DISASTER PREPAREDNESS

1. DISASTER PREPAREDNESS • A FRAMEWORK FOR INDIVIDUAL RESPONSE

2. Who am I? Disclaimer and Disclosures • I come with the experience of all these responsibilities but. . . . • I am NOT formally representing any single one of them today. • Attending Emergency Medicine Physician Barnes-Jewish Hospital in Saint Louis • Assistant Professor for Washington University in Saint Louis • Medical Director Christian Hospital EMS • Deputy Chief Washington University EMS • Missouri East Central Regional EMS Medical Director • Chair Missouri Regional Medical Directors Subcommittee • Chief Medical Officer Missouri Disaster Response System • Missouri State EMS Medical Director • Medical Officer Missouri Disaster Medical Assistance Team (MO-1 DMAT) • President and CEO Interstate Disaster Medical Collaborative • I get paid for some of these duties directly or indirectly through contracts.

3. Overview • Medical response to disasters follows some predictable patterns— How do we prepare for the expected and the unexpected? • Situational Awareness is critical to disaster response—A simple approach to personal situational awareness • Maintaining medical standards with limited resources

4. Objectives • Describe an array of personal disaster preparedness tools • Apply those tools to specific cases • Expand from individual response to system coordination • Focus on pediatrics in disasters with similarities and differences

5. Disaster • NHTSA “any occurrence that causes damage, ecological destruction, loss of human lives, or deterioration of health and health services on a scale sufficient to warrant an extraordinary response from outside the affected community area.” • “Community area” is left open.

6. Predictable Timeline • Pre-Event • Surge • Sustained Needs • Additional events • Resolution • Post-Event THE EVENT

7. Predictable Timeline • Pre-Event: • Pre-event Intelligence Reports • Warnings, weather reports, tremors, threat levels • Historical Precedent • Injury patterns, timelines, lessons learned, hotwashes • Epidemiology • Public health monitoring, disease patterns, resistance patterns Spell Check tried to change this to HOGwashes

8. Pay Attention to the Warning Signs

9. Predictable Timeline • Pre-event surge • People stocking up on supplies, trying to get to care before its too late • Event • Immediate Patient and resource surge • Sustained increase in needs and decreased resources • Resolution • Return to baseline • Post-Event • Additional smaller events or normal surges that overtax the depleted system.

10. STEMI

11. Disaster • Lessons Peak Resource Needs Intra-event surge Sustained Elevated Resource Use +/- Pre-event surge +/- Post events Lessons Learned from Previous Events Baseline Resource Utilization Return to Baseline Resource Utilization

12. Example 1—Severe Winter Storm • Medical Predictions: • Special Needs patients • Home Ventilators, CPAP • Dialysis • Wound care and dressing changes • Environmental (Hypothermia, CO) • Resource Predictions: • Power supply, generators, batteries • Oxygen, dialysis and wound care supplies

13. Example 1—Severe Winter Storm • Lessons Learned From Special Needs/ Some Injuries Injuries During Repair Efforts Exacerbations of Chronic Disease Stocking up on Supplies Storm #2 Weather Report Baseline Baseline Lessons Learned from Previous Storm

14. Two Problems • Disaster Medicine May be broken into two important categories: • Medical Problems: • Unique injury patterns • Epidemiological resistance patterns • Logistical Problems: • Structural Damage • Power outages • Staff and Resource limitations

15. Good News • The Medicine doesn’t change much • Some tactical environments alter ABCs to CBA • May alter antimicrobial choice passed upon an increase in certain flora • May increase conservative or presumptive treatment in absence of definitive diagnostic tests

16. Bad News • Logistical Problems • Can vary depending upon the type of disaster and can be a moving target • Shifting gaps in resources and supplies can be challenging to fill in time • New problems can develop at any time

17. Good News • Logistical Problems: • Historical precedent can teach us some expected demands and we can plan ahead • All-Hazards approach • Most bang for a limited buck • The predictable timeline in disaster can help us stay one step ahead in needs.

18. IMPORTANT • Do not alter your medical standards unless you absolutely have to. • START, Jump-START, SMAT, SALT triage tools and altered standards of care documents are all important tools • Just because we have these altered standards tools and we are in a disaster does not mean that they must be applied • The goal is the handle the logistical problems to prevent any effect on patient care • Shuffle excess resources to areas of need • Call for help early based upon predictable areas of need.

19. Summary • Disasters often follow a predictable timeline • Use ALL-hazards approach to prepare for most common expectations • Concentrate on meeting and predicting the logistical needs early to reduce alterations in patient care

20. Example 2—Earthquake • Amputations, crush injuries, surgical emergencies • Environmental (starvation, cold/heat injuries) • Respiratory distress (Asthma and COPD from dusts and molds) • General medical conditions • Medical Predictions: • Resource Predictions: • Trauma and orthopedic services and supplies • Working anesthesia • Power supplies and ventilators

21. Example 2—Earthquake • Lessons Learned Acute Traumas Injuries During Repair Efforts Chronic Exacerbations Warning Tremors After Shocks Lessons Learned Earthquake Drill Baseline Resource Utilization Return to Baseline Resource Utilization

22. Situational Awareness • You Are Here • Hierarchy, Chain of Command • NIMS, ICS, HICS (alphabet soup) • Know These Things • My specific task and who tells me • Where my patients come from • Where my patients are going • These may be different than your day to day duties

23. Personal Situational Awareness— Know Thy Self • Green? Yellow? Red? • I’M SAFE (FAA) • Illness, Medication, Stress, Alcohol, Fatigue, Eating • What is my Baseline? • Everyone in this room is 1/2 bubble off normal • We DO use CUS words (TeamSTEPPS) • C-Concern, U-Uncomfortable, S-Safety

24. Know Thy Self

25. Green • I have all the resources I need • Business as usual • Just another day • What’s all the fuss about? • It’s a Quiet Day. . . . . .

26. Yellow • We’re getting stretched pretty thin here • I can’t take much more of this • I’m going on vacation with my overtime pay for this • Where is my relief? • We show some Concerns. • Did you just use the “Q” word?

27. Red • I’m overwhelmed • Get me out of here! • Did I just push that on the wrong patient? • I’m sorry. . . .I just can’t • Someone help me! • I’m doing the best I can, but it’s just too much • $#!T yes we use CUS words • This is all my partner’s fault! She was having a “Quiet” day!

28. Situational Awareness • Knowing what is coming in and where things are going can help you make an informed decision about the here and now.

29. Patient Flow and Management—The System • Monitor each areas’ color status and update • Pre-hospital/ Scene • Triage area • Emergency Department • OR, ICU, Floors • Communicate the colors to each area one step ahead and one step behind • NO area should be in the RED if resources are available from a GREEN area!!

30. Example • In triage 84 yo COPD s/p severe respiratory distress from dust inhalation, 1 ventilator left • Scenario A: EMS-Red, Triage-Red, ED-Red, ICU-Red, OR-Yellow • Scenario B: EMS-Green, Triage-Red, ED-Yellow, OR-Green • What triage color? Red? Black? • Intubate the Patient? Use the Vent? • This is designed to be difficult. The idea is to make us think and prepare. Do these situational tools help us with these tough decisions? • How will you feel about this decision a few days later when you have had a full night sleep? • Disclaimer: This is my shameless plug to utilize mental health resources early in the process. Disclosure: My wife is a social worker and a mental health specialist for our disaster team.

31. Your System’s Resources

32. Local Resources Backup call, CERT, Sister hospitals, surge contracts

33. Regional/ State Resources SMAT, MRCs, ESAR-VHP, National Guard, NGOs, EMS Strike Teams 12-24h

34. National Resources EMACs, NDMS, FEMA, Military 48-72h

35. When asking for resources, be sure to follow the Chain of Command: Emergency Operations Center • Eventual Reimbursement • Regional Resource Tracking

36. Be sure to have a clear Final Decision Maker (Eg. Incident Commander, CEO, Chief, etc.) • Be sure to have a backup • Rotations to keep this person or team from falling into the red • Be sure to have the authority over the entire span of control • Yes a paramedic can intubate a patient in our ED, etc.

37. Tips • Be Specific with your needs: • 20 ventilators, 2 trauma surgeons, 20 ED nurses • Avoid request for packages specific teams such as send us a DMAT • The emergency operations center should be pairing the specific needs with available packages

38. Pediatrics in Disasters • First Steps: Evidence Based Medicine • Disaster Medicine falls under the purview of EMS Medicine (the last ABMS subspecialty of Medicine) • EMS Medical evidence as of ACEP/NAEMSP Review 2013 • Level 3 evidence (Expert opinion—Lowest Level) • 60% of EMS evidence is Level 3 • Disaster may be even more • Pediatrics. . . .well you get the idea

39. Pediatric Medical Problems • Children require different forms of mental health interventions than those used by adults. • Children may experience increased psychological effects as they may have difficulty comprehending disasters within the context of normal every day events. • This may leave children unable to cope long after disasters and result in later consequences including depression, lack of focus and poor school performance • Children require different dosages of medications • Children may require specifically sized or calibrated equipment http://www.fema.gov/pdf/government/grant/2012/fy12_hsgp_children.pdf

40. Logistical Problems • Children’s developmental and cognitive levels may impede their ability to escape danger, evacuate and self-identify. • Families may be separated or custodians injured or deceased • Young children may not be able to communicate enough information to be identified and reunited with parents or caregivers. • Children are in various stages of cognitive development • Children may experience increased psychological effects as they may have difficulty comprehending disasters within the context of normal every day events. This may leave children unable to cope long after disasters and result in later consequences including depression, lack of focus and poor school performance • Critically sick or injured children may have specialized transportation needs. http://www.fema.gov/pdf/government/grant/2012/fy12_hsgp_children.pdf

41. Solutions • Mental Health Needs • Request for mental health assistance early • Social Workers Rock!! • Pay careful attention to children’s affect • Most important changes in behaviors • Normally more quite, now acting out • Normally outgoing, now quiet and reserved

42. Solutions • Medication: • Work on double checks between dose administration and actual administration. • Working with different forms of meds as well as an environment where calculation errors can occur. • Out of routine can lead to errors • If implemented and standardized then an individual working in the yellow or red status may not have to recognize potential errors alone • Work with your pharmacist on liquid form options of common disaster medications (Benadryl, Tylenol, etc) • Do not rely on crushed up adult meds alone, if a kid wont take it at home on a good day do you really think they will take it when they haven’t had a nap in a week?

43. Solutions • Check EMS-C sites for latest equipment recommendations for pediatrics • Encourage local and regional participation in EMS-C programs to maintain pediatric appropriate equipment. • Remember EMS strike teams may be arriving from all over.

44. Solutions • Consider integrating children into your drills. • It is amazing how much more realistic and how much more challenging to perform regular medical operations when you have children around the area where they normally are not. • For those who have children consider bringing them in to share the chaos of a drill. Remember the system might be better tested when you have a 3 year old tugging at your leg the whole time.

45. Solutions • Temporary area for children • Block of safe zones with construction webbing rather than caution tape alone • Be careful to block off dangerous disaster equipment (Air-conditioners, Generators, etc.) • Include Outdoor play area • Consider sidewalk chalk rather than balls or other equipment that will encourage escape • Include Indoor quiet play and eat area • Include Indoor dark quiet nap area

46. Solutions • Work with Family Assistance Centers (ESF#6) • Recognize importance of proper identification • Often work in conjunction with Mortuary teams to facilitate death notifications • Work with Law enforcement and child protection agencies to ensure proper pairing http://www.fema.gov/pdf/government/grant/2012/fy12_hsgp_children.pdf

47. Solutions • Be sure to plan early to supply nutritious options for children • Children may not know of their allergies so prepare for reactions by preventative choices of food and allergic retain supplies • The disaster food can be geared toward high calorie for hard work • Can cause children to be more hyper especially in an overly stimulated environment

48. Solution • Triage arm bands on children will be removed as soon as you turn around—Houdini • Consider stickers on the back • Consider ankle bands • Magic markers can also work especially on clothing tags

49. Questions and Answers (?)