Disaster Facts and Myths Amy H. Kaji, MD, MPH November 16, 2005 Acute Care College Medical Student Seminar

1. Disaster Facts and MythsAmy H. Kaji, MD, MPH November 16, 2005 Acute Care College Medical Student Seminar

2. The Disaster Facts…

3. Disaster Facts • Disaster – defined as a natural or manmade event that results in an imbalance between the supply and demand for existing resources • Natural • Earthquakes, wildfires, hurricanes, floods, droughts, tsunamis, etc. • Manmade • Terrorist incidents including chemical, biological, radiological, nuclear, and explosive events • Civil unrest and riots

4. September 11, 2001 and the Dissemination of Anthrax

5. Disasters will Impact ALL Physicians • Emergency Physicians • Will likely be the first to assess victims of disaster • Anesthesiologists • Victims will often require operative care • Surgeons • Traumatic injuries may warrant operative treatment • Critical Care Specialists • Victims may require intensive care unit and ventilatory management • Primary Care • Victims will need care of their chronic underlying medical conditions • May be the first to see victims of a covert biological attack • Psychiatry • Victims may require supportive care and grief counseling

6. Disasters will Impact ALL Physicians • Teamwork will be critical • Flexibility in roles may be warranted • Surgeons and anesthesiologists may lend a helping hand in the emergency department

7. March 11, 2004:Madrid, Spain Train Bombings

8. How does disaster triage differ from ordinary triage? • Daily triage • Involves providing highest intensity of care to the most seriously ill patients • These patients may have a low probability of survival • Disaster triage • Doing greatest good for greatest number • Focus shifts on identifying victims who have a chance of survival with immediate medical interventions

9. Disaster Triage Systems • Red • Critical injuries that can be cared for with minimal time or resources • Example: obstructed airway or tension pneumothorax • Yellow • Significant injuries that can tolerate a delay in care • Example: femur fracture without neurovascular compromise • Green • Injuries that can wait for days to be treated • Example: minor contusions, sprains, and abrasions • Black • Expectant patients who have minimal chance of survival even if significant resources are expended

10. Triage Tag

11. Simple Triage and Rapid Treatment (START) • Assesses respiratory status, perfusion, and mental status • All patients who can walk are asked to move away from the incident • Green • Those remaining with RR>30, capillary refill >2 seconds, or are unable to follow commands • Red • Those remaining with RR<30, capillary refill <2 seconds, and are able to follow commands • Yellow

12. Children vs. Adults • Emergency Medical Services (EMS) will not respect “children only” and “adults only” emergency departments during disasters • Every facility must be able to care for and stabilize both children and adults

13. Common problem during disasters: Communications • Communication modes and routes may be destroyed mechanically by natural disasters • Sudden increase in volume and need to communicate with victims, responders, and witnesses • Landlines and cellular phone lines become saturated • Radio frequencies may not be coordinated

14. Communication Difficulties • People problems, not equipment problems predominate • What information needs to be collected? • Who should collect it? • How should the information be relayed expeditiously and comprehensibly to those that need it?

15. Importance of Redundant Communications • Many regions now enlist volunteer HAM operators

16. The Media • Lack of planning for interaction with the media is common • Planning with the media • Maximize risk communications • Precautions about heat illness, food and water safety, disease transmission, etc. • Source of education and support for community disaster mitigation and planning • Decrease disruptive aspects of their involvement • Designate single point of information release

17. Hospital as Victim • Structural and nonstructural damage • Examples: ceiling, water, emergency generator power failure • Prevention is critical • Hospitals should not be built in areas of recurrent floods, or near earthquake faults • Adherence to hazard resistant building codes • Is the hospital safe? • Post-impact assessment by trained structural engineers • Networking within the community • Inter-organizational cooperation with other hospitals, EMS, public health, and fire

18. Hospital as Victim • US Geological Survey estimates that 25% of hospital beds will be damaged and unavailable in a major earthquake • Northridge Earthquake, 1994 • 8/91 acute care hospitals required evacuation (2500 beds lost) • 4 hospitals condemned

19. Standardizing: Hospital Emergency Incident Command System (HEICS) • Originated in CA by the EMS Authority • Joint Commission of Accreditation of Hospital Organizations (JCAHO) requirement • Common terminology • Predictable chain of management • Flexible organization chart • Prioritized response checklists

20. HEICS

21. HEICS • Incident Command (IC) • Overall responsibility for incident management • Role often fulfilled by Hospital Administrator • Planning • Continually evaluates the event by developing action plans and conducting strategic meetings during the event. • Finance and Administration • Responsible for the payment, contracting, or implementation of other agreements required to obtain needed resources as identified by the IC.

22. HEICS • Logistics • Responsible for providing services, facilities, and materials needed to support the event. • May include communication equipment, information systems, food, clean water, medical supplies, and facilities construction. • Operations • All other functions of the ICS are performed to support the operations component. • Responsible for medical direction and communication required to accomplish the management, triage, treatment, and disposition of victims.

23. Hazard Vulnerability Analysis (HVA) • Joint Commission on Accreditation of Healthcare Organizations (JCAHO) definition of Hazard Vulnerability Analysis (HVA) – • “Identification of hazards and the direct and indirect effect these hazards may have on the hospital… • Hazards that have occurred or could occur must be balanced against the population at risk to determine vulnerability.”

24. Hazard Vulnerability Analysis (HVA) • HVA based on an “all hazards approach” • Begin with list of all disasters, regardless of their likelihood, geographic impact, or potential outcome • List should be as comprehensive as possible • Typical categories of potential hazards considered include natural hazards, technological hazards, and human events • Note possible overlap between categories

25. Hazard Vulnerability Analysis (HVA) • Prioritization Process due to limited resources • Evaluate each hazard for: • Probability of occurrence • Risk to organization • Organization’s current level of preparedness. • Disaster are not predictable with any degree of accuracy • Familiarity with geographic area, common sense, and research will help identify hazards • Important to consider likely and unlikely scenarios • Establishing probability of event is only part objective and statistical • Remainder is considered intuitive or highly subjective

26. Probability of Hazard • Evaluate each hazard for its probability of occurrence • Factors to consider: • Known risk • Historical Data • Manufacturer/vendor statistics • Tool presented here uses qualitative terms: high, medium, low, or no probability of occurrence

27. Risk of Hazard • Risk is potential impact hazard may have on organization, and issues to consider include: • Threat to life and/or health • Property damage – seismic activity • Disruption of services from systems failure • Economic loss - adverse financial impact • Loss of community trust/goodwill • Legal ramifications

28. Current Level of Preparedness • A final issue in HVA is hospital’s current level of preparedness, including: • Community resources -- hospital does not respond in a vacuum • Current status of emergency plans and training status of staff • Availability of insurance coverage or backup systems

29. The HVA Tool • Each potential hazard is evaluated and scored in areas of probability, risk, and preparedness • Factors are multiplied for overall total score for each hazard • Ordering total scores prioritize hazards in need of the attention and resources • Determine a score below which no action is necessary, and focus on hazards of higher priority

30. Example of the HVA Tool

31. July 29, 2003: Hospital Structural Damage from an Earthquake in Tokyo, Japan

32. Myth #1 • “I was told that hospitals do not need to prepare for disaster, since disasters are similar to daily emergencies on a large scale. Isn’t that true?”

33. The Truth • Fact: Disasters pose problems that require unique strategies, since disasters tend to disrupt normal communications systems, transportation routes, and normal response facilities.

34. Severe Drought

35. What other myths plague disaster medicine?

36. Myth #2 • Physicians and nurses should be sent to the field to help at the actual disaster site.

37. The Truth • Physicians and nurses depend upon monitors and equipment, not available in the field • On-site chaos of disaster may prove disabling • Goal of disaster medical response planners is to assign personnel to roles that are as familiar as possible and to enhance flexibility of response to extraordinary circumstances • Only physicians and nurses specially trained to work in the field environment should do so • Only if physicians are in surplus in the hospital/clinic environment should they be sent to the field as care providers

38. October 2003:California Wildfires

39. Myth #3 • A disaster plan is required for hospital accreditation. Thus, the existence of a written disaster plan is assurance that the hospital is indeed prepared.

40. The Truth • Written disaster plans • Can cause an illusion of preparedness • The “paper plan syndrome” • Often massive documents that are cumbersome • A disaster plan is only useful, if it is: • Based upon a valid hazard vulnerability analysis • Integrated with local and regional plans • Accompanied by resources necessary to carry out the plan • Associated with an effective training program

41. Avoiding the Paper Plan

42. Myth #4 • The EMS Agency will disperse and distribute the patients to various facilities so as to not inordinately impact one hospital.

43. The Truth • Closest hospital will be the one most significantly impacted • Laypersons assisting non-ambulatory patients will transport them to nearest facility • Many victims will go to closest facility out of loyalty or financial reasons

44. March 28, 1979:Three Mile Island

45. Myth #5 • Timely and appropriate information will be received from the disaster site, and responders will be able to prioritize the use of available resources.

46. The Truth • Communications from the disaster site occur in less than one-third of major incidents • Hospitals learn about disaster from mass media, first arriving casualties and ambulances, rather than from personnel at the actual site • Radio equipment and telephone lines may be damaged or overloaded

47. Water, water, everywhere…

48. Myth #6 • Most of the initial emergency response is carried out by well trained pre-hospital healthcare personnel.

49. The Truth • Most initial care provided by civilian bystanders • Majority of casualties not transported by ambulance • Field and first aid triage stations bypassed • Hospitals do not receive adequate information to guide response

50. Myth #7 • All patients will be transported to hospitals only after they have received adequate medical care in the pre-hospital setting.