On August 25, 2017, Hurricane Harvey made landfall near Corpus Christi, Texas. The ensuing unprecedented flooding throughout the Texas coastal region affected millions of individuals.1 The statewide response in Texas included the sheltering of thousands of individuals at considerable distances from their homes. The Dallas area established large-scale general population sheltering as the number of evacuees to the area began to amass. Historically, the Dallas area is one familiar with "mega-sheltering," beginning with the response to Hurricane Katrina in 2005.2 Through continued efforts and development, the Dallas area had been readying a plan for the largest general population shelter in Texas. (Disaster Med Public Health Preparedness. 2017;page 1 of 4).
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Introduction: Nankai Trough earthquake, with an anticipated death toll of 323,000, is a disaster for which the country of Japan set the highest priority on building capacities. Tokushima prefecture aims to minimize preventable death among survivors and has strived to build a medical and health response system and strengthen outreach systems for vulnerable populations. To actualize these aims, Tokushima prioritized human resource development.Methods: Tokushima has initiated periodic trainings based on the Sphere Standard, the internationally recognized minimum standards for humanitarian aid, since 2015. The trainings were conducted by certified trainers and trainees received an official certification recognized by the Sphere Project, Geneva. The training materials were localized and the trainings were contextualized to Japan as a developed and super-aged nation. The learning outcome was evaluated by a pre-post test. Results: Between April 2015 and November 2018 the two-day training was held seven times. There were two hundred twelve participants from various clusters such as health, education, logistics, nutrition and food, security, and protection. The results of the pre-post test were statistically significant (still in process) indicating the effectiveness of the training on knowledge. Training evaluations suggest nurturing ethical attitudes and skills utilizing the Sphere Handbook. Discussion: Despite under-recognizing the Sphere Standard in Japan, the Standard has been incorporated into the disaster risk reduction plan in Tokushima. For larger scale human resource development, training local representatives to be trainers would be the next step.
Mass casualty incidents involving active shooters are becoming more common, and many involve special weapons and tactics team responses. Standard of care is to have tactical emergency medical services paramedics or physicians direct triage and administer immediate interventions. In these situations, a clinical and ethical value is to do the greatest good for the greatest number of people. Cases in which beneficence and justice are at odds are particularly complex. This commentary on such a case argues that directing resources to patients most likely to survive accords triage principles and explores ethical complexity in resource allocation decisions. CaseAfter hours of talking, negotiations break down and, in the worst possible scenario, bullets ring as a shooter indiscriminately fires several rounds in a local business place and takes hostages. Law enforcement officers immediately make emergent entry into the building and engage the shooter. The shooter collapses, gunfire ceases, and officers rush to ensure that the shooter is contained. Additional law enforcement personnel begin to search and secure the scene. Due to staging until the scene is determined safe, combined with lack of protective armor and helmets, the nearest ambulance is 2 blocks away and stays back until ordered in by law enforcement.The tactical emergency medical services (TEMS) physician, Dr M, who is embedded within the special weapons and tactics (SWAT) team, enters and begins performing rapid triage of the patients who lie at the scene. Dr M notes 6 dead; 1 law enforcement officer who sustained a gunshot wound to the chest is unconscious, not breathing, and has a weak pulse; 1 civilian who sustained extensive injury by a gunshot wound to the right side of the neck is unconscious, with heavy bleeding, agonal respirations, and weak pulse; and 1 suspect who sustained a gunshot wound to the high right lateral chest is awake with minimal bleeding and significant respiratory distress. Dr M's heart sinks. Clinical and ethical principles of triage and protocol in this case suggest that lifesaving efforts should first be directed towards the suspect according to the Sort-Assess-Lifesaving Interventions-Treatment and/or Transport (SALT) mass
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