Mitigating disaster impact requires identifying risk factors. The increased vulnerability of the physically fragile is easily understood. Less obvious are the socio-economic risk factors, especially within relatively affluent societies. Hurricane Katrina demonstrated many of these risks within the United States. These factors include poverty, home ownership, poor English language proficiency, ethnic minorities, immigrant status, and high-density housing. These risk factors must be considered when planning for disaster preparation, mitigation, and response. Zoraster RM: Vulnerable populations: Hurricane Katrina as a case study. Prehosp Disaster Med 2010;25(l):74-78. IntroductionSocio-economic inequalities in health are well-documented in the relatively affluent, industrialized world. 1 " 3 Components of social status, such as income, education, primary language, legal status, and ethnicity, might seem to have little to do with the impact of ostensibly random "acts of nature", such as hurricanes, floods, and earthquakes. However, ecological upheavals are not egalitarian; they disproportionately affect those who are in lower socio-economic levels. 4 " 8 Many high-risk geographical areas have a disproportionately high percentage of marginalized populations; this same population is at a disadvantage for preparation, evacuation, response, and recovery. Multiple peer-reviewed articles and anecdotal reports demonstrate that Hurricane Katrina disproportionately affected the most socially vulnerable. This paper reviews disaster vulnerability and compares known risk factors to what occurred. It reviews the cultural and economic issues that put people at greater risk, factors that prevent their adequate preparation and evacuation, mechanisms by which disasters may disproportionately affect health, and specific issues of recovery. MethodsPubMed searches were performed utilizing the combinations of "Disaster" AND "Vulnerability", "Hurricane" AND "Vulnerability", and "Hurricane Katrina". These searches yielded a total of 901 articles. The titles, and abstracts if available, were scanned. Those that described populations at increased risk were selected and reviewed. Psychological trauma, substance abuse, and post-traumatic stress disorder issues were not reviewed due to the breadth of the topics. Article bibliographies also were utilized for research and selection.Population characteristics that demonstrated an increased risk of poor physical or social outcomes were identified, and comparisons were made with past anecdotal and epidemiological studies. A total or 228 articles and/or texts were selected and reviewed. Additionally, data were obtained from online reports of the United States Census. Prehospital and Disaster Medicine http://pdm.medicine.wisc.edu-Vol. 25, No. 1 Prehospital and Disaster Medicine

Ecological disasters impact large populations every year, and hundreds of nongovernmental organizations, thousands of aid workers, and billions of dollars are sent in response. Yet, there have been recurring problems with coordination, leading to wasted efforts and funds. The humanitarian response to the December 2004 Earthquake and Tsunami in Asia was one of the largest ever, and coordination problems were apparent. The coordination processes and attempts at coordination are discussed in this paper. Specific barriers to cooperation are discussed, such as weak leadership, the absence of accountability, the lack of credentialing, the diverse goals of the responding agencies, and the weaknesses in the coordination process itself.

IntroductionMass-casualty incidents (MCIs) may involve only a few patients or may involve thousands. The injuries may range from burns to penetrating trauma to chemical or radiation exposures. The quantity and nature of injuries determine what healthcare resources will best minimize morbidity and mortality, and it is the task of the emergency medical services (EMS) to optimize resource utilization.Matching a victim's needs to the appropriate resources starts with field triage. Ideally, victims are transported to the most appropriate facilities. This destination selection must be based on the best assumption of a patient's needs, on the individual hospital's capabilities and capacities, and the system's available resources. 1-6 For the critically injured, trauma centers have been demonstrated to have better outcomes, and their utilization should be optimized. 7-10 Optimally, victim's needs must be balanced with avoiding overwhelming any particular facility. AbstractIntroduction: Management of mass-casualty incidents should optimize outcomes by appropriate prehospital care, and patient triage to the most capably facilities. The number of patients, the nature of injuries, transportation needs, distances, and hospital capabilities and availabilities are all factors to be considered. Patient maldistributions such as overwhelming individual facilities, or transport to facilities incapable of providing appropriate care should be avoided. This report is a critical view of the application of the START triage nomenclature in the prehospital arena following a train crash in Los Angeles County on 26 January 2005. Methods: A scheduled debriefing was held with the major fire and emergency medical services responders, Medical Alert Center staff, and hospitals to assess and review the response to the incident. Site visits were made to all of the hospitals involved. Follow-up questions were directed to emergency department staff that were on duty during the day of the incident. Results: The five Level-I Trauma Centers responded to the poll with the capacity to receive a total of 12 "Immediate" patients, 2.4 patients per center, the eight Level-II Trauma Centers responded with capacity to receive 17 "Immediate" patients, two patients per center, while the 25 closest community hospitals offered to accept 75 "Immediate" patients, three patients per hospital. These community hospitals were typically about one-half of the size of the trauma centers (average 287 beds versus 548, average 8.7 operating rooms versus 16.6). Twenty-six patients were transported to a community hospital >15 miles from the scene, while eight closer community hospitals did not receive any patients. Conclusions: The debriefing summary of this incident concluded that there were no consistently used criteria to decide ultimate destination for "Immediates", and that they were distributed about equally between community hospitals and trauma centers. Zoraster RM, Chidester C, Koenig W: Field triage and patient maldistribution in a mass-casualty incident. Prehosp Disa...

IntroductionPatients with polycythemia vera are at high risk for vaso-occlusive events including cerebral ischemia. Although unusual, acute ischemic stroke may be an initial presentation of polycythemia vera. It had been previously assumed that cerebral ischemic events were due to increased blood viscosity and platelet activation within the central nervous system arterial vessels. However, there are now a few isolated case reports of probable micro-embolic events originating from outside of the brain. This suggests unique management issues for these patients.Case presentationWe present the case of a 57-year-old right-handed Caucasian male in excellent health who presented to the Emergency Department with acute right-handed clumsiness. Hematologic investigations revealed a hyperviscous state and magnetic resonance imaging was consistent with cerebral emboli. Symptoms rapidly improved with phlebotomy and hydration.ConclusionThe etiology of stroke in polycythemic patients is likely to be multifactorial. While hemodilution has been generally discredited for general stroke management, it is potentially beneficial for patients with polycythemia vera and euvolemic hemodilution should be considered for the polycythemic patient with acute cerebral ischemia.

The chronically ill are often the hardest hit by dis-ruptions in the healthcare system—they may be highly dependent on medications or treatments that suddenly become unavailable, they are more physically fragile than the rest of the population, and for socioeconomic reasons they may be more limited in their ability to prepare or react. Medical professionals involved in dis-aster response should be prepared to care for individu-als suffering from the complications of chronic illness, and they must have some idea of how to do so with lim-ited resources. Dialysis-dependent, end-stage renal disease patients are at especially high risk following disasters. Infrastructure damage may make dialysis impossible for days, and few physicians have experience or train-ing in the nondialytic management of end-stage renal disease. Nondialytic management strategies include dietary restrictions, aggressive attempts at potassium removal via resins and cathartics, and adaptations of acute treatment strategies. Appropriate planning and stockpiling of medications such as Kayexalate are crit-ical to minimizing morbidity and mortality