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Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e

Chapter 6: Natural Disasters Lisa D. Mills; Trevor J. Mills

INTRODUCTION AND EPIDEMIOLOGY

Natural disasters continue to be an unpredictable source of worldwide morbidity and mortality and present uniquechallenges for practitioners of emergency care. The 2002 to 2011 annual average worldwide mortality rate was 107,000deaths/year from natural disasters, with an average of 268 million worldwide victims per year during the same time period

and an economic cost of $143 billion in 2012.1 With the increase in rapidly mobilized recovery teams, emergencyphysicians are at the forefront of patient care following a natural disaster. It is here that we can have the greatest impact intreating survivors and minimizing secondary morbidity and mortality, o�en in the setting of a significantly impairedhealthcare system. Research suggests that the burden of natural disasters is likely to rise in the coming years, due toincreasing population density in high-risk areas and risks associated with expanding technology (e.g., fires or earthquakes

in larger and taller buildings or critical infrastructure).2

Although the mechanics, warning period, and impact vary widely between types of natural disasters, there is a predictablepattern of events that occur and may be used to maximize the subsequent response. Natural disasters result in a combinedloss of resources—infrastructure, economic, social, and health. While this may be tempered by pre-event preparednessand infrastructure strength, this combination of resource loss has a synergistic impact on the health of and the delivery ofhealth care to the a�ected population. Another commonality is the predictable pattern of pathology, seen in theprogression from the impact of the event itself, through the acute a�ermath, to the immediate postdisaster phase, into therecovery phase (Table 6-1). Perhaps most salient for emergency practitioners, relief e�orts can be implemented based ondata from previous disaster experience, while simultaneously being tailored to the type of disaster (e.g., hurricane,earthquake, tornado, flood, tsunami, or snow) and region a�ected. Finally, disaster responders should be prepared to facethe duty of management of dead bodies, on a scale otherwise only seen in the setting of combat.

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TABLE 6-1

Timing of Disease Presentation

Timing of

OnsetPresentation

Acute

phase

Trauma Stress

reactions

Drowning Inhalational

injury

Burns

Immediate

postevent

phase

Infectious

complications

of trauma

Exacerbation

of chronic

disease

Acute stress

disorder

Burns Inhalational

injury

Recovery

phase

Trauma Communicable

disease

Infectious

complications

of trauma

So� tissue

infections

Exacerbation

of chronic

disease

Vectorborne

disease

Posttraumatic

stress

disorder

LOSS OF RESOURCES

Most natural disasters—whether by water, wind, fire, or snow—cause some disruption of power, communication, andtransportation systems. In developed and developing nations, entire cities can be destroyed instantly, overwhelming

nearby healthcare facilities and personnel. In such cases, the traditional triage system may not be e�ective.3 A Centers forDisease Control and Prevention posthurricane assessment in 2012 determined that most of the resulting public health

emergencies were directly due to loss of public health infrastructure and related to clean up and repair activities.4 Becausestandard amenities, such as power, running water, and sanitation methods, may be unavailable for extended periods oftime, all medical disaster planning must include practical, simple alternatives to technologies that are likely to fail during adisaster.

Lack of communication is a common feature of both the impact and delayed phases of a disaster. Even the mostsophisticated equipment may fail due to regionwide outages or loss of electricity for charging devices. In our experienceduring the active phase of Hurricane Katrina, the only working means of communication within Charity Hospital was asingle landline telephone. Di�iculty in communication has led to recent innovation with proposals for disaster-specific

electronic medical records.5

Evidence suggests that the predisaster level of preparedness and resources in a community has a significant impact on itsresponse to a catastrophic event. Analysis of four earthquakes in di�erent regions (developed and developing countries)found that regions with the least preparedness and weakest preexisting medical infrastructure had the highest number of

deaths per patients injured.6 Investment in targeted disaster preparedness e�orts before an event occurs, particularly forthe most vulnerable populations, is crucial in mitigating the e�ects of an inevitable disruption in resources during a

disaster.7

DISEASE BURDEN

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Understanding of the likely health emergencies to be encountered in the acute and postdisaster phases is crucial to anyemergency response. Although it is widely thought that outbreaks of rare and/or severe disease inevitably follow many

types of natural catastrophe, evidence does not support this belief.8,9 Common medical problems a�er natural disastersinclude traumatic injury, infectious disease, exacerbations of chronic medical conditions, and a surge in mental healthissues (Table 6-2). In addition to the common medical problems previously listed, the handling of bodies has an additionalunique impact on the health of the a�ected population.

TABLE 6-2

Common Disease Patterns

TraumaCommunicable

DiseaseChronic Medical Conditions

Infectious

DiseaseMental Health

Strains and

sprains

Respiratory

infections

Hypertension So� tissue

infections

Stress reactions

Falls GI infections Diabetes Open fractures Depression

Lacerations Renal failure Vectorborne

disease

Exacerbation of chronic

condition

Burns Chronic obstructive pulmonary

disease

Local diseases

Fractures

TRAUMA

Traumatic injuries frequently occur in the acute phase of a natural disaster, commonly from direct trauma from collapsingstructures or flying debris. A second spike in trauma is seen during the recovery/clean-up phase, mainly due to unsafeinfrastructure. However, this secondary spike in trauma may also include violent injuries, depending on the level of civil

unrest.10 Although most trauma is minor, management of severe injuries by healthcare professionals can prove especiallychallenging when resources are lacking, as they o�en require coordinated surgical care. This necessitates adequateresources of anesthesia, blood products, surgical equipment and the ability to sterilize it, intensive care capacity, andoperating theaters. When these resources are unavailable, limb amputation, nonunion, and missed injury rates are high,

and lack of safe blood products hampers surgical capability.11,12 Recommendations for adequate surgical capabilityinclude mobile blood banks with adequate supply and well-trained sta�, at least two units of blood available peroperation, adequate supplies of appropriate anesthesia, strict adherence to national or international quality and safety

standards, and functioning critical care units.3,12,13

INFECTIOUS DISEASE

Infectious diseases are commonly feared and should be anticipated a�er natural disasters. Although popular media o�enfocuses on the possibility of rare disease epidemics, most postdisaster infections are directly related to the usual

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pathogens of that region.9,14 One exception to this was the outbreak of cholera a�er the 2010 earthquake in Haiti, which is

believed to have been brought in by United Nations relief workers.15 Evidence indicates that the combination ofcommunicable disease and population malnutrition is the major cause of morbidity and mortality in most disasters.

Infectious disease predominantly occurs in the extended postevent phase.16 Infectious disease risks are heightened bycertain characteristics common to natural disasters: mass population movement and resettlement; overcrowding; poverty;sanitation and waste issues, including water contamination; absence of shelter, food, and healthcare access; anddisruption of public health programs. Respiratory, GI, skin/so� tissue, and vectorborne infectious diseases are mostcommonly analyzed in disasters.

Respiratory illnesses range from direct aspiration of contaminated water (floods and tsunamis) to airborne droplettransmission to inhalation injuries caused by excess dust or debris. Although most infections are mild, respiratory illness

may account for 20% of all natural disaster deaths in children <5 years old.13 In the acute phase of a flood or tsunami,

inhalation of water with polymicrobial contamination may cause aspiration pneumonia.17 Most respiratory outbreaks,however, emerge several weeks a�er disaster as disease spreads through shelters and settlement camps. Both disaster

victims and rescue workers are at risk for respiratory illness due to crowded conditions and compromised sanitation.18,19

Some respiratory illnesses (pertussis and measles) are preventable with adequate vaccination; thus, knowledge of thepredisaster vaccination status of a population and su�icient vaccine stores may prevent severe outbreaks. Tuberculosispresents a special challenge for public health o�icials. To prevent outbreaks, adequate stores of antimicrobials must be on

hand, and strict adherence to surveillance of known infectious cases is essential.9

GI illness—primarily diarrheal—is another common feature of postdisaster health care. Approximately 40% of deaths in theacute postevent phase (with 80% of these being children) can be attributed to diarrhea. These diseases are mainly due toissues of water quality and availability, sanitation, and cleaning materials; in one study, the mere presence of soap

decreased diarrhea by 27% in a refugee camp.16 As with respiratory illness, the incidence of GI disease o�en peaks severalweeks a�er the disaster, and the infections are generally mild. With good health surveillance and attention to typicalendemic disease patterns, severe GI illness outbreaks requiring extraordinary public health resources are rare.

Skin and so� tissue infections are seen in a variety of natural disasters. Falling debris from wind, fire, or earthquake cancause traumatic abrasions or lacerations. With a disrupted healthcare system or contaminated water exposure to thewound, the incidence of infection is likely to increase. Although wounds are frequently seen in the acute phase of a

disaster, they are also o�en encountered during the clean-up phase several weeks to months a�er an event.20,21 Severeinfections are not prevalent; however, organisms such as Vibrio vulnificus in water-based disasters and gram-negativebacteria due to soil contamination of wounds in tornadoes and earthquakes have the potential for severe threats to life

and limb.9,22

Vectorborne illnesses, such as yellow fever, malaria, and dengue fever, generally have a higher incidence during water-based disasters but can occur a�er any event in a vulnerable population. Although rare, the outbreak can occur up to 8

weeks a�er disaster.13 Regions without predisaster populations of vectors or disease are not likely to suddenly acquiresuch infections; thus, although there was intense media speculation of the perceived risk of malaria, yellow fever, and

other vectorborne illnesses a�er Hurricane Katrina, these illnesses were not seen in the Gulf Coast.9 In regions where theseillnesses are endemic, vector control is key, and initial postdisaster public health e�orts should direct resources towardappropriate programs.

CHRONIC MEDICAL CONDITIONS

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Management of the chronic health conditions of a displaced population is a significant contributor to postdisastermorbidity. Separation from medications or health technology products, removal from the usual sources of care, anddisruption of the healthcare infrastructure a�er a catastrophic event can all contribute to exacerbations of patients'chronic disease. In an analysis of patients presenting to one of the few healthcare facilities available in the 2 months a�erHurricane Katrina, 51% of all native patients had at least one preexisting medical condition, and half took at least one

regular medication.20 Other studies have shown that >25% of patients presenting a�er a variety of natural disasters havechronic medical conditions, and "medication refill" or "chronic medical problem" is frequently among the top five

diagnoses made in disaster relief health clinics.21,23

Inability to properly control chronic diseases, such as hypertension, diabetes, asthma, or coronary artery disease, may well

be the biggest unanticipated health threat to a postdisaster population (Table 6-3).7 Understanding of the common chronicdiseases of a region is essential for health relief e�orts. In our experience, well-meaning donations of medications forconditions not normally experienced by our population (e.g., outdated psychiatric medications, older generationantiarrhythmics) went unused. Conversely, we were unable to keep enough antihypertensives or diabetic medications tosupply the vast demand.

TABLE 6-3

Commonly Neglected Disaster Response Medications and Supplies

Antihypertensives

Tetanus prophylaxis

Soap

Analgesics—oral and parenteral

Insulin

Oral hypoglycemics and sulfonylureas

Antibiotics, especially for so� tissue infections

Albuterol and ipratropium inhalers

MENTAL HEALTH

An o�en-overlooked consequence of natural disasters is the psychological burden inflicted on survivors. Destruction ofcommunities and property, witnessing terrifying and o�en fatal events, and disruption of normal life for days to years a�erthe disaster can cause severe mental health consequences in survivors. In one study of post–Hurricane Katrina survivors,rates of posttraumatic stress disorder were 10 times the expected population incidence and on par with rates in returning

Vietnam War veterans.24 Psychological disorders may be exacerbated by lack of housing and illness or death of a close

family member due to the disaster.25 Disaster-related physical injury or illness may also contribute to mental healthcomorbidity. The number of emergency amputations due to the 2004 tsunami in an Indonesian surgical clinic quickly

overwhelmed the ability of the healthcare system to provide the necessary psychological counseling for patients.26

Conversely, mental health conditions, such as major depression, may exacerbate acute or chronic physical ailments due toweakened immune systems, disconnection with the larger community and healthcare systems, or attempts to cope byusing drugs or alcohol. Suicide rates may also be elevated years a�er a significant disaster. Any appropriate healthcareresponse to disasters must include su�icient resources to deal with the degree and severity of psychological disorderssu�ered by survivors, including children, first responders, and those who have endured severe trauma or loss.

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HANDLING OF BODIES

Any natural disaster with a significant number of casualties requires e�icient and sanitary removal and proper burial ofdead bodies. Although the fear of disease outbreak from survivor or rescue worker exposure to corpses is prevalent, suchexposures are rare. Most initial victims of natural disasters die of traumatic injuries; few are likely to have acute,communicable diseases, although the standard transmission risks of chronic infectious diseases, such as human

immunodeficiency virus, tuberculosis, or hepatitis, to body-handling rescue workers are present.27 Universal precautionsfor protective coverings, hand washing, disposal bags, and vaccinations should be followed by anyone working with deadbodies; this includes having su�icient refrigerated trucks on standby should morgue capabilities be overwhelmed.

HURRICANES

Hurricanes are among the most destructive natural disasters, particularly in coastal areas. Morbidity in the acute phasemay be due to wind forces (collapsing buildings or flying debris) or water (storm surge or rapid flooding). Hurricanes tendto cause more structural damage than floods and therefore can disrupt infrastructure and population resettlement more

severely.28 Hospitals themselves are frequently damaged, but even if structurally intact, they may be a�ected by loss of

power.29 With catastrophic destruction of a densely populated region, such as in Hurricanes Katrina and Sandy, temporarymedical facilities may be needed months a�er a disaster. Indeed, hurricanes may be the only natural disaster where more

injury and death occur during the recovery period than in the acute phase.30

Most posthurricane illness and injury falls into predictable categories. Studies from eight di�erent hurricanes over the last15 years all list a handful of patient diagnoses that comprise the vast majority (up to 75%) of visits to healthcare centers:infections (specifically respiratory, GI, and skin); treatment of chronic medical conditions; wounds and lacerations;

musculoskeletal injury and trauma; and rashes.19,20,28,29,30,31,32,33,34 In functioning healthcare facilities, ED visits peakseveral days to weeks a�er the hurricane as citizens are allowed reentry into the area; there may be an acute, brief influx of

several times the normal patient volume or a steady rise in visits over time.5,20,31

Initial traumatic injury directly due to hurricanes is relatively uncommon, and simple supplies for minor sprain, strain, andfracture care are recommended. Although surgical units and personnel are an important adjunct, basic supplies and some

radiographic capability may provide the best investment of limited resources.28,30 Unintentional injuries predominate; a

post–Hurricane Katrina evaluation of injuries found that only 2% were due to intentional trauma.18 Causes of traumaticdeath in the acute period include falling objects, motor vehicle crashes, and electrocution. In the recovery period (weeks tomonths a�er the hurricane), clean-up–associated trauma predominates. One study a�er Hurricane Hugo found that one

third of all wounds evaluated in an ED were caused by chainsaw accidents.32

As with other disasters, infections are generally mild, reflective of the typical local disease burden, and occur several weeksto months a�er the hurricane. Scattered outbreaks of mild respiratory and GI illness have been described, withovercrowding in shelters and sanitation issues the main predictors of disease. Unless hurricanes are associated withconcomitant prolonged flooding in endemic areas, the risks of waterborne disease are minor. Post–Hurricane Katrina

incidence of V. vulnificus skin infection was consistent with typical nondisaster rates.9

Individuals without transportation or with tenuous connection to community resources are potentially more likely to benegatively impacted by the e�ects of a severe hurricane. These individuals may not be able to evacuate in advance of astorm and thus su�er greater risks of direct trauma and water- or wind-related morbidity during the initial impact. E�ectsmay persist beyond the acute phase. A study of Hurricane Mitch survivors noted that GI illness and emotional distress were

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more likely months a�er the storm in those without access to housing, food, or medical care.25 Other population concernso�en seen in hurricanes include the healthcare burden of relief workers (civilian and military). Recovery e�orts o�enrequire massive numbers of workers whose living conditions are o�en on par with storm victims. In one study, reliefworkers were nearly six times more likely than natives to use nonhospital healthcare facilities, and a spike in respiratory

illness was attributed to transmission through a military battalion.18 Our experience found that although younger than thenative population, nearly half of relief workers seeking care had significant comorbidities that further burdened the

struggling medical system a�er Hurricane Katrina.20 Disaster planning should account for the needs of disenfranchisedcitizens as well as the expected influx of relief workers, many of whom may have chronic medical conditions.

EARTHQUAKES

Earthquakes are a unique disaster phenomenon in that there is no technology to detect a pending earthquake and thus noopportunity to provide a warning. Due to the lack of warning, supplies and a response plan must be continuouslyavailable. As was evidenced by the Haiti experience in January 2010, earthquakes can destroy water, electric,communication, gas, and sewage lines and cause structural instability. With no opportunity to evacuate before anearthquake, there is increased potential for casualties. People are at increased risk for being trapped in rubble or stranded.The first 1 to 14 days of response to an earthquake are dedicated to recovery of the injured. A�er an earthquake, the

majority of fatalities occur within the first 3 hours.35

Injuries a�er earthquakes are the result of falling structures and debris. The most common injuries are fractures and crush

injuries.36,37 One hospital that registered 2892 patients a�er an earthquake reported that 37% of patients had

musculoskeletal injuries. This hospital also reported the frequent occurrence of scalp injuries with large tissue defects.36

Another hospital that registered 1500 patients in the first 72 hours a�er an earthquake reported that 78.4% of patients hadextremity injuries; 50.4% of injuries were fractures, primarily closed. This same study reported that 37% of injuries required

extensive debridement.12 A�er the Mansehra earthquake in Pakistan in 2005, the medical equipment that the response

teams found most useful was "external fixators that are easily applied."36

As with all disaster areas, the most common "illnesses" are the "regular medical needs of the people living in the

earthquake zone."36 In undeveloped regions recovering from large earthquakes, "preventable diseases, such as measles,

are on the rise."37 With proper sanitary and sewage techniques and adequate supplies of potable water, GI disease remainsuncommon.

People with compromised mobility, including some geriatric patients, people with paralysis, amputees, people onventilators, and people in wheelchairs and walkers, will be less likely to evacuate before the disaster and will haveincreased di�iculty extracting themselves from the ruins. These people are more likely to be stranded in debris and tosustain crush injuries (also see chapter 7, "Bomb, Blast, and Crush Injuries") by collapsing buildings. These populations areespecially at risk a�er earthquakes, because there will be no opportunity to evacuate before the disaster. Rescue andhealth services coordinators should make provisions for larger numbers of patients with increased needs a�erearthquakes. One study analyzed a metropolitan area in the United States and found that 31.6% of people >65 years oldhad a disability and 16.6% of people >65 years required assistance to evacuate. Planning for and responding to

earthquakes requires an estimate of the number of citizens with special needs.38

TORNADOES

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The continent of North America sustains more tornadoes than any other location in the world.39 Nationally, 800 tornadoes

are sighted annually. The annual human toll is estimated to be 80 deaths and 1500 injuries.40 Tornadoes cause focaldamage to buildings and lines above ground. It is unusual for entire regions to lose power and communications capacity. It

is unusual for multiple hospitals to be disabled by a single tornado.41,42 As a result, medical infrastructure in developedcountries remains functional. Surge capacity may be tested in the immediate a�ermath, but the provision of adequatechronic medical care is usually unhampered.

Most commonly, injuries from tornadoes result from being struck by flying debris or being thrown by the force of thetornado. Patients who were thrown or airborne as a result of the tornado sustain more severe injuries than patients who

are struck by debris.43,44 Additional risk factors for hospitalization or death include being struck by broken glass or fallingobjects, having one's home li�ed o� of its foundation, collapsed ceiling or floor, or loss of walls of the shelter

structure.44,45 Injuries are commonly multisystem. Fractures and so� tissue trauma are the most common injuries

reported.39,46,47,48 In one study, most patients (91%) sustained injuries to the extremities. Head, chest, and abdominal

injuries were also common, occurring in 45%, 45%, and 27% of patients, respectively.43 Head injuries are the more

common cause of death.39,47,48 Death from the impact a�er being thrown by the tornado is thought to most o�en occur at

the scene, rather than en route to or at the hospital.49,50,51

Wound contamination is common among patients who are thrown by the tornado. Polymicrobial contamination is

common.39,46 Gram-negative organisms commonly infect the wounds of those injured by tornadoes.43 Studies that report

low infection rates attribute this to meticulous attention to open wounds.52

Where functioning tornado warning systems exist, injury and loss of life are dramatically reduced.40,53 People in mobile

homes or outdoors without cover are more likely to sustain severe and fatal injuries during a tornado.45,53,54 Deaths aremore common in patients who are in mobile homes or in rooms above ground with windows, who are "older," or who have

less warning regarding the approaching tornado.43,44,48,49,55 Use of a tornado shelter is associated with a significant

reduction in tornado-associated injuries.54

FLOODS AND TSUNAMIS

Water-based natural disasters, such as floods and tsunamis, can be extremely destructive. Although floods can occur froma storm or flowing body of water, tsunamis are formed when a massive force (for example, an underwater earthquake,volcanic eruption, meteorite impact, or landslide) displaces a large amount of water in a rapid period of time. A springflood of the Yangtze River in China in 1931 caused >3 million deaths, and more recently, deaths from the Indian Oceantsunami in 2004 approached 300,000. Factors that contribute to the catastrophic nature of these events include the short(if any) warning period to vulnerable populations and their association with other natural events, such as an oceanicearthquake resulting in a tsunami. Key challenges faced by healthcare providers include severe and prolongedincapacitation of physical buildings due to structural damage or persistent standing water; handling and identification of

large numbers of dead bodies; and the chronic needs of a large, displaced population in temporary shelter.26,56,57

Acute injuries may be caused by sheer force of water, drowning, and trauma from falling objects. A review of flood deathsfrom 1989 to 2003 found that morbidity and mortality a�er flood were related not only to direct physical impact but alsothe socioeconomic conditions of the a�ected area. Two thirds of fatalities were from drowning, mostly associated withmotor vehicles in the acute phase (e.g., when floodwaters are still high); low crossings and bridges were most dangerous.

Only 12% of deaths were from trauma, and the vast majority of cases occurred in the initial impact phase of the disaster.58

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Illnesses from water-based disasters generally occur a�er the acute phase and are dominated by infectious disease. Trueepidemics are rare, and respiratory illnesses predominate. These are generally minor and self-limited, althoughuncommonly severe pulmonary infections or pneumonitis directly related to aspiration of floodwaters (e.g., "tsunamilung") may occur. As long as clean, safe, adequate supplies of potable water are available, acute gastroenteritis anddiarrheal illnesses are relatively rare; a Sri Lankan refugee camp a�er the 2004 tsunami diagnosed GI complaints in <1% of

patients.23 Minor skin trauma is common and has the potential to progress to infected wounds if prolonged exposure tofloodwaters and delayed access to care are present.

Certain population groups have been shown to have higher risks of morbidity and mortality a�er floods and tsunamis.Women had three times the risk of death compared with men a�er the 2004 tsunami due to heavier clothes impeding

escape, risking lives to save their children, lack of swimming ability, and increased dangers in settlement camps.26 In acomprehensive study of flood deaths, however, men had more than twice the mortality rate of women, which the authorssurmised was due to increased risk-taking behavior during the storm (attempting to drive through flooded passages,

traveling to unsafe areas in an attempt to retrieve belongings).58 Public awareness of the rapidity and danger of water,simple swimming instruction, and clear warnings of the dangers of driving during floods may prevent at-risk populationsin flood-prone areas from loss of life in future disasters.

BLIZZARDS AND SNOW DISASTERS

A blizzard is a winter storm with wind speeds of 35 miles per hour or higher accompanied by significant falling or blowingsnow. The Mid-Atlantic, New England, Midwest, Plains, Rocky Mountain states, and Alaska are a�ected by blizzards andsnow disasters. Above-ground power and communication lines are the primary resources lost during winter storms.Traditionally, these are restored relatively quickly as compared with the duration without resources a�er other natural

disasters.59

Generally, ED volumes do not significantly increase a�er blizzards and snow disasters. However, there is a shi� in the

presenting complaints.59,60,61 Injuries a�er winter weather disasters most commonly result from slipping on the ice, fallingfrom trees while clearing branches, and injuries from clearing snow. The most common injuries are back injuries and

fractures.62,63 In one study, the incidence of fractures increased until the sixth day a�er the storm.64

Carbon monoxide poisoning increases dramatically during and following winter weather disasters.60,62,65,66,67,68 Most

people presenting with carbon monoxide poisoning report using a portable generator.69 A smaller group reported burning

charcoal in the house to generate heat.65 In one study a�er a blizzard, the local hyperbarics services were overwhelmed

and unable to respond to the sudden surge in carbon monoxide poisonings.62

One study documented an increase in the number of myocardial infarctions and angina a�er a blizzard. This was primarilyin association with shoveling snow. The majority of these cases were in people who did not have previously diagnosed

coronary artery disease. One fourth of these patients were women.70

RELIEF EFFORTS

Of particular importance to the emergency medical practitioner is the experience and e�ect of postdisaster volunteer reliefe�orts. Although well meaning, the literature is filled with examples of emergency personnel who ended up burdeningrather than assisting a fractured community. Any emergency practitioner who truly wishes to provide meaningful health

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1. 

2. 

3. 

4. 

5. 

6. 

care to a displaced and disenfranchised patient population should be mindful of the lessons learned from a variety ofnatural disasters.

Medical relief volunteers are o�en the first outside help to arrive in the a�ermath of a disaster, and although some are wellcoordinated, many are not. Volunteers are o�en exuberant, expecting dramatic rescues and emergency interventions.They may be unwilling to provide much-needed routine medical care, unfamiliar with the region or local disease patterns,

and unable to fully comprehend the loss of resources.71 Furthermore, the needs of rescue personnel o�en strain a fragileinfrastructure, with demands on housing, food, health care, and essential resources; one analysis of relief e�orts a�er the2004 tsunami concluded that "personnel who do not bring essential skills are o�en a burden—much more should also be

done to ensure that the right type of people are sent on relief missions."26

Embedding locals familiar with the language, culture, and healthcare patterns of the a�ected region can significantlyenhance the e�ectiveness of relief e�orts and promote cooperation between disparate volunteer groups. Furthermore,appropriate anticipation by relief groups of the true population needs can be crucial: reproductive hygiene kits weredistributed to women in a postflood refugee camp a�er an initial spike in sexual assaults and were widely credited with

improving patient morale and health.26

The National Disaster Medical System, a government agency responsible for sending highly organized and o�enexperienced teams to disaster areas, recommends the following for disaster response: teams with well-trained andorganized support sta�; the ability to be self-su�icient for at least 72 hours; clear communication with area hospitals andmedical resources; individuals dedicated to transportation issues; a designated coordinator of walk-in volunteers; and

professional methods of record keeping, forms, and copy-making capability.30 Our experience during Hurricane Katrinaalso suggests that strong, coordinated partnerships between local emergency personnel and formal military medical unitshave great promise for sophisticated, expanded acute and delayed postdisaster medical relief as well as continuance of

medical education and resident training programs in a devastated community.20

REFERENCES

Guha-Sapir  D, Hoyois  PH, Below  R: Annual Disaster Statistical Review 2012: The Numbers and Trends . Brussels,Belgium: CRED; 2013.

Auf der Heide  E: Disaster Response: Principles of Preparation and Coordination . St. Louis, MO: Mosby; 1989.

Lee  CH: Disaster and mass casualty triage. Virtual Mentor 12: 466, 2010. [PubMed: 23158448]  

Brackbill  RM, Caramanica  K, Maliniak  M  et al.: Nonfatal injuries 1 week a�er Hurricane Sandy—New York Citymetropolitan area. MMWR Morb Mortal Wkly Rep 63: 950, 2014. [PubMed: 25340912]  

Lenert  LA, Kirsh  D, Griswold  WG  et al.: Design and evaluation of a wireless electronic health records system for fieldcare in mass casualty settings. J Am Med Inform Assoc 18: 842, 2011. [PubMed: 21709162]  

Bissell  RA, Pinet  L, Nelson  M, Levy  M: Evidence of the e�ectiveness of health sector preparedness in disaster response:the example of four earthquakes. Fam Community Health 27: 193, 2004.

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Centers for Disease Control and Prevention: Launching a national surveillance system a�er an earthquake—Haiti, 2010.MMWR Morb Mortal Wkly Rep 59: 933, 2010. [PubMed: 20689497]  

Lemonick  DM: Epidemics a�er natural disasters. Am J Clin Med 8: 3, 2011.

Centers for Disease Control and Prevention: Infectious disease and dermatologic conditions in evacuees and rescueworkers a�er Hurricane Katrina—multiple states, August–September 2005. MMWR Morb Mortal Wkly Rep 54: 961, 2005. [PubMed: 16195696]  

Pape  JW, Johnson  WD, Fitzgerald  DW: The earthquake in Haiti—dispatch from Port-au-Prince. N Engl J Med 362: 575,2010. [PubMed: 20107209]  

Roy  N: Surgical and psychosocial outcomes in the rural injured—a follow-up study of the 2001 earthquake victims.Injury 37: 469, 2006. [PubMed: 16569404]  

Mujeeb  SA, Ja�rey  SH: Emergency blood transfusion services a�er the 2005 earthquake in Pakistan. Emerg Med J 24:22, 2007. [PubMed: 17183037]  

Missair  A, Pretto  EA, Visan  A  et al.: A matter of life or limb? A review of traumatic injury patterns and anesthesiatechniques for disaster relief a�er major earthquakes. Anesth Analg 117: 934, 2013. [PubMed: 23960037]  

Waring  SC, Brown  BJ: The threat of communicable diseases following natural disasters: a public health response.Disaster Manag Response 3: 41, 2005. [PubMed: 15829908]  

Chin  CS, Sorenson  J, Harris  JB  et al.: The origin of the Haitian cholera outbreak strain. N Engl J Med 364: 33, 2011. [PubMed: 21142692]  

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