PowerPoint Presentation

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

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

3Texas Motor Speedway ExerciseScenario:Aircraft explodes on race dayResult: > 10,000 victimsIncluded a dirty bombStakeholders & Resources:All area Public Health departmentsOver 40 State and federal agenciesOver 2,300 victim volunteers Over 300 First Responders30 area hospitals participated

4Texas Motor SpeedwayExercise, November 2004

Three critical gaps identified: Casualty / Patient TriageMedical Decontamination (Med Decon)Personal Protective Equipment (PPE)

5Consequences of Non-preparednessHealthcare facilities closedMorbidity / mortality for healthcare providersMorbidity / mortality for our patients

6Working Together to Achieve Healthcare PreparednessTarrant 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.7NDLS Family of Courses

A comprehensive, nationally-standardized family of all-hazards training programs developed by the NDLS consortium of academic, state, and federal centers.

7These 3 courses address ALL levels of medical providers.

Also included in the target student group are;Law enforcement personnelFirefightersPublic health personnelMilitary personnelVolunteersEmergency planners / managersAny 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.8Establishing a Standard

9Academic StakeholdersNDLS Co-foundersSubject matter expertsAMA NDLS Text EditorsExperienced in statewide and national educational program distribution

10Texas State Guard unitUniformed MRCMobilized by Governor Subject matter expertsExperienced regional faculty

MRC Regional Stakeholders11

NDLS-Decon 2 day, 16-contact hoursMeets OSHA awareness and operational training levelsCDLS course, 4 hoursNDLS-Decon, 12 hoursIncludes 8 hours ofinteractive-skills session

12Establishing a StandardRecent course addition to the NDLS FamilyInternal validity assessmentBeta-tested statewide in GeorgiaCurrently in 2nd year of distributionExternal validity assessmentTexas roll-out Tarrant Co. APC, first to offer in TexasAPC in collaboration with stakeholders are establishing a national standard

13Preparing Our CommunitiesWelcome!RES 0404061314Continuing Medical EducationCME Faculty DisclosureIn 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. 15D-I-S-A-S-T-E-R Overview1516ObjectivesIdentify the critical need to establish healthcare preparedness for disastersDefine disaster and Mass Casualty Incident (MCI) Define All-hazards and list possibilitiesIdentify the components of the D-I-S-A-S-T-E-R paradigmIdentify and apply a mass casualty triage model utilizing M.A.S.S. and ID-me

16- These objectives are straight-forward and self-explanatory- These come directly out of the text at the beginning of the chapter17What is a Disaster?Disaster- disaster n. An occurrence causing widespread destruction and distress; a catastrophe. A grave misfortune.Informal- A total failure

17Different definitions have been put forth for the word, disaster.These are just a few18What is a Disaster?From another perspective

JCAHO: Something that disrupts the environment of care; disrupts care and treatment; changes or increases demand.

18-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) 19A disaster is present when need exceeds resourcesIn other words: the response need exceeds the resources availableDisaster DefinitionDisaster = Need > Resources19[[Self-explanatory]]20Multiple/Mass/Major Casualty Incident

An MCI is present when healthcare need exceeds available healthcare resources!

MCI DefinitionMCI = Healthcare Need > Resources20This same concept also applies to healthcare incidents.A multiple/mass/major casualty incident is present when healthcare needs healthcare resources.21MCI ManagementGoal:Do the greatest good for the greatest number of potential survivors!

This is an important concept!21The 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.)22Are We Prepared?The Concern:Increased likelihood of weapons of mass destruction (WMD) noted for yearsWorldwide arsenal of nuclear, biological and chemical (NBC) agents:Security, Political, Socioeconomic changesThe threat to intentionally harm large civilian populations has never been greater than today!22other abbreviations;WMD also known as WME (weapons of mass effect) CBRNE-chemical, biological, radiologic, nuclear, explosiveBNICE- biologic, nuclear, incendiary, chemical, explosive

these agents are found all over the world and may be deployed anywhere, against any group..even civiliansRecent events show increased attacks on U.S. citizens, both here and abroad

23Terrorism

The Reality:September 11, 2001 9 - 11 23The events of September 11th , 2001 were a clear message of the intentions of one terrorist organizationThis 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 agendas24TerrorismUse of force against persons or property: To intimidate or coerce To further political or social objectivesCriminal act

25WMD / WMEWeapons or devices that injure or kill large numbersCause widespread destruction and/or panicChemical, Biological, Radiological, Nuclear, Explosive (CBRNE)

Weapons of Mass Destruction / Effect Definition

25Weapons 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.

26Man-made poisons spread as gases, liquids, or aerosolsCause illness or death in humans, animals, plantsMay be inhaled, ingested or absorbedVariety of disseminating devices

Chemical Weapons

26We 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.

27Chemical WeaponsNerve agents: GA, GB, GD, VXBlood agents: CyanideBlister agents: Mustard, LewisiteChoking agents: Phosgene, ChlorineIncapacitating agents: BZ

27The five major categories of chemical agents include:Nerve agents (cholinesterase inhibitors), such as GA, GB, GD and VXBlood agents (asphyxiants), such as cyanide and carbon monoxideBlister agents (or vesicants), such as mustard and Lewisite,Choking agents (respiratory irritants or pulmonary agents), such as phosgene and chlorineAnd 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.]]]]28Chemical Weapons

Aum ShinrikyoSarin Gas ReleaseJune 27, 1994March 20, 1995Matsumoto, Japan Tokyo, JapanCourthouse/ResidenceSubway4 dead12 dead 150 injured >5000 arrived at hospital

Aum Shinrikyo

28Chemical 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 150. Far more media exposure was provided for a subsequent attack by this same cult in March 1995. 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. Lukes 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.

29Catastrophic explosionsMassive nuclear energy release through atom splittingTraumatic injuries, burns, fallout, delayed effects

Nuclear Weapons

29Nuclear 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.

30Devices to disperse radioactive substancesConventional explosive device (dirty bomb)Intentional radiation release: water, food, terrainLess energy & radiation release than a nuclear weaponDelayed detection: no sceneWorried well & civilian panic

Radiological Weapons

30Next 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.

31Aircraft as WMD

September 11, 2001World Trade Center Towers, NYCPentagon, Washington, DCSomerset, PA

31The 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.

32Are you the victim of a weapon of mass effect (WME)?33Anthrax as WMEAsymmetric warfare:Small eventWidespread effect

33What IS terrorism?Lets 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 populations beliefs, behaviors and practices. The most blatant recent example is that of the anthrax letters in 2001. 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.

http://www.mema.domestic-preparedness.net/index.html

34Disseminate disease-causing microorganisms or biologically-produced toxins (poisons)Cause illness or death in humans, animals, or plantsNumerous agents could be used

Biological Weapons34As 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

SmallpoxPlagueAnthrax35As 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 1970s 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.

36Biological Event

Influenza 1918-191936Emerging infectious diseases also cause natural disasters. During the 1970s, 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 2003. 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.37EpidemicsSevere Acute Respiratory Syndrome 2003

SARS (Corona virus)37SARS poses a significant public health threat. It is just the latest of natures 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 organisms 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.

38Natural EventsThe Reality:September 2005 Katrina&Rita

38The events of September 11th , 2001 were a clear message of the intentions of one terrorist organizationThis 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 agendas39Natural Disasters

The Concern:Numerous & widespreadMillions of fatalities worldwideCountless millions more injured$ Billions per eventCommon in the U.S. There WILL be a natural disaster in the U.S. this year39Many 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.40Katrina

EvacuationSurge CapacityTreatmentTriage41Rita

MitigationEvacuation

42What causes the greatest number of fatalities in the U.S. from natural disasters?43

Flash FloodsCause the greatest number of U.S. fatalities from natural disasters!Most deaths involve motor vehicles

43One 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.44Transportation 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 Marine44Transportation 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 HazmatMostly minor spills, occasionally severe!Massive explosionsHazardous materials releaseToxic fumes, radiation, biological agentsSecondary disastersMultiple casualtiesProlonged community impactLoss of homes & jobsEmotional impact45Although 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 3500. Casualties totaled more than 25% of the towns 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 900,000Estimates 6,000-10,000? Affected ~ 400,000Lack of safety devicesManuals in EnglishMore 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????46All-HazardsMan-madeFiresExplosive devicesFirearmsStructural collapseTransportation eventAir, Rail, Roadway, WaterIndustrial HAZMATWMD NBC eventsEtcNaturalEarthquakeLandslidesAvalancheVolcanoTornadoHurricanes, floodsFiresMeteorsEtc

46-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 soonthey 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)47All-Hazards DefinitionAll-Hazards: Man-made or natural events with the destructive capability of causing multiple casualtiesAll-Hazards Preparedness: Comprehensive preparedness required to manage the casualties resulting from All-Hazards47As 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.48NDLS ConceptCritical to healthcare preparedness: UniformCoordinated approach Mass casualty management from all-hazards

Best accomplished by standardized training and practice guidelines

49NDLS Family of Courses

A comprehensive, nationally-standardized family of all-hazards training programs developed by the NDLS consortium of academic, state, and federal centers.

49These 3 courses address ALL levels of medical providers.

Also included in the target student group are;Law enforcement personnelFirefightersPublic health personnelMilitary personnelVolunteersEmergency planners / managersAny 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.50Stakeholders

Research Triangle Institute

CDP50A partial listing of the NDLSEC members is shown in this slide.51Confidence and Teamwork!

51These are the topics covered in ADLS.

- Extensive simulations-training is utilized on Day 252D-I-S-A-S-T-E-R Paradigm

52These 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. 53DISASTER ParadigmDetection Incident CommandSafety & SecurityAssess HazardsSupportTriage & TreatmentEvacuationRecovery

Natural & AccidentalTrauma & ExplosiveNuclear & RadiologicalBiological AgentsChemical Agents

54D-I-S-A-S-T-E-R ParadigmA standardized method to recognize and manage the scene and care for victimsReinforced throughout all NDLS courses:A training toolPractical approach on scene!An organizational toolUtilize resources, assess needsA series of questions54This 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).55D-I-S-A-S-T-E-R ParadigmDo I detect something, what caused this?55-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!

56D-I-S-A-S-T-E-R ParadigmDo we need an incident command, where? 56-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.57D-I-S-A-S-T-E-R ParadigmIs a safety or security issue present?57-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)58D-I-S-A-S-T-E-R ParadigmDid we assess the hazards that could be here?58-are there any other hazards here?-Do I need to call for someone who can assess things that I cant? (radioactivity, etc)

Hazmat?Violence?Fire?Unstable structures?Explosives?Rioting?Weather?Gas leaks?Etc59D-I-S-A-S-T-E-R ParadigmWhat support, people, supplies are needed?59-What kind of help do I need here?Local?State?Federal?Military?Private?Volunteer?Equipment?Etc.60D-I-S-A-S-T-E-R ParadigmDo we need to triage, how much treatment?60Are 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?61D-I-S-A-S-T-E-R ParadigmCan we evacuate/transport the victims?61How will we evacuate the victims?.and in what order?Where will we send them? 62D-I-S-A-S-T-E-R ParadigmWhat recovery issues are present?62What is needed for this community and its responders to recover from this incident?63D-I-S-A-S-T-E-R ParadigmIs my need greater than my resources? KEY!63What is needed for this community and its responders to recover from this incident?64D-I-S-A-S-T-E-R ParadigmDetectionGoal assess:Is a disaster / MCI present?...Need > Resource?What caused this event?Detection is Awareness!TRAP!tunnel-vision on the injured patients

64-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!!!65D-I-S-A-S-T-E-R ParadigmDetectionSample 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? 65-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?66D-I-S-A-S-T-E-R Paradigm Incident Command

Incident Command System (ICS)

Born in Fire ServiceManaging wildfires in early 1970sInteragency task force collaborative effortUniform structureClearly defined roles & chain of commandAllows for a scalable response Unified Command

66ICS 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.67Incident Command SystemThe Basics

Unified CommandPlanningOperationsFinanceLogisticsCommanderThinkersGettersDoersPayers67INCIDENT COMMANDER (IC) IS:Ultimate responsibility and authority for the entire operation.Generally fire service or law enforcementUnified Command

Generally a staff will support the IC

68Incident Command SystemWhat does the Incident Command need to know?Number and type of casualtiesSubstances involvedEstimated time of arrival to hospitalTime / location of the incident Method of contamination (vapor or liquid)Necessary decontaminationUpdated information

68This 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. Its 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.69Incident Command SystemThe Basics

Unified CommandPlanningOperationsFinanceLogisticsCommanderThinkersGettersDoersPayers69Planning: Responsible for collection, evaluation and display of incident information. It also maintains status of resources, preparing a plan of action, and incident related documentationObtain 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

70Incident Command SystemThe Basics

Unified CommandPlanningOperationsFinanceLogisticsCommanderThinkersGettersDoersPayers70Logistics: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 supportTraditionally responsible for staging of vehicles/apparatus/ambulances and liaisons with OperationsSupports Operations closely

71Incident Command SystemThe Basics

Unified CommandPlanningOperationsFinanceLogisticsCommanderThinkersGettersDoersPayers71Operations: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 sceneResponsible for directing primary actionsResponsible for personnel accountability & scene controlResponsible for Triage and Transportation Sectors

72Incident Command System Operations

72An 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 physicianEMS-MD has oversight for healthcare providedMake difficult Triage decisionsAssist Transportation Officer in decision makingAssist Operations Officer in decision makingMedical Direction is NOT scene or operations controlThe 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)

73D-I-S-A-S-T-E-R Paradigm Incident CommandOperations personnel and resourcesMedical Control Responsibilities:On-scene Medical DirectionDifficult triage decisionsEmergent surgical proceduresAdvanced level treatment when necessaryAssist Transportation Officer in decision makingAssist Operations Officer in decision makingMedical Control is NOT scene control73Medical 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.74Incident Command SystemThe Basics

Unified CommandPlanningOperationsFinanceLogisticsCommanderThinkersGettersDoersPayers74FINANCE (Admin.)

Tracks Rescuer work hours/timeResponsible for payroll management, procurement, paying claims, estimating costs, reimbursementsThe finance sections work may continue long after the event is over.75

75This 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 hospitals 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 sectionwww.emsa.ca.gov/dms2/download.htm)76D-I-S-A-S-T-E-R Scene Safety & Security

Begins with Mental PreparationTrainingWhat could we encounter?IF/THEN: Think through / Plan initial tasksBe Flexible, only thing constant is changeResponse to SceneAvoid Siren PsychosisSafe Response Do not Drive it like you stole itRoutes in and out are plannedConsider terrain, weather, wind direction, time of day76Mentally 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 ones 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. 77D-I-S-A-S-T-E-RScene Safety & SecurityScene Priorities:Dont be foolish, protect yourself!Protect Yourself and Your Team FIRST!Protect the PublicProtect the PatientsProtect the Environment77Your safety is the number 1 priority at the scene. If you are injured or killed, then youre 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!78Example: Scene SafetyCasualty Collection PointWARM ZONE60 ftRS6,000 ft6,000 ftHOT ZONE300 ftWIND DIRECTIONHOT ZONEWARM ZONERS= Release SiteMinimum Site BoundariesOpen Area Chemical ReleaseAdapted from Illinois Emergency Management Agency Chem-Bio Handbook. April 2000COLD ZONECOLD ZONEUphill if agent heavier than air, downhill or level if lighter than airFigure 5CCP78This 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.79D-I-S-A-S-T-E-R ParadigmAssess HazardsPower lines downedDebris / traumaFire / burnsBlood and fluidsHazardous materialsFlooding / drowningExplosionsLow light/visibilitySmoke/toxic inhalationNatural gas linesStructural collapseWeather conditionNBC ExposuresDirty BombsSnipersSecondary devices

79This 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 sceneAircraft 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.80D-I-S-A-S-T-E-R ParadigmAssess HazardsAwareness is key to detection of hazardsTraining in All-hazards approachProtection more valuable than identificationPersonal Protective Equipment (PPE)Continual reassessment of sceneGet the job done, and get out!

80-if youre 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 PPEs 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).

81D-I-S-A-S-T-E-R ParadigmAssess HazardsBe Aware of Secondary Devices!Bombs, Shrapnel devices, Incapacitating Devices, Multiple Snipers/Terrorists, Delay Devices

81-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 rescuersA biological agent intended to infect/harm rescuersA 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 tacticAny 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)82D-I-S-A-S-T-E-R ParadigmSupportBottom-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?

82- Human resources/agencies police, firefighters, prehospital medical personnel, hospital personnel, physicians, animal control, EOD (explosive ordnance disposalbomb 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,.83D-I-S-A-S-T-E-R ParadigmSupportReview historical injury and ICS reportsVital to proper planning, logistics, etc..Establish proper policies & protocolsHuman resourcesPersonnel report automaticallySupplies & EquipmentStanding orders, passive implementationOccurrence based, duration based, etc..Vendors automatically ship pre-determined supplies83-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 needs84D-I-S-A-S-T-E-R ParadigmSupportUnexpected Volunteers and Donations:Positive intentions, can have negative impactDoes your preparedness plan include them?Ability to identify needed skills and needed suppliesNegatives:Time to sort large and label goodsStorage space usedUnplanned personnel are a liabilityAt risk of injuries, require food, water and shelter84-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)..85D-I-S-A-S-T-E-R ParadigmTriageSorting patients by the seriousness of their condition and the likelihood of their survival To achieve the greatest good for the greatest number possibleDependent on resources available85At 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 resourcesfewer resources will equate to treatment delays/omissions for more victims86D-I-S-A-S-T-E-R ParadigmTriageTriage methods and systems:Several different triage systems in useDifferent triage methods/ tags/ categories / colors / symbols usedIDEAL One system used by all agencies + hospitals

86In 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 agencys triage system.practice with it in drillsit 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 training87M.A.S.S. TriageM MoveA AssessS SortS Send87MASS is an easy-to-remember acronym for; MOVEASSESSSORTSEND MASS may be thought of as also referring to MASS casualty incident88D-I-S-A-S-T-E-R ParadigmMASS Triage ModelMove Anyone who can walk is told to MOVE to a collection areaRemaining victims are told to MOVE an arm or legAssess Remaining patients who didnt move (help these people first)Sort Categorize patients by ID-meImmediate, Delayed, Minimal, Expectant, DeadSendTransport IMMEDIATE patients firstSend to Hospitals and Secondary Treatment Facilities

88This 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.

89ID-me!I ImmediateD Delayed M - MinimalE ExpectantD - DEADID-me! - a mnemonic for sorting patients during MCI triage. It is utilized effectively in the M.A.S.S. Triage model. 89These 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 scene90D-I-S-A-S-T-E-R ParadigmMASS Triage ModelMOVE Step 1:GoalGroup - Ambulatory PatientsAction:Everyone who can hear me and needs medical attention, please move to the area with the green flagID-me CategoryMinimal initial group90The 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/flagThis gets them out of the way so that you may find the higher priority patientsThis 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 catagories91D-I-S-A-S-T-E-R ParadigmMASS Triage ModelMOVEMinimal group, initial screeningAirway, breathing, and circulation intactMental status: able to follow commandsNot likely low blood pressure or breathing troubleSome conditions worsen, more urgent triage categoryMust be reassessed and monitoredLimitations: not based upon individual assessment yetActively managing this group will reduce self-transports and perhaps unnecessary overburdening of nearest hospital ERsAssess last, after Immediate and Delayed groups

91This group is healthy enough to hear you, follow your commands, and self-ambulatethus it is a rapid way of finding the healthiest group of people at the scene so that they may be assessed LASTafter 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 92D-I-S-A-S-T-E-R ParadigmMASS Triage ModelMOVE Step 2:GoalGroup cant 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 youID-me CategoryDelayed initial group

92This process results in the discovery of the initial DELAYED groupthey 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, .93D-I-S-A-S-T-E-R ParadigmMASS Triage ModelMOVE Delayed groupAirway, breathing, and circulation adequate to follow simple commandsMental status: Conscious & able to follow simple commandsMay have low blood pressure or low oxygen levelLikely significant injuries presentLimitations: not based upon individual assessment yetAssess second, after Immediate group93The 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 assessmentIndividual assessment MUST BE PERFORMED as soon as possible to identify and treat immediate life threats that may be present.

94D-I-S-A-S-T-E-R ParadigmMASS Triage ModelASSESSGoalGroup Identify location of who is left, unable to ambulate and unable to follow simple commandsAction:Proceed immediately to these patients and deliver immediate life-saving interventionsID-me CategoryImmediate initial group

94Anyone 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).Dont 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.

95D-I-S-A-S-T-E-R ParadigmMASS Triage ModelASSESSImmediate groupABC status unknown, immediate assessmentMental status: Unresponsive to verbal commandsLikely low blood pressure or low oxygen levelLife-threatening injuries presentExpectant and dead patients may be in this groupMinor injuries may be present due to:Ruptured ear drums, hearing impaired, chronically disabledLimitations: not based upon individual assessmentAssess these people FIRST!95-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) 96D-I-S-A-S-T-E-R ParadigmMASS Triage ModelASSESS IMMEDIATE patientsRapidly Assess ABCs :Is airway open? Open it manuallyIs patient breathing? If not, EXPECTANT and go onIs 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 patientsIs transport available for anyone now? Move on!96Direct 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 accepthe must then ensure that the patients are distributed to the different hospitals in a logical manner and order97D-I-S-A-S-T-E-R ParadigmMASS Triage ModelSORT - ID-me: I ImmediateD Delayed M- MinimalE ExpectantD - DEADSORT them based upon individual assessment, continue lifesaving treatment97Now 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 personnelthus, wasting timeDead patients should also be tagged as such to prevent wasting resources to re-triage the patient. 98D-I-S-A-S-T-E-R ParadigmMASS Triage ModelSORT ImmediateLife or limb threatening injuryUsually persistent ABC problemExamples:Unresponsive, altered mental status, severe breathing trouble, uncontrollable bleeding, proximal amputations, turning blue, rapid and weak pulse

98 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 categorys physical collection area

99D-I-S-A-S-T-E-R ParadigmMASS Triage ModelSORT Delayed:Need definitive medical care, but should not worsen rapidly if initial care is delayedExamples:Deep cuts or open fractures with controlled bleeding and good pulses; finger amputations; abdominal injuries with stable vital signs

99These 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 categorys physical collection area100D-I-S-A-S-T-E-R ParadigmMASS Triage ModelSORT Minimal:Walking WoundedTreated and released (preferably without transport)Source of volunteer helpExamples:Abrasions, contusions, minor lacerations, no apparent injury

100 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 categorys 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

101D-I-S-A-S-T-E-R ParadigmMASS Triage ModelSORT Expectant

Severely injured with little or no chance of survivalCare resources not utilized initiallyComfort resources used as availableRemember death could be hours or days away!Require reassessment and transport: If alive after all immediate patients transported, resuscitate per available resources!

101 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 categorys physical collection area as more resources become available and the IMMEDIATEs have been dealt with, more resources can be devoted to this group102D-I-S-A-S-T-E-R ParadigmMASS Triage ModelSORT is dynamic! Reassess!

Who is left?Expectant group could become new Immediate groupMost serious injury present requires your immediate attention!102As 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 category103D-I-S-A-S-T-E-R ParadigmMASS Triage ModelWhen all patients have been triaged and immediate life saving procedures complete: Accurate count in each categoryAdvise incident commander/triage officer Move all immediate to collection point Prepare for immediate transport Often marked with red flag/tarp103The 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 firstIt is essential that a clear route of egress be preserved for the transport units to leave the sceneit 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 transport104D-I-S-A-S-T-E-R ParadigmMASS Triage ModelHow to handle the dead patients:Dead patients should not be movedMay aid in identification of the deceasedEvidence is important!Finding and convicting perpetrators....and possibly... PREVENTING future attacks! Excessive manipulation of human remains may destroy vital evidence104If 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 terrorismThe 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 victims 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. 105D-I-S-A-S-T-E-R ParadigmMASS Triage ModelSENDTraditional syntaxImmediate Delayed Minimal ExpectantObjectiveTransport or release ALL living patients ASAPMission FocusedSend Minimal(s) with each Immediate (if unused space available in vehicle), etcResourcefulSecondary treatment facilities for minimal pts (or on-scene treatment and release)Utilize buses, taxis, trains, boats, etc..105IMMEDIATE 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 dont 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)106D-I-S-A-S-T-E-R ParadigmTreatmentTreatment continues on-scene until:All patients transportedResources unavailable to provide treatmentComfort is Care!All-Hazards treatment plansAlgorithms of care deliveryDocumentationPatient Identification / Triage TagMedical Record 106Treatment 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 transportsit can also help track who has been decontaminated..who has received antidotes/prophylactic medications, etc Good documentation may also assist in law enforcement personnels subsequent investigation of the incident107D-I-S-A-S-T-E-R ParadigmEvacuationShort-term goal of the event!Preparedness Plan Evacuation of hospitalsHigh-rise office buildingsEgress route alternativesTransportationSEND of MASS Triage ModelMore than patients, includes families..public107Rapid 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

108D-I-S-A-S-T-E-R Paradigm RecoveryLong-term goal of the event!Minimize events impact Injured victims, families, rescue personnelCommunity, state, and nationEnvironmentPreparedness Plan must includeBegins when the incident occurredEnds often years later108-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 communitycriminal/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, etc109D-I-S-A-S-T-E-R Paradigm RecoveryOperational and Logistic considerations:Vehicles:Clean, disinfect, restock, refuel unitsEquipment:Repair / replace equipment (and evaluate)Inventory & order supplies (and evaluate)Personnel:Fed, hydrated, rested and released ASAPMany personnel may have been injuredTendency to down-play importancePre-release medical exams109-ensure that any HAZMATs were identified and equipment properly decontaminated or disposed ofDid 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 didnt? - 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 personnelthis will assist with compensation issues/insurance issues/legal issues/identifying trends or patterns of disease or injury, etcIt 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 110D-I-S-A-S-T-E-R Paradigm RecoveryPsychosocial:Debriefing of personnelCommonly occurs when relieved from duty Identify at risk potentialPost-incident observationObserve for stress related problemsWithdrawal, depression, hyper-excitability, unusual behavior, etc..Appropriate interventionMinimize negative psychosocial impact110 All persons involved in the incident may be affected by the stress.not just the rescuersSome 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/symptomsmany 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 wellsubstance abuse, sleep pattern changes, appetite changes, emotional lability, hypervigilance, etcthese can all take a heavy toll on family life (as well as future job performance)111D-I-S-A-S-T-E-R Paradigm RecoveryImmediate: food, water, shelter, clothingRecovery actions involve entire communityLocal is most important!Churches, temples, stores, hotels, restaurantsRegional, State and Federal resourcesDMAT Disaster Medical Assistance TeamsDMORT Disaster Mortuary Assistance TeamsVMAT Disaster Veterinary Assistance TeamsVA Teams Department of Veterans AffairsNMRT National Medical Response TeamsFEMA Federal Emergency Management Agency ($$)111- Also security/looting, restoration of utilities, sanitation, etc-many different agencies available to help..state EMA, FEMA, DMATs, military, Red Cross, EPA, private groups, businesses, etc- Federal agencies typically coordinated through state-level EMAs/government112D-I-S-A-S-T-E-R Paradigm RecoveryAfter-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 optionGoal: Update / revise disaster plans112Another 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?) and2. 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.113SummaryNow You Can:Identify the critical need to establish healthcare preparedness for disastersDefine disaster and Mass Casualty Incident (MCI) Define All-hazards and list possibilitiesIdentify the components of the D-I-S-A-S-T-E-R paradigmIdentify and apply a mass casualty triage model utilizing M.A.S.S. and ID-me

113-this slide is self-explanatory-remind students that all this material is in their BDLS textbook114Thank You!Questions?114- Encourage students to ask questions openlythere 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 attentionCan give instructors contact info. to students if desiredRemind students that they may ask questions later or during a break if they think of anyRemind students of instructors 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 instructors 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

115Contact informationRay E. Swienton, MD, FACEPCo-Director, EMS, Disaster Medicine & Homeland Security SectionAssociate Professor, Division of Emergency MedicineUniversity of Texas Southwestern Medical Center 5323 Harry Hines Blvd.Dallas, Texas 75390-8579

Email: BearDogMD@AOL.comVoice: (817) 271-7801