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Our Healthcare Facilities at Risk

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Presentation on theme: "Our Healthcare Facilities at Risk"— Presentation transcript:

1 Our Healthcare Facilities at Risk
Our Healthcare Facilities at Risk! Closing the Gaps in Critical Preparedness Areas

2 Working Together to Achieve Healthcare Preparedness
Identifying critical gaps in PHE preparedness is an important area of focus.

3 Texas Motor Speedway Exercise
Scenario: Aircraft explodes on race day Result: > 10,000 victims Included a dirty bomb Stakeholders & Resources: All area Public Health departments Over 40 State and federal agencies Over 2,300 victim volunteers Over 300 First Responders 30 area hospitals participated

4 Texas Motor Speedway Exercise, November 2004
Three critical gaps identified: Casualty / Patient Triage Medical Decontamination (Med Decon) Personal Protective Equipment (PPE)

5 Consequences of Non-preparedness
Healthcare facilities closed Morbidity / mortality for healthcare providers Morbidity / mortality for our patients

6 Working Together to Achieve Healthcare Preparedness
Tarrant County APC established a collaborative agreement with nationally and regionally recognized leading stakeholders to meet the educational and training needs of the critical gaps identified.

7 NDLS Family of Courses A comprehensive, nationally-standardized family of all-hazards training programs developed by the NDLS consortium of academic, state, and federal centers. These 3 courses address ALL levels of medical providers. Also included in the target student group are; Law enforcement personnel Firefighters Public health personnel Military personnel Volunteers Emergency planners / managers Any other personnel who may respond to a disaster -The NDLS family of courses trains the entire SYSTEM, and thus cuts across all barriers between types of responders and helps to create TEAMWORK, INTEROPERABILITY, and a more COORDINATED RESPONSE.

8 Establishing a Standard

9 Academic Stakeholders
NDLS Co-founders Subject matter experts AMA NDLS Text Editors Experienced in statewide and national educational program distribution

10 MRC Regional Stakeholders
Texas State Guard unit Uniformed MRC Mobilized by Governor Subject matter experts Experienced regional faculty

11 NDLS-Decon 2 day, 16-contact hours Meets OSHA awareness and
operational training levels CDLS course, 4 hours NDLS-Decon, 12 hours Includes 8 hours of interactive-skills session

12 Establishing a Standard
Recent course addition to the NDLS Family Internal validity assessment Beta-tested statewide in Georgia Currently in 2nd year of distribution External validity assessment…Texas roll-out Tarrant Co. APC, first to offer in Texas APC in collaboration with stakeholders are establishing a national standard

13 “Preparing Our Communities”

14 Continuing Medical Education CME Faculty Disclosure
In order to assure the highest quality of CME programming, the AMA requires that faculty disclose any information relating to a conflict of interest or potential conflict of interest prior to the start of an educational activity. The teaching faculty for the BDLS course offered today have no relationships / affiliations relating to a possible conflict of interest to disclose. Nor will there be any discussion of off label usage during this course.

15 D-I-S-A-S-T-E-R Overview

16 Objectives Identify the critical need to establish healthcare preparedness for disasters Define “disaster” and “Mass Casualty Incident (MCI)” Define “All-hazards” and list possibilities Identify the components of the D-I-S-A-S-T-E-R paradigm Identify and apply a mass casualty triage model utilizing “M.A.S.S.” and “ID-me” - These objectives are straight-forward and self-explanatory - These come directly out of the text at the beginning of the chapter

17 What is a “Disaster”? Disaster- dis·as·ter n.
An occurrence causing widespread destruction and distress; a catastrophe. A grave misfortune. Informal- A total failure Different definitions have been put forth for the word, “disaster.” These are just a few…

18 What is a “Disaster”? From another perspective…
JCAHO: “Something that disrupts the environment of care; disrupts care and treatment; changes or increases demand.” -these definitions come from a more medically-oriented perspective -Many events are, by themselves, not inherently disasters, but when they occur in certain places, or at certain inopportune times, they become disastrous. For example…….(next slide)

19 “Disaster” Definition
A disaster is present when need exceeds resources In other words: the response need exceeds the resources available Disaster = Need > Resources [[Self-explanatory]]

20 MCI = Healthcare Need > Resources
“MCI” Definition “Multiple/Mass/Major Casualty Incident” An MCI is present when healthcare need exceeds available healthcare resources! MCI = Healthcare Need > Resources This same concept also applies to healthcare incidents. A “multiple”/”mass”/”major” casualty incident is present when healthcare needs healthcare resources.

21 MCI Management This is an important concept! Goal:
Do the greatest good for the greatest number of potential survivors! This is an important concept! The goal of MCI management is to do the greatest good for the greatest number of potential survivors. This is ALSO the definition of “triage”, a term that arose on the battlefield but that also applies to civilian disasters. Although this goal makes sense intellectually and practically, it may pose emotional difficulties for those providers not accustomed to NOT doing everything possible for every possible patient every time. In other words, MCI response might require responders to withhold immediate care on-scene for those victims who might still be alive, but whose needs exceed available resources, in favor of those victims with a better chance of survival. (We will return to this concept during the Triage presentation.)

22 Are We Prepared? The Concern:
Increased likelihood of weapons of mass destruction (WMD) noted for years Worldwide arsenal of nuclear, biological and chemical (NBC) agents: Security, Political, Socioeconomic changes The threat to intentionally harm large civilian populations has never been greater than today! other abbreviations; WMD also known as “WME” (weapons of mass effect) CBRNE-chemical, biological, radiologic, nuclear, explosive BNICE- biologic, nuclear, incendiary, chemical, explosive these agents are found all over the world and may be deployed anywhere, against any group…..even civilians Recent events show increased attacks on U.S. citizens, both here and abroad

23 September 11, 2001 “9 - 11” Terrorism The Reality:
The events of September 11th , were a clear message of the intentions of one terrorist organization…… This is the type of event that we must now prepare to respond to…. We cannot remain complacent about the goals of terrorist organizations………….they actively seek the publicized deaths of as many Americans as possible, in order to draw attention to their political / fundamentalist agendas

24 Terrorism Use of force against persons or property:
To intimidate or coerce To further political or social objectives Criminal act

25 Destruction / Effect” Definition
“Weapons of Mass Destruction / Effect” Definition “WMD / WME” Weapons or devices that injure or kill large numbers Cause widespread destruction and/or panic Chemical, Biological, Radiological, Nuclear, Explosive (CBRNE) Weapons of Mass Destruction (or Mass Effect, as some prefer) are those that injure or kill large numbers of victims. These casualties are often accompanied by widespread destruction. Occasionally, however, the number of victims or the extent of destruction might be relatively limited, but the ensuing generalized panic is NOT. For example, although the anthrax scare of the autumn of 2001 claimed only 5 lives, it caused widespread panic throughout the US and abroad.

26 Chemical Weapons Man-made poisons spread as gases, liquids, or aerosols Cause illness or death in humans, animals, plants May be inhaled, ingested or absorbed Variety of disseminating devices We will discuss these agents in greater detail in subsequent sections. Briefly, however, chemical weapons may be divided into 5 categories: “lethal” agents, “blood” agents, “blistering” agents, “choking” agents and “incapacitating” agents.

27 Chemical Weapons “Nerve agents”: GA, GB, GD, VX
“Blood agents”: Cyanide “Blister agents”: Mustard, Lewisite “Choking agents”: Phosgene, Chlorine “Incapacitating agents”: BZ The five major categories of chemical agents include: Nerve agents (cholinesterase inhibitors), such as GA, GB, GD and VX Blood agents (asphyxiants), such as cyanide and carbon monoxide Blister agents (or vesicants), such as mustard and Lewisite, Choking agents (respiratory irritants or pulmonary agents), such as phosgene and chlorine And Incapacitating agents, such as BZ. [[Use of another incapacitating agent: Moscow Theater, Oct. 23, 2002: 41 Chechen rebels take >600 hostages in a Moscow theater. Crisis ends when authorities pump anesthetic gas (fentanyl) into the ventilation system. (Initially, outside experts speculated that the agent used was BZ, a drug similar to but 25 times more potent than atropine. It was initially developed for use to treat intestinal diseases, but the unacceptably high incidence of hallucinations and other side effects led the manufacturer to turn it over to the military for use as an incapacitating agent.) All the rebels and at least 130 of the hostages died, almost all from the effects of the gas. [The authorities refused to disclose to rescue personnel or even doctors in receiving hospitals that the agent used was only a narcotic whose effects could have been reversed with a readily available drug (naloxone or Narcan). Why? Allegedly because they did not want the rebels to know what was used. Consequently, many hostages died who could otherwise have been saved.]]]]

28 Chemical Weapons Aum Shinrikyo Sarin Gas Release
June 27, March 20, 1995 Matsumoto, Japan Tokyo, Japan Courthouse/Residence Subway 4 dead dead 150 injured >5000 arrived at hospital Aum Shinrikyo Chemical weapons have been used since the 5th century BCE, with the advent of poisoned arrows. More recently, in June 1994 in Japan a cult called “Aum Shinrikyo” used nerve agents as a chemical weapon, killing 4 and injuring Far more media exposure was provided for a subsequent attack by this same cult in March The Tokyo subway incident, which also involved the nerve agent, sarin, killed 12 and sent more than five thousand people to the hospital. Most of the injured transported themselves to St. Luke’s International Hospital which was just two blocks from the central subway station. To make matters worse, many health care providers, doctors and nurses were affected from the gases given off from the victims. The cult, holds assets of 20 to 30 billion dollars and includes many members with professional scientific and medical training It has built a terrorist network that will be a significant factor, at least in Asia, for years to come.

29 Nuclear Weapons Catastrophic explosions
Massive nuclear energy release through atom splitting Traumatic injuries, burns, fallout, delayed effects Nuclear weapons pose an entirely different threat altogether. A nuclear weapon is a device that releases nuclear energy in an explosive manner as a result of nuclear chain reactions involving the fission, fusion, or both, of atomic nuclei. In other words, this is the “mushroom cloud” of an atomic bomb, such as those dropped on Hiroshima and Nagasaki, Japan in 1945 to end World War II. The photo on the left shows a typical nuclear explosion, with its massive release of energy and radiation. The photograph on the right, taken in the aftermath of the bombing of Hiroshima and Nagasaki, graphically illustrates a typical immediate casualty from this type of incident. In this case, most of the immediate casualties will be suffering from massive burns. Even hospitals with specialized burn centers will be overwhelmed by the sheer numbers of victims. For this reason, healthcare personnel such as those of you in this audience will become critically important providers of care for these victims. Other victims will suffer from traumatic injuries due to the blast effect, acute and delayed radiation syndromes, and fallout.

30 Radiological Weapons Devices to disperse radioactive substances
Conventional explosive device (“dirty bomb”) Intentional radiation release: water, food, terrain Less energy & radiation release than a nuclear weapon Delayed detection: no “scene” “Worried well” & civilian panic Next in the “CBRNE” listing are radiological weapons. What is a “radiological” weapon, and how does it differ from a “nuclear” weapon? A radiological weapon is a device that is used to disperse radioactive materials. One form is the so-called “dirty bomb”, which is a conventional explosive device that contains radioactive substances. Other forms of radiological weapons might take the form of intentional radiation release into water supplies, food supplies or terrain. Radiological weapons release less energy and less radiation than a nuclear weapon. Victims may not become symptomatic for several hours or days, leading to delayed detection. Once the radiation release becomes “public”, an enormous number of “worried well” victims might complicate incident management.

31 Aircraft as WMD September 11, 2001 World Trade Center Towers, NYC
Pentagon, Washington, DC Somerset, PA The ultimate use of explosives was the high-jacking of commercial aircraft with their loads of jet fuel. On September 11, 2001, these aircraft were converted to weapons of mass destruction, killing approximately 3000 people.

32 Are you the victim of a weapon of mass effect (WME)?

33 Anthrax as WME “Asymmetric” warfare: “Small event” Widespread effect
What IS terrorism? Let’s start with a few definitions to lay the ground work for our understanding. Definition (FBI): “the unlawful use of force against persons or property to intimidate or coerce a government, the civilian population, or any segment thereof, in the furtherance of political or social objectives.” Most acts of terrorism are examples of “asymmetric warfare”, whereby a relatively “small” event can produce widespread panic and changes in a population’s beliefs, behaviors and practices. The most blatant recent example is that of the anthrax letters in Although only 6 people died, the attacks resulted in massive disruptions of the entire postal system and other government and private activities. This definition applies to local EMS systems, hospitals and health care providers. Although “historical” definitions implied the use of explosive and incendiary devices – which, in fact, are still the most common terrorist weapons -- there are new considerations with which most healthcare providers were until recently unfamiliar: - chemicals and hazardous materials not encountered on a daily basis. - biological diseases which may have only been covered briefly in initial training and have never been faced seen in clinical practice. - issues of personal protective equipment. - new multi-disciplinary response activities - new public health considerations. In other words, terrorism in the 21st century mandates a whole new set of operational guidelines for EMS providers, communities and the healthcare system as a whole.

34 Biological Weapons Disseminate disease-causing microorganisms or biologically-produced toxins (poisons) Cause illness or death in humans, animals, or plants Numerous agents could be used As opposed to the man-made chemical weapons, biological weapons distribute disease-causing micro-organisms or their toxins (poisons). These agents cause illness or death. Biological weapons have already been used in North America. In 1763: Sir Jeffrey Amherst wiped out the Delaware Indian tribe with a “gift” of smallpox-contaminated blankets. Almost any disease-causing organism or toxin could be used, and there are many from which to choose. Many – in fact, MOST -- of the organisms which might be used for biological weapons exist today in the natural world, and cause isolated cases or outbreaks of disease. As we shall see in subsequent presentations, biological weapons pose several unique threats to potential victims and to responding personnel.

35 Biological Weapons Smallpox Plague Anthrax
As mentioned above, most of the potential bioterrorism agents exist in the environment today. The major exception to this is *smallpox*, which theoretically exists only in 2 high-security research facilities in the U.S. and Russia, having been eradicated during the 1970’s through world-wide vaccination programs. As a result of security concerns about one of the research facilities, experts strongly believe that the deadly virus might, in fact, be in the hands of possible terrorists. This is the basis for the renewed interest in smallpox vaccination for military and – perhaps – civilian healthcare personnel and the general public. As we shall see in subsequent presentations, biological weapons pose several unique threats to potential victims and to responding personnel. Bacillus anthracis, the bacterium that causes anthrax, is another “endemic” organism in animals world-wide. There are occasional sporadic human cases (usually the skin (“cutaneous”) form). As we witnessed in 2001, bioterrorism with this agent would take the form of aerosolized, “weaponized” spores, which would be likely to cause the highly fatal inhalation (“pulmonary”) form of the disease. Nov 8, 2003: a NM couple on vacation in New York City became critically ill with high fever, exhaustion and severely swollen lymph nodes. Tests confirmed the first known cases of the disease in NYC in more than 100 years. Endemic in prairie dogs in the southwestern U.S., bubonic plague is only one of several bacterial agents which could be used for bioterrorism. Anthrax

36 Biological Event Influenza 1918-1919
Emerging infectious diseases also cause “natural disasters”. During the 1970’s, “Legionnaires’ Disease” caused numerous deaths in the United States, following an outbreak at an American Legion convention in Philadelphia. More recently, West Nile Virus has spread throughout at least 44 states, also causing fatalities, especially among the elderly. In 2002, more than 4100 cases were reported to the Centers for Disease Control and Prevention. As of late November 2003, that number had more than doubled to over 8500 cases for Both of these figures likely reflect a degree of under-reporting, so the actual number of cases may well be even higher. Although the number of reported deaths due to the virus has remained constant at approximately 200 for 2002 and for 2003, West Nile Virus is still a significant cause of morbidity. Although the virus is not directly communicable from person-to-person, it can be transmitted through blood transfusions or organ transplants. Consequently, the disease has also exacted a significant economic toll due to the introduction of screening and testing methodologies.

37 Epidemics Severe Acute Respiratory Syndrome 2003
SARS poses a significant public health threat. It is just the latest of nature’s emerging infectious diseases. As with West Nile virus (and the avian influenza that spread through southeast Asia in early 2004), these diseases emerge when humans come into contact with the organism’s natural reservoir, or when the organism adapts or mutates to a more lethal human form. Worldwide spread of these emerging infections creates a true public health emergency. SARS (Corona virus)

38 September 2005 “Katrina” & “Rita” Natural Events The Reality:
The events of September 11th , were a clear message of the intentions of one terrorist organization…… This is the type of event that we must now prepare to respond to…. We cannot remain complacent about the goals of terrorist organizations………….they actively seek the publicized deaths of as many Americans as possible, in order to draw attention to their political / fundamentalist agendas

39 Natural Disasters The Concern: Numerous & widespread
Millions of fatalities worldwide Countless millions more injured $ Billions per event Common in the U.S. There WILL be a natural disaster in the U.S. this year Many of us likely think of “terrorism” and man-made events when we think of “disasters” and “mass casualty incidents”. As already mentioned, natural disasters are far more numerous and widespread. They account for millions of casualties and injuries worldwide. The economic costs are enormous – often many millions or even billions of dollars per event. And they are often inescapable. There is no doubt that there *WILL* be a natural disaster in the United States this year.

40 “Katrina” Evacuation Treatment Surge Capacity Triage

41 “Rita” Mitigation Evacuation

42 What causes the greatest number of fatalities in the U. S
What causes the greatest number of fatalities in the U.S. from natural disasters?

43 Flash Floods Cause the greatest number of U.S. fatalities from natural disasters! Most deaths involve motor vehicles One particular type of flood is the most lethal of all: the “flash flood”. Flash floods account for more deaths in the US than any other natural disaster. Flash floods are characterized by a number of seeming paradoxes. Unlike the massive flooding that often accompanies other natural disasters, flash floods typically involve relatively small volumes of water that appear rather quickly. In developed areas, this can result in “urban rivers”, which occur ever more frequently now as a consequence of increased urbanization. Flash floods are SLOW killers – even water moving at the rather unimpressive speed of 6 to 12 miles per hour can be lethal. Even a small amount of water possesses enormous force – a 2-foot force is sufficient to wash away an automobile. And it is virtually impossible to guess. This is one reason why it is so dangerous to drive on a road surface covered with water. Another reason is that flash floods present the unique danger of a “blind trap”, due to submerged debris and undetectable road damage. For these reasons, most deaths due to flash floods involve motor vehicles.

44 Transportation Incidents
More than 6 million per year in U.S. More than 40,000 traffic fatalities Secondary hazards Fire, explosion, chemical, radioactive All modes: Highway Air Rail Marine Transportation incidents are easily the most numerous disasters in the US, with more than 6 million per year. They account for more than 40,000 fatalities. Everyone in this room has probably been involved in one, responded to one as an emergency services provider, or cared for victims. What we might not have realized at the time, however, was the possibility of secondary hazards: trains and trucks carrying all sorts of potentially toxic or deadly substances travel through our cities every day. And no mode of transportation is immune from the possibility of a disaster….

45 Industrial Hazmat Mostly minor “spills”, occasionally severe!
Massive explosions Hazardous materials release Toxic fumes, radiation, biological agents Secondary disasters Multiple casualties Prolonged community impact Loss of homes & jobs Emotional impact Although the explosion is impressive, this explosion in March 2000 at Phillips refinery in Pasadena, Texas “only” killed one and injured 68. A previous explosion at the same site in October 1989 killed 23, and injured 130. Even worse was the April 1947 disaster in Texas City, TX, when a cargo ship being loaded with 3000 tons of ammonium nitrate fertilizer caught fire and exploded, killing at least 600 (more than 100 additional persons were never accounted for and presumed dead), and injuring more than Casualties totaled more than 25% of the town’s population! Much of the town was destroyed and over 1/3 of its remaining structures were condemned, leaving >2000 homeless. The most horrific industrial accident occurred in Bhopal, India in 1984, when 40 Tons of Methyl Isocyanate were released from a Union Carbide plant. Population of 900,000 Estimates 6,000-10,000 ? Affected ~ 400,000 Lack of safety devices Manuals in English More recently, in December 2003: explosion at gas well in China – kills at least 200, injures ?? , causes evacuation of 41,000. Could something like this happen in the US????

46 “All-Hazards” Man-made Fires Explosive devices Firearms
Structural collapse Transportation event Air, Rail, Roadway, Water Industrial HAZMAT WMD – NBC events Etc… Natural Earthquake Landslides Avalanche Volcano Tornado Hurricanes, floods Fires Meteors Etc… -All-hazards refers to ALL the most likely causes of disasters………….they are listed on this slide. -Natural disasters have been occurring at least since the beginning of recorded history and there is no reason to think they will stop any time soon………………they have been responsible for the deaths of millions of people - Man-made disasters may be accidental or intentionally-caused………….it is quite possible that the responder will not know which one it is at the time of the response (thus the need for a response method that works for ALL-hazards)

47 All-Hazards Definition
Man-made or natural events with the destructive capability of causing multiple casualties All-Hazards Preparedness: Comprehensive preparedness required to manage the casualties resulting from All-Hazards As we saw in one of the very first slides, disasters come in many different shapes and sizes. In the vocabulary of disaster preparedness, “ALL-HAZARDS” is the term used to describe these varied causes. Similarly, “all-hazards preparedness” is the comprehensive preparedness required to manage the casualties resulting from all-hazards events.

48 NDLS Concept Critical to healthcare preparedness: Uniform
Coordinated approach Mass casualty management from all-hazards Best accomplished by standardized training and practice guidelines

49 NDLS Family of Courses A comprehensive, nationally-standardized family of all-hazards training programs developed by the NDLS consortium of academic, state, and federal centers. These 3 courses address ALL levels of medical providers. Also included in the target student group are; Law enforcement personnel Firefighters Public health personnel Military personnel Volunteers Emergency planners / managers Any other personnel who may respond to a disaster -The NDLS family of courses trains the entire SYSTEM, and thus cuts across all barriers between types of responders and helps to create TEAMWORK, INTEROPERABILITY, and a more COORDINATED RESPONSE.

50 Stakeholders CDP Research Triangle Institute
A partial listing of the NDLSEC members is shown in this slide. Research Triangle Institute

51 Confidence and Teamwork!
These are the topics covered in ADLS. - Extensive simulations-training is utilized on Day 2

52 D-I-S-A-S-T-E-R Paradigm
These 3 acronyms are mnemonic devices which can help rescuers remember critical information about disaster response and triage. These acronyms are taught in ADLS, BDLS, and CDLS as the organizational standard for disaster response and triage.

53 DISASTER Paradigm Detection Incident Command Safety & Security
Assess Hazards Support Triage & Treatment Evacuation Recovery Natural & Accidental Trauma & Explosive Nuclear & Radiological Biological Agents Chemical Agents

54 D-I-S-A-S-T-E-R Paradigm
A standardized method to recognize and manage the scene and care for victims Reinforced throughout all NDLS courses: A training tool… Practical approach on scene! An organizational tool… Utilize resources, assess needs A series of questions… This acronym outlines the major steps in a disaster response and is explained on the next slide. It is useful for both training purposes and as a practical method to aid in memory-recall during an actual response. It is usable by ALL responders at the scene of a disaster (whether they are medical personnel, law enforcement, firefighters, military, public health, volunteers, etc…).

55 D-I-S-A-S-T-E-R Paradigm
Do I detect something, what caused this? -Detection of an event is of course crucial to an efficient response. Some events are easy to detect and have an obvious origin (flood/tornado/etc…). Some events are easy to detect, but do not have an obvious origin (for example, an explosion at a manufacturing plant……..was it an accident or was it an act of terrorism?) Some events may be detected long after the actual event has occurred (patients start to seek treatment at hospitals for an infectious disease they were unknowingly exposed to 7 days ago in a quiet biological weapon release). An astute clinician or public health worker may detect the incident. Detection may also be accomplished by way of technology. Monitors may sound alerts in the presence of radiation, chemical agents, or certain biological agents. Is my need greater than my resources? If this is an MCI/disaster, sound the alert immediately!

56 D-I-S-A-S-T-E-R Paradigm
Do we need an incident command, where? -If this is truly a disaster or MCI, then we need a command structure to be set up to coordinate all resources and actions taken in our response. This command should be quickly set up in a secure and safe location.

57 D-I-S-A-S-T-E-R Paradigm
Is a safety or security issue present? -The scene must be screened for any safety/security issues present. If help is to be brought to the scene, then the scene must be relatively safe or else MORE casualties will be created. If a safety/security issue is present, it should be dealt with by the appropriate agency (law enforcement, hazmat team, fire dept., etc…)

58 D-I-S-A-S-T-E-R Paradigm
Did we assess the hazards that could be here? -are there any other hazards here? -Do I need to call for someone who can assess things that I can’t? (radioactivity, etc…) Hazmat? Violence? Fire? Unstable structures? Explosives? Rioting? Weather? Gas leaks? Etc……

59 D-I-S-A-S-T-E-R Paradigm
What support, people, supplies are needed? -What kind of help do I need here? Local? State? Federal? Military? Private? Volunteer? Equipment? Etc….

60 D-I-S-A-S-T-E-R Paradigm
Do we need to triage, how much treatment? Are there more patients than medical personnel? Do we need to sort (triage) the patients so the most injured are seen first? Can we begin treatment here?

61 D-I-S-A-S-T-E-R Paradigm
Can we evacuate/transport the victims? How will we evacuate the victims?………….and in what order? Where will we send them?

62 D-I-S-A-S-T-E-R Paradigm
What recovery issues are present? What is needed for this community and its responders to recover from this incident?

63 D-I-S-A-S-T-E-R Paradigm
Is my need greater than my resources? KEY! What is needed for this community and its responders to recover from this incident?

64 D-I-S-A-S-T-E-R Paradigm Detection
Goal assess: Is a disaster / MCI present? ...Need > Resource? What caused this event? Detection is Awareness! TRAP! “tunnel-vision” on the injured patients -if disaster/MCI is present……..SOUND THE ALARM IMMEDIATELY (declare an MCI by radio) !!! Do NOT wait to try to determine the cause. Sound the alarm first. -Some causes are obvious…..storm/earthquake/etc…. Some causes may be accidental or intentional (fire/explosion). The actual cause of an event may be investigated and debated for YEARS after the event (think of some plane crashes…..). We ,as responders, cannot wait for an official cause to be found before responding. We must simply assume that the event could have been either accidental or intentional and take all necessary precautions to protect as many lives as possible. Events with uncertain causes should be dealt with using extreme caution. -pitfall- beginning care of individual patients prior to assessing the whole scene. This may lead to a delay in the identification of the event as an MCI, and thus a delay in adequate resources arriving in a timely fashion. The SCENE takes priority over any one patient. You may be a medical person by title, but medical care is NOT the priority upon arrival!!!

65 D-I-S-A-S-T-E-R Paradigm Detection
Sample Checklist: Are my capabilities or capacity exceeded? Does my need exceed available resources? Before you step out of the vehicle, look around. If a threat or agent is suspected, what is it? What do you see, smell or hear that is different? What are bystanders saying or doing? Is everyone coughing, crying, staggering or lying still? -Identify disaster/MCI and declare it if present. Have you driven too far into the scene for your safety? Look around before exiting vehicle. Any threats? Any signs of hazardous materials? Violence? For hospital providers, is the influx of patients into your ER abnormal. Is something else going on? Is there a common complaint or symptom?

66 D-I-S-A-S-T-E-R Paradigm Incident Command
Incident Command System (ICS) Born in Fire Service Managing wildfires in early 1970’s Interagency task force collaborative effort Uniform structure Clearly defined roles & chain of command Allows for a scalable response Unified Command ICS was developed by FIRESCOPE (Firefighting Resources of Southern California Organized against Potential Emergencies) It has been tested in numerous emergencies/disasters and has proven to be an effective model for coordinating resources during a crisis.

67 Incident Command System
The Basics “Commander” Unified Command Planning Logistics Operations Finance INCIDENT COMMANDER (IC) IS: Ultimate responsibility and authority for the entire operation. Generally fire service or law enforcement Unified Command Generally a staff will support the IC “Thinkers” “Getters” “Doers” “Payers”

68 Incident Command System
What does the Incident Command need to know? Number and type of casualties Substances involved Estimated time of arrival to hospital Time / location of the incident Method of contamination (vapor or liquid) Necessary decontamination Updated information This is a lot information. As an individual responder, you do not need to know this entire list. However, you will be communicating with an Incident Commander and this is what he or she needs to know. It’s also to important to advise the Incident Commander of any CHANGES in this information (for example, fewer casualties than were previously thought to exist). Obviously, an Incident Commander needs much training and command experience to properly handle an incident. The commander also needs to have a familiarity with the capabilities of all the agencies involved, before an incident occurs. The time to exchange business cards is NOT in the hot zone.

69 Incident Command System
The Basics “Commander” Unified Command Planning Logistics Operations Finance Planning: Responsible for collection, evaluation and display of incident information. It also maintains status of resources, preparing a plan of action, and incident related documentation Obtain briefing from IC Establish necessary positions within function Supervise preparation of Incident Action Plan (IAP) Develop alternative strategies Provide periodic predictions on incident potential Supervise planning section units “Thinkers” “Getters” “Doers” “Payers”

70 Incident Command System
The Basics “Commander” Unified Command Planning Logistics Operations Finance Logistics: Is responsible for providing adequate services and support to meet all incident or event needs. Allocates resources where there are needed Obtain briefing from IC Establish logistics section positions as necessary and do briefings as necessary Identify service and support needs for the duration of the incident Coordinate and process requests for resources Advise IC and staff of current service and support capability Prepare "Service and Support" portions of the IAP Responsible for providing: supplies, equipment, personnel, facilities, food, services, communications support Traditionally responsible for staging of vehicles/apparatus/ambulances and liaisons with Operations Supports Operations closely “Thinkers” “Getters” “Doers” “Payers”

71 Incident Command System
The Basics “Commander” Unified Command Planning Logistics Operations Finance Operations: Operation Chief is responsible for directing tactical actions to meet incident objectives. There is only one Operations Chief (if activated by the IC) per operation period but that position may be deputies as needed. The operations section commonly uses Branches, Divisions, Groups, Task Forces, and Strike Teams to maintain unity, chain of command, and span of control Obtain briefing from IC Establish operational objectives per incident plan For the first hour For hours two - eight For extended operations Develop tactics to accomplish objectives Divide incident by geographic reference and/or function Appoint and brief Branch/Division/Group leaders Supervise operations Determine and acquire resources from Branch/Division/Group leader input Operations Officer is the ONE in charge of the actual scene Responsible for directing primary actions Responsible for personnel accountability & scene control Responsible for Triage and Transportation Sectors “Thinkers” “Getters” “Doers” “Payers”

72 Incident Command System Operations
An example of chain of command under the Operations Chief. Notice the distribution of Branches and sectors or divisions under the Chief of Operations. Medical Direction– Responsibilities: Onsite Medical Director is the EMS physician EMS-MD has oversight for healthcare provided Make difficult Triage decisions Assist Transportation Officer in decision making Assist Operations Officer in decision making Medical Direction is NOT scene or operations control The on-scene physician should serve as a consultant. He or she may provide oversight, medical command, and help with difficult medically-related decisions. May assist at different levels from triage up to sorting of patients among hospitals. Even though the physician may be the most advanced trained health professional at the scene, he/she may not assume command of the scene. Leave the operational decision-making issues to those most familiar with the agencies involved (Fire or LE personnel)

73 D-I-S-A-S-T-E-R Paradigm Incident Command
Operations personnel and resources Medical Control– Responsibilities: On-scene Medical Direction Difficult triage decisions Emergent surgical procedures Advanced level treatment when necessary Assist Transportation Officer in decision making Assist Operations Officer in decision making Medical Control is NOT scene control Medical control is one possible sub-section under the Operations section. If medical control is available on-scene, it is able to provide more services than if it is only available by radio or phone. Some of these services are listed on this slide. It is important to note that the Medical Control officer is NOT in control of the scene. That is the job of the Operations officer.

74 Incident Command System
The Basics “Commander” Unified Command Planning Logistics Operations Finance FINANCE (Admin.) Tracks Rescuer work hours/time Responsible for payroll management, procurement, paying claims, estimating costs, reimbursements The finance section’s work may continue long after the event is over. “Thinkers” “Getters” “Doers” “Payers”

75 This is the HEICS system - the Hospital Emergency Incident Command System. This was developed in San Mateo County, California. It provides a structure for the overall hospital’s response and provides for accountability, as does the prehospital system. Hospitals can adapt this to fit its system. This is to let you know there are plans out there to help you with an incident command structure at the hospital level. Your textbook lists a website from which a description of this system can be downloaded (in Chapter 1 of text, in ICS section……

76 D-I-S-A-S-T-E-R Scene Safety & Security
Begins with Mental Preparation Training What could we encounter? “IF/THEN”: Think through / Plan initial tasks Be Flexible, only thing constant is change Response to Scene Avoid “Siren Psychosis” Safe Response – Do not “Drive it like you stole it” Routes in and out are planned Consider terrain, weather, wind direction, time of day Mentally run through possible scenarios on a regular basis. How would you handle each situation? Visualization is an effective training tool that can help to decrease one’s surprise when encountering new/novel situations. If/Then thinking should be DAILY! (not just while enroute to the scene) Driving faster than the speed limit has a minimal impact on the response time. Remember, driving is one of the MOST DANGEROUS activities that public safety personnel perform.

77 D-I-S-A-S-T-E-R Scene Safety & Security
Scene Priorities: Don’t be foolish, protect yourself! Protect Yourself and Your Team FIRST! Protect the Public Protect the Patients Protect the Environment Your safety is the number 1 priority at the scene. If you are injured or killed, then you’re not doing anyone any good. You also may get other rescuers injured or killed if they have to come and rescue YOU. If they have to divert resources away from the victims in order to rescue YOU, then you have been “selfish.” Be responsible!!! Dead heroes are DEAD!

78 Example: Scene Safety WARM ZONE 300 ft 60 ft 6,000 ft HOT ZONE
Casualty Collection Point WARM ZONE 60 ft RS 6,000 ft HOT ZONE 300 ft WIND DIRECTION RS= Release Site Minimum Site Boundaries Open Area Chemical Release Adapted from Illinois Emergency Management Agency Chem-Bio Handbook. April 2000 COLD ZONE Uphill if agent heavier than air, downhill or level if lighter than air Figure 5 CCP This is just one possible example of the zones of an uncomplicated scene where a chemical agent has been released. Note the various distances in relation to the wind direction. If the wind direction changed, then this diagram and its zones would have to change. This is one reason why the assessment of scene safety must be thought of as an ongoing process and NOT just as an item to be checked off on a list and then forgotten about. As more information becomes available about the exact chemical involved, the zones may have to be adjusted again. Please note, however, that the zones must be created and enforced PRIOR TO having detailed knowledge about the type and amount of chemical agent released. This is another example of how PROTECTION takes priority over IDENTIFICATION.

79 D-I-S-A-S-T-E-R Paradigm Assess Hazards
Power lines downed Debris / trauma Fire / burns Blood and fluids Hazardous materials Flooding / drowning Explosions Low light/visibility Smoke/toxic inhalation Natural gas lines Structural collapse Weather condition NBC Exposures “Dirty” Bombs Snipers Secondary devices This list of hazards is by no means complete. Note that many of these are naturally occurring conditions which are frequently present at normal, everyday emergency responses. If you are unable to screen for a hazard (i.e.- radiation), do not just assume that the hazard is not present. Multiple hazards may be present together on a scene… Structure collapse, with subsequent release of hazardous materials onto the scene Aircraft crashes partly into a building. Building is on fire, with damaged power lines (still electrified) whipping around on the ground. Smoke inundating the area and aviation fuel on the victims and the ground. Secondary explosions occurring as stored pressurized containers inside the building rupture from the heat.

80 D-I-S-A-S-T-E-R Paradigm Assess Hazards
Awareness is key to detection of hazards Training in All-hazards approach Protection more valuable than identification Personal Protective Equipment (PPE) Continual reassessment of scene Get the job done, and get out! -if you’re not even AWARE of what possible hazards there are, then you will probably not DETECT them at a scene. This course will elaborate on potential hazards in each individual section (chemical, bio, etc…). -an ALL-HAZARDS mind-set ensures a broad spectrum of awareness…..this is critical, since specific information is often lacking in the early stages of a disaster -proper use of PPE’s is a MUST! Specific type of PPE is of course dependent on the situation. If you do not possess the correct type of PPE for the situation, that may be a clue to you that you have exceeded the limits of your training/role and it may be time to call for the SUPPORT of a more appropriate agency/group (i.e.-a Hazmat team, a SWAT team, bomb squad, etc…) -Scene hazards may not appear until rescuers have been on-scene for some time. Frequent reassessment is vital!!! -sometimes it may be safer to simply evacuate everyone off the scene to a different location (and let specialists go back to the scene later and investigate it more extensively, by themselves).

81 D-I-S-A-S-T-E-R Paradigm Assess Hazards
Be Aware of Secondary Devices! Bombs, Shrapnel devices, Incapacitating Devices, Multiple Snipers/Terrorists, Delay Devices -rescuers are TARGETS!!! (Atlanta abortion clinic bomb, Centennial Park bombing, recent incidents in Iraq, Israel, etc…) -could be….. A booby-trap (explosive or other type) (set off inadvertently by a rescuer or victim on-scene) A command-detonated explosive (or timed device) A chemical intended to harm rescuers A biological agent intended to infect/harm rescuers A group of armed individuals who fire upon rescuers and/or their vehicles at a very unexpected time to cause casualties, interfere with the disaster response, cause chaos, confusion, and generally terrorize the rescuers and population even more. New/novel device or tactic Any combination of devices/tactics (some attacks have been extremely well-planned and coordinated, and utilized multiple personnel, fake uniforms, fake ambulances, faked distress calls, firearms, explosives, etc…) (your official uniforms/patches/credentials/vehicles are assets to terrorists……….keep them secured at all times and report thefts of these items IMMEDIATELY to law enforcement)

82 D-I-S-A-S-T-E-R Paradigm Support
“Bottom-line”: What do I need to get the job done? What human resources or skilled teams? What agencies are needed? What facilities will be needed? What supplies do I need? What vehicles are needed? - Human resources/agencies– police, firefighters, prehospital medical personnel, hospital personnel, physicians, animal control, EOD (explosive ordnance disposal………”bomb squad”), heavy rescue, search-and rescue, urban-search-and-rescue, S.W.A.T., HAZMAT teams, high-angle rescue, dive team, confined-space rescue, K9, radiation experts, engineers, seismologists, meteorologists, infectious disease specialists, epidemiologists, riot squads, heavy equipment operators, utilities technicians, social services workers, Red Cross, + numerous other possible resources -Facilities- for incident command center, casualty collection points, family resource center, personnel housing, bathrooms, food preparation areas, secondary treatment areas, morgue,………….. Supplies- food, water, shelter, heaters, blankets, cots, medical/rescue supplies, batteries, power, fuel…………….. Vehicles- ambulances, helicopters, firetrucks, bulldozers, cranes, utility vehicles, 4-wheel-drive vehicles, fixed-wing-aircraft, boats, traines, buses,…….

83 D-I-S-A-S-T-E-R Paradigm Support
Review historical injury and ICS reports Vital to proper planning, logistics, etc.. Establish proper policies & protocols Human resources Personnel report automatically Supplies & Equipment Standing orders, passive implementation Occurrence based, duration based, etc.. Vendors automatically ship pre-determined supplies -Communication system outages and/or overloads may make it difficult to reach personnel for call-ins. -ensure that all personnel have provided their contact info. And keep files updated regularly. Get as many contact numbers as possible (home/cell phone/pager/…) -automatic reporting / shipping protocols can bypass need for communication systems - Learn from the past successes and failures (of yourself AND others). Tailor your planning and supplies around your needs

84 D-I-S-A-S-T-E-R Paradigm Support
Unexpected Volunteers and Donations: Positive intentions, can have negative impact Does your preparedness plan include them? Ability to identify needed skills and needed supplies Negatives: Time to sort large and label goods Storage space used Unplanned personnel are a liability At risk of injuries, require food, water and shelter -your area could be swamped by thousands of unannounced volunteers or items (or truckloads of items) -where will you put them all -can use the media to announce needs (and requests for NO uninvited volunteers) -telephone hotlines can be used to announce needs (and what is NOT needed) -”volunteers” and/or donated items may potentially be avenues for terrorist operations (ie.- poisoned food, volunteer status and I.D. may be used to gain access to sensitive areas for intelligence gathering or attack)…..

85 D-I-S-A-S-T-E-R Paradigm Triage
Sorting patients by the seriousness of their condition and the likelihood of their survival To achieve the greatest good for the greatest number possible Dependent on resources available At an MCI, all patients cannot be treated at once……… thus the need for a systematic method to quickly determine which patients need treatment most urgently the goal is to help as many patients as possible with the available resources the amount of help that can be given is of course dependent upon available resources………fewer resources will equate to treatment delays/omissions for more victims

86 D-I-S-A-S-T-E-R Paradigm Triage
Triage methods and systems: Several different triage systems in use Different triage methods/ tags/ categories / colors / symbols used IDEAL One system used by all agencies + hospitals In the past there has been little organized uniformity of triage systems/tags across the United States (in fact, many agencies within the same COUNTY often use totally different systems/tags/terms) multiple systems/tags equals more opportunities for confusion, miscommunication, mistakes, and time to be wasted know your own agency’s triage system…….practice with it in drills……it is rarely used and thus easy to forget strive to use similar systems as your corresponding hospitals/fire departments/EMS/etc… M.A.S.S. triage is becoming a nationwide standard as the NDLS courses are adopted by more organizations as the standard in disaster training

87 M.A.S.S. Triage A – Assess S – Sort S – Send M – Move
MASS is an easy-to-remember acronym for; MOVE ASSESS SORT SEND “MASS” may be thought of as also referring to MASS casualty incident

88 D-I-S-A-S-T-E-R Paradigm MASS Triage Model
Move Anyone who can walk is told to MOVE to a collection area Remaining victims are told to MOVE an arm or leg Assess Remaining patients who didn’t move (help these people first) Sort Categorize patients by “ID-me” Immediate, Delayed, Minimal, Expectant, Dead Send Transport IMMEDIATE patients first Send to Hospitals and Secondary Treatment Facilities This is a summary of the MASS triage method it is basically this simple…….just do what it says on this slide and you have accomplished MASS triage this can be done reasonably well even by non-medical personnel (ie. Police, firefighters, etc…) this exact same method is used in CDLS as well as ADLS…….everyone should be able to easily accomplish the triage (alone or working together) if they have been trained in one of these classes MASS Triage is based on research which shows that the motor component of the Glasgow Coma Scale is the best predictor of mortality for trauma patients. Of importance is the distinction between the intial triage group and the patients final triage category that has been assigned. Although a patient may have been grouped into the minimal intial triage group, upon individual assessment they may be foind to have a life threatening condition that requires immediate attention. This patient would therefore be triaged as an immediate patient, despite their initial grouping as a minimal patient. <<THIS IS A VERY IMPORTANT POINT TO MAKE>>

89 “ID-me”! D – Delayed M - Minimal E – Expectant D - DEAD
I – Immediate D – Delayed M - Minimal E – Expectant D - DEAD  “ID-me”! - a mnemonic for sorting patients during MCI triage. It is utilized effectively in the M.A.S.S. Triage model. These are the 4 triage categories that are used in MASS triage “ID-me” is the acronym used to teach these categories each category is associated with the color it is printed in here this color coding can be helpful in organizing/sorting patients and the scene

90 D-I-S-A-S-T-E-R Paradigm MASS Triage Model
“MOVE” Step 1: Goal Group - Ambulatory Patients Action: “Everyone who can hear me and needs medical attention, please move to the area with the green flag” “ID-me” Category Minimal initial group The first step identifies which group of people on-scene is still ambulatory (Most likely MINIMAL group, but may contain delayed patients) they are directed to move to an area with a green marker/flag This gets them out of the way so that you may find the higher priority patients This also puts them in one area so they may be contained and assessed there when enough personnel become available ideally, assign someone to keep them in that area or else they will wander off. These patients must be assessed and reassessed as soon as possible as patients may deteriorate and change from their initial triage catagories

91 D-I-S-A-S-T-E-R Paradigm MASS Triage Model
“MOVE” Minimal group, initial screening Airway, breathing, and circulation intact Mental status: able to follow commands Not likely low blood pressure or breathing trouble Some conditions worsen, more urgent triage category Must be reassessed and monitored Limitations: not based upon individual assessment yet Actively managing this group will reduce self-transports and perhaps unnecessary overburdening of nearest hospital ER’s Assess last, after Immediate and Delayed groups This group is healthy enough to hear you, follow your commands, and self-ambulate………thus it is a rapid way of finding the healthiest group of people at the scene so that they may be assessed LAST………after the IMMEDIATE and DELAYED groups some people in this initial group may not really be minimally injured……..they will be weeded out when the individual assessments begin (whenever personnel can be assigned to the MINIMAL/green area ) the initial sorting is a broad and fast action……….individual assessments come later …….first to the IMMEDIATEs, then to the DELAYEDs……… (this system is presented in a linear fashion, as if there was only one person doing the triage. If this were the case, then the above syntax would be used. If more rescuers were available, then the patient groups might be assessed in a more simultaneous time-frame, with the IMMEDIATEs of course getting the most personnel/attention

92 D-I-S-A-S-T-E-R Paradigm MASS Triage Model
“MOVE” Step 2: Goal Group – can’t walk, but awake and able to follow commands to MOVE an arm or leg Action: Ask the remaining victims “everyone who can hear me please raise an arm or leg so we can come help you” “ID-me” Category Delayed initial group This process results in the discovery of the initial DELAYED group……they will be screened again (more thoroughly) after the IMMEDIATEs have been dealt with it may be desirable to use a public address system to give the commands……….commands will need to be repeated many times…………. Pitfalls to verbal commands-- language barriers, tympanic membrane injuries (ie.- blast-injury), chronic hearing loss, auditory exclusion from fight-or-flight response, developmentally delayed individuals, ….

93 D-I-S-A-S-T-E-R Paradigm MASS Triage Model
“MOVE” Delayed group Airway, breathing, and circulation adequate to follow simple commands Mental status: Conscious & able to follow simple commands May have low blood pressure or low oxygen level Likely significant injuries present Limitations: not based upon individual assessment yet Assess second, after Immediate group The accuracy of the initial triage will be refined upon assessment of the individual patients in the group there may be minimally or critically injured patients in this group who will be discovered during individual assessment Individual assessment MUST BE PERFORMED as soon as possible to identify and treat immediate life threats that may be present.

94 D-I-S-A-S-T-E-R Paradigm MASS Triage Model
“ASSESS” Goal Group – Identify location of who is left, unable to ambulate and unable to follow simple commands Action: Proceed immediately to these patients and deliver immediate life-saving interventions “ID-me” Category Immediate initial group Anyone left on-scene who is not raising a limb should be considered to be an IMMEDIATE initial group patient. Go to these patients first and deliver immediate life-saving interventions (bleeding control, airway opening, etc…) Whatever category the patient is in, tag him as such and move quickly to the next IMMEDIATE (failure to tag patient will result in another rescuer having to spend time triaging the same patient). Don’t forget that some of these patients may belong in other triage groups despite their initial grouping as immediate. For example, some may be dead or expectant. Expectant patients are those with likely fatal injuries. Dead patients should be tagged as such to prevent consumption of reasources of other personnel attempting to triage the patient again.

95 D-I-S-A-S-T-E-R Paradigm MASS Triage Model
“ASSESS” Immediate group ABC status unknown, immediate assessment Mental status: Unresponsive to verbal commands Likely low blood pressure or low oxygen level Life-threatening injuries present Expectant and dead patients may be in this group Minor injuries may be present due to: Ruptured ear drums, hearing impaired, chronically disabled Limitations: not based upon individual assessment Assess these people FIRST! -this is the group of patients on-scene who are most likely to need immediate assistance…………..they are also likely to be the quietest group (the people yelling for help the loudest are NOT the ones who probably need help the most; thus, it may take some amount of willpower to bypass the louder patients on the way to the unresponsive ones)

96 D-I-S-A-S-T-E-R Paradigm MASS Triage Model
“ASSESS” IMMEDIATE patients Rapidly Assess ABC’s : Is airway open? Open it manually Is patient breathing? If not, EXPECTANT and go on Is uncontrolled bleeding present? Assign direct pressure (do not hesitate to use tourniquet!) Is likely fatal injury present? If yes, EXPECTANT Correct immediate life threats Accurate count of immediate patients Is transport available for anyone now? …Move on! Direct pressure and elevation may be held by volunteers…….. If severe bleeding does not respond almost immediately to direct pressure, elevation, and pressure points, then a tourniquet should be immediately applied correctly (along with the time of application recorded, etc…) minimize amount of time spent with each patient until all IMMEDIATES have been individually assessed………..then time can be spent on most urgent/salvageable patients first as soon as the number of IMMEDIATE patients is known, advise the Incident Commander and/or Triage Officer ………this is the number of patients for which immediate transport to a hospital is needed NOW any available transports can begin taking IMMEDIATES to the hospitals designated by the Incident Commander / Transport Officer the I.C. or Transport Officer should contact hospitals to advise them of the number of patients on-scene and to ask how many IMMEDIATE patients each hospital can accept………he must then ensure that the patients are distributed to the different hospitals in a logical manner and order

97 D-I-S-A-S-T-E-R Paradigm MASS Triage Model
“SORT” - “ID-me”: I – Immediate D – Delayed M- Minimal E – Expectant D - DEAD “SORT” them based upon individual assessment, …continue lifesaving treatment Now that the most immediately-needed life-saving interventions have been performed on the IMMEDIATE patients, all the rest of the patients are individually assessed and then sorted further in to the most appropriate triage category. (starting with the DELAYED group……..unless there are enough rescuers to start all groups simultaneously) The individual assessments would be best performed by trained medical personnel, however this of course may not be possible. TAG patients as they are triaged…….otherwise they will be triaged by multiple personnel………thus, wasting time Dead patients should also be tagged as such to prevent wasting resources to re-triage the patient.

98 D-I-S-A-S-T-E-R Paradigm MASS Triage Model
“SORT” Immediate Life or limb threatening injury Usually persistent ABC problem Examples: Unresponsive, altered mental status, severe breathing trouble, uncontrollable bleeding, proximal amputations, turning blue, rapid and weak pulse… if IMMEDIATE patients are found to be among the other triage groups, then immediately render life-saving interventions,TAG them, and move them to the IMMEDIATE area or the TRANSPORT area and advise the I.C./Triage Officer of the additional IMMEDIATE pt. -ideally they will be physically grouped together into an IMMEDIATE area, marked with RED signs/flags/tarps/etc… -ideally a team of rescuers will be monitoring and treating them until they are transported -if their condition changes, their triage category can be changed at any time and they can be moved to the other category’s physical collection area

99 D-I-S-A-S-T-E-R Paradigm MASS Triage Model
“SORT” Delayed: Need definitive medical care, but should not worsen rapidly if initial care is delayed Examples: Deep cuts or open fractures with controlled bleeding and good pulses; finger amputations; abdominal injuries with stable vital signs… These patients should generally be OK to wait on transport until all the IMMEDIATEs have left the scene ideally they will be physically grouped together into a DELAYED area, marked with YELLOW signs/flags/tarps/etc… ideally a team of rescuers will be monitoring and treating them until they are transported if their condition changes, their triage category can be changed at any time and they can be moved to the other category’s physical collection area

100 D-I-S-A-S-T-E-R Paradigm MASS Triage Model
“SORT” Minimal: “Walking Wounded” Treated and released (preferably without transport) Source of “volunteer” help Examples: Abrasions, contusions, minor lacerations, no apparent injury ideally they will be physically grouped together into a MINIMAL area, marked with GREEN signs/flags/tarps/etc… ideally a team of rescuers will be monitoring and treating them until they are transported if their condition changes, their triage category can be changed at any time and they can be moved to the other category’s physical collection area if medical providers and equipment can be brought to the scene, then it may be possible to treat and release them AT THE SCENE (thus keeping the hospitals from being overwhelmed) they may be able/willing to assist as volunteers

101 D-I-S-A-S-T-E-R Paradigm MASS Triage Model
“SORT” Expectant Severely injured with little or no chance of survival Care resources not utilized initially Comfort resources used as available Remember death could be hours or days away! Require reassessment and transport: If alive after all immediate patients transported, resuscitate per available resources! ideally they will be physically grouped together into an EXPECTANT area, marked with BLUE signs/flags/tarps/etc… ideally a team of rescuers will be monitoring and treating them until they are transported if their condition changes, their triage category can be changed at any time and they can be moved to the other category’s physical collection area as more resources become available and the IMMEDIATEs have been dealt with, more resources can be devoted to this group

102 D-I-S-A-S-T-E-R Paradigm MASS Triage Model
“SORT” is dynamic! Reassess! Who is left? Expectant group could become new Immediate group “Most serious” injury present requires your immediate attention! As patients are evacuated from the scene, the amount of resources available per patient changes. Thus, patients may need to be re-evaluated and re-sorted based on the NEW situation patient condition also will necessitate frequent reassessment and occasional re-assignment of triage category

103 D-I-S-A-S-T-E-R Paradigm MASS Triage Model
When all patients have been triaged and immediate life saving procedures complete: Accurate count in each category Advise incident commander/triage officer Move all immediate to collection point Prepare for immediate transport Often marked with red flag/tarp The Transport Officer will have to control the flow of transport units into the scene and will have to ensure there are enough units enroute he will also need to ensure that the most urgent patients are transported first It is essential that a clear route of egress be preserved for the transport units to leave the scene………it is not uncommon for incoming units to block EMS units in landing zones for helicopter transports may be needed and patients may need to be further prioritized for ground versus air transport

104 D-I-S-A-S-T-E-R Paradigm MASS Triage Model
How to handle the dead patients: Dead patients should not be moved May aid in identification of the deceased Evidence is important! Finding and convicting perpetrators....and possibly... PREVENTING future attacks! Excessive manipulation of human remains may destroy vital evidence If final determination has been made that patient is dead and no resuscitation is to be attempted, DO NOT DISTURB THE REMAINS OR THEIR IMMEDIATE SURROUNDINGS evidence may be lost that could have lead to; proper identification of the remains cause of death time of death crucial information about the incident determination of whether this was an accident or an act of terrorism The person or persons responsible for the attack/crime PREVENTION of future attacks ***Exception- small soft-tissue fragments may rapidly degrade if exposed to high temperatures (thus DNA may be denatured). If these are the only remains found, it may be advisable to obtain permission from law enforcement personnel to quickly move the tissue out of sunlight and into a cool area to preserve the DNA. Dead patients should not be moved unless enough resources are present to attempt resuscitation if no resuscitation is to be attempted, tag the patient with a BLACK triage tag reading, “DEAD”………....the highest level medical provider on scene should personally re-assess all such patients as soon as possible following the treatment of the most severely injured patients on scene (and ideally he should also sign or otherwise mark the tags with his name/title and the time) Law enforcement authorities will typically determine the deceased victim’s disposition (whether the body will be released to the family or if an autopsy/investigation is to be performed by the medical examiner/coroner/etc…). This may vary according to state law.

105 D-I-S-A-S-T-E-R Paradigm MASS Triage Model
“SEND” Traditional syntax Immediate →Delayed →Minimal →Expectant Objective Transport or release ALL living patients ASAP Mission Focused Send Minimal(s) with each Immediate (if unused space available in vehicle), etc… Resourceful Secondary treatment facilities for minimal pts (or on-scene treatment and release) Utilize buses, taxis, trains, boats, etc.. IMMEDIATE patients should be sent off scene as soon as transports are available if there is left-over room on a transport unit for a seated patient, then a lower priority patient who can tolerate that position can be sent along with the IMMEDIATE patient (but don’t delay transport of the immediate just to find a MINIMAL patient…) depending on the number of patients, non-medical vehicles may need to be utilized ideally, a large number of minimal patients could be transported to a secondary facility for treatment (instead of a hospital) . This is only feasible if it were planned out ahead of time. For example, medical personnel could quickly set up a makeshift ‘clinic’ at a local gymnasium near a hospital and MINIMAL patients could be taken there by bus from the scene (thus preventing the hospital from being overrun with patients)

106 D-I-S-A-S-T-E-R Paradigm Treatment
Treatment continues on-scene until: All patients transported Resources unavailable to provide treatment Comfort is Care! All-Hazards treatment plans Algorithms of care delivery Documentation Patient Identification / Triage Tag Medical Record Treatment may be very rudimentary (bandaging and splinting only) or quite advanced (open-surgery conducted in a mobile surgical suite) depending on the personnel and assets available on-scene specific treatments will dealt with in later lectures (also in the text) general trauma care is dealt with in various other trauma courses available (ATLS,TNCC,BTLS,PHTLS,…). Strong skills in general trauma care are essential! (most terrorist attacks have thus far been ‘conventional’ in nature……..bullets/bombs/etc…) good documentation of patient treatment/transport is essential! this helps to track patient flow and to prevent any one hospital from being swamped with EMS transports………it can also help track who has been decontaminated……..who has received antidotes/prophylactic medications, etc… Good documentation may also assist in law enforcement personnel’s subsequent investigation of the incident

107 D-I-S-A-S-T-E-R Paradigm Evacuation
Short-term goal of the event! Preparedness Plan Evacuation of hospitals High-rise office buildings Egress route alternatives Transportation “SEND” of MASS Triage Model More than patients, includes families..public… Rapid evacuation of the scene is one way to deal with the possibility of secondary devices at the scene and can also minimize the exposure of victims and rescue personnel to hazardous materials at the scene. Pitfall- if decon. is not done prior to evacuation, then vehicles/ hospitals/personnel may become contaminated -see "SEND" slide of MASS TRIAGE section for more info -pre-planning is essential for evacuating large structures such as hospitals -if evacuation is not possible or feasible, then sheltering-in-place may be necessary -even UNINJURED people at the scene may need to be evacuated in order to prevent exposure to hazards at the scene (fire/violence/HAZMAT...).....also, crowds of uninjured people contribute to confusion and congestion of the scene

108 D-I-S-A-S-T-E-R Paradigm Recovery
Long-term goal of the event! Minimize event’s impact Injured victims, families, rescue personnel Community, state, and nation Environment Preparedness Plan must include Begins… when the incident occurred Ends… often years later -may require assistance with shelter, food, water, clothing, transportation, sanitation, schooling, financial assistance, legal aid, etc………… -recovery may involve many different sectors and aspects of the community……criminal/legal actions, judgements, civil court actions, regulatory issues, fines, tax changes, financial incentives/subsidies, industry involvement, social/racial/ethnic issues, basic infrastructure repair, utilities restoration, etc…

109 D-I-S-A-S-T-E-R Paradigm Recovery
Operational and Logistic considerations: Vehicles: Clean, disinfect, restock, refuel units Equipment: Repair / replace equipment (and evaluate) Inventory & order supplies (and evaluate) Personnel: Fed, hydrated, rested and released ASAP Many personnel may have been injured Tendency to down-play importance Pre-release medical exams -ensure that any HAZMATs were identified and equipment properly decontaminated or disposed of Did your equipment function properly? Ask the troops! Do you need to get refunds? Do you need to order more of the same? Do you need to network to find what equipment has worked for others in the same situations? Is there any equipment that you should have had that you didn’t? - Were your supplies adequate? Well chosen? Ask the troops! Were they accessible to those that needed them? - Thorough records should be kept of what personnel were deployed to what locations during the disaster…….this may be essential if further information regarding on-scene HAZMATs becomes available later (after investigations of incident) Records should also be kept of all injuries/illnesses to rescue personnel……this will assist with compensation issues/insurance issues/legal issues/identifying trends or patterns of disease or injury, etc…It may also assist law enforcement officials with their investigation of incident - If personnel were exposed to any HAZMATs or infectious substances ensure they receive immediate care and document the materials/source and arrange for followup testing/care

110 D-I-S-A-S-T-E-R Paradigm Recovery
Psychosocial: Debriefing of personnel Commonly occurs when relieved from duty Identify “at risk” potential Post-incident observation Observe for stress related problems Withdrawal, depression, hyper-excitability, unusual behavior, etc.. Appropriate intervention Minimize negative psychosocial impact All persons involved in the incident may be affected by the stress……….not just the rescuers Some literature now questions the efficacy of CISD-type activities…… should be conducted by personnel trained appropriately excessive stress may cause a very wide variety of signs/symptoms……many of these may not be recognized as being related to stress many negative effects of stress may affect the family of the rescue worker as well………substance abuse, sleep pattern changes, appetite changes, emotional lability, hypervigilance, etc…these can all take a heavy toll on family life (as well as future job performance)

111 D-I-S-A-S-T-E-R Paradigm Recovery
Immediate: food, water, shelter, clothing Recovery actions involve entire community Local is most important! Churches, temples, stores, hotels, restaurants… Regional, State and Federal resources… DMAT – Disaster Medical Assistance Teams DMORT – Disaster Mortuary Assistance Teams VMAT – Disaster Veterinary Assistance Teams VA Teams – Department of Veterans Affairs NMRT – National Medical Response Teams FEMA – Federal Emergency Management Agency ($$) - Also security/looting, restoration of utilities, sanitation, etc… -many different agencies available to help…..state EMA, FEMA, DMAT’s, military, Red Cross, EPA, private groups, businesses, etc… - Federal agencies typically coordinated through state-level EMAs/government

112 D-I-S-A-S-T-E-R Paradigm Recovery
After-Action Reviews Forces us to ask questions: “How could this have been prevented?” “How could our response be improved?” Learn all you can from the incident This is a DUTY, not an option Goal: Update / revise disaster plans Another long-term goal of recovery is the improvement of the various agencies, systems, plans, protocols, and policies that… 1. attempt to prevent disasters from occurring (“What could we have done to have prevented this disaster from occurring in the first place?”) and… 2. are involved with the actual emergency response to the disaster (“What areas of our response could we improve upon?”) Thorough after-action-reviews are essential to this phase of recovery and are the key to effectively learning from our experiences. If we fail to learn from our past disasters (and those of others as well), the price will be increased death and suffering at future disasters. No agency or policy should be immune from examination. If the status quo is not working, then it must be changed to address the current threats, hazards, and tactics of these dynamic times. A community that has fully “recovered” from a disaster is one that has not only learned as much as possible from the incident, but has also fully integrated those lessons into its future disaster prevention, response, and training plans.

113 Summary Now You Can: Identify the critical need to establish healthcare preparedness for disasters Define “disaster” and “Mass Casualty Incident (MCI)” Define “All-hazards” and list possibilities Identify the components of the D-I-S-A-S-T-E-R paradigm Identify and apply a mass casualty triage model utilizing “M.A.S.S.” and “ID-me” -this slide is self-explanatory -remind students that all this material is in their BDLS textbook

114 Thank You! Questions? - Encourage students to ask questions openly……there are no stupid questions Answer any questions (or refer them as appropriate) remind students that at the end of Chapter 1 in their textbook there is a page of essential BDLS information condensed onto one page. encourage students to copy this page and keep it at their work stations for quick reference during an actual disaster (it can also be posted up at E.R.,fire stations, inside ambulance, etc…..) Thank students for their attention Can give instructor’s contact info. to students if desired Remind students that they may ask questions later or during a break if they think of any Remind students of instructor’s name and remind them to fill out course evaluations (preferably after each lecture is completed) time for a break??? (remind students of location of restrooms/refreshments/smoking area/etc…) Clearly define when they are to return to classroom. retrieve instructor’s personal equipment/laptop as needed leave slide remote/laser pointer out in a prominent place assist next instructor with setup for next lecture as needed

115 Contact information Ray E. Swienton, MD, FACEP Co-Director, EMS, Disaster Medicine & Homeland Security Section Associate Professor, Division of Emergency Medicine University of Texas Southwestern Medical Center 5323 Harry Hines Blvd. Dallas, Texas Voice: (817)

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