Transcript “disaster”?

Amy Gutman MD
[email protected] / www.TEAEMS.com
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Exploring fundamentals of disaster
management utilizing real-life experiences
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Examine local, regional & national
disasters:
 Case Presentations
 Disaster Issue Teaching Points
 Discussion Questions
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Air Force Base
Airports
Bridges
Chemical Plants
Hospitals
Ohio River
Skyscrapers
Sports Arenas
Train Depot
Universities
Weather
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Any event overwhelming
available resources
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Initial disasters often
compounded by poor planning
& communication, costing
time, resources & lives
• Q: What is the main distinction
in altering standards of care in a
“daily emergency” vs a
“disaster”?
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I “Expanded Medical Incident”
 >10 critical, <50 patients
 Local resources available to treat injured
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II “Major Medical Incident”
 >50 critical, <200 patients
 Regional resources available to treat injured
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III “Disaster”
 >200 patients of any type
 Lack of regional resources available to treat injured
 State, Federal resources required
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1830: Tornado warning sounded
for Albion community; 5
ambulances to “corners”
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1845: 1st of 6 tornadoes touches
down
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1855: Ambulance C reaches trailer
park, begins triage
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1860: Funnel cloud sighted over
trailer park, emergency
evacuation occurs
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1868: Tornado sets down 1 mile
from trailer park, evacuation
completed
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Casualties:
 Trailer Park – 22 injured; 45
evacuated
 Community Hospital /
Nursing Home – 15 injured;
150 evacuated
 Albion College Freshman
Dorm – 25 injured
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Disaster Issues:
 Chain of Command
 Location, Evacuation &
Transportation
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Based on commonality
 Many organizations work as “One”
 Utilizes one system of integrative, standardized
procedures for rural, suburban, urban areas
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5 synergistic characteristics:
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1 Organizational Structure
1 Incident Command Post
1 Planning Process
1 Logistics Center
1 Communications Framework
Core Concept: “The Whole is Greater than
the Sum of Its’ Parts”
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Incident Command Officer
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Communications Officer
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Extrication / Hazards Officer
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Triage Officer
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Treatment Officer
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Loading/Transportation Officer
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Support & Supplies Sector
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Public Information Officer
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Q: What are some limitations of the ICS?
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Q: Can ICS be utilized in “non-disaster” situations?
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Q: What is your departmental policy & procedure for ICS
implementation?
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At 2100, a lone shooter
opens fire at a Waffle
House with an AK 47
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Passing squad car calls for
“every unit available” to
the scene
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Unfortunately, the 1st
“unit” to show up was the
local news
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1st patients arrive at ED by
car 10 minutes prior to
any ambulance
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Casualties
 21 injured including 4
children
 6 trauma arrests
 1 medical arrest
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Disaster Issues
 Field vs ED triage
 Immediate stabilization of
critical patients
 Scene management
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Command
Safety
Communication
Assessment
Triage
Treatment
Transport
Treatment Area Diagram
Morgue
Medical
Supplies
SRC &
Rest Area
Immediate
Secondary
Triage
Delayed
Minor
Entrance From
Scene START
Triage
Transportation
Area
Rest Center
Police
Media Area
Outer
2
3
Inner
1
Triage
SRC
ICS
LZ
Ambulance Loading
Train Derailment;
Wales, 2001
14 Black
12 Red
30 Yellow
38 Green
Ambulance Parking Area
777 London Bombings
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“In an uncontrolled incident vast numbers of ‘walking
wounded’ (& non-patients) leads to a reverse triage effect
where patients with minor injuries present to hospitals
before the serious casualties arrive, swamping emergency
services to the detriment of the severely wounded”
 Chaloner; BMJ 2005;331:119
Hospital Distribution of Disaster Casualties
(Quarantelli; Delivery of emergency services in disasters: Assumptions and realities)
Number of Casualties
Number of Hospitals
Receiving Casualties
Number of Hospitals
Capable of Receiving
Casualties
266
4
43
141
4
41
381
12
78
298
11
105
5 mins Air
25 mins Ground
15 mins Air
45 mins Ground
25 mins Air
100 mins Ground
20 mins Air
70 mins Ground
30 mins Air
45 mins Air
180 mins Ground
130 mins Ground
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Scene Q’s:
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“Contained” vs “Open”?
Hazard identification?
Secondary incident potential?
Immediate vs delayed emergencies?
Evacuation & Transportation Q’s:
 Secondary evacuation site? Third? Fourth?
 Access or egress?
 How do you transport more individuals than you have
physical space for?
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Category 5 hurricane makes landfall
on 8/29
 Coastal regions under mandatory
evacuation for days but warnings
largely ignored
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1st patients in Shreveport 8/28
 800+ patients arrive in 29 sorties of
C130s, Blackhawks, cargo planes &
ambulances in <24 hours
 Few “Walking Wounded” from New
Orleans
 Estimated 5-10,000 patients arrive
from Gulf Coast over next 5-10 days
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Immediate Casualties:
 1,830 deaths
 750+ missing
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Delayed Casualties:
 Unknown
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In 3 months population of Shreveport doubles*
 Violent & gang-related crime quadruples
 Uninsured population with no “medical homes”
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Scene Disaster Issues
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Communication
Triage
Health care worker safety
Lack of personnel &
equipment
ED Disaster Issues
 Communication
 Triage
 Lack of personnel &
equipment
 Family & Home
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Dynamic process in which patients sorted into groups,
priorities of care established & resources allocated
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Sorting based on limited data & resources to get care to
those who will benefit from it the most (“Salvage”)
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Objective framework for stressful & emotional decisions
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Provides equal & rational distribution of casualties to
reduce burden on each to a manageable level
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Sort patients based on physiologic
needs
 Is patient utilizing their own resources
to deal with their injuries?
 Which conditions most benefit from
limited resource expenditure?
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Close to incident in a “safe” area
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Assumptions:
 Medical needs outstrip immediately
available resources
 Additional resources soon available
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Match patients’ current &
anticipated needs with available
resources
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Incorporates:
 Physiologic reassessment
 Knowledge of resource availability
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Goal is to distinguish between:
 Those needing initial treatment in a hospital
 Those needing initial treatment on scene
 Those needing no initial treatment, but at risk for complications
 Those needing no treatment
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Goal is to optimize the
outcome of the individual
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Incorporates:
 Sophisticated assessment &
treatment
 Further assessment of
available medical resources
 Determination of best venue
for definitive care
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National Disaster Life Support Education Consortium, via Medical
College of Georgia’s Center of Operational Medicine
 Disaster Medicine Online University (www.dmou.org)
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Endorsed by the AMA & NREMT
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MASS Triage
 Move
 Assess
 Sort
 Send
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? Assessment guidelines or Pediatric considerations
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Prepares emergency personnel to quickly organize resources to handle
disasters by assuming predetermined roles
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Based upon ambulatory status, respirations, pulse, & mentation to
provides a rapid assessment of resource needs
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Gold standard for field adult multiple casualty triage
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Problems:
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Does not take resources into account
Some patients more “Red” than others
Uses a limited number of physical parameters
Not commonly used during daily operations
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Green
 Minor or no injuries that can
wait for treatment
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Green
 Minor lacerations, contusions,
sprains, superficial burns
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Yellow
 Potentially serious injuries, but
stable to wait a short while for
medical treatment
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Yellow
 Open abdominal wound, eye
injury, pulseless limb, fractures,
significant burns other than
face, neck or perineum
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Red
 Life-threatening but treatable
injuries requiring rapid medical
attention
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Red
 Airway obstruction, cardiorespiratory failure, external
hemorrhage, shock, open chest
wound, burns of face or neck
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Black
 Dead or injuries incompatible
with survival in austere
conditions
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Black
 GCS<8, burns >85% BSA,
multisystem trauma, signs of
impending death
RESPIRATIONS
Minor
NO
ALL WALKING
WOUNDED
YES
POSITION AIRWAY
Under
30/Min.
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Separate walking
wounded from others
Use physiology to
assess:
 Breathing
NO
Over
30/Min.
YES
Immediate
Morgue
Immediate
PERFUSION
Radial Pulse Absent
OR
Capillary Refill
Nail Bed Press
 Blood flow
 Mental status
Over
2 Seconds
Under
2 Seconds
Control
Bleeding
MENTAL STATUS
Immediate
Can’t Follow Simple
Commands
Can Follow Simple
Commands
Immediate
Delayed
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If not walking & talking, begin assessing life functions
ALL WALKING
WOUNDED
RESPIRATIONS
NO
Minor
YES
POSITION AIRWAY
Under
30/Min.
Over
30/Min.
Immediate
NO
YES
PERFUSION
Morgue
Immediate
MENTAL STATUS
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Cannot breathe on own after airway opened = BLACK
Breathing rapidly = RED
Breathing regularly = go to next step in flow chart
ALL WALKING
WOUNDED
RESPIRATIONS
NO
Minor
YES
POSITION AIRWAY
NO
YES
Morgue
Immediate
Under
30/Min.
Over
30/Min.
PERFUSION
Immediate
PERFUSION
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If radial pulse = go to
“Mental Status”
Radial Pulse Absent
OR
If no radial pulse, check
capillary refill
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If refill >2 secs = RED
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If refill <3 secs = go to
“Mental Status”
Capillary Refill
Nail Bed Press
Over
2 Seconds
Control
Bleeding
Immediate
Under
2 Seconds
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Cannot follow simple command = RED
Can follow simple command = YELLOW
All victims have now completed primary triage
MENTAL STATUS
Can’t Follow Simple
Commands
Immediate
Can Follow Simple
Commands
Delayed
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Q: What are the most
useful tools in the
triage area?
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Q: Easier to “upgrade”
or “downgrade” a
patients’ condition?
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Q: How does triage
affect patient
disposition?
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3 days warning that Category 5
storm headed directly for Saba
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1 day prior all communication
shut off & islanders counted or
moved to “safe” locations
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Georges slow-moving, with eye
lasting 8 hrs
 Wall of 140+ mph winds hit island
 Hurricane front wall lasts 1.5 days
 Hurricane back wall lasts 2 days
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Casualties:
 Few buildings left intact
other than schools &
government buildings
 Majority of 1600
islanders with mild to
moderate injuries
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Disaster Issues:
 Ham radio operator
killed
 Minimal water, food or
shelter or medical
supplies
 Who rescues the
rescuers?
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MCI “triage” may extend days
to weeks past an incident
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The WHO estimates that more individuals have indirect
morbidity & mortality post a major disaster than direct
results of the incident
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No antibiotics or antivirals
No maintenance medications
No clean water source
No means of evacuation
Q: How does the rescuer overcome these obstacles?
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At 0430 a chlorine leak
reported at Bossier KFC
chicken processing plant
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MCI “Code” called
 Mayhem comically ensues
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Casualties
 Initial reports of 100+
 15 contact injuries
 10 inhalation injuries
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Disaster Issues
 Field casualty reports
 Weather reports
 “WMD” issues
 MCI Response & Panic
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WMD triage models must include
decontamination plans for conventional,
chemical, radiological, or nuclear attacks
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Difficulty of conducting assessments & care in protective gear
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Biological agents impact triage & destination facility
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Patterns of EMS calls may assist in identification of a occult biological
agent attack or a natural epidemic
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First Watch Biosurveillance tool: www.stoutsolutions.com/firstwatch
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Agent-specific triage dependent
upon suspicion of the agent’s use
 Neurotoxins: contact or inhalation
 Respiratory Toxins: inhalation
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Very difficult to train & maintain readiness with multiple
agent-specific triage schemes
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Agents cause “toxidromes” allowing outcome prediction
of outcome based on presenting symptoms & signs
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Q: What is “SLUDGE”
Syndrome?
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Q: Has anyone in this
room practiced
patient care in a Level
A or B suit?
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EMS notified of MVC with
“multiple injuries”
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1 BLS unit with ALS
intercept dispatched;
upon arrival found:
 2 adult DOAs
 2 adult, 1 teen critical
 1 adult mild injuries
 1 child critical
 3 children moderate injuries
 1 infant missing from scene
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First on scene calls a “Code
Black”
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Response:
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6 BLS & 2 ALS units mutual aid
Multiple engines / Heavy Rescue
Helicopter
Police
Volunteers
Disaster Issues:
 Resource Allocation
 Panic
 Communication failures
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Responders from non-local agencies
often not in contact with IC center
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Increased use & number of private agencies contributes to
this problem
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The KC Hyatt Skywalk Collapse post-disaster review noted
that at no point was communication established with
Incident Command, Triage or Transportation Officers, The
LZ Coordinator or Communications Center by one HEMS
crew for the 9 critical patients transported (KC Health Dept,
1981:7)
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Major incident Declared
Exact Location
Type of incident
Hazards
Access & Egress
Number of casualties / severity of injuries
Emergency services required (personnel & equipment)
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90 mins post event, 5080% of acute casualties
arrive at the ED
 1/3 critical
 2/3 mild to moderate injuries
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3-6 hrs for casualties to be
treated in the ED before
disposition
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To predict total casualties
each facility can expect,
double number of
casualties hospital receives
in the first hour
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Q: How & who
determines what
resources needed for a
scene?
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Q: Who is (are) your
mutual aid, & what
are their capabilities?
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At 0846, American flight
11 directly impacts WTC
south tower
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17 minutes later, United
flight 175 impacts WTC
north tower
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Towers fall at 0959 & 1029
at same time reports
coming in of synchronized
attack on the Pentagon &
United flight 93
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Casualties:
 2,750 deaths
 343 FDNY
 84 Port Authority
 23 PDNY
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Of persons in the
towers when they
collapsed, only 20
pulled out alive
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Disaster Issues:
 Communication
 Triage
 Scope of the Disaster
 Personal Involvement
of rescuers
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Either cause or effect of
the disaster
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Difficult to overcome as
infrastructure disrupted
or eliminated
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Q: What are examples of
natural communication
failures?
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Loss of infrastructure or system
incompatibility
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Difficult to overcome if infrastructure
disturbed
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System incompatibility easy to
overcome if IC is prepared
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Q: What are examples of technological
failures?
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Human error generally
the easiest to
overcome
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Q: What are examples
of human failures?
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“Bands” are collections of
neighboring frequencies
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Cannot communicate if
different bands
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Low (37-47 mHz)
High (250-255 mHz)
UHT (450-470 mHz)
UHF-TV (450-470 mHz)
800 mHz Band (806-902 mHz)
Military & Ham bands
PDAs, pagers & Blackberries
allow alerts & private
communications if tower intact
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“Normal” emergencies use all available manpower &
supplies to save a few lives
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In a “Disaster” the number of injured > ability to treat in
normal manner, therefore “Utilitarian Rule” governs
medical care
 Resource use focuses on saving as many lives as possible
 The greater good of the greater number rather than the particular
good of the individual
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Looks good on paper…doesn’t work so well in real life
A. Jonsen and K. Edwards, “Resource Allocation” in Ethics in Medicine, Univ. of Washington School of Medicine
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Scope does not matter
 343 firefighter vs 1
firefighter death is a tragedy
 Scope of large disasters
“numbs” the impact
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Delayed response more
difficult to overcome than
immediate response
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Q: What resources do you
have available to you?
Katrina
Georges
WTC
Immediate Critical
Medical Services
Minimal
No
Yes
Immediate &
Delayed Scenes
Yes
Yes
Yes
Medical Supplies
Available
Minimal
No
Yes
Medications
Available
No
No
Yes
Difficult Access &
Egress
Immediate –Yes
Delayed - No
Yes
No
Communication
Intact
Yes
No
Yes*
Rescuers as
Patients
Yes
Yes
Yes
Albion Tornado
Waffle House
Van MVC
Immediate Critical
Medical Services
Yes
Yes
Yes
Immediate &
Delayed Scenes
Yes
No
No
Medical Supplies
Available
Yes – Supplies
No – Hospital Staff
Yes – Supplies
No – ED Staff
Yes
Medications
Available
Yes
Yes
Yes
Difficult Access &
Egress
Yes
No
No
Communication
Intact
No
Yes
Yes
Rescuers as
Patients
Yes
No
Yes*
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2008-2009 Gathering of Eagles
 35 medical directors of US & international cities
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“What MCI Scenario Scares You The Most?”
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Avian Flu
Conventional Weapons (i.e. Bombs, Dirty Bombs)
Mass Poisonings
Electromagnetic Pulse Wave
A Single Man with A Cause
 Nuclear Weaponry (“Kill Us? We’ll kill you right back!”)
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“LSU…This is Medic
10 with a busload of
hemophiliacs…I need
a doc on the line
STAT”
 “No…it’s not a F-ing
joke, Doc”
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Understanding basics
of Incident
Command, triage &
resource allocation
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Failing to Plan is
Planning to Fail!
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Brady, Paramedic Emergency Care, Bledsoe, Porter, Shade
NIMS ICS Field Guide, 1st Edition – Infomed
Disaster Medicine, 2002 Lippincott Williams & Wilkins, Hogan and
Burnstein
Emergency Medical Services at a Mass Casualty Incident, Joseph
Cahill, Domestic Preparedness Journal V. III, Issue 7, July 2007
Creating Order from Chaos: Part II: Tactical Planning for Mass
Casualty and Disaster Response a Definitive Care Facilities,
Baker, Michael S., Article Military Medicine, Mar 2007
In a Moment’s Notice: Surge Capacity for Terrorist Bombings,
Challenges and Proposed Solutions, CDC, April 2007
International Nursing Coalition for Mass Casualty Education,
Educational Competencies for Registered Nurses Responding to
Mass Casualty Incidents, August 2003
Mass Casualty Incident Program, Initial Triage Training, AEMS,
courtesy of Phoenix FD.
Virginia Mass Casualty Incident Management, Secondary Triage
Improving health system preparedness for terrorism and mass
casualty events, Recommendations for action, July 2007,
AMA/APHA Consensus report
Mass Medical Care with Scarce Resources, A Community Planning
Guide, Health Systems Research Inc., Feb. 2007
Nancy Caroline’s, Emergency Care in the Streets, Sixth Edition
National Incident Management System, Principles and Practice,
Walsh, Christen, Miller, Callsen and Maniscalco
[email protected]
[email protected]