Disaster Medicine and the Emergency Medicine Resident

Transcription

1 EDUCATION/RESIDENTS PERSPECTIVE Amy H. Kaji, MD Joseph F. Waeckerle, MD From the Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, CA (Kaji), and the Department of Emergency Medicine, University of Missouri Kansas City School of Medicine, Kansas City, MO (Waeckerle). Dr. Waeckerle is Editor Emeritus of Annals of Emergency Medicine. Copyright 2003 by the American College of Emergency Physicians /2003/$ doi: /mem Disaster Medicine and the Emergency Medicine Resident [Ann Emerg Med. 2003;41: ] INTRODUCTION A disaster is defined as a natural or manmade event that results in an imbalance between the supply and demand for existing resources. 1 Although disasters are routinely characterized by certain characteristics (Table 1), each is unique. 2 Natural disasters, including floods, earthquakes, hurricanes, and tornadoes, occur regularly. During the past 20 years, such natural disasters have caused the deaths of at least 3 million people and incurred more than $50 billion in property damages. 3 Manmade disasters include technical accidents and structural collapses, chemical incidents, and nuclear-radiation incidents. In the United States, there are 60,000 chemical spills, leaks, and explosions, with more than 300 deaths per year. 4 Acts of terrorism, defined as the unlawful use of force or violence against persons or property to intimidate or coerce a government of civilian population in the furtherance of political or social objectives, are now a real threat (Nuclear, Biologic, and Chemical Domestic Preparedness Training Hospital Provider course, instructor guide, 1997). Conventional weapons, bombs and bullets, remain the weapons of choice because of their availability and familiarity. However, more than 20 nations currently have chemical and biological weapons, including Iran, Iraq, Libya, North Korea, and Syria. The outcome of the use of these weapons is staggering, whether these states support terrorist groups or lone individuals. Historical examples of terrorist attacks include the Oklahoma City bombing, the attack on the World Trade Center in 1993, Aum Sinrikyo s use of Sarin gas in the Tokyo subway in 1995, the 1996 car bombing at Khobar Towers, the 1998 attacks on US embassies in the Horn of Africa, and the events of September 11, The recent anthrax incidents in the United States demonstrated the power of even limited use of bioagents. Not only did the unfortunate 22 patients suffer or die, the overarching fear of contagion paralyzed our country into a standstill. The events of September 11, 2001, and the unprecedented bioterrorismrelated anthrax cases highlight the importance of disaster preparedness and response. Lessons learned from prior disasters provide perspective on the current threats and misconceptions in disaster medicine. JUNE :6 ANNALS OF EMERGENCY MEDICINE 865

2 Table 1. Characteristics of disasters. Characteristic Natural Manmade No. of locations/occurrences Single site/single occurrence Single site/multiple occurrences >1 site/single occurrence Tornado >1 site/multiple occurrences Terrorism Predictability Fairly predictable Unpredictable Onset Gradual Sudden Duration Brief Extended Frequency Common Rare Extent of damage To people To property cal for the emergency physician to receive disaster preparedness training. However, disaster medicine presents difficult challenges for the emergency medicine resident. It is an area of emergency medicine that has recently received much publicity, and residency-trained emergency physicians may be expected to have had training in disaster management in this post September 11, 2001, era. Yet, few residents will ever have direct exposure to a disaster. This paper elucidates misconceptions about disasters and highlights features of a comprehensive disaster plan that will hopefully provide emergency medicine residents with a better conceptual framework for disaster planning and response. MISCONCEPTIONS There are numerous misconceptions regarding disasters. Many assume that disaster planning requires a Example Earthquake, volcanoes, hurricanes, tornadoes, temperature extremes, floods Acts of terrorism and war, transportation accidents, structural collapses, hazardous materials accidents, fires, explosions Airplane crash Earthquake and aftershocks Floods Earthquake Hurricanes Coal mine explosion Structural collapse Hazardous materials accident Tornado (in season) 100-year floods Hotel fire Wildfires Confusion over roles and responsibilities, poor communication, lack of planning, suboptimal training, and a lack of hospital integration into disaster planning are some of the major problem areas identified in previous disasters. More than any other medical specialist, emergency physicians are expected to alleviate suffering, allocate resources, and bring order to the chaotic environment that is inevitable in any disaster because they are practiced in rapid assessment, basic treatment, and triage. As the final receiving area for all patients, the emergency department is responsible for the triage, stabilization, decontamination, and treatment for all disaster victims. In addition, unlike other areas of the hospital, EDs can expect increased patient volumes for 2 to 3 months after a disaster. 5 The emergency physician interfaces with the emergency medical services (EMS), the community, and the hospital, and it is therefore critilarge mobilization of resources and personnel. 6 Yet, most disasters in the United States are not of extraordinary magnitude, and there have only been 7 US civilian disasters with fatality rates exceeding 1, In fact, most disasters are of moderate size, within 100 to 200 casualties. 2 In addition, the medical care component of the disaster response is usually over in a few hours. 2 Until now, federal and state aid has not been available for 24 to 48 hours, although federal agencies have long realized the importance of faster response times. Thus, all disasters require planning at a local level. That is, all disasters are local events and all communities must be self-sufficient for 24 to 48 hours. As such, every hospital, along with other critical components of the response effort, must be integrated into the disaster plans. Funds must be allocated for state and local responders, so that each and every hospital and local response team is prepared to perform the initial critical interventions. 7 Many of the logistic problems faced in disasters are not caused by shortages of medical resources but rather from failures to coordinate their distribution. 8 In fact, large numbers of unsolicited and unannounced personnel arrive at the scene or ED to offer assistance. Convergent volunteerism and altruism compound the disaster because response organizations are rarely prepared for the quantity of volunteers that appear. Many volunteers forget the principle of personal safety and endanger themselves. When a responder is injured, it adds another casualty and only compounds the problem. Additionally, most inexperienced volunteers have never used the disaster triage tagging system and are uncomfortable receiving orders from the chain of command implemented during the disaster. The end result is disorganization and inefficiency. 866 ANNALS OF EMERGENCY MEDICINE 41:6 JUNE 2003

3 form this procedure because they are busy at the site of release. Failing to train ED personnel in patient decontamination may place the hospital staff and facility at risk for secondary contamination. Having a written disaster plan does not equal preparedness. Unfortunately, the mere existence of a disaster plan may create a false sense of security. The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) mandates that all accredited hospitals in the United States have a written disaster plan, and many assume that the Incident Command System (ICS) is understood and in place in hospitals. 10 However, very few hospitals have emphasized the importance of integrated plans, and very few hospital disaster planners have actual experience. The alternative to first-hand experience is the disaster drill, which may range from rehearsals on paper to realistic scenarios with simulated patients. If they are planned carefully, drills may prompt an evaluation of the response plan and help train personnel in disaster medicine. However, health care workers and administrators may not appreciate the importance of maintaining a viable disaster plan and regularly conducting disaster drills, because disasters are low probability events, and the cost of maintaining readiness is high. In fact, the published literature demonstrates that hospitals are inadequately prepared. A 1995 nuclear, biologic, and chemical exercise in New York City determined that the first 100 responders to arrive at the scene would be killed because they are not adequately trained to deal with this type of situation. Similar results occurred in a 1997 exercise in Salt Lake City. In a survey of 45 hospitals in California, two thirds thought they had personal protective equipment. Yet, only 2 of the 45 hospitals Institutions are often ill prepared for the hundreds of blood donors that appear, especially when there are no shortages of blood. Ironically, vital personnel are diverted to process unneeded blood donations, and the surplus of volunteers are allocated in an inefficient manner. 9 It is therefore critically important to coordinate the efforts of both private and public sectors and to integrate local, regional, and federal resources into the disaster plan. Many hospitals incorrectly assume that all of the disaster victims will arrive by ambulance after being decontaminated, triaged, and stabilized by out-of-hospital personnel. In fact, most victims usually arrive on foot or by personal vehicles and go to the nearest hospital within 1.5 hours of the disaster (Nuclear, Biologic, and Chemical Domestic Preparedness Training Hospital Provider course, instructor guide, 1997). The closest hospital usually receives the greatest number of patients, while other hospitals in the area receive few, if any disaster victims. In 29 recent mass casualty disasters, 67% of the victims were treated at 1 hospital. 6 Hospitals are therefore often unprepared not only for the number of patients but also for the patients who have not received any out-of-hospital care. Most of these individuals will only have minor injuries, but will consume most of the bed space and personnel before the arrival of the more critical patients. During incidents involving hazardous materials, 18.5% of the victims are treated at the scene of the incident, whereas 64% are transported to the hospital for definitive care (Nuclear, Biologic, and Chemical Domestic Preparedness Training Hospital Provider course, instructor guide, 1997). Although hospitals depend on fire personnel to perform patient decontamination, fire personnel are often unable to peractually had protective equipment assigned to the ED. 11 In a questionnaire published in the American Journal of Public Health in May 2001, fewer than 20% of respondent hospitals had plans for biological or chemical weapons incidents, and only 12% had 1 or more self-contained breathing apparatuses. 12 Although the US government has developed a Domestic Preparedness Program to aid local emergency response agencies, there is clearly a gap between federal efforts and the current state of preparedness at the level of individual hospitals. Federal planners must therefore confront these deficiencies in local preparedness. Finally, many assume that physicians and nurses should be at the disaster scene to immediately treat the casualties. In fact, medical rescue personnel perform best at tasks that are familiar to them. 2 Thus, physicians and nurses should be used to staff the hospitals where they work most efficiently. The disaster scene is not the pristine setting of a hospital ED, and it presents vastly different challenges. Unless specially trained in the field of search and rescue, EMS, or disaster response, physicians and nurses are ill-equipped to function effectively at a disaster scene. PLANNING Integration With the Community Because hospitals do not function in isolation, it is essential for out-ofhospital and hospital disaster plans to be integrated into the community disaster plan. By working together, government authorities, community leaders, EMS, law enforcement, and hospital disaster planners can develop an effective approach to disasters and mass casualty events. The emergency physician plays a crucial role in disaster planning, JUNE :6 ANNALS OF EMERGENCY MEDICINE 867

4 because the ED interfaces with EMS, the community, and the hospital. A survey performed in 1994 showed that hospitals were better prepared when the medical directors of the ED participated in the community planning. 13 Disaster planning requires a comprehensive risk assessment and vulnerability analysis. Studies have identified variables that predict the likelihood of injury (Table 2). 2 It is important to identify the most likely disaster threats to one s particular hospital and community, according to the environment, and aim to be prepared for the most likely scenarios. Thus, earthquakes are a relevant threat to Californians, whereas hurricanes and tornadoes remain a real threat to other areas of the country. Industrial facilities, military bases, storage depots, and nuclear plants are some of the potential targets of terrorists, and risk and vulnerability analysis should be done for such attacks as well. Each disaster is unique, and a disaster plan must account for an appropriate response to each of the different types of disasters. Table 2. Variables used to predict the potential injury from a disaster. Variable Community resources Medical resources Community disaster plan Advance warning Population Time of day Weather conditions Geographic location Accessibility of disaster site Secondary catastrophic events and after-effects Levels of Response Disasters can be classified according to the level of resources needed to meet the demands. A Level 1 emergency requires an escalated response by the local EMS system in cooperation with current agencies. A Level 2 incident requires a more regional response, whereas a Level 3 disaster necessitates the involvement of state and federal authorities to cope with massive and widespread destruction. 2 However, all disaster responses start with the local response. Thus, activation and escalation of the response plan must be defined and communicated clearly. Management System and Command Structure Governed by the concept of a unified command, the ICS is a management system designed to ensure a cooperative and effective response to a crisis. The ICS incorporates all community and local agencies. There are 5 functional groups in the ICS: command staff, operations, planning, logistics, and finance. The com- Questions Are there public safety agencies, specialized equipment/aid from the private sector, communications systems, support services, and shared resources? Is there an emergency medical system, adequate transportation, a response team of physicians, adequate medical facilities, supplies and equipment, and shared resources? Is there a plan in place? Is it comprehensive? Is it accepted and understood? What is the duration of advance warning and the possible preparation? What is the population density and are there high-risk groups (extremes of age and the existence of comorbid illnesses)? Did the disaster happen during daylight hours or at night? What is the ambient temperature and precipitation? Is there wind? Did the disaster occur in an urban, suburban, rural, or wilderness location? Is it easily accessible or inaccessible? Are there secondary casualties and effects? mand staff is responsible for the overall management of the incident. The operations section carries out directions for the command staff, while the planning section collects and evaluates all of the information and provides information to the command and operations sections. The logistic section is responsible for supplies, equipment, personnel, and facilities. Finally, the finance section authorizes and analyzes all expenditures during the response phase. 2 There is a hospital ICS as well, and realizing its benefits during a crisis requires that hospital personnel understand how it works. Supplies, Equipment, and Designated Areas It is important to prepare an up-todate inventory of supplies and capabilities of the hospital. A basic plan will address how increased numbers of patients will be triaged, stabilized, decontaminated, and ultimately treated. If training, equipment, or supplies are lacking, as is usually the case in today s austere financial environment for hospitals, these deficiencies should be addressed. Hospitals will need to parallel the community plan by having enough food, resources, and medical supplies to be self-sufficient for 48 to 72 hours. Hopefully, the federal government s commitment to provide rapid response teams and such critical supplies through the national pharmaceutical stockpile program will remedy these issues. Preparation, however, is the best plan. The recent anthrax scare demonstrates the need for hospitals to evaluate antibiotic and vaccine supplies as well as the ability to expand capacity. Certain areas should be designated for contaminated and decontaminated patients, as well as for contaminated waste. 868 ANNALS OF EMERGENCY MEDICINE 41:6 JUNE 2003

5 Communication Lessons from past disasters show that effective communication is critical. Ideally, the central command center will communicate with all local and regional hospitals, and these facilities in turn will continually keep the command center informed of their bed and resource availability. Knowledge of hospital capabilities will help guide response leaders and out-of-hospital care providers to direct victims to the most appropriate facility. However, the Disaster Research Center only found evidence of communication between the disaster site and any ambulance or hospital in 33% of disasters. 6 The lack of communication probably resulted in the most problems during the attack on September 11, 2001.Because of the early destruction of the communication tower, telephone communication by cellular telephone and landline were nonexistent. There was therefore no means of communication between many of the ambulances and central dispatch, and many patients were taken to the nearest hospital without any knowledge of the availability of resources. Whereas staff at St. Vincent s and New York University Downtown Hospital worked under difficult conditions, health care professionals at St. Luke s-roosevelt Hospital, a trauma center only 3 miles away from the World Trade Center, saw little increase in their census. 14 In any disaster, an emergency backup telephone and redundant communication systems, such as a 2-way radio network, should be in place. Preparation of Treatment Guidelines The most common terrorist weapon is the explosive, because bombs are relatively simple to manufacture, and all of the required ingredients are accessible to the general public. 15 Every community is susceptible to a terrorist bombing. The hospital staff should be familiar with the management of the various types of injuries sustained by victims, such as blast injury, crush syndrome, compartment syndrome, particulate inhalation, and traumatic asphyxiation. 15 First responders may become secondary victims, so hospitals must be prepared to treat all involved parties. Hospital staff must maintain basic treatment guidelines for the types of nuclear, biologic, and chemical events likely to be seen. There are a wide variety of organisms that may present a threat, and these include anthrax, plague, smallpox, viral vectors that cause viral hemorrhagic fevers, and biological toxins such as botulism and staphylococcus enterotoxin B. Summarizing this information on treatment cards or posters may help streamline the delivery of medical care. A system whereby the public can also be educated rapidly regarding exposure and transmission risk of disease processes would be helpful. This requires cooperation and coordination with the local media who can educate, inform, and comfort the community. Disaster Drills In accordance with Occupational Safety and Health Administration standards and regulations, a hospital disaster plan includes policies to handle chemically contaminated patients and education about personal protective equipment, patient decontamination, hazardous materials emergency response training, and knowledge of antidote therapy. JCAHO recently expanded the requirements of hospital preparedness, and it now mandates the performance of an annual evaluation of the emergency preparedness plan s objectives, scope, performance, and effectiveness in the form of at least one community-wide practice drill per year. RESPONSE Triage Triage is an ongoing process that is based on the likelihood of survival with the resources available at the time. 2 Appropriate triage is the most important medical task performed at the disaster site. Medical personnel must understand that the philosophy of care on site differs from the care that is usually rendered to an individual patient. The natural instinct to deliver as much care as needed for each patient may be harmful, as medical resources, personnel, supplies, and facilities must be allotted to provide the greatest good for the greatest number. 2 The second stage in the triage process occurs at casualty collection points, where more definitive triage, stabilization, and treatment are provided before patients are definitively evaluated. The level of care offered is determined by the availability of hospitals and the presence of personnel, equipment, and supplies at the collection point. 2 The third and final stage of triage occurs at the hospitals. After evaluation by the emergency physician, patients are assigned to predesignated areas where they will receive definitive care. Law Enforcement In every aspect of disaster management, law enforcement should be integrated. For both manmade and natural disasters, members of law enforcement will provide order and direction in a time of chaos. During terrorist events, law enforcement takes on an even more critically important role because such events require retribution and justice. Every JUNE :6 ANNALS OF EMERGENCY MEDICINE 869

6 single injury, lost life, and damaged piece of property serve as links in the chain of evidence. Thus, the importance of accurate record keeping can not be overstated. Record Keeping Accurate record keeping is also important to identify patients, their location, and disposition. On presentation, records should include a description of the patient and the patient s name (if available), as well as the type of injuries, triage classification, initial care rendered, and disposition. Further documentation may be performed at casualty collection points. At the hospital, medical records staff can collect more detailed information to assist in locating victims and notifying families. The Postdisaster Recovery Period During the recovery phase of a disaster, the focus shifts from acute injury to the everyday needs of the population. The hospital will need to be prepared for the effected population to have increased needs for medication, shelter, food, water, clothing, and emotional support. Patients from a disaster further impose on a medical system that must also meet the typical day-to-day medical needs of the population. Hospitals will need to be stocked with basic chronic care medications in addition to the supplies that are required to treat acute illnesses and injuries. Disasters also heavily affect victims emotionally and psychologically; thus, any comprehensive disaster plan should incorporate a critical incident stress management program for both responders and victims. 16 In summary, all hospitals represent a vital disaster resource to their respective communities, and each and every hospital must be integrated into a disaster plan. After any disaster, victims will be taken to EDs regardless of the institution s level of preparedness. True preparedness to reduce morbidity and mortality after a disaster depends on the availability of resources at the local level. The federal government must address the large deficiencies that currently exist in local preparedness. In turn, hospital personnel and emergency care providers must expand their scope of services in order to care for disaster victims. This will require hospitals to plan and prepare, including stockpiling medical supplies, antibiotics, antidotes, various levels of personal protective equipment, and committing to train appropriate staff. Because of the unconventional threats of today s world, special teams may need to be assembled that have unique knowledge and training in nuclear, biologic, and chemical weapons, decontamination, and antidote therapy. Hospital personnel will benefit from didactics on explosives and on nuclear, biologic, and chemical threats. Disaster drills should be performed on a regular basis, and emergency and backup communication systems must be in place. Procedures will be needed to integrate the large numbers of unsolicited volunteers and donations into the disaster plan. A general knowledge of the epidemiology of the morbidity and mortality caused by disasters can be helpful in determining what relief supplies, equipment, and personnel will be required in future emergency situations. It is therefore critically important for emergency medicine residents to receive training in disaster planning and management in this post September 11, 2001, era. We should take advantage of the heightened awareness for disaster preparedness and ascertain that we are ready for the next inevitable disaster. The authors report this study did not receive any outside funding or support. Address for reprints: Amy Kaji, MD, 1000 West Carson Street, Box #21, Torrance, CA 90509; akaji@emedharbor.edu. REFERENCES 1. Noji E. Disaster epidemiology. Emerg Med Clin North Am. 1996;14: Waeckerle J. Disaster planning and response. 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