Disaster Facts and Myths Amy H' Kaji, MD, MPH November 16, 2005 Acute Care College Medical Student S

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Disaster Facts and Myths Amy H. Kaji,
MD, MPH November 16, 2005 Acute Care College
Medical Student Seminar

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• The Disaster Facts

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Disaster Facts

• Disaster defined as a natural or manmade event
  that results in an imbalance between the supply
  and demand for existing resources
• Natural
• Earthquakes, wildfires, hurricanes, floods,
  droughts, tsunamis, etc.
• Manmade
• Terrorist incidents including chemical,
  biological, radiological, nuclear, and explosive
  events
• Civil unrest and riots

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September 11, 2001 and the Dissemination of
Anthrax
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Disasters will Impact ALL Physicians

• Emergency Physicians
• Will likely be the first to assess victims of
  disaster
• Anesthesiologists
• Victims will often require operative care
• Surgeons
• Traumatic injuries may warrant operative
  treatment
• Critical Care Specialists
• Victims may require intensive care unit and
  ventilatory management
• Primary Care
• Victims will need care of their chronic
  underlying medical conditions
• May be the first to see victims of a covert
  biological attack
• Psychiatry
• Victims may require supportive care and grief
  counseling

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Disasters will Impact ALL Physicians

• Teamwork will be critical
• Flexibility in roles may be warranted
• Surgeons and anesthesiologists may lend a helping
  hand in the emergency department

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March 11, 2004Madrid, Spain Train Bombings
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How does disaster triage differ from ordinary
triage?

• Daily triage
• Involves providing highest intensity of care to
  the most seriously ill patients
• These patients may have a low probability of
  survival
• Disaster triage
• Doing greatest good for greatest number
• Focus shifts on identifying victims who have a
  chance of survival with immediate medical
  interventions

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Disaster Triage Systems

• Red
• Critical injuries that can be cared for with
  minimal time or resources
• Example obstructed airway or tension
  pneumothorax
• Yellow
• Significant injuries that can tolerate a delay in
  care
• Example femur fracture without neurovascular
  compromise
• Green
• Injuries that can wait for days to be treated
• Example minor contusions, sprains, and abrasions
• Black
• Expectant patients who have minimal chance of
  survival even if significant resources are
  expended

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Triage Tag
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Simple Triage and Rapid Treatment (START)

• Assesses respiratory status, perfusion, and
  mental status
• All patients who can walk are asked to move away
  from the incident
• Green
• Those remaining with RRgt30, capillary refill gt2
  seconds, or are unable to follow commands
• Red
• Those remaining with RRlt30, capillary refill lt2
  seconds, and are able to follow commands
• Yellow

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Children vs. Adults

• Emergency Medical Services (EMS) will not respect
  children only and adults only emergency
  departments during disasters
• Every facility must be able to care for and
  stabilize both children and adults

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Common problem during disasters Communications

• Communication modes and routes may be destroyed
  mechanically by natural disasters
• Sudden increase in volume and need to communicate
  with victims, responders, and witnesses
• Landlines and cellular phone lines become
  saturated
• Radio frequencies may not be coordinated

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Communication Difficulties

• People problems, not equipment problems
  predominate
• What information needs to be collected?
• Who should collect it?
• How should the information be relayed
  expeditiously and comprehensibly to those that
  need it?

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Importance of Redundant Communications

• Many regions now enlist volunteer HAM operators

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The Media

• Lack of planning for interaction with the media
  is common
• Planning with the media
• Maximize risk communications
• Precautions about heat illness, food and water
  safety, disease transmission, etc.
• Source of education and support for community
  disaster mitigation and planning
• Decrease disruptive aspects of their involvement
• Designate single point of information release

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Hospital as Victim

• Structural and nonstructural damage
• Examples ceiling, water, emergency generator
  power failure
• Prevention is critical
• Hospitals should not be built in areas of
  recurrent floods, or near earthquake faults
• Adherence to hazard resistant building codes
• Is the hospital safe?
• Post-impact assessment by trained structural
  engineers
• Networking within the community
• Inter-organizational cooperation with other
  hospitals, EMS, public health, and fire

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Hospital as Victim

• US Geological Survey estimates that 25 of
  hospital beds will be damaged and unavailable in
  a major earthquake
• Northridge Earthquake, 1994
• 8/91 acute care hospitals required evacuation
  (2500 beds lost)
• 4 hospitals condemned

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Standardizing Hospital Emergency Incident
Command System (HEICS)

• Originated in CA by the EMS Authority
• Joint Commission of Accreditation of Hospital
  Organizations (JCAHO) requirement
• Common terminology
• Predictable chain of management
• Flexible organization chart
• Prioritized response checklists

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HEICS
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HEICS

• Incident Command (IC)
• Overall responsibility for incident management
• Role often fulfilled by Hospital Administrator
• Planning
• Continually evaluates the event by developing
  action plans and conducting strategic meetings
  during the event.
• Finance and Administration
• Responsible for the payment, contracting, or
  implementation of other agreements required to
  obtain needed resources as identified by the IC.

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HEICS

• Logistics
• Responsible for providing services, facilities,
  and materials needed to support the event.
• May include communication equipment, information
  systems, food, clean water, medical supplies, and
  facilities construction.
• Operations
• All other functions of the ICS are performed to
  support the operations component.
• Responsible for medical direction and
  communication required to accomplish the
  management, triage, treatment, and disposition of
  victims.

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Hazard Vulnerability Analysis (HVA)

• Joint Commission on Accreditation of Healthcare
  Organizations (JCAHO) definition of Hazard
  Vulnerability Analysis (HVA)
• Identification of hazards and the direct and
  indirect effect these hazards may have on the
  hospital
• Hazards that have occurred or could occur must be
  balanced against the population at risk to
  determine vulnerability.

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Hazard Vulnerability Analysis (HVA)

• HVA based on an all hazards approach
• Begin with list of all disasters, regardless of
  their likelihood, geographic impact, or potential
  outcome
• List should be as comprehensive as possible
• Typical categories of potential hazards
  considered include natural hazards, technological
  hazards, and human events
• Note possible overlap between categories

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Hazard Vulnerability Analysis (HVA)

• Prioritization Process due to limited resources
• Evaluate each hazard for
• Probability of occurrence
• Risk to organization
• Organizations current level of preparedness.
• Disaster are not predictable with any degree of
  accuracy
• Familiarity with geographic area, common sense,
  and research will help identify hazards
• Important to consider likely and unlikely
  scenarios
• Establishing probability of event is only part
  objective and statistical
• Remainder is considered intuitive or highly
  subjective

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Probability of Hazard

• Evaluate each hazard for its probability of
  occurrence
• Factors to consider
• Known risk
• Historical Data
• Manufacturer/vendor statistics
• Tool presented here uses qualitative terms high,
  medium, low, or no probability of occurrence

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Risk of Hazard

• Risk is potential impact hazard may have on
  organization, and issues to consider include
• Threat to life and/or health
• Property damage seismic activity
• Disruption of services from systems failure
• Economic loss - adverse financial impact
• Loss of community trust/goodwill
• Legal ramifications

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Current Level of Preparedness

• A final issue in HVA is hospitals current level
  of preparedness, including
• Community resources -- hospital does not respond
  in a vacuum
• Current status of emergency plans and training
  status of staff
• Availability of insurance coverage or backup
  systems

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The HVA Tool

• Each potential hazard is evaluated and scored in
  areas of probability, risk, and preparedness
• Factors are multiplied for overall total score
  for each hazard
• Ordering total scores prioritize hazards in need
  of the attention and resources
• Determine a score below which no action is
  necessary, and focus on hazards of higher
  priority

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Example of the HVA Tool
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July 29, 2003 Hospital Structural Damage from
an Earthquake in Tokyo, Japan
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Myth 1

• I was told that hospitals do not need to prepare
  for disaster, since disasters are similar to
  daily emergencies on a large scale. Isnt that
  true?

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The Truth

• Fact Disasters pose problems that require unique
  strategies, since disasters tend to disrupt
  normal communications systems, transportation
  routes, and normal response facilities.

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Severe Drought
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• What other myths plague disaster medicine?

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Myth 2

• Physicians and nurses should be sent to the field
  to help at the actual disaster site.

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The Truth

• Physicians and nurses depend upon monitors and
  equipment, not available in the field
• On-site chaos of disaster may prove disabling
• Goal of disaster medical response planners is to
  assign personnel to roles that are as familiar as
  possible and to enhance flexibility of response
  to extraordinary circumstances
• Only physicians and nurses specially trained to
  work in the field environment should do so
• Only if physicians are in surplus in the
  hospital/clinic environment should they be sent
  to the field as care providers

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October 2003California Wildfires
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Myth 3

• A disaster plan is required for hospital
  accreditation. Thus, the existence of a written
  disaster plan is assurance that the hospital is
  indeed prepared.

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The Truth

• Written disaster plans
• Can cause an illusion of preparedness
• The paper plan syndrome
• Often massive documents that are cumbersome
• A disaster plan is only useful, if it is
• Based upon a valid hazard vulnerability analysis
• Integrated with local and regional plans
• Accompanied by resources necessary to carry out
  the plan
• Associated with an effective training program

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Avoiding the Paper Plan
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Myth 4

• The EMS Agency will disperse and distribute the
  patients to various facilities so as to not
  inordinately impact one hospital.

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The Truth

• Closest hospital will be the one most
  significantly impacted
• Laypersons assisting non-ambulatory patients will
  transport them to nearest facility
• Many victims will go to closest facility out of
  loyalty or financial reasons

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March 28, 1979Three Mile Island
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Myth 5

• Timely and appropriate information will be
  received from the disaster site, and responders
  will be able to prioritize the use of available
  resources.

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The Truth

• Communications from the disaster site occur in
  less than one-third of major incidents
• Hospitals learn about disaster from mass media,
  first arriving casualties and ambulances, rather
  than from personnel at the actual site
• Radio equipment and telephone lines may be
  damaged or overloaded

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Water, water, everywhere
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Myth 6

• Most of the initial emergency response is carried
  out by well trained pre-hospital healthcare
  personnel.

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The Truth

• Most initial care provided by civilian bystanders
• Majority of casualties not transported by
  ambulance
• Field and first aid triage stations bypassed
• Hospitals do not receive adequate information to
  guide response

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Myth 7

• All patients will be transported to hospitals
  only after they have received adequate medical
  care in the pre-hospital setting.

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The Truth

• Casualties arrive to ED in two waves
• First wave within the first 30 minutes
• Walking wounded and self-transporters
• Second wave after 30-90 minutes
• More critically ill patients needing extrication
  and ambulance transportation
• Up to 80 of victims will seek medical care on
  their own, by foot or by private automobile
• During HAZMAT incidents, 64 are transported to
  the hospital for decontamination

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Tokyo, Japan March 20, 1995 -Sarin in the Subway
System
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Ambulance Transport in less than 20
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Myth 8

• Primary medical need will be to deal with large
  numbers of victims suffering from multiple
  trauma.

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The Truth

• Most disaster injuries requiring medical care are
  minor
• Only 20 of victims are admitted
• Many injuries occur during the clean-up period
• Many have lost access to routine care and
  medications and follow-up of chronic medical
  conditions

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Minor Injuries Predominate
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Attention to Chronic Medical Conditions
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Myth 9

• Disasters bring out the worst in human nature and
  behavior
• There is a great deal of looting in the aftermath
  of a disaster (This used to be a myth until
  Hurricane Katrina!!!)
• This myth likely becomes a truth when there is a
  disaster of catastrophic proportions with
  thousands of displaced persons, famine, and death
• There are very few donations in the setting of a
  disaster
• All types of supplies, medications, and blood are
  needed
• Any supply of drug is better than none

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The Truth

• Looting is seldom a major problem after any major
  disaster (unless disaster is of catastrophic
  proportions)
• Helping response after a disaster is impressive
• Massive donation programs often cause a second
  disaster
• Staffing and resources must be diverted to manage
  the donations
• Problems with massive quantities of improperly
  labeled, packaged, expired, and unsorted
  pharmaceuticals
• World Health Organization (WHO) guidelines for
  pharmaceutical donations

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Unfortunately, looting after a disaster may not
be as mythical as once thought
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The Helping ResponseDecember 26, 2004 and the
Tsunami
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Donations for Indonesia after the Tsunami
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Myth 10

• All disasters are catastrophic and involve
  hundreds of thousands of victims.

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The Truth

• Very few disasters in the US have resulted in gt
  1,000 casualties
• Only 10-15 disasters per year result in gt 40
  casualties
• World Trade Center (WTC) attack on 9/11/01 was
  only the 8th peacetime disaster in US history
  resulting in more than 1,000 fatalities

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Transportation Disasters
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Myth 11

• Massive epidemics will result from disasters,
  particularly if there are many dead victims at
  the site. Thus, mass vaccination programs should
  be instituted, and corpses should be disposed of
  rapidly.

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The Truth

• Dead bodies rarely cause mass epidemics of
  disease
• There is time to respect the dead and observe a
  proper burial
• Non-endemic diseases will not pose a problem
  unless brought into disaster area
• Public health efforts should concentrate on
  pathogens endemic to the region
• Immunizations should be administered judiciously
• Increased disease transmission is greater risk
  than risk of epidemic outbreaks

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Myth 12

• The disaster-stricken region is helplessly
  waiting for external (state, federal, or
  international) help.

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The Truth

• All disasters are local
• Indigenous population will have performed much of
  the disaster response and recovery before
  external help arrives
• Rescue teams responding to large-scale disasters
  involving trapped victims will have little impact
  unless they arrive within 1-2 days
• Federal and state aid will not arrive for 24 to
  48 hours

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April 19, 1995Oklahoma City Bombing
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Myth 13

• Critical Incident Stress Debriefing (CISD),
  where disaster victims and responders are
  encouraged to express and voice their feelings
  and emotions, is a necessary and important
  component of acute disaster recovery and
  response.

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The Truth

• No evidence that CISD in the acute phase is
  helpful in decreasing rate of post-traumatic
  stress disorder (PTSD)
• Single-session debriefing
• Victims encouraged to relive traumatic event
  shortly after incident
• Controversial and may be harmful

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Myth 14

• Most of the recovery will be performed within the
  first few days, and things will return to
  normal relatively quickly.

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The Truth

• Recovery process occurs over months and years
• Media attention dwindles
• Aid becomes sparse
• Example Northridge Earthquake in 1994 recovery
  is still ongoing
• Retrofitting of buildings to meet earthquake
  standards still not complete

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April 29, 1992Rodney King Riots
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July 7, 2005 London Terror Bombings
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August 29,2005Hurricane Katrina Estimated
Damage gt 200 Billion
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AL, LA, MSHurricane Katrina Estimated
Damage gt 200 Billion

• Probably the worst natural disaster in the
  United States
• Catastrophic, with over 50,000 evacuees and
  refugees (displaced persons)
• All hospitals evacuated

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Lessons from Katrina?

• Poor coordination of local, state, and federal
  resources
• Who should have taken control?
• Years prior to Katrina, the State knew that they
  were only prepared for a Category Three storm
• What is the role of mandatory evacuation?
• Were security measures in place at the Superdome
  and the convention center?
• Were they prepared to shelter evacuees for longer
  than 2 days?
• Did they have mutual agreements in place with
  other states?
• The hospitals had less than 3 days worth of
  supplies. Why?

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Hospital Disaster Preparedness

• Hospital disaster preparedness requires
• Improving physician knowledge and understanding
  of all types of disasters, including chemical,
  biological, and radiological events
• Improving daily surge and disaster surge capacity
  
• Drills

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Hospital Disaster Preparedness

• Community involvement and cooperation
• Communication and cooperation with Public Health
• Communication and cooperation with law
  enforcement
• Communication and cooperation with fire
  department and EMS

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Hope this presentation has helped dispel some
disaster myths

• Questions?

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Selected References

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Selected References

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Selected References

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Selected References

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