Title: Paul K. Carlton, Jr., MD, FACS Lt. Gen, USAF, Ret Director, Homeland Security The Texas A
1Training Together First Responders and First
Receivers Playing the Same Game
Paul K. Carlton, Jr., MD, FACS Lt.
Gen, USAF, Ret Director,
Homeland Security The Texas AM University
System Health Science Center January 20, 2006
2 Preparation for the NationMaking the Pieces
Fit
First Preparers
First Receivers
Trauma Critical Care Pararescue Course
Public Health Course
Bio-Terrorism Course
Trauma Disaster Course
Mental Health Aspects Course
Mental Health Aspects Course
Trauma Critical Care Pararescue Course
WE
Trauma Disaster Course
Mental Health Aspects Course
Public Health Course
Eye Trauma Course
Critical Infectious Diseases Course
Bio-Terrorism Course
Critical Care Transport
First Responders
Public Health Course
Bio-Terrorism Course
Trauma Dusaster Course
3Surge Discussion
4Surge Protection
Protection from surges of electricity
5Surge Protection
Surge Hospital
Protection for surges of patients from natural or
man made disasters
6Surge Protection
Surge Hospital
Protect our most valuable asset PEOPLE
7Surge Hospital Definition
TRATEGIC HARED
S
U
TILIZATION OF
R
ESOURCES FOR
G
EOGRAPHICAL
MERGENCIES EFFICIENCIES
E
8Surge Hospital/ Facility
Definition A facility that can be used to
provide sufficient medical care when a primary
medical facility is -destroyed
-contaminated denied -overwhelmed
9Criteria for Surge Hospital
10Threats, Challenges and Viable Solutions
11A Word on the Slides
- You will see almost ---- slides today!
- On average the slide will be up 6 seconds!
- Each slide with information has the reference at
the bottom right hand side of the slide - This is a visual presentation!
- If you want it to review, it is available
- What I want you to do is listen, reflect, and if
you decide anything said is useful to you, THEN
figure out how you WILL USE THE INFORMATION TO
IMPROVE YOUR STATE OF PREPAREDNESS and the
Nations!
12Begin with the end in mind
FINISH
13Criteria for Surge Hospital
14Surge Hospitals
Hospitals become ICU other buildings become wards
15Goal Solid Structure Addressing ALL Areas
Our House
- People
- Equipment
- Training
- Organization
E
O
Heretical Thinking!
ALL HAZARD ENVIRONMENT
16The interface of standard of care and sufficiency
of care
Graceful Degradation of Care
GOLD STANDARD
Care Standards
Plan B Operations Results in more survivors
???
Demand
MORAL IMPERATIVE
17Build a Solid Structure
Our House
Use 4 components to build a solid structure
18Organization
Standard of Care/Sufficiency of Care
Move out of circle as needed Move back as
quickly as possible
Sophisticated care done in hospitals Less
sophisticated care done in surge hospitals
Sufficiency of Care
Sufficiency of Care
Standard of Care
19Plan A
- Standard of Care
- What is currently used in USA today
20BUT
- If Plan A is denied because
- Loss of hospital
- Contaminated hospital
- Numbers are overwhelming
- THEN
21Must move smoothly and quickly to Plan B, C, D
Operations
22Then
1,000 Burn Patients If engaged 50
If engaged 100 at 84
at 84 420 survivors 840
survivors
23SO
Plan B 84 survivors 1,000 burn patients
Standard Plan A 90 survivors 1,000 patients
only 100 engaged 90 survivors
If engaged 50 at 84
420 survivors
If engaged 100 at 84
840 survivors
466
933
A tremendous improvement
Source Journal of Burn Care and Rehabilitation
Volume 18, Number 3, 1997
24Solve for rate limiting step!
25The interface of standard of care and sufficiency
of care
Graceful Degradation of Care
GOLD STANDARD
Care Standards
???
Results in more survivors
Demand
MORAL IMPERATIVE
26ITS ALL ABOUT PEOPLE Not about bricks or lumber
in a pile, not about concrete destroyed It is the
dead and injured.
Medical Must Be Considered
27Overview
28If you believe the threat is real Then It demands
solutions now!
29Disaster Preparedness
Its All About Me!
- Three deadly misconceptions
- It will not happen here!
- It will not happen to me!
- Someone else will be there to take care of the
problem!
Jay A Johannigman Crit Care Med Vol 33, No1
30Disaster Preparedness
Its All About Me!
- Three deadly misconceptions
- OUR REALIZATIONS!!
- It will not happen here! IT DID!
- It will not happen to me! IT DID!
- Someone else will be there to take care of the
problem! THEY WERE NOT!
Jay A Johannigman Crit Care Med Vol 33, No1
31LEARNERS
In a time of drastic change it is the learners
who inherit the future. The learned usually find
themselves equipped to live in a world that no
longer exists!
Eric Hoffer
32LEARNERS
ALL OF US MUST BE LEARNERS!
33Dont be learned!
34You may obtain a copy of this presentation at
www.tamhsc.edu/homeland/
35America is in Danger!
36Danger Always Present, Just
Beneath the Surface
37Facing Reality is Difficult
None of us Want to Face What Lies Ahead of
Us We Must!
38Change Is Hard
Every revolutionary idea evokes three stages of
reaction
- Youre nuts!
- It would work, but no reason to change!
- You like it? It was MY idea!
39Response Chain
40- LINKS
- Prevention
- Mitigation
- Consequence Management
- Recovery
41All of these have some part of the response
chain-
42Weak Link
Medicine may be the Weakest Link!
43It all comes to life or death!
44ITS ALL ABOUT PEOPLE Not about bricks or lumber
in a pile, not about concrete destroyed It is the
dead and injured.
Medical Must Be Considered
45Weak Link
We could see collapse of our health care system
in any bio event! Chuck
Ludlam, Chief of Staff
Senator Lieberman
15 April 05
46Weak Link
We are totally unprepared medically! We have
none of the vaccines nor antibiotics that we
would need in a bio event. Defense Contract
model will not work in this situation.
Chuck
Ludlam, Chief of Staff
Senator Lieberman
15 April 05
47Weak Link
Medicine is our weak link and that is where we
will break. Ed Eberhart
CINC NORTHCOM
May 3, 2004
48These people could be wrong but I doubt it
49Medical Response
Why?
Different worlds they do not understand each
other
50Medical Response
Different worlds they do not understand each
other
51Medical Response
- NO OWNED ASSETS
- ALL PRIVATE
- REQUIRES BETTER COOPERATION and UNDERSTANDING
THAN WE HAVE EVER SEEN!
52Threats
Medicine, as we know it, is in danger of failing.
53The Current Hospital Environment
- Key component of consequence management is timely
medical care for victims of mass casualty
incidents - Incorrect assumptions made about existing
medicalcapabilities to treat mass casualties - Hospital surge capacity has never been more
restricted - Medical community struggling just to maintain
everyday capacity - Majority of preparedness issues are financially
(revenue vs cost) based - Without prompt action, the nation carries the
risk thatvictims of a mass-casualty disaster
might end up in ambulances to nowhere."
Source Barbera, Macintyre, and DeAtley Mar 2002
54Ambulances to Nowhere
- Funding shortfalls
- Decline in government support for public and
privatehospitals - Increasing number of expensive, unfunded, or
under-funded regulatory mandates - Continued expectation that hospitals will
maintain highlevels of charity medical care - National shortage of nurses for acute care
hospitals, resulting in need for special
compensation packages to attract personnel - Results -- closure, downsizing, consolidation,
reconfiguration, and partnering - Abolition or downsizing of specialty services
crucial todisaster preparedness!
Source Barbera, Macintyre, and DeAtley , Mar
2002
55Ambulances to Nowhere
- Delivery of acute medical care evolved beyond
ordinary business relationship to "trust" with
patients - Trust has extended to current threat
environment - Move from individual patient to community as a
whole - Financial support to hospitals by community
create expectation hospitals will address
community's health/medical needs, including
disaster preparedness - Reasonable cost for hospital preparedness for
mass casualtieswas assumed to be necessary cost
of doing business - Financing costs
- Old Medicare and fee for service
- New Managed care payment system (capitation)
- Bottom line Disconnect between expectations and
funding!
Source Barbera, Macintyre, and DeAtley , Mar
2002
56Troubled Medical System
- Growing concern over projected shortage of
healthcare providers in coming years - Other factors aging population, increased
demand, and increased costs - Troubled specialties -- orthopedics, radiology,
dermatology, cardiology, ophthalmology and
anesthesiology - Bleak future forecast
- Shortage of 200,000 doctors,
- 157,000 pharmacists
- 20 shortfall in nursing
- requirements by 2020
- Quality of life greatest deterrent
Kiplinger, Mar 05
57A Strained System
- Hospital capacity continues to be main limiting
factor in disaster medical response - Critical care services and intensive care units
most affected - Recent examples
- Only 25 ICU beds usable for 27 patients in Madrid
bombing - Only 12 ICU beds available for 20 patients in
Bali bombing - 2001 Houston floods reduced ICU capacity by 75
- More challenges
- Toxic chemical scenario 1200 bed hospital could
handle only two patients at one time - Poor staffing levels for critical care areas
Dara, Ashton Farmer, Feb 05
58A Strained System
- Possible surge solutions
- Pre-emptive education Increased disaster
response awareness, improved skill sets,
comprehension of roles and responsibilities,
alternate communication styles, and expertise in
cooperation during chaos - Interfacility cooperation Creation of flexible
plans for interchanging resources to supplement
existing capacity of hospitals - Dual usage of resources Critical care units
respond outside geographical locations merge
training and education
Dara, Ashton Farmer, Feb 05
59Trauma Center Problems
- Trauma center experts announce facilities
ill-prepared to handle disaster or epidemic - It's a struggle to meet the nightly demand of
911 calls, but somehow we're supposed to deal
with a terrorist bombing? Or a new strain of
influenza? -- ER Physician - A losing battle
- Trauma care is money loser serves many patients
without health insurance - Expensive to maintain a round-the-clock staff
and specialists - Atlanta ER expecting loss of 10M in 2005!
Miller, Dec 05
60TEAM
61 Preparation for the NationMaking the Pieces
Fit
First Preparers
First Receivers
Trauma Critical Care Pararescue Course
Public Health Course
Bio-Terrorism Course
Trauma Disaster Course
Mental Health Aspects Course
Mental Health Aspects Course
Trauma Critical Care Pararescue Course
WE
Trauma Disaster Course
Mental Health Aspects Course
Public Health Course
Eye Trauma Course
Critical Infectious Diseases Course
Bio-Terrorism Course
Critical Care Transport
First Responders
Public Health Course
Bio-Terrorism Course
Trauma Dusaster Course
625 Ps
- Prior
- Planning
- Prevents
- Poor
- Performance
63ITS ALL ABOUT PEOPLE Not about bricks or lumber
in a pile, not about concrete destroyed It is the
dead and injured.
Medical Must Be Considered
64Independent Missions
Independent Missions
Wartime Readiness
Peacetime Benefit
Military
USA
65Interdependent Missions
Interdependent Missions
aaaaa
Peacetime Benefit
Wartime Readiness
Military
USA
Inherently Governmental!
66- Those with a military background have an
obligation to share what we know with our
civilian colleagues! - Our civilian colleagues do NOT have an obligation
to listen- but it is at their and their patients
peril!
67Finding a Balance
Balanced Surge Capacity Scale
Efficient
Effective
68Finding a Balance
Current Surge Capacity Scale
Not Balanced!
Effective
Efficient
69Solutions
Dollars Do Matter!
70Master Plan
Low hanging least expensive and everyone should
do it
71Master Plan
Mid level more expensive highest risk targets
should do it
72Master Plan
Top level most expensive only highest ??
Targets should do it Washington Hospital Center,
Houston, etc.
73Goal Leak Proof Umbrella
P
E
T
O
ALL HAZARD ENVIRONMENT
74Texas AM Conference
- Texas AM Health Science Center plans to have a
conference 4-5 April that will fill in these
thoughts about what to do to properly prepare! - Most of the solutions are cheap and easy to
apply! - The conference will be aimed at decision makers
in the major health care systems.
75Current Threats to the Medical System
Impact
Terrorism
Epidemics
Natural Disasters
Underinsured /uninsured
Baby Boomers
Probability of Occurrence
76President George W. Bush October 1, 2003
- On September 11, 2001
- Enemies of freedom made our country a
battleground - Used mass murder of innocent
- Make Americans live in fear
We refuse to live in fear!
77 President George W. Bush
October 1, 2003
The best way to overcome fear and frustrate the
plans of our enemies is to be prepared and
resolute at home, and to take the offensive
abroad.
78Closing the Gaps
- U.S. still inadequately prepared to respond to
natural disasters - No overall strategy for reducing lives lost and
property destroyed for wildfires, earthquakes,
floods, hurricanes, and tsunamis - Specific agencies focused on natural disasters
must negotiate federal bureaucratic
infrastructures! - Closing the gaps
- Enhanced monitoring and detection systems.
- Techniques for mitigating destruction from one
hazard can be applied to other hazards
National Journal, Dec 05
79Closing the Gaps
- Improving preparedness through educating public
and developing coordinated response strategies
for federal, state, and local agencies - National Science and Technology Council Report
- Right people need to be warned at right time
- Scientists need to understand causes of disasters
- Communities built to resist natural hazards
- Vulnerability of critical infrastructure reduced
- Communities must regularly assess resilience to
disasters using standard methods. - Educate people about risks and disaster
preparations
National Journal, Dec 05
80Hospitals Still Unprepared
- Hurricane Katrina revealed majority of U.S.
hospitals unprepared for catastrophic disaster - Mandatory twice/year exercises ineffective
- Vague planning guidelines little regulation
- Unable to sustain contingency ops for long period
of time - Tough decision
- When and where to evacuate patients
- Limited budgets and resources
- Cooperating with competing organizations
- Balance readiness vs normal operations
Market Watch, Nov 05
81Lessons Learned
- Recent natural disasters tested system
- Many New Orleans hospitals closed for lost power
and competing resources (patient helicopters) - Lapses in infrastructure (no power,
communications, etc) - Must prepare for surge!
- It's a calculated risk being taken (surge
preparation) and if there isn't a disaster at
your hospital, you win and if there is, then the
victims lose. -- Dr Rob Sutter - Financial gaps
- Disaster planning typically less than 1 or 2 of
hospital's budget
Market Watch, Nov 05
82Complaints without Solutions Whining
83Whining
84 President George W. Bush
October 1, 2003
The best way to overcome fear and frustrate the
plans of our enemies is to be prepared and
resolute at home, and to take the offensive
abroad.
85SOLUTIONS
Currently under way at AM Health Science Center
- 1. Education and Training
- 2. Menu Brief
- 3. Medical Student Education
- 4. Leadership Program for Disaster Response
- 5. Master Plans
- Plan B
- Triage
- 8. Mobile Solutions
- 9. Surge Hospitals or Community Health Centers
- 10. Veterinary School Surge Hospital
- 11. VA Proposal
12. Incentives Carrot Credentials 13.
Medical Operations Center Proposal 14. Proposal
to Dr. Eduardo Sanchez Commissioner of
Health 15. NORTHCOM 16. Diabetic Retinopathy
Screening 17. Isolations Rooms 18.
Scancorder 19. Ventilators
7 April 05
86Plan for Surge
- Advance planning is key
- Locate buildings of opportunity
- Train staff
- Equipment ready to set up
87Surge Protection
Surge Hospital
Protect our most valuable asset PEOPLE
88All Hazard
89Forward Operation Base Marez Mosul, Iraq 24
December 04
90Forward Operation Base Marez, Mosul, Iraq
1215 pm Explosion in dining facility
Evacuation begins 1225 pm 12
casualties arrive at medical facility
Medical Fights On To Save Lives
91Forward Operation Base Marez, Mosul, Iraq
1225 pm Triage begins 1240 pm Mortar
attack hits hospital
Hospital hard and no casualties Full speed for
12 hours 1130 pm Breath 200 am
CCATTs arrive- medical tune up for flight
400 am CCATTs fly away 12 patients to
Germany
92Statistics
9 OR cases 7 Open laparotomies 10 surgeries in
hallway 8 pts mechanical ventilation 14 chest
tubes placed 39 CT scans done 200 plain
radiographs 294 lab tests 40 units of blood
products 217 IV meds given
91 patients 18 DOA 4 DOW 69 left 20 to other
military hospitals 49 to treat
Great Job Army!
93A Busy Day
- Attack by suicide bomber on food tent in Forward
Operating Base Marez created numerous casualties - 91 casualties in 11 hours
- 22 died in attack 18 were American
- 17 dead on arrival 5 with nonsurvivable wounds
- A busy day for casualties
- Highest number of casualties treated at military
hospital in Iraq during war - 9 surgeries performed in OR 10 performed outside
OR - Mortuary established in parking lot
NY Times, Dec 04
94What can we learn from this?
95Standard of Care/ Sufficiency of
Care
Sufficient care
Demands
Standard of Care
Care Capability
96Standard of Care/ Sufficiency of
Care
Sufficient care
10 surgeries in hallway
Demands
Smooth transition
Standard of Care
7 Open laparotomies
9 operations in OR
Care Capability
97The interface of standard of care and sufficiency
of care
Graceful Degradation of Care
GOLD STANDARD
Care Standards
???
Plan B Operations
Demand
MORAL IMPERATIVE
98The interface of standard of care and sufficiency
of care
Graceful Degradation of Care
GOLD STANDARD
This plan stays within SOC
Care Standards
Double the numbers moves to Sufficient Care
???
Plan B Operations
Demand
MORAL IMPERATIVE
99Standard of Care/Sufficiency of Care
Move out of circle as needed Move back as
quickly as possible
Sophisticated care done in hospitals Less
sophisticated care done in surge hospitals
Sufficiency of Care
Sufficiency of Care
Standard of Care
100Lessons Learned
- Triage needs work
- Training saves lives
- Resource allocation is critical!
101Surge Protection
Surge Hospital
Protect our most valuable asset PEOPLE
102Criteria for Surge Hospital
103Criteria for Surge Hospital
104Surge Hospitals
Hospitals become ICU other buildings become wards
105Goal Solid Structure Addressing ALL Areas
Our House
- People
- Equipment
- Training
- Organization
E
O
Heretical Thinking!
ALL HAZARD ENVIRONMENT
106The interface of standard of care and sufficiency
of care
Graceful Degradation of Care
GOLD STANDARD
Care Standards
Plan B Operations Results in more survivors
???
Demand
MORAL IMPERATIVE
107Build a Solid Structure
Our House
Use 4 components to build a solid structure
108Organization
Standard of Care/Sufficiency of Care
Move out of circle as needed Move back as
quickly as possible
Sophisticated care done in hospitals Less
sophisticated care done in surge hospitals
Sufficiency of Care
Sufficiency of Care
Standard of Care
109Plan A
- Standard of Care
- What is currently used in USA today
110BUT
- If Plan A is denied because
- Loss of hospital
- Contaminated hospital
- Numbers are overwhelming
- THEN
111Must move smoothly and quickly to Plan B, C, D
Operations
112Rate Limiting Steps for Mass Casualties
P E
T O Burns Yes
Yes No No Chem
Yes Yes Yes
No Radiation Yes Yes
Yes No Bio Yes
Yes Yes No
113For Example
- Current burn therapy
- Uses sulfamylon
- Silver sulfadiazine
- Other topicals
- Heavily reliant on surgical wound care and skin
grafting - Very labor intensive
Source Journal of Burn Care and Rehabilitation
Volume 18, Number 3, 1997
114But
Burn Care
- Mafenide hydrochloride
- Mafenide acetate
- Both Proven Effective
Sulfamylon
Source Journal of Burn Care and Rehabilitation
Volume 18, Number 3, 1997
115Numbers
- 1,000 burn patients- using mafenide acetate
(sulfamylon) Plan A - only treat 100 conventionally
- 90 survival of those treated
- 90 survivors
- Very labor intensive
Source Journal of Burn Care and Rehabilitation
Volume 18, Number 3, 1997
116Solve for rate limiting step!
117Numbers
Mafenide hydrochloride spray used in Viet Nam to
stabilize burn wounds Had 16 death rate (17 of
110) And much less labor intensive
Source Journal of Burn Care and Rehabilitation
Volume 18, Number 3, 1997
118Numbers
- 1,000 burn patients
- Less labor intensive methods
- Mafenide hydrochloride results in 84 survival
- Less efficacious in small numbers
- 6 less efficacious in preventing deaths on small
scale
Source Journal of Burn Care and Rehabilitation
Volume 18, Number 3, 1997
119But
Engage greater numbers because less wound
management required so solves people and
equipment problem
Source Journal of Burn Care and Rehabilitation
Volume 18, Number 3, 1997
120Then
1,000 Burn Patients If engaged 50
If engaged 100 at 84
at 84 420 survivors 840
survivors
121SO
Plan B 84 survivors 1,000 burn patients
Standard Plan A 90 survivors 1,000 patients
only 100 engaged 90 survivors
If engaged 50 at 84
420 survivors
If engaged 100 at 84
840 survivors
466
933
A tremendous improvement
Source Journal of Burn Care and Rehabilitation
Volume 18, Number 3, 1997
122Solve for rate limiting step!
123The interface of standard of care and sufficiency
of care
Graceful Degradation of Care
GOLD STANDARD
Care Standards
???
Results in more survivors
Demand
MORAL IMPERATIVE
124Rate Limiting Steps for Mass Casualties
P E
T O Burns Yes
Yes No No Chem
Yes Yes Yes
No Radiation Yes Yes
Yes No Bio Yes
Yes Yes No
125Rate Limiting Steps for Mass Casualties
Graceful Degradation of Care
Accept lower percent survival to affect a higher
survival depending on rate of limiting steps
Mafenide Acetate
90
Care Standards
Mafenide Hydrochlorine
84
Demand
MORAL IMPERATIVE
126That is Plan B operations perhaps not optimal on
an individual basis But Far more survivors on a
large group basis depending on what is the rate
limiting step
Source Journal of Burn Care and Rehabilitation
Volume 18, Number 3, 1997
127We need such thinking for
128Plan A, Plan B, C, D
E
O
129Criteria for Surge Hospital
Split Operation
Group inside cannot come out Group
outside cannot come in Two facilities Contamin
ated Facility Clean Facility
130Contaminated facility mitigate with
Killer filter
Killer
M95 masks
Isolation technology
surge isolation Clean facility
Bare bones only emergent care
STOP all elective
surgeries
131The interface of standard of care and sufficiency
of care
Graceful Degradation of Care
People and equipment are rate limiting steps
GOLD STANDARD
Care Standards
???
Results in more survivors
Demand
MORAL IMPERATIVE
132Criteria for Surge Hospital
Most expensive option Most difficult option
Destroyed
133Destroyed
- Reconstitute a medical facility
- alternative facility (large animal clinic)
- Soft sided
- Temporary hard sided
- Modular building
134Destroyed
P lose some of yours those on duty
reconstitute with those at home E must have
bare bones back up T in austere treatment O
must be flexible to accommodate change
135Help will be on the way!
Local Infrastructure Baseline Capability
Units of Medical Capability
Time
136ITS ALL ABOUT PEOPLE Not about bricks or lumber
in a pile, not about concrete destroyed It is the
dead and injured.
Medical Must Be Considered
137Way Ahead
- Planning for surge
- Isolation issues
- Present these concepts to VA Senior leadership!
- Enter political arena with these thoughts!
138Need of Triage
- Evidence based
- Reliably reproducible
- Based on survival and deterioration rate
- Scalable
139Triage System
- Started addressing fixes in 83
- Dedicated resources and equipment in triage to
redefine - 98 Ben Taub in Houston
- Scalable
- Factors to measure
- Reproducible
- Uses computers
140Triage System
- 750 now in database
- Pulse ox not reliable indicator of survival
- Respiratory rate
- Motor responses
- Pulse
- Institute of Surgical Research
is still accruing patients for database
still key
141November 2003
- Given SACCO brief
- Evidence based
- reproducible
- Factored in survival and deterioration
- Scalable
102,000 patients in Pennsylvania Trauma Registry
database
142Not Reproducible
143Evidence Based
144(No Transcript)
145(No Transcript)
146(No Transcript)
147(No Transcript)
148Resource Allocation is Critical
149Surge Examples
- Surge in place
- Austin
- Surge into building of opportunity
- Earl K. Long facility
- PMac
- Field House
- K Mart
- Surge into preplanned building of opportunity
- Vet School
150Surge in Place
Austin, Texas
151Austin, Texas How to
Build a Surge Hospital for a Song
Austin, Texas August 2005
152This Plan Protects
- Staff
- Patients
- Victims of MCI
- State Capitol
- Football Stadium
153Requirement by Department of State Health Services
112 Bed Surge Facility in place St.
Davids requirement from the DSHS as fair share
for Austin community
154The Red Wedge Concept
Sufficient care
Plan B
At some point we will go to sufficient care ,
not standard of care
Demand
Soft sided solutions may apply
Standard of Care
Surge from outside sources
Peacetime Surge - within
Care Capability
155The interface of standard of care and sufficiency
of care
Graceful Degradation of Care
GOLD STANDARD
This plan stays within SOC
Care Standards
Double the numbers moves to Sufficient Care
???
Plan B Operations
Demand
MORAL IMPERATIVE
156Entry
Sequence 1.
Notification of MCI 2.
Decon and Triage prepared
3. Day surgery empties
4. Opens beds for MCI
Key
- Control hospital
- Not allowed into facility until decon is done
- Allow time for preparation of day surgery for
mass casualty incident (MCI) - Allows isolation from rest of facility
- Central to downtown
Photo by Salvador Monastra-SeBasoc
St. Davids Safety Officer
157Flow Pattern in Triage Area
Decontamination
Immediate
Sequence 1.
Notification of MCI 2.
Decon and Triage prepared
3. Day surgery empties
4. Opens beds for MCI
Minimal
Delayed
Expectant
Triage entirely dependent on resources and load
from MCI
158Whole separate HVAC system protected by Isolate
Filter
Day surgery patients go straight to central
hospital
Sequence 1.
Notification of MCI 2. Decon and Triage prepared
3. Day
surgery empties
4. Opens beds for MCI
Immediate RX area
To OR
ICU
Holding beds
Photo by Salvador Monastra-SeBasoc
St. Davids Safety Officer
159Summary
Gives them 127 Standard of Care beds by just
rearranging!
160The Red Wedge Concept
Sufficient care
Plan B
At some point we will go to sufficient care ,
not standard of care
Demand
Soft sided solutions may apply
Standard of Care
Surge from outside sources
Peacetime Surge - within
Care Capability
161The interface of standard of care and sufficiency
of care
Graceful Degradation of Care
GOLD STANDARD
Care Standards
Demand
MORAL IMPERATIVE
162Recent Threats
Hurricanes Katrina and Rita
163KATRINA A Rain of Terror
164Medical Victory Due to
- Ingenuity
- Dedication to patient care
- Volunteerism
- Good planning by some!
165Surge
- Surge in place
- Austin
- Surge into building of opportunity
- PMac
- Earl K. Long Facility
- Field House
- K Mart
- Surge into preplanned building of opportunity
- Vet School
166LSU Campus
Field House
Maravich Coliseum
167Surge into Buildings of
opportunity Pete Maravich Coliseum
168Board from Fall 04 College of Architecture
Semester Project
What idiot would build a hospital in a sports
facility?
Any idiot that needs to!
169Maravich Coliseum
170SURGE CONCEPTS
171Standard of Care/Sufficiency of Care
Move out of circle as needed Move back as
quickly as possible
Sophisticated care done in hospitals Less
sophisticated care done in surge hospitals
Sufficiency of Care
Sufficiency of Care
Standard of Care
172Standard of Care/Sufficiency of Care
Move out of circle as needed Move back as
quickly as possible
Sophisticated care done in hospitals Less
sophisticated care done in surge hospitals
Standard of Care
173The interface of standard of care and sufficiency
of care
Graceful Degradation of Care
GOLD STANDARD
Care Standards
???
Plan B Operations
Demand
MORAL IMPERATIVE
174Maravich Coliseum
Lab
Pharmacy
SIC U
MIC U
Dialysis
Wards
Surgical Ward
Peds
Isolation
Red to Yellow level patients
Registration
Entrance
175Maravich Coliseum
Red to Yellow level patients
176Maravich Coliseum
Red to Yellow level patients
177Maravich Coliseum
Red to Yellow level patients
178Surge
- Surge in place
- Austin
- Surge into building of opportunity
- Earl K. Long Facility
- PMac
- Field House
- K Mart
- Surge into preplanned building of opportunity
- Vet School
179Surge into Buildings of
opportunity Carl Maddox Field House
180Field House (Special Needs)
Yellow to Green Level Patients
181SURGE CONCEPTS
182Standard of Care/Sufficiency of Care
Move out of circle as needed Move back as
quickly as possible
Sophisticated care done in hospitals Less
sophisticated care done in surge hospitals
Sufficiency of Care
Sufficiency of Care
Standard of Care
183The interface of standard of care and sufficiency
of care
Graceful Degradation of Care
GOLD STANDARD
Care Standards
???
Plan B Operations
Demand
MORAL IMPERATIVE
184Field House (Special Needs)
Yellow to Green Level Patients
185Field House (Special Needs)
Yellow to Green Level Patients
186Field House (Special Needs)
Yellow to Green Level Patients
187Field House (Special Needs)
Yellow to Green Level Patients
188Surge
- Surge in place
- Austin
- Surge into building of opportunity
- Earl K. Long Facility
- PMac
- Field House
- K Mart
- Surge into preplanned building of opportunity
- Vet School
189Surge into Buildings of
opportunity Vacant Building (Formerly
Kmart)
190Surge Hospital/ Facility
Definition A facility that can be used to
provide sufficient medical care when a primary
medical facility is -destroyed
-contaminated and thus denied -overwhelmed
191Hospital Requirements
- Nice to have
- AC
- Power
- Gases
- Back up power
192Empty Building (formerly Kmart)
104,992 sq. ft.
193Vacant Building Set Up
DECON
194Vacant Building Set Up
DECON
195Vacant Building Set Up
DECON
196Vacant Building Set Up
DECON
197Vacant Building Set Up
DECON
198Vacant Building Set Up
DECON
199Lessons Learned - Katrina
- Start training
- Volunteerism
- Tabletops
- Shorten mother may I loop
- Senior mentors/strike force
- Medical mosaic
- Graceful degradation of care
- Buildings of opportunities/surge hospital
- Validate DLS family of courses
- Communications must be fixed
- Security is critical
200Lessons Learned P.K.
Carlton, Jr., M.D.
- 9. Validate DLS family of courses
- 10. Communications must be fixed
- 11. Security is critical
- 12. Dialysis patients
- 13. Pre-planning is critical
- 14. Flexibility is key to every disaster
response! - 15. Veterinary community
- 16. Standards
- Chain of Command Clear
- Training - invaluable
- Volunteerism
- Tabletops
- mother may I loop was proactive and extremely
well done - Medical mosaic
- Graceful degradation of care
- Buildings of opportunities/surge hospital
I was on the way to debrief this slide in Baton
Rouge---then I received the telephone call!
201Hurricane Rita
202Worst Nightmare
Evacuated special needs population out of major
metropolitan area Galveston/ Houston
Lose whole local health care network!
Rita
203Medical Victory Due to
- Ingenuity
- Dedication to patient care
- Volunteerism
- Good planning!
- Rapid federal response
- Unbelievable Vet School attitude
204Lessons Learned - Rita
- Chain of Command Clear
- Training - invaluable
- Volunteerism
- Tabletops
- mother may I loop was proactive and extremely
well done - Medical mosaic
- Graceful degradation of care
- Buildings of opportunities/surge hospital
- Validate DLS family of courses
- Communications must be fixed
- Security is critical
- Dialysis patients
- Pre-planning is critical
- Flexibility is key to every disaster response!
- Veterinary community
- Standards
205Good
- Transportation evacuation early and reasonably
orderly - Communication for medical capability
- Surge
- Regional and national plan
- Thinking about this for long term
- Exercises for last 4 years
- Attitude
- MOC up and functional early
- Home of National Disaster Life Support (NDLS)
consortium so well educated - Had a plan and executed plan
206Bad
- Transportation hung up with numbers so patients
arrived without staff - Deaths
- Overwhelming number
- Highway congestion
207Ugly
208Worst Nightmare
Evacuated special needs population out of major
metropolitan area Galveston/ Houston
Lose whole local health care network!
Rita
209SURGE CONCEPTS
210Surge Hospital/ Facility
Definition A facility that can be used to
provide sufficient medical care when a primary
medical facility is -destroyed
-contaminated denied -overwhelmed
211Surge Facility
212Texas AM University College of Veterinary
Medicine Surge
Hospital
Model for the State
213Surge
- Surge in place
- Austin
- Surge into building of opportunity
- Earl K. Long Facility
- PMac
- Field House
- K Mart
- Surge into preplanned building of opportunity
- Vet School
214The Concept
215Begin with the end in mind
FINISH
216Potential
- Mortuary reception area for thousands
-Forensic issue - Surge reception area
-local
events
-over flow
from State for current sick people
to offload medical facilities who are
primary receivers - Headquarters for Texas Medical Rangers training
- Equipment
-700 bed
-Storage
facility for
-Vents, OR
supplies, etc - Model for every College of Veterinary Medicine in
the Nation - Answers some of national surge concerns
217Surge Hospital
700 beds 24-32 ORs 64 ICU beds Full Decon Full
Mortuary Ready accessible to most vulnerable
sites in area
218Total
Triage 100 patients Hallway
260 patients ICU 32-
45 Beds
(30-45 plumbed) PACU/ICU
32 beds-16 rooms (2 per) Surgical Ward 36
Beds Peds unit 250 patients
Total 710
219Increments
1st 700 bed easily into Large Animal Hospital
This is the subject of the presentation
today 2nd 700 bed easily into Large Animal
Hospital 3rd 700 bed into Small Animal
Facility 4th 700 bed into Small Animal Facility
220Way Ahead
- Present concept to Dean and Executive Committee
of Vet School 1 Sept and 5 Sept approved - Present concept to Emergency Management Planner
approved 5 Sept - Present concept to local health care facilities
20 Sept - Approve plan Texas AM University
- Seek funding Texas AM System, Board of
Regents, State - Present to State
- Could be up to 2,800 beds!
221From Concept to Reality 20 Sept 2005
222Built of Units of Capabilities
223Surge Hospital
224Chain of Command
State Government
Texas AM
Gates
Dickey
Health Commissioner
Presidents
College of Veterinary Medicine
College of Medicine
County Health Officer
Colleges
Adams
Colenda
EPR Coordinator (Mike
Paulus)
Deans
Carlton Moyer
Medical Director (PK Carlton)
Directors
Volunteers
PHS
225FLOW
Concept of Flow for a Health Care Facility How
to optimize your facility for casualty management!
226Large Animal Facility Surge Flow
Registration
North
250 Beds
250 Beds
Large animal hospital
227Large Animal Facility
Shriners/100
1
North
Wednesday night/Thursday morning
Large animal hospital
228(No Transcript)
229(No Transcript)
230Large Animal Facility
Shriners/100
1
2
Special People
North
Wednesday night/Thursday morning
Large animal hospital
231(No Transcript)
232Large Animal Facility
Shriners/100
Special People
North
Thursday morning/Thursday afternoon-set up in
hours
1st 250 bed package
3
Large animal hospital
233(No Transcript)
234Large Animal Facility
Shriners/100
Special People
North
Friday morning/Friday afternoon- set up in hours
4
1st 250 bed package
2nd 250 bed package
Large animal hospital
235CDC Push Pack
Days to set up Veterinary College did it in
hours! First deployment of equipment
236(No Transcript)
237(No Transcript)
238CDC/PHS Arrival The Cavalry!
Full time staff
239(No Transcript)
240A Perfect Fit!
Uniformed Personnel plus Volunteers A
perfect fit!
241Arrival of Patients
242Patients Area
243Patients Area
244Patients Area
245Patients Area
246Large Animal Facility
Shriners/100
1
North
Wednesday night/Thursday morning
Large animal hospital
247Patients Area
248Patients Area
249Large Animal Facility
Shriners/100
1
2
Special People
North
Wednesday night/Thursday morning
Large animal hospital
250Patients Area
251Patients Area
252Patients Area
253Patients Area
254Patients Area
255Patients Area
256Patients Area
257Patients Area
258SURGE CONCEPTS
259Standard of Care/Sufficiency of Care
Move out of circle as needed Move back as
quickly as possible
Sophisticated care done in hospitals Less
sophisticated care done in surge hospitals
Sufficiency of Care
Sufficiency of Care
Standard of Care
260The interface of standard of care and sufficiency
of care
Graceful Degradation of Care
GOLD STANDARD
Care Standards
???
Plan B Operations
Demand
MORAL IMPERATIVE
261Good
- Transportation evacuation early and reasonably
orderly - Communication for medical capability
- Surge
- Regional and national plan
- Thinking about this for long term
- Exercises for last 4 years
- Attitude
- MOC up and functional early
- Home of National Disaster Life Support (NDLS)
consortium so well educated - Had a plan and executed plan
262Bad
- Transportation
- Deaths
- Overwhelming numbers
263Overwhelming Numbers
- Actual numbers of special needs patients must be
obtained - It is larger than we expected
264Nursing Home
265Ugly
266UGLY Bus fires kills 20
Source Dallas Morning News 24
September 05
267Lessons Learned P.K.
Carlton, Jr., M.D.
- 9. Validate DLS family of courses
- 10. Communications must be fixed
- 11. Security is critical
- 12. Dialysis patients
- 13. Pre-planning is critical
- 14. Flexibility is key to every disaster
response! - 15. Veterinary community
- 16. Standards
- Chain of Command Clear
- Training - invaluable
- Volunteerism
- Tabletops
- mother may I loop was proactive and extremely
well done - Medical mosaic
- Graceful degradation of care
- Buildings of opportunities/surge hospital
268Chain of Command
State Government
Texas AM
269CDC 22 Sept
We are here to help! What do you need?
270Lessons Learned P.K.
Carlton, Jr., M.D.
- 9. Validate DLS family of courses
- 10. Communications must be fixed
- 11. Security is critical
- 12. Dialysis patients
- 13. Pre-planning is critical
- 14. Flexibility is key to every disaster
response! - 15. Veterinary community
- 16. Standards
- Chain of Command Clear
- Training - invaluable
- Volunteerism
- Tabletops
- mother may I loop was proactive and extremely
well done - Medical mosaic
- Graceful degradation of care
- Buildings of opportunities/surge hospital
271Training
- Full menu of courses must be available to train
on these scenarios - Available today include the Disaster Life Support
Family of Courses - Their importance was demonstrated clearly here in
this disaster!
272Disaster Life Support
- Product of
- University of Georgia
- Louisiana State University
- University of Texas Southwest
- University of Texas Scott Lillibridge
273Education Training Cardiac Life
Support
Education
In Hospital Care
ACLS
More Advanced
More Specialized
Pre-hospital life support
CPR
Training
274Education Training
Advanced Trauma Life Support ATLS
Education
In Hospital Care
ATLS
More Advanced
More Specialized
PHTLS
First Aid
Training
275Disaster Life Support Courses
Education
Instructor
Advanced
Basic
More Advanced
More Specialized
Core
Introduction
Training
276Education Training
Our job is to fill in the Educational pyramid!
Our job fill in the blanks for this menu
Education
?
400
?
Advanced Disaster Life Support Course
?
300
More Advanced
More Specialized
Basic Disaster Life Support Course
?
?
?
200
Core Disaster Life
Complex Disasters
PHLS
CPR
100
Training
277Education Training Disaster Life Support
FCC
Response to Radiological Terrorism
Hospital DLS
Education
More Specialized
Basic Disaster Life Support Course
Who will review? Who will certify? Who will
teach? What is the reward?
Mayo course
FDM
DIMO
Core Disaster Life Support Course
Harvard Course
Hopkins Course
CERT
Training
278Disaster Life Support
A Advanced Life Support 2 day
First Receivers B Basic Life Support 8 hours
First Responders C Core 4 hours
Community/First
Preparers D Intro hour
Community awareness AMA
meeting December 2003 1st full course
New Product modeled after ACLS/ATLS
279DLS Family of Courses
- Disaster Life Support courses should be added to
Veterinary Colleges curriculum - Study side by side with College of Medicine
students - Set standard for Nation
280Surge Discussion
281Begin with the end in mind
FINISH
282Criteria for Surge Hospital
283Surge Hospitals
Hospitals become ICU other buildings become wards
284Goal Solid Structure Addressing ALL Areas
Our House
- People
- Equipment
- Training
- Organization
E
O
Heretical Thinking!
ALL HAZARD ENVIRONMENT
285The interface of standard of care and sufficiency
of care
Graceful Degrada