Grand Rounds Recap 4.20.22
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BASICS IN DISASTER MANAGEMENT WITH DR. TOM BLACKWELL
Definitions
A disaster may be defined as a situation in which the severity of damage or number of patients exceeds the ability to provide immediate management. The World Health Organization (WHO) defines a disaster as a sudden ecological phenomenon of magnitude to require external assistance. It may result in loss of communication, transportation, infrastructure, adequate food and water, shelter, means for sanitary conditions, and it can propagate disease, suffering, and PTSD.
A Mass (Multiple) Casualty Incident (MCI) is a situation in which the number and severity of patients overwhelm routine capabilities of an area or organization in a short amount of time
Types
An open disaster occurs over a large geographic area and is usually natural in origin (ie, tsunamis, hurricanes).
A closed disaster occurs in a small or confined area (often urban) and is usually technologic in nature.
Four Phases of Emergency Management
Emergency managers think of disasters as recurring events with four phases: Mitigation, Preparedness, Response, and Recovery.
Mitigation Phase - pre-event planning to reduce the impact of potential or impending disasters (ie, tornado sirens, evacuation plans and routes, sprinkler systems and smoke detectors)
This phase may rely on tools to identify deficiencies and is iterative in nature.
The Hazards Vulnerability Assessment (HVA) Tool identifies direct and indirect effects of hazards, estimates and ranks probability of occurrence and potential severity of various events. It is performed by hospitals every 3-5 years.
As noted above, this phase is iterative and may involve evaluation of current response configuration with respect to law enforcement, fire services, and medical services and then appropriate augmentation to supplement deficits
Preparedness Phase - actions and activities taken before an emergency to prepare the organization for a response. This may include planning, training, and educational activities (ie, Hospital Preparedness Program (ASPR), Emergency System for the Advanced Registration of Volunteer Health Professionals (ESAR-VIP), Governor’s Emergency Declaration)
Response Phase - activities in the immediate aftermath of a disaster to address the immediate and short-term effects of disaster to save lives, protect property, and ensure public safety
Recovery Phase - activities following response designed to help organizations and communities return to a pre-disaster level of function (ie, FEMA, Salvation Army, etc).
National Organizations and Structures
National Response Framework guides and provides information on the component parts of US national disaster response with supporting public-private agencies (for example, transportation, public health and medical response, public information, etc). It is built on scalable, flexible, and adaptable concepts like the National Incident Management System (NIMS)
National Incident Management System (NIMS) - system that guides all levels of government, NGOs, and the private sector to work together to prevent, protect against, mitigate, respond and recover from incidents. Includes defining roles and command structure for disaster response.
Disaster Operations Response
General process: Federal response and state response collaborate to perform a preliminary damage assessment. The Governor of the state may or may not request a Presidential Disaster Declaration. FEMA Regional Direct can recommend to the FEMA Director whether or not damage qualifies as disaster, which will influence presidential declaration of disaster. In the event a disaster is declared, contracts between the state and national government are signed, and money is released. FEMA determines needed resources and issues mission assignments.
Scene mitigation involves degree of situational awareness with appropriate scaling of resources and command structures set in place during the preparation phase.
Casualty collection involves rapid scene assessment and establishing a decontamination zone; however, this must be preceded by evaluation for secondary devices, actors, and scene safety.
Triage process separates individuals into those who can move and those who can’t initially. These people are later categorized into red (immediate/emergent), yellow (expectant or urgent), green (delayed or nonurgent), black (expectant or deceased) based on their medical needs. There are different triage methods and systems such as METTag (™), START, or Reality to facilitate this, but the simplest means is colored tape.
It is important to remember that triage is a dynamic process wherein an individual’s categorization can change.
Pre-hospital care - Incident Command System (ICS) governs this process and involves triage (as noted above) with minimal interventions/treatment initially, and transportation.
Public health - Incorporates hospital surge capacity, alternate care facilities, and aforementioned resources, processes
AIRPORT RESCUE MCI RESPONSE WITH ASST. CHIEF RAY DABBELT
MCI event is one that overwhelms and exceeds local resources and capabilities in a short period of time, and more locally often thought of as involving more than 10 or more patients.
Local fire departments must be ready to respond to signal events in which, for example, an airplane crashes and which will necessarily involve multiple local, state, and potentially federal resources. The initial response for an airplane crash will include crash trucks, quick response vehicles, engines, ambulances, and command vehicles.
Staging areas are critical to ensure organization for response teams, and likewise treatment areas and associated kits can be arranged and color coded according to emergent, urgent, delayed care required by victims.
Typical aviation injuries include spinal and head injuries, soft tissue and limb injuries, and abdominal injury.
There is considerable on-going research and innovation occurring at different levels related to disaster coordination, triage, and medical prep and management.
The primary goal in management of multiple patients or MCI is to do the most good for the most number of people.
BASICS OF CHEMICAL EMERGENCIES WITH DR. CALHOUN
Chemical properties may influence the degree of permeation, effects.
Solid - smaller particles penetrate more deeply
Liquids - these are most dangerous as aerosols and vapors (such as Hg)
Gasses - their effect is influenced by water solubility. For example, ammonia and chlorine are highly soluble whereas phosgene by contrast is poorly soluble, but will have a delayed effect as it becomes absorbed.
Safety considerations for chemicals
Most chemicals will have an MSD sheet; however, these are less helpful from a medical perspective.
Zoning is often divided into hot zone, warm zone, and cold zone. The hot zone is at the scene of rescue with strict entry and exit control; any person or vehicle that leaves this zone is contaminated. The hot zone transfers to the warm zone via a triage point with appropriate decontamination. Individuals can leave the warm zone and exit to the cold zone via an additional exit only point. The hot zone should be downwind of the cold zone.
Pathology, treatment, and examples of specific chemicals:
Simple asphyxiants displace oxygen from the environment. Examples include CO2 (dry ice), nitrogen, helium, hydrocarbons. Treat with supplemental oxygen and supportive care.
Irritants disrupt pulmonary diffusion. Examples include ammonia, chloramine, sulfur dioxide, phosgene. Treat with supplemental oxygen and airway/pulmonary support.
Chemical asphyxiants interfere with oxygen utilization at the mitochondria. Examples include Cyanide, HS, and carbon monoxide (both). Symptoms include headache, AMS, seizures, and acidosis. Treatment is agent-specific.
Organophosphates include acetylcholinesterase inhibitors such as tabun, sarin, soman, VX, GF, insecticides. Symptoms characterized by DUMBBELLS. Treat with 2-PAM and Atropine as well as Atropine, benzos, and Atrovent.
Vesicants (“blister agents”) include mustard gas, phosgene oxime, lewisite. Treat with irrigation and supportive care.
Ricin is a toxin derived from castor beans and causes RNA destruction and cell death. It must be inhaled or injected (ingestion is usually non-lethal). Symptoms are often generalized and non-specific. Treat symptoms and support.
