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Background The SARS-CoV-2 pandemic is still ongoing and a major challenge for health care services worldwide. In the first WSES COVID-19 emergency surgery survey, a strong negative impact on emergency surgery (ES) had been described already early in the pandemic situation. However, the knowledge is limited about current effects of the pandemic on patient flow through emergency rooms, daily routine and decision making in ES as well as their changes over time during the last two pandemic years. This second WSES COVID-19 emergency surgery survey investigates the impact of the SARS-CoV-2 pandemic on ES during the course of the pandemic. Methods A web survey had been distributed to medical specialists in ES during a four-week period from January 2022, investigating the impact of the pandemic on patients and septic diseases both requiring ES, structural problems due to the pandemic and time-to-intervention in ES routine. Results 367 collaborators from 59 countries responded to the survey. The majority indicated that the pandemic still significantly impacts on treatment and outcome of surgical emergency patients (83.1% and 78.5%, respectively). As reasons, the collaborators reported decreased case load in ES (44.7%), but patients presenting with more prolonged and severe diseases, especially concerning perforated appendicitis (62.1%) and diverticulitis (57.5%). Otherwise, approximately 50% of the participants still observe a delay in time-to-intervention in ES compared with the situation before the pandemic. Relevant causes leading to enlarged time-to-intervention in ES during the pandemic are persistent problems with in-hospital logistics, lacks in medical staff as well as operating room and intensive care capacities during the pandemic. This leads not only to the need for triage or transferring of ES patients to other hospitals, reported by 64.0% and 48.8% of the collaborators, respectively, but also to paradigm shifts in treatment modalities to non-operative approaches reported by 67.3% of the participants, especially in uncomplicated appendicitis, cholecystitis and multiple-recurrent diverticulitis. Conclusions The SARS-CoV-2 pandemic still significantly impacts on care and outcome of patients in ES. Well-known problems with in-hospital logistics are not sufficiently resolved by now; however, medical staff shortages and reduced capacities have been dramatically aggravated over last two pandemic years.

Introduction The interaction between military and civilian healthcare systems has contributed to the development of medical care. Swedish innovations such as the Seldinger technique for angiography, Leksell Gamma Knife for cranial surgery, and the introduction of pacemakers and ultrasound have contributed to the global development of medicine. Several authors have described the Swedish civilian healthcare system and its development. However, the development and history of its military healthcare system and its influence on the civilian healthcare system remain untold. This review aims to describe the historical development of the Swedish military healthcare system and its path toward civilian-military collaboration and a total defense healthcare system. Material and Methods A search for all published scientific papers in Swedish and English, along with available legal documents and directives, was made. We used CINAHL, PubMed, Scopus, and Gothenburg University’s databases and search engines. The following keywords, Swedish, military, civilian, healthcare, collaboration, and development, were searched for, alone or in combination, using a PRISMA flow chart. Duplicates, abstracts, and nonscientific publications were excluded. Results Each of the four distinct periods of historical development in the Swedish military healthcare system can be characterized by the changes necessary for transforming Sweden from an aggressive to a defensive and collaborative nation, with national and international engagement. Collaboration not only encompasses readiness and willingness to share resources and information, and to adjust routines and guidelines, but also needs a culture of consensus and respect for each other’s limitations and capabilities. The definition of military medicine and the military physician’s role in Sweden is imperative for further civilian-military collaboration. Conclusions Recent global sociopolitical changes necessitate civilian-military healthcare collaboration. Although civilian-military healthcare partnerships in various medical fields have been reported earlier, the Swedish concept of total defense’s healthcare system integration and collaboration may be a more fruitful approach. The collaboration within the total defense healthcare system will result in technical achievements, innovations, and medical advancements for the benefit of the whole nation.

Background In Sweden the surgical surge capacity for mass casualty incidents (MCI) is managed by county councils within their dedicated budget. It is unclear whether healthcare budget constraints have affected the regional MCI preparedness. This study was designed to investigate the current surgical MCI preparedness at Swedish emergency hospitals. Methods Surveys were distributed in 2015 to department heads of intensive care units (ICU) and surgery at 54 Swedish emergency hospitals. The survey contained quantitative measures as the number of (1) surgical trauma teams in hospital and available after activating the disaster plan, (2) surgical theatres suitable for multi-trauma care, and (3) surgical ICU beds. The survey was also distributed to the Armed Forces Centre for Defence Medicine. Results 53 hospitals responded to the survey (98%). Included were 10 university hospitals (19%), 42 county hospitals (79%), and 1 private hospital (2%). Within 8 h the surgical capacity could be increased from 105 to 399 surgical teams, while 433 surgical theatres and 480 ICU beds were made available. The surgical surge capacity differed between university hospitals and county hospitals, and regional differences were identified regarding the availability of surgical theatres and ICU beds. Conclusions The MCI preparedness of Swedish emergency care hospitals needs further attention. To improve Swedish surgical MCI preparedness a national strategy for trauma care in disaster management is necessary.

Background Defined goals for hospitals’ ability to handle mass-casualty incidents (MCI) are a prerequisite for optimal planning as well as training, and also as base for quality assurance and improvement. This requires methods to test individual hospitals in sufficient detail to numerically determine surge capacity for different components of the hospitals. Few such methods have so far been available. The aim of the present study was with the use of a simulation model well proven and validated for training to determine capacity-limiting factors in a number of hospitals, identify how these factors were related to each other and also possible measures for improvement of capacity. Materials and methods As simulation tool was used the MACSIM® system, since many years used for training in the international MRMI courses and also successfully used in a pilot study of surge capacity in a major hospital. This study included 6 tests in three different hospitals, in some before and after re-organisation, and in some both during office- and non-office hours. Results The primary capacity-limiting factor in all hospitals was the capacity to handle severely injured patients (major trauma) in the emergency department. The load of such patients followed in all the tests a characteristic pattern with “peaks” corresponding to ambulances return after re-loading. Already the first peak exceeded the hospitals capacity for major trauma, and the following peaks caused waiting times for such patients leading to preventable mortality according to the patient—data provided by the system. This emphasises the need of an immediate and efficient coordination of the distribution of casualties between hospitals. The load on surgery came in all tests later, permitting either clearing of occupied theatres (office hours) or mobilising staff (non-office hours) sufficient for all casualties requiring immediate surgery. The final capacity-limiting factors in all tests was the access to intensive care, which also limited the capacity for surgery. On a scale 1–10, participating staff evaluated the accuracy of the methodology for test of surge capacity to MD 8 (IQR 2), for improvement of disaster plans to MD 9 (IQR 2) and for simultaneous training to MD 9 (IQR 3). Conclusions With a simulation system including patient data with a sufficient degree of detail, it was possible to identify and also numerically determine the critical capacity-limiting factors in the different phases of the hospital response to MCI, to serve as a base for planning, training, quality control and also necessary improvement to rise surge capacity of the individual hospital.

Background Little is known about vital signs during the very first minutes after an accident. This study aimed to describe the vital signs of motorcycle riders shortly after racetrack crashes and examine the clinical value of these data for the prehospital clinical assessments. Methods A retrospective observational cohort based on data from medical records on 104 motorcycle accidents at a racetrack in Sweden, covering the season of 2019 (May 01 until September 17), was conducted. Both race and practice runs were included. In addition, data from the Swedish Trauma Registry were used for patients referred to the hospital. Kruskal-Wallis test and linear regression were calculated in addition to descriptive statistics. Results In all, 30 riders (29%) were considered injured. Sixteen riders (15%) were referred to the hospital, and of these, five patients (5% of all riders) had suffered serious injuries. Aside from a decreased level of consciousness, no single vital sign or kinematic component observed within the early minutes after a crash was a strong clinical indicator of the occurrence of injuries. However, weak links were found between highsider or collision crashes and the occurrence of injuries. Conclusion Except for a decreased level of consciousness, this study indicates that the clinical value of early measured vital signs might be limited for the pre-hospital clinical assessment in the motorsport environment. Also, an adjustment of general trauma triage protocols might be considered for settings such as racetracks. Using the context with medical professionals at the victim’s side within a few minutes after an accident, that is common in motorsport, offers unique possibilities to increase our understanding of clinical signs and trauma in the early state after an accident.

Background: The SARS-CoV-2 pandemic is a major challenge for health care services worldwide. It’s impact on oncologic therapies and elective surgery has been described recently, and the literature provides guidelines regarding appropriate elective patient treatment during the pandemic. However, the impact of SARS-CoV-2 pandemic on emergency surgery services has been poorly investigated up to now. Methods: A 17-item web survey had been distributed to emergency surgeons in June 2020 around the world, investigating the impact of SARS-CoV-2 pandemic on patients and septic diseases both requiring emergency surgery and the time-to-intervention in emergency surgery routine, as well as experiences with surgery in COVID-19 patients. Results: Ninety-eight collaborators from 31 countries responded to the survey. The majority (65.3%) estimated the impact of the SARS-CoV-2 pandemic on emergency surgical patient care as being strong or very strong. Due to the pandemic, 87.8% reported a decrease in the total number of patients undergoing emergency surgery and approximately 25% estimated a delay of more than 2 h in the time-to-diagnosis and another 2 h in the time-to-intervention. Fifty percent make structural problems with in-hospital logistics (e.g. transport of patients, closed normal wards etc.) mainly responsible for delayed emergency surgery and the frequent need (56.1%) for a triage of emergency surgical patients. 56.1% of the collaborators observed more severe septic abdominal diseases during the pandemic, especially for perforated appendicitis and severe septic cholecystitis (41.8% and 40.2%, respectively). 62.2% had experiences with surgery in COVID-19-infected patients. Conclusions: The results of The WSES COVID-19 emergency surgery survey are alarming. The combination of an estimated decrease in numbers of emergency surgical patients and an observed increase in more severe septic diseases may be a result of the fear of patients from infection with COVID-19 and a consecutive delayed hospital admission and diagnosis. A critical delay in time-to-diagnosis and time-to-intervention may be a result of changes in in-hospital logistics and operating room as well as intensive care capacities. Both reflect the potentially harmful impact of SARS-CoV-2 pandemic on emergency surgery services. publishedVersion

The Terror and Disaster Surgical Care (TDSC®) course on mass casualty incident management was formulated in Germany by military medical personnel, who have been deployed to conflict areas, but also work in hospitals open for the lay public. In this manuscript we discuss different concepts and ideas taught in this course as these are described in a focused issue recently published in the European Journal of Trauma and Emergency Surgery. We provide reinforcement for some of the ideas conveyed. We provide alternative views for others. Injuries following explosions are different from blunt and penetrating trauma and at times demand a different approach. There are probably several ways to manage a mass casualty incident depending on the setup of the organization. An open discussion on the topics presented in the manuscripts included in the focused issue on military and disaster surgery should enrich everyone.

The Walker Dip refers to the cycle of the improvement of care for the battle injured soldier over the course of a conflict, followed by the decline in the skills needed to provide this care during peacetime, and the requisite need to relearn those skills during the next conflict. As the operational tempo of the conflicts in Afghanistan and Iraq has declined, concerns have arisen regarding whether US military surgeons are prepared to meet the demands of future conflicts. This problem is not unique to the US military, and allied nations have taken creative steps to address the Walker Dip in their own surgical communities. A panel entitled "Military and Civilian Trauma System Integration: Where Have We Come; Where Are We Going and What Can We Learn from Our International Partners" at the 2018 American Association for the Surgery of Trauma meeting brought together a cadre of civilian and military surgeons with experience in this area. The efforts described involved the creation of a new trauma training program in Doha, Qatar, the military civilian partnership in the Netherlands, and the steps taken to address the deficit of penetrating trauma in Sweden. This article focuses on the lessons that can be learned from our allied partners to assure readiness for deployment among military surgeons. LEVEL OF EVIDENCE: Economic and Value Based Evaluations, level V.

Objective: Thoracic trauma is one of the most common and lethal types of injury, causing over a quarter of traumatic deaths. Severe thoracic injuries are often occult and difficult to diagnose in the field. There is a need for a point-of-care diagnostic device for severe thoracic injuries in the prehospital setting. Electrical bioimpedance (EBI) is non-invasive, portable, rapid and easy to use technology that can provide objective and quantitative diagnostic information for the prehospital environment. Here, we evaluated the performance of EBI to detect thoracic injuries. Approach: In this open study, EBI resistance (R), reactance (X) and phase angle (PA) of both sides of the thorax were measured at 50 kHz on patients suffering from thoracic injuries (n = 20). In parallel, a control group consisting of healthy subjects (n = 20) was recruited. A diagnostic mathematical algorithm, fed with input parameters derived from EBI data, was designed to differentiate patients from healthy controls. Main results: Ratios between the X and PA measurements of both sides of the thorax were significantly different (p < 0.05) between healthy volunteers and patients with left-and right-sided injuries. The diagnostic algorithm achieved a performance evaluated by leave-one-out cross-validation analysis and derived area under the receiver operating characteristic curve of 0.88. Significance: A diagnostic algorithm that accurately discriminates between patients suffering thoracic injuries and healthy subjects was designed using EBI technology. A larger, prospective and blinded study is thus warranted to validate the feasibility of EBI technology as a prehospital tool.

In the aftermath of the Haiyan typhoon, disaster radio was used to spread information and music to the affected population. The study described survivors' experiences of being in the immediate aftermath of a natural disaster and the impact disaster radio made on recovery from the perspective of the individuals affected. Twenty eight survivors were interviewed in focus groups and individual interviews analyzed with phenomenological-hermeneutic method. Being in disaster mode included physical and psychosocial dimensions of being in the immediate aftermath of the disaster. Several needs among the survivors were expressed. Disaster radio contributed to recovery by providing facts and information that helped the survivor to understand and adapt. The music played contributed to emotional endurance and reduced feelings of loneliness. To re-establish social contacts, other interventions are needed. Disaster radio is a positive contribution to the promotion of survivors' recovery after disasters involving a large number of affected people and severely damaged infrastructure. Further studies on the use and impact of disaster radio are needed.

The aim of this study was to use a simulation model developed for the scientific evaluation of methodology in disaster medicine to test surge capacity (SC) in a major hospital responding to a simulated major incident with a scenario copied from a real incident. The tested hospital was illustrated on a system of magnetic boards, where available resources, staff, and patients treated in the hospital at the time of the test were illustrated. Casualties were illustrated with simulation cards supplying all data required to determine procedures for diagnosis and treatment, which all were connected to real consumption of time and resources. The first capacity-limiting factor was the number of resuscitation teams that could work parallel in the emergency department (ED). This made it necessary to refer severely injured to other hospitals. At this time, surgery (OR) and intensive care (ICU) had considerable remaining capacity. Thus, the reception of casualties could be restarted when the ED had been cleared. The next limiting factor was lack of ventilators in the ICU, which permanently set the limit for SC. At this time, there was still residual OR capacity. With access to more ventilators, the full surgical capacity of the hospital could have been utilized. The tested model was evaluated as an accurate tool to determine SC. The results illustrate that SC cannot be determined by testing one single function in the hospital, since all functions interact with each other and different functions can be identified as limiting factors at different times during the response.

Background Natural disasters affected millions of people worldwide every year. Evaluation of disaster health and health response interventions is faced with several methodological challenges. This study aimed (1) to describe survivors’ and health professionals’ health, 30 months after a natural disaster using a web-based self-selected Internet sample survey designed and (2) to evaluate the health effects of disaster response interventions, in the present study with a focus on disaster radio. Methods A web-based survey was used to conduct a cross-sectional study approximately 30 months after typhoon Haiyan. The GHQ-12, EQ-5D-3L, and EQ-VAS instruments were used in addition to study-specific questions. A self-selected Internet sample was recruited via Facebook. Results In total, 443 survivors, from what 73 were health professionals, participated in the study. The Haiyan typhoon caused both physical and mental health problems as well as social consequences for the survivors. Mental health problems were more frequently reported than physical injuries. Health professionals reported worse overall health and a higher frequency of mental health problems compared to other survivors. Conclusions There were short-term and long-term physical, psychological, and social consequences for the survivors as a result of the Haiyan typhoon. Mental health problems were more frequently reported and lasted longer than physical problems. Health professionals deployed during the disaster reported worse health, especially concerning mental health problems. The survey used was found useful to describe health after disasters.

Aims: To evaluate hospital evacuation in light of recent hospital evacuations in Bangkok and surrounding areas. This information was compared with results reported in the literature. Study Design: Retrospective and qualitative. Place and Duration of Study: Bangkok, Thailand, December 1 to December 11, 2011. Methodology: Four facilities were included in this study, three hospitals and one “prehospital” facility, each of which had either experienced evacuation or had been receiving facilities during disaster response operations. Data were obtained using questionnaires and interviews to characterize facility backgrounds and capacities. Responses were obtained from one representative of each of the four Thai facilities. The questionnaire was designed for this study following recommendations by an earlier Swedish study that employed “risk and vulnerability analysis” (RVA), and was further Research Article British Journal of Medicine & Medical Research, 4(1): 395-415, 2014 396 adapted according to results of a literature review. Results: Overall, consistent results in the literature, as well as in the recent Thai disaster experience, about hospital evacuation indicate shortcomings in planning (including training), command and control, communication, support, resources and transportation. Patient safety, transfer of medical data, care and treatment of patients during transportations showed positive outcomes in recent Thai evacuations. Conclusion: Despite numerous previous findings and recommendations found in the literature, the need exists for continuous improvement in evacuating a hospital, especially in improving planning (coordinated emergency plans and synchronized exercises), leadership, communications and collaboration and implementation of best medical facility response to disasters.

ObjectiveCrisis communication is seen as an integrated and essential part of disaster management measures. After Typhoon Haiyan (Yolanda) in the Philippines 2013, radio was used to broadcast information to the affected community. The aim of this study was to describe how disaster radio was used to communicate vital messages and health-related information to the public in one affected region after Typhoon Haiyan.MethodsMixed-methods analysis using qualitative content analysis and descriptive statistics was used to analyze 2587 logged radio log files.ResultsRadio was used to give general information and to demonstrate the capability of officials to manage the situation, to encourage, to promote recovery and foster a sense of hope, and to give practical advice and encourage self-activity. The content and focus of the messages changed over time. Encouraging messages were the most frequently broadcast messages. Health-related messages were a minor part of all information broadcast and gaps in the broadcast over time were found.ConclusionDisaster radio can serve as a transmitter of vital messages including health-related information and psychological support in disaster areas. The present study indicated the potential for increased use. The perception, impact, and use of disaster radio need to be further evaluated. (Disaster Med Public Health Preparedness. 2016;10:591–597)

We aimed to describe characteristics associated with rescue from drowning as reported by the Swedish Fire and Rescue Services (SFARS) and their association with survival from the Out of Hospital Cardiac Arrest (OHCA) registry.This retrospective study is based on the OHCA registry and the Swedish Civil Contingencies Agency (SCCA) registry. All emergency calls (1996-2010) where the SFARS were dispatched were included (n=7175). For analysis of survival, OHCAs that matched events from the SCCA registry were included (n=250).Calls to lakes and ponds were predominant (35% of all calls reported). Rescues were more likely in cold water,10 °C (45%), in open water (80%) and in April-September (68%). Median delay from a call to arrival of rescue services was 8min, while it was 9 min for rescue diving units. Of all OHCA cases, the victim was found at the surface in 47% and underwater in 38%. In events where rescue divers were used, victims were significantly younger than in non-diving cardiac arrests and the mean diving depth was 6.3±5.8 m. Overall survival to one month was 5.6% (13% in diving and 4.7% in non-diving cases; p=0.07).In half of more than 7000 drowning-related calls to the SFARS during 15 years of practice, water rescue was needed. In all treated OHCA cases, the majority were found at the surface. Only in a small percentage did rescue diving take place. In these cases, survival did not appear to be poorer than in non-diving cases.

Objective: Malfunction in hospitals' complex internal systems, or extern threats, may result in a hospital evacuation. Factors contributing to such evacuation must be identified, analyzed and action plans should be prepared. Our aims in this study were 1) to evaluate the use of risk and vulnerability analysis as a basis for hospital evacuation plan, 2) to identify risks/hazards triggering an evacuation and evaluate the respond needed and 3) to propose a template with main key points for planning, performance and evaluation of such evacuation. Methods: A risk and vulnerability analysis at two county hospitals along with a systematic online literature search based on the following keywords; “evacuation/closure”, “hospitals/medical facilities” and “disaster/hazards” alone or with “planning”, was conducted. Results: We found that although all hospitals have a disaster plan, there is a lack of knowledge and appropriate instruments to plan, perform and evaluate a hospital evacuation. Risk and vulnerability analysis can be used to reveal threats leading to an evacuation (e.g. on-going climate changes and terror actions). These key points can later be used to plan, perform and evaluate such evacuation. Conclusion: There is a need for an elaborated evacuation planning for hospitals. An evacuation plan should continuously be drilled based on a risk and vulnerability analysis. A general guide can be used as foundation to plan, perform and evaluate such plan.

Background The timely provision of emergency medical services might be influenced by discrepancies in triagesetting between emergency medical dispatch centre and ambulance crews (ACR) on the scene resulting in overloaded emergency departments (ED) and ambulance activities. The aim of this study was to identify such discrepancies by reviewing ambulance transports within a metropolitan city in the western region of Sweden. Methods All data regarding ambulance transports in Gothenburg, Sweden, during a 6-month period were obtained and analyzed by reviewing the available registry. Results There was a discrepancy between emergency medical dispatch centre and ACR in priority setting, which may result in a number of unnecessary transports to the hospital with consequent overloading of ED and a negative impact on ambulance availability. Conclusion Appropriate ambulance use is one important part of emergency preparedness. Overuse results in decreased emergency medical services (EMS) availability and ED-overcrowding. Several factors, such as an imprecise triage system and increased public demands, may influence such overutilization. Improving the triage system and comprehensive public education on appropriate use of ambulances are two important steps toward a better use of national EMS resources.

By using 111In-labelled platelets and dynamic gamma camera scintigraphy, platelet production rate and intrasplenic platelet kinetics were determined in 13 patients at 1 and 4 months after aortic reconstructive vascular surgery with implantation of dacron prostheses. A significant decrease in platelet production rate and venous platelet count was recorded over time after surgery. Irrespective of whether the exchangeable splenic platelet pool was estimated from initial recovery of platelet-bound radioactivity or from compartmental analysis, the size of this pool was significantly lower at the first study; a change in intrasplenic platelet transit time accounted for the observed difference. Platelet mean life-span increased over time after surgery but the difference between the duplicate studies was not statistically significant. It can be concluded that there is a reduction of platelet production rate and venous platelet count over time after major reconstructive vascular surgery. The early postoperative elevation in the platelet count is mainly the result of an increased platelet production and to a lesser degree due to redistribution of platelets between the splenic platelet pool and general circulation.

This is a descriptive report of the Swedish authorities' responses to the tsunami that affected Southeast Asia in December 2004. The main focus is the care of survivors and the injured during their transportation from Thailand and their return to Sweden. The psychological and physical after-effects also are presented based on a poll conducted one year after the tsunami.

The science of disaster medicine is more a descriptive than analytical type. Research, in most instances, has not employed quantitative methods and there is very sparse knowledge based on analytical statistics. One consequence of this is that similar mistakes are repeated over and over. Lessons that should be learned are merely observed. Moreover, there are almost no practical or ethical ways in which randomised controlled studies can be performed. The management, command and control of situations on different levels of hierarchy has eldom been evaluated and there have been no standards against which performance can be evaluated. Furthermore, the documentation of decisions and staff work is rarely sufficient enough to evaluate command and control functions. Setting standards that may be used as templates for evaluation and research is an issue that is constantly being addressed by leading experts in the field of disaster medicine and this is also an important issue that is expressed in the Utstein Template. Swedish National Board of Health and Welfare, templates of performance indicators were developed. These were tested on reports available from incidents, and our conclusion was that documentation in this form was not adequate enough for use in this method of evaluation. Documentation must be improved and data probably need to be captured and stored with the help of information systems. A template developed for the evaluation of medical command and control at the scene was tested in standardised examinations. When using this template in this setting it was possible to obtain specific information on those aspects of command and control that need to be improved. An information system using on-line Internet technique was studied twice. The first study concluded that in spite of technical disturbances the system was acceptable to the organisation but could not yet be recommended for use during major incidents. The second study concluded that the retrieval of information was, in all respects not as good as the control system, a conventional ambulance file system. In a study of staff procedure skills during training of management staffs in command and control it was concluded that documentation during training sessions was not adequate and this lack of staff procedure skills could possibly be a contributing factor to the fact that lessons in command and control are not learned from incidents. Conclusions in thesis are that measurable performance indicators can be used in the training of command and control. If performance indicators are to be used in real incidents and disasters, functioning information systems have to be developed. This may lead to a better knowledge of command and control and could possibly contribute to a process where lessons are learned and mistakes are not repeated.

This is a descriptive study of the medical responses to the bombings by terrorists in Madrid on 11 March 2004. The nature of the event, the human damage, and the responses are described. It describes the: (1) nature and operations associated with the alarm; (2) assignment of responding units and personnel; (3) establishment and operations of casualty collection points; (4) medical transport and distribution of injured victims; (5) prioritization and command; (6) hospital care; (7) psychosocial care; (8) identification of the dead; and (9) police investigation and actions. Each of these descriptions is discussed in terms of what currently is known and the implications for future planning, preparedness, and response.

On 12 October 2002, two bombs exploded on the island of Bali in Indonesia, destroying two bars in the tourist district of the holiday resort Kuta Beach. The explosions killed 202 people from 21 different countries, and >300 people were injured. A team of observers conducted structured and unstructured interviews, and lessons learned from the experience were identified. This report summarizes various elements of the response including: (1) prehospital care; (2) coordination; (3) hospital response; and (4) Australia's efforts in air evacuation.

Background and aims: The benefit of simulation models for interactive training of the response to major incidents and disasters has been increasingly recognized during recent years and a variety of such models have been reported. However, reviews of this literature show that the majority of these reports have been characterized by significant limitations regarding validation of the accuracy of the training related to given objectives. In this study, precourse and postcourse self-assessment surveys related to the specific training objectives, as an established method for curriculum validation, were used to validate the accuracy of a course in Medical Response to Major Incidents (MRMI) developed and organized by an international group of experts under the auspices of the European Society for Trauma and Emergency Surgery. Methods: The studied course was an interactive course, where all trainees acted in their normal roles during two full-day simulation exercises with real time and with simultaneous training of the whole chain of response: scene, transport, the different functions in the hospital, communication, coordination, and command. The key component of the system was a bank of magnetized casualty cards, giving all information normally available as a base for decisions on triage and primary management. All treatments were indicated with attachments on the cards and consumed time and resources as in reality. The trainees’ performance was recorded according to prepared protocols and a measurable result of the response could be registered. This study was based on five MRMI courses in four different countries with altogether 235 participants from 23 different countries. In addition to conventional course evaluations and recording of the performance during the 2 exercise days, the trainees’ perceived competencies related to the specific objectives of the training for different categories of staff were registered on a floating scale 1-10 in self-assessment protocols immediately before and after the course. The results were compared as an indicator of to which extent the training fulfilled the given objectives. These objectives were set by an experienced international faculty and based on experiences from recent major incident and disasters. Results: Comparison of precourse and postcourse self-assessments of the trainees’ perceived knowledge and skills related to the given objectives for the training showed a significant increase in all the registered parameters for all categories of participating staff. The average increase was for prehospital staff 74 percent (p < 0.001), hospital staff 65 percent (p < 0.001), and staff in coordinating/administrative functions 81 percent (p < 0.001). Conclusions: The significant differences in the trainees’ self-assessment of perceived competencies between the precourse and postcourse surveys indicated that the methodology in the studied course model accurately responded to the specific objectives for the different categories of staff.

PurposeAortic dissection is difficult to detect in the early phase due to a variety of symptoms. This report describes the prehospital setting of aortic dissection in terms of symptoms, treatment, and suspicion by the Emergency Medical Service (EMS) staff.Basic ProceduresAll patients in the Municipality of Gothenburg, Sweden, who, in 2010 and 2011, had a hospital discharge diagnosis of aortic dissection (international classification of disease (ICD) I 71,0) were included. The exclusion criteria were: age < 18 years of age and having a planned operation. This was a retrospective, descriptive study based on patient records. In the statistical analyses, Fisher's exact test and the Mann-Whitney U test were used for analyses of dichotomous and continuous/ordered variables.Main findingsOf 92 patients, 78% were transported to the hospital by the EMS. The most common symptom was pain (94%). Pain was intensive or very intensive in 89% of patients, with no significant difference in relation to the use of the EMS. Only 47% of those using the EMS were given pain relief with narcotic analgesics. Only 12% were free from pain on admission to the hospital. A suspicion of aortic dissection was reported by the EMS staff in only 17% of cases. The most common preliminary diagnosis at the dispatch center (31%) and by EMS clinicians (52%) was chest pain or angina pectoris. In all, 79% of patients were discharged alive from the hospital (75% of those that used the EMS and 95% of those that did not).ConclusionAmong patients who were hospitalized due to aortic dissection in Gothenburg, 78% used the EMS. Despite severe pain in the majority of patients, fewer than half received narcotic analgesics, and only 12% were free from pain on admission to the hospital. In fewer than one-in-five patients was a suspicion of aortic dissection reported by the EMS staff.AxelssonC, KarlssonT, PandeK, WigertzK, ÖrtenwallP, NordanstigJ, HerlitzJ. A description of the prehospital phase of aortic dissection in terms of early suspicion and treatment. Prehosp Disaster Med. 2015;30(2):1-8.

Objectives: To determine if an on-line information system is superior to a conventional ambulance file system regarding the possibility of retrieving information as follow-up in daily use and also ...

The objective of this study was to determine if a set of performance indicators could indicate what part of medical command and control needs to be improved in a training concept designed for medical officers at major incidents. A set of 11 different performance indicators previously proposed was used as a template when examining ambulance staff in medical command and control. The results were graded 0 to 2 where 0 = not acceptable, 1 = partially correct and 2 = correct. A total of 46 examinations comprising more than 200 students was included. Performing a correct second report (score 1.15), the ability to establish general guidelines for medical response (score 1.20), setting level of medical ambition (score 1.24) and informing media (score 1.33) had significantly lower scores than the other performance indicators. Performance indicators for medical management in a major incident can be used in a training setting for identifying areas that need improvement.

Objective. The ‘Swede information system’ was introduced in a county with approximately 450,000 inhabitants in April 2000. The implementation of this information system, intended to be operative in major incidents and disasters, has included the introduction of new technologies as well as new standard operating procedures for both ambulance crews and hospital staff. The objective of this study was to see how this information system with digitally mediated transmission was used as a daily routine during a 2‐month period, 1 year after its introduction. Methods. The Swede information system sends on‐line information from ambulances to emergency wards in the county. The technique used is a LAN (local area net) for communication within the site of the accident, Mobitex® from the ambulances to a data server and from this by Internet to the hospitals. During March and April 2001 all events when an ambulance was dispatched were recorded. All cases when the system was used to notify the receiving hospital were rec...

On the evening of 11 October 2002, a 19-year-old student detonated a home-made bomb inside the Myyrmanni shopping mall, located in the city of Vanda (Vantaa) just north of Helsinki, Finland. The device was an anti-personnel type of bomb (equal to 2-3 kg of trotyl with a covering of steel and copper pellets) made from easily available materials and from instructions available over the Internet. It was hidden in a backpack and detonated in the middle of a crowd of people who were watching a clown's performance. Five people were killed instantly, two died later, and more than 160 persons were injured.The management of the incident caused a major strain on the Emergency Medical Services as well as the hospitals within Helsinki. This report discusses weaknesses in the command and control system (mainly from communication failures) ways to improve a coordinated response in the future.

OBJECTIVES: The aim of this study was to evaluate the procedures adopted by the staff of the Shiraz Emergency Medical Services (EMS) and the outcome of the patients discharged from the scene over a one-year period. BACKGROUND: Unnecessary use of ambulances results in the overloading of EMS and the over-crowding of emergency departments. Medical assessment at the scene by EMS staff may reduce these issues. In an earlier study in Shiraz, 36% of the patients were left at home/discharged directly from the scene with or without treatment by EMS staff after consulting a physician at the dispatch center. However, there has been no evaluation of this system with regard to mortality and morbidity. MATERIALS AND METHODS: Retrospective data on all missions performed by the Shiraz EMS (2012-2013) were reviewed. All the patients discharged from the scene by the EMS staff on the 5th, 15th, and 25th days of each month were included. A questionnaire with nine questions was designed, and available patients/relatives were interviewed prospectively (2014; follow-up period 4-12 months). RESULTS: Out of 3019 cases contacted, 994 (almost 33%) replied. There were 26%-93% reductions in the complaints in all disease categories. A group of the patients left the scene at their own will. Of those who were discharged by the EMS staff at the scene, over 60% were without any complaints. Twelve out of 253 patients died after they were sent home by the EMS staff. CONCLUSIONS: Patients may be discharged at the scene by EMS staff and after consulting a physician. However, there is a need for a solid protocol to ensure total patient safety. This calls for a prospective study. Language: en

To find out if the presence of a sternal fracture indicates cardiac and aortic injuries and to clarify the difference between a retrosternal haematoma and widened mediastinum.Retrospective study.Teaching hospital, Sweden.418 patients with blunt chest trauma of whom 29 had a fractured sternum (11 with retrosternal haematoma and 18 without) and 389 did not (7 with widened mediastinum and 382 without).Definitions, risk factors, morbidity, and mortality.Retrosternal haematomas were found adjacent to many fractures and ranged in size from a few mm to 2 cm. They were more common in fractures of the body of sternum. There was no significant difference in the number of associated lesions between patients with sternal fractures with or without a retrosternal haematoma. Conversely, patients with a widened mediastinum had a higher injury severity score, longer hospital stay (p0.0001), and more associated lesions (p0.05) than those with retrosternal haematomas. Six patients still had pain 1 month after injury of whom two had injury-related long-term disability because of pain. No serious cardiac or aortic injuries were detected in this series. The early mortality in our study was 2/29 in patients with sternal fractures and 1/7 in patients with widened mediastinum.Sternal fractures are more common than previously reported. An aggressive approach including early operative reduction is recommended even for a stable fracture to reduce the overhelming pain. Sternal fracture with or without retrosternal heamatoma is not a reliable indicator of cardiac and aortic injuries, while mediastinal widening is still a fairly reliable clue that should indicate further investigation.

Objective. To present our experience of cardiac injuries treated at one Swedish emergency department in the 10 years 1988-97. Design: Retrospective study. Setting: Teaching hospital. Subjects: 11 patients (9 men and 2 women, mean age 33 years, range 19-54); in 7 they were penetrating injuries and in 4 blunt. Main outcome measures: Morbidity and mortality. Results: The mechanisms of injury were stab wound (n = 7), and car crash, fall, boat crash, and abuse (n = I each); drug or alcohol misuse played a part in all those with penetrating injuries. The penetrating wounds involved the left ventricle (n = 3), the right ventricle (n=2), and the pericardium (n=2). All 5 patients with ventricular wounds presented with cardiac tamponade, in 1 of whom it was fatal (he bled to death during emergency thoracotomy). The main complications were anoxic brain damage and postpericardiotomy syndrome (1 each). There was no case of myocardial concussion. Conclusion. Our data reflect the Swedish experience of heart trauma: there are few cases, alcohol and drug misuse is the principal risk factor, and there were no gunshot wounds.

Objective: To find out whether we could manage critical pulmonary haemorrhages in penetrating injuries, and to report our experience with blunt trauma of the lung. Design: Retrospective study Setting: Teaching hospital, Sweden. Subjects: 81 patients who presented with pulmonary injuries during the period January 1988-December 1997; 6 were penetrating and 75 blunt. Results: There was only one patient with an isolated lung contusion. The remaining was divided into 2 groups: those with pulmonary contusion and thoracic lesions (n = 32), and those with pulmonary contusion and extrathoracic lesions (n = 42). Four patients in the penetrating group were shocked and required urgent operations; emergency room thoracotomy (n = 1), urgent thoracotomy (n = 2), and urgent thoracoabdominal exploration (n = 1) were done successfully. We correlated grade of lung injury [American Association for the Surgery of Trauma-Abbreviated Injury Scale (AIS) ] with mortality. All patients with penetrating injuries survived without se...

Background: Extrapleural hematoma has been found mostly in single case reports as diagnoses with different names. Although huge extrapleural hematoma can cause ventilatory and circulatory disturbances and even death, it has received almost no attention in the literature. Certain basic and modern facts need to be clarified regarding the definition, classification, and significance of extrapleural hematoma in the practice of chest trauma. Methods: A 10-year retrospective study was undertaken to analyze the incidence, diagnosis, management, morbidity, and mortality of patients with chest trauma and a documented extrapleural hematoma. Results: The incidence of traumatic extrapleural hematoma was 34 of 477, 7.1%. The incidence of thoracic lesions was 86 of 34 = 2.5 lesions per patient, whereas the incidence of extrathoracic lesions was 30 of 34 = 0.9 lesions per patient. Associated rib fractures were found in 30 of 34, 88.2%. More than half of the patients had an associated hemothorax. A thoracotomy was used successfully to remove a huge hematoma in one patient. Conclusion: Extrapleural hematoma has been found to be more common than previously reported. Nomenclature and classification are suggested. One of the common injuries to the chest, particularly rib fracture, hemothorax, lung contusion, or pneumothorax might provide the surgeon with a reliable clinical clue that the patient is at inordinate risk to have associated extrapleural hematoma. A formal or mini-thoracotomy is the recommended procedure in cases of huge hematomas.

Background and purpose:to determine if diabetes mellitus is a risk factor for outcome after carotid endarterectomy (CEA).Methods:the outcome and complications of all vascular procedures performed in Sweden are registered prospectively in the Swedish Vascular Registry (Swedvasc) and form the basis of this report. During the 10-year period 1987–96 2622 CEAs were analysed for notified complications.Results:of the 2622 CEAs, 341 (13%) were performed on diabetics and 2281 (87%) on non-diabetics. Patients with diabetes presented at a younger age (67.1±8.3 years vs. 68.2±8.3 years p =0.028), were more likely to have a history of hypertension (61.9% vs. 50% p =0.001) and were less often smokers (34.9% vs. 43.2% p =0.001). Diabetics presented more often with minor stroke (41.3% vs. 30.8% p =0.002) and non-diabetics more often with amaurosis fugax (18.9% vs. 14.4% p =0.04). Diabetics had a higher 30-day mortality (3.2% vs. 1.4% p =0.02). The 30-day neurologic and cardiac morbidity did not differ. The 1-year mortality was 7.9% in diabetics and 4.4% in non-diabetics (p =0.008). Non-diabetics operated on in 1992–96 compared to those operated on in 1987–91 had a significantly lower combined permanent stroke and death rate (3.7% vs. 5.7% p =0.05), a difference not found in diabetics (6.3% for 1987–92 and 6.8% for 1992–96Conclusions:diabetics had both a higher 30-day and 1-year mortality after CEA compared to non-diabetics, mainly because of cardiac complications. However, postoperative neurologic morbidity did not differ.

The need for and benefit of simulation models for interactive training of the response to major incidents and disasters has been increasingly recognized during recent years. One of the advantages with such models is that all components of the chain of response can be trained simultaneously. This includes the important communication/coordination between different units, which has been reported as the most common cause of failure. Very few of the presently available simulation models have been suitable for the simultaneous training of decision-making on all levels of the response. In this study, a new simulation model, originally developed for the scientific evaluation of methodology, was adapted to and developed for the postgraduate courses in Medical Response to Major Incidents (MRMI) organized under the auspices of the European Society for Trauma and Emergency Surgery (ESTES). The aim of the present study was to describe this development process, the model it resulted in, and the evaluation of this model. The simulation model was based on casualty cards giving all information normally available for the triage and primary management of traumatized patients. The condition of the patients could be changed by the instructor according to the time passed since the time of injury and treatments performed. Priority of the casualties as well as given treatments could be indicated on the cards by movable markers, which also gave the time required for every treatment. The exercises were run with real consumption of time and resources for all measures performed. The magnetized cards were moved by the trainees through the scene, through the transport lines, and through the hospitals where all functions were trained. For every patient was given the definitive diagnosis and the times within certain treatments had to be done to avoid preventable mortality and complications, which could be related to trauma-scores. The methodology was tested in nine MRMI courses with a total of 470 participants. Based on continuous evaluations and accumulated experience, the setup of the simulation was step-wise adjusted to the present model, including also collaborating agencies such as fire and rescue services as well as the police, both on-scene and on superior command levels. The accuracy of the simulation cards for this purpose was evaluated as "very good" by 63 % of the trainees and as "good" by 33 %, the highest two of the six given alternatives. The participants ranking of the extent that the course increased their competencies related to the given objectives on a 1-5 scale for prehospital staff had an average value of 4.25 +/- A 0.77 and that for hospital staff had an average value of 4.25 +/- A 0.72. The accuracy of the course for the training of major incident response on a 1-5 scale by prehospital staff was evaluated as 4.35 +/- A 0.73 and that by hospital staff as 4.30 +/- A 0.74. The simulation system tested in this study could, with adjustments based on accumulated experience and evaluations, be developed into a tool for the training of major incident response meeting the specific demands on such training based on recent experiences from major incidents and disasters. Experienced trainees in several courses evaluated the methodology to be accurate for this training, markedly increasing their perceived knowledge and skills in fields of importance for a successful outcome of the response to a major incident.

Objectives:To test the hypothesis that oral ciprofloxacin is equally effective as intravenous cefuroxime in preventing postoperative infectious complications in patients undergoing peripheral arterial surgery involving the groins.Design:Prospective, randomised, double-blind multicentre study.Materials:580 patients undergoing arterial surgery involving the groins were randomised to ciprofloxacin (Ciproxin, Bayer) 750 mg × 2 p.o. or cefuroxime (Zinacef, Glaxo) 1.5 g × 3 i.v. given only on the day of surgery. The primary endpoint was wound/graft infection within 30 days postoperatively. Wound infection was defined as pus.Results:The wound infection rate in the ciprofloxacin group was 9.2% (27 patients) and in the cefuroxime group 9.1% (26 patients) according to intention to treat. For correct treatment the corresponding numbers were 9.5% (23 patients) and 9.7% (22 patients), respectively. There were three graft infections (0.5%). The infection rate was 7.1% (31/433) in the absence and 14.9% (22/147) in the presence of distal ulcers (p

The optimal administration regimens of low molecular weight heparins (LMWHs) have not yet been established. The aim of this study was to compare the efficacy and safety of 2500 and 5000 Xal units of the LMWH dalteparin in patients undergoing elective general surgery for malignant and benign abdominal disease. Prophylaxis was started in the evening before surgery and given once-daily every evening thereafter. The study was designed as a prospective, randomized, double-blind, multicentre trial. Some 66.4 per cent of patients were operated on for a malignant disorder. The primary endpoint was deep vein thrombosis (DVT) detected with the fibrinogen uptake test. Bleeding complications were recorded and classified. Analysis was made both on an intention to treat basis and in patients given correct prophylaxis (86.3 per cent). A total of 2097 patients were randomized and 27 excluded after randomization. A technically correct fibrinogen uptake test was obtained in 1957 patients. The incidence of DVT was significantly lower in patients given 5000 Xal units, this being true for both correct prophylaxis (6.8 versus 13.1 per cent, P < 0.001), on an intention to treat basis (6.6 versus 12.7 per cent, P < 0.001), and in patients with malignant disease (8.5 versus 14.9 per cent, P < 0.001). Sixty-seven patients (3.2 per cent) died within 30 days with no difference between the groups. There were two cases of fatal pulmonary embolism. The frequency of bleeding complications in the whole series was higher in patients randomized to 5000 Xal units (4.7 versus 2.7 per cent, P = 0.02), although this was not the case in those operated on for malignant disease (4.6 versus 3.6 per cent, P not significant). Dalteparin in the dose of 5000 Xal units started in the evening before surgery has a good thromboprophylactic effect in high-risk general surgery at the cost of a small bleeding risk. In patients with malignant disease there was no increased risk of bleeding. The overall frequency of fatal pulmonary embolism with dalteparin is extremely low, even in this high-risk group of patients.

The evolution of trauma care is dependent on a thorough and correct description of the injuries sustained, the pathophysiological derangement of the injured individual, as well as outcome in terms of mortality and morbidity. Thus, scales for categorizing injuries have been developed that describe the injuries in anatomical terms and assess the physiological response to trauma. Taking into account the physiological reserve and the mechanisms of injury, these factors together constitute the most accurate basis for predicting the outcome of trauma to date. The effect of injuries is usually considered in terms of survival at 30 days after the trauma, but should also refer to the extent of disability and functional recovery. More than 50 different scoring systems for trauma have been proposed, indicating that the ideal system does not yet exist. Outcome prediction after trauma is still evolving and all of the systems used have their weaknesses. This chapter will give an overview and discuss some of the most commonly used systems in more detail.

Background:The consequences of a major incident at a sporting event could be catastrophic. Therefore, there should be an estimation of the healthcare resources at such events as part of the planning. Although there are National guidelines (e.g., Planning Safe Public Events: Practical Guidelines in Australia) defining the role of the healthcare system at sporting events, these guidelines either lack a simple calculating method to estimate the need for healthcare resources or the methods are complex and impractical to use. The objective of this study was to find a safe and easy method for the estimation of healthcare resources at sporting events.Methods:A model for the estimation of healthcare resources at music events recently has been approved in Sweden. After minor adjustments, this model was used at sport events by a number of planning officers. The models' accuracy and usability was evaluated by analyzing its outcome in a pilot and a controlled study using different sporting and non-sporting scenarios.Results:The pilot study showed that the model was valid and easily could be used for various sporting events. The obtained estimations were consistent with the methods used by experienced planning officers in 97% of cases. The results of the controlled study showed that by using this model, the minimum amount of resources required easily could be calculated at sporting events and by people with different backgrounds.Conclusions:This model safely can be used at sporting events.

The incidence and mortality rate of ruptured aortic aneurysm in a defined and stable Swedish population was determined for the period 1952-1988. The annual rupture rate of abdominal aneurysm rose significantly from 0.9 per 100 000 inhabitants in the 1950s to 6.9 in the 1980s. After standardization for age, the mortality rate increased between 1960 and 1988 by 2.4 per cent annually (95 per cent confidence interval 1.2–3.6 per cent, P = 0.0004). Comparable figures from the UK during the 1980s have been reported to be two to three times higher. The mortality rate of ruptured thoracic aneurysm in the Swedish population did not increase when adjusted for age. In the 1980s the overall mortality rate of ruptured abdominal aneurysm was 85 per cent. Death occurred outside surgical clinics in 52 per cent of cases; 37 per cent of the total number of patients with ruptured aneurysm reached the operating table but only 30 per cent underwent aortic reconstruction. Patients treated by vascular surgeons had lower blood loss and transfusion needs, shorter aortic clamp time and operation time, and lower mortality rate than patients treated by non-specialized general surgeons. Specialized vascular surgeons also completed the reconstruction, and used straight grafts, in a higher proportion of cases than general surgeons.

The overall aim of this study was to describe changes in health-related quality of life, anxiety, depression, and return to work from 0.5-1.5 yrs to 4.5-5.5 yrs after injury in patients with and without delusional memories during their intensive care unit stay. A secondary aim was to explore factors that were related to health-related quality of life and to compare trauma patients' health-related quality of life 4.5 to 5.5 yrs after injury with a reference group.Longitudinal, prospective.Multicentre study.Trauma patients treated in the intensive care unit.None.A follow-up study was conducted with 153 consenting adults. Each patient answered a postal questionnaire twice, 0.5-1.5 yrs to 4.5-5.5 yrs after the injury. Health-related quality of life was assessed by Short Form-36 and anxiety and depression by the Hospital Anxiety and Depression Scale. Delusional memories and other clinical variables were assessed in a previous study and used in this study as possible precipitants of poor health-related quality of life. Seventy-five percent were males and mean Injury Severity Scores were 10.7 +/- 7.1. When comparing health-related quality of life over time, there was significant improvement in five domains of health-related quality of life for patients with delusional memories compared with 4 yrs previously. Significantly more patients with delusions had anxiety and depression (Hospital Anxiety and Depression Scaleor =8). Patients with delusional memories were still significantly separated from the other patients in all health-related quality-of-life domains except for general health. Seventy-five percent of all patients had returned to work. Despite a poorer health-related quality of life, patients with delusions had returned to work to the same degree. Patients with trauma still scored significantly lower in all domains 4.5 to 5.5 yrs after the injury compared with the Swedish population in the reference group (p.001). Two factors, delusional memories during intensive care unit stay and pre-existing disease prior the trauma, had the most influence on a poorer health-related quality of life.From a long-term perspective, health-related quality of life has improved but not reached the reference sample scores in Short Form-36. Seventy-five percent had returned to work. Patients with delusional memories still experienced poorer health-related quality of life and more patients had anxiety and depression compared with patients without those memories.

Background Although disasters and major incidents are difficult to predict, the results can be mitigated through planning, training and coordinated management of available resources. Following a fire in a disco in Gothenburg, causing 63 deaths and over 200 casualties, a medical disaster response centre was created. The center was given the task to coordinate risk assessments, disaster planning and training of staff within the region and on an executive level, to be the point of contact (POC) with authority to act as "gold control," i.e. to take immediate strategic command over all medical resources within the region if needed. The aim of this study was to find out if the centre had achieved its tasks by analyzing its activities. Methods All details concerning alerts of the regional POC was entered a web-based log by the duty officer. The data registered in this database was analyzed during a 3-year period. Results There was an increase in number of alerts between 2006 and 2008, which resulted in 6293 activities including risk assessments and 4473 contacts with major institutions or key persons to coordinate or initiate actions. Eighty five percent of the missions were completed within 24 h. Twenty eight exercises were performed of which 4 lasted more than 24 h. The centre also offered 145 courses in disaster and emergency medicine and crisis communication. Conclusion The data presented in this study indicates that the center had achieved its primary tasks. Such regional organization with executive, planning, teaching and training responsibilities offers possibilities for planning, teaching and training disaster medicine by giving immediate feed-back based on real incidents.

The clinical efficacy of the prostacyclin analogue iloprost was studied during a 2 week treatment and 6 month follow-up period in 103 patients with ischaemic ulcers who were randomised to receive active treatment or placebo. Responders were defined as those patients who achieved healing of at least one third of the ulcer area during the study period. The overall responder rate was 41.3%, compared with 25% for the control group ( P =0.086). Side effects including flushing and headache, were common. The study population had a mortality of 23 % during the 6 month period, the amputation rate was 43.5% for iloprost and 50% for placebo treated patients. In this severely diseased population of patients a treatment period limited to 2 weeks did not sufficiently improve ulcer healing.