Disaster Medical Services Tintinalli Chap. 6

1. Disaster Medical ServicesTintinalli Chap. 6

2. Katrina Anthrax Mailings Haiti 9/11 Picher, Oklahoma Guatamala

3. Trumbull County May 31, 1985 F-5 Tornado

4. Natural Disasters • Have claimed approximately 3.5 million lives worldwide during the past 25 years, adversely affecting the lives of at least 1 billion more people, and have resulted in property damages exceeding $50 billion. • Bleak Future • Increasing population density in flood plains and seismic-/hurricane-prone areas • Development of transportation of thousands of toxic and hazardous materials on the nations’ roads • Potential risks that can occur from incidents at fixed-site industrial facilities • Catastrophic possibilities from nuclear, explosive, biological, and chemical terrorism

5. Definition of Disaster • WHO • A sudden ecologic phenomenon of sufficient magnitude to require external assistance • ED perspective • When the number of patients presenting in a given space of time are such that the emergency department cannot offer even minimal care without external assistance

6. Types of Disasters • Mass Casualty Incidents • Incidents causing Massive Disruptive Impact • Arrival of one important political person or celebrity will completely disrupt normal operations • External Disasters • Occur physically outside the hospital • Internal Disasters • Occur within the hospital • Fire, power failure, water contamination

7. Mass Casualty Events • ED’s experience great difficulty coping with even moderate numbers of patients following a disaster • Confusion • Lack of planning, training, and practice drills • Hospital Shortcomings • Delayed or improper notification • Poor delineation of command structure • Overloaded or broken communication networks • Improper or incomplete identification • Lack of supplies • Lack of public relations

8. Mass Casualty Events • EMS • Transport is complicated • Confusion • Route obstacles • Communication breakdown • Highly injured and ill are often transported to the nearest hospital ED rather than the most appropriate • Other Factors • Overwhelming numbers of “walking wounded” and “worried well” arrive within minutes and peak at 2-3 hours • Poor communication with the scene and within the facility • Incident Command System not followed • Convergence of rescuers, EMTs, and media within the ED • Convergence in the ED of other hospital physicians and nurses • Convergence of family and friends searching for loved ones

9. Disaster Planning • Hazard Analysis • What type of disasters are most likely to occur in the community? • LEPCs – local emergency planning committees • JCAHO Requirements • Written plan for timely care of casualties arising from both internal and external disasters

10. Disaster Planning • Hospital-Community Cooperation • Medical and Health Incident Management (MaHIM) System • Model for planning a regional response • Strong Relationships with Community Agencies • City/County Health Department • EMS, Fire, Police • Public Works • FBI • FEMA • State Governor • State Health Department • State Emergency Management Association

11. Disaster Planning • Hospital-Community Cooperation • Mutual aid agreements or memoranda of understanding with hospitals outside the immediate area • Integration with Other Response Assets • United States Public Health Service/Office of Emergency Response (USPHS/OER) • Office within Department of Health and Human Services • Dedicated to the management and coordination of federal health and medical activities related to preparation, response, and recovery from major emergencies and Presidentially declared disasters

12. USPS/OER • Metropolitan Medical Response System (MMRS) • Promotes coordination between local responders to affect an adequate community response system • National Disaster Medical System (NDMS) • Disaster Medical Assistance Teams (DMATs) • Physicians, nurses, medics, pharmacists, and logisticians • Deploy in response to federally declared disasters and emergencies • National Medical Response Teams (NMATs) • Specialty teams developed to respond to chemical, biological, and radiological events • Commissioned Corps Readiness Force (CCRF) • Disaster Mortuary Operations Response Teams (DMORTs)

13. CDC • Lead federal agency in developing and applying disease prevention • Rapid Response Teams • CDC epidemiologists on standby • Laboratory Response Network (LRN) • Links state and local public health laboratories to advanced-capacity labs • Rapid Response and Advanced Technologies Lab (RRAT) • Support terrorism response teams • National Electronic Disease Surveillance System (NEDSS) • Health Alert Network (HAN) • National Pharmaceutical Stockpile (NPS)

14. The Hospital Disaster Plan • Hospital Emergency Incident Command System (HEICS) • Developed to mitigate confusion and chaos that can paralyze hospitals’ response during a disaster • Employs a clear management structure with defined responsibilities and mechanisms of reporting using a uniform nomenclature that allows clear communication and understanding between hospitals and with other emergency responders

15. Hospital Planning • Responsibility of administration, nursing, and the entire medical staff • Activation of the Disaster Plan • Who, what, and how? • Assessment of the Hospital’s Capacity • Has the hospital itself sustained any structural damage or loss of utility? • How many casualties it can safely manage? • Establishment of Disaster Command • Physician, nurse, and hospital administrator • Must have the ability to communicate with triage, patient care areas, and regional EMS, police, fire, and government authorities • Communication • Critical yet difficult to achieve • Use all resources including cell phones, two-way radios, email, intercoms, television, runners • Supplies • Estimate amount needed above the regular supply • Most centers keep only 2-3 days worth of consumables

16. Hospital Disaster Administrative and Treatment Areas • Disaster Control Center • Remote from ED • Coordinates hospital activities with those at disaster site • Triage • Rapid assessment of all incoming patients • Assignment of Priorities for Management • Classification of Dispositions • Patient Care Areas • Major Trauma and Medicine • Minor Trauma-Primary Care • Admission Presurgical Holding • Surgery • Morgue • Decontamination • Psychiatry • Family Waiting and Discharge

17. Training and Drills • JCAHO requires 2 drills per year • Familiarize staff with roles and responsibilities • Point out weaknesses and omissions in the plan • May be mini-drills, tabletop scenarios, or full-scale community-wide simulations

18. Catastrophic Casualty Management: Disaster Operations • Field Medical Care • START technique (Simple Triage and Rapid Treatment) • Quick assessment of respirations, perfusion, and mental status • Field Hospital • Initiation of treatment d/t delayed evacuation in a mass casualty situation • SAVE system (Secondary Assessment of Victim Endpoint) • Identifies patients who will benefit from treatment in the field • 3 categories • Those who will die regardless of treatment • Those who will survive without care • Those who will benefit significantly from field interventions

19. Disaster Operations • Incident Command System (ICS) • Standard emergency management system used throughout the country when there is a single scene for a disaster event • 5 main components • Incident Command • Operations • Planning • Logistics • Finance

20. Disaster Operations • Communication from Disaster Site to Hospital • Local Emergency Communications Center • Number of Casualties (Serious vs. Ambulatory) • Hospital • Communicate bed availability, number of casualties received, number of casualties prepared to accept, and items in short supply • Distribution of Casualties to Receiving Hospitals • On-Site Incident Commander • Less injured, more stable can be sent a further distance to outlying hospitals • Specific injuries, i.e. burns, spinal cord injuries, sent to specialized facilities • On-Site Disaster Medical Teams from Hospitals • Dispatch with great caution • Few physicians and nurses are prepared to work under austere field conditions • Conditions for dispatch • Prolonged Extrication • Blocked Transportation Routes • Casualty Numbers Exceed Transportation Capacities

21. The Emergency Department • Initial Response • Verification of the Incident • Disaster Notification Form • Questions to ask the caller • Initial Needs Assessment • Charge Nurse and Physician In Charge • Disposition current patients, determine priority of care, number of patients that can be received, additional staffing requirements, and assign staff responsibilities • Personnel Notification • Security and Traffic Control • Reception of Patients • All litters and wheelchairs near ambulance ramp • Re-stock ambulances with consumables including ET tubes, IV fluids, C collars, splints, and bandages

22. Therapeutic Management During Disaster Situations • Triage • Defined as the prioritization of patient care based on severity of illness/injury, prognosis, and availability of resources • Determine where the patient needs to go • Decontamination • Resuscitation Areas (“Crash Rooms”) • Major Trauma-Medical Area • Minor Surgery-Primary Care • Morgue

23. Triage • Triage Teams • Consist of a physician (Triage Officer), ED nurse, and admitting clerk • Responsibilities • Assign patients to appropriate treatment areas • Institute the most basic life-support measures • Admitting clerk completes tags, attaches them to victims, and retrieves valuables/clothing

24. Triage Classification • NATO Triage Card (METTAG) • Red • Life-threatening shock or hypoxia is present or imminent • Patient can likely be stabilized if given immediate care • Yellow • Patients are not yet in life-threatening shock or hypoxia although decline may ensue • Can likely withstand 45-60 minute wait • Green • Injuries are localized without immediate systemic implications • Unlikely to deteriorate for several hours if at all • Black • Expectant or dead

25. Patient Care in the ED • Wounds • Should be copiously irrigated • If > 6-12 hours old, treat with debridement and leave open • Tetanus prophylaxis • Radiographic and Laboratory Studies • Use sparingly, if at all, and only if they will change therapeutic intervention • Blood Bank • May need to utilize volunteer donors, family/friends, “walking wounded”

26. Patient Care in the ED • Patient Identification and Record Keeping • Usually poor to nonexistent • Many implications • Cost of care • Billings, Reimbursement, Insurance collection • Quality of care • Efficacy of disaster procedures • Media Relations • Media should be directed to a room or office away from the ED and be closely supervised by a hospital administrator/PR specialist • Handling of Family Members • Direct to separate family area • Operator will be overwhelmed with calls

27. Aftermath of Disaster • Return to Normal Operations ASAP • Restock and clean • Address emotional stress • Critical Incident Stress Debriefing (CISD) • Record, Review, and Criticize Deficiencies • Take immediate steps to correct