals, delayed evacuation from the incident place (trapped casualties, for example), and inadequate transport facilities will require a different strategy: Stay and play. Hospitals should have disaster plans that will work in reality to avoid paper plan syndrome (“illusion of emergency preparedness based on the mere completion of a written plan”)[5]. Hospital disaster plans should be integrated into regional and national crisis plans. During major incidents, hospital emergency departments usually receive casualties in a dual wave. Lightly wounded and walking casualties come in a first wave without ambulance transport and tend to overload an emergency department. Heavily injured casualties (priorities 1 and 2) come in a second wave by ambulance. Good triage on the scene can decrease the impact of this dual-wave phenomenon. Proper education and training in terror medicine will enable us to avoid over-triage at hospitals during major incident management. Most terrorist attacks have occurred in areas of high population density with the intention to maximize damage, with injury patterns characterized by a large number of minor injuries, and even a large clinic hospital could be overcrowded. Experience from terrorist incidents shows us that over-triage is common in those events. Frykberg’s analysis of 12 major terrorist bombing incidents showed a linear relationship between over-triage and the critical mortality rate[6]. Special attention has to be given to hospitals, which are designed to welcome patients and because of their construction and organization are potentially soft targets. Proper hospital plans for mass-casualty incidents that include possible terrorist activity need to consider these factors: 1. Security of the hospital 2. Security of the patients 3. Security of the ambulance vehicles parked at the entrance 4. Security of the grounds 5. Issues regarding ethnic groups within the hospital 6. Care of casualties’ relatives 7. Coordination with police and security services 8. Coordination with media 9. Communications with foreign embassies and VIP visitors Good coordination, communication, and a multiagency approach with adequate information sharing from the scene to the hospitals after a mass-casualty incident caused by terrorist activity could benefit organization and damage control in the chaotic first phase. In our daily practice, the majority of civilian trauma casualties are caused by traffic accidents, dominated by blunt trauma. Casualties from terrorist attacks suffer from a

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combination of blunt, penetrating, burn, and blast injuries (see “Guidelines for Limb Amputation and Reconstruction in Mass-Casualty Incidents,” “Burn Injuries during Mass-Casualty Incidents,” and “Blast Injuries”). Blast injuries cause many problems because most critical care providers are unfamiliar with the signs and symptoms of blast overpressure damage to the human body. Explosions produce multiple lifethreatening injuries to many casualties simultaneously, and this presents unique triage, diagnostic, and treatment challenges to medical providers. Civilian emergency departments are mostly unprepared for many sudden incoming casualties suffering from IED wounds (see “Treatment Algorithms and Hospital Triage in Mass-Casualty Incidents”).

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Figure 6. IEDs are the leading cause of traumatic amputations

Terror medicine emphasizes specific management of terror injuries, with attention to the principles of blast injury care. More than 80% of terrorist activity uses conventional explosive devices, and emergency personnel involved in managing the casualties should have basic education in blast physics and its effects on the human body. Blast injuries are divided into five categories: 1. Primary—caused by the direct effect of the blast wave (the immediate increase in air pressure after the explosion). The distance from the center of the explosion, the environment where the explosion occurs, and the duration of the overpressure wave affect injury severity. A blast wave in a closed space could be intensified by reflections from the walls, creating a stronger and more lethal complex blast wave. Primary blast injuries are usually lethal or lead to traumatic amputations and seriously damage vital organs (lungs, intestine, brain). 2. Secondary—produced by shrapnel from IEDs, fragments from the blast environment (glass), or fragments from the suicide bomber’s body or other victims. 3. Tertiary—produced by the impact of the casualties’ bodies with another object thrown or pushed by a strong blast wind. In the case of structural collapse from an explosion, we can expect crush injuries also. 4. Quarternary—produced by dust, smoke, and toxic fumes and manifested in the form of burns, asphyxiation, and inhalation injuries. 5. Quinary—produced by additives to the weapon (bomb)—radiation, chemical agents, bacteria.

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Many articles, seminars, symposiums, media, and government attention are devoted to weapons of mass destruction. Biological, chemical, and radiological agents pose great risks to our society; these weapons are extremely dangerous and need our attention and preparedness, but they are complex and hard to create. Meanwhile, the number of deaths caused by simple, inexpensive, easy-to-make IEDs is continuously increasing, and we should be educated and trained in the epidemiology and management of injuries caused by this fourth weapon of mass destruction. For more information on medical treatment of blast injuries see “Treatment algorithms and hospital triage in masscasualty incidents.” 3.2. Epidemiology and management of psychological consequences To live in an unsafe environment could be traumatic and lead to various psychological disorders. Terrorists use violence to raise fear in the population and count on wideranging psychological effects such as anxiety and behavior changes simply by raising the threat of terrorist attack. The possible threat of a biological weapon could produce fear and a variety of anxiety symptoms in society. Post-traumatic stress disorders are common among victims and their relatives after terrorist attacks, and we should know how to cope with this specific issue and what we can do to prevent it. Casualties and their relatives need psychological support, and all emergency personnel should be educated in psychological first aid.

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Conclusion The increasing incidence of terrorist activity in the last decade with specific types of injuries among a wide population, usually in the form of major incidents with significant psychological consequences for individuals and society, establishes a need for a new discipline: terror medicine, a special part of disaster medicine. In many parts of the world the question is when, rather than whether, a terrorist attack will occur. The mechanism and distribution of injuries caused by terrorist attacks are different from what we see in the trauma victims we deal with in everyday practice. Terror medicine includes medical management from the scene to post-hospital care and a multiagency approach. Education and training about basic terror medicine will provide our society with better protection against terrorist incidents without sacrificing any individual rights in order to make society safer.

References [1] Annan lays out detailed five-point UN strategy to combat terrorism, United Nations press release, 10 March 2005, www.un.org/apps/news/story.asp?NewsID=13599&Cr=terror&Cr1=. [2] European Union EurLex, Council Framework Decision of 13 June 2002 on combating terrorism, http://eur-lex.europa.eu/LexUriServ/LexUriServ.do?uri=CELEX:32002F0475:EN:HTML. [3] T.L. Friedman, citing D. Rumsfeld, The world is flat, Macmillan, New York, 2007, 600. [4] Adapted from S. Lennquist, Medical Response to Major Incidents Student Manual, Springer, New York, 2011, courtesy of the MRMI faculty board. [5] Disaster Dictionary, Suburban Emergency Management Project. [6] E.R. Frykberg, Medical management of disasters and mass casualties from terrorist bombings: How can we cope? Journal of Trauma 53 (2002) 201-12. [7] M. Abrahms, What terrorists really want, International Security 32 (2008), 78-105.

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[8] L. Aharonson-Daniel, Y. Klein, K. Peleg, and Israel Trauma Group, Suicide bombers form a new injury profile, Annals of Surgery 244 (2006), 1018-23. [9] G.R. Ciottone, et al., Disaster Medicine, Elsevier-Mosby, Philadelphia, Pennsylvania, USA, 2006. [10] Y. Musharbash, The future of terrorism: What al-Qaida really wants, Spiegel (2005). [11] D. Goldschmitt and R. Bonvino, Medical Disaster Response, CRC Press, Boca Raton, Florida, USA, 2009. [12] N. Hassan, An arsenal of believers, New Yorker, 2001. [13] N. Hassan, Al-Qaeda’s understudy, Atlantic Monthly 293 (2004); 42-44. [14] D.E. Hogan and J.L. Burstein, Disaster Medicine, second edition, Lippincott, Philadelphia, Pennsylvania, USA, 2007. [15] C.L. Horrocks, Blast injuries: Biophysics, pathophysiology and management principles, Journal of the Royal Army Medical Corps 147 (2001), 28-40. [16] S. Lennquist, ed., Medical Response to Major Incidents: A Practical Guide for All Medical Staff, Springer Verlag, Berlin Heidelberg, 2012. [17] S. Lennquist, Education and training in disaster medicine, Scandinavian Journal of Surgery 94 (2005), 300-310. [18] S. Lennquist, Management of major incidents and disasters: An important responsibility for the trauma surgeons, Journal of Trauma 62 (2007), 1321-1329. [19] London Metropolitan Police, London Emergency Services Liaison Panel Major Incident Procedure Manual, seventh edition, 2007. [20] L. Napoleoni, Insurgent Iraq, Seven Stories Press, New York, 2005. [21] Y. Kluger, K. Peleg, et al., The special injury pattern in terrorist bombings, Journal of the American College of Surgeons 199 (2004), 875-9. [22] A. Mayo, Y. Kluger, Terrorist bombing, World Journal of Emergency Surgery 1 (2006), 1-33. [23] R.A. Pape, The strategic logic of suicide terrorism, American Political Science Review 97 (2003), 346-361. [24] J.P. Gutierrez de Ceballos, Casualties treated at the closest hospital in the Madrid, March 11, terrorist bombings, Critical Care Medicine 33 (2005), S 107–S 112. [25] S.C. Shapira and J. Shemer, Medical management of terrorist attacks, Israel Medical Association Journal 4 (2002), 489-92. [26] S.C. Shapira, et al., eds., Essentials of Terror Medicine, Springer, New York, 2009. [27] J. Wightman, S. Gladish, Explosion and blast injuries, Annals of Emergency Medicine 37 (2001), 664-78.

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Mass-Casualty Planning and Response a

Robert (Bob) DOBSONa Hanover Associates London, Croatian Urgent Medicine and Surgery Association

Abstract. Mass-casualty incidents will always pose challenges to those involved. Every organization has the same goal, and that is to save lives. Research has shown that good preparation and training and an understanding of and respect for the role of all participants in the chain of survival will result in lives being saved. Targeting the avoidable deaths requires well-trained staff to triage patients effectively. Part of that triage is to get the patients to the most appropriate hospital with the most appropriate facilities and medical staff without unnecessary delay. Systems for dealing with mass casualties within the UK have been developed over many years of experience. Can this experience be used by other countries? Most systems around the world have been developed from each country’s historical multiagency links; some countries have no multiagency forum and therefore it is questionable how effective they really are. What does the future hold with developing technologies and transport systems giving easy access to worldwide personal travel on a scale never seen before? What about the political, social, and economic impact of natural and manmade disasters? Advanced training such as the Medical Response to Major Incidents (MRMI) course was designed to assist with understanding local capabilities and response. It was also designed to assist and develop networks between emergency responders to maximize cooperation and ultimately to save lives.

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Keywords. Major incidents, mass casualties, natural disasters, terrorism, future planning, MRMI

Introduction Natural disasters have always been present, but with global technology beaming pictures into millions of homes, disasters have never been more visible, so the need for planning and response has never been greater. The reputation of the country is at stake as the world watches and judges. The victims are not always from the affected country, and difficult questions are often asked in subsequent inquiries. Questions about how the emergency services communicated, how the information was shared, the initial response, and what recovery plan was in place will all add to the pressure on those responsible for dealing with the disaster. Maybe accusations of negligence will follow, so it is important to have a plan before the event. It is an unfortunate fact that some developed countries do not invest in the planning for or response to major incidents or disasters. They hope it will never happen to them. The increased movement of people around the world has also played a significant part in the increased differences between cultures or beliefs. Some of these differences have manifested and resulted in the rise of global terrorism. Arguably one of the best countries for planning and response is the United Kingdom. After 30 years of Provisional Irish Republican Army terrorism and disasters at football stadiums as well large train crashes, the UK has had many opportunities to respond to

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mass-casualty incidents. The other unique element in its favor was the desire of all the emergency services to work together and the attitude of mutual respect for each other’s roles. How was this achieved? It was recognized in the 1970s when the first IRA bombs exploded in London that a plan was required, not only to save the lives of the victims but also as a duty of care to those responding so that medics, firefighters, or police were not blindly going into dangerous situations. For every bomb that exploded in London there were often four or five false alerts. This created havoc across the capital and advertised the IRA cause as tourists witnessed a deluge of emergency service sirens daily. Something needed to be done. The key player for organizing the response was the police. They recognized that the communication between emergency services was so poor that it was impossible to organize the scene or keep London’s road clear for the emergency vehicles to respond. When the police had information regarding intelligence or known trends of the terrorists, due to a lack of trust they were unable to share it with the fire brigade or medical services. It was obvious that there was no network or system among the emergency services. The time to set up a forum is not when the incident occurs. Recognizing these factors, the police suggested, coordinated, and organized discussion groups with the other emergency services, and in 1973 they formed the London Emergency Services Liaison Panel. This group consisted of representatives from the Metropolitan Police, City of London Police, British Transport Police, London Fire Brigade, London Ambulance Service, and local authorities. In later years the group would also include the Port of London Authority, Marine Coastguard, Royal Air Force, military, and voluntary sector. This was a massive task coordinating all of these groups, but the Liaison Panel is still fully functional and meets every three months. To give a gauge of the problem, the chart below shows the number of fatal incidents and their type. It is not an exhaustive list; it covers only the incidents in or around the London area. There were other large incidents in major cities across the UK at the same time.

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The terrible football disasters at Bradford in 1985 where 55 people died and 200 were injured when a fire engulfed the main stand, along with the tragedy at Hillsborough in 1989 (where people were crushed: 96 died and 200 were injured) resulted in an enquiry that insisted a major incident plan be put in place for all stadia containing over 5,000 people. London is the home of Wembley (football), Twickenham (rugby), and the Olympic Stadium (2012), along with Premiership Football clubs—Arsenal, Chelsea, Fulham, Queens Park Rangers, and Tottenham. At every stadium event, every single week in London, the briefings include the major incident plan. Staff regularly use action cards to refresh their memory. The end benefit was that when multiple bomb blasts occurred across London on 7 July 2005, London was ready. Below is the structure used for the multiple bomb blasts in London on 7 July 2005. The structure itself looks extremely complicated, but in fact it is understood by all members of the London Ambulance Service, because of regular practice.

1. Planning and training NATO already uses the Major Incident Medical Management and Support (MIMMS) course as part of its predeployment training for hostile environments. This is a very British-based course that assists with the planning for a mass-casualty event. The more European Medical Response to Major Incidents course (MRMI) is the next step after MIMMS and deals with capabilities and response. The MRMI course not only looks at what the country’s internal response would be, but also gives levels of response that include external help. Experience with the Van earthquake in 2011 showed that Turkey had planned and trained for such an event, but because of extensive media coverage was presented with pressure from countries wanting to assist. There is obviously a problem with countries wanting to be involved whether it is via NATO, the UN, or the European Union. MRMI suggests that there be should be four levels of response and a common language when organizing a response.

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1.1. Major incident level 1 By adjusting organization and methodology, we can maintain the level of ambition for our medical care and save all normally salvageable patients. 1.2. Major incident level 2 The load of casualties is so high that even by adjusting organization and methodology we cannot maintain the level of ambition, and not all normally salvageable patients can be saved. 1.3. Major incident level 3 Similar to level 2, but includes the destruction of the infrastructure in a region or in a country[1]. The levels could be further clarified by adding level 4, which requires international help.

2. Response

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No matter what level the mass-casualty incident, there will always be five primary layers of response: 1. Initial response 2. Consolidation period 3. Recovery phase 4. Standby phase 5. Restoration of normality. Includes hearings, trials, inquests, or public inquiries In the overall scheme of things, the initial response is a very short period compared to the other phases. The incident moves from the emergency services into local government services—for example, for re-housing or counseling, as well as rebuilding of the infrastructure such as homes, roads, and businesses. Victims of the incident can be in hospitals for extensive periods, and some will be receiving treatment for the rest of their lives. In the standby and restoration phases, the main focus turns to what happened and why. All parties of all phases will come together as the hearings and potential trials begin. These hearings often take years to complete. At this stage comes the analysis of how effectively the complete chain of rescue communicated from the moment the incident started and when rescue workers were first alerted: Who knew what, who had the information, and what was shared are key questions that would be asked.

3. What of the future? New technologies in communication are being developed at the hospital in Utrecht, Holland, where a bar-coded tracking system gives instant access to exactly where patients are, their medical condition, and their treatment. Through a secure network,

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patients with previous medical conditions can be tracked as medical data can be shared between computers. The network can also offer descriptions and locations of individuals, making it easier for the police to reunite families. As data are added to the system at the receiving hospital, it can aid or alert foreign embassies if any of their citizens are involved, sparking a repatriation possibility at an earlier stage, thus possibly taking pressure off those hospitals involved. The developments have endless possibilities.

Conclusion Every major city around the world has mass-casualty events, and I expect that they will continue to have them. The many examples cited above made communication between those involved essential. Emergency command centers should all be linked so that information can be sent in nanoseconds between them and to vehicles using computers. There are still problems to solve with radio systems. Mobile phone systems consistently become overloaded during major incidents and generally fail. All the agencies should be networked so that relevant information sharing can be done in confidence, especially when dealing with terrorist incidents or incidents of a sensitive nature. If one organization has hard intelligence regarding a potential or imminent threat—such as further attack, building collapse, risk of fire, or chemical hazards—then it must be shared. Many countries have experiences like the British examples. Transport, industrial incidents, large stadia events, and terrorism along with natural disasters will at some stage be a challenge that the emergency services will have to deal with. If they fail to plan, they are planning to fail. Communication, information sharing, and networking in disaster preparedness are the key to success.

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References [1] S. Lennquist, Medical Response to Major Incidents and Disasters, New York, Springer, 2012. [2] London Metropolitan Police, London Emergency Services Liaison Panel Major Incident Procedure Manual, 7th edition, 2007. [3] D. Mercer, Chronicle of the 20th Century, London, Chronicle Communications, 1988. [4] G. Weightman, Rescue: The History of Britain’s Emergency Services, Boxtree, 1996. [5] G. Marres, Disaster Medicine, from Preparedness to Follow Up, Utrecht (Netherlands) University, 2011. [6] London Ambulance Service National Health Service Trust, 2012.

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Interoperability within Military Medical Forces in Contemporary NATO Operations a

Radek HUBACa Interoperability Branch Chief, NATO Centre of Excellence for Military Medicine

Abstract: Differences among nations in cultures, languages, doctrines, procedures, and materials pose specific requirements for NATO forces for current operations and for the future. The quality of service today especially depends upon how the differing elements can operate together. Optimized interoperability leads to increased mission effectiveness through improved cohesion, performance, and speed, and it radically lowers the expenditures. This applies to the military medical sphere too; the proper interoperability level results in increases in both capability and capacity. Within the NATO military medical community, the Committee of the Chiefs of Military Medical Services in NATO (COMEDS) is the coordinating body for the NATO Military Committee (MC) regarding military medical policies, doctrines, concepts, procedures, techniques, programs, and initiatives. To meet the new requirements with the available resources, multinational solutions are increasingly applied in the whole spectrum of expeditionary military medical support. International cooperation in primary and secondary care, in medical evacuation, in preventive medical care, and in medical staff functions is common today. Keywords. NATO standardization, Committee of the Chiefs of Military Medical Services in NATO (COMEDS), standardization procedure, tasking authority, Medical Standardization Board

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1. What is interoperability in NATO medical forces about? NATO has 28 member nations, more than 30 Partners, out-of-area expeditionary operations, and different backgrounds. Today, more than ever, the ability to work together is important for the Alliance. Therefore, nations need to share a common set of standards, especially between military forces, to be able to professionally execute operations in the various theaters. Considerably higher challenges for interoperability and standardization are non– Article 5 operations, which range from humanitarian aid to combat operations, especially when they are run from the multinational level down to the unit level. Nations need standardization to be interoperable. Standardization is the main tool used to achieve interoperability, because it provides, particularly in the area of operational standardization, common doctrines and procedures. This article aims to support a common understanding of standardization and interoperability, focusing on medical support.

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2. Standardization Standardization is the development and implementation of concepts, doctrines, procedures, and designs in order to achieve and maintain the compatibility, interchangeability, or commonality necessary to attain the required level of interoperability or to optimize the use of resources in the fields of operations, material, and administration. 2.1. Levels of interoperability Compatibility: The suitability of products, processes, or services for use together under specific conditions to fulfill relevant requirements without causing unacceptable interactions. Adopted from AAP-6(2009), NATO Glossary of Terms and Definitions. Interchangeability: The ability of one product, process, or service to be used in place of another to fulfill the same requirements. Adopted from AAP-6(2009), NATO glossary of terms and definitions. Commonality: The state achieved when the same doctrine, procedures, or equipment are used. Adopted from AAP-6(2009), NATO Glossary of Terms and Definitions. 2.2. NATO standardization bodies

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2.2.1. Committee for Standardization (CS) The CS is the senior NATO committee for Alliance standardization; it operates under the authority of the North Atlantic Council. It issues policy and guidance for all NATO standardization activities. The CS is chaired by the Secretary General, normally represented by two permanent Co-Chairmen, namely the Assistant Secretary General for Defence Investment and the Director General of the International Military Staff. Since September 2000, Partner countries have become actively involved in the Committee’s activities. The CS meets in full format twice a year and comprises 28 NATO countries and more than 30 Partner countries. It is assisted by National Representatives with delegated authority, who meet four times a year. The work of the National Representatives focuses on harmonizing standardization activities between NATO and national bodies and promoting interaction between them in all fields of standardization. The Committee is the Board of Directors of the NATO Standardization Agency (NSA), directing and managing the latter’s work in accordance with its Terms of Reference. 2.2.2. The NATO Standardization Organization (NSO) The NSO is a NATO subsidiary body responsible for harmonizing and coordinating all standardization activities of the member states of the Alliance, NATO’s Strategic Commands and principal committees, and its Partner countries. The NSO operates under the authority of the North Atlantic Council, which established the NSO in 1995 by agreeing on a founding charter describing NSO tasks and responsibilities. Each NATO member state is responsible, to the extent that it is capable, to support the NSO’s work. The NSO has two main functional elements: the CS and the NSA.

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The Tasking Authorities (TAs) are senior NATO committees that can task subordinate groups to produce Standardization Agreements (STANAGs) and Allied Publications. They are therefore deeply involved in NSO activities within their respective fields of standardization. 2.2.3. NATO Standardization Staff Group The NATO Standardization Staff Group assists the NSA Director. Its principal task is to harmonize standardization policies and procedures and to coordinate all NATO standardization activities at the staff level. It is responsible for liaising with staff and preparing documentation that contributes to the formulation of standardization requirements for NATO’s military commands and standardization objectives for the NATO Standardization Programme. 2.2.4. The NATO Standardization Agency A single, integrated body, the NSA has the authority to initiate, coordinate, support, and administer standardization activities conducted under the authority of the CS. It is composed of military and civilian staff. In addition, it especially supports the MC Joint, Maritime, Land, Air, and Medical Standardization Boards through four military operational-oriented branches within the NSA. Each board acts as a Delegate TA for operational standardization, including doctrine, as delegated by the MC. The Director of the NSA is the principal advisor to the MC on operational standardization and to the Secretary General on overall standardization matters. He or she is selected by the CS, endorsed by the MC, and appointed by the Secretary General, normally for a three-year period. The authority to promulgate NATO STANAGs and Allied Publications is vested in the Director.

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2.3. Standardization boards The boards consist of members of the appropriate Services of the NATO nations and the NATO Strategic Commands; Belgium represents Luxembourg. While most board members are on the staff of their Military Representative at NATO HQ, those from Belgium, Denmark, the Netherlands, and the United Kingdom are based at their respective ministries of defense. The United States has a separate NSA delegation at NATO HQ. NSA boards are in permanent session and meet once a month. The Joint and Medical Standardization Boards, with one member per nation, meet less frequently. Decisions are normally reached on the basis of unanimity. However, as standardization is a voluntary process, agreements may also be based on majority decisions. The NATO Strategic Commanders have a representative on each board but do not have a vote. The Medical Standardization Board manages the standardization efforts of working groups and expert panels dealing with military medical structures and operations procedures, military health care, medical standardization, and nuclear, biological, and chemical medical.

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2.3.1. Tasking authority A TA is a senior committee that makes all its decisions by consensus and has the authority within its area of responsibility to a) Coordinate its standardization activities with the CS, the NSA, and other TAs through the NATO Standardization Staff Group b) Validate standardization objectives and standardization proposals and translate them into standardization tasks c) Approve and assign standardization tasks, including, when appropriate, the relevant interoperability requirements d) Develop and approve the terminology in its area of responsibility e) Manage the production and the maintenance of standardization documents: 1. Approve the Custodian proposed by a working group or a panel 2. Establish promulgation criteria of their NATO standardization documents 3. Submit STANAGs and Standardization Recommendations (STANRECs) for promulgation by the NSA Director 4. Approve the cancellation or supersession of NATO standardization documents 5. Approve transfer of NATO Standards to civil standards-developing organizations or cooperation for development of a dual-use standard A TA may delegate its responsibility to a subordinate body, which then becomes a delegated TA. A delegated TA cannot delegate its responsibility further. COMEDS is the delegated TA for military medical standardization.

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2.3.2. Committee of the Chiefs of Military Medical Services in NATO COMEDS is composed of the senior military authorities of member countries. It acts as the central point for developing and coordinating military medical matters and for providing medical advice to the NATO MC. COMEDS objectives include improving and expanding arrangements between member countries for coordination, standardization, and interoperability in the medical field and improving the exchange of information relating to organizational, operational, and procedural aspects of military medical services in NATO and Partner countries. 2.4. Responsibilities of key players 2.4.1. Tasking authority x x x x

Development of NATO Standards Management, harmonization and updating of all their STANAGs and Allied Publications Identification of, formulation of, and agreement on new standards Recording of national or Strategic Commands’ ratification, implementation, details, comments, and reservations

2.4.1.1. Nations x Ratification and implementation of NATO standards x Identification of requirements for standardization

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2.4.1.2. Strategic Commands x Implementation of STANAGs affecting NATO assigned forces x Identification of Military Standardization Requirements in Force Proposals x Indication of their Priority Scores and the required level of standardization x Initial formulation of Standardization Requirements in draft Partnership Goals 2.4.1.3. NATO Committee for Standardization x Coordination among the TAs through the NATO Standardization Staff Group x Supported by the NSA 2.5. NATO Standardization Agreement A STANAG is the record of an agreement among several or all member nations to adopt like or similar military equipment, ammunition, supplies, or stores, as well as operational, logistic, and administrative procedures. A STANAG specifies the agreement of member nations to implement a standard, in whole or in part, with or without reservation, to meet an interoperability requirement. Note: A NATO STANAG is distinct from the standard(s) it covers. STANAGs should be implemented, as applicable, and complied with to the maximum extent possible by nations and NATO bodies. 2.6. NATO Standardization Recommendation A STANREC is a NATO standardization document used exclusively in the materiel field of standardization that lists one or several NATO or non-NATO standards relevant to a specific Alliance activity unrelated to interoperability. A STANREC is a nonbinding document employed voluntarily and does not require commitment of the nations to implement the standards listed in it.

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2.7. Allied Publication An Allied Publication is an official NATO standardization document that some or all NATO nations agree to use as a common implementing document and that is distributed down to the user level. Allied Standards are developed or selected in the framework of the NATO standardization process. They include NATO Standards as well as standards used by NATO but developed elsewhere. An Allied standard that is deemed to be related to interoperability requirements is promulgated with a covering STANAG. An Allied Standard that is unrelated to interoperability requirements and is strictly related to the field of materiel standardization is promulgated with a covering STANREC. 2.8. Multinational publications “Allied Publication” designates both standards and standards-related documents published by NATO. NATO forces must be able to operate with non-NATO forces. Unclassified Allied Publications may easily be released to non-NATO forces; however, specific approval must be granted for the release of classified Allied Publications. To improve interoperability of NATO and non-NATO forces in areas covered by a classified Allied Publication, TAs may produce a Multinational Publication—an unclassified

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extract from a classified Allied Publication, approved by all NATO member nations at the TA or delegated TA level for release to non-NATO nations or bodies. 2.9. NATO Standard A NATO Standard is one developed and promulgated in the framework of the NATO standardization process. It is formatted and published as an Allied Publication or Multinational Publication. 2.10. Non-NATO standard A non-NATO standard is one developed outside NATO. This includes civil standards, as well as national or multinational defense standards. They are selected based on their suitability to meet an Allied standardization need and open availability in at least one official NATO language. 2.11. Standards-related document A standards-related document facilitates understanding and implementation of one or more Allied Standards. It may provide additional data and information to support the management and implementation of standard(s).

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2.12. Production and maintenance of standardization documents Developing, approving, and maintaining NATO standardization documents throughout their life cycle includes the following phases: a) Creation of standardization tasks based on 1. Top-down standardization objectives 2. Bottom-up standardization proposals b) Realization of the standardization tasks, which includes the selection, production, or updating of standardization documents c) Selection of the covering document d) Endorsement process: 1. Ratification (STANAGs) 2. Approval (STANRECs) e) Promulgation and distribution of standardization documents f) Initiation of the time life of the standardization documents: 1. Implementation (STANAGs) 2. Use (STANRECs) g) Review and maintenance of the standardization documents 2.13. Creation of a standardization task A standardization task is generated through the top-down or bottom-up process to satisfy a standardization need. The top-down process is based on the NATO defense planning process: interoperability and standardization requirements identified, developed, and solved in this process are derived from force goals.

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The bottom-up standardization may be initiated by national staff, NATO bodies, commanders, TAs or delegated TAs, and subject matter experts to represent interoperability and standardization needs or deficiencies—for example, identified through lessons learned. 2.14. Realization of a standardization task A Custodian selects one of the options to fulfil the standardization task in the following order of priority: a) Select the most appropriate non-NATO standards b) Select and, if required, update existing NATO standardization documents c) Cooperate with relevant civil standards-developing organizations to develop or revise a dual-use standard d) Develop a new NATO Standard e) Report that none of the above solutions is feasible and provide the rationale to the TA or delegated TA 2.15. Selection of the covering document (see Allied Publication)

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2.16. Endorsement process When the document is assessed by the Medical Standardization Board to be mature enough, it enters the ratification process (in the case of a STANAG) or the approval process (in the case of a STANREC). Nations respond to the ratification request and address their responses to the NSA within 6 months for edition 1 of a new STANAG and 4 months for a new edition of a STANAG. They provide one of six possible responses: 1. Ratifying and implementing 2. Ratifying and implementing, with reservations 3. Ratifying, future implementation 4. Ratifying, future implementation, with reservations 5. Not ratifying 6. Not participating The NSA will consolidate national replies received and provide the information to the Medical Standardization Board for a decision on promulgation. Authority to promulgate STANAGs is vested in the NSA Director, who would normally perform the action on the advice of the Medical Standardization Board. STANRECs are approved by a silent procedure. 2.17. Review of standardization documents It is the TA or delegated TA’s responsibility to ensure that all standardization documents within the TA’s area of responsibility are reviewed at least once every three years to verify their validity. The TA or delegated TA must also include the document’s terminology in this effort (there is a limited shelf life for NATO Agreed terminology) and submit terminology proposals accordingly. Moreover, the review of a STANAG addresses any issues that prevent a nation from ratifying and implementing, even partially, through the national reservations expressed during the ratification process. Nations

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with reservations are expected to make change proposals through a standardization proposal to resolve their reservation(s) if they were not proposed through their comments. 2.18. What is the practical outcome of the standardization effort? Multinational solutions are increasingly applied in the whole spectrum of expeditionary military medical support. We can demonstrate it as a capability-based modular approach developed by Allied Command Transformation. Nations are deploying modules, not whole medical treatment facilities, based on operational needs and national resources. To ensure that multinational medical facilities will provide medical support at the proper level, nations agreed on STANAG 2560, the Medical Evaluation Manual. Based on this agreement, multinational medical treatment facilities are built and evaluated in the predeployment phase. We can conclude that performance in the current NATO operations proves the proper interoperability level of allied medical services. NATO Centre of Excellence for Military Medicine (MILMED COE)—Interoperability Branch

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MILMED COE is an international military organization with the core task to facilitate interoperability among the military medical services in NATO. It was accredited by NATO on 12 October 2009 and is located in Budapest, Hungary. The branch mainly focuses on assisting NATO’s medical community in achieving standards and harmony in personnel, administration, and operation in today’s combined joint-type medical missions. This activity includes supporting NATO COMEDS working groups and expert panels in initiating, developing, and reviewing NATO medical concepts and policies, including the facilitation of incorporating clinical lessons learned into NATO medical doctrines.

References [1] NATO home page, www.nato.int/cps/en/natolive/index.htm. [2] NATO Standardization Agency website, www.nsa.nato.int/nsa. [3] AAP-03(J)(2)E, Production, maintenance and management of NATO standardization documents.

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Handbook for Pandemic and Mass-Casualty Planning and Response E. Gursky and B. Hrečkovski (Eds.) IOS Press, 2012 © 2012 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-61499-135-9-134

The Complete Protection of a Combat Soldier Mark LOADESa, Boris HREKOVSKIb, Philip FISCHERc, Robert DOBSONd a FMP Protection Services, London, Croatian Urgent Medicine and Surgery Association b Department of Surgery, General Hospital Slavonski Brod, Croatian Urgent Medicine and Surgery Association c Department of Surgery, University Clinic Bonn, Germany d Hanover Associates London, Croatian Urgent Medicine and Surgery Association

Abstract. The personal protection of battlefield combatants espouses the fundamental aim of keeping the soldier alive and in the fight. Historically, some semblance of clothing that blended into the environment and rudimentary head protection were considered the necessary ingredients in modern pre–20th century conflicts for supporting this aim. During the 20th century, however, huge steps were taken to improve the personal protection given to soldiers on the battlefield— the principles, philosophy, and policy of which now underpin today’s doctrine. However, warfare is a constantly evolving process, and now our serving combatants are provided with cutting-edge technology, advanced materials, and firstclass training that aim to ensure their survival in a multilayered and diverse theater of operations; historical threats are seamlessly entwined with hybrid threats where an enemy employs a potent mix of conventional weapons, irregular tactics, criminal behavior, and terrorism to achieve political aims while exploiting the vulnerabilities of the regular forces[1].

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Keywords. Personal protection equipment, technology, threat, combatants

Background The effective protection of soldiers in battle has always preoccupied the serious exponents of war. To effectively shield one’s forces from enemy assaults while inflicting greater injury on the enemy has been a tactical conundrum for many years. The use of materials, ideas, and strategies that defeat the enemy’s weapons has now become a science, with technology assisting the design of ballistic-defeating materials that are both comfortable to wear and capable of stopping projectiles flying at hundreds of feet per second. Ballistic protection is now a multimillion-dollar business, and the success of the products literally translates to soldiers returning from overseas missions and police officers completing a tour of duty. But personal protection in its wider sense encompasses more than ballistic protection. Force protection means an overarching responsibility to keep people safe; the maintenance of health, training, protective equipment, and education are some of the strands that support this concept, and it is the responsibility of all. The introduction in 1996 of Tactical Combat Casualty Care (TCCC) created an environment where soldiers were able to help determine their own survival by taking

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simple immediate lifesaving actions while in contact with the enemy. Use of considered movement to cover, positioning, and the self-application of tourniquets enabled injured soldiers to increase their chances of survival while continuing to contribute to the fight. An often-quoted aphorism, “Victory is the best medicine,” underpins the value that is placed on having as many effective combatants engaged as possible to achieve mission success. The complete integration of TCCC principles within the soldiers’ battle drills ensures that all personnel have the ability to provide casualty care as first responders and an awareness of self-help if they become a casualty themselves.

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1. Training The multiplication of medical training opportunities endorses the importance placed on improving trauma and primary health care management. Planning, preparation, and threat assessment form part of the medical contingencies register for current operations, and the ability to train, develop, and implement procedures is an important aspect of medical preparedness. The growth of simulation models for dealing with mass-casualty incidents underpins the wish of planners and decision makers to better understand this challenging aspect of casualty management. The Medical Response to Major Incidents[2] course and the Major Incident Medical Management and Support course are good examples of structured response planning models used to test capabilities; to replicate such exercises in the field would be prohibitively expensive and unsustainable if practiced regularly. However, the opportunity for individual soldiers to gain knowledge and apply practical skills in a safe learning environment should be seized at every opportunity. Progressive educational development, judiciously applied from infantryman through military surgeon, is of vital importance; simple first-aid training has proven ineffective for today’s combat. The application of lifesaving skills aligned to tactical awareness and mission prioritization is the focus for battlefield medicine and underpins TCCC. The ability of all soldiers to identify life-threatening conditions that can be effectively treated or at least mitigated within the context of their mission should be a training priority; the blending of tactical decisions, medical prioritization, and ultimate mission success are inextricably linked components that every soldier should understand. As an example, the Combat Life Saver course, where lifesaving techniques are immersed within the tactical training scenario, ideally fulfills the need of many units deploying overseas. It is important to delineate the student’s preconceptions in this multifaceted area; the provision of appropriate medical aid within the combat zone should form a recurring part of our warriors’ tactical awareness training.

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Figure 1. Croatian Combat Life Saver course.

TCCC improves gross and fine motor skills and raises confidence among deploying troops; with the ever-increasing tempo of current operations, training can sometimes be seen as an administrative burden, costly, and an unnecessary burden before deployment. The elementary self-assurance that realistic and appropriate training brings to a deploying soldier is immeasurable; the awareness that skills, methods, and systems have been practiced and tested ensures a huge morale lift and focuses the mind positively for combat.

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2. Equipment Aligned to the environmental stress encountered in today’s combat is the increasing physical payload that must be carried by our troops. Body armor is intended to help the body survive potential penetrative and blunt trauma by dissipating the energy of projectiles or forces to such a degree that the body can continue to function. It also engenders a sense of physical protection that psychologically allows the wearers to engage in combative action against the enemy, knowing they are protected or safe. Body armor is considered standard dress by the current generation of combat soldiers; indeed it is generally considered that a lack of protection indicates negligence on the part of commanders who do not provide personal protective equipment, particularly to frontline combat troops. Modern body armor is generally constructed of highperformance polyethylene fibers—for example, Dyneema—or Para-aramid fibers (aromatic polyamide), such as Twaron or Kevlar[3].

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Figure 2. British Osprey ballistic vest.

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A further protective measure developed from the current threat profile is ballistic groin protection against increasingly powerful improvised explosive devices (IEDs) and roadside bombs, a favored weapon of the Taliban and other insurgents. Lower-body injuries requiring amputation have become common as the IED threat in Afghanistan accounts for the majority of severely wounded soldiers returning home as casualties. The groin protector, weighing less than 1 kg, will not protect from the direct upward blast of an IED, but will significantly reduce the serious injuries to genitalia and protect the femoral artery from fragmentation if the victim is caught at a blast site. Another recent innovative addition is a protective zone to the axilla. This part of the body, with the vulnerable axillary artery and vein, is often exposed to the enemy when the wearer is firing a weapon from the shoulder, and conventional body armor design fails to protect this area.

Figure 3. Modern body armor with groin protection plate.

However, full-torso body armor can also be enhanced by placing specially designed ballistic plates within the carrier system itself, increasing protection of the vital organs from high-velocity penetrative strikes, and can also be found in civilian law enforcement, particularly with special weapons and tactics (SWAT) teams for use in prepared assaults or raids. The plates normally weigh around 1.5 kg and are constructed of Kevlar; they are worn back and front, and although their use can greatly reduce the mobility of the wearer, the extra protection offered often offsets this inconvenience.

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Figure 4. Ballistic plate for enhanced protection.

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A further derivative is the plate carrier. This equipment is favored by troops because it allows freedom of movement and is easy to don. The carrier is a simple backand-front bib combination that allows ceramic or Kevlar plates to be simply dropped into place. It is less robust than body armor and does not provide full torso protection, but given the right operational backdrop it is an important stopgap in providing ballistic protection. The helmet available to troops on the ground must be lightweight, offer protection from multiple high-velocity round strikes and fragmentation, and be of a design that allows the user to operate weaponry from a variety of positions and postures. The infantryman’s helmet has undergone a revolutionary transformation since the steel helmet of the previous century; a typical helmet for today’s battlefield will weigh around 1 kg and be constructed of Kevlar and be capable of defeating projectiles travelling up to 650 m/s.

Figure 5. Typical modern combat helmet design.

The helmet will ideally have a robust chin strap assembly, ensuring stability; the shape of the rear of the helmet must allow the soldier to lie prone when shooting, particularly without interference from the body armor. The modern helmet must also be compatible with issued respirator and communications equipment and be able to mount night vision paraphernalia. A soldier can also wear other garments to increase personal protection—for example, Kevlar high neck collars attached to the body armor; eye protection, including sunglasses and goggles as well as full face helmet visors; gloves that

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are flame resistant and woven to protect from cuts and slashes; and protective shoulder, elbow, and knee pads.

Figure 6. U.S. combat protective clothing.

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3. Medical By the nature of modern warfare, combat troops are finding themselves operating more and more within the local civilian population or indigenous people rather than in a classic battlefield encounter with the enemy. This often manifests itself as a counterinsurgency mission, with a feeling of armed social work that brings troops into daily contact with the populace. The attitude of the population will ultimately influence the success or failure of an insurgency, and it is no longer the unique place of the special forces and in particular their medics to attend illness and injury among the civilian population in a remote valley, hamlet, or village. The war of “hearts and minds” is a common thread for all operations, with regular units operating for prolonged periods within the community. As these operations unfold, prolonged integration with the civilian population will expose a greater range of conditions and ailments linked to the demographic of the region. The fighting force will be exposed to local hygiene threats and diseases, and consequently force and personal health care will take on a great importance: physically fit soldiers are needed to undertake today’s missions, and the traditional prerequisite for any warrior is now aligned to general mental and physical well-being. A much broader understanding, particularly by military health care providers of clinical practice, is required, along with trauma management, as vaccination, prophylactics, and education will fashion an understanding of local health care issues and help mitigate the hazardous environment in which the mission takes place. The ability to perform in spite of injury or illness is imbued within the warrior code, and today’s soldiers need to be examples of supreme physical fitness and a determined attitude; harsh operating conditions will quickly affect an ill-prepared soldier.

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From a medical perspective, the introduction of vital lifesaving equipment brings additional considerations. A dismounted soldier routinely carries around 45 kg of equipment into combat, including food, water, weapons, ammunition, batteries, night vision goggles, helmets, radios and IT equipment, and body armor—Enhanced Combat Body Armour (Osprey) or NATO equivalent weighs in at around 13 kg. Therefore, identifying an illness such as heat exhaustion at an early stage is key. The correct regulation of body temperature through hydration is therefore particularly important when operating in harsh climatic conditions, and the use of the ubiquitous bespoke CamelBak portable hydration system adds to the payload but allows the wearer to drink on demand through the integrally fitted bite valve—a far cry from the standard water bottle of 20 years ago. The absence of external signs of injury is often associated with successful protection, but recent studies have shown that there is more to this than was first apparent. A Johns Hopkins study found that mild trauma, resulting from the initial shock of exploding mines, grenades, and IEDs, now accounts for more than 80 percent of all brain injuries among U.S. troops engaged in combat missions. Senior study investigator and Johns Hopkins neuropathologist Professor Vassilis Koliatsos, M.D., found that “protecting the body is absolutely essential to protecting the brain. Blast-related injuries, including what we call blast-induced neurotrauma, are the signature medical events of current wars, and improvements to body armor in addition to helmet-wearing are likely going to be needed if we want to minimize their threat to our soldiers’ health”[4]. The study results do not undermine the need to wear a ballistic helmet to shield the head from shrapnel and other debris and to offer protection from secondary blast waves. Axonal nerve cell damage can be reduced by wearing body armor enveloping the torso, thus protecting axons responsible for body movement, including the cerebellum and the corticospinal tract, which links nerves in the brain to those in the spinal cord. Military surgeons should closely monitor wounded soldiers for mild traumatic brain injury even in the absence of any obvious “blast” lung or traumatic injury.

Summary The complete protection of a combat soldier is an evolving, expensive, and emotional subject. The morality of deliberately sending your troops into harm’s way has been debated ad infinitum and will preoccupy for years to come. However, to send people to war unprepared, untrained, and ill equipped is not an acceptable decision in our society. Protective and preventive measures should underpin every deployment into combat operations, thereby increasing the survival ability of each soldier. Great steps have been taken in providing our soldiers with modern arms, ammunition, and protective clothing. The cost of dressing and arming a modern U.S. soldier for current operations is around $18,000. Add to this the per capita cost of transport, support, and medical services, and the cost of modern warfare in its present format is spiraling to a level that some would argue is unsustainable. A soldier on today’s field of conflict has a much greater chance of survival, being able to kill the enemy quicker and in greater numbers, engage the enemy better protected, and, if wounded, survive severe injury and return to combat duties. The ratio of wounded in action to killed in action is around 8.3:1. The speed of medical transfer from the battlefield to definitive care, the ability to give aid even when confronted with catastrophic injury, and the capacity to engage the enemy at close quarters while

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protected by advanced personal protection equipment allows our modern soldiers the preparedness they deserve.

References

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[1] Army Field Manual, Countering Insurgency, Volume 1, Part 10, UK Ministry of Defence, January 2010. [2] Sten Lennquist, ed., Medical Response to Major Incidents—A practical guide for all medical staff, Springer Verlag, Berlin Heidelberg, 2012. [3] Martin J. Brayley, Modern Body Armour, Crowood Press Ltd., Marlborough, UK, 2011. [4] Shielding body protects brain from “shell shocking” blast injuries, Johns Hopkins Medicine press release, 28 April 2011, www.hopkinsmedicine.org/news/media/releases/shielding_body_protects_ brain_from_shell_shocking_blast_injuries; see Vassilis Koliatsos, et al., A mouse model of blast injury to brain: initial pathological, neuropathological, and behavioral characterization, Journal of Neuropathology & Experimental Neurology 70 (May 2012), 323-416.

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Handbook for Pandemic and Mass-Casualty Planning and Response E. Gursky and B. Hrečkovski (Eds.) IOS Press, 2012 © 2012 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-61499-135-9-142

Experience from Past Conflicts a

Boris HREKOVSKIa, Mark LOADESb, Bob DOBSONc, and Philipp FISCHERd Department of Surgery, General Hospital Slavonski Brod, Croatian Urgent Medicine and Surgery Association b FMP Protection UK, Croatian Urgent Medicine and Surgery Association c Hanover Associates Ltd., UK, Croatian Urgent Medicine and Surgery Association d Surgery Department, University Clinic Bonn, Germany

Abstract. The history of medicine is inextricably linked to conflict. Man has waged and continues to wage war, but besides the destruction and human tragedy, war often brings clinical advances, innovative practices, and patient treatment protocols that are often cascaded into civilian practice. Both civilian and military planners should be cognizant of the bloody lessons learned from the battlefield and ensure that this hard-won experience is harnessed, understood, and translated into advantageous outcomes for future casualties. Keywords. Conflict, lessons learned, future casualties

Introduction

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“Those who cannot remember the past are condemned to repeat it.” —George Santayana[1] Learning the lessons from past conflicts prepares us to meet new challenges in the future. History is littered with examples of recurring issues that were once overcome, only later to resurface and present a challenge for a later generation. From a medical perspective, historical learning linked to the continuum of care has fared well, and many solutions championed by our medical forefathers can be seen in use today; clearly the consequence of failing to learn from past conflicts has life-threatening consequences. Despite this apparently positive state of affairs, it is understandable that lessons can take considerable time and effort to convert into everyday practice. A recent example of battlefield immediate aid protocols appearing as a best practice in prehospital care is the acceptance that stemming a catastrophic bleed should take priority over airway management in the initial care phase; this has proved a lifesaver in Iraq and Afghanistan where the ever present and deadly use of improvised explosive devices has taken a heavy toll on our combat forces. Many soldiers who would have normally died in action are now living testimony to the effectiveness of a rapidly applied tourniquet and other trauma life support interventions as a part of Tactical Combat Casualty Care (TCCC) protocols. Military evidence-based medical experience from combat casualty care influenced civilian trauma care protocols in the past decade. Strategic history is truly cyclical—a judgment resisted weakly and unsuccessfully by those who believe in progress in strategic affairs[2]. A learned understanding of an enemy’s strategy, tactics, and end game allows the erudite planning of one’s own strategy, counterstrokes, and tactics. Success cannot be guaranteed in any conflict, but

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what is of supreme importance in war is to attack the enemy’s strategy[3]. The Croatian Homeland War of 1991 fought in the former republic of Yugoslavia gave a clear example of how a force holding the military advantage vastly underestimated their foe’s strategy. In general, the prosecution of war by regular forces against an irregular force will not succeed unless different methods are employed. The British used such tactics well during their many encounters with communist forces in the postwar years, operating among the insurgents and terrorists and using a hearts-and-minds approach with the indigenous people. The United States’ prosecution of the war in Vietnam could well have recognized more fully the strategic failings of the occupying French colonial forces in Indochina, especially their end-game or exit strategy. When Russian forces withdrew from Afghanistan in 1989, serious questions were raised about their exit strategy. The reasons for invasion 10 years earlier and the strategic plan had been overturned by political change, economic challenge, and a perceived military impotency to defeat the enemy. The Soviet forces, despite great tactical efforts, never truly grasped the strategic concept of countering irregular warfare in the mountains of that vast country and continued to make use of mass force and materiel, a strategy that had worked against the Wehrmacht (the German Army) but would never succeed against the Mujahedeen. The renowned Soviet Frunze Military Academy conducted a study of Soviet tactics and subsequently acknowledged several combat principles that lay at the heart of the successful Mujahedeen tactics; these will sound very familiar to today’s warriors and planners. First, the Mujahedeen avoided direct contact with larger regular forces that could destroy them. Second, they never conducted positional warfare and would readily abandon positions if they were likely to be encircled. Third, they would always seek surprise in attack. Last, they employed terror and ideological conditioning on a peaceful populace as well as government officials[4]. The majority of recent wars had these characteristics: 1. More intrastate wars than interstate 2. Ethnic and religious conflicts more than political 3. Civilian casualties increased 4. Human displacement increased The situation for starting a civil war usually starts with partial erosion of state authority, with a parallel rise in social vulnerabilities that can develop because of economic, social, political, or religious motives. Before the Second World War, the majority of casualties were among the combatant soldiers, with disease being the leading cause of death. In World War II, around 60% of all casualties were civilians. In the past decade, 80% of casualties were from the civilian population. An International Committee of the Red Cross study from 2001 showed that the civilian-to-soldier death ratio in wars fought after World War II sometimes exceeded 10:1, which means ten civilian deaths for every soldier death. Historically, the deliberate involvement of the civilian population on the field of battle has in general been avoided. There have always been civilian casualties as fighting ensued, but the tactical plan involved the movement and involvement of troops and not the movement of civilians. Medieval siege operations employed the use of the populace to help defeat the entrapped enemy, with extra mouths to feed (the civilians) putting immense logistical pressure on the defenders; coupled with the spread of disease among a frightened population, the conditions within the castle, citadel, or town would quickly deteriorate and impact the combat effectiveness of the soldiers. In today’s

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world, terrorists and insurgents use media like a weapon and plan combat and terrorist attacks in areas of high population density (see “Basics of Terror Medicine”). This high percentage of civilian casualties put more demand on NATO military medical personnel and the organization of medical care in areas of conflict. The competencies of a NATO military surgeon should be much wider than those of a general surgeon from civilian practice. In the civilian model, education and training for modern surgery focus on subspecialties within surgery. Specialization in general surgery is slowly disappearing in many European countries. This condition raises a question of the education and training of a military surgeon for forward surgical trauma care on NATO missions. In the civilian model, the European Society for Trauma and Emergency Surgery recognized that fact and put a lot of effort into ensuring better education and training of trauma and emergency surgeons through courses and scientific communication and defining core competencies of trauma and emergency surgery care. Tremendous improvements have been made to the military medical system aligned to the exposure of our forces to combat over recent years, and lessons have been learned. Huge steps have been taken in the complete protection of combat soldiers augmented by the Combat Life Saver program, TCCC protocols, critical care air transport, damage control surgery, and, in particular, advances in reconstructive and maxillofacial surgery, infection control, pain management, and physiotherapy. The lessons from past conflicts are there to be learned—an interesting position for NATO.

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1. Medical lessons learned Around 400 B.C., the father of medicine, Hippocrates, is said to have commented that war is the physician’s best training place. The definitive treatment and nursing of the injured soldier is underpinned by the general principles of minimizing the time between injury and treatment, stopping blood loss, and avoiding infection. In the conflicts of previous centuries, inadequate control of infection, the absence of basic hygiene protocols, and a lack of nursing greatly contributed to the huge mortality rates of combatants. However, the defining point in British military history was the horrific casualty rates sustained during the Crimean War. The war was reported on daily by embedded war correspondents whose loyalty was to their editor back home and not to the military leadership in theater. The British forces suffered 18,058 fatalities throughout the campaign of 1854-56; of these only 1,761 were killed in action with the enemy. The remaining 16,297 died either from poor nursing of wounds and from rudimentary surgery or more commonly from disease, particularly typhoid, cholera, and diarrhea. During the first nine months of the campaign, the mortality rate among some regiments reached a staggering 60 percent[5]. The scandal in England shocked the public and moved the pioneering Florence Nightingale to take matters into her own hands. She introduced an improvement in nursing standards and in particular introduced hygiene protocols that undoubtedly saved many soldiers’ lives and are still practiced in the wards of our hospitals today. The introduction of the tourniquet to the battlefield was a medical landmark, with every soldier being trained in its self-application and an understanding of medical care principles integrated into squad-level tactical doctrine. The idea of TCCC was presented in August 1996 and conceptualized as a result of a two-year study sponsored by the United States Special Operations Command[6] and linked to the hard lessons learned from the conflict in Somalia in 1993 and data from the Vietnam War.

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TCCC has three goals[7]: 1. Treat the casualty 2. Prevent additional casualties 3. Complete the mission

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It consists of 1. Care under fire 2. Tactical field care 3. Tactical evacuation care Blending combat medicine and tactical doctrine presented through TCCC as the vehicle created a standard of care on the battlefield that is today the foundation of all military medical training. Other adjuncts that have been developed to deal with catastrophic bleeding in the field now include hemostatic agents and combat field dressings specifically designed for self-application as well as for treating others. Minimizing the time between battlefield injury and medical care is a tactical conundrum that, sadly, field commanders, particularly in Afghanistan, may deal with daily. However, the decisions of when and how to care for the wounded during and after battle and who should do it has not always preoccupied the minds of leaders and planners. The period from 1631 to 1815 is often referred to as the Age of Battles, which involved thousands of troops in climactic encounters, where the fate of continents might be decided in a single afternoon while leaving thousands of dying and wounded men on the field of battle. It would have been inconceivable to those combatants that their care should have a priority and ludicrous to the commanders that their tactics should consider an individual soldier’s well-being. At the Battle of Waterloo in 1815, many wounded men lay in the open during the night after the fight only to be quietly despatched by local peasants seeking booty from the corpses of the fallen. Some who did survive were transported by ox cart to the nearby field hospital, where surgery awaited them. Most gunshot and cannon wounds to the extremities were routinely dealt with by amputation as expedient treatment, the sheer number of casualties likening the operating table to a butcher’s shop slab. By the First World War, the medical services had learned many lessons from the past, and stretcher bearers were specifically employed to bring in the wounded; clearing stations were established; and field hospitals were positioned behind but close to the front line. Rudimentary triage was practiced, and the art of care was developed by both sides. World War II saw combat medics in the front line accompanying the infantry and being exposed to the same life-threatening conditions as the fighting men. “Foxhole surgery” being performed by first-aiders certainly did wonders for the reputation of the medical services and, more important, the morale of the men. During World War II, the United States forces lost around 4,700 medics killed in action while trying to treat others; at Iwo Jima, for instance, the mortality rate among medics was higher than for the fighting Marines.

2. Vietnam War Vietnam saw the true development of medevac and the use of the helicopter as the platform to achieve incredibly fast patient delivery times. The whole procedure could be measured in minutes, with the reputed fastest medevac taking 18 minutes from receiving the call in the squadron office to delivery of the patient at the hospital. The medevac was broken into four phases: the field, the pickup, the flight, and the facility.

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2.1. The Field During the Vietnam War this phase started with the point of injury or illness, the treatment given, and the request for evacuation. First aid would be provided by a corpsman, and basic wound classification would take place. 2.2. The Pickup

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This phase was determined as actual time on the ground. It was measured from the helicopter arriving until its departure from the scene with the casualty aboard. It was determined that the pickup should not exceed 50 seconds, with the infantry providing fire suppression if the landing zone was “hot,” or the pilot would call for fire support, directing it onto the target.

Figure 1. Medevac pickup, Vietnam. U.S. Army photo.

2.3. The Flight The helicopter flight retuning to the medical facility with the casualty. 2.4. The Facility The final stage where the patient is handed over to the medical facility. The similarities to current strategy are obvious, and many lessons were learned from the Vietnam experience. Data collected from Vietnam contributed to the formulation of TCCC and the concept of operations for current medical emergency response teams.

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The fully operational hospital facility at Camp Bastion in Helmand, Afghanistan, provides state-of-the-art technology to support medical services that would have been unimaginable in past conflicts and is supported by the Deployable Aero-medical Response Teams that provide repatriation services for wounded combatants.

3. Croatian Homeland War, 1991-1995

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The Integral Health Care System was established to achieve better military and civilian medical care during the Homeland War. The Ministry of Health formed the Crisis Headquarters Group with the task to prepare all medical institutions and personnel in case of a crisis such as a war (see “Education and Training for Major Incidents and Disasters: Croatia Case Study”). This model enables control of proper distribution of medical personnel in military and civilian units during wartime and quick transformation of civilian hospitals into war hospitals. Civilian hospitals raised their levels of alert and properly organized and educated medical personnel for a warfare situation in a short time. The Integral Health Care System enables simple, effective, quick decision making in a chain of command.

Figure 2. Operating theaters in a basement of General Hospital Slavonski Brod (a gym theater), located there to protect medical personnel and patients from artillery shells, May 1992. Photo by D. Jankovic.

Military doctrine was based on NATO doctrine. The majority of civilian medical personnel adapted quickly to the military system and worked with significant enthusiasm and motivation. Small differences existed between professional and reserve army units in field trauma care because of differences in education and training. Helicopters were not used for a medical evacuation of casualties during the first phase of

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the war (1991-1992) because they were not available then. Also, having a lower proportion of officers in the ranks enabled faster decision making.

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Figure 3. Evacuation of a wounded soldier, 108th Brigade of the Croatian Army, November 1991. Photo by D. Jankovic.

Forward surgical teams (surgeon, surgeon medical technician, anesthesiologist, anesthesiologist medical technician, and driver) were formed immediately at the beginning of the war and followed professional military units on missions. The Integral Health Care System fulfilled the task of providing quality medical care for military and civilian casualties and was economically affordable. The system took care of more than 500,000 refugees in 1991 through 1995 while maintaining good quality of medical care in all parts of Croatia despite the problems with medical supplies.

4. Major incidents Every war situation puts high demands on the medical care system to maintain proper organization and ensure good quality of medical care for casualties. Proper planning and preparation with an effective command decision system are essential. The prewar phase of the conflict had clear, visible signs of warning and left us enough time for proper preparedness. Major incidents caused by terrorist attacks in today’s world come with hidden signs of warning and could happen anytime (see “Basics of Terror Medicine”). The majority of civilian hospitals are inclined to operate under financial restraints that pressure a health management system with permanent cost-reduction goals. Reserve capacities in all European hospitals are smaller than they were 20 or 30 years ago, because of economic health management models. Although information technology has made a huge advance in the organization and efficiency of daily medical care, at the same time it has in some ways made the system more vulnerable when

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facing complex situations where the risk of technical failure at the time of crisis would have a catastrophic effect. Any developed backup systems must be prepared and regularly tested and prove efficient in response to major incidents, when detailed, workable disaster plans are of incredible importance. The Medical Response to Major Incidents Course is an example of a cost-efficient simulation model taking lessons forward for the beneficial treatment of casualties in the future[7].

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Figure 4 (a, b). The Hospital Command Group and Regional Command Center need to have accurate, continuous reports from hospitals in order to make proper decisions. Medical Response to Major Incidents course, Slavonski Brod, 2011.

Major incidents are not daily emergencies or a part of daily routine work, but medical personnel, like other emergency services and all communities, have a responsibility to be prepared for this type of incident. Civilian medical personnel and institutions need a military-like organization to make plans and to educate and train all involved staff. Hospital plans for major incidents should guarantee that all involved personnel know general information about levels of alert of the hospital, coordination and command, and their tasks. In case of a major incident, hospitals need to form a hospital command group, which will enable proper organization and efficient work during a crisis. The hospital command group is formed by the senior surgeon on call, the senior manager on call, and the senior anesthesiologist on call. If they are not immediately available, other senior colleagues should cover these positions. Table 1. Hospital Command Group Action Card, adapted from MRMI[14]

Green alert 1. Inform the hospital telephone operator that the command center is open and staffed. 2. Inform the regional medical center that the command center is open and staffed, inform the center about the decided level of alert, and ask for available new information. Document information on the prepared whiteboard. 3. Request a report of immediately available capacity in operating rooms (theaters available now and within 1 hour) and intensive-care unit (available ventilators) with a response < 10 minutes. Report this information to the regional medical center < 15 minutes after the alarm.

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4. Consider whether planned surgery and other treatments that can wait should be “frozen” to await further information. This is not a mandatory part of the green alert but can be used when it is likely that the hospital will receive casualties. If so, inform the senior operative nurse. 5. Based on information from the regional command center, consider whether the level of alert should be changed. If so, inform  The senior nurse and emergency department  The hospital telephone operator  The surgeon, anesthesiologist, and orthopedic surgeon on duty  The regional medical center 6. Define and appoint staff in command for critical functions; register the names and telephone numbers for the  Emergency department  Operative rooms  Preoperative and postoperative departments  Intensive-care unit  Coordinators for wards in involved departments 7. Give a short press announcement to the hospital telephone operator for the media to relieve the pressure on the hospital command group. It should state what we know, what we have done, any casualties received or on the way, and a time for the next press announcement. 8. If green alert is cancelled, inform those listed in step 5.

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Yellow alert Follow the steps for green alert; in addition: 1. Request continuous reports from operating rooms, the intensive-care unit, the emergency department, and the coordinating senior nurses in wards with regard to available capacity, updated according to arriving staff, possible evacuation of patients, and redistribution of resources. If information is missing, search for it. Report capacity continuously to the regional medical center. 2. Consider whether more staff should be alerted than the minimal level automatically connected to a yellow alert (six emergency teams in the emergency department, six operative teams, six anesthesiologists and six nurses of anesthesia, four surgeons, and two orthopedic surgeons). 3. Collect the now mobilized hospital command support group for a briefing and report. Check that all tasks connected to this group have been initiated. Make a plan for staff meetings at regular intervals for exchange of information. Red alert 1. Staff (and organize room for arriving staff) with a responsible senior manager, senior physician, senior nurse, and secretarial support. Coordinate distribution of arriving staff to fill needs reported to the hospital command group. Give information to arriving staff and consider the coming need of replacements (it might be indicated to send some staff home for rest, being available on call). Give this information also to units with an expected heavy workload in the coming 24 hours.

In times of austerity, it is important to balance financial restraints with the core function of the organization, and the edict that life must go on is particularly pertinent to the medical fraternity. Simulation models can be a cost-efficient way of continuing to develop protocols and policy to meet the challenge of mass-casualty incidents. In recent times, the phenomenon is all too often being played out, and whether the disaster is a manmade one or natural, the devastating effects live on for many years. The skill of

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learning lessons is not to repeat mistakes and to take forward experiences for the future that will prove beneficial.

Summary The 21st century started with the global war on terrorism after the terrible 9/11 attacks in the USA. The fight against tyranny will continue, and it is obvious that more casualties will be incurred both on and off the battlefield. Sharing knowledge, mentoring those who need help, and offering expertise are the hallmarks of a developed society. Within this society, knowledgeable groups can disproportionately influence the impact of those virtues. The medical profession has a supreme responsibility to care and impartially deliver its skills, and long may that continue. The development of strategic policies to tackle complex and demanding challenges, the formulation of tactical doctrine to implement those policies, and the training for those chosen to deliver the product should be based on the simple principle of not making the same mistake twice and of indeed learning from past conflicts.

References George Santayana, The Life of Reason, Volume 1, 1905. Colin S. Gray, Another Bloody Century: Future Warfare, Weidenfeld and Nicolson, London, 2005. Sun Tzu, The Art of War, translated by Ralph D. Sawyer, Westview Press, Boulder, Colorado, USA, 1994. Lester W. Grau, ed., The Bear Went over the Mountain: Soviet Combat Tactics in Afghanistan, Frank Cass Publishers, London, 1998. [5] Denis Judd, The Crimean War, Granada Publishing, London, 1976. [6] Captain Frank Butler, MC, U.S. Navy; Colonel John Haymann, MC, U.S. Army; Ensign E. George Butler, MC, U.S. Navy; Tactical combat casualty care in special operations, supplement to Military Medicine, Official Journal of the Association of Military Surgeons of the U.S. 161 (1996). [7] Sergeant First Class Cesar Veliz, National Registry of Emergency Medical Technicians; Master Sergeant Harold Montgomery, BA, National Registry of Emergency Medical Technicians; Lieutenant Colonel Russ Kotwal, MD, MPH; Ranger first responder and the evolution of Tactical Combat Casualty Care, Journal of Special Operations Medicine 10 (2010). [8] Mass Casualty Simulation System website, www.macsim.se. [9] S. Lennquist, Management of major incidents and disasters: An important responsibility for the trauma surgeon, Journal of Trauma 62 (2007), 1321-1329. [10] London Metropolitan Police, London Emergency Services Liaison Panel Major Incident Procedure Manual, seventh edition, 2007. [11] L. Napoleoni, Insurgent Iraq, Seven Stories Press, New York, 2005. [12] Y. Kluger, K. Peleg, et al., The special injury pattern in terrorist bombings, Journal of the American College of Surgeons 199 (2004), 875-9. [13] A. Mayo, Y. Kluger, Terrorist bombing, World Journal of Emergency Surgery 1 (2006), 1-33. [14] S. Lennquist, ed., Medical Response to Major Incidents and Disasters—A Practical Guide for All Medical Staff, Springer Verlag, Berlin Heidelberg, 2011. [15] G.R. Ciottone, et al., Disaster Medicine, Elsevier-Mosby, Philadelphia, Pennsylvania, USA, 2006.

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[1] [2] [3] [4]

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Triage Protocols for Critical-Care Patients in Disaster Conditions a

Asja AJDINOVIa, Matija JURJEVIa, Jasminka KOPIa, Boris HREKOVSKIb Department of Anesthesiology, Reanimatology and Intensive Care, General Hospital Dr. Josip Benevi, Slavonski Brod, Republic of Croatia b Department of Surgery, General Hospital Dr. Josip Benevi, Slavonski Brod, Republic of Croatia

Abstract. The medical and healthcare needs of a community during disaster conditions could be drastically changed. Hospital capacities, especially the number of intensive-care unit beds and ventilators, are usually constant, so careful planning and great efforts should be made to adapt to altered circumstances. Triage for critical care patients is tertiary triage and is provided according to the hospital disaster plan, which defines triage protocols, the triage officer, and the triage support team. The triage protocols are based on inclusion and exclusion criteria combined with prioritization tools and stratifies patients into priority categories. The most recommended prioritization tool is the SOFA scoring system. The triage process is dynamic, and patients’ medical conditions should be periodically reassessed and their priority category amended if necessary. When a major incident is declared, it may be necessary to triage non-disaster patients in the intensive-care unit to free beds and respirators for expected disaster casualties. Triage protocols should be objective, ethical, transparent, and publicly disclosed to avoid a collision between individual rights and community needs.

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Keywords. Triage, critical care, disaster

Introduction The medical and healthcare needs of a community during disaster conditions could be drastically changed. Hospital capacities, especially the number of intensive-care unit beds and ventilators, are usually constant. Mass critical care will be declared when 80% of surge capacity is used and the remaining 20% of capacity carries a risk of being rapidly used. Therefore careful planning and great efforts should be made for adaptation to the new circumstances. Triage for critical-care patients is “tertiary” triage and is provided according to the hospital’s disaster plan. The word triage originates from the French word trier and means “to choose among several.” It was introduced in medicine by D.J. Larrey (17661842), Napoleon’s military surgeon, for sorting wounded soldiers. A hospital disaster plan defines triage protocols, the triage officer, and the triage support team. The triage officer should be a well-experienced medical professional from the field of intensive medicine, surgery, or emergency medicine. The triage support team consists of medical and non-medical staff supporting the triage officer.

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Triage protocols should have well-defined inclusion and exclusion criteria for admission to the intensive-care unit and as a prioritization tool. The Sequential Organ Failure Assessment (SOFA) score is the most recommended scoring system, because it follows physiological and biochemical parameters and changes according to the applied medical treatment. Use of inclusion and exclusion criteria combined with a SOFA score stratifies patients into priority categories.

1. Inclusion Criteria The patient must have one of the following: A. Requirement for invasive ventilatory support  Refractory hypoxemia (SpO2 < 90% on non-rebreather mask or FIO2 > 0.85)  Respiratory acidosis (pH < 7.2)  Clinical evidence of impending respiratory failure  Inability to protect or maintain airway B. Hypotension (systolic blood pressure < 90 mm Hg or relative hypotension) with clinical evidence of shock (altered level of consciousness, decreased urine output, or other evidence of end-organ failure) refractory to volume resuscitation requiring vasopressor or inotrope support that cannot be managed in a ward setting

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2. Exclusion Criteria A. Severe trauma B. Severe burns with any two of the following:  Age > 60 yrs  > 40% of total body surface area affected  Inhalation injury C. Cardiac arrest  Unwitnessed cardiac arrest  Witnessed cardiac arrest, not responsive to electrical therapy (defibrillation or pacing)  Recurrent cardiac arrest D. Severe baseline cognitive impairment E. Advanced untreatable neuromuscular disease F. Metastatic malignant disease G. Advanced and irreversible immunocompromise H. Severe and irreversible neurologic event or condition I. End-stage organ failure meeting the following criteria: 2.1. Heart x

NYHA class III or IV heart failure

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2.2. Lungs x x x x

COPD with FEV1 < 25% predicted, baseline PaO2 < 55 mm Hg, or secondary pulmonary hypertension Cystic fibrosis with postbronchodilator FEV1 < 30% or baseline PaO2 < 55 mm Hg Pulmonary fibrosis with VC or TLC < 60% predicted, baseline PaO2 < 55 mm Hg, or secondary pulmonary hypertension Primary pulmonary hypertension with NYHA class III or IV heart failure, right atrial pressure > 10 mm Hg, or mean pulmonary arterial pressure > 50 mm Hg

2.3. Liver x Child–Pugh score t7 J. Age > 85 yrs K. Elective palliative surgery

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Note: SpO2 = oxygen saturation measured by pulse oximetry, FIO2 = fraction of inspired oxygen, NYHA = New York Heart Association, COPD = chronic obstructive pulmonary disease, FEV1 = forced expiratory volume in 1 second, PaO2 = partial pressure of arterial oxygen, VC = vital capacity, TLC = total lung capacity. The patient is excluded from admission or transfer to critical care if any of the following is present: Variable PaO2/FIO2 mmHg Platelets, x 103/μL (x 106/L) Bilirubin, mg/dL (μmol/L) Hypotension

0 > 400 > 150 (> 150) < 1.2 (< 20) None

SOFA Scale 1

3 4  200  100  50  20 ( 50) ( 20) 6.0–11.9 > 12 (101–203) (>203) Dop > 5 Dop > 15 Epi  0.1 Epi > 0.1 Norepi  0.1 Norepi > 0.1 Glasgow Coma Score 15 13–14 10–12 6–9 5 (μmol/L) (< 106) (106–168) (169–300) (301–433) (> 434) Dopamine [Dop], epinephrine [Epi], norepinephrine [Norepi] doses in μg/kg/min SI units in brackets Adapted from F.L. Ferreira, D.P. Bota, A. Bross, C. Melot, and J.L. Vincent, Serial evaluation of the SOFA score to predict outcome in critically ill patients, Journal of the American Medical Assn. 286 (2001), 1754-58.  400  150 ( 150) 1.2–1.9 (20–32) MAPB < 70 mmHg

2  300  100 ( 100) 2.0–5.9 (33–100) Dop  5

3. Triage protocols consist of three steps Step 1. Assess to see whether the patient meets inclusion criteria. If yes, proceed to Step 2. If no, reassess the patient in the future or if there is deterioration in clinical status. Step 2. Assess for exclusion criteria. If no, proceed to Step 3. If yes, do not admit or transfer patient to intensive-care unit. Step 3. SOFA initial assessment.

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4. SOFA assessment stratifies patients into three categories: 1. 2. 3.

< 7, single organ failure, highest priority: red 8-12, intermediate priority: yellow > 11, or meets exclusion criteria: blue (provide best available alternative care) CriticalCareTriageTool (InitialAssessment

ColorCode

Criteria

Priority/Action

Blue

Exclusioncriteria or SOFA>11

Medicalmanagementr palliate anddischargefromcriticalcare

Red

SOFA7 or Singleorganfailure

Highest

Yellow

SOFA8–11

Intermediate

Green

No significantorganfailure

Deferordischarge, reassessasneeded

The patient’s medical condition could change, so clinical and SOFA reassessment should be done according to the situation or after some defined time (48 or 120 hrs). 4.1. 48-Hour SOFA Score x x

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x

If score is < 11 and decreasing, high priority (red) If score remains < 8 with no decrease from initial, intermediate priority (yellow) If score > 11 or 8-11 with no decrease from initial, D/C from critical care (blue)

4.2. 120-hour SOFA score x x x x

If score is < 11 and decreasing progressively, high priority (red) If score is < 8 and showing a minimal decrease (< 3 points), intermediate (yellow) If there has been no change in score and < 8, expectant (blue) If score is greater than 11 at any point in first 120 hrs, expectant (blue)

After 5 days, the 120-hour SOFA tool can be reapplied daily for a determined period. The aim of triage protocols in disaster conditions is to maximize benefit for the largest number of patients. Such a situation could easily lead to collision between individual rights and community needs, so the whole system should be based on solid ethical standards: individual liberty, protection of the public from harm, proportionality, privacy, duty to provide care, reciprocity, equity, solidarity, and trust. Procedural values should be reasonable, open and transparent, inclusive, responsive, and accountable.

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Development of Standards of Care for Polytrauma in Multiple-Casualty Incidents a

Mario KOPLJARa and Bore BAKOTAb University Hospital Dubrava, Croatian Urgent Medicine and Surgery Association b General Hospital Karlovac, Croatian Urgent Medicine and Surgery Association

Abstract. Over the last 25 years, many advances have resulted in improved survival of severely injured patients in multiple-casualty incidents. Some of the most important are the development of trauma centers and trauma systems and improved proficiency of surgeons with severe injury management. The cornerstone of surgical practice remains the care of the patient with a surgical emergency and the provision of an emergency operation where appropriate. The ideal resuscitation strategy for multiply injured patients remains a topic of ongoing debate. This is a brief overview of the existing resuscitation protocols for multiply injured patients, including Advanced Trauma Life Support and damage control, and it will address evolving controversies in the field. A damage control approach was developed to improve survival in severely injured trauma patients. The role of damage control in the acute surgery of polytraumatized patients progressing to sepsis or overwhelming hemorrhage continues to be debated. These patients are best managed by a multidisciplinary team, which includes trauma surgeons, orthopedic surgeons, and interventional radiologists. Such an approach represents the challenge in multiple-casualty incidents, necessitating the development of standardized algorithms.

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Keywords. Vascular trauma, abdominal trauma, critical care, multiple-casualty incidents

Hemorrhage still represents a leading cause of death among mass-casualty trauma victims. A major problem in both medical and surgical management is vascular injuries that often endanger patients’ lives and threaten limbs, leading to high amputation rates. This is particularly the case in military operations, where medical care often has to be provided in an austere and dangerous environment with limited resources. Artery ligation, being the easiest and most convenient method of hemorrhage control, leads to unacceptably high amputation rates. In World War I, when ligation was used as a primary means of hemorrhage control, amputation rates were over 70%[1]. Gradually, more emphasis was placed on limb preservation, resulting in reduced amputation rates in subsequent military operations. During the Korean War, amputation rates were successfully reduced to 13%, although vascular injuries below the knee were still associated with the considerably high amputation rate of 38%[2]. With modern high-velocity, high-energy military trauma, vascular injuries are increasingly associated with extensive soft tissue and bone damage, rendering vascular control even more challenging. In the front lines, management of these injuries is becoming much too complex, often requiring highly specialized surgical teams. Such requirements in the field cannot be met due to the nature of conflict and the status of a patient. Therefore, alternative standards of care had to be considered to optimize treatment of polytraumatized patients in mass-casualty incidents, such as a military conflict.

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The emphasis was therefore moved to early damage control procedures with the aim of saving the life and the limb, providing a secure window of opportunity for patient transport to a background facility where more extensive procedures can safely be performed under optimal conditions. In respect to vascular injury, simple arterial ligation no longer suffices. In addition, other relatively simple means of vascular control, such as balloon occlusion or clamping of the injured vessel, may lead to endothelial injury with subsequent thromboses and occlusions, finally resulting in the loss of limbs. Furthermore, these methods, although potentially enabling later reconstruction, interrupt vascular supply for a significant amount of time during patient extraction and transport, ultimately leading to limb loss due to ischemic tissue damage even after successful vascular reconstruction[3]. Complex repairs, including end-to-end anastomosis, saphenous vein grafts, and vascular prosthesis transplantation, were time consuming; for the cold, coagulopathic, exsanguinating victim, they might have disastrous outcomes such as infection, amputation, thrombosis, or death[4-6]. These observations led to the development of intravascular shunts that were intended to preserve vessel patency during patient extrication and transport, enabling successful damage control procedures to be performed to stabilize the patient. Such endoluminal vascular shunts should be simple, easy to use in the front lines, and secure to prevent dislodgement and exsanguination during transport, and they should preserve vessel patency long enough to provide soft tissue perfusion until damage control procedures are performed and the patient is stable enough to undergo more complex vascular repairs. The first vascular shunt was used back in 1915. These shunts were made of silver tubes and were subsequently replaced with glass and plastic tubes that provided better vascular control in the setting of associated bone injuries. However, these attempts were abandoned due to a high shunt thrombosis rate. In 1971, Eger again started using temporary intravascular shunts that were irrigated with heparin to prevent shunt thrombosis[7]. Since then, intravascular shunts have gained ever more widespread acceptance in the management of polytrauma, especially in mass-casualty incidents. Temporary intravascular shunts in such cases had the potential advantage of facilitating rapid control of hemorrhage and restoration of distal flow while permitting deferment of definitive repairs to higher echelons of care where greater resources and expertise would be available[4]. Therefore, the role of temporary intravascular shunts is to prevent warm ischemia time and allow transport to higher echelons for definitive reconstruction. Today, there is a great variety of both commercially available and improvised shunts. The choice of shunt material and configuration depends mainly on the experience and preference of the surgeon, and good results obtained with both commercially available and self-made tubes of different diameters have been reported[4]. Some of the best-known commercial shunts are the Javid shunt, Sundt shunt, and Pruitt-Inahara shunt, with many more variants. The Sundt shunt (internal and external) is made of elastic silicone polymer with stainless steel spring reinforcement to minimize kinking and occlusion of the lumen and to ease insertion of the proximal and distal ends[8]. At both ends of the Sundt shunt there are cone-shaped bulbs that fit firmly against the vessel wall and help maintain the position of the shunt within the vessel. The Javid shunt, on the other hand, has fusiform thickenings at both ends and is held in place with external clamps. The Pruitt-Inahara shunt is a dual lumen shunt, with inflatable balloons on each end designed to keep the shunt in place and an external safety

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balloon to control the pressure of intravascular balloons and thus minimize the damage to the endothelium. Although these shunts have theoretical advantages over simpler Javid or Sundt shunts (and their modifications, such as the Argyle shunt), they are expensive and complex to use on the battlefield. Improvised shunts are usually made of silastic tubes, such as nasogastric tube or infusion tube, although any other tube can be used if it fits the required length and diameter. The advantages of these self-made shunts are simplicity, low cost, and high availability. The most important factor is the diameter of the shunt. It should ideally be of the same diameter as the lumen of the vessel, and if it is too thick it will lead to endothelial injury with subsequent complications. Generally, shunts can be straight or looped, depending on the material and design. It was thought that looping of the shunts should be avoided in order to reduce resistance to flow and prevent dislodgement with fatal consequences[9]. Although these complications are rare in the front line, it is suggested that shunts should lie straight for best performance. The question of the duration of shunt patency is another important factor. Shunts should remain patent until reconstruction is possible. Generally, this includes extrication time, transport time, and additional time required to stabilize the patient in cases where other damage control surgery is mandatory. Although there are reports that shunts remained patent for as long as 10 days, most shunts are functional for 12 to 24 hours. In most cases, this time is sufficient, and quick extrication and transport can now be achieved in no more than 2 hours. With prolonged shunt placement, the risk of shunt occlusion and distal embolization increases. The use of systemic anticoagulation to reduce the risk of shunt thrombosis is questionable. Although hypothetically systemic anticoagulation may be preferable to keep intravascular shunts open, patients in whom shunts are used are usually polytraumatized, and systemic anticoagulation may put them at risk of increased unstoppable bleeding (especially pertaining to intracranial or intra-abdominal bleeding). Therefore, systemic anticoagulation should be used cautiously, or even better should be avoided. It is preferable to irrigate both ends of the vessel as well as the shunt itself with heparinized saline solution to preserve shunt patency. The recommended use of intravascular shunts would therefore be to use shunts of appropriate diameter (avoiding situations where shunt diameter is greater than the diameter of the vessel), place them straight without looping, and ensure that sufficient length is inserted intravascularly on both sides to prevent dislodgement. External angulations should be prevented (most easily achieved with extremity immobilization) and distal pulses regularly checked. Shunts may be replaced if occluded, although distal embolization may not be easily addressed during transport. No systemic anticoagulation seems necessary if shunts irrigated or coated with heparin are used. Possible shunt-related complications are dislodgement, occlusion, distal thrombosis, or embolization and infection. Dislodgement of temporary shunts is rare and is generally the result of improper shunt fixation. Limb immobilization and avoiding shunt looping generally suffice to prevent shunt dislodgement. Should the shunt be dislodged, significant arterial bleeding may result, which can be quickly addressed by simple finger compression of both ends. Another surgeon can then loop both ends of the injured vessel and replace or reinsert the shunt securely. If there is significant disproportion in diameters of the vessel lumen

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and shunt, or if the shunt is not long enough to be securely placed inside the lumen, the shunt should be tied in place. Shunt occlusion is a more frequent problem. Initially, as the patient is hypothermic, exsanguinated, and in coagulopathy, shunt occlusion usually does not represent a major concern. However, after initial resuscitation and the patient is rewarmed, with coagulopathy corrected, several important events may occur: shunt occlusion due to thrombosis, distal embolization, and the development of compartment syndrome that may ultimately result in limb amputation even after seemingly successful shunt bridging and vascular reconstruction. Therefore, shunt patency must be repeatedly and regularly checked, palpating distal pulses and monitoring skin perfusion (capillary refill and changes in skin color and temperature), especially comparing it to the non-injured skin. Handheld portable Doppler devices, although not mandatory, may be of great help to assess vessel patency and perfusion, especially considering difficulties in clinical assessment of perfusion in a hypothermic and hypotensive polytraumatized patient. Over 90% of cases of temporary vascular shunting reported in the literature developed no complications[4]. The optimal type and composition of shunt, the safest methods of insertion, and the most appropriate durations in place are still uncertain[4]. Hemodynamically unstable pelvic fractures represent a difficult diagnostic and therapeutic challenge for the trauma team[10]. Such fractures are often markers of significant blunt trauma associated with chest trauma, intra-abdominal trauma, or fractures of long bones. Pelvic fractures can result in significant bleeding, with mortality rates often exceeding 40%. Bleeding from the shattered pelvis can be either venous (from the sacral plexus) or arterial (from the branches of the internal iliac artery). The primary source of hemorrhage is from the venous plexus and accounts for over 80%. In 10 to 15% of cases, bleeding is arterial. Even simple fractures of pelvic bones may lead to exsanguination. The initial management of the patient with suspected pelvic fracture consists of primary assessment, followed by ABC principles of Advanced Trauma Life Support. All other sources of bleeding must be identified and all active bleeding must be stopped. Examination must be directed to identifying signs of pelvic fracture. These include external signs of hematoma, such as hematoma above the inguinal ligament or hematoma about the flank associated with retroperitoneal bleeding. Palpation of the pelvis can reveal deformities and pathological movements. The pelvis is examined by first applying force over the iliac crests to detect open-book fracture. If pelvic fracture is proved or suspected, further pelvic manipulation must be avoided, since it can aggravate bleeding. If available, frontal X-ray should be performed; it can detect pelvic fractures in only 78% of cases. External bleeding can be stopped with sufficient compression. Once the pelvis is identified as the major source of bleeding, adequate resuscitation should be provided. This consists of repleting packed red blood cells, fresh frozen plasma, and platelets, ideally in a 1:1:1 ratio. Adequate replenishment of fresh frozen plasma and platelets is essential to correct trauma-associated coagulopathy. Although different ratios of packed red blood cells, fresh frozen plasma, and platelets may be used, all these components are essential in resuscitation of a polytraumatized patient, and the 1:1:1 ratio was found to be associated with increased patient survival[11-13]. In addition, recombinant factor VIIa can be used together with the correction of acid base deficits. Furthermore, every effort should be made to maintain normothermia using warm infusions and warm blankets for active and passive warming.

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Since the majority of bleeding from the broken pelvis is venous, splinting the pelvis may significantly reduce the blood loss. Pelvic splinting is most expeditiously accomplished using a longitudinally folded bed sheet wrapped circumferentially around the pelvis. This must be positioned between the iliac crests and the greater trochanter in order to avoid abdominal compartment syndrome. Such immobilization is effective in reducing open-book injuries and avoiding pathological sheer movements that may exacerbate bleeding. However, the volume reduction effect is not so pronounced since it was found that pubic diastasis of 10 cm corresponds to less than 500 cc of increased pelvic volume. There are other commercially available pelvic binders, such as the pelvic sling. These binders enable free access to the abdomen and lower extremities and do not require any special training. They are therefore recommended for prehospital use before patient transport. It has been demonstrated that the use of pelvic binders may result in significantly smaller amounts of required transfusions and a shorter hospital stay[14]. On the other hand, complications associated with pelvic binders include tissue necrosis, nerve injury, and compartment syndromes[15-17]. Pelvic binders should be used only for a limited time to prevent necrosis over bony prominences. Military antishock trousers may have a detrimental effect on exsanguination and also prevent access to the traumatized regions, which is why they are generally advised against. More advanced fixation techniques include anterior external fixation (EX-FIX) or pelvic C-clamp. The principal role of these devices is to exert compression and thereby reduce primarily venous bleeding. The EX-FIX device, however, does not correct for vertical instability. On the other hand, it can be applied in the emergency department, although visualization under X-ray control is preferable. EX-FIX can be placed so that it does not compromise access to the abdomen. Pins can be placed either to the iliac crest or to the supra-acetabular region, which is the preferred option. A C-clamp is used to stabilize the pelvis posteriorly by compressing sacral iliac joints. This device, however, must be used cautiously to avoid fracture displacement, perforation, or nerve injury. Signs of continued bleeding after the pelvis is immobilized mandate the search for other sites of bleeding. As much as 30% of bleeding in these patients is from extra-pelvic sources. Frontal chest X-ray can be used to exclude intra-thoracic bleeding. Abdominal injury is very often associated with pelvic fracture, and intra-abdominal bleeding must be excluded. This can be accomplished by the means of diagnostic peritoneal lavage, ultrasound (Focused Assessment with Sonography in Trauma, or FAST), or computed tomography (CT) scanning. Abdominal ultrasound (FAST) is a quick and accurate method of diagnosing hematoperitoneum and should be used as an initial screening method. Diagnostic peritoneum lavage can be used in suspicious cases, especially to exclude urinary bladder damage, since as much as 4 to 8% of patients with pelvic fracture also sustain bladder injury. Although abdominal CT scans are highly accurate, they can be performed only in hemodynamically stable patients. Abdominal CT can demonstrate contrast blush in up to 10% of patients and is more sensitive than angiography[18]. The size of this blush or the presence of large pelvic hematoma may predict the benefit of therapeutic angiography. Therapeutic strategy for unstable pelvic fractures is thereby directed by the hemodynamic status of the injured patient. In cases of hemodynamic stability, abdominal CT scans and angiography may be performed with potential of successful embolization. However, in hemodynamically unstable patients, angiography can be therapeutic only if it can be performed within 3 hours of admission: only within this time limit can it demonstrate its advantage in reducing arterial bleeding. Consequently, in cases where angiography is not readily available, an urgent operation must be performed, especially

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if there’s any doubt regarding abdominal bleeding. Pre-peritoneal packing has been shown to stabilize the patient and even dismiss the need of angiography. The procedure is carried out through a short, 6 to 8 cm midline incision above the symphysis. The peritoneum should not be entered. If major bleeding is present, the hematoma often bluntly dissects the peritoneum. The hematoma can be removed and the space packed with three large sponges on each side. The sponges may be safely left in place for 24 to 48 hours. Pre-peritoneal packing can successfully stop massive bleeding while avoiding unnecessary laparotomy and can be performed within 20 minutes. In cases where persistent hypotension is observed after pre-peritoneal packing, angiography should be used to identify and stop arterial bleeding. Pre-peritoneal packing is also associated with a much lower rate of abdominal compartment syndrome in comparison to laparotomy. In conclusion, in patients with hemodynamically unstable pelvic fractures, the initial effort must be to stop the bleeding. This can be achieved by either pelvic slings or external fixation. If these methods do not stop the bleeding, pre-peritoneal packing should be attempted before the transport. In cases where laparotomy is required, the easiest way to avoid abdominal compartment syndrome is to leave the abdominal fascia open. All patients with unstable pelvic fractures should be monitored for increased intra-abdominal pressure.

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References [1] G.W. Fisher, Acute arterial injuries treated by the United States Army Medical Service in Vietnam, 19651966, Journal of Trauma Injury, Infection, and Critical Care 7 (1967), 844-55. [2] S.F. Hughes, M.J. Cotter, S.-A. Evans, K.P. Jones, and R.A. Adams, Role of leucocytes in damage to the vascular endothelium during ischaemia-reperfusion injury, British Journal of Biomedical Science 63 (2006), 166-70. [3] J.G. Nichols, J.A. Svoboda, and S.N. Parks, Use of temporary intraluminal shunts in selected peripheral arterial injuries, Journal of Trauma 26 (1986), 1094-6. [4] W. Ding, X. Wu, and J. Li, Temporary intravascular shunts used as a damage control surgery adjunct in complex vascular injury: collective review, Injury 39 (2008), 970-7. Epub 14 April 2008. [5] B.R. Horne and F.G. Corley, Review of 88 nail gun injuries to the extremities, Injury 39 (2008), 357-61. [6] S.R. Menakuru, A. Behera, R. Jindal, L. Kaman, R. Doley, and R. Venkatesan, Extremity vascular trauma in civilian population: A seven-year review from North India, Injury 36 (2005), 400-6. [7] M. Eger, L. Golcman, A. Goldstein, and M. Hirsch, The use of a temporary shunt in the management of arterial vascular injuries, Surgery, Gynecology and Obstetrics 132 (1971), 67-70. [8] B. Lindberg, B. Norbäck, P. Svendsen, and V. Synek, Carotid endarterectomy: A review of 104 operations, Journal of Cardiovascular Surgery 16 (1975), 161-70. [9] L.W. Chambers, D.J. Green, K. Sample, B.L. Gillingham, P. Rhee, C. Brown, et al., Tactical surgical intervention with temporary shunting of peripheral vascular trauma sustained during Operation Iraqi Freedom: One unit’s experience, Journal of Trauma Injury, Infection, and Critical Care 61 (2006), 824-30. [10] C.E. White, J.R. Hsu, and J.B. Holcomb, Haemodynamically unstable pelvic fractures, Injury 40 (2009), 1023-30. [11] M.A. Borgman, P.C. Spinella, J.G. Perkins, K.W. Grathwohl, T. Repine, A.C. Beekley, et al., The ratio of blood products transfused affects mortality in patients receiving massive transfusions at a combat support hospital, Journal of Trauma Injury, Infection, and Critical Care 63 (2007), 805-13. [12] J.C. Duchesne, J.P. Hunt, G. Wahl, A.B. Marr, Y.Z. Wang, S.E. Weintraub, et al., Review of current blood transfusions strategies in a mature level I trauma center: Were we wrong for the last 60 years? Journal of Trauma 65 (2008), 272-6; discussion 276-8. [13] J.B. Holcomb, D. Jenkins, P. Rhee, J. Johannigman, P. Mahoney, S. Mehta, et al., Damage control resuscitation: Directly addressing the early coagulopathy of trauma, Journal of Trauma Injury, Infection, and Critical Care 62 (2007), 307-10.

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[14] M.A. Croce, L.J. Magnotti, S.A. Savage, G.W. Wood II, and T.C. Fabian, Emergent pelvic fixation in patients with exsanguinating pelvic fractures, Journal of the American College of Surgeons 204 (2007), 935-9. [15] J.C. Krieg, M. Mohr, T.J. Ellis, T.S. Simpson, S.M. Madey, and M. Bottlang, Emergent stabilization of pelvic ring injuries by controlled circumferential compression: A clinical trial, Journal of Trauma Injury, Infection, and Critical Care 59 (2005), 659-64. [16] C.M.L. Routt Jr., A. Falicov, E. Woodhouse, and T.A. Schildhauer, Circumferential pelvic antishock sheeting: A temporary resuscitation aid, Journal of Orthopaedic Trauma 16 (2002), 45-8. [17] J.R. Shank, S.J. Morgan, W.R. Smith, and F.N. Meyer, Bilateral peroneal nerve palsy following emergent stabilization of a pelvic ring injury, Journal of Orthopaedic Trauma 17 (2003), 67-70. [18] S.W. Anderson, J.A. Soto, B.C. Lucey, P.A. Burke, E.F. Hirsch, and J.T. Rhea, Blunt trauma: Feasibility and clinical utility of pelvic CT angiography performed with 64-detector row CT, Radiology 246 (2008), 410-9.

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Handbook for Pandemic and Mass-Casualty Planning and Response E. Gursky and B. Hrečkovski (Eds.) IOS Press, 2012 © 2012 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-61499-135-9-163

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Treatment Algorithms and Hospital Triage in Mass-Casualty Incidents Matija JURJEVIa, Asja AJDINOVIa, Boris HREKOVSKIb, Jasminka KOPIa, Zvonimir LOVRIc, Mario KOPLJARd, Bore BAKOTAe

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a

Department of Anesthesiology, Reanimatology and Intensive Care, General Hospital Dr. Josip Benevi, Slavonski Brod, Republic of Croatia b Department of Surgery, General Hospital Dr. Josip Benevi, Slavonski Brod, Republic of Croatia c Trauma Department, University Hospital Dubrava, Zagreb, Croatian Urgent Medicine and Surgery Association d University Hospital Dubrava, Zagreb, Croatia, Surgery Clinic e General Hospital Karlovac, University of Rijeka, Croatia, Department of Traumatology

Abstract. Triage is defined as medical screening of patients to determine their relative priority for treatment. When preparing for triage of patients in a mass disaster, physicians must be aware of the many unique situations and patient conditions. The most frequently used triage methods are sieve and sort—they are the simplest and are mostly used in the field. In hospital conditions, physicians also use more complicated scales: the Glasgow Coma Scale, Injury Severity Score, New Injury Severity Score, Revised Trauma Score, and Trauma Injury Severity Score. All of these scales are used to define the severity of injury as well as to predict patient mortality rates. Besides triage, hospitals in mass disaster settings face resource deficiencies and the lack of highly trained manpower—another important issue when making disaster treatment plans. Keywords. Mass disaster, triage, Injury Severity Score, ISS, Revised Trauma Score, RTS

Introduction Triage is defined as medical screening of patients to determine their relative priority for treatment—the separation of a large number of casualties, in military or civilian disaster medical care, into three groups[1].

1. Preparing for triage When preparing for triage of mass-disaster patients in hospitals, physicians must be ready for multiple victims, a variety of injury types, and medical conditions arising not only from the mass-casualty incident itself but also from victims’ poor health (myocardial infarctions, arrhythmias, etc.) and, most important of all, probably insufficient

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personnel and equipment to provide the full standard of care for all patients as practiced under normal circumstances. Although response to the initial incident can be over in hours or even minutes in the emergency department, it can last days to weeks or months in the intensive-care unit (ICU), placing a heavy weight on the personnel and on the available resources. Therefore, it is important to establish hospital disaster plans that will take into account the multiple victims, their existing health problems, and insufficient resources to provide full, normal care, and for hospital staff to have modified triage and treatment algorithms available for mass-casualty incidents.

2. Triage methods 2.1. Sieve and sort

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Two standard triage methods used worldwide are sieve and sort[1]. 1. Triage sieve is a simple method based on the patient’s walking, breathing, respiratory rate, and circulatory status. 2. Triage sort is based on three variables: the Glasgow Coma Scale, systolic blood pressure, and respiratory rate. The possible score is 1 to 12, with 1 to 10 indicating an urgent priority patient, 11 a “yellow” priority, and 12 a “green” priority patient. It is important to note that the same parameters are used for the Revised Trauma Score (RTS), discussed later. The sieve and sort systems are adequate for field triage, but in the hospital more complex triage is necessary. For in-hospital triage, many anatomical and/or physiological scales are used. The Abbreviated Injury Scale was first introduced in 1969 and has since then been the mainstay for most anatomical trauma scores on which the hospital triage protocols are based. This scale rates the injuries from minor to fatal, assigning them numbers 1 to 6, with 1 standing for minor injury and 6 for unsurvivable wound. It is important to note that the scale is not linear, which means that the difference between AIS 1 and 2 is not the same as between AIS 2 and 3, etc.[2]. Also, it is not used as a sole means for predicting mortality from multiple injuries but rather as a mathematical base for more complex scores. 2.2. Injury Severity Score The Injury Severity Score (ISS), used worldwide, is the most popular score for assessing injury severity and predicting mortality rates. It was first introduced in 1974. Its developers divided the human body into six regions (head, face, chest, abdomen, extremities, external). Every sustained injury is assigned an AIS value and recorded on a chart according to the region of the body affected. After that, the highest three AIS scores are taken, with the limitation of only one injury per body region, and then squared. The sum of these squares is the ISS score.

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2.3. Glasgow Coma Scale and Revised Trauma Score The other in-hospital scores are the so-called “physiological” scores. The best known are the Glasgow Coma Scale and the RTS. The Glasgow Coma Scale rates eye, verbal, and motor response, then adds the values from each of the three categories, yielding values for level of consciousness ranging from 3 (worst) to 15 (best). Table 1. Glasgow Coma Scale No eye opening Best eye response Eye opening to pain Eye opening to verbal command Eyes open spontaneously Best verbal response No verbal response Incomprehensible sounds Inappropriate words Confused Orientated Best motor response No motor response Extension to pain Flexion to pain Withdrawal from pain Localizing pain Obeys commands

1 2 3 4 1 2 3 4 5 1 2 3 4 5 6

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The Glasgow Coma Scale is used worldwide and has entered many treatment algorithms, especially in anesthesiology and trauma, because a value of 8 or lower is used as a diagnostic tool for severe brain trauma and an indication for endotracheal intubation. RTS is another physiological score used in trauma patients. It uses the same parameters as triage sort, namely the Glasgow Coma Scale, systolic blood pressure, and respiratory rate. Table 2. Revised Trauma Scale Glasgow Coma Scale Systolic blood pressure Respiratory rate Value 13-15 >89 10-29 4 9-12 76-89 >29 3 6-8 50-75 6-9 2 4-5 1-49 1-5 1 3 0 0 0 Revised Trauma Score is equal to 0.9368 Glasgow Coma Scale plus 0.7326 systolic blood pressure plus 0.2908 respiratory rate. Range is 0 to 7.8408.

This score has demonstrated accuracy in predicting mortality in a single patient. Its main limitations are that it is not accurate for patients who are already intubated and mechanically ventilated and that it tells nothing about the type of injuries sustained[4]. The newest score is the Trauma and Injury Severity Score. It determines the probability of patient survival (Ps) from the combination of ISS and RTS scores. A logarithmic regression equation is used: Ps = 1/(1 + e – b), where b = b0 + b1 (RTS) + b2 (ISS) + b3 (age)

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RTS and ISS are calculated as above, and the age value is either 0 (if the patient is < 55 years old) or 1 (if 55 or over). The coefficients b0 through b3 depend on the type of trauma.

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Coefficient b0 b1 b2 b3

Blunt trauma or age < 15 years -0.4499 0.8085 -0.0835 -1.7430

Penetrating trauma -2.5355 0.9934 -0.0651 -1.1360

While it is clear that anatomical and physiological scores can be used singly or combined, none of them can provide an accurate but also quick and applicable score for all patients in hospital triage. Therefore, the quality of the hospital response to mass-casualty incidents falls again mainly on the knowledge and experience of the physicians present. It would be highly recommended to have emergency medicine specialists available for each of the examination bays supported, with at least one qualified trauma surgeon and one anesthesiologist when receiving patients from a mass-casualty incident. Since emergency medicine is not present as a specialty in many countries, anesthesiologists and surgeons must fill this role in the emergency departments. Unfortunately, this will limit their roles in the operating theaters and ICUs. Other medical specialists (radiologists; ultrasound– internal medicine specialists; surgical assistants; urologists; orthopedic surgeons; ear, nose, and throat specialists; etc.) can then come into play, performing, for example, easier tasks (ultrasound, X-rays) in the ICU or emergency department. In this way, a higher quality of medical care can be provided for numerous patients who can overwhelm hospital resources. Also, in-hospital triage and preparation plans must take into account the so-called “upside-down” triage—patients who are less injured arrive at the hospital, bypassing the emergency medical services (EMS) triage, possibly depleting the hospital’s resources; the most severely injured arrive later, after the EMS triage. If a terrorist bombing is the source of casualties, it is good to calculate their likely number: for a rough prediction of the total first wave of casualties, double the first hour’s casualties. Obtain and record details about the nature of the explosion, potential toxic exposures and environmental hazards, and casualty location (information provided by the police, fire department, EMS, Incident Command System commander, regional emergency management association, health department, and reliable news sources). If a structure has collapsed, expect increased severity and delayed arrival of casualties. In the end, it is important to stress that, unlike any other condition, trauma is a dynamic state, quickly changing the patient’s condition as time elapses, making judgment errors in many cases rapidly fatal. Although there are many trauma scores available, none can be used as a sole means of measuring injury severity and/or mortality but only as one tool in the hands of highly educated and capable physicians.

References [1] D. Talmor, A.E. Jones, L. Rubinson, et al., Simple triage scoring system predicting death and the need for critical care resources for use during epidemics, Critical Care Medicine 35 (2007), 1251-6. [2] W.S. Copes, W.J. Sacco, H.R. Champion, and L.W. Bain, Progress in characterising anatomic injury, in Proceedings of the 33rd Annual Meeting of the Association for the Advancement of Automotive Medicine, Baltimore, Maryland, USA, 205-218.

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[3] H. Husum and G. Strada, Injury Severity Score versus New Injury Severity Score for penetrating injuries, Prehospital and Disaster Medicine 17 (2002), 27-32. [4] H.R. Champion et al., A revision of the Trauma Score, Journal of Trauma 29 (1989), 623-629.

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Handbook for Pandemic and Mass-Casualty Planning and Response E. Gursky and B. Hrečkovski (Eds.) IOS Press, 2012 © 2012 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-61499-135-9-168

Guidelines for Limb Amputation and Reconstruction in Mass-Casualty Incidents Bore BAKOTAa, Mario KOPLJARb, and Boris HREKOVSKIc a

General Hospital Karlovac, University of Rijeka, Croatia, Department of Traumatology b University Hospital Dubrava, Zagreb, Croatia, Surgery Clinic c General Hospital Slavonski Brod, Croatia, Department of Traumatology

Abstract. Treatment of a mangled lower extremity represents a major challenge in mass-casualty incidents. The decision whether to amputate or attempt reconstruction is currently based upon surgical evaluation. The aim of this chapter is to propose a new approach to surgical evaluation based on scoring systems and local clinical status of the patient, as well as comorbidities, mechanism of trauma, and hospital resources. Based on current literature guidelines and evidence-based medicine, management for borderline cases is proposed to aid clinical decision making in these situations. Despite a borderline Mangled Extremity Severity Score (see Table II in K. Johansen et al.[1]), in some cases reconstruction can be attempted considering the overall health status of the patient and local clinical status, with preserved plantar sensitivity and satisfactory capillary perfusion. In conclusion, management of mangled extremity treatment should refer to evidence-based literature in correlation with clinical evaluation of every individual patient. Scores are helpful but should not be taken as a sole indication for amputation.

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Keywords. Limb salvage, amputation, MESS score, leg injuries, surgery, decision making

Introduction Treatment of a mangled lower extremity represents a major challenge. The decision whether to amputate or attempt reconstruction is currently based upon surgical evaluation. Until now, the absolute criteria for amputation have been non-reconstructable vascular injury, crush injury with warm ischemia over 6 hours, and severe bone and soft tissue loss with tibial nerve transsection[2, 3]. Relative criteria are elderly patients in shock with a mangled limb, massive soft tissue loss associated with bone loss, Mangled Extremity Severity Score (MESS)  7 (especially with absent plantar sensation), severe ipsilateral foot trauma, polytrauma, and patients who are not expected to tolerate reconstruction[1]. However, these criteria should not be considered strict rules, but rather guidelines, due to many patient and wound-related variables[4]. A patient with a mangled extremity that matches criteria for amputation can successfully have a salvaged limb with restoration of full function due to an individualized approach to treatment and consideration of many other patient and wound variables. Decision making in the clinical situation of a mangled extremity is complex[5]. Thanks to the development of surgical techniques and technologies, comprehensive

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reconstructions are possible today in limb salvage procedures[6-11]. However, uncritical limb salvage attempts expose patients to increased morbidity and mortality, as well as prolonged and costly treatment, and they often result in a dysfunctional extremity and disappointment[1]. Although in many cases based solely on clinical examination the decision to amputate or attempt salvage is clear, in borderline cases the decision requires the use of different tools, such as scoring systems, that may help differentiate salvageable from non-salvageable extremities. There are a variety of scoring systems designed to aid clinical decision-making: MESS, Limb Salvage Index, Predictive Salvage Index, NISSA (nerve injury, ischemia, soft tissue injury, skeletal injury, and age of the patient), Hannover Fracture Scale-97, and many others[1, 12-16]. The purpose of these scores is to allow accurate prediction of either the need for amputation or the possibility of salvage. Several clinical trials were conducted to determine the exact cutoff point for these scores for use in decision making. Johansen et al. reported that a MESS greater than or equal to 7 predicted amputation with 100% accuracy[1]. Since delayed amputation in that study resulted in over 20% mortality from sepsis as compared to no mortality in primary amputation[1], the importance of accurate decision making is obviously of paramount importance. Given the large number of scoring systems, a prospective, observational, multicenter evaluation of patients with Gustilo IIIB and IIIC (Table 3) open tibia fractures— the Lower Extremity Amputation Prevention (LEAP) study—was performed[15]. The results, however, failed to validate the clinical utility of any scoring system in predicting the need for amputation, though it did demonstrate the important role of psychosocial issues in long-term outcomes. Furthermore, initial absence of plantar sensation was not a reliable indicator of the need for amputation, as 55% of patients with no plantar sensation initially reported plantar sensation at 24 months. A repeat of the LEAP study confirmed these previous results, emphasizing the inability of scoring systems to accurately predict the need for amputation, although low scores may predict salvage potential[17, 18]. The results of treatment followed by the LEAP study clearly demonstrate the possibility of limb salvage even in patients with borderline MESSes, showing that one cannot rely on definite cutoff points when using scoring systems. Consequently, there is an obvious need for a new criteria proposal of mangled extremity treatment for borderline cases (Table 1) that will take into account not only scoring systems, but also important patient and wound variables[19].

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Table 1. Borderline cases criteria proposal for mangled lower limb extremity treatment. Absolute criteria for amputation Non-reconstructable vascular injury Crush injury with warm ischemia > 6h Severe bone and soft tissue loss with tibial nerve transsection Relative criteria for amputation Wound-related Fracture grade and type Compartment syndrome Wound contamination Possibility of immediate fixation Duration and severity of ischemia Loss of soft tissues of the foot Patient-related Associated injuries Shock Coagulopathy Need for vasoconstrictors Acute Respiratory Distress Syndrome Age Comorbidities Hospital resources Transport time Mass or military casualty Scoring systems Copyright © 2012. IOS Press, Incorporated. All rights reserved.

Expected outcome Mandatory weight bearing Presence of protective sensation Presence of durable skin and soft tissue

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Summary It is necessary to include other patient and wound variables in addition to scoring systems to allow improved treatment outcomes using an individualized approach to patients with mangled extremities.

References [1] K. Johansen, M. Daines, T. Howey, D. Helfet, and S.T. Hansen Jr., Objective criteria accurately predict amputation following lower extremity trauma, Journal of Trauma 30 (1990), 568-72; discussion 572-3. [2] S.T. Hansen Jr., The type-IIIC tibial fracture: Salvage or amputation, Journal of Bone and Joint Surgery, American Volume 69 (1987), 799-800. [3] R.H. Lange, A.W. Bach, S.T. Hansen Jr., and K.H. Johansen, Open tibial fractures with associated vascular injuries: prognosis for limb salvage, Journal of Trauma 25 (1985), 203-8. [4] P.R. Wolinsky, L.X. Webb, E.J. Harvey, and N.C. Tejwani, The mangled limb: salvage versus amputation, Instructional Course Lectures 60 (2011), 27-34. [5] S.B. Shawen, J.J. Keeling, J. Branstetter, K.L. Kirk, and J.R. Ficke, The mangled foot and leg: salvage versus amputation, Foot and Ankle Clinics 15 (2010), 63-75.

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[6] Q.F. Guo and Z.H. Xu, Rescue and treatment of severely injured lower extremities, Chinese Journal of Traumatology 8 (2005), 81-5. [7] G.G. Hallock, The utility of both muscle and fascia flaps in severe upper extremity trauma, Journal of Trauma 53 (2002), 61-5. [8] E.G. Melissinos and D.H. Parks, Post-trauma reconstruction with free tissue transfer—analysis of 442 consecutive cases, Journal of Trauma 29 (1989), 1095-102; discussion 1102-3. [9] D. Mileto, S. Cotrufo, G. Cuccia, G. Delia, G. Risitano, M.R. Colonna, et al., The distally based sural flap for lower leg reconstruction: Versatility in patients with associated morbidity, Annali Italiani di Chirugia 78 (2007), 323-7. [10] O. Ozkan, O.K. Cokunfirat, and H.E. Ozgenta, The use of free anterolateral thigh flap for reconstructing soft tissue defects of the lower extremities, Annals of Plastic Surgery 53 (2004), 455-61. [11] J. Tang, K. Li, and J. Liu, [Repairing widespread traumatic soft tissue defects in lower limb with free latissimus dorsi muscle-skin flaps], Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 20 (2006), 1087-9. [12] H.R. Howe Jr., G.V. Poole Jr., K.J. Hansen, T. Clark, G.W. Plonk, L.A. Koman, et al., Salvage of lower extremities following combined orthopedic and vascular trauma: A predictive salvage index, American Surgeon 53 (1987), 205-8. [13] W.L. Russell, D.M. Sailors, T.B. Whittle, D.F. Fisher Jr., and R.P. Burns, Limb salvage versus traumatic amputation: A decision based on a seven-part predictive index, Annals of Surgery 213 (1991), 473-80; discussion 80-1. [14] N.P. Suedkamp, N. Barbey, A. Veuskens, A. Tempka, N.P. Haas, R. Hoffmann, et al., The incidence of osteitis in open fractures: An analysis of 948 open fractures (a review of the Hannover experience), Journal of Orthopaedic Trauma 7 (1993), 473-82. [15] M.J. Bosse, E.J. MacKenzie, J.F. Kellam, A.R. Burgess, L.X. Webb, M.F. Swiontkowski, et al., A prospective evaluation of the clinical utility of the lower-extremity injury-severity scores, Journal of Bone and Joint Surgery, American Volume 83-A (2001), 3-14. [16] M.G. McNamara, J.D. Heckman, and F.G. Corley, Severe open fractures of the lower extremity: A retrospective evaluation of the Mangled Extremity Severity Score (MESS), Journal of Orthopaedic Trauma 8 (1994), 81-7. [17] M.J. Bosse, M.L. McCarthy, A.L. Jones, L.X. Webb, S.H. Sims, R.W. Sanders, et al., The insensate foot following severe lower extremity trauma: An indication for amputation? Journal of Bone and Joint Surgery, American Volume 87 (2005), 2601-8. [18] M.J. Bosse, E.J. MacKenzie, J.F. Kellam, A.R. Burgess, L.X. Webb, M.F. Swiontkowski, et al., An analysis of outcomes of reconstruction or amputation after leg-threatening injuries, New England Journal of Medicine 347 (2002), 1924-31. [19] T.M. Scalea, J. Dubose, E.E. Moore, M. West, F.A. Moore, R. McIntyre, C. Cocanour, J. Davis, M.G. Ochsner, and D. Feliciano, Western Trauma Association critical decisions in trauma: Management of the mangled extremity, Journal of Trauma 72 (2012), 86-93.

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Burn Injuries during Mass-Casualty Incidents Darko JURIŠIa, Boris HREKOVSKIa, Josip JANKOVICa, Damir ROSKOa, and Matija JURJEVIb a Department of Surgery, General Hospital Slavonski Brod, Croatian Urgent Medicine and Surgery Association b Department of Anesthesiology, General Hospital Slavonski Brod, Croatian Urgent Medicine and Surgery Association

Abstract. Burn injuries are usually treated according to Advanced Burn Life Support guidelines. In mass-casualty incidents, we recognize four phases of burns treatment according to International Society for Burn Injuries guidelines: 1. First triage 2. Initial wound care and fluid resuscitation, including secondary triage 3. Burn wound care with excision, grafting, and infection control 4. Rehabilitation with reconstructive surgery The International Society for Burn Injuries proposes guidelines based on proper planning for burns treatment in mass-casualty incidents and the need to clarify levels of care and the transport of patients between these levels. Every country needs to have plans for fire incident management. Emergency medical and rescue personnel need to know basic principles of burn treatment and the locations of burn centers.

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Keywords. Burn injuries, burn assessment, treatment of burns

Background The International Society for Burn Injuries has proposed guidelines for dealing with disasters that involve large numbers of serious burn patients. The aim is that each country have a disaster planning system that addresses its own particular needs. Since adequate equipment and supplies are expensive and not always easily acquired, it is important to prepare and store the minimum amount of equipment and medical supplies if possible. Every region of each country must designate areas or locations where these emergency packages will be stored and supervised. According to these needs, the International Society for Burn Injuries proposed a functional system that does not indicate or depend on hospital location, size, or available equipment.

1. Burn treatment facilities Burn treatment facilities for disaster victims may be classified as one of three types: Type A: Facilities that provide resuscitation treatment only Type B: Facilities that provide both resuscitation and post-resuscitation treatment Type C: Facilities that provide rehabilitative and reconstructive treatment only

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Every hospital, if it is in a safe zone, can function as Type A. If there is a general hospital without a specialized burn center near the disaster area, and if pre-planned national burn teams and a supply system are available, it may be possible to transform this center into a Type C or even Type B burn treatment facility.

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2. First aid and triage The most important part of response to a burn disaster is rapid and appropriate evacuation of patients from the zone and transportation of each patient to a facility that can provide appropriate medical therapy. Following first-aid rules: x The victim should be removed from the heat source and moved to a safe place. The casualty should not be rolled on the ground. The stop-and-drop procedure should be followed. When electricity is involved, power should be turned off before administering first aid. x Make the victim lie supine. Watch for the response and assess for ABCDE (airway, breathing, circulation, disability, compartment syndrome, and exposure: percentage area of burn). If there is no response and there are no chest movements, cardiopulmonary resuscitation (CPR) should be instituted urgently. x In scalds, clothing acts as a heat reservoir and should be removed along with all jewelry. Do not peel off the victim’s clothes; if clothing is stuck to the burn, do not remove it. x Start cooling the affected area with running water between 8C and 25C (15C is ideal) for 30 minutes. Do not use ice; watch for hypothermia in children and in victims with burns that affect large amounts of body surface area. x Prevent contamination: cover the victim with a clean, non-adherent burn dressing (or wrap the victim in a clean sheet or towel until the person receives medical attention). x Do not apply any medications locally. They make the formal assessment of the nature, depth, and extent of the burn wound difficult. x If the victim is trapped in a burning enclosed space such as a building, keep in mind smoke inhalation and potentially life-threatening airway burns. The burn patient has the same priorities as all other trauma patients. After appropriate evacuation, the degree of the burn wounds and the need for intensive care should be evaluated on site and resuscitation should start immediately. The aim of triage is to shelter the injured person in a safe, supportive environment at the disaster site while the person’s condition stabilizes, and then care for the person until transportation is done.

3. Burn assessment The severity of a burn injury is related to the depth of skin involvement, the percentage of total body surface area (TBSA) involved, and location. Burns are most severe when located on the face, neck, hands, feet, or genitals, or when they are spread over large parts of the body or combined with other injuries. Burn depth can progress without adequate first aid and without treatment such as appropriate fluid resuscitation and dressings. Burns are especially serious for a child or an elderly person.

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x

x

x

x

175

First degree (superficial) A first-degree burn involves only the top layer of skin: the epidermis. The skin is red and dry and usually painful. The burned area may also swell. Most sunburns are superficial burns. This type of burn usually heals in 5-6 days without any permanent scarring. Second degree (partial thickness) A second-degree burn involves the top layers of skin. The skin is red or mottled with blisters that may open and weep clear fluid, giving the skin a wet appearance. Second-degree burns are usually the most painful. These burns heal in 3-4 weeks, and scarring may occur. Superficial partial-thickness wounds appear pink and moist, while deep partial-thickness wounds look dry and pale. Third degree (full thickness) A third-degree burn destroys all layers of skin and any or all of the underlying structures (fat, muscles, bones, and nerves). The burn appears brown or black (charred) with the tissues underneath sometimes appearing white. This type of burn can be extremely painful (or relatively painless if the burn destroys the nerve endings). The pathognomonic finding on physical examination is thrombosed vessels. Fourth-degree burn extends deep to the bone

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4. Estimating the percentage of total body surface area burned The “Rule of 9’s” is commonly used to estimate the burned surface area in adults. The body is divided into anatomical regions that represent 9% (or multiples of 9%) of the total body surface. The outstretched palm and fingers approximate to 1% of the body surface area. The Rule of 9’s is too imprecise for estimating the burned surface area in children because the infant or young child’s head and lower extremities represent different proportions of surface area than in an adult. Alternatively, the patient’s unstretched open hand (palm and extended fingers) represent 1% of TBSA. Burns greater than 15% in an adult, burns greater than 10% in a child, or any burns in the very young or elderly are serious. Accurate estimation of burn size is critical to ongoing fluid replacement and management.

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Figure 1: Rule of Nines: The most universal guide for initial estimate of TBSA burned.

Figure 2: Full-thickness flame burn of the left arm.

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Figure 3: Full-thickness contact burn (patient was alcoholic and fell unconscious against an oven).

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5. Treatment Protocol 5.1. Airway and breathing x x x x x

Indications for airway assessment include the presence of pharyngeal burns, air hunger, stridor, carbonaceous sputum, and hoarseness. Fiberoptic bronchoscopy can be performed at the bedside. All patients with major burns must receive high-flow oxygen for 24 hours. If breathing seems to be compromised because of tight circumferential trunk burns, consult with the burn center surgeons immediately regarding the need for escharotomy. In the case of carbon monoxide poisoning, 100% oxygen via a non-rebreathing face mask should be administered. Intubation is generally necessary only in the case of unconscious patients, hypoxic patients with severe smoke inhalation, or patients with flame or flash burns involving the face and neck.

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5.2. Circulation x x x x x x x x x

x

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x x

Stop any internal bleeding. Identify potential sources of internal bleeding. Establish large-bore intravenous (IV) lines and provide resuscitation bolus fluid as required in all compromised patients, using standard Advanced Trauma Life Support protocols. Perfusion of potentially viable burn wounds is critical. Patients with < 10% TBSA burns can be resuscitated orally (unless the patient has an electrical injury or associated trauma). This needs ongoing evaluation, and the patient may still require an IV line. In the case of patients with burns on 10% to 40% TBSA, secure a large-bore IV line; add a second line if transportation will take longer than 45 minutes. Burns > 40% TBSA require two large-bore IV lines. If the transfer will take less than 30 minutes from the time of the call, do not delay transfer for the sake of an IV line. An intraosseous line is an excellent alternative in children. Burn wounds involving greater than 20% TBSA typically mount a systemic inflammatory response with resultant capillary leak. Initiate fluids for ongoing resuscitation and fluid losses using the Parkland formula: 4mL crystalloid × _kg of body weight_× (% burn) = mL in first 24 hours, with half of this total given in the first 8 hours after injury (note that this is the time from burn, not from presentation to healthcare services). Crystalloid fluid is keystone; colloids are not useful. Fluid requirements in children are estimated with the Parkland formula, as in adults. Children must have their additional maintenance fluids added to these replacement fluids (including dextrose). Assess urine output (this is the best guide to resuscitation); insert a Foley catheter in patients with burns > 15% TBSA. Adequate urine output is 0.5 mL/kg/h in adults and 1.5 mL/kg/h in children. Nutritional status should be monitored at least twice weekly with a serum prealbumin.

5.3. Decompression incisions (escharotomy) Assess for circumferential full-thickness burns of the extremities or trunk. If wounds are circumferential or nearly circumferential, pulses need to be assessed hourly. Elevate the burned extremities on pillows above the level of the heart. If transfer will be delayed, discuss indications and methods for decompression incisions (escharotomies) with a burn surgeon. Deep or full-thickness burns make the skin inelastic and act like a tourniquet. They should be released by escharotomy to prevent respiratory embarrassment (of the chest and abdomen) or vascular compromise of the limbs. This may need to be done before transfer to a specialist unit.

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5.4. Medication x x

Give tetanus immunization After fluid resuscitation has been started, start adequate pain control with medication

5.5. Wound care Care of the wound itself should be designed to x Prevent infection x Prevent further tissue loss x Promote spontaneous healing x Provide optimal conditions for surgery if required x Be as painless as possible 5.5.1. Initial wound care x x x

Debridement and application of topical antimicrobials are usually unnecessary. Initial wound care needs to ensure that the burn is kept covered and the patient kept warm. The simplest way is to wrap the patient in a dry, sterile sheet. Apply a thin layer of silver sulfadiazine to open areas if transportation will be delayed for more than 12 hours. Use of Burnshield is a very effective means of cooling and dressing the injury in the first 24 hours.

5.6. Minor burn injuries

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5.6.1. Debridement Burn debris should be removed with mild soap and water, sterile saline, or a topical antiseptic solution before dressings are applied. The dead skin of open blisters should be removed, and large or friable blisters should also be opened. Small blisters may be left intact. Antibiotics are not routinely prescribed in minor burns. The tetanus status of the patient should be checked. 5.6.2. Dressings Initially a topical antimicrobial is used for most partial-thickness wounds. They include povidone-iodine ointment, silver nitrate, silver sulfadiazine cream, and mafenide acetate cream. Mafenide acetate is the only agent that penetrates eschar. For debridement of partial-thickness wounds, enzymatic agents such as collagenase are very useful. In the clean, partial-thickness burn, without necrotic tissue and bacteria, dressings such as paraffin gauze, chlorhexidine-impregnated gauze, or similar dressings such as soft silicone can be used with an overlying gauze pad. Hydrocolloid dressings are particularly good for use on hands and other small areas of superficial or partial-thickness burns. In bigger burns, several layers of dressing are usually required to absorb exudate. Dressings such as alginate adhere to the wound and should be reviewed after 24 hours. At this point only the secondary dressing immediately overlying the alginate needs to be replaced. Once the wound is healed, the alginate separates off. If there is

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excessive exudate or a full-thickness burn, the dressing fails to stick, indicating the necessity for further assessment. Repeated review of the burn wound and multiple dressing changes are unnecessary. A change of dressings and wound review after 48 hours is usual. Further changes are guided by the rate of healing, but are generally needed at intervals of two to three days. More frequent change of dressing is needed if there is a high volume of exudate or evidence of infection. 5.7. Major burn injuries

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Surgical debridement of the major burn is based on the vitality of the patient to undergo a procedure and the depth and location of the burn. Excision of the burn may be required. Tangential excision is a technique used to remove the burn eschar. Basically, the eschar is removed tangentially in layers until all of the necrotic tissue has been excised and a viable wound bed is present. In very deep burn wounds, fascial excision, which removes the entire subcutaneous layer up to the fascia, has to be done instead of tangential excision. Reconstruction is often done with mesh or sheet split-skin grafts harvested from the patient in single or multiple stages. The skin graft usually is secured to the recipient site with sutures, staples, or fibrin sealant. If the patient has insufficient donor skin, this may be combined with cadaveric skin (allograft), pig skin (xenograft), or artificial skin substitutes (Integra, Biobrane, TransCyte, AlloDerm, etc.) Several layers of dressings are used to minimize mechanical shear forces at the site of skin grafting. These should not be too tight, as swelling often occurs after a burn injury. Once a burn has healed, the area should be regularly moisturized and protected from the sun by sunblock cream or clothing. Physiotherapy may be required to prevent burn contractures. Burn reconstruction surgery is needed for release of contractures and the correction of contour abnormalities in case of remaining functional consequences after burn injuries.

References [1] J.R. Campbell, International Trauma Life Support for Prehospital Care Providers, 6th edition, Pearson Education, Upper Saddle River, New Jersey, USA, 2008. [2] M. Haberal, Guidelines for dealing with disasters involving large numbers of extensive burns, Burns 32 (2006), 933-9. [3] E. J. van Hasselt, Burns Manual, 2nd edition, Beverwijk, Netherlands, Nederlandse Brandwonden Stichting, 2008. [4] A. Benson, W.A. Dickson, and D.E. Boyce, ABC of wound healing: Burns, British Medical Journal 332 (2006), 649-52. [5] Committee on Tactical Combat Casualty Care meeting minutes, 3-4 November 2009, Denver, Colorado, USA. [6] R.L. Sheridan, Burns, Critical Care Medicine 30 (Suppl.) (2002). [7] M. Stander and L.A. Wallis, The emergency management and treatment of severe burns, Emergency Medicine International 2011 (2011). [8] L.C. Cancio and B.A. Pruitt, Management of mass casualty burn disasters, International Journal of Disaster Medicine (2005), 1-16. [9] Advanced Burn Life Support, American Burn Assn., www.ameriburn.org/ablscoursedescriptions.php. [10] Satelitski simpozij o opeklinama. Nacionalne smjernice za organizaciju i suvremeno lijecenje opeklina. 8. Hrvatski kongres Plasticne rekonstrukcijske i estetske kirurgije s medjunarodnim sudjelovanjem, 6-10 October 2010, Dubrovnik, Croatia.

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Blast Injuries Matija JURJEVIa, Ivo MATIa, Asja AJDINOVIa, Boris HREKOVSKIb, Ivana PAJI-PENAVIc, Josip SAMARDŽIb, Zvonimir LOVRId a Department of Anesthesiology, Reanimatology and Intensive Care, General Hospital Dr. Josip Benevi, Slavonski Brod, Republic of Croatia b Department of Surgery, General Hospital Dr. Josip Benevi, Slavonski Brod, Republic of Croatia c Department of Ear, Nose and Throat, Head and Neck Surgery, General Hospital Dr. Josip Benevi, Slavonski Brod, Republic of Croatia d Trauma Department, University Hospital Dubrava, Zagreb, Croatian Urgent Medicine and Surgery Association

Abstract. An increasing number of mass disasters involve explosions. Their principal effect is the creation of tremendous kinetic energy over a short period. The main cause of blast injuries is explosives, and there are five injury types. When approaching an explosion site, medical personnel must coordinate their actions with the police and fire-rescue services to ensure their own safety. Patient care can then be performed using standard the ABCDE principle and trauma algorithms. All vital organ systems can be affected by the blast, so a medical rescuer in the field can expect a variety of injuries. Keywords. Blast injury, mass disaster, explosives.

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Introduction An increasing number of mass-casualty incidents are combined with explosions[1]. The principal effect of an explosion is the creation of a tremendous kinetic energy over a short period[2]. Mortality rates are high, varying from about 8% in open-air blasts to 49% when the explosion occurs in a confined space[3]. About 70% of victims have soft tissue injury, and 11% have traumatic amputations. The main cause of blast injuries is explosive devices, primarily improvised explosive devices. They are categorized as either high-order explosives (HE) or low-order explosives (LE). HE produce a defining supersonic over-pressurization shock wave. LE create a subsonic explosion and no over-pressurization wave. Since HE and LE cause different injury patterns, it is crucial for medical personnel to be aware of the kind of injuries each causes and their pathophysiology and to know how to manage blast injuries; management includes adequate triage, diagnosis, and treatment.

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1. Types of blast injuries Typically, we recognize five types on injuries caused by explosion[4]: 1. Primary or so-called “blast wave” injuries. This injury type is caused by the over-pressurization impulse wave created by the explosion. Anatomical and physiological changes are the result of the direct or indirect over-pressurization force impacting the body’s surface. This injury type is exclusively caused by HE. Other injuries include those originating from the so-called “blast wind,” which is in fact forced superheated airflow. It can be found with both HE and LE. Primary injuries are found in about 20% of victims. Factors influencing the number and the severity of injuries are the peak pressure created by the wave, duration of the wave, distance from the explosion, and location (indoors or outdoors)[5]. Most affected are the sensitive membranes in the human body, found in the ears, lungs, and gastrointestinal tract. 2. Secondary injuries, caused by shrapnel and other flying objects. Injuries in this category are numerous and present the main cause of death from explosions. The flying objects can be blunt or penetrating, depending on the type of explosive as well as the surroundings in which the explosion occurs. Terrorists often include nails, sharp metal fragments, or other objects in their explosive devices to maximize the number of casualties. 3. Tertiary injuries, caused by the victim being pushed or thrown by the blast. Injuries vary, depending on the surrounding area and the proximity to the explosion, from minor abrasions to severe blunt and/or penetrating injuries. 4. Quaternary injuries, not directly caused by the explosion. Here, patients will present mainly with burns, but also with crush injuries or radiation, carbon monoxide, or chemical poisoning. 5. Quinary injuries, induced by toxic substances released upon detonation (radiation, carbon monoxide or chemical poisoning, biological agents, etc.).

2. The field approach The safety of medical personnel is a difficult issue in mass-casualty incidents. If a terrorist attack is suspected, there is a possibility of a secondary explosive device intended to kill or injure the rescue personnel. Furthermore, buildings could collapse, and ships

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or other large vessels could sink, as a result of structural damage caused by the primary explosion. Also, sometimes, terrorists will disguise themselves as victims, aiming to launch another attack when the time is right. It is therefore important for the medical staff to coordinate their actions with the police and fire/rescue services in order to ensure their own safety. After the initial procedures are completed, the patients can be examined and triaged. Triage can be performed according to the standard trauma treatment algorithms, using the ABCDE (airway, breathing, circulation, disability, compartment syndrome, and exposure) approach. If the victim is alive, rescuers must cover open chest wounds, treat tension pneumothorax, and control the bleeding. Burns must be covered with sterile dressings. Impaled objects can be removed only if they are interfering with the airway; otherwise they should be left alone until advanced treatment methods are available (surgery, intensive-care unit, X-ray, etc.). The objects should be shortened only if they prevent patient transport. Long bone fractures should be splinted to prevent instability and/or bleeding. 1. Central nervous system x Symptoms: headache, fatigue, lethargy, anxiety, poor verbal response and concentration, insomnia, depression. x Injuries: concussion; cerebral contusion; open and closed brain injury, including subdural, epidural, subarachnoidal, and intracerebral hemorrhage; stroke; spinal cord injury; air embolism–induced injury. x Proximity to the blast is important in evaluating central nervous system injury. Also, remember that blast waves can cause mild to severe concussions even without direct mechanical trauma to the head.

Figure 1. Brain trauma in an explosion is caused by a combination of shockwave injury, shrapnel wounds, and acceleration, as well as impact bruises of the brain.

2.

Ear and auditory system x Symptoms: headache, fatigue, lethargy, anxiety, poor verbal response and concentration, insomnia, depression. x Injuries: concussion; cerebral contusion; open and closed brain injury, including subdural, epidural, subarachnoidal, and intracerebral hemorrhage; stroke; spinal cord injury; air embolism–induced injury.

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3.

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4.

x Ear injuries are often overlooked but are very important in evaluating the severity of other (respiratory/lung) injuries. Also, remember that the orientation to the blast is important for left/right lateralization of the injury. One positive factor is that most symptoms are present immediately after injury. In any case, blast victims should always be examined by an ear, nose, and throat specialist and have audiology testing. Ophthalmic injuries x Symptoms: altered vision, eye pain and/or irritation, foreign body sensation, periorbital swelling or contusions, decreased visual acuity. x Injuries: perforated globe, foreign body, sub-conjunctional hemorrhage, fractures, air embolism, lid lacerations. x Eyes are extremely sensitive to mechanical, chemical, or wave damage. Therefore, about 10% of victims will have some kind of eye injury. Since visual loss or impairment presents a severe decrease in life quality, it is rational to include ophthalmologic consultation for all blast victims. Respiratory/lung x Symptoms: dyspnea, chest pain, cough, hemoptysis, absent lung sounds on auscultation or percussion abnormalities, low oxygen saturation on pulse oximetry. x Injuries: Blast lung, hemothorax, pneumothorax, pulmonary contusion and hemorrhage, tracheal injuries, rib fractures, arteriovenous fistulas (source of air embolism), airway epithelial damage, late complications—aspiration pneumonitis, sepsis. x “Blast lung” is the most common fatal injury among primary survivors. Symptoms are presented as the clinical blast lung triad: apnea, bradycardia, and hypotension. Other symptoms include cough, dyspnea, hemoptysis, and chest pain. Pulmonary injuries vary from petechiae to confluent hemorrhage. X-rays will show a characteristic “butterfly” pattern. Symptoms are usually present during initial examination but have been reported up to 48 hours after the initial incident. All patients with any of the symptoms above should have an X-ray, in-hospital observation, and, in case of air transport or general anesthesia, a prophylactic chest tube.

Figure 2. Pneumothorax can be caused by blunt or penetrating trauma that tears or punctures the chest wall or parenchyma. Examples are high-velocity ballistics and fragment wounds, blast injuries, and bullet wounds. Handbook for Pandemic and Mass-Casualty Planning and Response, IOS Press, Incorporated, 2012. ProQuest Ebook Central,

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5.

6.

7.

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Cardiovascular system x Symptoms—chest pain, dyspnea, hypotension, pale and/or cold skin, tachyor bradycardia, absent peripheral pulses, prolonged capillary refill. x Injuries: cardiac contusion, myocardial infarction from air embolism, hemorrhagic or cardiogenic shock, vasovagal hypotension, peripheral vascular injury, air embolism–induced injury. x Massive bleeding leading to shock and death can be the result of penetrating injuries or extremity amputations but also of multiple long bone fractures as well as internal bleeding. Patients with a history of previous myocardial infarction and/or pectoral angina are especially susceptible to new myocardial infarction. Gastrointestinal tract x Symptoms: abdominal pain, nausea, vomiting, hematemesis, rectal pain, testicular pain, acute abdominal pain, otherwise unexplainable hypovolemia, abdominal distension. x Injuries: bowel perforation, hemorrhage, ruptured liver and/or spleen, mesenteric ischemia from air embolism, sepsis, testicular injuries. x Primary blast will affect mainly the bowels, as they are gas-filled. Small bowel perforations and/or hemorrhage can be detectible only after complications have already occurred. Renal x Symptoms: abdominal pain, visible contusions on inspection, hematuria. x Injuries: renal contusion, laceration, hemorrhage, acute renal failure due to hypotension, hypovolemia, rabdomiolysis. Extremities x Symptoms: visible amputations, pain on palpation, swelling, numbness, muscle spasm. x Injuries: fractures, traumatic amputations, crush injuries, compartment syndrome, burns, cuts, lacerations, acute arterial occlusion, air embolism– induced injury.

In conclusion we can say that blast injuries are linked with a large variety of signs and symptoms as well as a high mortality rate if not treated promptly. Keep in mind that these injuries can also be combined with chemical and or biological toxins that can present a danger to the rescue personnel as well as the victims.

References [1] Fernando Turégano-Fuentes, P. Caba-Doussoux, J.M. Jover-Navalón, E. Martín-Pérez, D. FernándezLuengas, L. Díez-Valladares, D. Pérez-Díaz, P. Yuste-García, H. Guadalajara Labajo, R. Ríos-Blanco, et al., Injury patterns from major urban terrorist bombings in trains: The Madrid experience, World Journal of Surgery 32 (2008), 1168-1175. [2] J.M. Wightman and S.L. Gladish, Explosions and blast injuries, Annals of Emergency Medicine 37 (2001), 664-678. [3] J.L. Arnold, P. Halperin, M.C. Tsai, and H. Smithline, Mass casualty terrorist bombings: a comparison of outcomes by bombing type, Annals of Emergency Medicine 43 (2004) 263-273. [4] Ralph G. DePalma, David G. Burris, Howard R. Champion, and Michael J. Hodgson, Blast injuries, New England Journal of Medicine 352 (2005), 1335-1342. [5] R.J. Guy, M.A. Glover, and N.P. Cripps, The pathophysiology of primary blast injury and its implications for treatment, Part I: The thorax, Journal of the Royal Navy Medical Service 84 (1998), 79-86.

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Section 3: Communication and Information Sharing

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Handbook for Pandemic and Mass-Casualty Planning and Response E. Gursky and B. Hrečkovski (Eds.) IOS Press, 2012 © 2012 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-61499-135-9-189

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Information Sharing in Practice and for Practice: Mass-Casualty Cases a

Boris HREKOVSKIa, Mark LOADESb, Bob DOBSONc Department of Surgery, General Hospital Slavonski Brod, Croatian Urgent Medicine and Surgery Association b FMP Protection, United Kingdom, Croatian Urgent Medicine and Surgery Association c Hanover Associates Ltd., United Kingdom

Abstract. We live in a time when the “need to share” principle is acting in many parts of our lives and information is decentralized and distributed. To know where the information is and who has it is the first step of information sharing. How to use it and distribute it properly is another step. Finally, how to use information for urgent decision making in real situations such as major incidents is something for which we need education and training. Keywords. Information sharing, major incidents, education and training

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Introduction The sharing of information is a critical aspect of emergency management in a masscasualty incident and underpins any comprehensive emergency management plan. The key elements of mitigation, preparedness, response, and recovery need to be harmonized and worked in order for the plan to remain cohesive and deliverable, despite the probable interference of unplanned events. The regular practice of rescue teams responsible for implementing the response element of the plan is an essential ingredient to ensure that communication, cooperation, and functionality are honed for delivery during the mass-casualty situation.

1. Information sharing in practice Information sharing or data exchange is a multifaceted process, with both the sender and receiver contributing to the outcome. A collapse in communications during a masscasualty incident would be catastrophic. Even the misinterpretation of messages will lead to ineffective responses and may well be detrimental to the overall effort. Therefore efforts should be made to ensure that our pathways for exchange are continuously tested and improved. The four primary information-sharing processes are one-to-one, one-to-many, many-to-many, and many-to-one. The intelligent use of information and communication technology linked to common language, agreed policies, and guidelines will prove an effective tool in overcoming communication barriers. When designing a communi-

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cation strategy, we should also be cognizant of the responsibilities of confidentiality and ethical values; we must ensure that our procedures comply with the relevant data protection legislation that governs our activities. As emergency care providers, we always sense immense pressure to deliver a quality service to those in need. The world in which we live is overshadowed by the constant threat of terrorism, frequent natural disasters, and calamitous accidents. Our rescue services need to be integrated and share the responsibility to provide quality care; acting in isolation is flawed, and a multilayered communication process is a powerful weapon in overcoming barriers to understanding. Learning from history and avoiding common mistakes will encourage resilience in our strategy, and the use of tried and tested protocols and communication mediums will engender confidence in our response and prove invaluable when solving problems. A standardized and rational procedure will allow complex data to be exchanged and messaging to be understood. Decision making is based on having the correct and current subject matter to discuss and appraise and should be shared with other stakeholders. Commonality in language is critical when communicating with partners; all emergency services adopt bespoke jargon that is understood in the closed setting of their service, but jargon or slang should be avoided when dealing with other responder partners. A complete understanding of the various system responses by each interoperating agency is critical to providing efficient information-sharing networks. Capabilities, limitations, and redundancy must be understood and clear lines of responsibility agreed to by statute, memorandum, or some other binding process that allows each partner to know its own responsibilities and liability. Establishing training workshops, multiagency exercises, and communication forums will do much to engender a team spirit. All obstacles to information sharing must be removed, ideally before an incident occurs. Education and guidance to enable proper information sharing processes are key to eradicating avoidable deaths caused by confusion. A central focus of effort, the collecting point for strategic decision making, is invariably through a central command complex. A controlled system of distribution of information is necessary to inform other strategists, tacticians, and responders responsible for implementing the plan. An uncontrolled information-sharing network will cause confusion, add to the burden, and produce inefficient responses that may produce more casualties. Information and communication technology must be tested and easily understood. Emergency responders must have access to equipment and be able to practice with the tools they are to use. The equipment must be compatible and functional, with the ability to integrate into the agreed communication pathways. Network access should be tested against the four primary information-sharing processes, and problems should be identified and removed, with testing undertaken on the ground and, where possible, in the environment in which it will be used; local knowledge and intelligence will identify key areas of vulnerability. The disaster response management plan will be underpinned by a comprehensive risk assessment that identifies vulnerabilities and that lists mitigating factors. It is crucial that information sharing be reviewed in this process and appropriate mitigation implemented. The plan must ensure that rapid and clear communication is possible within the demanding boundaries of mass-casualty management and that misinterpretation or lack of clarity is avoided.

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2. Exercises as instruments of information sharing The perfect exercise for sharing information has yet to be found. In mass-casualty exercises, it is common for the prehospital responders to exercise alone and the hospital to exercise alone. Most exercises include setting up the scene, making up role players as casualties, and supplying vast amounts of resources, all at a cost. What is learned and by whom is questionable. There is a place for this type of exercise, but evaluations often show that people are training just to do their bit. There is a whole chain involved in a successful outcome for a patient, yet in some countries the prehospital effort is strong and the hospital is weak, whereas in other countries the prehospital effort is weak and the hospital is strong[1]. At what stage do the prehospital workers discover the needs of the surgeons, and at what stage do the surgeons understand the difficulties, often nonclinical, facing the prehospital workers? Exercises like Medical Response to Major Incidents have been designed to meet the needs of all parties and provide a forum for discussion and understanding at all levels. Information sharing along the complete chain is vital if all sides are to understand each other’s needs. Simply rushing patients to the nearest hospital may meet the needs of the prehospital teams but not the needs of the surgeons and definitely not the needs of the patient. During post-incident analysis, being stuck (trapped) and attempting to stabilize is often confused further down the chain as staying and playing on scene. The objective of any exercise is that learning take place; the question is how much learning? We need to have an optimal learning curve to avoid too much congestion of unnecessary, unuseful information delivered for the decision-making process.

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Conclusions Lessons learned from experience in information sharing during crises: 1. To make critical decisions, official qualifications and jurisdictions happen to be less important than the capacity for a resolute and rapid response to the crisis. 2. Increasing the volume and speed of upward and downward information sharing in a crisis could pose a problem, especially if high-ranking personnel directly communicate with low-ranking bureaucrats. Decision makers should not be overloaded with information that is not relevant and not needed in the particular situation[2]. 3. For decision making in a crisis, content is more important than the source of information (information about the location of weapons of mass destruction, for example). 4. Risk assessment analysis is needed because of the complexity of information exchange in terms of time, volume, integrity, accessibility, confidentiality, and concomitant threats that occur during disasters. 5. Simplicity is the key in complex situations. We need simplification of methods and tools for practical application, which enables information exchange to continue during a mass-casualty incident or other disaster. 6. A decision based on wrong information in actual management of major incidents could cause many lives to be lost, as shown many times by experience. 7. Information sharing during a major incident should be transferred with clear speaking, avoiding code talking.

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8. Our experience from evaluating Medical Response to Major Incidents courses shows that there is always a problem with communication and information sharing. Special attention should be given to education and training. Personnel from different agencies need to know that they have a responsibility to provide and share information.

References

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[1] S. Lennquist, Medical Response to Major Incidents and Disasters, New York, Springer, 2011. [2] U. Rosenthal, P. ’t Hart, and M.T. Charles, The world of crises and crisis management, in U. Rosenthal, P. ’t Hart, and M.T. Charles, eds., Coping With Crises: The Management of Disasters, Riots and Terrorism, Charles C. Thomas, Springfield, Illinois, USA, 1989, 3-33. [3] G.R. Ciottone, ed., Disaster Medicine, Mosby Elsevier, Philadelphia, Pennsylvania, USA. [4] United States Intelligence Community, Information sharing strategy, February 22, 2008. [5] Markle Task Force on National Security in the Information Age, Mobilizing information to prevent terrorism: Accelerating development of a trusted information sharing environment, white paper, 13 July 2006.

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Handbook for Pandemic and Mass-Casualty Planning and Response E. Gursky and B. Hrečkovski (Eds.) IOS Press, 2012 © 2012 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-61499-135-9-193

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Communication between Emergency Medical Services and Media during MassCasualty Events in Croatia Branka BARDAKa, Marijan BAŠIb, and Igor PAVLIŠKOc a Chief, Emergency Department, Slavonski Brod, Croatia b Prehospital emergency medical service, Slavonski Brod, Croatia c Information Manager, Association for the International Exchange of Students in Economics and Commerce, Zagreb

Abstract. When we discuss communication during a mass-casualty event, we first refer to communication between EMS (emergency medical services) staff and the EMS and other emergency services. However, in a mass-casualty event it is necessary to take communication between victims and their families into account, as well as communication with the wider public. Crisis emergency risk communication was a protocol designed in the United States with the goal of assisting this communication. EMS in Croatia have no official protocols for communication with media during mass-casualty events. Keywords. Risk communication, mass casualty

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1. The importance of getting medical information to the public In a mass-casualty event, every medical system requires time to organize and respond appropriately. No two situations are the same. They are often impossible to predict. Most of the time they incorporate a large number of injuries, along with psychological trauma suffered by the victims, their families, and the public. How the victims, their families, and the community will respond to such an event partially depends on the traits of individuals, their opinions, and their former insights and experience with similar occurrences, as well as their cultural affiliations. We recently witnessed a nuclear catastrophe in Japan in which citizens stood in lines in a calm and orderly fashion. We were expecting panic, chaos, and unrest in the streets, but not such calm and conscientious community behavior—presumably, due in no small part to Japanese culture and tradition[1]. One of the most important factors on which emergency services, victims, and families and others depend is information[2]. Information must have quality and be confirmed and delivered in time. Based on the information we send to the public during a mass-casualty event, it is possible to control the efficiency of public reaction and conduct. Therefore the source of the information is relevant, as are its timing and manner of delivery. Oftentimes, along with information, misinformation goes into circulation. It can lead to panic and an even larger catastrophe. Such misinformation can also lead to unneeded mobilization of healthcare workers and wasteful usage of additional resources from emergency and other public services.

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Great catastrophes were once considered the will of the gods, and information would take months or even years to spread via word of mouth. Today such events make the headlines all over because bad news is good for selling the news. News of such events spreads significantly faster via the Internet, cellphones, and social networks. The community is no longer a passive consumer of information. We often react to some news actively, more so to events in our vicinity. We can expect the victims, their families, and the public to react in terms of disbelief, rejection of reality, anger and aggression, searching for a scapegoat, and mourning. Good information can be spread as well as misinformation that can ultimately lead to the mobilization of the community in a good or bad direction[3]. The first task presented to the medical staff in a mass-casualty event is to care for the victims. At the same time, to avoid chaos, it is important that the victims’ families and the community receive information about the community’s continued functioning (the location of the casualties, what actions are being taken, where to find fresh water, where to find food, shelters for rest, ambulance locations, etc.). The community needs to know that the medical staff is doing everything in its power to assist the victims, but that they are also there to tend to any further needs of the families, as well as the community. By spreading true information and preventing false information from spreading, we avoid negative opinions within the community, stir the community from idleness, and activate it to assist with the ongoing actions (by gathering blankets, food, drinkable water, medicine, etc.). The first information in a mass-casualty event is exchanged between the victims and the emergency services and hospitals, as well as other healthcare institutions. Later, the media enter the event, and their fastest way of gathering information is via witnesses and the victims’ families. Overall, during larger mass-casualty events, the government, the wider community, and (through the media) even the world join the ongoing development in one form or another[3]. Through their inevitable coverage of a mass-casualty event, the media can assist but also hamper ongoing actions to deal with the crisis[4]. One problem is their way of work. They are occupied with sensations, and at that moment they do not give important medical information to the public. They also are not involved in education about mass-casualty events. In Croatia, certain institutions, such as the police, the government agency for search and rescue, and the army, have public relations personnel who work with the media in such events. They have protocols for communication[5]. EMS and other medical services in Croatia do not have their own public relations personnel, nor does the Croatian minister of healthcare. Usually the minister himself or the clinic general managers must communicate with the media. However, the same people are charged with organizing hospitals and services during a mass-casualty event and therefore lack the time for quality communication with the media[6]. Quality communication with the media is a skill that requires education[7].

2. Crisis emergency risk communication (CERC) CERC was developed in the United States. It is a tool or a guideline for medical staff that explains how and when they should communicate with the media. According to CERC, a crisis consists of five phases: the pre-crisis phase, the initial phase, the maintenance phase, the resolution phase, and finally the evaluation phase. It is during a pre-

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crisis phase that all medical staff opinions must be formed and consider future questions by the victims’ families, the community, and the media. After this phase comes the initial phase during which the media interest in the event emerges with the usual questions: what happened, where it happened, and what has been done so far. The creators of CERC recommend an invitation to the media so that answers to these questions may be given to them before they ask the questions themselves. News should be delivered with empathy, and it should be valid, as credibility is garnered during this phase. Reactions from experts of organizations different than the ones the public relations people are working for can be expected during the maintenance phase. In this phase the community must be given instructions as to what they must do next and why they must do it. Feedback should be taken into consideration and information rectified if it is invalid. During the resolution phase, the media interest still exists. An especially important characteristic of this phase is that the community is open to health promotion, and this should be done. During the evaluation phase, people should objectively review their own work and consider room for improvement if it is necessary. The overall goal is to take care of the community while maintaining its functionality[3].

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3. Risk communication in Croatia Depending on the scale of the event itself, the national television and minor, local TV stations are included. During the 2010 floods in the area around Slavonski Brod in Croatia, there were no casualties, but there was mass property damage. This event received little coverage on national television. However, local TV maintained contact with the community and forwarded regular instructions from the Brodskoposavska županija crisis headquarters. The local TV employees were a part of the same community. For them, it wasn’t “just news” on the TV station they worked at that day. Some of the people who suffered property damage were their fellow citizens. Their interest in assisting the victims in any way possible was noticeable. Therefore it is vital to have a public relations representative in the Croatian EMS department who will build a positive image of the service. It is more probable that even in a mass-casualty event, the community will react positively to a familiar face from the TV screen who has already achieved some public credibility. As we are now in the reorganization phase and upgrading our activities beyond hospital EMS, one point we should definitely consider is drafting a protocol for public relations. In case of a mass-casualty event, an EMS employee should be on hand whose only duty will be to communicate with the media. Here is a possible protocol for communication with media during the first phase of a mass-casualty event: 1. Appoint a person to communicate with the media 2. Find out from the dispatchers and scene coordinators what happened, what time it happened, the casualty count, how many staff are on hand to take care of the patients, where the patients are receiving treatment, and whether there are any problems impairing the services’ work 3. Establish contact with scene coordinators of other emergency services or any public relations employees in their organizations in order to avoid differing statements

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4. 5. 6. 7.

Check what has been stated about the event thus far Reach a consensus on the general opinion Determine the scope of the information that will be released to the media Invite local media from a predetermined list (do not leave out any single medium) and set the time of a conference 8. Determine dates and times for communication with the media in advance 9. Depending on the type and scope of the event, give a general guideline to the public on what they can do by themselves 10. Evaluate the success of communicating with the media at the beginning of the first phase of a mass-casualty event

Conclusion EMS in Croatia require a standard by which to determine to what level an individual within a service will communicate with the media in a mass-casualty event. A unique protocol for communication with the media is required as well in these kinds of situations. Besides education on mass-casualty events, education of the media should be implemented as well.

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References [1] T. Perko, Importance of risk communication during and after a nuclear accident, Integrated Environmental Assessment and Management 7 (2011), 388-392. [2] R.J. Wray, S.M. Becker, N. Henderson, D. Glik, K. Jupka, S. Middleton, C. Henderson, A. Drury, and E.W. Mitchell, Communicating with the public about emerging health threats: lessons from the PreEvent Message Development Project, American Journal of Public Health, 98 (2008), 2214-2222. [3] See Crisis + Emergency Risk Communication on the Centers for Disease Control and Prevention website at www.emergency.cdc.gov/cerc/cerconline/index.html. [4] T. Anzur, How to talk to the media: Televised coverage of public health issues in a disaster, Prehospital and Disaster Medicine, 15 (2000), 196-198. [5] K. Borovec, Policija i mediji, Polic. Sigur. (2009), 65-84. [6] M. Lichtveld, J.G. Hodge Jr., K. Gebbie, F.E. Thompson Jr., and D.I. Loos, Preparedness on the frontline: What’s law got to do with it? Journal of Law, Medicine and Ethics, 30 (2002), 184-188. [7] W. Lowrey, W. Evans, K. Gower, J. Robinson, P. Ginter, L. McCormick, and M. Abdolrasulnia, Effective media communication of disasters: Pressing problems and recommendations, BioMed Central Public Health 7 (2007).

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Handbook for Pandemic and Mass-Casualty Planning and Response E. Gursky and B. Hrečkovski (Eds.) IOS Press, 2012 © 2012 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-61499-135-9-197

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Just-in-Time Information Eugene SHUBNIKOV, M.D.a, Andrey TRUFANOVb, Faina LINKOV, Ph.D.c, Nicolas PADILLA, M.D.d, and Ronald LAPORTE, Ph.D.c a Institute of Internal Medicine, Novosibirsk, Russia b Irkutsk State Technical University, Irkutsk, Russia c University of Pittsburgh, Pittsburgh, Pennsylvania, USA d University of Guanajuato, Celaya, Mexico

Abstract. Just-in-time (JIT) information is highly relevant to a person’s current interest. It is educational information and may be widely used before, during, and after disasters. JIT educational information may be distributed by different ways, including the Internet and mobile Internet. It is important to distribute scientific JIT knowledge on disasters rapidly, within hours. JIT lectures, created by scientists, public health professionals, are one of the “Supercourse” special Internet applications created and distributed when major disasters happen around the world. These cutting-edge PowerPoint lectures aim to reduce fear and save lives by providing the best possible knowledge as soon as possible. The model of JIT lectures includes the development of lecture templates describing the scientific basis of the particular disaster, distributed through email and the website, updating the lecture regularly if needed. We started to build JIT lectures in 2002 shortly after 9/11. This paper describes our 10 years’ experience of targeting educators, the public, and officials with timely and appropriate JIT lectures. Keywords. Supercourse, public health education, Internet, just-in-time

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Introduction JIT information is “proactively offering information to a user that is highly relevant to what s/he is currently focused on”[1]. It is educational information and may be widely used before, during, and after disasters. JIT information may be distributed by different ways, including the Internet and mobile Internet. It is important to distribute scientific JIT knowledge on disasters rapidly, within hours. Supercourse is a repository of lectures on global health and prevention designed to improve the teaching of prevention. Supercourse has a network of over 56,000 scientists in 174 countries who are sharing for free a library of 5,100 lectures in 31 languages. Supercourse has been produced at the World Health Organization Collaborating Center, University of Pittsburgh[2]. Networking and training in prevention, via the Internet and mobile Internet, are the primary goal of the collaboration. A global Supercourse faculty are developing and sharing their best, most passionate lectures in the area of prevention and the Internet using an open-source model. This benefits all. The experienced faculty members can improve their lectures that are not cutting edge. New instructors reduce preparation time and have better lectures. The Library of Lectures consists of exciting lectures by academic prevention experts. The classroom teacher or any other person downloads them for free as from a library.

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JIT lectures, created by scientists, public health professionals from the Supercourse network, are one of the special applications of Supercourse created and distributed when a major event happens anywhere around the world. These cutting-edge educational lectures aim to reduce fear and save lives by providing the best possible knowledge as soon as possible. In the field of disasters, continuous PowerPoint lectures are provided on the science aspect of disasters and the epidemiology as well their consequences. These are the highest-rated disaster lectures on the Internet.

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1. Just-in-time Supercourse lectures The model of JIT lectures includes the development of single lectures or lecture templates describing the scientific basis of the particular disaster; these are distributed through email and the website, with the lecture updated regularly if needed. We started to build JIT lectures in 2002 shortly after 9/11. We constructed a website[3] with links to JIT lectures. Here is a list of some JIT lectures available: x “Air Safety and Terrorism” in English, Spanish, and Arabic x “Severe Acute Respiratory Syndrome (SARS): Basics” in English and Spanish (in six parts) x “Monkeypox: Outbreak in the US” in English and Spanish x “Mad Cow Disease Outbreak in the United States: Following the Story in USA Today” in English x “The Iranian Earthquake: Bam, December 26, 2003” in English, Spanish, and Chinese x “Avian Influenza: Zoonosis” in English, Spanish, and Chinese x “Bird Flu” in English, Spanish, and Chinese x “Tsunami” in English, Spanish, Arabic, and Telugu x “Tornados” in English and Spanish x “Hurricane” in English, Spanish, and Chinese x “Influenza A(H1N1) (Swine Flu): Pandemic” in English, Russian, Spanish, Farsi, Arabic, Vietnamese, Malay, French, Macedonian, Chinese, Hebrew, Bosnian, and Japanese x “Haiti Earthquake” in English, French, Spanish, and Arabic x “Earthquake/Tsunami Impacts Japan” in English, Spanish, Russian, and Chinese The concept of JIT lectures comes from manufacturing. We have over 1,500 people worldwide who are our suppliers of lectures. Should an anthrax attack occur, we can immediately identify the experts and work with them to construct background lectures in order to rapidly put up a lecture and to continuously update the lecture until the events are resolved. When applied to medicine, the basic idea of JIT lectures is that new information about a disease presented in a structured format (using PowerPoint) can be disseminated instantly. The benefit of JIT lectures is the speed with which critical lectures can be written and distributed. The widespread use of computing in health-care systems enhances the flow of information over the Internet. Thus, JIT lectures can be sent around the world in a matter of minutes. Information from scientific journals can also be compiled, together with the most current reports from affected hospitals. These lectures should focus on a single disease, such as SARS, or on an

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event, such as a natural or human catastrophe. The processing of the JIT lectures needs to be quick to maximize their rapidly decaying shelf life.

2. SARS lecture Lack of information and knowledge about a global outbreak such as SARS makes all affected people vulnerable, especially health professionals who need accurate and upto-date information to care for patients and undertake crucial research. Advances in information technology, however, have meant that health information can be rapidly accumulated and disseminated through the Internet to the global medical community. The wide accessibility of this medium means that JIT lectures, which target educators, can help to improve the dissemination of information in a health crisis. The value of JIT lectures was tested during the SARS outbreak. The first lecture on SARS[4] by Rashid Chotani from the USA went on the University of Pittsburgh Supercourse website on 18 April 2003, with following updates and translations. The response from the Internet community was incredible. Subsequently, other lectures were uploaded and the traffic on the website increased; requests to download the lectures came from all over the world, including remote parts of China, India, Thailand, and Korea, as well as from Europe and the USA. Many people contacted the website for more information. JIT lectures are a viable educational tool and can provide much-needed information anytime, anywhere, to the global community in a very short time. The JIT SARS lecture through the Supercourse website has been used worldwide. This spread of knowledge and information provides intervention strategies to educators to help them respond to chaotic situations. JIT lectures can reduce fears and help health professionals make informed decisions using accurate information[5].

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3. H1N1 lecture Our H1N1 lecture[6] was a remarkable achievement, as we were able to teach 50 million people in 13 languages about H1N1. In April 2009 we got media information from Nicolas Padilla, a Supercourse member in Mexico, on influenza A(H1N1) cases in Mexico. Ron LaPorte connected with experts in this field, and Supercourse author Rashid Chotani designed a lecture providing basic information about swine influenza, and it was launched as a JIT lecture on 26 April in English; four hours later, it was translated and available in Russian and Spanish. x The lecture was created in 24 hours x It was translated in three days into 13 languages, including Arabic, Farsi, and Hebrew x It reached 40 million via Chinese TV x It became a trusted source x It is the leading H1N1 lecture on the Web Since the original English version of “Influenza A(H1N1) (Swine Flu) Pandemic” was uploaded, it has had more than 65,000 visits, especially during the first days: 2,064 visits on 17 April, 8,847 on 28 April, and 5,888 on 29 April. This was the most viewed Supercourse lecture during 2009-2011. It is still number 4 among 2,020,000 Google Handbook for Pandemic and Mass-Casualty Planning and Response, IOS Press, Incorporated, 2012. ProQuest Ebook Central,

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results for “H1N1 lecture”[7]. The lecture was updated many times, including the latest information and data. The last update was on 30 December 2009. Our material was used by the Ministry of Health in Mexico and in other Latin American countries; by U.S. embassies in Latin American countries; and by the U.S. Department of State (which linked to our Supercourse lecture on its web page). Jianshi (Jesse) Huang, M.D., MHPE, MPH, MBA, leader of the Chinese Supercourse, Assistant President of the Chinese Academy of Medical Sciences, Assistant President of Peking Union Medical College (the Medical Center of Qinghua University), Dean for Continuing Medical Education, and professor of epidemiology, and his team translated the lecture[8] into Chinese; it was used for a closed-circuit television interview that was viewed by about 40 million Chinese people.

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4. Japan’s 2011 disaster On 11 March 2011, the fifth-largest quake ever, with tsunami waves of 7 to 10 meters, struck Japan[9]. We had lectures already on tsunamis and on various earthquakes. Two years earlier we had developed, with the lead epidemiologist at Chernobyl and a lead scientist from Three Mile Island, lectures on radiation. Walter Hays from the Global Alliance for Disaster Reduction, University of North Carolina, USA, created a JIT lecture on the Japan disaster within 12 hours after the event. Within 14 hours Supercourse members were able to put the lecture on the Web and to link it to three of our major disaster lectures: “Earthquake,” “Tsunami,” and “Radiation Health.” These lectures had been translated into Japanese and up to 13 other languages. Within 15 hours after the earthquake, we notified all 50,000 registered Supercourse faculty and distributed the lecture to many thousands of people, who copied their colleagues. Our radiation lecture was distributed hours before there was known major damage to the nuclear reactor. Many deans of medical and public health schools shared it with their faculty and students. We had the first lecture on the Japan disaster on the Web, and it became one of the leading lectures. Our purpose was simple: to teach people about this and other disasters at the time of a learning moment. Good science will trump some of the fear and uncertainty surrounding the disaster. If you evaluate the interest in the disasters using Google Trends, you will see that there was a spike of interest that lasted 48 hours. By sharing the lecture at 15 hours we were able to have top-flight, up-to-date information available before the interest started to wane. We are pleased to be able to educate many people worldwide. We hope we helped. We were pleased that we had been able to reduce our response time from about two weeks (when we created our first JIT lecture, on airline safety) to about half a day. We did not miss the learning moment, which lasts only about 48 hours. The window of opportunity closes rapidly, but the English version of the lecture got up to 1,000 visits per day. We like Hays’s idea of an educational surge married with the JIT lectures[10]. An educational surge transforms information and experience gained from a disaster into knowledge, best practices, and technologies that help communities become disaster resilient. We prefer that the JIT Supercourse be shared with disaster academic educational centers and networks. How do we build capacity for disaster resilience? Identify the gaps in community capacity in the four critical elements of the solution: preparedness, protection, response, and recovery. Use the accumulated knowledge and experience base to fill the perceived

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gaps in those areas in the community, taking advantage of the JIT educational surge disaster network.

Conclusions Information about disasters is broadly sought. We feel that at the time of a disaster, educators and other people need the best possible information from the leading scientists of the world. When we hear about a disaster, we spring into action worldwide, from Russia, to Japan, to the USA, with leading disaster experts. We are also prepared for local disasters: suppose there is a flood in India; within hours, we will customize our flood lecture that disaster experts created and share it with those in India. We hope that in the near future we can push out the JIT lectures through cell phones. We may have taught more people about the science of disasters than any other scientific group. Our teaching helps not only in coping with the current disaster, but helps people in future disasters. We have seen that people often pay more attention to us, a group of scientists worldwide, than they would their governments, the media, and industry. We are working to build a bridge between Supercourse and the media, as we prefer to have scientists provide information to the media, instead of having the TV newscasters act as epidemiologists. When scientists provide the information, we can reach millions, as Jesse Huang did when our H1N1 lecture taught 40 million in China. We need to make significant progress in networking the academic disaster networks worldwide. Someone who has the disaster experts networked is someone who knows everyone and can reach anyone. The primary goal of this is to increase training about disasters in higher education and among educators. Welcome to Supercourse.

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References [1] I. Travis, Just-in time-information: Is it in your future? ASIS Bulletin (2006), quoting P. Maes of the MIT Media Laboratory’s Ambient Intelligence Group. [2] See the Supercourse website at www.pitt.edu/~super1/index.htm. [3] www.pitt.edu/~super1/JIT/jit.htm. [4] www.pitt.edu/~super1/lecture/lec10131/index.htm. [5] R.A. Chotani, R.E. LaPorte, F. Linkov, S. Dodani, D. Ahmed, and K.M. Ibrahim, Just-in-time lectures: SARS, Lancet 361 (2003). [6] www.pitt.edu/~super1/lecture/lec34601/index.htm. [7] The search was done from Novosibirsk, Russia, in December 2011. [8] Online at www.pitt.edu/~super1/lecture/lec34691/001.htm. [9] See the Supercourse lecture M8.9 earthquake/tsunami impacts Japan with the tsunami waves reaching Pacific rim countries, www.pitt.edu/~super1/lecture/lec41441/index.htm. [10] See his Supercourse lecture Turning 2011’s disasters into educational surges that will advance disaster resilience, www.pitt.edu/~super1/lecture/lec43851/index.htm.

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Handbook for Pandemic and Mass-Casualty Planning and Response E. Gursky and B. Hrečkovski (Eds.) IOS Press, 2012 © 2012 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-61499-135-9-202

Collaboration Topologies for Interdisciplinary and Interlevel Information Exchange Fernando GALINDOa, Ron LAPORTEb, Faina LINKOVc, Alessandra ROSSODIVITAd, Eugene SHUBNIKOVe, Elisaveta STIKOVAf, Andrey TRUFANOVg, Natalia VYNOGRADh a

University of Saragossa, Saragossa, Spain University of Pittsburgh, Pennsylvania, USA c University of Pittsburgh Cancer Institute, Pennsylvania, USA d San Raffaele Hospital Scientific Foundation University, Milan, Italy e Institute of Internal Medicine, Novosibirsk, Russian Federation f University of Sts. Cyril and Methodius, Skopje, Macedonia g Irkutsk State Technical University, Irkutsk, Russian Federation h Danylo Halytski Lviv National Medical University, Lviv, Ukraine

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b

Abstract. There are many isolated human and financial resources, advanced technologies, and theoretical basics throughout the world within diverse disciplinary, agency, and national cones: the problem is how to concert those to use them effectively against global threats. The objective is to bring together necessary knowledge, instruments, and resources of actors who can, want to, and are obliged to cooperate globally. A proposed topological consideration with its mapping tools gives us a unique language to understand each other. Aiming at greater cooperation and collaboration, the present consideration comprises sizing of the community, balancing its homophily and heterophily, networking the actors of proper rank and status, and other theoretical and practical issues. The study focuses on topology issues to enforce emergency information-sharing networks, to seek effective strategies to implement the networks, and eventually to make relations between pertinent national and international agencies sustainable. Keywords. Global disasters, collaboration, topology, networking, mapping

Introduction Counteracting global disasters and emergencies and mitigating their consequences requires good cooperation, finely collaborated and thoroughly balanced efforts, and coherent actions of numerous pertinent national and international agents. Such a coworking construction needs sophisticated and reliable information sharing between the agents. Lack of just-in-time trustworthy data and lack of effective models might lead decision makers to wrong solutions, or fake targets, or trivial failures. A December 2009 event demonstrated the point. The U.S. National Security Agency four months earlier had “intercepted conversations among leaders of Al Qaeda in Yemen” talking of a plot to enable “a Nigerian man for a coming terrorist attack.”

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The “electronic intercepts were translated and disseminated across classified computer networks.” But concatenated agencies “later failed to” integrate “the intercepts with other information that might have disrupted” the plans of U.F. Abdulmutallab, now accused of the attempted bombing[1]. Despite the billions of dollars spent since 11 September 2001 to improve intelligence flow and secret communications, there are still problems with the U.S. Information Sharing Environment. But what is wrong, and which link is the weakest? A proper analysis will help build an effective information interaction environment for diverse experts, groups, departments, organizations, associations, and agencies, national and international, aimed at counteracting global threats. Advanced Internet instruments technologically enable actors to share information easily among themselves through a variety of formats. Diverse national and international networks on disasters and emergencies have been launched by workgroups to support their efforts. But global international and interdisciplinary networks usually are not sufficiently robust, and new difficulties or threats jeopardize the fragile networks. This study pays lesser attention to technological information and communications technologies issues but targets the comprehensive factors that might promote evolution of the disaster and emergency information-sharing networks: productivity and robustness of architecture for information interaction, which is reflected by network topology. The network topology is determined only by the graphical mapping of the configuration links between nodes (agencies, organizations, employees). The word topology is polysemantic and a bit vague but might be explained as “a description of any kind of locality in terms of its physical layout. In the context of communication networks, a topology describes pictorially the configuration or arrangement of a network, including its nodes and connecting communication lines”[2]. Often topology is regarded as a “map or plan of the network.” Also there are some topic topologies: “physical topology describes how the wires or cables are laid out, and the logical or electrical topology describes how the information flows”[2]. This study focuses on topology issues to enforce emergency information-sharing networks, to seek effective strategies to implement the networks, and eventually to make relations between pertinent national and international agencies sustainable. The approaches we applied have been linked with diverse fields involving a diverse range of issues, including international studies, globalization, terrorism, disaster medicine, information sharing, social ecology, social networks, agent-based analysis, and simulation instruments. Our objective is to build an alternative network for countering global threats that can x Support top-level decisions on global problems (for example, a climate change conference or a financial crisis) x Recruit forces that are on the periphery x Make cooperation sustainable x Develop a trustful structure and trustful relations x Enforce the information-sharing infrastructure

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All these will lead to x Better information sharing x Reduction of dis- and misinformation x Peacekeeping x Dissemination of good ideas x Just-in-time reaction to diverse threats x Better interaction with current government structures x Better interaction with nongovernmental entities

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1. Global Threats “Today’s concept of” security “goes far beyond traditional national” and international “defence and military considerations. Its establishment as a focal point of the current” global “security debate is the result of” three “interlinked and at times reinforcing factors”[3]: x The shift of the anthropogenic “threat spectrum after the Cold War, especially in terms of” diffused, uncertain and indirect “malicious actors and their capabilities” x The extension and diversification of the natural and man-caused threats x “A new kind of vulnerability due to modern society’s dependence on inherently insecure” infrastructures[3] Natural and complex disasters caused a dramatic increase in the demand for emergency medical care in the last decade. The increasing population, migration of people to urban areas, increase in population density, location of cities in high-risk areas, population mobility, climate changes, economic disequilibrium, wars, development of complex and integrated technologies, global Internet era, increasing and new emerging infectious diseases (HIV, Ebola, hepatitis C, hantavirus, avian flu, etc.), and terrorism now represent a new chapter in emergency preparedness, response, and public policy in public health issues and homeland security. The avian influenza H5N1 virus, tuberculosis, pandemics, and a possible nonconventional terrorist attack are the most likely current threats and have been the focus of substantial funding, research, preparedness planning, and public policies at the global level. During any disaster, rapid public health response to prevent the occurrence of new casualties, coupled with the treatment of victims and maintenance of a viable health care delivery system for the public, is essential. Responders need accurate and timely information in order to distribute critical supplies, equipment, and resources effectively. Without appropriate information, the efforts often are inadequate, misdirected, or excessive. As a key enabler, information technology and telecommunications capability demand high priority within disaster management support. Cooperative, strategic logistics planning is a critical component for the timely, adequate, and appropriate response to any disaster. Without warning, such events can instantly become true disasters, overwhelming the capacity of the community to respond and imposing significant clinical, moral, and ethical challenges at the local, national, and international levels.

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2. Co-working and information sharing People often cooperate when facing common problems and troubles. At every new stage of mankind’s development, there was a demand in new principles and technologies for information exchange to support pertinent cooperative actions. A cooperative strategy increases the number of ideas, improves the quality of the outcome, and facilitates a better working environment. Entities “maintain their own management, tasks, issues, data, knowledge and ideas, making” cross-entity co-operation difficult. These entities “are based on skill sets, which means they’re based on personal histories, professional affiliations, and common language.” The “natural barriers are further entrenched by internal” entity protocols and codes of practice “that create defendable barriers to external groups.” Experts, organizations, and societies “are now realizing the need to manage effectively across” entities “far more aggressively than in the past”[4]. Contradictions of interests do not promote cooperation. If an actor perceives that cooperation does harm or damage, there is no advantage of collaboration. We follow P.L. Rosenfield’s approach to definitions concerning cross-disciplinary, cross-national, and cross-level activities for research and practice[5]. Multi- refers to a process whereby actors in different disciplines (countries, levels) work independently with limited information sharing, all from their own disciplinary (nation, level) specific perspective, to address a common problem. Inter- is a process in which actors work jointly, with sufficient information sharing but from each of their respective disciplinary (nation, level) perspectives, to address a common problem. Trans- is a process by which actors work jointly using a shared conceptual framework and common information-sharing environment that draws together disciplinespecific (nation, level) features into a new synthesis of concepts, methods, measures, approaches, tools, and instruments to address a common problem. To cooperate means to take concerted actions, which are provided by pertinent information sharing. Current technologies offer much more possibilities for sharing, archiving, processing, and retrieving knowledge than previous ones. Counteracting disasters and emergencies always requires cooperation and collaboration among all entities and actors. In general there is a spectrum of prominent practices of cooperation and information sharing to solve common problems in the academic, research, and intelligence fields. Academic sector: a) Supercourse is a project designed to create a free lecture library of PowerPoint prevention lectures. To date, over 56,000 academic faculty from 174 countries with over 5,100 available free PowerPoint lectures have participated to bring Internet-based education to prevention of all forms of diseases and terrorism or bioterrorism. With its network, Supercourse reacts instantly to diverse dangers. b) International Space University provides “graduate-level training to the future leaders of the emerging global space community at its Central Campus in Strasbourg, France, and at locations around the world”[6]. The university “offers its students a unique Core Curriculum covering all disciplines related to space programs and enterprises, space science, space engineering, systems engineering, space policy and law, business and management, and space and society.” The “two-month Space Studies Program and one-year” master’s program “also involve

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an intense student research Team Project providing international graduate students and young space professionals the opportunity to solve complex problems by working together in an intercultural environment. Since its founding in 1987, ISU has graduated more than 3000 students from 100 countries. Together with hundreds of ISU faculty and lecturers from around the world, ISU alumni [compose] an extremely effective network of space professionals and leaders that actively facilitates individual career growth, professional activities and international space cooperation.” c) The Legal Framework for the Information Society network is an infrastructure to introduce the information and communication technologies in the faculties and schools of law and to promote the study of regulations and practice codes in the polytechnic centers. It elaborates policies on law and new technologies coming from discussions originated in different regions of the European Union and in other countries. Since 2007, the Legal Framework for the Information Society has promoted the establishment of an observatory on e-government and a shared virtual campus on law and technology.

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Research sector: a) The European Organization for Nuclear Research (CERN) is the world’s largest particle physics laboratory. The organization has 20 European member states and is the workplace of thousands of employees, representing 500 universities and 80 nationalities. Recently CERN launched the Large Hadron Collider, the world’s largest and most complex scientific instrument[3]. The World Wide Web began as a CERN project. Practice sector: a) The National Center for Crisis Control, Emercom, Russian Federation, focuses on setting the information environment. It[6] has planned to create a specialized automated system and supports information interaction with the crisis centers of foreign countries. It was organized in response to the expansion of Emercom’s scope and to the essential transition to new technology and efficiency of interagency cooperation. b) The U.S. Information Sharing Environment was created in response to the Intelligence Reform and Terrorism Prevention Act of 2004, Section 1016, which defined it as “an approach that facilitates the sharing of terrorism and homeland security information.” c) NATO’s Science for Peace and Security Programme aims to contribute to security, stability, and solidarity among nations by applying the best technical expertise to problem solving, using collaboration, networking and capacity building. The program provides a paramount forum for sharing knowledge and experience on technical, scientific, and policy aspects of social and environmental matters in both the civilian and military sectors among NATO and Partner countries. In 2008, the international conference on “Preparing regional leaders with the knowledge, training and instruments for information sharing and decision-making against biological threats and pandemics” within the framework of this program took place in Milan, attended by 65 representatives from 14 countries; it was prominent for its international and interdisciplinary scope and civil-military collaboration.

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3. Team size

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Such a purposefully created community as one for countering global threats can take a colossal amount of hard work, so the next factor upon which its success ultimately depends is the number of community members. Thus the next issue to be described through topology is sizing of the members and groups within a society (network, community). Naturally that sizing is determined by available resources, personal predilections, and other objective and subjective reasons. But modern studies argue that there are some basic numbers of members that can have a crucial impact on whether the community is successful. Diverse works[7, 8, 9, 10, 11] estimate the optimal size of a team as 5 to 12 members, but 7 is a pretty good average, and one that shows up in multiple studies. “Fewer than 5 members results in decreased perspectives and diminished creativity”[12]. This threshold number may well relate to the general suggestion that 7 is a number that the brain can easily and intuitively comprehend. “Membership in excess of 12” (the nadir number) “results in increased conflict and greater potential of sub-groups forming”[12]. A nadir number occurs somewhere between 9 and 25, but it is worst in the range of 12 to 15. In general several threshold and nadir numbers for group sizing have been found. Many teams go successfully through a life cycle of stages starting with a threshold number. If the group is unfortunately stuck at a nadir, most commonly, the team members unsatisfied with the group’s evolution abandon it. Otherwise the bulky group decays into two or more smaller groups. For example, a team of 13 could generate two more functional teams of 6 and 7.

Figure 1.

Many studies suggest that the size of 4 to 9 members with a median of 7 (so-called working groups) is optimal for communication, collaboration, and decision making[7]. D. Pollard noted that this size works well for dinner parties and poker games. While forming research or field teams, an official should take into account that beyond 9 and up to 25 members, relatively small groups become increasingly effete (12 to 15 is worst). Also, the studies found that 25 to 75 members (with a median of 50) is the optimal size for guilds, associations, business enterprises, and social networks (so-called enterprise groups).

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Figure 2.

Beyond 75, these large groups again become more and more ineffective until, beyond 150, drastically increasing work is needed to provide real cohesion. This “magic” number, “the Dunbar Number, is a hypothesized cognitive upper limit to the number of individuals one can form a social relationship with at a given time”[10] (figure 2). Take into account that Dunbar’s group threshold of 150 applies more to groups that are highly motivated and whose goal is survival. However, the Dunbar number may well be the highest limit of all for a tightly knit community. Beyond this limit, guilds and associations are less trusted, less participatory, and less cohesive. To be correct, “Dunbar’s later work hypothesized that the Dunbar Number of 150 was just one of a series of ‘circles of intimacy’ in human social relationships”[10]. Developing his original idea, “Dunbar hypothesized that the number of social contacts people possess follows a vaguely exponential curve, where one in general has 5 intimate friends, followed by 12-15 members in a sympathy group, followed by 150 friends one can maintain, followed by 1500 acquaintances”[10]. Thus there is no single Dunbar number. Instead, there is a Dunbar distribution, where the magic Dunbar number “is just an estimate of the maximum number of friends one can actively maintain via contact at a single time, a single point on a distribution of social contacts”[10]. Anyway, organizers of communities to counter global threats must consider group thresholds and group nadirs just to understand how to create a cohesive guild, rather than groups that are inwardly and fundamentally unstable.

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This work NISHADA

Figure 3.

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4. Trust as a crucial factor Sustainable cooperation needs trust; robust information-sharing networks are constructed on trust. Social relations (trust, conflict, and performance) are one dimension of collaboration. Trust is crucial to all human interactions; therefore the ability to express and perceive trust in geographic proximity or electronically is essential to successful collaboration. Repeated simple encounters (in person or electronically) help develop trust and friendships. “It takes time and repeated interactions to develop trust. Those interactions may be as simple as having tea or doing training exercises together, but they build up trust over time. This trust is a key ingredient for cooperation-based organizations”[13].

5. Homophily and heterophily of counteracting agents National and international networks countering global disasters have been launched by workgroups of users to support their work efforts. Multidisciplinary and international cooperation imply severe heterophily of the actors and the fact that the society is constantly updated. One should imply that the fairness of a network “affects its level of social trust more than does its homogeneity.” Network “societies with fair procedural rules … fair administration of rules,” and fair codes of practice “produce incentives for trustworthy behavior, develop norms of trustworthiness, and enhance interpersonal trust”[14]. It was found that all the factors of fairness in a society “are positively associated with trust, while ethnic diversity loses significance once these factors are accounted for,” and inequality has an adverse impact on norms and perceptions of trustworthiness,

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“rather than its simple heterogeneity.” Actually there is a reciprocal situation to the one described in the example: a network society implies fair procedural rules and diversity of networking participants, so one has to pay greater attention to the heterophily of the actors. Trust needs homophily and fairness both, but within cross-silo disaster and emergency medicine networks fairness is observed by default, and heterophily is observed by default as well; the networks are interdisciplinary, international, interlevel. “Homophily theory predicts that people are more likely to interact with individuals similar to themselves in respect to a variety of qualities and characteristics”[15]. The lesson learned from NATO Science for Peace and Security Advanced Study Institute events is that networking implementation “requires close attention to cultural differences in communications … The failure to acknowledge the importance of cultural affinities … or the tendency to selectively interact with and learn from individuals seen as similar to self”[16] was a key implementation factor. The experience of the Advanced Study Institutes also confirms that heterophily in network processes is an important factor in the ability of networked organizations to find and exploit opportunities created by networked functioning. In practical networking there are diverse ways to promote homophily: working together (on the same project); bringing people together in one physical or virtual site (place, room); supporting information exchange by co-papers, blogs, emails; and providing cultural events. These results indicate the urgency of introducing some more homophily (for example, temporarily placing team members at one site) while establishing formal or informal institutions to counter the chemical, biological, radiological, nuclear, and highexplosive threat. One way to measure the relative homophily of a group is to use the E – I index (E – I)/(E + I) proposed by S. Borgatti[17]: x “E is number of ties between groups (External)” x “I is number of ties within groups (Internal)” The E – I “Index is positive when a group is outward looking, and negative when it is inward looking … “E-I index is often negative for close affective relations, even though most possible partners are outside a person’s group.” The problem is to redistribute the resources an entity possesses—health, time, knowledge, materials, contacts—and a comprehensive measure of those is money. Lack of funding is clearly the important final argument. However, funding may be an initial problem that intensifies tensions within the institution or project. While simulating, we considered three dimensions of diversity (heterophily): citizenship, discipline, and rank; those are characterized by gaps. The greater the gap between actors, the less they trust each other—that is, trust is a function of diversity (or similarity-homophily). We use a complex factor of heterophily—a multiplicative one: Hg = Hc*Dd*Hr (citizenship, discipline, and rank diversities respectively).

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TrustT(H)

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Heterophily ,H=EI Figure 4.

The next processes take into account x production of knowledge x sharing of information among trustees x utilization of knowledge in practice

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The variable we control is investments in these processes: Wm, Ws, and Wu, respectively. Combining the pertinent bi-agent interactions among nodes of the network and taking into account diverse distributions of T(H) (threshold and continuous) and the H = E – I factor for the agents, we found that a utilized knowledge of the collaborative work reaches a maximum when Ws is an interval of 0.05-0.20 of the total sum of investments. Regarding composition, all guilds have an element of homophily and heterophily. The starting point declares that the more homophileous the guild, the more cohesive it is. Further, the more heterophileous the guild, “the greater the differences in perspective and increased potential for creativity, but also the greater potential for conflict”[12]. Thus that makes a competition between homophily and heterophily. In simple tools it is possible to map this point on homophily and heterophily factors (figure 5):

Figure 5.

Figure 6. Seven-level model of information structure. Handbook for Pandemic and Mass-Casualty Planning and Response, IOS Press, Incorporated, 2012. ProQuest Ebook Central,

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6. Seven-level stereo model of cross-cone information sharing In line with our approach of mapping while demonstrating the topology structure of an information-sharing environment, we utilized two models developed in the study. In current work we suggest a multilevel, agent-based simulation model with competitive and collaborative agents to perform a simple quantitative analysis of interagency and international cooperation networks with diverse topologies. To realize that, we drew the essential distinction of information network topologies of the entities. According to our synthesized model, comprehensive information processes in international society are supported by interconnected agents placed on seven levels: individual, group, department, organization, association, agency, and top (figure 6).

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Figure 7. Three levels of agents (top, high, and middle) and corresponding in- and cross-cone information flows.

To simplify the model for simulation and mapping, we are leaving only three levels of agents: top, high, and middle ranks. The first two are rather managerial agents, while the latter comprises actors who bear core work (academicians, researchers, and field combatants)—that is, information production. We imply that all the agents of an entity are not only in collaboration but in competition as well—vertically (for agents of adjacent levels) and horizontally (for agents of the same level), shown in figure 7. All the entities form a complicated space (stereo) network. Just to map the network model we represent the entities by cones with a height that depends on their level (figure 8).

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Figure 8.

Competition and collaboration are managed by investments to the principal information processes we consider for any agent i: x

information production with funding W pi

x

direct information exchange with other producers of the same middle rank (which requires expenses of Wmi )

x

indirect information sharing through the higher level (high- and top-rank concentrators) with expenses of Whi and Wti

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The assumption that interagency and international interaction is horizontal only (through middle, high, and top rank links) has been made (figure 9).

Figure 9.

Metrics is an urgent factor for efficiency of the model. The first point is that to collate diverse topologies we used the parameters characterizing the network efficiency and vulnerability such as flows, capacities, betweenness centrality, and relative size of the largest cluster. Many studies[18, 19, 20] showed that “scale-free networks (i.e., networks with power-law degree distributions)”[19] seem much more robust than random networks in case of failures (that is, random events), while they are more sensitive to intentional attacks.

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A network counteracting global threats might withstand failures and attacks. So our strategy is to construct a resilient network structure that behaves as a scalefree network while random threats are active and is easily reformed in case of intentional attacks. According to traditional hierarchical architecture of national emergency services, a scale-free topology is provided with top and high-rank actor nodes, but a random network structure requires essential middle-rank links. A NATO Science for Peace and Security Programme promotes just these cross-cone direct links (horizontal and vertical) between actors that belong to diverse levels, disciplines, and nations. To simulate information processes, we confined the budget of agent i:

W pi + Wmi + Whi + Wti = Const, so that information production is in competition with information sharing, which is realized through three channels (m, h, t). Let

c p , cm , ch , ct consequently be effectiveness coefficients of the processes.

We suggest also that vertical channels (h, t) provide creative actors of the m-level with additive information, while information transferred directly through the horizontal channel (m) helps the actors to multiply their knowledge. If we omit the h channel and correspondent investments Whi , binary interaction of i and j agents leads to data volume

Vi

ª º «¦ g j (c pW pi  c t Wti Wtj W pj  c mW miW mj W piW pj )» ¬ j zi ¼

¦g

j

j zi

Average data volume ¢V ² allows us to use that as a criterion of network information effectiveness and information-sharing effectiveness. No one knows the exact

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values of coefficient c p , c m , ct , but anyway the equation allows us to demonstrate the competitive and collaborative nature of all the information processes and the levels’ activities. The network analysis led to the finding that the optimal funding and topology for interagency and international interaction prefers top-rank links for “tree” (hierarchical) networks when c m < ct and corresponds to middle-rank horizontal links in other cases ( c m > ct ). The study based on qualitative and quantitative simulation, topological analysis, and mapping demonstrates that it is of great value to support not only information production (collecting, creating, processing, storing) and top-level contacts but ties with information sharing of middle-rank agents of national and international agencies for effectively counteracting global threats.

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Figure 10. Network information effectiveness versus funding of top-rank links (line) and middle-rank ones (boxes).

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Summary There are enough isolated human and financial resources, advanced technologies, and theoretical basics throughout the world within diverse disciplinary, agency, and national cones. The problem is how to concert those to use them effectively against global threats. The objective is to bring together necessary knowledge, instruments, and resources of actors who can, want, and are obliged to cooperate globally. Topological consideration with its mapping tools gives us a unique language to understand each other. Aiming at greater cooperation and collaboration, the consideration comprises sizing of the community, balancing its homophily and heterophily, networking the actors of proper rank and status, and other theoretical and practical issues. Organization of an International Association for cross-cone Networked Information Sharing in Disasters and Global Threats (NISHADA) targets improvement effectiveness and efficiency of counteracting disasters and chemical, biological, radiological, nuclear, high-explosive, and other threats on global and local scales. We are at the starting point.

References [1] M. Mazzetti and E. Lipton, Spy agencies failed to collate clues on terror, New York Times, 30 December 2009, www.nytimes.com/2009/12/31/us/31terror.html?pagewanted=all. [2] A. and L. Wheeler, Security Glossary, www.garlic.com/~lynn/secgloss.htm. [3] M.D. Cavelty, Critical information infrastructure: Vulnerabilities, threats and responses, ICTs and International Security (2007), 15-22, www.unidir.org/bdd/fiche-article.php?ref_article=2643&vm=r. [4] IT Infrastructure Library press release, 30 September 2007, www.24-7pressrelease.com/press-release/itiland-business-intelligence-working-together-to-improve-business-delivery-33930.php.

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[5] P.L. Rosenfield, The potential of transdisciplinary research for sustaining and extending linkages between the health and social sciences, Social Science and Medicine 35 (1992). [6] International Space University website, What is ISU? www.isunet.edu/index.php/about-us. [7] Dave Pollard, The optimal size of groups, How to Save the World blog (2009), http://howtosavetheworld.ca/2009/03/18/the-optimal-size-of-groups/. [8] E. A. Hammel, Kinship-based politics and the optimal size of kin groups, Proceedings of the National Academy of Sciences 102 (2005), 11951–11956, www.pnas.org/cgi/doi/10.1073/pnas.0504647102. [9] L. Barrett, R. Dunbar, and J. Lycett, Human Evolutionary Psychology, Princeton University Press, Princeton, New Jersey, USA, 2002. [10] A. Baldassarri, A. Barrat, A. Capocci, H. Halpin, U. Lehner, J. Ramasco, V. Robu, D. Taraborelli, The Berners-Lee hypothesis: Power laws and group structure in Flickr, Dagstuhl Social Web Communities Working Group, Schloss Dagstuhl, September 2008, Dagstuhl Seminar Proceedings 08391, http://drops.dagstuhl.de/opus/volltexte/2008/1789. [11] R.A. Hill and R.I.M. Dunbar, Social network size in humans, Human Nature 14 (2003), pp. 53-72. [12] Wikipedia, Team, http://en.wikipedia.org/wiki/Team. [13] Dan Bricklin, Trust and cooperation cannot be surged: From US maritime strategy to the Little Prince and the fox, Dan Bricklin’s Web Site (2007), paraphrasing Admiral Gary Roughead, www.bricklin.com/ trustthrutime.htm. [14] J.-S. You, A comparative study of income inequality, corruption, and social trust, draft doctoral thesis, www.courses.fas.harvard.edu/~gov3009/Calendar/jsyou.doc. [15] C. Yuan and G. Gay, Homophily of network ties and bonding and bridging social capital in computermediated distributed teams, Journal of Computer-Mediated Communication (2006), http://jcmc.indiana.edu/ vol11/issue4/yuan.html. [16] M. Rivera and E. Rogers, Evaluating public sector innovation in networks: Extending the reach of the National Cancer Institute’s Web-based Health Communication Intervention Research Initiative, Public Sector Innovation Journal 9 (2004), www.innovation.cc/discussion-papers/rivera-rogers-9-3.pdf. [17] S. Borgatti, Knowledge & networks: A research agenda, www.analytictech.com/mb874/Slides/ Knowledge.pdf. [18] R. Albert, H. Jeong, and A.-L. Barabási, Error and attack tolerance of complex networks, letter, Nature 406 (2000), 378–382, www.nature.com/nature/journal/v406/n6794/full/406378a0.html. [19] P. Crucitti, V. Latora, M. Marchiori, and A. Rapisarda, Efficiency of scale-free networks: error and attack tolerance, Physica A 320 (2003), 622-642, www.ct.infn.it/~latora/crucitti_physicaa_03.pdf. [20] S. Xiao, G. Xiao, and T.H. Cheng, Tolerance of intentional attacks in complex communication networks, IEEE Communications Magazine 46 (2008), 146-152.

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Networks and Their Role in Counteracting Contemporary Global Threats: A New Model Alexei TIKHOMIROVa, Andrey TRUFANOVb, Antonio CARUSOc, Alessandra ROSSODIVITAd, Eugene SHUBNIKOVe, Rustem UMEROVf a

International Informatization Academy, Moscow, Russian Federation b Irkutsk State Technical University, Irkutsk, Russian Federation c Court of Auditors, Regional Chamber of Control, Milan, Italy d San Raffaele Hospital Scientific Foundation, Milan, Italy e Institute of Internal Medicine, Novosibirsk, Russian Federation f NGO Terra Tavrida, Simferopol, Ukraine

Abstract. Within the context of developing complex network theories and a netcentric approach, this paper introduces a new concept that describes the elements of interaction of complex network systems, including comprehensive network lace (supercomplex networks), with its intrinsic multilayered thematic and dynamic nature. It emphasizes inter-penetrative competitive and cooperative relationships of thematic layers. Contemporary interpretations of supercomplex networks instantiated by biologic, social, and economic systems have been considered. The new concept will give a basis for developing instruments for effective management, governance, and support of state regulation processes in countering global disasters.

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Keywords. Complex networks, supercomplex networks, global disasters

Introduction To counteract disasters and emergencies, it is necessary to build cooperation and collaboration among all entities and actors. Interagency and interdisciplinary aspects Cooperation and collaboration—that is, information sharing and integration based on new information and communications technologies approaches—are of value for the most sensitive fields, such as disaster medicine and intelligence services. The Haiti earthquake case demonstrated difficulties for international medicine and other rescuers and its impact on national and international actions to counter global disasters and emergencies.

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1. Network modeling One of the modern and fruitful analysis instruments for complicated social and group processes is complex network modeling. In any discipline, the large number of participants—subjects, objects, actors—and their relationships (interactions) suggests that such a set (chain) of interacting entities itself has some common fundamental features (figure 1).

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Figure 1.

These network properties of the set depend on its structure, rather than on internal contents of individual entities. While math graph theory studies structural properties, interdisciplinary intersection has formed a new field: theory of networks. Examples of meaningful and relevant networks are the Internet, the World Wide Web, network governance, economic networks, social networks, knowledge networks, political networks, TV networks, national and local transportation routes (air, rail, water, metro, bus, tram), electrical networks, communications (postal, telephone), thermal network water supply and sanitation, trade networks, webs of the nervous system, intelligence networks, and terrorist networks. Applications of the theory of networks find themselves wherever there is a network—that is, everywhere. Modern complex systems are identified by a high number of elements, which can reach tens and hundreds of thousands, and by irregular ties. The term complex may best describe such systems and their network models with non-trivial topological properties. Resilience of network architecture is one of the major problems of building effective complex social, biological, technical, and other systems. For a graphical representation of exponential and scale-free networks, see figure 1 in R. Albert, et al., “Error and attack tolerance of complex networks”[1]. Complex network tools have been successfully applied to understanding and counteracting such threats as the spread of infectious diseases and terrorist activity.

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Another significant use of the complex network approach is to develop good governance, management, and organizational processes in international, national, and corporate landscapes[2].

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2. Problems and limits of applicability of current network models Complex network ideas have been steadily and successfully applied to the analysis of metabolic and genetic regulatory networks, in developing reliable scalable networks of wired and wireless communications, for developing vaccination strategies in the fight against diseases, and in a wide range of other practical issues. A new program known as DataSphere “will enhance data fusion and entity resolution, as well as discovery of unknown relationships.” It “enables analysis of the activities of terrorists such as their communication networks and travel”[3]. However, neither in public nor corporate governance have these ideas been applied widely and significantly. Many problems of modeling organizational structures and cross-sectoral governance are resolved, yet the issues of controlling complex networks continue to be complex and daunting. This can be seen in the discussion of various approaches in directing the Internet Governance Forum network. Most biosocial systems are characterized by some degree of inequality of individuals, so in that part of the system, individuals differ in their (bio-) social ranks. Sets of ranks—hierarchy—form special relationships, and their correspondent performance is a hierarchical one. Hierarchical and egalitarian structures in many biosocial systems coexist and continually interact with each other. Often one and the same biosocial system is considered by researchers and practitioners from different points of view: depending on their preferences, the focus is either hierarchy with domination and subordination, or presence of equal relations in the system. Many distributed systems—particularly cellular networks, computer networks, and the Internet—possess developed topologies and are based on complex and diverse social processes. According to the founder of the technology of the World Wide Web, T. BernersLee, the next step in developing the Web can be a Giant Global Graph. Berners-Lee believes that such a graph—in contrast to a network of computers and the WWW— linking documents, interconnecting people, and based on semantic technologies will provide users with services of higher class than the existing one.

3. Comprehensive networks as an approach to studying huge and especially complex systems The concept of comprehensive network lace (CNL)[4] is based on an end-to-end description of major categories of interactions for sets of entities (subjects and objects) using a multilayer (multilevel) variety of complex networks (figure 2). The core of the approach is binary interactions of actors in separate thematic layers.

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Figure 2.

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The actor of the lace in a comprehensive network is a stem; stems attach the nodes of networks of different thematic layers (figure 4).

Figure 3.

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A classic network has no two distinct links connecting the same pair of nodes; in a lace the number of links connecting a pair of stems might be multiple to the number of layers. In simple words, a network is a set of points (for convenience, the image shows them on a plane) linked in pairs by lines; the CNL is a set of points and corresponding joint lines in different thematic planes, which might be described by multigraphs in graph theory. In a social system we define thematic layers by relationships between 1. relatives 2. classmates 3. employees of one organization and agencies, superiors, and subordinates 4. colleagues in one subject area 5. neighbors and childhood friends 6. countrymen 7. coreligionists 8. friends with shared interests 9. business partners 10. random acquaintances

4. Discussions

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Based on a CNL scope, we have proposed a novel three-layer model (figure 4) of public connections for diverse state regimes for further simulation, quantitative assessment, and practical implementation in countering global disasters by international and interdisciplinary teams.

Figure 4.

Traditionally the process of emergency management involves four phases: mitigation, preparedness, response, and recovery (figure 5).

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Figure 5.

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Contrary to the known hierarchical layer approach for knowledge acquisition and information sharing, this new model describes an overall national society network by division into the next three layers (figure 6): x Formal (state), as hierarchical government structures x Informal (presented by different long-time sustainable link groups) x Informal (acquaintances with short-term links—so-called weak ties)

Hierarchical

Severely State Formal

Scale-free

Sustainable Group

Random

Severely Informal Figure 6.

The approach ambiguously considers communication between actors that are on different levels of hierarchy in a comprehensive network—for example, information exchange is modeled in several streams of information, formal and informal, from the more meaningful stem in a given hierarchy to a peripheral one (figure 7).

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Figure 7.

New metrics have been proposed to assess an imbalance of formal and informal structures of social control that might be of value for rescue teams: 1. Mc is a moment of centrality for the node i and the centrality C (degree centrality, betweenness centrality, or closeness centrality):

M Ci

( ¦ C j ˜ Lij ) /( n  1)

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j zi



(1)

Lij is the path length between nodes i and j, and n is the number of nodes (stems)

in the network; 2. 3.

Nodes

I min, ,t of thematic layer t, for which the moment of centrality C

have minimal value in the layer t; Shift of t2 in t1:

S Ct1,t 2

( ¦ C jt 2 ˜ LIminCt1, jt 2 ) /(n  1) jt 2 z i



(2)

LImin,t1, jt2 is a path length between I min,,t1 (a node for which the moment

of centrality C has a minimum value within layer t1) and jt2 (a node in layer t2), t1, t2  t; 4. Set (vector) of centralities for a stem: [Cd, Cb, Cc]; 5. Set (vector) centrality moments for a stem: [MCd, MCb, MCc]. Handbook for Pandemic and Mass-Casualty Planning and Response, IOS Press, Incorporated, 2012. ProQuest Ebook Central,

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5. CNL interpretation for human health problems Evolution of a bacteria colony might be described by a dynamic lace model (figure 8).

Vertical(V)genetransfer Themelayerofsociallinks(Hs) Hg—genetransferinsyngenesis Horizontal(randomHr)genetransfer

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Figure 8.

The CNL approach is in connection with the cultivation of genetically modified crops, where one of the most important considerations is the possibility (horizontal) of gene transfer from genetically modified plants to other inhabitants of the biocenosis. We assume the effective utilization of modern techniques and tools of cytology and genetics to track and measure the structure of relationships in bacteria populations, representing full-scale tests of real super-networks. Knowing the details of lace evolution will enable us in the future to act as needed, not only on the protokariot colony, but to regulate key processes in high-level biological and social systems. It may well be the task of optimizing the structure of relations in the CNL. It is reasonable to assume that it must be a balance between the V- and H- informational interactions of actors, provided that the total exchange volume is constant.

Summary According to each of the layers—Severely State Formal, Sustainable Group (Formal and Informal), and Severely Informal—we see three types of network topologies: hierarchical, scale-free, or random, respectively. Information exchange is supported by diverse links, formal and informal, for different state power status.

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If we follow Lefebvre’s Reflexive-Intentional Model[5], the stems of the network lace are conscious entities, but the lace trajectories in the “phase space” defined on the basis of possible significant characteristics unify the comprehensive network and harness into that all the stems. The CNL describes and clarifies the state of the art of government impact on national and international actions to counter global disasters and emergencies, proposes visualization as a common language for experts of diverse disciplines, and gives a roadmap for countering actions. A.-L. Barabási argued the possibilities of ruling all the networks of diverse nature by “evaluating an object as a system with nodes of varying importance”[6]. According to Barabási, a car, for instance, “is made of 5,000 components,” but a driver has “‘access to only three to five nodes’—the steering wheel, the gas pedal, the brake, and maybe the clutch and shifter. ‘With those three to five knobs, you can make this system go anywhere a car can go.’” What he proposes is to “look at any network, not just engineered ones, and find those control nodes. Among the thousands of” elements of complex networks, “could he find the steering wheel, the gas pedal and the brake?” Unfortunately this excellent example with a car gives no chance for nodes of a sociobiological network to be free in their choices. The CNL approach we have promoted is in line with V. Lefebvre’s philosophy of reflexive conscious entities, which are sensitive to learning and adopting. The analyzed supercomplex networks supply policymakers, practical experts, researchers, and academics with lessons learned in terms of trends, preferences, assessments, and pitfalls. We call this process “to learn and to enable sustainable development of the world.” We would emphasize that synergetic CNL is a prospective approach that promotes instruments for assessing robustness of information sharing in disaster management and clarification of interagency, military, and civilian collaboration; with its socioeconomic core, it is of value for risk communications, public behavior, politics, and funding.

References [1] R. Albert, H. Jeong and A.-L. Barabási, Error and attack tolerance of complex networks, Nature 406 (2000), 378-382, www.nature.com/nature/journal/v406/n6794/full/406378a0.html. [2] M. Rosvall and C. Bergstrom, An information-theoretic framework for resolving community structure in complex networks, Proceedings of the National Academy of Sciences 104 (2007), 7327–7331. [3] Director of National Intelligence 2010 Data Mining Report. [4] M. Aminova, A. Rossodivita, A.A. Tikhomirov, and A.I. Trufanov, Comprehensive network lace (How to govern the world), Proceedings of Free Economic Society of Russia 148 (2011), 190-207. [5] V.A. Lefebvre, Mentalism and behaviorism: Merging? Reflexive Processes and Control 2 (2003), 56-76. [6] G. Mone, This man could rule the world: How Albert-László Barabási went from mapping systems to controlling them, Popular Science (2011), www.popsci.com/science/article/2011-10/man-could-rule-world. [7] S.P. Kapitsa, Scale and significance of crisis, its impact on modernization processes, Scientific Proceedings f Free Economic Society of Russia 140 (2010), 116-123. [8] F. Galindo, M. Guidotti, V. Gulevich, et al., Information sharing in knowledge society, Pandemics and Bioterrorism: Transdisciplinary information sharing for decision-making against biological threats, NATO Science for Peace and Security Series–E: Human and Societal Dynamics 62 (2010), 15-22. [9] R. LaPorte, W.-T. Chiu, L. Chie, et al., Supercourse: translation from research to the classroom, Journal of Experimental and Clinical Medicine 1 (2009), 8-11.

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Architecture of R&D Project Management Systems at Medical Institutions Andrey GOVORKOVa, Alessandra ROSSODIVITAb, and Andrey TRUFANOVa a Irkutsk State Technical University, Irkutsk, Russian Federation b San Raffaele Hospital Scientific Foundation University, Milan, Italy

Abstract. The increasing volume and number of ongoing projects at a medical institution require prompt management of the overall projects at all stages. The work described in this article attempts to build an effective and robust system architecture for managing research projects, with these requirements formulated for project management: creation of multidisciplinary teams with a specific research project; context development of the project; identification of the criteria of novelty; creation of space for action (time, financial, infrastructure); building and maintaining a comprehensive network of communications and interactions with peers; attachment to search process alternatives and options (if necessary, to organize a parallel project with the same formulation of the problem); promotion of spontaneity and creativity in a project team; and active transfer of knowledge during the project and its distribution to all project participants. Keywords. Project management, research and development, medical institution

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Introduction Modernization of medical higher education and medical research to meet the requirements of the global trend of transition to an innovation-based economy places high demands on the management of medical institutions and their ongoing scientific research. The most successful management tools, which enabled medical higher education institutions to adapt to the competitive environment in the previous decade, no longer meet the new challenge and are insufficient for today’s international competitiveness. The ability of medical institutions to meet the demands of high-tech business becomes the main condition of their existence. This calls for a review of project management systems of scientific activities at the medical higher education institutions. The change in the methods and mechanisms to create a sustainable, competitive advantage requires medical institutions to develop and adopt fundamentally new architecture models to manage scientific activities and research projects.

1. R&D at medical higher education institutions Any activity in a modern economy is based on the results of preliminary research or conducting new research. This can be seen in medical higher education institutions’ development, with the work of many scholars deciding the same issues, supporting each other, interfering with each other, erring, discovering—because a large number of

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different research projects releases potential for irritation, while raising the possibility of opening unknown areas of knowledge. Many follow-up concepts and linear structures in research development must be understood in this context when there is a problem of management. The modern economy is based on the ever-increasing pace of activity in expanding knowledge, networking, and focusing on projects. This entails a corresponding impact on the organization of labor, management functions, and qualifications. To improve the efficiency of scientific research, the application of modern information technologies and the introduction of automated control systems for scientific projects is particularly important. Such systems allow researchers to obtain quickly and more accurately the required information on the objects and phenomena, accelerate research projects and reduce their complexity, study complex objects and processes, and study traditional techniques and tools—all tasks that are technologically difficult and time consuming. A model of project implementation at medical higher education institutions can be represented in a scheme of separate elements that interact. Figure 1 shows a typical model of an organizational schema.

Formalleader

Projectmanager

Leaderoffirst direction

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1

2

Leaderofnext direction

3

...

Leaderoflast direction

...

...

...

...

...

L

Decisionmakers

1N

Employeesof1level

EmployeesofLlevel

Figure 1. Organizational structure of a research project.

The structure presented shows that many actors can take part in different areas of research for one project. Ongoing projects tend to develop inside, within the given directions. It turns out that if the institution implemented several projects in parallel (and their number may reach several tens), then each project remains autonomous from initialization to completion. In the results of their study, the authors showed that, in many instances, different projects present similar scientific and practical direction. But because each project is carried out independently, the relevant studies are carried out in parallel.

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2. A way to project management To improve the organization of scientific research each year, it is necessary to develop and expand a network of scientific and medical engineering centers, centers for collective use, and research and testing laboratories. This development will enhance the quality of training received by young professionals, creating highly qualified personnel. Diverse resources on governance of research activities at medical higher education institutions exhibit a widespread conception of the process approach, whereby management functions can be represented as continuous interconnected actions. In the process approach, a model of managing scientific activity is defined as a relationship of the basic functions of management: planning, organization, motivation, feedback (analysis, monitoring, control) and coordination, which are combined with the processes of communication and intervention development. In the beginning of the 20th century, P. Freeman formulated a hypothesis of the research process in terms of control[1]. In recent years the term management of research has been increasingly replaced by the term management of scientific projects. To meet the dynamically changing requirements for the results of scientific activity, it is necessary to clearly highlight the results to be achieved by a certain point in time and analyze what means were used, what it cost, and what results were achieved. All this is typical for any project. In recent years, the results of research have become more and more a requirement in the social sphere and in business. It is evident that each project has its own limits and simultaneously creates something new. It is complex and risky, dynamic and strategically significant. A project is created to aim at a certain purpose. Thus we conclude that projects take the forms that are particularly suitable for organizations to solve problems in scientific research management. Most projects can be divided into external projects involving internal and external groups, internal projects involving only employees of medical institutions, conceptual projects, and projects for implementation. According to the Project Management Institute, project management “is the application of knowledge, skills and techniques to execute projects effectively and efficiently”[2]—under the given constraints of time, money, and resources, as well as the quality of the project’s outcomes. In its most general form, the project management process can be represented by the concept shown in figure 2.

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Statement ofpurpose

Initiating theproject Successful executionofthe project’sobjectives

Problem statement

Project constraints (budget,time, resources

Gettingthe project’sresults

Analysisofreports

Incasethe projectisnot completed

Reports Onproject status Datafrom monitoring

Adjustingthe listofworks

Making decisionsabout controlactions

Monitoringthe project(work,time, cost,resources

Adjusting theschedule

Description ofworkand conditions

Network scheduleof theproject

Adjusting theplan

Schedules

Execution phasesofthe project

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Figure 2. Project implementation scheme.

In the general classification of projects, a research project stands out above all by the nature of its target. In its content, a research project is one of the major forms of organization of scientific activity, defined as activities aimed at generating and applying new knowledge. Thus, the purpose of research projects is twofold and defines the basic content of the interrelated processes of producing and applying new knowledge. The process of obtaining new knowledge takes the form of basic and applied research and is implemented in the form of pilot projects. Considering research projects at medical higher education institutions, the following features might be emphasized: x The specific hierarchical structure of management of scientific activities x The nonprofit nature and government funding of most research projects x A significant degree of external uncertainty in determining the purposes of implementing long- and medium-term research projects x The dispersal of the scientific potential among teaching and research units The main goal of managing scientific projects at medical higher education institutions is to provide the required level of quality of results for fixed or varying parameters of social demands for training graduates. Within research project management the following steps might be defined: 1. planning scientific activities 2. performing research projects  examining and accepting results of research projects or phases  implementing research projects in educational processes of medical higher education institutions 3. reporting the results of scientific activities

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Within the major phases, the following tasks of research project management are solved: x Evaluation x Planning the portfolio x Allocating resources x Encouraging researchers x Operational management To solve these problems of controlling scientific projects, it is necessary to develop appropriate mechanisms for management using the basic tools of organizational control systems. Given their similarity, research projects and classical projects can apply the methods and tools of project management. But, despite their common elements, as appropriate, management of scientific projects using modern information technologies must develop a method of information systems project management to effectively implement them at medical institutions. It should be emphasized that concomitant issues of information security are specific for medicine generally and research in particular[3].

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3. Information support of project management Information sharing is a problem for intelligence and for countering global disasters and emergencies, not only for medicine[4]. In fact, knowledge and scientific capacities of medical institutions are high enough. However, it is not possible to use and apply the results of employees’ intellectual activities 100% because of the weak structuring and systematization of information on the available human resources and knowledge resources of an institution. To solve this problem, we propose to build a specialized information system to support the scientific activities of a medical higher education institution. Its main functions should include the ability to manage scientific projects and the possibility of strategic planning. Such a system will integrate into a unified information space all aspects of planning and implementation for research projects. The information model should provide a unified view and data storing for all projects. As a platform for building the information system, we selected Microsoft SharePoint[5]—a collection of software products and components with the following elements: x A set of web-based applications for collaboration x Functions to create portals x A module to find information in documents and information systems x Functionality for a workflow and content management system of enterprise scale x A module to create forms for entering information x A functionality for business analysis The chosen software solution provides enough flexibility to configure the system to implement all the functions of project management and strategic planning. The proposed approach provides an opportunity not only to monitor the stages of any ongoing research projects, but also to search for potential performers, depending Handbook for Pandemic and Mass-Casualty Planning and Response, IOS Press, Incorporated, 2012. ProQuest Ebook Central,

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on the scientific field of the project. This will allow monitoring of the dynamics of implementation of new projects according to their topics and thus support a to-date list of all projects, regardless of their level of development.

Conclusion

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Proceeding from the above, we can formulate the requirements for project management at a medical institution: x Creation of multidisciplinary teams with a specific research project x Context development of the project x Identification of the criteria of novelty x Creating space for action (time, financial, infrastructure) x Building and maintaining a comprehensive network of communications and interactions with peers x Attachment to search process alternatives and options (if necessary, to organize a parallel project with the same formulation of the problem) x Promotion of spontaneity and creativity in a project team x Active transfer of knowledge during the project and its distribution to all project participants For research projects it is necessary to develop different versions of their implementations. That will make solutions easy to find and significantly improve the quality of research. Based on the results of conceptual design, it is decided whether one needs a project for implementation in general. Differentiation of complexity is the main criterion for project preparation. The next criterion for assessing complexity has been proposed: diversity of possible work packages (documents); using network packets and the number of employees in working groups, taking into account risks while implementing the project, novelty, duration and time limits, and use of resources. Implementing the system while taking into account the described requirements and implementation approaches will reduce information losses, having a key role in a single project or a portfolio of projects. The project approach will create the conditions for the organization of research and scientific projects by optimizing the number of members in the group of performers. This will improve the quality and competitiveness of the specialists on the market of innovative technologies. While the volumes and numbers of ongoing research projects performed by numerous participants of multidisciplinary, international and interagency teams are increasing, the ideas of complex[6] and comprehensive[7] networks might be applied for further development of scientific project management architecture.

References [1] R.J. Freeman, R&D Management Research, Rand Corporation, Santa Monica, California, USA (1965), P-3216. [2] Project Management Institute, What is project management? www.pmi.org/en/About-Us/About-Us-Whatis-Project-Management.aspx. [3] G. Maltseva, N. Nagaeva, and A. Trufanov, Information Confidentiality in Contemporary Practice of Higher Education, Information Security Technologies, Moscow (2000), 90-93.

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[4] F. Galindo, M. Guidotti, V. Gulevich, et al., Information Sharing in Knowledge Society, NATO Science for Peace and Security Series–E: Human and Societal Dynamics, 62 (2010), 15-22. [5] T. Pattison and D. Larson, Inside Microsoft Windows SharePoint Services 3.0., Piter Press, Moscow (2008), 448. [6] A.-L. Barabási, R. Albert, H. Jeong, Mean-field theory for scale-free random networks, Physica A, 272 (1999), 173-187, http://arxiv.org/abs/cond-mat/9907068. [7] M. Aminova, A. Rossodivita, A. Tikhomirov, and A. Trufanov, Comprehensive network lace (How to govern the world), Proceedings of Free Economic Society of Russia, 148 (2011), 190-207.

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Lessons Learned

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Handbook for Pandemic and Mass-Casualty Planning and Response E. Gursky and B. Hrečkovski (Eds.) IOS Press, 2012 © 2012 The authors and IOS Press. All rights reserved. doi:10.3233/978-1-61499-135-9-235

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Lessons Learned Elin GURSKYa and Boris HREKOVSKIb Analytic Services Inc., Arlington, Virginia, USA b Croatian Urgent Medicine and Surgery Association a

Abstract. The Advanced Study Institute “Addressing Pandemics, Mass Casualty and Catastrophic Health Events” convened experts from more than 12 countries and produced eight lessons for NATO to consider in preparing for mass-casualty incidents. Keywords. Advanced Study Institute, pandemics, mass-casualty incidents, lessons learned

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Introduction The Advanced Study Institute “Addressing Pandemics, Mass Casualty and Catastrophic Health Events” convened experts from more than 12 countries representing a broad spectrum of skill sets and capabilities and providing a rich learning experience. This ASI was organized into six learning modules interspersed through lectures across 12 days. The modules were Epidemiology and Surveillance; Clinical Management; Critical Care and Special Populations; Force Protection and Emerging Technologies; Legal, Ethical, Economic and Social Considerations; and Disaster Operations, Training and Education. Faculty, guests, and participants listened to and engaged in discussion of topics: planning for and responding to an influenza pandemic, procedures for treating blunt trauma to the head and neck, infection control during mass-casualty incidents, improving the hospital response during catastrophes, and more. Despite—and perhaps because of— the diversity of topics, it is important to illuminate the core concepts that pervaded these sessions and helped unite this ASI.

Lesson 1. The value of planning, education, and training (practice, training, exercises, simulations) “If you fail to plan, you plan to fail,” says an adage. For those working in the health enterprise in these times of natural and deliberate threats, planning is essential and failure unacceptable. Planning requires not only thorough knowledge of the concepts of operations but also verification of the plan. During this ASI, the faculty witnessed a mock disaster and the use of the Medical Response to Major Incidents (MRMI) system. Both travel team and host team members joined with Croatian prehospital and hospital medical personnel, along with police and dispatch personnel, in a simulation exercise based on a terrorist incident scenario. The simulation model that was used covered the whole chain of medical response, with interactive training. The plans for detecting and responding to casualties, the triage and staging of victims, the call-up of physicians and

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surgeons, and other key response components were displayed over many hours. Fault lines were discussed with “mock” responders: “What would you do if …”? Injects tested capabilities to alter course and adjust the approach as the situation required. From these exercises and drills, planning is refined and skills sensitized and recalibrated for the unexpected. The exercise was evaluated with analysis of avoidable deaths and complications based on the Injury Severity Score and Revised Trauma Score. PreHospital Trauma Life Support and Advanced Trauma Life Support were the care protocols for casualties. Planning takes time, exercises consume resources, and training drills and simulations disrupt routine schedules. Yet when a tragedy occurs, the investment in constructing and testing plans pays dividends in the lives saved.

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Conclusions after the simulation exercise 1. There is a need for education and training for mass-casualty incidents and disasters. Planning cannot replace education and training. 2. We need simultaneous training together for all medical and emergency personnel who are involved in management of mass-casualty incidents (scene, transport, command and control, communication, hospital management). 3. Education and training have to be based on completely correct and accurate input and output data. All data about decisions and medical treatments should be evaluated according to international standards. 4. Education and training should be fully interactive, with participants acting in their own roles. 5. The MRMI course simultaneously trains all personnel who are involved in management of a mass-casualty incident organization, with evaluation based on accurate and correct input and output data. The MRMI course is fully interactive. 6. There is a need for a “common language” for education and training of EU emergency personnel, to build preparedness in case of a mass-casualty incident that will involve emergency personnel and casualties of neighboring countries. 7. With education and training through the MRMI course, we could build bridges between countries (for example, the Slovenia-Croatia partnership in disaster education by means of MRMI courses) and their health care providers.

Lesson 2. Standardization Not surprisingly, all disciplines have their unique discourse and jargon—the terminology that offers a timesaving “shorthand” during incidents. Training and methodologies, too, can be regionally tailored consistent with needs and available resources. These variations can disrupt multi-sector efforts during a disaster response. As evidenced during this ASI, the response to a catastrophe amasses expertise across a spectrum of disciplines. Moreover, as we plan for global events emanating from horrific weather events, acts of terrorism and aggression, and pandemics, the response may necessitate an outpouring of help from many nations. Greater interoperability across response disciplines and nations will act as force multipliers and supply much-needed surge capacity.

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This ASI calls upon the disaster health community—its physicians and surgeons, emergency responders, public health practitioners, and others—to work towards standards of training and response that can swiftly harmonize and align efforts to mitigate morbidity and mortality. It is important that our language and methodologies unify joint efforts when we intercede on behalf of affected populations.

Lesson 3. The multidisciplinary team

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This ASI brought together experts from medicine and its subspecialties of trauma surgery, cardiology, and preventive medicine; emergency response; public and preventive health; epidemiology; nursing; law; ethics; and communication—among other disciplines. Each has critical equities in the disaster response paradigm. Frequently, however, these key disciplines train independently—not interdependently—and their unique contributions may not be fully appreciated. Pandemics, mass-casualty events, and catastrophes are first and foremost public health emergencies that act to dislocate the health, civil, and economic base of the affected populations. Initial triage will identify specific vulnerabilities and the most atrisk groups to prevent the evolving ravages of chronic health problems, hunger, behavioral outbursts, and environmental conditions that can exacerbate and further disable already affected individuals. Effective staging of the injured readies them for the medical and surgical interventions that can prevent loss of life. Special-needs populations—including infants and children, pregnant women, and the elderly—will require screening and additional medical and other supportive services. All care must be provided within an ethical context that is just and respectful of basic humanitarian needs. Identifying and including the relevant skill sets and disciplines that are needed to support a catastrophic health event are essential to proper planning. This ASI and its multidisciplinary, multi-module approach highlighted the contributions of many key areas of expertise that ultimately contribute to mitigating and recovering from a crisis.

Lesson 4. Information sharing & situational awareness Although the necessity of many core disciplines has been highlighted, their safety and effective participation in a crisis is contingent upon access to early and continually updated information. Both sophisticated, nearly real-time electronic information streaming and low-tech approaches should be harnessed to ensure that the response team remains in touch with incident command leaders and with one another and that risks to themselves and patients are informed by refreshed situational awareness. Getting information to the community is equally important. Systems of multimethod, culturally appropriate risk messaging are critical components of disaster planning. The public needs information regarding the scale and scope of a disaster, the actions that should be taken to protect themselves and their families from further exposure and harm, and sites to access for medical care and supportive services. Communication plans for the responder communities and the public should be frequently tested and evaluated within response drills and exercises.

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Lesson 5. Educating both professionals and the public This chapter has addressed the importance of educating and training the professional community. It has also discussed the need for both intra- and interdisciplinary training, through traditional learning methods as well as exercises and simulations. It is equally important that the public understand—in advance—the nature of the response. This will help to manage their expectations regarding the time span for receiving assistance and to shape their own efforts to sustain their health and safety in the interim. This will vary considerably across communities, depending upon inherent resource capacity as well as the nature of the catastrophe. Additionally, the professional response community should have a plan for calling up and using non-trained volunteers. It is commonplace for people to want to help their neighbors and assist their communities, yet frequently the outpouring of volunteers can impede the work of trained professionals—and place the volunteers and others at further risk.

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Lesson 6. Communication The importance of communication discussed above indicates the value of situational awareness and the importance of information sharing across the response community and the public. There is value, however, in identifying “communication” as its own “lesson learned.” Communication serves to help shape the behaviors that will influence the aftermath of a catastrophe as people and governments ask, “Did we do all we could?” “Could we have done more to protect lives?” “Were we adequately prepared?” and so forth. Communication is an invaluable key for building trust, without which even the most practiced response will fail to reverse the powerful effects of a disaster. The host team presented experience from MRMI courses organized in five European countries and listed common mistakes: 1. Lack of preparation and training for communication—occurring with the same incidence in all five countries 2. The alert process is unclear for the majority of medical personnel—they are not trained in who declares major incidents or the alert process in hospitals, and action cards are not available.

Lesson 7. Ethical principles Disasters and catastrophes frequently strain available human resources and material. Inherent to a disaster response is the concept of triage—prioritizing those with immediate needs over those with less life-threatening conditions. In routine practice many experts are convened to produce guidance regarding priority groups for vaccines and postexposure treatment. Within the context of medicine and health care, there are systems for determining who comes first and who receives priority access to resources. Within these parameters, however, there must be an underlying ethical framework that respects and preserves the dignity of all people. These can be difficult determinations, especially in situations that are the result of deliberate aggression, not acts of weather or natural disasters. However, if there is any cohort that can champion the

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value of engaging in an ethical framework, it is the medical and health professionals who train for and respond to catastrophes. They must lead by example.

Lesson 8. Leadership That this multi-country, multidisciplinary ASI engaged in such robust learning and discussion over 12 days in 2011 is a testament to the leadership of the faculty. Within their own countries, these experts apply their skills amid often dwindling resources and shifting priorities. Yet they remain solid voices for improving health care delivery and disaster response capabilities for the populations they serve. They demonstrate wisdom and courage as true medical and public health leaders, and they help to expand the strength of global disaster preparedness and response. At the ASI conference we also discussed strategic leaders’ values, especially critical thinking and the use of concepts in decision making.

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Perhaps the greatest lesson is that, while enormous challenges face us in the coming decades, our friendships and professional relationships offer us the opportunity to fulfill our mutual goals of intervening upon and improving the health security of global populations. Yet another successful NATO ASI concludes.

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Subject Index abdominal trauma Advanced Study Institute amputation blast injury burn assessment burn injuries character clinic collaboration combatants Committee of the Chiefs of Military Medical Services in NATO (COMEDS) community competency complex humanitarian emergencies complex networks conflict conflicts critical care Croatia curriculum decision making disaster medicine disaster disasters DITAC Project dual-wave phenomenon education and training epidemiology ethics explosives future casualties future crisis future planning global disasters global health (H1N1)pdm09 health organization hospital preparedness HPAI H5N1

156 235 168 181 173 173 95 31 202 134

126 101 72 84 217 142 62, 84 152, 156 98, 101 12 168 72 3, 152 84, 92 12 92 62, 189 31 95 181 142 84 119 202, 217 84 31 98 92 31

humanitarian assistance 72 humanitarian crises 84 influenza 31 information sharing 189 Injury Severity Score (ISS) 163 interactive training 3 international crises 12 Internet 197 just-in-time 197 leg injuries 168 lessons learned 142, 235 limb salvage 168 major incident 3 major incidents 59, 62, 107, 119, 189 mapping 202 mass casualty 59, 193 mass casualties 119 mass disaster 163, 181 mass-casualty incident 3 mass-casualty incidents 235 medical institution 226 medical response 59 126 Medical Standardization Board MESS score 168 monitoring 31 MRMI 59, 119 multiple-casualty incidents 156 NATO standardization 126 natural disasters 119 networking 202 pandemics 31, 235 personal protection equipment 134 preparedness 59 preparedness & response 31 professionalization 72 project management 226 public health 98, 101 public health education 197 public health emergency 84 research and development 226 reserves 92 resilience 101

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163 193 3 126 217 197 168 31 126 134 3 107

terrorism threat topology training training and education treatment of burns treatment triage vascular trauma vulnerable people war wars

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Revised Trauma Score (RTS) risk communication simulation models standardization procedure supercomplex networks Supercourse surgery surveillance tasking authority technology terror actions terror medicine

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107, 119 134 202 12 72 173 31 95, 152, 163 156 84 62 84

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Author Index

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Ajdinovi, A. Bakanidze, L. Bakota, B. Balen, I. Bardak, B. Baši, M. Burkle, F.M. Caruso, A. Cvitkovi, A. Dobson, B.

152, 163, 181 31 156, 163, 168 95 193 193 72 84, 217 31, 98 3, 12, 107, 119, 134, 142, 189 Fischer, P. 12, 107, 134, 142 Galindo, F. 202 Govorkov, A. 226 Guidotti, M. 84 Gursky, E. 101, 235 Herman, S. 59, 92 Hrekovski, B. 3, 12, 62, 107, 134, 142, 152, 163, 168, 173, 181, 189, 235 Hubac, R. 126 Ivic-Hofman, I. 31 Jackson, K. 101 James, J.J. 72 Jankovic, J. 173 Juriši, D. 173

Jurjevi, M. 152, 163, 173, 181 Komadina, R. 92 Kopi, J. 152, 163 Kopljar, M. 156, 163, 168 LaPorte, R. 197, 202 Lennquist Montán, K. 3 Linkov, F. 197, 202 Loades, M. 107, 134, 142, 189 Lovri, Z. 62, 163, 181 Lyznicki, J.M. 72 Mati, I. 181 Padilla, N. 197 Paji-Penavi, I. 181 Pavliško, I. 193 Ranghieri, M. 84 Rosko, D. 173 Rossodivita, A. 84, 202, 217, 226 Samardži, J. 62, 181 Shubnikov, E. 197, 202, 217 Simoniti, M. 92 Stikova, E. 84, 202 Strahovnik, A. 92 Tikhomirov, A. 217 Trufanov, A. 197, 202, 217, 226 Umerov, R. 217 Vynograd, N. 31, 202

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