Rhode Island Disaster Initiative Research Briefing 2005 NDMS Conference

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Rhode Island Disaster InitiativeResearch
Briefing2005 NDMS Conference

• Kenneth A. Williams, MD, FACEP
• Principal Investigator and Medical Director,
  Rhode Island Disaster Initiative / Lifeguard EMS
• Physician Medical Consultant, RI DOH EMS
• Medical Director, City of Providence EMA/Office
  of Homeland Security/MMRS
• Senior Medical Officer, RI-1 DMAT
• Past President, Air Medical Physician Association
• Department of Emergency Medicine, Brown
  University
• University Emergency Medicine Foundation
• Providence, RI

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Selim Covered --

• Use of simulation for disaster research
• Example of one RIDI Focused Study
• Example of MESS in Full Scale Drills

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Im going to

• Briefly introduce the RIDI project
• Cover 2 Focused Studies
• And then discuss how those findings led to design
  and training for full scale studies
• Briefly discuss full scale results

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Greetings from Rhode Island!
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Rhode Island

• 1 million people, 10 million within 100 miles,
• 200,000 in Providence
• 35 x 47 miles ? 1045 square land miles
• as big as Houston! city limits cover 617 square
  miles.
• 39 cities and towns
• 89 licensed ambulance services, limited time for
  training
• 10 acute care hospitals
• RIH one of 5 busiest EDs in US (about 140,000
  pts/year)
• ACS Level 1 adult and pediatric
• 27 buildings on 56 acres
• Limited formalized interagency coordination (89
  Rescue 1s), but friendly community
• Enough size to be a model for hundreds of
  metropolitan areas.
• Small enough to meet, gather data, and train.
• No existing internal critical care transport
  system.

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RIDI Support and Partners

• Lifespan / RIH / HCH
• Battelle Memorial Institute
• Thanks Joanne!
• CBIAC TAT 128
• US Dept. of Health and Human Services
• Office of Naval Research

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Grateful Thanks

• Acknowledgment
• "This material is based upon the work supported
  by the Office of Naval Research."
• "The Rhode Island Disaster Initiative (RIDI) is
  work performed under Chemical-Biological
  Information Analysis Center (CBIAC) Contract
  number SP0700-00-D-3180, Task Number
  128, Delivery Order 0122 sponsored by the U.S.
  Office of Naval Research (ONR)."
• Disclaimer
• "Any opinions, findings, and conclusions or
  recommendations expressed in this material are
  those of the authors and do not necessarily
  reflect the views of the Office of Naval Research"

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Rhode Island Disaster Initiative

• A research project with 3 phases
• Designed to
• identify shortfalls in current disaster response,
  
• test proposed solutions, and
• demonstrate these proven best practices
• Focus on first responder / emergency department
  care in the first hour after an event.
• Ground Level. Very personal behavioral focus.
• Presumes US site, trained responders (EMT)
• Recognizes recurring failures in civilian
  response
• Communication
• Logistics
• Command/control
• Treatment delay
• Equipment

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RIDI Background

• White paper in 1999
• Phase 1 2001-2002
• 3 Consortia
• VRA
• Expert Panels
• Technology Insertions
• Annotated Bibliography
• Phase 2 2002-2003
• Drills
• Focused
• Full-Scale
• DCP
• Phase 3 2003-2006
• Dissemination and Demonstration Project

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RIDI Plan

• What doesnt work currently?
• Pick a few problems, propose best practice
  solutions
• Test these solutions in repetitive drills
• Finalize findings
• Disseminate findings using critical care
  transport as mentor/mobile training model

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RIDI FocusFirst Responder, First Hour

• Initial awareness and response
• Hazard recognition and scene entry/safety
• Patient access, decon, care and transport
• What do they do now?
• What do the current plans call for?
• Are they followed?
• Do they make sense?
• What should they do?
• How can plans and practices be improved?
• How can we train these new requirements?

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Where does RIDI fit?
Rehab Discharge ICU ED Decon Field Dispatch
Awareness
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What do we do nowTraditional Civilian Disaster
Plans

• First Responder tasks
• Identify Disaster
• Set up Command Post
• Locate and Triage All Victims
• Apply Triage Tags
• Move victims to treatment area
• Stage transport vehicles
• Coordinate additional resources
• Load and distribute transport for patients
• gt 4 cycles of triage / handoff
• primary triage, secondary triage, treatment,
  staging, loading/transport

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Does this look familiar?

• Pretty much what was required in RI
• 4 initial roles
• Establish Command
• Triage, Treatment, Staging, Loading
• Triage using modified START, MetTags

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Summary of traditional system

• MCI/Disaster differs from daily system
• Multiple layers / handoffs of patients at the
  scene
• Different treatment priorities
• Different documentation
• Different organizational structure and roles

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Does this work?

• Whos been to a real event where things went this
  way?
• If youve been there, how did you train so that
  things went this way?
• If youve never been there, are you still trained
  to do things this way?

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What Works?Station Nightclub Fire
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Within minutes 96 dead, 200 injured. At least
25 dead lying in the main doorway area, blocking
egress.

• First calls to 911 within minutes.
• Local Fire/EMS 3 EMTs nearby.
• About 100 outside when EMS arrived.
• Mutual Aid requested immediately.

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State Disaster Plan
Plan
Actual

• Command post at scene
• START triage
• MedTags
• Stand up EOC
• Distribute victims widely
• Use interagency communications network

• Rescue screaming victims or set up a command
  post?
• Ambulatory victims herded into nearby hotel
• Victims found hundreds of feet away, walking
  about aimlessly or sitting on ground
• About 40 self-presented to closest ER
• Capillary refill? Most victims had hand burns
• No charting at scene
• No tags used on any victim
• Proximity triage at first, then some severity
  sorting based on respiratory function and facial
  exam
• Limited scene-to-hospital communications
• EOC standup in about 2 hours, most victims
  transported by then
• Hospital communications network not used

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Station Nightclub Fire

• No tags, limited documentation
• Multi site triage/transport without turnover
• Layered communication
• About 200 transported and hospitalized, over 45
  intubated and 75 in ICU.
• 1 short-term in-hospital death. One.
• Mostly over in 90 minutes.

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Titan Corp Debriefing Report
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Station Club Fire Summary

• Second deadliest U.S. nightclub fire
• Over 6000 lives affected
• 583 scene first responders
• Excellent EMS and hospital care
• Should be emulated by others
• Provides a model for other systems
• Need for better communications, state agency
  response

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Lessons for others to emulate

• managed to rescue, evacuate to area hospital
  and treat 186 patients, many with critical
  injuries. Every victim evacuated from the site
  by EMS rescue units arrived safely at area
  hospitals. About 50 additional victims reported
  to hospitals on their own. With a total of
  approximately 230 injured victims, this was a
  monumental accomplishment.

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EMS Findings and Recommendations

• EMS-018 Those personnel who performed triage
  did a phenomenal job of assessing and
  prioritizing nearly 190 victims in a short period
  of time. The speed and efficiency displayed in
  triaging so many patients, including the most
  critically injured, illustrates what an adequate
  number of experienced, dedicated personnel using
  a basic approach to triage can accomplish.
• The procedures used by EMS commanders during the
  response to the Station club fire should be
  analyzed by other jurisdictions so that they can
  replicate these results.

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EMS Findings and Recommendations

• Multiple qualified triage providers/sites a
  model for other communities, but needed
  coordination with IC and better patient
  distribution (avoid closest/overwhelmed
  hospitals)
• Patient prioritization was assessment-based in
  accordance with single-patient protocols, not
  START. MCI plans should be changed to reflect
  this.
• Tags not used and documentation limited
  emphasized the need for victim tracking.
• Comprehensive search for victims essential
• Need for uniform ID system for volunteer helpers
• Need for physician response to scene/medical
  control
• Admirable job with staging/resource use by
  experienced fire EMS chief
• Need for coordinated communications system

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What doesnt work?
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So, things to solve through research

• Response and triage approach
• Communications
• Teamwork
• PPE, Decon, Antidotes

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RIDI Hypotheses

• Familiar, Flexible and Scalable plans work.
• Structure and Familiarity breed Teamwork.
• Its over before help arrives.
• If soldiers fight like they train, disaster
  responders like they work daily job is
  training for the disaster, so daily practice
  must allow for surge and flexibility in a
  disaster.
• Abby Williams, MPH Thesis, Harvard University,
  1995

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RIDI Phase 1

• Expert Panels
• VRA
• Technology Insertions
• Annotated bibliography
• Study design
• What is readiness?
• Anyone?
• How do you measure outcome in a disaster drill?
• Anyone?

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First things first

• How can we study readiness and response if they
  are not defined and if there is no accepted data
  collection technique?

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RIDI Phase 2

• Defined readiness
• The ability to perform a specified task upon
  request
• Developed patient-based timed critical action
  outcome tool.
• Elapsed time to performance of an objective
  measurable action
• Each victim has a unique group of such actions

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Example

• Task
• Safely enter the space within 10 minutes of
  arrival, find and perform initial assessment on
  all victims.
• Critical Actions
• Locate victim
• Assess viability
• Inject MK-1
• Implies recognition of agent sx and correct tx
  choice
• Transport victim out of high risk area

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Data form Full Scale Drills
Observer Date Study Group
Scenario Start Time EMT s ,
, , Entry Yes / No
Patient 4 Name John Puloswki 63yr ?
janitor trapped SIM Time EMT
Notes
Patient 5 Name Suzanne Delbonnel 11mo ? with
father Time EMT Notes
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RIDI Phase 2 Focused Studies

• Focused Studies in the RIH Simulation Center
• Scene entry, video and sim
• Search
• Triage
• Skills in PPE

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The RIH Medical Simulation Center

• High fidelity facility for hands-on medical
  simulation
• Over 2000 square feet
• Multiple manikin/multiple encounter environment
  one of few civilian sites
• Multi-channel digital audio and video recording
  for debriefing

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Rhode Island Hospital Medical Simulation Center
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RIH Sim Control Room RIDI P2 Focused Studies
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RIH Sim Center in RIDI P2 Full Scale Drills
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Do first responders enter unsafe environments?

• Williams K, Sullivan F, Suner S, Shapiro M,
  Kobayashi L, Woolard R, Seekell C

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Objective

• To determine if first responders can accurately
  assess the safety of entry into a simulated
  hazardous materials (HAZMAT) scene.

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Methods

• 41 First responders (56 emergency medical
  technicians (EMTs), 39 emergency physicians, 5
  nurses) were presented with a HAZMAT scene.

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Methods

• They received either training for several hours
  (lecture/discussion format) that focused on
  weapons of mass destruction (WMD) and HAZMAT
  awareness
• (trained group, n23),
• or no training
• (control group, n18).

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The scene

• Youre the response team supervisor
• Your team responded 20 minutes ago for a man down
  in a room
• You respond because they are not answering the
  radio
• Through the window into the room, you see
• 3 victims,
• an exterminator sprayer,
• a puddle of white liquid, and
• a bottle of concentrated organophosphate

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V1
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V1 cardiac arrest
V3 seizing
V2 ill
bottle
Entry Door
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Critical Action Score Sheet

• Briefing delivered Y N
• Start time _______
• Opened door? Y N Time if opened ____
• Entry (touch victim)? Y N Time ____

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What do you think happened?

• What were they trained to do?
• What would you do?
• What did they do?

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Results

• 18/41 (44) of all first responders opened the
  door,
• 8/23 (35) trained, 10/18 (55) control
• 14/41 (34) of first responders entered the
  hazardous scene
• 6/23 (26) trained, 8/18 (44) control
• t-test
• open door p-value 0.1835,
• enter room p-value 0.2186.

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Results, Again

• ALMOST HALF OPENED THE DOOR
• ALMOST A THIRD WALKED IN AND TOUCHED A VICTIM
• TRAINING DIDNT MATTER (MUCH)

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Triage Behavior of First Responders

• Williams K, Sullivan F, Suner S, Shapiro M,
  Kobayashi L, Woolard R, Seekell C, Trespalacios F

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Objective

• Determine if EMTs triage according to a required
  method (START) in a high-fidelity simulated
  disaster drill.

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METHODS

• 24 EMTs, trained in and required by protocol
  to use the START (www.start-triage.com) triage
  system, were individually exposed to a
  three-victim drill in a prospective descriptive
  experimental design.

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START timing

• START allows 30 seconds to triage each victim
  hence the hypothesis was completion of 3
  assessments within 90 seconds by all EMTs.

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Triage Victims

• Victims are
• V1, in cardiac arrest (furthest from entry), V2,
  responsive but with illness (closest to entry),
  and
• V3 (close to V2) seizing.
• None are bleeding.
• All can be seen upon entry.

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V1 cardiac arrest
V3 seizing
V2 ill
bottle
Entry Door
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RESULTS

• 17/24 EMTs (71) took over 90 seconds to
  complete the 3 assessments, disproving the
  hypothesis of 0
• plt0.0001.

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V1 cardiac arrest
3
V3 seizing
11
5
V2 ill
bottle
Entry Door
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Conclusions

• Most EMTs do not triage using the required
  method.
• Most EMTs approached the viable victims before
  the victim in cardiac arrest.

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Discussion

• The triage method EMTs actually use appears
  related to victim-EMT proximity, and perhaps to
  visual assessment of victim condition and other
  factors.
• Distance motion/sx triage
• Physics
• Chivalry
• Proximity
• ???

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Focused Study Summary

• Helpers rush in they need PPE and training
• Triage by EMTs is professional and high-level.
• Trauma algorithms dont apply to all WMD issues.
• EMTs can operate in Level C PPE for about 1 hour,
  but need radio communication, decon and adaptive
  equipment.
• First Responder training should be brief,
  focused, and practical.

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What does this mean?

• Helpers want to help?
• Do we put disaster responders in a rush-in
  situation
• Do we EQUIP THEM and TRAIN THEM for this type of
  response???
• What should we do with this information?

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What we thoughtto train the Full-Scale
responders

• First Responders need adequate PPE for reasonable
  (not Hot Level A) response
• Level C suite with PAPRs
• NOT intended to replace true HAZMAT team response
  into a known hot zone
• Theyre down
• Youve got a powdered donut to save your life
• IS intended for overwhelming multi-victim
  no-other-option warm / cool theyre coming at
  you situations.
• Exposure with multiple victims approaching EMS
  upon arrival

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What we thought

• Develop reasonably safe entry algorithm
• Multiple victims, trauma ?
• All down / visible danger
• NO ENTRY
• Ambulatory, no vis threat
• VENT,
• BRIEF ENTRY IN LEVEL C
• DECON VICTIMS AND STAFF UPON EXIT
• Single victim
• Increased awareness
• Access to antidotes, Level C suite
• NOT OSHA / NIOSH safe entry
• IDLS environments can be entered in Level ???
• Unknown environments are presumed to be ???
• Realistic approach until agent known

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So, the trained group in 2 hours

• Got Level C with PAPRs
• Got brief discussion on the victim-as-canary
  entry decision scheme
• Got scissors and sprayers for decon
• Got told that brief is brief -- ? SCBA ?
• Got brief antidote anecdotes
• MK-1 WET
• Versed WET
• BAL BLISTERS
• Narcan Respiratory depression/arrest
• B-12 Cyanosis / Cyanide
• Got focused discussion on teamwork and
  communications
• Practiced for an hour

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The untrained group got

• Standard state protocols and resources
• No entry if HAZMAT
• Call HAZMAT and Decon (team/trailer response)
• Prepare triage and treatment for removed and
  decontaminated victims
• Use tags
• 4-level approach with START triage

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Brown Medical School Emergency Medicine
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RIDI Phase 2 Full Scale Design

• Training brief, focused, urged to use daily
  practice. Level C PAPR PPE.
• 12 evolutions (2 hours each), 60 EMTs, 9 victims
• Dirty bomb (Lewisite) in a pediatric clinic. Mix
  of manikins and professional actors, alarm
  strobes, smoke, screaming, odors.
• Range of problems to test various response issues
• 4 EMTs respond, 1 dispatcher
• Level C PPE and medical equipment available
• Break point if incorrect entry decision
• Measured time, action, and quality
• 8000 data points.

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Look this time at

• Coordination and teamwork
• Communications
• Patient care
• Decon
• Antidotes

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RIDI Full Scale Drills
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RIDI Full Scale Drills
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RIDI Full Scale Drills
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Trained
Control
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What does this mean?

• Both groups did the same medical job
• Except antidotes
• Similar timing
• Found all patients
• Performed medical critical actions
• Oxygen, splints, IV airway, etc.
• Similar transport priority

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Full Scale Drill Preliminary ResultsControl
Groups

• 100 entry into hazardous space without PPE
• No decon prior to transport
• 1 group called for decon, didnt wait
• No antidotes administered
• Had Narcan, D50, Versed
• Didnt have MK-1, BAL, B-12
• Called for antidote 1/54 encounters
• 199 Critical Actions

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Full Scale Drill Preliminary ResultsTrained
Groups

• 50 entered hazardous space w/o PPE
• P 0.09 by Fishers Exact Test
• 10/54 received BAL (correct choice)
• 1 team delivered divided dose to children
• 34/54 received decon at the scene
• Clothing cut off
• Water spray
• 251 Critical Actions

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Critical Actions
Brown Medical School Emergency Medicine
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Critical Actions on MESS Patients
Brown Medical School Emergency Medicine
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Phase 2 Full Scale Preliminary Results

• RIDI training delays overall patient care
  slightly.
• All non-trained teams entered the contaminated
  space without PPE, none decontaminated patients,
  much care focused on non-viable victims
• RIDI training improves
• entry decision,
• PPE use,
• focus of care, teamwork, coordination (critical
  actions),
• WMD recognition,
• antidote use,
• decon

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Summary Points

• High fidelity simulation center disaster research
  is possible although complex.
• Most current civilian First Responder disaster
  plans are wrong in many ways.
• First responders act under stress like they do in
  daily operations, so
• Daily operations must be standardized but
  adaptive, scalable, and flexible to meet disaster
  surges and circumstances.
• Brief training in WMD recognition, PPE, decon and
  WMD treatment can alter practice and outcome.
• Longer training may be justified for the
  trainers/leaders.

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Currently Phase 3

• Demonstration Vehicle (big ambulance) for scene
  response and support on order
• Daily Critical Care Transport / sim training /
  lecture to train EMTs and provide ready response.
  Lifeguard EMS. Average 1pt/12 hours to date.
• Revised statewide EMA and DOH plans and protocols
  completed.
• Ordering equipment for ambulances, teams / caches
  of decon, HAZMAT, and MCI supplies in place, need
  to standardize bags.

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Questions?
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Thank you, thank you very much.

• www.RIDIproject.org
• kwilliams_at_lifespan.org