Moving from situational awareness to decisions during disaster response: transition to decision making.

During major disasters, at what point in the decisional process do senior government officials transition from developing necessary situational awareness to perform decision making? This "transition to decision making" (TDM) concept was analyzed through a structured interview survey of 25 current and former US Federal Coordinating Officers (FCOs) and focused on their decision-making process during the initial response period in a Presidentially declared Stafford Act disaster. This analysis suggests that the TDM for these emergency leaders is influenced by the following five factors: 1) Analogue Factor: the decision maker's previous knowledge and experience from analogous disaster situations; 2) New Paradigm Factor: the degree to which the disaster situation is very atypical to the decision maker due to hazard type and or situation severity, 3) Data Capture Factor: the quality, amount, and speed of disaster situation data conveyed to the decision maker; 4) Data Integration Factor: the decision maker's ability to integrate situational data elements into a mental framework picture; and 5) Time Urgency Factor: the decision maker's perception as to time available before a decision has to be made. The article describes the factors and graphs that how these may influence the timing of the TDM in four types of emergency situations faced by FCOs: 1) an analogue disaster, 2) a disaster situation that presents a new paradigm, 3) an intuitive disaster situation, and 4) a disaster requiring an urgent response.

Fatal inhalational anthrax with unknown source of exposure in a 61-year-old woman in New York City.

A 61-year-old woman who was a New York City hospital employee developed fatal inhalational anthrax, but with an unknown source of anthrax exposure. The patient presented with shortness of breath, malaise, and cough that had developed 3 days prior to admission. Within hours of presentation, she developed respiratory failure and septic shock and required mechanical ventilation and vasopressor therapy. Spiral contrast-enhanced computed tomography of the chest demonstrated large bilateral pleural effusions and hemorrhagic mediastinitis. Blood cultures, as well as DNA amplification by polymerase chain reaction of the blood, bronchial washings, and pleural fluid specimens, were positive for Bacillus anthracis. The clinical course was complicated by liver failure, renal failure, severe metabolic acidosis, disseminated intravascular coagulopathy, and cardiac tamponade, and the patient died on the fourth hospital day. The cause of death was inhalational anthrax. Despite epidemiologic investigation, including environmental samples from the patient's residence and workplace, no mechanism for anthrax exposure has been identified.