Evolving a strategy for emergency response to natural disaster

Emergency Response to Natural Disaster: Floods, Winds, and Earthquakes

Nicholas E. Kman, MD FACEPMedical Team Manager, Ohio Task Force 1The Ohio State University Department of Emergency MedicineTwitter @drnickkman

Disclosures

Ohio Task Force 1: FEMA Urban Search and Rescue

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September 11th, 2001

http://www.dispatch.com/content/graphics/2015/01/07/meiling-hall.jpg



2005 Hurricane Season

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March 2011, Japan Earthquake and Tsunami

Hurricane Sandy 10/25/12

Hurricane Sandy

Boston 4/15/13

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2014-2015 Ebola Outbreak

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2014-2015 Ebola Outbreak

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Boko Haram

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Objectives

Provide a background on Emergency Preparedness and Disaster Response since 9/11/01.

Analyze the Disaster Response Paradigm. Discuss Natural Disasters as they relate to

Preparedness. Define the injury patterns from Collapsed Buildings:

crush injury, compartment syndrome, and crush syndrome

Define the injury patterns from Wind Disasters. Describe flooding dangers.

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What we will not cover!

Ebola Bomb and Blast Infectious Agents of Bioterrorism Chemical Agents of Terrorism

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Disaster Defined

The United Nations Disaster Management Training Program defines Disaster as: A serious disruption of the functioning of society,

causing widespread human, material, or environmental losses which exceed the ability of affected society to cope using only its own resources.

Bonnett et al. Surge Capacity: A proposed conceptual framework. Amer J of Emerg Med 2007; 25: 297-306.

Dominique Faget—AFP/Getty Images

A Disaster: more simply…

Any event that threatens or overwhelms the normal operational capacities of the local healthcare system and emergency medical services (EMS).

University of Wisconsin Cooperative Institute for Meteorological Satellite Studies

Disaster Management Cycle

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Preparation

Getting people and equipment ready to quickly and effectively respond to a disaster.

Conduct a Hazard Assessment Actual and potential hazards

Develop a simple disaster plan (EOP) Failing to plan is planning to fail!

Train all hospital staff in its application Awareness Technicians Patient care

American College of Surgeons, 2008, Advanced Trauma Life Support for Doctors, American College of Surgeons. Eighth Edition.American Medical Association, 2012, Basic Disaster Life Support, Course Manual. V. 3.0.

Preparation

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Preparation

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Preparation

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Preparation-100 Year Flood

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Preparation and Education

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Preparation and JCAHO

6 focus areas for hospitals in disaster planning:o Communications –internal and external to

community care partners, state/federal agencieso Supplieso Security – Enabling normal hospital operations

and protection of staff and propertyo Staff – Roles and Responsibilities within a

standard Hospital Incident Command Structureo Utilities – Enabling self-sufficiency for goal of 96

hourso Clinical Activity – Maintaining care, supporting

vulnerable populations, alternate standards of care

26 http://www.jointcommission.org/emergency_management.aspx


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Mitigation

Sustained actions taken to reduce or eliminate long-term risk to people and property from hazards.Reducing effects before the eventHave an Incident Command System

HICS (Hospital Incident Command System): organizational structure that provides direction for management of disaster response within hospital.

Train all staff in its application and use Plan in advance to ensure a coordinated response


National Preparedness

National Disaster Medical System

Ohio Task Force-1

1 of 28 Urban Search and Rescue (US&R) teams in National US&R Response System managed by FEMA.

OH-TF1 also State of Ohio rescue response asset. MA-TF1 Urban Search & Rescue Structural Collapse

Training - YouTube

https://www.youtube.com/watch?v=LG2qB6LP3ns&list=TLKFCGY9esLIY

https://www.youtube.com/watch?v=LG2qB6LP3ns&list=TLKFCGY9esLIY

Ropes TrainingCamp Ravenna Joint Military Training Center

Florida State Fire College

Camp Atterbury, Muscatatuck Urban Training Center

National Incident Management System

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Incident Command System (ICS)

Set of personnel, policies, procedures, facilities, and equipment, integrated into common organizational structure designed to improve emergency response operations of all types.

May be used for planned events, natural disasters, and acts of terrorism.

Is a key feature of the National Incident Management System (NIMS 2004).


Based upon changeable, scalable response organization providing hierarchy within which people can work together effectively.

“First-on-scene" structure: First responder to scene has charge until incident has been declared resolved or more qualified responder arrives and receives command.

Used by all levels of government—Federal, State, local, and tribal—as well as by many private-sector and nongovernmental organizations.

http://emilms.fema.gov/IS200b/ICS0102summary.htm

ICS

Structured to facilitate activities in 5 major functional areas: Command Operations Planning Logistics Finance and administration.

37 http://emilms.fema.gov/IS200b/ICS0102summary.htm



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Response: Prehospital and Inhospital Care Saving life and property during and immediately

after a disaster. Implement the planned response quickly Decontaminate every patient

Avoid contamination of facility, quarantine

Disaster triage scheme (SALT) Effective surge capability

Expect patient volume increased 20%

Don’t expect outside help for at least 24 hours


Response: SALT Triage

Image adapted from: “SALT mass casualty triage: concept endorsed by the American College of Emergency Physicians, American College of Surgeons Committee on Trauma, American Trauma Society, National Association of EMS Physicians, National Disaster Life Support Education Consortium, and State and Territorial Injury Prevention Directors Association.” Disaster medicine and public health preparedness, v. 2 issue 4, 2008, p. 245-6.

Response: Surge Capacity

If a mass casualty incident occurs, a healthcare system may be suddenly faced with significant increase of patients (Surge generating event).

Response: Surge Capacity

Surge capacity is the ability of healthcare facility or system to expand operations to safely treat an abnormally large influx of patients.

Surge Generating Event Contained

Geographically Defined (tornado, flood, bombing) Population Based

Infectious Diseases and Bioterrorism

http://buckeyextra.dispatch.com/

Inherent Response Problems

Sudden and unpredictable onset Chaos Loss of services Disruption of gov’t

Loss of infrastructure Transportation Communications Utilities

http://blogs.sacbee.com/photos/2010/08/hurricane-katrina-five-years-l.html

Inherent Response Problems (continued)

Variable mitigation and preparation for response at local level

Loss of basic physiological necessities Shelter Food/water Sanitation

Secondary hazards Further structural

damage Hazardous materials

Medical Response Obstacles

Medical system overwhelmed Non-selective victim process

Unusual medical problems Victims with previous problems Delay in treatment

High risks to rescue personnel

http://video.foxnews.com/v/2674051681001/oklahoma-city-bombing-missing-videos/?#sp=show-clips


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Recovery

Putting a community back together after a disaster.

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Prevention

Similar to Mitigation.

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Natural Disaster Crash Course

Photo: NASA GOES Project

Natural Disasters

Natural Disasters Earthquakes Landslides and Mudslides Tsunamis Volcanoes Wildfires

Weather Emergencies Extreme Heat Floods Hurricanes Tornadoes Tsunamis Lightning Winter Weather

An event of nature that overwhelms local resources and threatens the function and safety of the community.

Wind Disasters

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Marchigiani R, Gordy S, Cipolla J, et al. Wind disasters: A comprehensive review of current management strategies. International Journal of Critical Illness and Injury Science. 2013;3(2):130-142. doi:10.4103/2229-5151.114273.

Hurricanes

Most mortality originates from secondary disasters (storm surges, flash flooding, and tornados) triggered by original event.

In coastal regions, level of hurricane’s storm surge is strong predictor of mortality.

Winds are 2nd deadliest aspect. Most common non‑fatal traumatic injury pattern in a

hurricane consists of superficial lacerations from airborne glass and/or other debris.

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Tornados

Tornados usually develop during intense “supercell thunderstorms”.

Result from updrafts created by solar warming of earth’s surface. Updrafts then develop into vortex with strong rotary winds and violent pressure changes.

Due to brief or absent warning, community has little time to prepare or seek shelter, and morbidity and mortality is proportionally higher compared to other WDs.

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Tornado Associated Injuries

Most tornado fatalities die at scene and tend to be either in exposed areas or in mobile homes.

Risk factors for injury and death during a tornado include: Poor building anchorage Occupant location other than a basement Age over 70 years High wind strength

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Earthquake Injuries

60 Haiti Earthquake 2010 US&R LA County

Crush Injury

Lactic acid produced

Myoglobin, Potassium and other electrolytes released

Other toxins created/released (superoxides, O2 free radicals)

Capillary leak

Thromboxane, prostaglandins, and other immune system substances generated

Muscle cell enzymes released

Crush Injury

Effects are LOCAL ONLY until pressure released and tissue reperfused

Reason that patients survive entrapment despite severe crush injury

Adverse processes begin immediately upon pressure release

Effects of Releasing Compressed Tissue

Immediate: Capillary leak

Hypovolemia/Hypotension Shock

Severe metabolic acidosis: dysrhythmias, V-fib High serum potassium: cardiac dysrhythmia or arrest

Delayed: Myoglobin/uric acid/renal toxins: kidney failure Other toxins: lung/liver/renal injuries

Cause of Death

Major Hypovolemia Dysrhythmia Renal failure

Other Adult Respiratory Distress Syndrome (ARDS) Sepsis Other electrolyte disturbances Ischemic tissue infection (gangrene)

EKG Abnormalities

Related to Potassium levels and rate of rise Acidosis Other electrolyte abnormalities Other injuries Peaked T-waves, AV blocks, widened QRS, sine wave

Responds rapidly to effective intervention

Strategies to Prevent Renal Injury

Maximize renal perfusion IV normal saline

Diuresis (brisk urine flow)

Careful alkalinization of urine (pH > 6.5) Sodium bicarbonate

Monitor urine flow and pH (Bladder catheterization if possible)

Initial Management “in the Rubble”

Maintain ABCs Protect airway Assess for crush injury potential Provide psychological support

Initial Management “in the Rubble” (continued)

If crush potential is identified Establish IV access Fluid resuscitation prior to extrication Pre-release alkalinization Cardiac monitor (run baseline strip) Be prepared during extrication to treat

Hypovolemia Acidosis Hyperkalemia

Floods-Preparedness

Recognize Flood Risk Identify flood-prone or landslide-prone areas near

you. Know your community’s warning signals, evacuation

routes, and emergency shelter locations. Know flood evacuation routes near you.

69 www.dispatch.com

Floods-Response

Unplug appliances to prevent electrical shock when power comes back on.

Gather emergency supplies and follow local radio or TV updates.

Do NOT drive or walk across flooded roads. Cars and people can be swept away

70 www.cdc.gov

Floods-Response and Recovery

Practice safe hygiene Wash hands with soap and water to prevent germs. Listen for information from local officials on how to

safely use water to drink, cook, or clean. Use fans, air conditioning units, and dehumidifiers for

drying. For cleanup, wear rubber boots and plastic gloves.

Clean walls, hard floors, and other surfaces with soap and water. Use mixture of 1 cup bleach and 5 gallons water to disinfect.

71 http://emergency.cdc.gov/disasters/floods/readiness.asp

Disaster Management Cycle Review

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Disaster Management Cycle Review

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Emergency Preparedness

Disaster Management

Final Pearls

Have a straightforward disaster plan and educate everyone in its use.

Have an incident command structure and drill often.

Have a disaster triage scheme, and mobilize surge resources as needed.

Have a traffic control system and communication system.

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Final Pearls

Communications-Cell Phones Go Down! Redundant modes / systems / equipment

Supplies-Bring your own Ample supply stores / reliable supply chains

Security Control traffic flow / patient, staff safety

Volunteers Physician role is hospital-based patient care

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What can you do?

Be Informed: Learn your Emergency Operations Plan (EOP) and exercise it.

Find out where you would report in a disaster. Make a Plan: Prepare yourself and your family (

www.ready.gov). Build a kit.

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http://www.costco.com/American-Preparedness-Emergency-Backpack-Kit.product.11100551.html

What can you do?

Get Involved: Join your Emergency Preparedness Committee.

Go Regional, then National!

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References

FEMA Medical Team Training Student Reference CD (2/2009)

FEMA WMD for Medical Specialist Training CD

Franco et al. The National Disaster Medical System: Past, Present, and Suggestions for the Future. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, Science 2007; 5: 319-325.

Bonnett et al. Surge Capacity: A proposed conceptual framework. Amer J of Emerg Med 2007; 25: 297-306.

ATLS 8th Edition.

Kman NE, Bachmann D. “Biosurveillance: A review and Update.” In Special issue: Advances in Development of Countermeasures for Potential Biothreat Agents. Advances in preventive medicine, v. 2012, 2012, p. 301408.

Kman N, Rund D. “Disaster Preparedness 10 years after 9/11: The Experts Weigh In”. Emergency Medicine. Emerg Med 2011; 43(9): 12-13. (September) www.emedmag.com.

Marchigiani R, Gordy S, Cipolla J, et al. Wind disasters: A comprehensive review of current management strategies. International Journal of Critical Illness and Injury Science. 2013;3(2):130-142. doi:10.4103/2229-5151.114273

References

www.fema.gov

www.cdc.gov

http://phil.cdc.gov/phil/home.asp

Marchigiani R, Gordy S, Cipolla J, Kman NE, Stawicki S, et al. "Wind disasters: A comprehensive review of current management strategies." International journal of critical illness and injury science. Vol. 3, no. 2. (Apr 2013): 130-142.

Kman N, Bachmann D, Folley A, Adams J, Greer M. Emergency Preparedness Simulation Cases for Medical Students: Crush and Organophosphate Exposure. MedEdPORTAL; 2013. Available from: http://www.mededportal.org/publication/9330.

Yuri Rojavin, Mark J Seamon, Ravi S Tripathi, Thomas J Papadimos, Sagar Galwankar, Nicholas Kman, James Cipolla, Michael D Grossman, Raffaele Marchigiani, Stanislaw P A Stawicki. “Civilian nuclear incidents: An overview of historical, medical, and scientific aspects.” Journal of emergencies, trauma and shock, v. 4 issue 2, 2011, p. 260-72.

Kman NE, Nelson R. Infectious Agents of Bioterrorism: A Review for Emergency Physicians. Emerg Med Clin N Am 2008; 26: 517-547.

Questions

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Evolving a strategy for emergency response to natural disaster

Healthcare

simple disaster

disaster management

disaster response paradigm

basic disaster life

emergency response

hospital staff

emergency preparedness

property o staff roles