Download Disaster Response And Healthcare

Disaster Response
And Respiratory Care
Objectives


Understand the universal characteristics of
disasters and the components of an all hazards
approach to disaster management involving
healthcare practitioners.
Demonstrate understanding of the role of
Respiratory Therapists in disaster response and
emergency management; and, describe the role
of Respiratory Therapists as volunteers for
disaster response.
Objectives



Explain the various levels of equipment and
support Respiratory Therapists will utilize in
responding to mass casualty incidents and
disasters.
Discuss the implication of Pandemic Influenza
as it relates to planning and response capability
and capacity.
Describe the impact of Bioterrorism and manmade disasters to health care systems,
providers, and disaster preparedness plans.
What’s The Fuss?
How Do We Respond To This…
So We Don’t Feel Like This…
Disaster Characteristics





Increased death, injury,
illness that can’t be
managed
Coordination public,
government, and
private organizations
Equal triage distribution
Notification of family
Evacuation/Sheltering
of evacuees
Disaster Characteristics




Media attention
Heightened security;
crime scene
Immediate and long
term emotional
support
Significant property
damage
Impact of Disasters

In the past 20 years “Although the yearly
death totals from disaster declined by
approximately 30%, the number of people
affected by disaster increased 59%”
(AARC Times. 2006. p. 8)
Consequence Management

The objective of consequence
management is:
 Provide
support
 Save lives
 Relieve suffering
 Mitigate further harm
Preparedness Cycle
Health systems
will be prepared
through a
continuous cycle
of planning,
equipping,
training and
exercising.
Plan
Train
P.E.T.E.

Plan
 Public

Health Preparedness Strategic Plan
Equip
 Ventilators,

Train
 OSHA,

PPE, Pharmaceuticals, etc…
DHS, Other
Exercise
 Local,
Regional, Statewide, Interstate,
National
Public Health Response
County Health
Departments
Pre-hospital
Outpatient
Services
Hospitals
Pharmacies
Laboratories
Mortuary
Services
Health Care System
Surge
Capacity
Domestic Security Regions







Region 1
Region 2
Region 3
Region 4
Region 5
Region 6
Region 7
Integrated Plans

Federal
 National

Response Framework (NRF)
Supported by National Incident Management
System (NIMS) and the National Disaster
Medical System (NDMS)
 Comprehensive
Emergency Management
Plan (CEMP)
Provides guidance
 Integrated and coordinated response
 Emergency Support Functions (ESF-8)
 Follows NRF

Integrated Plans

State
 Florida
Department of Health
Bomb, Blast, Burn (B3)
 Biological (B4)
 Pandemic Influenza
 Public Health and Medical Preparedness
Strategic Plan 2007-2010

 County
CEMP Plans
 Hospital CEMP Plans
Goal of Surge Thinking
 Maximize
survival for all
players!
 Minimize morbidity!
 Maximize resource
utilization!
 Will require new thinking!
Natural Disasters
Natural Disasters
Tornadoes
 Forest Fires
 Floods
 Blizzards
 Cyclones/Typhoon
 Hurricanes
 Heatwave

Tsunami
 Volcanic Eruption
 Earthquakes
 Mudslides
 Limnic Eruption
 Draught/Famine
 Hail

Natural Disasters - Florida
Hurricanes
 Tornadoes
 Forest Fires
 Flooding
 Freezing
 Sinkholes
 Drought
 Heatwave
 Hail

Natural Disasters - Florida

2004
 July
31 to December 3
 9 Hurricanes; 5 Tropical
Storms
 Charley, Frances,
Jeanne, Ivan

2005
 June
8 to January 6
 15 Hurricanes; 12
Tropical Storms
 Katrina, Rita
Cost – 2004 Hurricane Season
Florida’s hospitals incurred $163.2 million
in unexpected costs
 Expenses related to facility modifications
to reduce damage from future storms
would exceed $48 million
 Average hospital impact of more than $1
million
 Total impact on hospitals > $200 million

Lessons Learned


Preparation
Facility Planning
 Power,
Medical Gases, Water, Etc.
 Flood zone
 Material Resources

Communication
 Redundancy
 Contingency
plans
 Incident Command!
Lessons Learned

Workforce issues
 Adequate

staff
Hospital Planning
 Incident
Command
 Education/Training
Special Needs
 Behavior Health

 Patient
& Employee
Lessons Learned

Hospital Security
 Facility
support
 Protective measures


Patient Safety
Mutual Aid
 Public
and private
partners

Medivac
Man-Made Disasters
Unintentional / Accidental

Engineering Failures


Transportation






Planes, Trains, Automobiles,
Shipping
Environmental


Bridges, Buildings, Dams
Oil spills, pollution, waste
runoff
Explosions
Mine disasters
Industrial accidents
War
Fire
Terrorism
Poking
skunks is
dangerous!
Terrorism

The goals of terrorists
are to:
 Create
confusion, fear,
chaos, and mistrust.
 Break down the
physical and political
infrastructure.
 Intimidate, subjugate,
and weaken authority.
HOW WILL OUR ENEMIES FIGHT US?
UNCLASSIFIED
Chemical
Biological
Radiological
A Weapon of Mass Destruction is a
device or material specifically designed
to produce casualties or terror. CBRNE
incidents may result from industrial
accidents, acts of war, or acts of
terrorism.
Nuclear
Energetics /
Explosives
Chemical Agents





Mustard gas
Sarin
Phosgene
Cyanide
Chlorine
Chemical Agents
Industrial Chemicals
Warfare Agents
Choking Agents
 Blood Agents


Blister Agents
 Nerve Agents
Exposure To Chemicals
Routes of exposure
 Inhalation, skin contact, ingestion, injection
Effect depends on dose
 Larger dose: earlier and more severe effects
 Effects may be immediate or delayed
Individual susceptibility varies
 Age, chronic illness, medications
Biological Agents:
Undetectable by human senses +
Prolonged incubation period +
Limited surveillance capability =
Unrecognized exposure
Bio-threats
Biological agents may be:



Bacteria
Viruses
Toxins
They are naturally occurring
and / or can be
bioengineered as Weapons
of Mass Destruction.
Routes of Transmission

Absorption:
 Skin

and mucus membranes
Inhalation
 Respiratory

through air droplets
Ingestion
 Gastrointestinal
through consumption of food or
drink

Injection
 From
needle or other object
Vectors





Letters / packages
Insects / animals
Contaminated food /
water
Contaminated
clothing
Air via aerosol
dissemination device
CDC Category A Agents






Anthrax (Bacillus anthracis)
Botulism (Clostridium botulinum toxin)
Plague (Yersinia pestis)
Smallpox (Variola major)
Tularemia (Francisella tularensis)
Viral Hemorrhagic Fevers (Filoviruses
[e.g., Ebola, Marburg] and Arenaviruses
[e.g., Lassa, Machupo])
Nuclear / Radiological Agents

Any source that emits
radiation
Radiation Exposure
External – deposited on skin
 Internal – inhaled, swallowed, absorbed
through skin, or introduced through
wounds

of radioactive materials –
uptake by body cells, tissues, or organs such
as kidney, liver, and bone
 Incorporation
Symptoms of Radiation
Exposure




Nausea
Vomiting
Diarrhea
Changes in mental
status
Early Detection

Is your key to limiting
potential exposure.

Time is a huge factor
in how much
exposure one could
receive.
Radiation Penetration
Alpha - a
Beta - b
Gamma - g
Image Source http://www.awe.co.uk/
Neutron - n
Dirty Bomb vs. Atomic Bomb

The atomic explosions that
occurred in Hiroshima and
Nagasaki were conventional
nuclear weapons involving a
fission reaction.

A dirty bomb is designed to
spread radioactive material
and contaminate a small
area.
Terrorist Attacks





So called suicide attacks
Unfortunate experience and expertise from
Israel
Use of explosives and shrapnel (bolts, nails,
nuts)
Predominate injury is lung injury (blast injury)
50% of patients who survive to hospitalization
develop ARDS and require mechanical
ventilation
Terrorist Attacks




20 attacks > 10
wounded
Total of 1475
wounded, 92 ICU
admissions, 80
patients requiring MV
52% of patients had
acute lung injury
Blast injury is the
major mechanism
Aschkenasy-Steuer et al Crit Care 2005;9:1186
Terrorist Attacks
1983-2004 all multiple casualty events
 875 patients from 31 events in Jerusalem
 Average of 28 patients per event
 ICU admission 5% (n=43) - of these70%
had blast lung injury
 73% of patients required mechanical
ventilation

Avidan V, J Trauma. 2007 May;62(5):1234-9.
Plausible Scenarios
Trauma – natural or man-made
 Nerve agents – sarin, tabun, VX, soman
 Pulmonary Irritants – phosgene,
ammonia
 Biologic Agents – plague, tularemia,
anthrax, botulism
 Radiologic Events – nuclear weapon,
dirty bomb

Plausible Scenarios
SCENARIO
TIME TO MV
DURATION
OF MV
VICTIMS
NEED FOR MV
Immediate
Days to weeks
< 100
Hemo – pneumothorax,
blast injury, burns
smoke inhalation
Nerve Agent
Immediate
Hours
Up to 1000
Paralysis, bronchospasm,
bronchorrhea
Pulmonary
Irritants
Hours
Days to weeks
Up to 1000
ARDS, pulmonary
edema, airway injury
Biologics
Hours to days
Days to weeks

1000
ARDS, hemorrhagic
pulmonary edema
Radiologic
Days to weeks
Days to weeks
Hundreds
Traumatic lung injury,
sepsis,
Trauma
Rubinson L, Biosecur Bioterror. 2006;4(2):183-94.
Vulnerabilities

Hard Targets

Military instillations
 Government buildings
 Secure Areas

Soft Targets

Hospitals
 Schools
 Churches
Prevention Efforts

Rely on:
 Federal,
State, & Local Law Enforcement
Agencies
 Hospital Hazard Vulnerability Assessments
 Accreditation and Regulatory Authorities
 Diligence, Observation, Reporting
 Safety Committees >>> Performance
Improvement
Probability vs. Impact
NUCLEAR
WEAPON
BIOLOGICAL
AGENT
IMPROVISED
NUCLEAR
DEVICE
POTENTIAL
IMPACT
RADIOACTIVE
MATERIAL
PROBABILITY/LIKELIHOOD
CHEMICAL AGENT
OR TOXIC
INDUSTRIAL
CHEMICAL
Pandemic Influenza
Is it here
yet?
Natural Biologic Threat

What is a pandemic?
 The
spread of disease
over a wide
geographic area
affecting much of the
population
Natural Biologic Threat

Pandemic Influenza
 Increased
morbidity
(sickness) and
mortality (death)
 Social disruption
 Economic disruption
Seasonal vs. Pandemic Flu

Seasonal

Pandemic
 Yearly
 Rarely
 Familiar
 New
virus
 Mild/Moderate
Symptoms
 Very young, very old;
Health problems
 Vaccine available
virus
 Severe symptoms
 Healthy people
 No vaccine
Influenza Disease Characteristics
Inflammation of the respiratory system
 Headache
 Fever
 Chills
 Cough
 Muscle aches
 Several days sick, several weeks
recovering

Pan Flu Stats

Pandemic Influenza
 History
1918
 1957
 1968

 Frequency
50 – 100 million deaths
2 million deaths
1 million deaths
~ every 35 years
 Duration
1 – 3 years
 Worldwide
6 – 9 months, 3 months?
 Waves
1 – 3, 4 – 8 weeks/wave
National Strategy
1. Stop, slow or otherwise limit the spread of a
pandemic to the United States
2. Limit the domestic spread of a pandemic,
and mitigate disease, suffering and death
3. Sustain infrastructure and mitigate impact to
the economy and the functioning of society
U.S. Planning Assumptions
 Attack
rate
 Treatment rate
 Hospitalization
rate
 Case fatality rate
 Pre/asymptomatic
transmission
 Incubation period
35% of population
25% of population
~75% of cases
10% of cases
2% (2% - 50%)
30% - 50% (?)
2 days (1 – 8 days)
Florida Planning Assumptions
 Cases
 Hospitalized (10%)
Surge Beds (130%)
ICU
ICU Ventilator
Surge Ventilators
 Dead (2%)
Florida population: 18.3 million
1st Wave/2nd Wave
Total
3.2 million
6.4 million
320,000
65,000
640,000
48,000
24,000
5,000
64,000
128,000
Plan Components





Rapid Response
Isolation &
Quarantine
Social Distancing
Non-Pharmaceutical
Interventions
Pharmaceutical
Interventions
On-going Planning Issues




Community Interventions
Hospital Planning Support
Alternate Medical Treatment Sites
Mass care with limited supplies and resources
Current Situation
Human Deaths*
353 cases, 221 deaths (62.2% Mortality)
 14 countries

Bird Deaths
150 – 200 million bird deaths
 >50 countries (Asia, Europe, Africa)

*WHO, 24 January 2008
Respiratory Care
Your Role In A Disaster
Healthcare Considerations

Adequate bed space

 ICU
Capability and
Capacity

Workforce reduction
 Options



Pharmaceutical
stockpiles
Material resource
utilization



Continuity of quality
Standard of Care
Command & Control /
Security Plan
Infection Control
Employee and
Community Education
Financial Challenge
Healthcare Considerations

External Influences
 Social
& Economic Disruption
 Mutual aid difficulties
 School and Child Welfare issues

Internal Influences
 Employee Issues
 Single parent families
 Both parents work in health care
 Children sick, parent / employee(s) not working
Hospital Issues






Patient Volume
High-volume demand for
medical attention
Competition for scarce
medical resources
Impact on caregivers
Need for psychological
support
Need for security
Material Resource Management



IV Tubing
Lab Resources
Pharmaceutical
 IV
Fluids
 Antibiotics
 Antiviral
 Vaccine





Mechanical
Ventilators
Medical Gas supply
Food Services
Environmental
Service supplies
Linens
The Gas Source Issue
The Gas Source Issue
 What
is the best source of
oxygen?
 What about home health
agencies and their patients?
 Power is an issue!
Necessary Ventilator Features for
Each Scenario?
Where will mechanical ventilation be
performed?
 Who will perform mechanical ventilation?
 Where will the gas supply come form?
 How long will it last?
 Does the ventilator’s capabilities match the
needs of the patient, skill of the operator?

Necessary Ventilator Features
for Each Scenario?



Most mass casualty injuries result in ARDS
All scenarios except nerve agent exposure
require constant volume delivery, control of
airway pressures, monitoring, alarms, and
control of PEEP and FIO2
When nerve agents result in paralysis – airway
control and short term ventilation – “good air in –
bad air out” may be all that is necessary
Ventilator Characteristics






FDA approved for
adults/peds
Ability to operate without
compressed gas
Battery life 4 hrs
Volume control
CMV and IMV
PEEP to 20 cm H2O




Utilize both high and
low pressure O2
sources
Control of RR, PEEP,
VT, Flow or I:E
Monitor Paw and VT
Alarms
 Disconnect,
apnea,
high/low pressure,
high pressure source
gas disconnect
Ventilator Characteristics






Rugged
Light weight (<10kg)
Easy to use
Gas consumption low
Battery life - long
Easy to trigger




< $10 K
Vendor support and
longevity
Maintenance
Training
Critical Factors




In a MCI – many patients will need ventilation
exceeding not only equipment but staff
capabilities
Likely that critical care RRT will supervise noncritical care RRT and others in care of the
ventilated patients
The ventilator must have adequate alarms and
monitoring
The ventilator must have a simple interface and
be easy to use
Specific Devices
Concerns




Education and
training
Universal response
Decentralization of
supplies and
equipment
Operability in MCI
environments







Safety
Age capability
Compensation
Legal protection
Communications
Vulnerable
Populations
Volunteerism
FEHVR


Florida Emergency
Health Volunteer
Registry, the Florida
Department of Health
online system for health
care providers and other
private volunteers.
https://www.servfl.com/
Medical Reserve Corps

Mission: To augment local community health and
medical services with pre-identified, trained and
credentialed volunteers during emergency medical
operations and vital public health activities.

Purpose: The Florida Medical Reserve Corps (MRC)
Network was established for the purpose of effectively
facilitating the use of health professional volunteers in
local, state, and federal emergency responses in every
county within Florida.
Licensure Renewal Statement

If you are renewing to active status,
would you be available to provide
health care services in special needs
shelters or to help staff disaster
medical assistance teams during times
of emergency or major disaster? □ Yes
Other Issues
Disaster Implications

Communities
 Food,
Water, Shelter
 Power
 Economic
and Social
Disruption
 Child Safety
 Domestic Animals
 Personal Property
Damage
Disaster Implications

Patient Populations
 Food,
Water, Shelter
 Power for medical
equipment
 Medications
 Renal Dialysis
 Increase hospital
surge!
Healthcare Impacts







Road Closures
Hospital Closures /
Evacuation
Workforce Shortage
Resource
Management
HVAC
Water, Food
Sanitation
Supplies Management

Surrounding Issues
 Just-In-Time
Inventory
 Access

Equipment & Supplies
 Vent
Circuits
 Aerosol and Humidity
 Medications
 Oxygen Supplies
 Other Medical Supplies
Infrastructure Support

Mutual Aid Agreements
 Vendor Agreements
 Hospital Agreements
 Government Agreements
Local (i.e. – City, Municipality, County)
 Regional
 State / Inter-State
 Federal

Infrastructure Support

Workforce & Staffing
 Personal
Plan
 PPE



Plant Facilities
Security Plans
Facility Safety
Communication Devices







Phones: cell, satellite,
land based
800 mgHz / MED Radios
Pagers
Overhead paging
systems
Dispatcher
Email
HAM Radio
Special Populations
This is an everyday
issue for hospitals on
a small scale. We
need to plan to
support large
numbers of persons
who are hard to reach
or have disabilities.
Deadly Misconceptions

“It won’t happen
here”

It won’t happen to
me”

“Someone else will
take care of it”
Q & A?
Thank You!
Acknowledgements
The 2008-2009 Florida State Working Group Ventilator Capability Team members are:















John Wilgis, MBA, RRT - Florida State Working Group Ventilator Capability Team Chair, Director, Emergency
Management Services, Florida Hospital Association
Melanie McDonough, MSHS, RRT - Florida State Working Group Ventilator Capability Team, Education SubGroup Chair, Director of Clinical Education, Cardiopulmonary Sciences, University of Central Florida
Scott Kirley, RRT - State Working Group Ventilator Capability Team, Equipment Sub-Group Chair, West Centrak
Florida Disaster Services, Inc.
Mary Martinasek, MPH, RRT-NPS, RPFT, AE-C - Florida State Working Group Ventilator Capability Team,
Response Sub-Group Chair, American Public Health Student Assembly- Secretary
Kris-Tena Albers, ARNP, CNM, MN - Florida State Working Group Ventilator Capability Team Liaison, Public
Health Preparedness Hospital Liaison, Florida Department of Health
Dr. Jennifer Bencie Fairburn, MD, MSA, Director, Division of Emergency Medical Operations, Florida
Department of Health
Dr. David V. Shatz, MD, FACS - Professor of Surgery, Trauma Surgery/Surgical Critical Care, University of Miami
Paul Stephan, MPS, RRT - Program Director, Respiratory Care, Santa Fe Community College
Randy De Kler, MS, RRT - Program Director, Respiratory Care, Miami Dade College
Phil Khan, RRT - Florida Society for Respiratory Care
Sandra J. Barker, MS, RRT - Director, Cardiopulmonary Services, Largo Medical Center
Timothy J. Coons - Director, Cardio-Pulmonary Services, Shands Hospital at the University of Florida
Bill Cunningham, BS, RRT - Adult Critical Coordinator, Cardiopulmonary Services, Shands Hospital at the
University of Florida
Joseph Albino, BS, RRT - Manager, Respiratory Care, Mease Dunedin Hospital
Kelly Sebree, RRT, NPS - Director, Respiratory Care, Lawnwood Regional Medical Center
References:
Anonymous. (2006). Ventilation for Life – Mechanical ventilators in Mass
Casualty Incidents. AARC Times. 30(3), 8-11.
Anonymous. (2007). List of Disasters. Wikipedia. The Free encyclopedia.
Retrieved 8/14/07 from: http://en.wikipedia.org/wiki/List_of_disasters
Barnett, D.J., Balicer, R.D., Blodgett, D. Fews, A.L., Parker, C.L., Links, J.M.
(2005). The Application of the Haddon Matrix to Public Health
Readiness and Response Planning. Environmental Health
Perspectives. 113(5), 561-566.
Branson, R. (2007). Augmenting Positive Pressure Ventilation Capacity. AARC
Summer Forum Journal Conference Presenation.
Bunch, D. (2006). Are We Ready for the Worst? AARC Times. 30(3), 36-44.
Committee Working Document. (May 2005). Florida HRSA National
Hospital Bioterrorism Preparedness Program FY05 Projects.
Carlton, P.K. (May 30, 2007). A Culture of Preparedness. Texas A&M
University. Health Science Center. Retrieved June 30, 2007 from:
www.tamhsc.edu/homeland/
References:
Florida Hospital Association. (May. 2005). Eye of the Storm: Impact of the 2004
Hurricane Season on Florida Hospitals. Retrieved 6/30/07 from:
http://www.fha.org/protected/hospitalpreparedness.html
Hall, B. (2007). Dirty Bombs. Eastern Shore (VA) Health District. Retrieved from
personal email.
Rubinson, L., O’Toole, T.O. (2005). Critical care during epidemics. Critical Care.
Vol. 9. BioMed Central Ltd. Published on-line 4/27/2005 at
http://ccforum.com/inpress/cc3533
Rubinson, L., Nuzzo, J., Talmor, D., O’Toole, T., Kramer, B., Inglesby, T. (2005).
Augmentation of hospital critical care capacity after bioterrorist attacks or
epidemics: Recommendations for the Working Group on
Emergency
Mass Critical Care. Critical Care Medicine. 33(10), E1-13.
State of Florida, Department of Health, Division of Emergency Medical
Operations. Office of Public Health Preparedness (2007). Working
Together for a Safe and Secure Future: Florida Public Health and
Medical Preparedness Strategic Plan 2007 – 2010. Retrieved June 30,
2007 from Florida Department of Health.
References:
State of Florida, Division of Emergency Management. (2007). Public
Information. Retrieved June 30, 2007 from: www.floridadisaster.org
Tynan, B. (2007). Pandemic Influenza: Healthcare Planning. Florida Department
of Health. Retrieved through personal email.
U.S. Department of Health and Human Services. (2007). Federal Planning &
Response Activities. Retrieved 7/1/07 from:
http://www.pandemicflu.gov/plan/federal/index.html
U.S. Department of Health and Human Services. (2007). State and Local
Government Planning & Response Activities. Retrieved 7/1/07 from:
http://www.pandemicflu.gov/plan/states/index.html
U.S. Department of Homeland Security, Federal Emergency Management
Agency (2007). Introduction to Incident Command System. Emergency
Management Institute. Retrieved 6/30/2007 from:
http://emilms.fema.gov/