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The case study provides an insight to where due process for looters is not necessarily being employed by the police or the military cheap super viagra 160 mg online erectile dysfunction 16 years old. While bringing in the military had some advantages buy cheap super viagra 160mg online intracorporeal injections erectile dysfunction, there were also signifcant disadvantages generic super viagra 160 mg free shipping erectile dysfunction doctor in nj. Military personnel are in general not trained as policemen discount super viagra 160 mg free shipping erectile dysfunction caused by hydrocodone, which can intro- duce problems when contending with civilians in an emergency manage- ment situation. What steps need to be taken to ensure that law and order is being enforced judicially and correctly? City ofcials will need to ensure that military person- nel that are deployed in this type of situation understand that civilians do have a right to due process and that shooting looters should be a last resort, not a frst one. In addition, the municipal ofcials in the particular case could have redeployed their police ofcers to accompany the military on patrols to where their judgment and training could potentially alleviate soldiers shoot- ing alleged looters. The municipal ofcials will need to devise a new communication plan to communicate with the resources that are deployed to work on the diferent issues at hand, as well as the citizenry to state where food, shelter, and medical assistance can be found. If the resources are on hand to send active patrols with troops and police through the city to show a presence, then the order should not have been given. In a large emergency management situation such as the case study earthquake there are multiple situations that are ongoing (e. Declaring martial law would have also had drawbacks since there are so many people without 84 ◾ Case Studies in Disaster Response and Emergency Management housing or any place to go. Tere needs to be a plan to arrest suspected looters and have them taken to a temporary holding pen for detention and processing. Stage 5 of the Disaster The full impact is now starting to set in with you and the rest of your municipal staf. Now that the initial emergency has passed, what are your priorities for resources? The immediate problem you face is an ongoing search and rescue operation for survivors as well as ensuring food, water, shelter, and medical assistance are provided to those citizens that need them. Secondary concerns should be to call in additional resources from other organizations, get an efec- tive communication system up and running, and complete repairs to your infrastructure. Another method is to have those citizens removed to other municipalities where temporary shelters could be staged (e. Another alternative is to have mobile trailers set up for temporary hous- ing until better accommodations can be located. First and foremost, a logistical plan has to be in place or formulated to get food, water, medical supplies, and housing to those who are in need. Next, there will need to be a plan in place to inspect the infrastructure to ensure that the repairs that were made were more than a temporary stopgap measure. Infrastructure such as critical roads, bridges, and sewer lines can now be focused on for your recovery plan. Removing debris and rubble will also need to be addressed since new resident housing and potentially other damaged facilities will need to be constructed or repaired in order to move your temporary residents to more permanent structures. Last, there is a need to formulate a plan for future earthquakes to mitigate the damage and loss of life that could potentially occur. Ensure that supplies are positioned and stockpiled to facilitate quick distribution to municipalities and citizens in the event of a large emergency management situation. For sanitation reasons, corpses should be recovered to prevent the spread of dis- ease through the remaining citizenry. Tis issue could further compound any strains on your medical resources that city ofcials are using to treat the injured. Case Studies: Earthquakes and Volcanoes ◾ 85 Key Issues Raised from the Case Study Tere is a great danger in letting the military act as a police force. While the mili- tary has discipline, soldiers are not trained in law enforcement, which can lead to additional problems. The military should be used as a police force as a last resort to restoring law and order. Tis case study also demonstrates the importance of repairing damaged infrastructure to assist not only in combating the disaster (i. In this case study, failure to repair the infrastructure quickly resulted in 80% of the city burning down. Whether or not the resources existed to repair such infrastructure is unknown, but what is known is that the earthquake damaged both water mains and natural gas lines, which caused more damage to occur. The failure to cap of natural gas lines quickly and repair the water mains in essence allowed the fres to spread unabated throughout the city. In addition, there were individuals who were not looting, but attempting to retrieve their own possessions from the rubble who were shot by the military (U. Items of Note In addition to the monetary damage that resulted, many landmark buildings (e. Many residents and business owners burned down their structures through arson since insurance would not cover damage or destruction through earthquakes (Virtual Museum of the City of San Francisco, 2012). Aleutian Island Earthquake, 1946 Stage 1 of the Disaster You are the governor of Hawaii, an island territory in the United States. The main concern for any island or coastal area is that a tsunami could result from an earthquake, which could devastate any population or infrastructure in a low-lying coastal region. An additional concern would be the evacuation of populations located in certain regions that may be impacted by a tsunami. First responders should be acti- vated as well as mobilizing any type of transportation that could be used * Hawaii and Alaska were territories of the United States until they became states in 1959. National Guard units should be activated and temporary shelters should be made ready to receive citizens that have to be evacuated. The citizens of your state need to be alerted to the possibility of a tsunami hitting the coastal areas of the state. The citi- zens need to be prepared to evacuate on short notice to temporary shelters that will be set up to receive anyone who has to evacuate. Stage 2 of the Disaster You have new information that a state on the western coast of the United States has just been hit with a tsunami that caused the destruction of a reinforced concrete Coast Guard lighthouse and the deaths of all of its occupants (Joint Australian Tsunami Warning Center, 2008). Five hours after the tsunami hit the western coast, the tsunami slammed into one of your islands, completely wrecked the beaches, and killed over 159 residents (Joint Australian Tsunami Warning Center, 2008). The governor should have search and rescue teams deployed to search for any survivors that may still be in the area where the tsunami hit. Medical teams and resources should be mobilized to take care of the victims of the tsunami in addition to ensuring that displaced residents have shelter as well as provisions. The governor needs to communicate with local government ofcials to ensure that assistance is arriving quickly and efectively to those communities in need of assistance. In addition, victims’ families or next of kin need to be notifed of citizens that have been killed or hospitalized. The rebuilding of infrastructure, homes, and businesses will need to commence after the initial recovery operations are completed. Key Issues Raised from the Case Study Once a warning has been sounded, government ofcials need to immediately com- municate with low-lying communities in coastal areas to evacuate or have an evacu- ation plan ready. In addition, search and rescue resources need to be earmarked as soon as possible to respond to any population that could not evacuate the area successfully due to lack of transportation or infrastructure.
All of these descriptions convey that buy super viagra 160 mg line erectile dysfunction remedies diabetics, externally the heart is normal discount 160mg super viagra erectile dysfunction trimix, but the apex is rotated toward the right hemithorax purchase super viagra 160 mg with amex effective erectile dysfunction drugs. The base–apex axis of the heart actually is directed to the right super viagra 160mg fast delivery strongest erectile dysfunction pills, and the ventricular and great artery relationships are normal. The atrial and ventricular septum are not aligned, typical of isolated dextrocardia. The clinical presentation of patients with this form of dextrocardia depends upon associated lesions that may be present, rather than upon the malposition itself. The geometric distortion of isolated dextrocardia compounds the clinical differential diagnosis and surgical management. Radiographic findings include the finding of dextrocardia with the heart positioned in the right chest. Visceral situs solitus is recognized by the left-sided stomach bubble and right-sided liver. Atrial activation is normal, and the P-wave frontal plane axis is 70 to 80 degrees. Other voltage abnormalities would depend on associated congenital cardiac anomalies. Although these hearts meet all the criteria for dextrocardia, the cardiac position is often close to the midline with only a slight rightward dominance, mimicking mesocardia (Figs. A: Posteroanterior chest radiograph demonstrating cardiac malposition consistent with dextrocardia, with the base–apex axis oriented to the right; however, the heart is just slightly to the right of a midline location, illustrating an intermediate position between mesocardia and dextrocardia. B, C: Angiocardiograms demonstrating dextrocardia with atrioventricular and ventriculoarterial discordance. They also show a large ventricular septal defect and some degree of pulmonary arterial overriding. Pathologic specimen illustrating the most common form of dextrocardia associated with atrial and visceral situs solitus. The resulting hemodynamics are consistent with the physiology of congenitally corrected transposition of the great arteries. Dextrocardia with Situs Inversus Dextrocardia with Atrial and Visceral Situs Inversus (Situs Inversus Totalis) This clinical situation is the mirror image of normal. The cardiac structures are malpositioned (within the right hemithorax), but right/left asymmetry is still present, and organ positions are opposite (mirror image) of normal. This form of dextrocardia is underreported in pathologic series because patients have normal physiology with no obvious signs or symptoms. Absence of major additional cardiac anomalies (beyond the malposition) is likely to be associated with normal survival. The radiographic findings are consistent with visceral situs inversus and dextrocardia. The electrocardiographic findings in this form of dextrocardia include atrial and ventricular voltage changes that are inverted from normal. The P-wave axis is directed to the right and inferiorly because of atrial inversion. The coexistence of situs inversus totalis, chronic sinusitis, and bronchiectasis is referred to as Kartagener syndrome. The respiratory manifestations are secondary to a primary ciliary abnormality resulting in dyskinesia (immotility) of the cilia of the airways. These patients have impaired mucociliary clearance and frequent recurring respiratory tract infections as a result. Approximately one-half of those with primary ciliary dyskinesia will also have situs inversus totalis, strongly suggesting that ciliary motility is a critical component in the development of sidedness during embryogenesis. It is one of the most common forms of dextrocardia with situs inversus and occurred in 7/24 patients in the Van Praagh et al. The electrocardiogram shows an inverted P-wave axis because of the atrial inversion and evidence of right and left ventricular hypertrophy because of transposition physiology. Although the segmental connections could theoretically create normal physiology in these hearts, there was a high frequency of associated anomalies, resulting in profound hemodynamic impairments. Also, there is significant cardiac rotation to the right, so that the aorta is actually in a right posterior position relative to the pulmonary valve and main pulmonary artery. This is an extremely rare form of dextrocardia, with only two cases in the Van Praagh et al. Levocardia (Isolated Levocardia) When the heart is in a normal position and has a normal base–apex cardiac axis, isolated levocardia implies that either atrial situs inversus or atrial situs ambiguus is present. A: The posteroanterior chest radiograph demonstrates dextrocardia with a right-sided stomach bubble consistent with situs inversus and dextrocardia. Note that the ascending aorta (Ao) is right posterior in relation to the pulmonary valve because of marked cardiac rotation to the right. Autopsy series (6,8,9) have consistently included a very low incidence of mesocardia. The low incidence of mesocardia in these reports may reflect a tendency to have included such cases in the groups with dextrocardia or isolated levocardia. As a group, the hemodynamic and clinical abnormalities in mesocardia are similar to those described with dextrocardia. Situs Ambiguus Situs ambiguus is most often seen in the context of the heterotaxy syndromes and can be present in association with right atrial (asplenia) or left atrial (polysplenia) isomerism. Dextrocardia with situs ambiguus was the most common form of dextrocardia in the Van Praagh et al. Patients with heterotaxy syndrome (either right or left isomerisms) have a constellation of anomalies that create relatively consistent patterns (see Tables 51. Patients with polysplenia demonstrate a wider spectrum of cardiovascular pathology and include many with the potential for biventricular reconstruction. The cardiac base–apex axis (arrow) points to the right, consistent with dextrocardia. The white arrowhead indicates a hypoplastic rudimentary morphologic left ventricle to the right and posterior. The ventricular relationships are consistent with ventricular inversion or l-ventricular looping. The remaining three were similar with the exception of the ventricular arrangement. As is typical with asplenia, all had multiple anomalies of systemic and pulmonary venous connections. This constellation of anatomic features is characteristic of situs ambiguus and right isomerism, regardless of the cardiac position (levocardia, mesocardia, or dextrocardia). Eleven patients with dextrocardia and asplenia were observed in the series reported by Stanger et al. However, some outstanding differences are noteworthy, including a lower incidence of associated pulmonary stenosis and a more frequent occurrence of bilateral pulmonary venous connections to the ipsilateral atrium.
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