Texas A

1
Texas AM Health Science CenterMedical
Special Needs (MSN) Preparedness SymposiumIn
the wake of Hurricane IkeFebruary 10-11,
2009Augmenting Medical ResourcesMSN Medical
and Public Health Challenges

• Raymond E. Swienton, MD, FACEP
• UT Southwestern Medical Center Dallas

2
Objectives

• The learner will be able to
• Discuss strategic approach in augmenting medical
  resources for MSN (e.g., strategies)
• Describe examples during H. Ike impacting medical
  resources for MSN (e.g., realities)
• Discuss advancements achieved augmenting medical
  resources for MSN (e.g., inroads)
• Inroad an advance often at the expense of
  someone or something (Merriam-Webster, online
  dictionary)

3
MSN Mission-Tasking

• The art and science of managing people
  (casualties) with pre-existing disease, injuries
  and disabilities in a sufficiency of care
  environment caused by a disaster or public health
  emergency.

4
Hurricane Ike, 2008
5
MSN Strategic Approach

• Begins with ownership It is our disaster
• To rapidly identify the medical and health needs
  of casualties
• To coordinate, verify, and optimize local
  healthcare infrastructure
• To deliver disaster medical and public health
  emergency services

6
MSN Strategic Challenges

• Strategies H-4,-3,-2,-1 days, pre-impact
  period
• Prevent, Protect, and Mitigate
• Where?..., Who?..., When?...

7
MSN Evacuation

• At the risk of putting

8
MSN Evacuation

• Begins with recovery - repatriation planning
• Realities MSN evacuation, essential to saving
  lives in the short term long term
• Places casualties at risk
• New injuries or illness, acute exacerbations of
  chronic disease, mental health decline, etc.
• Places receiving healthcare communities at risk
• Resource utilization, costly hospitalizations,
  etc.

9
MSN Evacuation

• Evacuation Strategies
• Manage transportation, early rapid health decline
• Evacuation Realities
• Experiences from H. Gustav and H. Ike
• Evacuation Inroads
• Medically trained observers in vehicles
• EMS escort
• Notification of EMS hospitals along route

10
MSN Strategic Challenges

• Strategies H-0, 1, 2, Immediate and early
  response period, Situational Awareness
• Realities Limited communication, difficult
  verification, challenging access
• Descriptions obtained in impacted areas
• I heard, Someone saw, No help yet
• Eyewitness accounts by objective-based,
  mission-focused medical and health personnel are
  needed to improve decision making and resource
  allocation, but not always available!

11
Improving Decision Making Rapid Acute Medical
Care
12
MSN Strategic Challenges

• Inroads Immediate post impact period
• Rapid Medical Public Health Assessment Strike
  Team
• Eyewitness accounts by trained, objective-based,
  mission-focused medical and health personnel to
  guide decision making and resource allocation
• just-in-time first implemented during H.
  Katrina Rita
• Deployed during H. Dolly, H. Gustav and H. Ike
• Recognized component of early response strategy
• Collaborative academic partners and DSHS
  initiative

13
MSN Strategic Challenges

• Inroads Immediate post impact period
• Medical Special Operations Strike Team
• Tactically oriented medical and health personnel
  mission to deliver acute and emergent care in an
  austere environment during the early response
  phase.
• Eyewitness accounts trained to aid decision
  making and resource allocation during early
  response
• Deployed during San Angelo Incident, H. Dolly and
  H. Ike
• Recognized component of early response strategy
• Collaborative academic partners and DSHS
  initiative

14
MSN Strategic Challenges

• Inroads Immediate post impact period
• Task Force Ike
• Preassembled convoy including hundreds of
  vehicles and personnel for first opportunity
  early response
• Collaborative GDEM, DSHS many state and federal
  
• Guide decision making, provide timely resource
  allocation, and prompt service delivery
• just-in-time implemented during H. Ike
• Recognized component of early response strategy

15
MSN Impacting Local Healthcare Infrastructure

• Inroads Preservation of local healthcare
  infrastructure
• Realities H. Katrina, 2005
• Minimizing local emergency department surge by
  utilizing acute care services delivery at the
  Dallas Convention Center

16
Dallas Convention Center Medical Unit

• Over the 16 days of operation
• 23,231 displaced persons registered
• 10,367 emergent or urgent care visits
• 619 care visits per day of operation
• 257 patients observed (3.2)
• 236 patients ER transported (2.9)
• 0 deaths
• J Trauma. 2007 63253-257

17
MSN Impacting Local Healthcare Infrastructure

• MSN Shelter at Reed Arena, College Station, TX

18
MSN Impacting Local Healthcare Infrastructure

• Strategies Preservation of sheltering
  communities local healthcare infrastructure
  during H. Ike
• Strategies Reed Arena, College Station, TX
• MSN Shelter on the campus of Texas AM Univ.
• Projected daily census maximum 500 casualties
• Staffing PHS RDF (Rapid Deployable Force)
• Augmented with TAMU personnel and students

19
MSN Impacting Local Healthcare Infrastructure

• Realities MSN Shelter at Reed Arena, College
  Station, Texas
• Peak daily census only 250-275 of projected 500
• Reasons noted included unexpected high acuity,
  insufficient staff personnel per PHS-RDF staff on
  site
• Risk of surge impact to local area hospitals

20
MSN Impacting Local Healthcare Infrastructure

• Realities Surge managed effectively by acute
  care services provided on site by DMAT Strike
  Team (KY-1) at MSN Reed Arena Shelter
• Inroads On-site shelter access to acute care is
  successful in managing shelter surge

21
MSN Health and Medical Information Access

• Strategies Facilitating information access to
  providers and facilities managing MSN casualties.
• Realities Health and medical information is
  usually not available for at risk MSN casualties
  unable to effectively communicate

22
MSN Health and Medical Information Access

• Realities Public Health Service RDF EMR used at
  Reed Arena MSN Shelter
• Future Inroads Prioritizing information access
  for vulnerable populations statewide

23
MSN Management George R. Brown Convention
Center, Houston

• GRB CC was utilized in several capacities
• Such as general population shelter, casualty
  collection and stabilization, workforce
  protection and shelter, medication refills, etc.

24
MSN Caught Between ESFsMission Drift Vs.
Mission Gap

• they are going to send me away
• Realities GRB CC, for some being labeled MSN
  placed them at risk of being removed from
  remaining family, near-local community, and
  further from usual medical care, medication and
  supply access
• ESF-6, Red Cross medical needs exceed gen pop
• ESF-8, DMAT chronic illness management is not
  our mission as we do not run a nursing home

25
GRB Convention Center State and Federal
Collaboration

• Solving the gap (some of it at least)
• Realities Texas Military Forces Medical
  Brigade stepped up to fill this gap
• Inroads Successful collaborative modification
  of federal agency mission with delegation to a
  state organization serving under federal chain of
  command

26
Emergency Department Surge
27
MSN Impacted by Emergency Department Surge

• Realities Texas Medical Center facilities
  emergency departments
• Immediate large EMS surge and early response
  sustained increase in patient volumes
• Ongoing site survey of facilities
• Immediate surge doubled or more usual census
• Sustained 25-27 increase in daily census
• Early tremendous surge a risk to worker safety,
  patient safety and timely access to medical care

28
MSN Impacted by Emergency Department Surge

• Strategies Just-in-time utilization of DMAT to
  reduce EMS volume to TMC EDs
• Realities TX-4 DMAT established EMS reception
  center and acute care delivery site on campus of
  Rice University
• Realities Underutilization of capabilities
• Inroads Collaboration of many groups
• Houston city, Harris County, private university,
  EMS, TMC, NDMS / DMAT, etc..

29
MSN Impacted by Emergency Department Surge

• Inroads Model for early response strategy for
  reducing EMS surge volume on local healthcare
  infrastructure

30
MSN Impacted by Emergency Department Surge

• Realities Texas Medical Center facilities
  emergency departments early surge
• Medication refills
• Wound management
• Low acuity musculoskeletal injuries
• Renal disease assessment for hemodialysis
• Home oxygen access
• Lack of public services
• Increase in CO poisonings
• MSN significantly represented in early surge

31
MSN Impacted by Emergency Department Surge

• Future Inroads identified
• Medical POD-like access sites
• Medical supplies pharmaceuticals
• Medication refills
• Home oxygen access
• Wound management
• Improving access to lab screening
• Renal disease assess for hemodialysis
• Health safety education programs
• Increase in CO poisonings

32
Priority to Reestablish Local Community Medical
Care

• Realities Complete lack of pre-existing local
  health and medical care services after H. Ike on
  Galveston Island.
• Completely

33
Priority to Reestablish Local Community Medical
Care

• Realities Only one community medical clinic
  opened early after H. Ike on Galveston Island.
• Future Inroads, improve planning and
  operational incentives to encourage return of
  local medical care community to service

34
MSN Ethics

• Local healthcare infrastructure faces many
  challenges providing disaster assistance
• Helping all people in need of health and medical
  services

Star-Telegram, Feb. 6, 2009
35
MSN Ethics and Family Values

• Likely Realities My family would not likely be
  welcome to stay as a intact family unit in a
  disaster sheltering environment
• Meet my son, Kyle
• Unintended negative consequences
• Should we care?
• Many higher functioning lives at risk
• Risk of applying triage to ethical situations
• Federal and State agencies consider ethical risks
• Regulatory and legislative implications

36
Summary

• The learner is now able to
• Discuss strategic approach in augmenting medical
  resources for MSN (e.g., strategies)
• Describe examples during H. Ike impacting medical
  resources for MSN (e.g., realities)
• Discuss advancements achieved augmenting medical
  resources for MSN (e.g., inroads)
• Inroad an advance often at the expense of
  someone or something (Merriam-Webster, online
  dictionary)

37
Thank You ! Any Questions ?
38
Contact information

• Ray E. Swienton, MD, FACEP
• Co-Director, EMS, Disaster Medicine Homeland
  Security Section
• Associate Professor, Emergency Medicine
• University of Texas Southwestern Medical Center
  at Dallas
• 5323 Harry Hines Blvd., Dallas, Texas 75390-8579
• Email BearDogMD_at_AOL.com
• Voice [phone]

39
Last Slide

• Intentionally blank