PDLSPDLS©©::EMS Response to DisasterEMS Response to Disaster

Prehospital ConsiderationsPrehospital Considerations

Jorge D. Yarzebski, NREMTP

ObjectivesObjectives

To review EMS considerations in disaster To review EMS considerations in disaster situations and the unique needs of childrensituations and the unique needs of children

What to expect from prehospital providersWhat to expect from prehospital providers

Review the Incident Command System (ICS) Review the Incident Command System (ICS) and Field Triage as it applies to prehospital and Field Triage as it applies to prehospital providersproviders

ObjectivesObjectives

Recognize and formally declare a MCIRecognize and formally declare a MCI

CommunicationCommunication- InteragencyInteragency

- HospitalsHospitals

Emergency Medical ServicesEmergency Medical Services

Network of multiple services and agencies Network of multiple services and agencies ‘coordinated’ to provide aid and medical care ‘coordinated’ to provide aid and medical care from 1º response to definitive care based on from 1º response to definitive care based on trainingtraining- First ResponderFirst Responder

- BasicBasic

- IntermediateIntermediate

- ParamedicParamedic

- RN’s/MD’sRN’s/MD’s

CoordinationCoordination

Incident Command SystemIncident Command System- Management system created to address Management system created to address

concerns of interagency compatibility and concerns of interagency compatibility and interactioninteraction

- Direct Direct

- ControlControl

- CoordinateCoordinate

ICS (Incident Command System)ICS (Incident Command System)

Senior on scene: commandSenior on scene: command- assess need for further resources and direct assess need for further resources and direct

incoming resources to where they are neededincoming resources to where they are needed

- This starts with first to arriveThis starts with first to arrive

- Triage: initial fast assessment of every patient, Triage: initial fast assessment of every patient, sort for evacuation and first in line for care when sort for evacuation and first in line for care when additional resources arriveadditional resources arrive

Responsibilites delegated through ICS Responsibilites delegated through ICS

ICSICS

Scene control Scene control - limit access for civilianslimit access for civilians

- media camerasmedia cameras

- maintain in/out routes for vehicles which do need maintain in/out routes for vehicles which do need entryentry

CommunicationsCommunications- notify hospitals of rough numbers, kinds of notify hospitals of rough numbers, kinds of

injuriesinjuries

When YOU are the first to arrive…When YOU are the first to arrive…

Declaring the Multiple Casualty IncidentDeclaring the Multiple Casualty Incident- Recognize the major incidentRecognize the major incident

- Available resources are insufficient to manage Available resources are insufficient to manage the number and nature of injuries and the number and nature of injuries and environmentenvironment

PossibilitiesPossibilities- More than two ambulances required (dependent More than two ambulances required (dependent

on resources)on resources)

When YOU are the first to arrive…When YOU are the first to arrive…

- HAZMATHAZMAT

- Special resources: Fire, Police, rescue with Special resources: Fire, Police, rescue with specialized extrication equipment, SAR, Medivacspecialized extrication equipment, SAR, Medivac

DispatchDispatch- En route request for assistance, confirm upon En route request for assistance, confirm upon

arriving on scene or cancel request*arriving on scene or cancel request*

*follow SOP for particular department*follow SOP for particular department

EMS ICSEMS ICS

Coordinates EMS activities – Activates MCI Coordinates EMS activities – Activates MCI response planresponse plan

Supervises Supervises - TRIAGE, TAGGING, TREATMENT, TRIAGE, TAGGING, TREATMENT,

TRANSPORTATIONTRANSPORTATION

Assigns personnelAssigns personnel

Guides difficult medical decisions Guides difficult medical decisions

Need Help?Need Help?

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

QuickTime™ and aTIFF (Uncompressed) decompressor

are needed to see this picture.

First to ArriveFirst to Arrive

Initial units assumes commandInitial units assumes command- Senior/most experience takes controlSenior/most experience takes control

- Requests additional supportRequests additional support

- Updates safety/mechanism/conditionsUpdates safety/mechanism/conditions

SupportSupport

SupportSupport

TriageTriage

““to sort” or place in orderto sort” or place in order

Guides decisions about allocating scarce Guides decisions about allocating scarce resources and limited timeresources and limited time

““greatest good for greatest number”greatest good for greatest number”

Protocol helps make decisionsProtocol helps make decisions

ICS separates triage from treatment ICS separates triage from treatment immediately: see everybody once briefly for immediately: see everybody once briefly for focusfocus

STARTSTART

Most commonly used triage system across Most commonly used triage system across countrycountry

Initial eval –not finalInitial eval –not final

Time limited (plan 1 min/patient)Time limited (plan 1 min/patient)

Categorize and move onCategorize and move on

STARTSTART

““If you can hear me and are able, walk over here” If you can hear me and are able, walk over here” GREEN triage done – still need individual GREEN triage done – still need individual evaluation, but can await more staff, allows initial evaluation, but can await more staff, allows initial rescuers to focus on more severely injured people.rescuers to focus on more severely injured people.

Avg 80% of victims will be green, self extricate Avg 80% of victims will be green, self extricate (may self transport – eases burden on field but hard (may self transport – eases burden on field but hard on hospitals)on hospitals)

*Not applicable for under 8 years old**Not applicable for under 8 years old*

Kids in triageKids in triage

Don’t follow commandsDon’t follow commands

May actually hide from rescuers in full gear May actually hide from rescuers in full gear (spaceman look)(spaceman look)

May be extricated by GREEN parents/ adults May be extricated by GREEN parents/ adults with delay in triage and treatmentwith delay in triage and treatment

Need distraction and dedicated supervisor Need distraction and dedicated supervisor able to run after wandering toddlersable to run after wandering toddlers

JumpSTART (under 8)JumpSTART (under 8)

Kids more airway dependent – rescue Kids more airway dependent – rescue breaths attempted if pulse present (unlike breaths attempted if pulse present (unlike adults) Resp 15-40 instead of <30adults) Resp 15-40 instead of <30

Vascular system clamps down sooner, so Vascular system clamps down sooner, so cap refill less reliablecap refill less reliable- Use peripheral pulse insteadUse peripheral pulse instead

Mental status AV/PU instead of follow/notMental status AV/PU instead of follow/not

JumpSTARTJumpSTART

““If you can hear me and you are able, walk If you can hear me and you are able, walk over here for help.” over here for help.”

GREENs are done. Screen GREEN adults GREENs are done. Screen GREEN adults for RED/YELLOW kids carried out.for RED/YELLOW kids carried out.

Assess non-ambulatory patients as you find Assess non-ambulatory patients as you find them using RPM.them using RPM.

ICSICS

Treatment: patients may outnumber Treatment: patients may outnumber transport, leading to time in field where transport, leading to time in field where treatment can be started. treatment can be started.

Sort patients by category (greens, yellow, Sort patients by category (greens, yellow, red, black) and treat within areas. If greens red, black) and treat within areas. If greens self triaged, they need evaluation.self triaged, they need evaluation.

TreatmentTreatment

Limited initial treatment – don’t delay Limited initial treatment – don’t delay evacuation if vehicle availableevacuation if vehicle available

Oxygen, dressings, splintsOxygen, dressings, splints

Airway management? Remember, no Airway management? Remember, no intubations during triage, and no codes intubations during triage, and no codes during mass casualty event, unless sufficient during mass casualty event, unless sufficient personnel and equipment that no other care personnel and equipment that no other care is delayedis delayed

TreatmentTreatment

Kids will be mixed in – do you have enough Kids will be mixed in – do you have enough supplies in kid size (oxygen, IVs, splints)?supplies in kid size (oxygen, IVs, splints)?

Does your locality stock a “disaster truck”?Does your locality stock a “disaster truck”?

Does it have kid size equipment and kid Does it have kid size equipment and kid sized doses of Hazmat antidotes?sized doses of Hazmat antidotes?

Do you have Broselow tapes to guide Do you have Broselow tapes to guide dosing?dosing?

Treatment - airwayTreatment - airway

Non breathing child (with pulse): rescue Non breathing child (with pulse): rescue breaths, then if no response, BLACKbreaths, then if no response, BLACK

Non breathing child without pulse: BLACKNon breathing child without pulse: BLACK

Oxygen: how administered? Do you have Oxygen: how administered? Do you have octopus adaptors to set more than one octopus adaptors to set more than one NRBM off each nozzle? REDs first.NRBM off each nozzle? REDs first.

TreatmentTreatment

IV fluids? Depends on numbers: does IV fluids? Depends on numbers: does everyone need an IV? Are there enough IV everyone need an IV? Are there enough IV kits to give everyone an IV? Use triage to kits to give everyone an IV? Use triage to guide => treat REDs first, then YELLOWs. guide => treat REDs first, then YELLOWs. Do GREENs need IV?Do GREENs need IV?

BLACK/expectant: pain control (if drugs BLACK/expectant: pain control (if drugs available) NO IV fluids, NO oxygenavailable) NO IV fluids, NO oxygen

Treatment:Treatment:

Dressings – rinse gross dirt with sterile fluids or tap Dressings – rinse gross dirt with sterile fluids or tap water if available, sterile cover to prevent further water if available, sterile cover to prevent further contaminationcontamination

Pressure dressing for active bleedingPressure dressing for active bleeding- Recruit neighbor to help hold pressure during triage while Recruit neighbor to help hold pressure during triage while

awaiting transport/evacuationawaiting transport/evacuation

- ARE KIDS CAPABLE OF THIS?ARE KIDS CAPABLE OF THIS?

- IS IT APPROPRIATE PSYCHOLOGICALLY?IS IT APPROPRIATE PSYCHOLOGICALLY?

Splint – extremity injuriesSplint – extremity injuries

TreatmentTreatment

Medications: pain control, specific antidotes Medications: pain control, specific antidotes with Hazmat event/teamwith Hazmat event/team

Monitoring: repeat assessment after triage, Monitoring: repeat assessment after triage, re-categorize if necessary (to worse, never re-categorize if necessary (to worse, never better – even if they respond to treatment, better – even if they respond to treatment, they have the same underlying injury)they have the same underlying injury)

ICSICS

Transport: decides which patients leave Transport: decides which patients leave scene first and where they’re goingscene first and where they’re going- Remember that helpful bystanders and self Remember that helpful bystanders and self

transporters will fill nearest hospital firsttransporters will fill nearest hospital first

- Includes decisions about longer transport times Includes decisions about longer transport times for specialty care ( e.g. out of town for burn unit for specialty care ( e.g. out of town for burn unit straight from scene rather than to hospital for straight from scene rather than to hospital for transfer)transfer)

- PEDIATRIC SPECIALTY CENTERSPEDIATRIC SPECIALTY CENTERS

CommunicationCommunication

TelephonesTelephones

Cellular PhonesCellular Phones

Pager SystemPager System

Radios Radios

WhistlesWhistles

Loudspeakers/MegaphonesLoudspeakers/Megaphones

Your Pedi First in BagYour Pedi First in Bag

Is your ambulance equipped to handle a Is your ambulance equipped to handle a Pediatric MCI?Pediatric MCI?

What is essential to your first in bag?What is essential to your first in bag?- Airway suppliesAirway supplies

- DressingsDressings

- TagsTags

Do we include Broselow tapes to guide Do we include Broselow tapes to guide dosing?dosing?

Ambulance / Disaster PreparednessAmbulance / Disaster Preparedness

Top to bottomTop to bottom

BLS / ALS specificBLS / ALS specific

Pre-determined scope of practice rulesPre-determined scope of practice rules

Policy formulationPolicy formulation

Incident specific arrangementsIncident specific arrangements

Sectioning shell - age specificSectioning shell - age specific

Supplies:Supplies:

Oral pharyngeal Oral pharyngeal airwaysairways

Bag Valve Mask’sBag Valve Mask’s

O2 / delivery devicesO2 / delivery devices

Pulse oximeter Pulse oximeter

P.O. ear probesP.O. ear probes

CO2 monitorsCO2 monitors

Trauma scissorsTrauma scissors

StethoscopesStethoscopes

Blood pressure cuffsBlood pressure cuffs

Cervical collarsCervical collars

Portable suctionPortable suction

Padded board splintsPadded board splints

Obstetrics kitObstetrics kit

BlanketsBlankets

SheetsSheets

SuppliesSupplies

Car seats Car seats

ToysToys

Airway rollsAirway rolls

O2 multiplexerO2 multiplexer

Naso-gastric tubesNaso-gastric tubes

Chest tubesChest tubes

NebulizersNebulizers

I.V. solutionsI.V. solutions

NeedlesNeedles

Sharps containersSharps containers

GlucometerGlucometer

I.O. needlesI.O. needles

Broselow TapeBroselow Tape

Adhesive tapeAdhesive tape

MedicationsMedications

Clean water / cupsClean water / cups

SuppliesSupplies

FormulaFormula

Purifier / preservativePurifier / preservative

hand lights with hand lights with batteriesbatteries

Light sticksLight sticks

Candles / waterproof Candles / waterproof matchesmatches

Rain tarps/ polesRain tarps/ poles

Ground clothesGround clothes

Paper / waterproof Paper / waterproof penspens

Disaster TagsDisaster Tags

Disposable bagsDisposable bags

Chlorine bleachChlorine bleach

Soap / towelsSoap / towels

Hand toolsHand tools

SuppliesSupplies

Radio CB/am/fmRadio CB/am/fm

WhistleWhistle

Meals Ready to EatMeals Ready to Eat

BandageBandage

Triangular bandageTriangular bandage

KlingKling

Aluminum foilAluminum foil

Vaseline gauzeVaseline gauze

Trauma dressingsTrauma dressings

GauzeGauze

Hydrogen peroxideHydrogen peroxide

AlcoholAlcohol

Cold / hot packsCold / hot packs

GlovesGloves

InstaglucoseInstaglucose

Sterile water / salineSterile water / saline

SuppliesSupplies

Backboards/ strapsBackboards/ straps

Optional / Monitors defibrillatorsOptional / Monitors defibrillators

AED / SAEDAED / SAED

Other regional specific adjunctsOther regional specific adjuncts

SuppliesSupplies

Expanded practiceExpanded practice

Special needsSpecial needs

Thank youThank you