European Journal of Trauma and Emergency Surgery
Focus on Disaster Medicine
Preparedness of German Paramedics and Emergency Physicians for a Mass Casualty Incident: A National Survey Philipp Fischer1,*, Karoush Kabir1,*, Oliver Weber1, Dieter C. Wirtz1, Hermann Bail2, Steffen Ruchholtz3, Mickey Stein4, Christof Burger1
Abstract Objective: Paramedics and physicians are important components of our emergency medical system. To date, no survey has been carried out assessing physicians and paramedics regarding their preparedness for a mass casualty incident (MCI) resulting from a terrorist attack in Germany. The aim of this study was to assess the current state of preparedness of emergency physicians and paramedics for an MCI. Materials and Methods: Using an online questionnaire, we interviewed 1,707 emergency physicians and paramedics in Germany. The replies were analyzed statistically with the one-way analysis of variance (ANOVA) test and the Tukey-Kramer multiple comparisons test. Results: In all, 95% of the emergency physicians and paramedics knew their area of responsibility in the case of an MCI. However, 45% of them were unaware of injury patterns and treatment strategies in patients following nuclear, chemical or biological contamination. Of the interviewed emergency physicians and paramedics, 97% asked for further specific training for MCI/terrorism attacks. Conclusions: Emergency physicians and paramedics are still insufficiently prepared for nuclear, chemical, and biological as well as conventional terrorism attacks. The emergency training of emergency
physicians and paramedics must be modified to accommodate the increased risk of catastrophes and terrorist attacks. Key Words Paramedics Æ Physicians Æ Mass casualty incident Æ Preparedness Æ Emergency training Eur J Trauma Emerg Surg 2008;34:443–50 DOI 10.1007/s00068-008-8803-4
Introduction The events of 11 September 2001 have become catalysts for federal authorities, hospitals and emergency services to reconsider existing concepts regarding the management of damaging events, and to adapt these concepts to the new requirements of a mass casualty incident (MCI). The attacks in Madrid and London [1, 2] and the foiled attacks in Germany [3] clearly demonstrate that such events have arrived in Europe and that Germany is now also part of a danger zone for terrorist attacks. In preparation for the 2006 Football World Cup in Germany, many practical drills in the preclinical management of an MCI were carried out by the emergency services. The aim of this study was to assess the terrorism-related knowledge and the
1
Department of Orthopedics and Trauma Surgery, University Hospital Bonn, Bonn, Germany, Center of Musculoskeletal Surgery, Charité-University Medicine Berlin, Berlin, Germany, 3 Department of Accident and Reconstructive Surgery, University Hospital Giessen and Marburg, Marburg, Germany, 4 Trauma Services, Department of Surgery, Rabin Medical Center, Petach Tikva, Israel. 2
*P. Fischer and K. Kabir have contributed equally to this article. Received: September 2, 2007; revision accepted: September 28, 2007; First Published on January 30, 2008. Doi 10.1080/15031430701705808 Published Online: September 26, 2008
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response readiness of German emergency physicians and paramedics for an MCI or terrorist-associated event after these drills.
Materials and Methods As part of a nationwide online survey, emergency physicians and paramedics were interviewed regarding their knowledge in relation to MCIs and in particular in connection with radioactive, biological and chemical terrorist or conventional attacks. In total, 7,700 questionnaires were sent out. Of these, 2,890 were sent to surgeons and trauma surgeons, 2,176 to anesthetists and 2,634 to specialists in internal medicine. With respect to paramedics, a total of 129 questionnaires were sent out to NGOs (German Red Cross, JohanniterUnfall-Hilfe, Workers’ Samaritan Federation, Malteser Hilfsdienste) and fire departments. In Germany, 80% of the rescue services and 95% of disaster medical relief are carried out by these NGOs, with government organizations and NGOs employing more than 1.2 million volunteers and approximately 100,000 professionals. The survey was addressed to junior doctors and specialists in surgery, trauma surgery, anesthesia and internal medicine trained in emergency services/ emergency medicine and employed in level 1, 2 and 3 hospitals in Germany. In addition, the study was addressed to members of the emergency and ambulance services. Addresses were selected randomly nationwide. Using the ‘‘Traumanetzwerk’’ (trauma network) of the Deutsche Gesellschaft fu¨r Unfallchirurgie e.V. (DGU, German Association of Trauma Surgeons), home pages of registered clinics were selected. The DGU registers level 1, 2 and 3 hospitals in Germany. Physicians from all three categories with their e-mail addresses listed on the respective home pages received our questionnaire by e-mail. In addition, questionnaires were sent to members of staff of NGOs (German Red Cross, Johanniter-Unfall-Hilfe, Workers’ Samaritan Federation, Malteser Hilfsdienste) and fire depart-
ments, also through the available information on their respective home pages. The questionnaire included a total of 13 questions dealing with general aspects of MCIs. The questionnaire was anonymous, and participants were merely asked to provide information on gender, age, area of expertise (chief emergency physician, head of organization of emergency services), specialist qualification (yes/no) and level of training (emergency assistant with high grade education (1,600 hours), paramedics with lower grade education (520 hours)). It was also possible to provide information on specialist training in emergency services/emergency medicine. All questions had 2–4 possible answers. Questions 1–4 dealt with general knowledge about MCIs, while questions 5–8 dealt with specific injury patterns and symptoms following a bomb explosion and contamination with radioactive, biological or chemical agents and their treatment. The remaining questions, 9–13, asked them whether there was a need for further training regarding MCIs and explosion trauma/terrorism for emergency physicians, emergency assistants and paramedics, and whether their knowledge of disaster medicine was sufficient. Finally, personal experience with and participation in an MCI could be documented. In the description of metric variables, the following parameters were applied (Tables 1, 2): number (n), mean value (mv), standard deviation (SD), minimum and maximum (min and max), quartile (25th and 75th percentile) and median (m). We used absolute and relative frequencies to describe categorical and ordinal data. Metric variables and normal distributions were calculated with the Shapiro–Wilk test. When the assumption of a normal distribution was flawed, two independent samples were compared in terms of a metric variable using the Mann–Whitney U test (more than two samples: Kruskal–Wallis test) or the t test (more than two samples: F test). Regarding distributions of ordinal and categorical variables, independent groups were compared with Fisher’s exact test.
Table 1. Descriptive age parameters for emergency physicians, emergency assistants and paramedics.. Variable
Category
n
Mean
SD
Min
25th Percentile
Median
75th Percentile
Max
p Valuea
Age (years)
Emergency physician Paramedic Emergency assistants
432 335 857
40.0 27.1 31.9
7.5 6.4 8.0
27.0 20.0 20.0
34.0 23.0 26.0
39.0 25.0 30.0
45.0 29.0 37.0
65.0 54.0 59.0
< 0.001
a
A significant difference was noted regarding age: on average, emergency physicians were older than emergency assistants, who in turn were older than paramedics
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Table 2. Demographic factors and training.. Variable
Gender Chief emergency physician Head of organization Qualified in emergency medicine Qualified in emergency services a b
Value
M F Yes No Yes No Yes No Yes
Emergency physician
Paramedic
p Valueb
Emergency assistants
n
%a
n
%a
363 69 189 243 15 417 300 132 264
84.0 16.0 43.8 56.3 3.5 96.5 69.4 30.6 61.1
303 32
90.5 9.6
335 12 323 1 334 11
100.0 3.6 96.4 0.3 99.7 3.3
n
%a
810 47 2 855 287 570 5 852 14
94.5 5.5 0.2 99.8 33.5 66.5 0.6 99.4 1.6
< 0.001 < 0.001 < 0.001 < 0.001 < 0.001
Percentages refer to the portion of the answer category within the individual category (column total per question = 100%) p Value of Fisher’s exact test
All tests, with the exception of the test for a normal distribution, were calculated two-way to the level p = 0.05 (Shapiro–Wilk: special character alpha = 0.1).
Results In total, 1,707 questionnaires were completed. Questionnaires received from outside Germany as well as those completed by individuals older than 65 years of age, by emergency physicians younger than 26 years of age, and by emergency assistants and paramedics younger than 20 years of age were excluded from analysis. Of the 1,707 completed questionnaires, 432 were completed by emergency physicians, 857 by emergency assistants and 335 by paramedics. Of the 432 emergency physicians, 69 were female and 363 were male, while 300 had specialist training in emergency medicine, 264 in emergency services and 189 were qualified chief emergency physicians. (The chief emergency physician is director of operations in the medical area of an emergency, directing, coordinating and supervising all medical procedures at the location of loss. Together with the head of organization, he/she is responsible for all subordinate units that deal with a major incident with several casualties or diseased individuals, ensuring that the best possible care is provided for all of those affected). Forty-seven of the 851 emergency assistants and 32 of the 335 paramedics completed the questionnaire. The question regarding participation in an MCI practice drill (Table 3) was answered with a ‘‘yes’’ by 90.8% (n = 78) of emergency assistants, 86.7% (n = 373) of emergency physicians and 79.7% (n = 267) of paramedics. Only 9.2% (n = 78) of emergency assistants,
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13.3% (n = 57) of emergency physicians and 20.3% (n = 68) of paramedics had never participated in such a drill. Of those who had participated, 86% (n = 1266) took part in a realistic drill with actors and 7% (n = 108) had only participated in a training exercise. Of the emergency assistants, 98.5% (n = 829) knew their area of expertise in an MCI, and so did 97.0% (n = 416) of emergency physicians and 91.4% (n = 297) of paramedics. There were significant differences between the professional qualifications regarding knowledge of how to manage an MCI and training evaluation. Emergency physicians showed better results and self-evaluations than emergency assistants and paramedics (p = 0.001). On a scale of 1–6, with 1 being the highest and 6 the lowest grade, 80% (n = 1397) of the participants graded themselves 1–2 and 20% (n = 310) graded themselves 4–6. The principles of triage were known by 98.8% (n = 432) of emergency physicians, 94.7% (n = 805) of emergency assistants and 81% (n = 268) of paramedics. Knowledge of a triage tag system was claimed by 94.5% (n = 805) of emergency assistants, 92.6% (n = 400) of emergency physicians and 89.8% (n = 299) of paramedics. When asked to grade their knowledge of a triage tag system, there was a significant difference between the professional qualifications. Emergency physicians gave themselves better grades than emergency assistants, who in turn gave themselves better grades than paramedics (p = 0.001). Asked about injury patterns and treatment strategies following a bomb explosion, 51.4% (n = 433) of emergency assistants and 41.4% (n = 137) of paramedics stated knowledge of these, while 48.6% (n = 410) of emergency assistants and 58.6% (n = 194)
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Table 3. Participation in MCI practice drill; distribution of basic variables and replies.. Variable
Participated in exercise Definition of exercise
MCI knowledge Grading of MCI knowledge
Triage knowledge Grading of triage knowledge
Triage tag system knowledge
Explosion injury pattern knowledge Grading of explosion injury pattern knowledge
Chemical contamination knowledge Grading of contamination knowledge
a b
Value
Emergency physician
Yes No Partial drill Emergency telephone tree drill Training exercise Realistic drill with actors Yes No 1 2 3 4 5 6 Yes No 1 2 3 4 5 6 Yes No Not known Yes No 1 2 3 4 5 6 Yes No 1 2 3 4 5 6
Paramedic
Emergency assistants
n
%a
n
%a
n
%a
373 57 17 7 30 310 416 13 88 144 124 41 18
86.7 13.3 4.7 1.9 8.2 85.2 97.0 3.0 21.2 34.7 29.9 9.9 4.3
423 5 109 168 101 36 7
98.8 1.2 25.9 39.9 24.0 8.6 1.7
400 19 13 318 110 34 99 96 59 23 2 255 164 14 58 87 52 48 2
92.6 4.4 3.0 74.3 25.7 10.9 31.6 30.7 18.9 7.4 0.6 60.9 39.1 5.4 22.2 33.3 19.9 18.4 0.8
267 68 18 5 15 225 297 28 16 94 100 67 22 1 268 63 9 79 95 56 21 4 299 15 19 137 194 2 21 46 48 20 3 151 178 3 19 48 41 33 4
79.7 20.3 6.8 1.9 5.7 85.6 91.4 8.6 5.3 31.3 33.3 22.3 7.3 0.3 81.0 19.0 3.4 29.9 36.0 21.2 8.0 1.5 89.8 4.5 5.7 41.4 58.6 1.4 15.0 32.9 34.3 14.3 2.1 45.9 54.1 2.0 12.8 32.4 27.7 22.3 2.7
768 78 24 12 57 675 829 13 109 312 265 103 40 4 805 45 82 319 247 110 38 2 805 29 18 433 410 24 113 162 94 48 2 440 393 24 71 135 126 84 8
90.8 9.2 3.1 1.6 7.4 87.9 98.5 1.5 13.1 37.5 31.8 12.4 4.8 0.5 94.7 5.3 10.3 40.0 31.0 13.8 4.8 0.3 94.5 3.4 2.1 51.4 48.6 5.4 25.5 36.6 21.2 10.8 0.5 52.8 47.2 5.4 15.9 30.1 28.1 18.8 1.8
p Valueb
< 0.001
0.202
< 0.001
< 0.001
< 0.001
< 0.001
0.025 < 0.001
< 0.001
< 0.001
0.061
Percentages refer to the portion of the answer category within the individual category (column total per question = 100%) p value of Fisher’s exact test
of paramedics claimed not to know anything about it. However, 74% (n = 318) of the emergency physicians stated knowledge and 25% (n = 110) claimed no knowledge.
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Seventy-six percent (n = 1078) of the participants gave themselves grades 1–3 and 34% (n = 629) gave themselves grades 4–6 regarding their knowledge of explosion injury patterns.
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Knowledge of symptoms, injury patterns and treatment strategies following chemical contamination was confirmed by 60.9% (n = 255) of emergency physicians, 52.8% (n = 440) of emergency assistants and 45.9% (n = 151) of paramedics. Here, 46.9% (n = 425) of participants gave themselves grades 4–6, while 53% (n = 482) gave themselves grades 1–3. Knowledge of symptoms, injury patterns and treatment strategies in patients exposed to biological agents was claimed by 57.9% (n = 245) of emergency physicians, 50.4% (n = 422) of emergency assistants and 37.9% (n = 125) of paramedics. In this context, 51% (n = 446) gave themselves grades 1–3, while 48.1% (n = 415) gave themselves grades 4–6. The question of knowledge of treatment of patients with radioactive contamination was answered with a ‘‘yes’’ by 65% (n = 277) of emergency physicians, 54% (n = 460) of emergency assistants and 41% (n = 136) of paramedics. Their knowledge regarding radioactively contaminated patients was graded as 1–3 by 52% (n = 488) and as 4–6 by 48% (n = 448) of the participants. In all four questions regarding knowledge of injury patterns following a conventional bomb explosion and treatment of patients with NBC (nuclear/biological/ chemical) contamination (Table 4) there were significant differences between the professional qualifications. Emergency physicians showed better knowledge and gave themselves better grades than emergency assistants, who in turn gave themselves better grades than paramedics (p = 0.001). Thus, questions 5–8 regarding knowledge of symptoms, injury patterns and treatment strategies following NBC contamination or explosion were answered with a ‘‘no’’ by, on average, 46% of emergency physicians, emergency assistants and paramedics. Regarding disaster medicine and the importance of medical or emergency handling, 63% (n = 1073) of the participants considered their preparedness to be excellent to satisfactory, while 37% (n = 613) graded themselves insufficiently trained or completely untrained. Again, emergency physicians showed a better knowledge of this topic and graded themselves better than emergency assistants, who in turn graded themselves better than paramedics (p = 0.001). As many as 92.7% (n = 703) of emergency assistants, 69.9% (n = 302) of emergency physicians and 57.1% (n = 190) of paramedics had been involved in an MCI. The question of whether there was a need for specific further training of the emergency services in explosion trauma/terrorism and MCI was answered with a ‘‘yes’’ by 94% of all participants.
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Discussion In Germany, MCI experiences are based on recent major incidents such as the Ramstein air show disaster (1988) or the Eschede railway accident (1998) [4]. The positions of chief emergency physician and head of organization responsible for coordination and tactical and medical management of the disaster scene were developed as a consequence [5, 6]. With the hosting of the Football World Cup, the German government entered into an agreement to guarantee, inter alia, medical protection for the duration of the tournament [7]. Therefore, many practical drills in the preclinical management of an MCI were carried out. As a result of these preparations, the Football World Cup in Germany was, despite some shortfalls, an excellently simulated trial run for concepts developed in the area of disaster medicine. This was apparently not only an innovative incentive for NGOs; new concepts were designed and tested in drills to ensure care of the population after the World Cup. Hence, it can also be considered a success in the medical fields [6, 8]. Paramedics and physicians are important components of our emergency medical system. All three of these professional groups surveyed in this study – emergency physicians, emergency assistants and paramedics – considered that they had good to excellent basic knowledge regarding management of an MCI. In detail, 90% of emergency assistants, 86% of emergency physicians and 79% of the paramedics had already participated in MCI drills. Of these, a total of 1,226 (74%, n = 1,707) had participated in a realistic MCI drill. Also, 97% of the emergency assistants, 96% of emergency physicians and 88% of paramedics knew their area of responsibility in case of a major incident, and the majority of those surveyed considered themselves well to satisfactorily trained in this area. Therefore, the preparedness of the emergency services in Germany can be classified as good. However, 46% of the participants did not know injury patterns and treatment strategies following a bomb attack or NBC contamination. This (globally) insufficient preparedness of health service staff for NBC incidents has been recorded in previous studies [9–12]. In Germany, we also see a considerable need for improvement in the training of emergency services regarding preparedness for MCIs as well as NBC incidents. Completed emergency physician training, or further training as a chief emergency physician and/or head of organization, was reflected in all questions by a better test result. On average, physicians, chief emergency physicians and heads of organization were older
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Table 4. Knowledge of injury patterns after bomb explosion and NBC contamination; distribution of basic variables and replies.. Variable
Biological contamination knowledge Grading of biological contamination knowledge
Radioactive contamination knowledge Grading of radioactive contamination knowledge
Grading of skills in catastrophe medicine
Participation in an MCI No. of patients in MCI
Problems during MCI Communication problems Personal safety at risk Transport problems Unclear orders Specific training in terrorism necessary Specific training in MCI necessary
Value
Yes No 1 2 3 4 5 6 Yes No 1 2 3 4 5 6 1 2 3 4 5 6 Yes No Up to 5 Up to 10 Up to 20 More than 20 Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Emergency physicians
Paramedics
Emergency assistants
n
%a
n
%a
n
%a
245 178 13 55 72 57 48 5 277 148 17 54 78 67 59 4 47 108 128 75 67 5 302 130 42 106 58 95 234 86 204 30 46 188 110 126 131 104 394 34 407 24
57.9 42.1 5.2 22.0 28.8 22.8 19.2 2.0 65.2 34.8 6.1 19.4 28.0 24.0 21.2 1.4 10.9 25.1 29.8 17.4 15.6 1.2 69.9 30.1 14.0 35.2 19.3 31.6 73.1 26.9 87.2 12.8 19.7 80.3 46.6 53.4 55.7 44.3 92.1 7.9 94.4 5.6
422 415 23 82 122 107 93 5 460 381 26 101 116 113 104 6 47 213 299 169 107 14 703 147 73 226 165 239 611 136 546 70 119 492 303 312 385 232 809 44 817 35
50.4 49.6 5.3 19.0 28.2 24.8 21.5 1.2 54.7 45.3 5.6 21.7 24.9 24.3 22.3 1.3 5.5 25.1 35.2 19.9 12.6 1.7 82.7 17.3 10.4 32.2 23.5 34.0 81.8 18.2 88.6 11.4 19.5 80.5 49.3 50.7 62.4 37.6 94.8 5.2 95.9 4.1
125 205 2 16 37 39 27 5 136 195 5 21 36 39 28 5 3 62 112 78 68 7 190 143 26 71 41 51 176 83 152 26 28 148 75 103 96 81 323 11 321 13
37.9 62.1 1.6 12.7 29.4 31.0 21.4 4.0 41.1 58.9 3.7 15.7 26.9 29.1 20.9 3.7 0.9 18.8 33.9 23.6 20.6 2.1 57.1 42.9 13.8 37.6 21.7 27.0 68.0 32.1 85.4 14.6 15.9 84.1 42.1 57.9 54.2 45.8 96.7 3.3 96.1 3.9
p Valueb
< 0.001
0.165
< 0.001
0.612
< 0.001
< 0.001
0.185
< 0.001 0.466 0.550 0.239 0.065 0.018 0.425
In many questions, there were significant differences between emergency physicians, emergency assistants and paramedics a Percentages refer to the portion of the answer category within the individual category (column total per question = 100%) b p value of Fisher’s exact test
than emergency assistants, who in turn were older than paramedics. Hence, they had better training and more professional experience, which may explain these re-
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sults. Yet the number of well-qualified personnel – especially for catastrophes or major incidents – is limited, with many paramedics and helpers on location
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working on a voluntary basis (1.2 million in Germany) [6]. Full-time members and, in particular, voluntary members of the emergency services must be better trained and prepared for such major incidents. As only 7% of the participants of our survey had taken part in a practical drill on the management of an MCI, opportunities to easily and effectively prepare emergency staff for an MCI through training are clearly being significantly underutilized, and this situation must be redressed. In the US, this has already been put into practice [13–15]. Training programs and table-top exercises in the management of a terrorism attack for emergency assistants and emergency physicians are designed by the newly created German Federal Office of Civil Protection and Disaster Assistance (Bundesamt fu¨r Bevo¨lkerungsschutz und Katastrophenhilfe, BBK) in cooperation with the Institute of Emergency and Disaster Medicine of the University Clinics, Bonn (Germany) and the Institute for Disaster Medicine Tu¨bingen (Germany) to improve reactions to threatening situations. The first instruction courses have been successfully completed. Furthermore, a curriculum for the training of medical students in disaster medicine has been developed by the Deutsche Gesellschaft fu¨r Katastrophenmedizin (DGKM – German Association for Disaster Medicine) and the BBK, and this will be implemented at all German universities. This should provide the medical profession with basic knowledge of disaster medicine. Seventy-three percent of the participants in our survey had been involved in a real MCI. Seventy-six percent reported that problems had been encountered, of which 87% were communication problems. The current development of a disaster network (a network of hospitals that are able to coordinate the accommodation of large numbers of patients during an MCI, based on the ‘‘trauma network’’ of the DGU), and with it a network of trauma clinics, will enable the accommodation of a specific number of patients during disasters without incurring communication problems. Therefore, this network contributes to an optimization of patient care during disasters [16]. Our study is limited by the fact that the entire survey was Internet-based, and so excluded members of the emergency services without online access. Also, our survey may have only attracted individuals that were already interested in the subject of disaster medicine. Therefore, results that included all members of emergency staff could be even lower.
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Conclusion In Germany, the 2006 Football World Cup initiated a discussion of disaster medicine and the preparedness of the emergency services for an MCI. Therefore, the tournament acted as a catalyst for disaster medicine issues. However, 46% of the emergency physicians and paramedics surveyed in the present study did not know injury patterns and treatment strategies for a bomb attack or NBC contamination. Ninety-four percent of the participants in this survey called for specific training in emergency procedures after a terrorist attack. Although cost-cutting in the health services is high on the agenda, the question ‘‘is there still a need for emergency physicians in the preclinical emergency services in Germany?’’ must be answered with a ‘‘yes.’’ The level of training was the single factor that led to an improvement in the test results. Paramedics and emergency physicians must be trained in how to react to a conventional or an NBC terrorist attack in Germany. The problem of insufficient hospital capacities during a disaster can be addressed by implementing a disaster network through the trauma surgery departments in German hospitals [16]. In addition, effort is required to sufficiently prepare the emergency services in Germany for MCIs, terrorist attacks and catastrophes. Obviously, the challenge of a disaster or an MCI can only be met through an interdisciplinary approach. However, the surgeon/trauma surgeon should take on a leadership role during disasters, as large numbers of physically injured patients can be expected in most of these incidents [17]. Hence, the trauma surgeon must attend to planning and preparedness, education and training, as well as development and research in the area of disaster medicine [18]. References 1.
2.
3.
4.
5.
de Gutierrez Ceballos JP, Turégano Fuentes F, Perez Diaz D, Sanz Sanchez M, Martin Llorente C, Guerrero Sanz JE. Casualties treated at the closest hospital in the Madrid, March 11, terrorist bombings. Crit Care Med 2005;33:S107–S112. Mohammed AB, Mann HA, Nawabi DH, Goodier DW, Ang SC. Impact of London’s terrorist attacks on a major trauma center in London. Prehosp Disaster Med 2006;21:340–4. Whitlock C. Germany disrupts plot targeting Americans. Authorities foil ‘‘massive’’ bombing plot targeting American interests in Germany, express alarm suspects had visited militant camps in Pakistan. Washington Post, 6 September 2007. Oestern HJ, Huels B, Quirini W, Pohlemann T. Facts about the disaster at Eschede. J Orthop Trauma 2000;14:287–90 Discussion 277. Mitschke Th, Peter H. Handbuch für Schnell-Einsatz-Gruppen, 1. Auflage. Edewecht: Stumpf und Kossendey-Verlag, 1994, ISBN 3-923124-45-7.
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6.
Domres B, Schauwecker HH, Rohrmann K, Roller G, Maier GW, Manger A. The German approach to emergency/disaster management. Med Arh 2000;54:201–3. 7. Kreimeier U, Schäuble W, Weidringer J-W. Fußball-WM Deutschland- Medical Lessons Learned. Notfall + Rettungsmedizin. German Interdiscip J Emer Med 2007;10:6–7. 8. Adams H-A, Altheim C, Knopf S, Dietering BK, Kreimeier U, Latasch L, Lemke H, Luiz Th, Pfefferkorn J, Schmidt J, Storch W-H, Stratmann D, Tittelbach U, Wenderoth St. Erfahrungen anlässlich des Expertenpanels ‘‘Fußball-WM Deutschland – Medical Lessons Learned,’’ 6.10.2006, München: Berichte aus den 12 Austragungsorten. Notfall + Rettungsmedizin 2007;10:13–22. 9. Katz AR, Nekorchuk DM, Holck PS, Hendrickson LA, Imrie AA, Effler PV. Hawaii physician and nurse bioterrorism preparedness survey. Prehosp Disaster Med 2006;21:404–13. 10. Furbee PM, Coben JH, Smyth SK, Manley WG, Summers DE, Sanddal ND, Sanddal TL, Helmkamp JC, Kimble RL, Althouse RC, Kocsis AT, et al. Realities of rural emergency medical services disaster preparedness. Prehosp Disaster Med 2006;21:64–70. 11. Alexander GC, Larkin GL, Wynia MK. Physicians’ preparedness for bioterrorism and other public health priorities. Acad Emerg Med 2006;13:1238–41. 12. Lennquist S. Education and training in disaster medicine. Scand J Surg 2005;94:300–10. 13. Henning KJ, Brennan PJ, Hoegg C, O’Rourke E, Dyer BD, Grace TL. Health system preparedness for bioterrorism: bringing the tabletop to the hospital. Infect Control Hosp Epidemiol 2004;25:146–55.
450
14. 15.
16.
17.
18.
Burr R. Training for hospital emergency preparedness. Md Med 2001;2:7–16. Center for Healthcare Environmental Management. Healthcare emergency preparedness: is the facility ready? Health Hazard Manage Monit 2002;15:1–7. Ruchholtz S, Kühne CA, Siebert H; Arbeitskreis Umsetzung Weissbuch/Traumanetzwerk in der DGU – AKUT (Trauma network of the German Association of Trauma Surgery, DGU). Establishment, organization, and quality assurance of a regional trauma network of the DGU. Unfallchirurg 2007;110:373–9. Born CT, Briggs SM, Ciraulo DL, Frykberg ER, Hammond JS, Hirshberg A, Lhowe DW, O’Neill PA, Mead J, et al. Disasters and mass casualties: II. Explosive, biologic, chemical, and nuclear agents. J Am Acad Orthop Surg 2007;15:461–73. Lennquist S. Management of major accidents and disasters: an important responsibility for the trauma surgeons. J Trauma 2007;62:1321–9.
Address for Correspondence Philipp Fischer Department of Orthopedics and Trauma Surgery University Hospital Bonn Sigmund-Freud-Str. 25 53127 Bonn Germany Phone (+49/228) -9107637 e-mail:
[email protected]
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