Disaster Preparedness

1. Disaster Preparedness Susanne Spano MD Assistant Clinical Professor of Emergency Medicine, UCSF

2. Objectives • Review key components of ICS • “Size-up” the scene for safe zoning • Practice START Triage • Test communication strategies • Demonstrate a disaster response • Debrief: disaster psychology

3. Pretest • 1. The BESTindicator of a Disaster/MCI is: A. Infrastructure is disrupted B. Terrorism or a natural disaster is the cause C. Available resources are overwhelmed D. There are more than 5 patients

4. Pretest • 2. Using the Incident Command System: A. Establishes a chain of command B. Ensures key functions are covered C. Standardizes incident organization D. All of the above

5. Pretest • 3. Triage using START triage: Unresponsive; Jaw thrust results in respirations of 25/min; Capillary refill is brisk A. GREEN (minor) B. YELLOW (delayed) C. RED (immediate) D. DECEASED

6. Pretest • 4. Which airway technique is preferable in suspected cervical spine injury? A. Axial cervical spine traction B. Head Tilt - Chin Lift maneuver C. Jaw thrust maneuver D. Safety pin tongue to lower lip

7. PRETEST • 5. Which of the following is NOT a determinant of triage acuity using START Triage? A. ability to follow commands B. brisk capillary refill C. presence of extremity deformities D. respiratory rate > 30

8. Incident Command System

9. Incident Command System Structure: • Modular structure • Defined responsibilities • Key functions covered • Clear Language Responsibilities: • Chain of Command • Commander and Leaders • “Talk Up one and Down one”

11. Incident Command Challenges? • Establishing command • Sizing up the situation • Determining the best use of resources • Coordinating the response • Communicating among incident personnel • Managing the flow of public information

12. Incident: • Several minutes ago, a gas line exploded in your campus building.  You were not injured but are isolated in a damaged part of the building with students and no other faculty or staff personnel. What are the first actions that you would take? • Establish the initial Incident Command • Size up the situation • Ensure safety (shut off gas)

13. Incident Commander • First person on scene, often reassigned • Plays all major roles until back up arrives: • Requesting resources • Rescue people in immediate danger • Assign treatment and staging areas • Designate leaders

14. Incident command exercise • Scenario given to each group: 5 minutes • Task: Describe the steps • Establishing command • Sizing up the situation • Determining the best use of resources • Coordinating the response • Communicating among incident personnel • Managing the flow of public information

15. Triage/ Extrication Leaders • Use START Triage • Move patients from scene • Maintain Patient Log • Each leader ideally supervises 6 people • Can be as many as 10-20 • Reports directly to IC

16. Treatment Leader • Manage treatment of patients in color coded areas • Coordinate with Transport RE: patients needing transport by ground or air • Supervise as people become available • Reports directly to IC

17. Transport Leader • Coordinates communication for ETA’s of personnel and hospital arrivals • Relays triage tag # and color, age, sex, main injury to receiving hospitals- not detailed reports • Does not supervise others • Maintain Transportation Log (Transport) • Reports directly to IC

18. MCI/Disaster Triage • No CPR unless adequate resources • Extrication/Treatment/Transport Priorities • Immediate (Red) • Delayed (Yellow) • Minor (Green) • Morgue (Black)

19. START TriageSimple Triage and Rapid Treatment“Walk, 30-2, can do.” CAN YOU WALK? YES NO BREATHING? MINOR YES NO OPEN AIRWAY BREATHING ? RESPIRATIONS <30 PER MIN. ? YES NO YES NO CIRCULATION CAP REFILL<2 SEC ? YES NO MENTAL STATUS FOLLOWS COMMANDS ? YES NO DELAYED IMMEDIATE DECEASED

20. METTAG - California State Fire Chiefs’ Association Triage Tag

21. CAN YOU WALK? YES NO BREATHING? MINOR YES NO OPEN AIRWAY RESPIRATORY RATE? 15-45/MIN Regular <15/MIN >45/MIN or Irregular BREATHING? YES NO PALPABLE PULSE? PALPABLE PULSE? YES NO YES NO Perform 15 sec. mouth to mask ventilations MENTAL STATUS ? SPONTANEOUSRESPIRATIONS? Awake Verbal Pain (appropriate) Pain (inappropriate) Unresponsive YES NO DELAYED IMMEDIATE DECEASED Jump START Triage *Used in children shorter than the Broselow tape, generally about age 8.

22. Jump Start Triage • Exceptions: • Kids < 8yo, get 15 seconds BVM if no RR but + pulse • Kids RR ‘normals’ are different • RR 15-45 regular = yellow • RR <15 or >45 or irregular = red

23. Tabletop Exercise • START Triage exercise • “Walk, 30-2, Can Do” • WALK (green) • 30 (RR> 30 = red) • 2 (capillary refill>2 sec = red) • Can-do (cannot follow commands = red)

24. Life-Threatening Conditions • Use a standard approach • A-B-C’s • Treat causes of airway obstruction first • Intervene for acute respiratory failure • Rapidly treat circulative shock- controlling internal and external bleeding

25. Life saving interventions • Open the airway • Address mechanical respiratory failure • Aggressively treat active bleeding/ shock • Don’t need a hospital to start an intervention

26. Airway • Most common airway obstruction? • Head-Tilt Chin Lift • Jaw Thrust

27. Make it work- ABC’s • Airway- safety pins

28. Make it work- ABC’s

29. Why are Drills Necessary? • Operate when resources overwhelmed • Can be >2 pts for one first responder! • Switch to an ICS system from immediate treatment model • Practice the roles of defined responsibilities, organized structure, and lines of communication used in disasters • Test vulnerabilities of a system

30. Communication • Talk “Up one” and Talk “Down one” • Communication • Interactive drill exercise

31. Classic Errors • Unfound patients • Searching the scene • A medical patient who presents as a trauma patient • Keeping the differential open • Scenarios which obtain additional patients/EMS providers who become patients • Securing the scene

32. Classic Errors cont. • Improper triage and triage tag use • Communications errors/failures • Failure to use checklists • Patients and details don’t add up • Can test with “Tabletop Drills” • Failure to follow ICS structure • Don’t follow chain of command up/down • Reassignment issues

33. Disaster Psychology • Survival improves with numbers • People will organize, create solutions • Awareness • Value in formally announcing needs, worries, goals • When you aware, you can take action • Become a rescuer, not a victim • Doctors and Nurses tend to survive better • Well-defined purpose

34. Psychological vs. physical skills • I. Impact phase • 10-15% remain relatively calm • 75% stunned and bewildered • 10-15% Inappropriate behavior • II. Recoil phase • Inventory & Rescue • III. Recovery phase • PTSD (9 months)

35. Disaster Psychology: THPs • Survivors will show psychological effects from the disaster, and some of the psychological warfare will be directed towards you, the rescuer • You are not immune • CISD

36. Critical Incident Stress Debriefing • Introduce team, assure confidentiality • Review facts of incident • Share initial thoughts, emotional reactions • Review symptoms of normal stress reactions • Close debrief with a needs assessment

37. Key Points • ICS provides structure, responsibilities, and assignments in disasters • START Triage: Walk, 30-2, Can-Do • Emergent treatment of ABC’s is paramount • CISD is critical for team well being • Disaster planning starts with you • Corrections, suggestions and feedback are welcome: sspano@gmail.com

38. Questions? mci