Disasters follow o rules: Preparig your hospital for disaster respose Toy Forgioe, lp O October 18, 1989, a earthquake, registerig 6.9 o the momet magitude scale, hit the Sa Fracisco Bay Area of Califoria. The quake lasted oly 15 secods, but caused severe structural damage throughout the Bay Area, icludig the collapse of portios of double-decker highways, packed with commuters. Sixty-three people were killed ad 3,757 were ijured i the disaster. LEARNING OBJECTIVES Evaluate a hospital s ability to meet disaster preparedess requiremets Uderstad your role as a medical professioal i a disaster sceario Compare ad cotrast differet types of disasters ad their impact Evaluate the chai-ofcommad structure durig a mass casualty icidet Recogize the challeges a hospital will face durig a sustaied surge Associatio of Surgical Techologists For reprit permissio: publicatios@ast.org OCtOber 2008 The Surgical Techologist 445
298 OCtOber 2008 3 Ce Credits Disasters ca be divided ito two major categories: atural disasters, which iclude hurricaes, earthquakes ad floods; ad mamade disasters, such as idustrial catastrophes ad terrorism. No oe ca predict the complexity, time or locatio of the ext disaster, however, mamade disasters, especially those ivolvig terrorism, have prove to be the most challegig disaster threat for medical providers due to the upredictability of the icidet ad the umber of casualties ivolved. Today s terrorists have a wide spectrum of threats available to them. They do ot ecessarily have to kill people to achieve their goals. They just have to create a climate of fear ad paic that will overwhelm the health care system. A prime example is the Sara gas attack i Japa i 1995. Of the 5,000 admissios to hospital emergecy departmets, oly aroud 500 patiets were actually sufferig from the physical effects of Sara. The remaiig patiets were all sufferig from psychological stress related to the icidet. 1 WhAT IS A MASS CASUALTy INCIDENT? O April 19, 1995, a 5,000-poud truck bomb detoated i frot of the Alfred P Murrah Federal Buildig i Oklahoma City, just after 9 a.m. The blast damaged or destroyed 324 buildigs withi a 16-block radius, creatig a crater 30-feet wide ad eight-feet deep. There were 168 fatalities ad 853 people ijured i the explosio. A mass casualty icidet (MCI) is a evet that produces eough casualties to disrupt the ormal fuctioal capacities of the affected commuity. The severity ad diversity of ijuries, i additio to the umber of victims, is a major factor i determiig whether or ot a MCI will overwhelm the local medical ad public health ifrastructure. There is a myth that all disasters are differet, but the reality is that there are commo, basic medical ad public health issues shared by all disasters, regardless of their etiology. A Natioal Guardsma ad a firema work side by side i the aftermath of the Oklahoma City bombig. FEMA The Surgical Techologist OCtOber 2008 446 Associatio of Surgical Techologists For reprit permissio: publicatios@ast.org
Medical issues iclude: Search ad rescue Triage ad iitial stabilizatio Defiitive care Evacuatio Figure 1. Triage tag. Public health issues iclude: Water Food Shelter Saitatio Trasportatio Commuicatio Edemic ad epidemic disease Security ad safety 1 Search ad Rescue Local populatio ad assets close to the disaster are the iitial search ad rescue resources. I disasters ivolvig large umbers of victims trapped i collapsed structures, the local respose may be haphazard. O September 11, 2001, two hijacked airliers were flow ito the World Trade Ceter i New York City, i the worst terrorist attack i US history. A third hijacked aircraft crashed ito the Petago i Washigto, DC, ad a fourth, believed to be targetig either the US Capitol Buildig or the White House, crashed i a field i Pesylvaia. All told, 2,998 people lost their lives ad more tha 6,000 were ijured. May coutries have specialized search ad rescue teams as a itegral part of their disaster respose pla. These teams cosist of a cadre of medical specialists ad techical specialists kowledgeable i hazardous materials, structural egieerig, heavy equipmet operatio ad techical search ad rescue methodology, icludig sesitive listeig devices ad remote cameras. There are also traied caies ad their hadlers. 1 Triage ad iitial stabilizatio Triage is the most importat missio i a disaster respose sceario. Disaster triage is differet tha covetioal medical triage i that covetioal triage provides the greatest good for the patiet, while disaster triage provides the greatest good for the greatest umber of patiets. Disaster triage requires the respose teams to prioritize ad categorize the casualties, allowig for timely rescue, treatmet ad evacuatio i a orderly fashio. They must also optimize the use of available medical, ursig ad emergecy persoel at the disaster site. Fially, they must optimize the use of available logistical support ad equipmet. There are differet levels of disaster triage. The level will be determied by the ratio of casualties to available resources. Durig o-site triage, patiets are characterized as acute or oacute ad are labeled red, yellow or gree, respectively, based o the extet of their ijuries ad the resources at had. Durig medical triage, rapid categorizatio of victims at the casualty site is essetial, ad should be completed by the most experieced medical persoel available. Victims are color-coded (uiversal amog most emergecy medical services) accordig to the severity of their ijuries: Associatio of Surgical Techologists For reprit permissio: publicatios@ast.org OCtOber 2008 The Surgical Techologist 447
Methods of Evacuatio Method Groud Small Aircraft Large Aircraft Red (immediate) is used to label those who caot survive without immediate treatmet, but who have a chace of survival. Yellow (observatio) is for those who require observatio (ad possible later re-triage). Their coditio is stable for the momet ad they are ot i immediate dager of death. These victims will still eed hospital care ad would be treated immediately uder ormal circumstaces. Gree (wait) is reserved for the walkig wouded who will eed medical care at some poit, after more critical ijuries have bee treated. Black (expectat) is used for the deceased ad those whose ijuries are so extesive that they will ot be able to survive give the care that is available. 2 Cost/Beefit Ratio Simple ad geerally available Iefficiet (low trasport capacity) May remove critical resources High cost ad complexity Iefficiet (low trasport capacity) Difficult to provide advaced care Aircraft may be better-utilized i disaster area Very high cost ad complexity More efficiet (medical crew ca maage multiple casualties over log distaces) Possibility of retrograde airlift (use of aircraft to brig supplies to disaster area) I a disaster sceario, all patiets should be brought to a casualty collectio site, which should be located close eough to the disaster site for easy casualty trasfer, but far eough away to be safe. The collectio site should be large eough to adequately hadle the umber of victims of the disaster. Collectio sites should ot, ideally, be o hospital property ad should be located a safe distace from ay hazards, upwid ad uphill from cotamiated areas ad sheltered from the elemets. 1 Defiitive medical care Defiitive medical care improves, rather tha just stabilizes, the casualty s coditio. It varies widely, depedig o the magitude of the disaster, umber of casualties ad resources at had. Both small ad large-scale mass casualty icidets may require the mobilizatio of specialty medical teams to participate i the field medical respose or supplemet resources i the disaster regio. Defiitive care ca be provided i either a fixed facility, such as a existig hospital or buildig, or a mobile facility, such as a free-stadig field hospital. However, lessos i surge capacity maagemet leared i the Iraq War may chage the way certai civilia MCIs are approached. Specifically, Iraq s experiece with damage-cotrol (emergecy) surgery has show that more patiets lives ca be saved through temporizig damage-cotrol surgery tha if patiets received time-cosumig defiitive surgery. 3 Evacuatio Evacuatio is useful i a disaster as a meas of decompressig the disaster scee, removig the patiets who are cosumig the most resources. Evacuatio of seriously-ijured casualties to offsite medical facilities ot oly improves their care, but also allows icreased attetio to remaiig casualties at the disaster site. Mass Casualty Icidet Respose O August 29, 2005, Hurricae Katria made ladfall i Southeaster Louisiaa. The high wids ad uprecedeted raifall proceeded to batter the Gulf Coast, causig early every levee i metro New Orleas to breach, floodig 80 percet of the city. The storm left 1,836 cofirmed dead ad 705 missig. Respose to a mass casualty icidet ivolves may differet orgaizatios with differet commad structures ad missios simultaeously participatig i the disaster respose. For example, the New York City Police ad Fire Departmets, New York ad New Jersey Port Authori- The Surgical Techologist OCtOber 2008 448 Associatio of Surgical Techologists For reprit permissio: publicatios@ast.org
ties, state police, FBI, Natioal Guard ad the US Coast Guard, amog others, were all o had for the search ad rescue effort after the World Trade Ceter attack o September 11. A mass casualty respose eeds to have a cosistet approach to disasters based o a uderstadig of the commo features of disasters ad the respose expertise required. A key compoet that has brought about this cosistet approach is the icidet commad system (ICS). INCIDENT COMMAND SySTEM (ICS) O April 16, 2007, a shootig icidet occurred o the Virgiia Tech campus i Blacksburg, Virgiia. The shooter etered two campus buildigs, where he killed 33 studets ad faculty, icludig himself, ad ijurig 26 others. The icidet is the greatest shootig rampage by a sigle guma i US history. S.T.A.R.T. The simple triage ad rapid treatmet (START) system was developed to allow first respoders to triage multiple victims i 30 secods or less, based o three primary observatios: respiratio, perfusio ad metal status. It allows rescuers to locate the most severely-ijured patiets i the least amout of time. As more ma power ad other resources arrive o the scee, the patiets will be re-triaged for further evaluatio, treatmet ad trasportatio. Triage tags are the easiest way to desigate a patiet s status o the disaster scee. The most commo types of tags are either colored paper tags or colored surveyors tape. There are four desigated colors for triage tags: Mior Delayed Immediate Dead Delayed care/ca delay up to three hours Urget care/ca delay up to oe hour Immediate care/lifethreateig Victim is dead/o care required The first step i a disaster settig is to tell all the people who ca get up ad walk to move to a specific area. If patiets ca get up ad walk, they are probably ot at risk of immediate death ad are idicated with a gree tag. However, if a patiet complais of pai o attemptig to walk or move, do ot force them to do so. After clearig the gree/mior patiets, begi movig from where you stad. Work your way through the remaiig victims i a systematic maer. Each assessmet should take o loger tha oe miute. The cetral poit of disaster triage is to fid ad tag the patiets that require immediate care. Evaluatio The START system is based o three observatios: respiratio, circulatio ad metal status. Respiratio: If the patiet s breathig rate is greater tha 30 breaths per miute, a red/ immediate tag is used. This respiratory patter is idicative of the primary sigs of shock ad eeds immediate care. If the patiet is ot breathig, clear the mouth of obstructios ad tilt the head to ope the airway. Positio the patiet to maitai the airway. If the patiet breathes, tag as immediate. Patiets who require assistace to maitai a ope airway are also tagged as red/immediate. If you are usure of a patiet s ability to breathe, use a red/immediate tag. If the patiet is ot breathig ad does ot start to breathe with simple airway maeuvers, tag as black/dead. While certai steps i this process may cotradict stadard cervical spie guidelies, they may be igored durig a mass-casualty triage situatio. This is the oly time i emergecy care whe there may ot be time to properly stabilize every ijured patiet s spie. If the patiet is breathig at a rate of less tha 30 breaths per miute, the ext step i the 30-secod evaluatio is circulatio. Circulatio: The best method for checkig circulatio is takig the radial pulse. If it is abset or irregular, the patiet should be tagged red/immediate. If the radial pulse is preset, move o to evaluate the patiet s metal status. Metal status: Metal status ca be evaluated through the patiet s ability to follow simple commads, such as ope your eyes or squeeze my had. If the patiet ca follow these commads ad exhibits adequate breathig ad circulatio, he or she is tagged as yellow/delayed. A patiet who is uresposive to verbal stimuli is tagged as red/immediate. Follow up This system is desiged to fid the most seriously ijured patiets. As resources become available, patiets will be re-triaged for further evaluatio, treatmet, stabilizatio ad trasportatio. Keep i mid that ijured patiets do ot remai i the same coditio. Coditios may deteriorate over time, ecessitatig a patiet to be upgraded i status. As time ad resources permit, patiets should be re-evaluated as ofte as possible. Refereces 1. CERT Los Ageles. Simple Triage ad Rapid Treatmet. March 26, 2003. Available at http://www.cert-la. com/triage/start.htm. Accessed: September 2, 2008 Associatio of Surgical Techologists For reprit permissio: publicatios@ast.org OCtOber 2008 The Surgical Techologist 449
Medics receive a patiet from a Coast Guard helicopter durig the Hurricae Katria disaster. The ICS provides a commo orgaizatioal structure ad laguage to simplify commuicatio amog disaster respoders. The goal of the ICS is to utilize disaster resources i the most efficiet maer at the disaster scee. It is a modular system readily adaptable for all icidets ad facilities regardless of the site. Fuctioal requiremets, ot titles, determie the orgaizatioal hierarchy, ad the structure remais the same regardless of the icidet. The ICS should be started as early as possible to prevet the situatio from spiralig out of cotrol. Job descriptio of key ICS leaders The ICS hierarchy is built aroud five maagemet activities. Commad is resposible for all icidet or evet activities. Operatios is resposible for directig the tactical actios to meet the icidet objectives. Plaig collects, evaluates ad displays the icidet iformatio ad maitais the status of resources. Logistics provides adequate services ad support to meet all icidet eeds. Admiistratio/Fiacial tracks icidetrelated costs, persoel ad equipmet records, ad admiisters ay procuremet cotracts. 1 Hospital Emergecy Icidet Commad System May hospitals are icorporatig the ICS ito their emergecy preparedess pla. This system is kow as the hospital emergecy icidet commad system (HEICS). The HEICS is desiged to help miimize a lot of the cofusio ad chaos experieced by hospitals i a medical emergecy. It is a pla desiged to fit withi U.S. Coast Guard Petty Officer 2d Class Nyxo Lyo Cagemi the hospital s emergecy preparedess pla. The HEICS features the same flexible maagemet chart used i the ICS, which allows for a customized hospital respose to the crisis at had. 1 The features offered to hospitals are: Predictable chai of commad Flexible orgaizatioal chart allowig a flexible respose Prioritized respose checklist Accoutability Improved documetatio Commo laguage Cost effective emergecy plaig What is my role i a disaster? Be able to respod Kow where to respod Kow alterate routes to hospital Be flexible Remai calm Good itetios aloe do ot costitute a effective disaster respose. Give the complexity of today s medical disasters, medical persoel eed to icorporate the priciples of the mass casualty icidet respose i their traiig, regardless of their specialties or the size of their istitutios. ABOUT ThE AUThOR Toy Forgioe, lp, has worked at Massachusetts Geeral Hospital i Bosto for more tha 30 years. He is a member of the Iteratioal Medical Surgical Respose Team of the Departmet of Huma Services. As a member of this team, Forgioe has become familiar with disasters ad their aftermath. He was part of the respose team i New York durig the September 11 disaster ad also traveled to Ira i 2003, to care for victims of a massive earthquake. Refereces 1. Advaced Disaster Medical Respose. Harvard Medical Iteratioal. 2003. 2. Critical Illess ad Trauma Foudatio Ic. START Simple Triage ad Rapid Treatmet. 2001. Available at: http://www.citmit. org/start/default.htm. 3. Natioal Ceter for Ijury Prevetio ad Cotrol. I a Momet s Notice: Surge Capacity for Terrorist Bombigs. Atlata: Ceters for Disease Cotrol ad Prevetio; 2007. The Surgical Techologist OCtOber 2008 450 Associatio of Surgical Techologists For reprit permissio: publicatios@ast.org
Case study: Virgiia Tech mass casualty icidet Tom Borak BACkgROUND O April 16, 2007, a shootig occurred o the campus of Virgiia Polytechic Istitute ad State Uiversity (Virgiia Tech) i Blacksburg, Virgiia. The loe guma, a Virgiia Tech studet, etered a studet dormitory, where he claimed his first two victims. Nearly two hours later, the shooter made his way across campus ad etered a academic buildig, where he proceeded to murder 30 more studets ad faculty, before takig his ow life. dead-o-arrival (DOA) ad the other, presetig with a gushot woud to the head, was trasferred to the earest level 1 trauma ceter, Carilio Roaoke Memorial Hospital (CRMH). A medevac was iitially requested, but deied due Blacksburg is a small tow i a rural part of Virgiia with a populatio of just uder 40,000 icludig the studet populatio of 25,000. As such, the area does ot ejoy the luxury of the advaced medical structure available i may large cities. The closest level 1 trauma ceter is 42 miles away i Roaoke, Virgiia. The ext closest is i Charlottesville, Virgiia, which is approximately 150 miles from the Virgiia Tech campus. The three closest hospitals, Motgomery Regioal Hospital (MRH), Carilio New River Valley Medical Ceter (CNRV)ad Lewis Gale Medical Ceter (LGMC) are either level 3 trauma ceters or odesigated. 1 EMERgENCy MEDICAL SySTEM RESPONSE Shortly after 7 a.m., the shooter fired two shots, claimig his first two victims i the West Ambler Johso Hall dormitory. The icidet was phoed i to campus police by a studet who suspected that someoe had falle out of bed. The first respoders discovered the victims shortly after 7:20 a.m. 2 Virgiia Tech Rescue requested assistace from the Blacksburg Voluteer Rescue Squad ad both patiets were trasferred to Motgomery Regioal Hospital, three miles from the dormitory. Oe of the victims was proouced to iclemet weather: o April 16, 2007, high wids with gusts of up to 60 mph made a medical airlift impossible, meaig all patiets had to be moved via groud trasport. The secod patiet died shortly after arrival at CRMH. 3 Because the shootig i the dormitory was iitially cosidered a isolated icidet, campuswide actio was ot take. Two hours later, while police were still workig the iitial crime scee, the shooter made his way ito Norris Hall, where he chaied the three mai doors shut ad bega his rampage o the buildig s secod floor. At 9:42 a.m., campus dispatch received a 9-1-1 call reportig multiple shots fired at Norris Hall. Police were o the scee by 9:45. The Ala Kim, The Roaoke Times Police officers carry Virgiia Tech studet, Kevi Stere, from Norris Hall. The former Eagle scout was shot through the right leg, severig the femoral artery. He saved his ow life by makig a make-shift touriquet from a electrical cord before first respoders applied a real oe. Associatio of Surgical Techologists For reprit permissio: publicatios@ast.org OCtOber 2008 The Surgical Techologist 451
first mutual aid vehicle arrived o campus at 9:50 a.m. ad staged i the forward stagig area as directed by EMS commad. Additioal EMS was requested via mutual aid with 14 agecies respodig. 1 Because of the active shooter, these resources were desigated to a secod stagig area located less tha oe-quarter mile from campus util the area was secured. Staffig levels were adjusted for all staged ambulaces to esure that each was staffed by advaced life support providers. 1 At 9:50 a.m., two medics etered the buildig. They were held up i the stairwell for two miutes for safety precautios before beig allowed to proceed. 4 They bega triage o victims brought to the stairwells while police were movig them out of the buildigs. The triage had two specific goals: first, to idetify the total umber of victims who were alive or dead; ad secod, to move ambulatory victims to a safe area where further triage ad treatmet could begi. 4 The medics used the Simple Triage ad Rapid Treatmet (START) system to evaluate the severity of the ijuries ad assig treatmet priorities. Those tagged as red or yellow were immediately trasported for hospital care. hospital RESPONSE At 9:45 a.m., MRH was otified of shots fired somewhere o the Virgiia Tech campus. Without sigificat iformatio, the hospital iitiated a security lockdow procedure as a precautio. At 10:00 a.m., the hospital received cofirmatio of multiple gushot victims ad a code gree (disaster code) was iitiated: The hospital icidet commad ceter was opeed ad pre-assiged persoel reported to commad. The hospital facility was placed o a cotrolled access pla (strict lockdow). Oly persoel with appropriate idetificatio (other tha patiets) could eter the hospital, ad the oly through oe etrace. All elective surgical procedures were postpoed. Day surgery patiets with early surgery times were set home as soo as possible. The emergecy departmet was placed o divert for all EMS uits except those arrivig from the Norris Hall icidet. The emergecy departmet was staffed at full capacity. A rapid emergecy departmet discharge pla was istituted. Stable patiets were trasferred from the emergecy departmet to the outpatiet surgery suite. 4 The regioal hospital coordiator received iformatio from the scee of the shootig at 10:13 a.m. ad activated the Regioal Hospital Coordiatig Ceter (RHCC), at which time the icidet commad system (ICS) was set i motio. 1 At the atioal level, Homelad Security Presidetial Directives 5 ad 8 require all federal, state, regioal, local ad tribal govermets, icludig EMS agecies, to adopt the Natioal Icidet Maagemet System (NIMS), icludig a uiform ICS. 5 The NIMS is defied by Wester Virgiia EMS Cousel i their Mass Casualty Icidet (MCI) Pla as: A writte pla, adopted ad utilized by all participatig emergecy respose agecies, that helps cotrol, direct ad coordiate emergecy persoel, equipmet ad other resources from the scee of a MCI or evacuatio, to the trasportatio of patiets to defiitive care, to the coclusio of the icidet. 6 A level 3 trauma ceter, the MRH emergecy departmet received 17 patiets from the Virgiia Tech icidet, icludig the two victims of the dormitory shootig. 4 The first patiet from the Norris Hall shootig arrived via self-trasport at 10:05 a.m., presetig with mior ijuries sustaied while escapig from the buildig. Whe two more patiets arrived via EMS trasport at 10:14 ad 10:15, the hospital realized that they might cotiue to receive both expected ad uexpected patiets. I preparatio for the surge, MRH took the followig precautios: The Red Cross was alerted ad the blood supply reevaluated. The Surgical Techologist OCtOber 2008 452 Associatio of Surgical Techologists For reprit permissio: publicatios@ast.org
Additioal pharmaceutical supplies ad a pharmacist were set to the emergecy departmet. A ruer was assiged to assist with brigig additioal materials to ad from the emergecy departmet ad the pharmacy. Disaster supply carts were moved to the hallways betwee the emergecy departmet ad outpatiet surgery. 4, 7 At 10:17 a.m., the RHCC otified the Virgiia Hospital ad Health Care Associatio ad the Virgiia Departmet of Health i Richmod, Virgiia, of the situatio i Blacksburg. Other hospital plaig regios activated their RHCCs ad logged oto Web Emergecy Operatios Ceter (EOC), a virtual EOC ad bed-moitorig system used throughout the state to track hospital resource availability ad bed accessibility. 1 After activatig its EOC, LGMC caceled some elective surgeries ad made hospital staff available to assist MRH if ecessary. Betwee 10:30 ad 10:55 a.m., ie additioal patiets arrived at MRH via EMS. At 11:30 a.m., a surgeo from LGMC was issued emergecy credetials from MRH to assist with emergecy procedures, which is otable because LGMC ad MRH are ot affiliated. 4 Table 1. All i a day s work: Patiets presetig from the Virgiia Tech icidet Hospital Ijuries Dispositio MRH Gu shot woud (GSW) left had fractured 4th figer OR ad admissio MRH GSW right chest hemothorax Chest tube i OR ad admissio MRH GSW right flak OR ad admissio to ICU MRH GSW left elbow, right thigh Admitted MRH GSW x2 left leg OR ad admissio MRH GSW right bicep Treated ad discharged MRH GSW right arm, grazed chest wall, abrasio to left had Admitted MRH GSW right lower extremity; laceratio to femoral artery OR ad ICU MRH GSW right side abdome ad buttock OR ad ICU MRH GSW right bicep treated ad discharged MRH GSW face/head Itubated ad trasferred to CRMH MRH Asthma attack precipitated by ruig from buildig Treated ad discharged MRH Tib/fib fracture due to jumpig from secod-story widow OR ad admissio MRH First-degree burs to chest wall Treated ad discharged MRH Back pai due to jumpig from secod-story widow Treated ad discharged CNRV GSW face, pre-auricular area, bleedig from exteral auditory caal, GCS of 7, poor Surgical cricothyrotomy; trasferred to CRMH airway, aesthesiologist recommeded surgical airway CNRV GSW flak ad right arm, hypotesive Immediately take to OR; small bowel resectio CNRV GSW posterior thorax (exit right medial upper arm), additioal GSWs to right buttock OR for surgical repair of left femur fracture ad left lateral thigh CNRV GSW right lateral thigh, exit through right medial thigh, lodged i left medial thigh Admitted i stable coditio ad observed; o vascular ijuries LGMC GSW grazed shoulder ad lodged i occipital area; did ot eter the brai Take to surgery by ENT for debridemet LGMC GSW i back of right arm; bullet ot removed Admitted for observatio LGMC GSW face, bullet fragmet i hair, likely secodary to shrapel spray Treated ad discharged LGMC Shattered tib/fib due to jumpig from secod-story widow Admitted, take to surgery the ext day LGMC Soft tissue ijuries, eck ad back sprai due to jumpig from secod-story widow Treated ad discharged Associatio of Surgical Techologists For reprit permissio: publicatios@ast.org OCtOber 2008 The Surgical Techologist 453
To ease commuicatio with EMS at the scee, MRH set a emergecy admiistrator to determie how may more patiets would be trasported to the hospital. The last gushot victim was received at 11:40 a.m., ad the oscee liaiso cofirmed that all patiets had bee trasported at 11:51 a.m. The code gree was lifted at 1:35 p.m. 4 AFTERMATh By 11 a.m., the hospital had established a base where staff ad couselors could assist family ad frieds of patiets, however, may were usure of the status or locatio of the persos they were tryig to fid. MRH established a psychological crisis couselig team to provide services to victims, their families, loved oes ad hospital staff. 4, 8 All told, 24 patiets were treated i local emergecy departmets, icludig MRH, LGMC ad CNRV. (Table 1) CONCLUSION The overall assessmet of the EMS respose ad hospital preparedess is positive, however, there are always improvemets to be made. Accordig to the report issued by the Virgiia Tech Review Pael, the hospitals ad public safety agecies should have used the RHCC ad WebEOC expeditiously to gai better cotrol of the situatio. With rumors ad ucofirmed reports cocerig patiet surge, it would have made coordiatio of the icidet much easier. 4 MRH requested activatio of the RHCC at 10:05 a.m. It was activated uder stadby status at 10:19 a.m. ad siged o to WebEOC. At 10:40 a.m., the RHCC requested a update of bed ad diversio status from all hospitals i the area. By 10:49 a.m., however, oly LGMC (of the hospitals that received patiets from the Norris Hall icidet) had siged o to WebEOC. MRH did ot provide its status util 11:49 a.m., followed by CNRV at 12:33 p.m. 4 Commuicatio was also a sigificat issue durig the Virgiia Tech icidet. Similar to the widely-publicized commuicatio roadblocks o September 11, every service operated o a differet radio frequecy, makig dispatch, iteragecy ad medical commuicatio difficult. 4 It cogested both o-scee ad i-hospital situatios that could be avoided with more plaig ad implemetatio of uiform disaster protocol. While cosidered a overall success, give the coditios ad circumstaces of this disaster, this icidet highlights the importace of commuicatio durig icidet respose ad preparedess for surge capacity. It also idicates the importace of costat preparatio ad regular traiig drills for a uforeseeable evet. Refereces 1. Kaplowitz Lisa. Reece Morris. Hershey Jody Hery. Gilbert Carol M. Subbarao Italo. Regioal Health System Respose to the Virgiia Tech Mass Casualty Icidet. Disaster Medicie ad Public Health Preparedess. Accessed August 25, 2008. 2. Williams Reed. Morriso Shawa. Police: No Motive Foud. The Roaoke Times. April 26, 2007. Available at: http://www.roaoke.com/vtshootigaccouts/wb/114655. Accessed August 25, 2008. 3. Perkis Timothy J. Virgiia Tech Mass Shootig Review Pael Report. EMS Respoder.com. July 8, 2008. Available at: http://www.emsrespoder.com/prit/emergecy-- Medical-Services/Virgiia-Tech-Mass-Shootig-Review-Pael- Report/1$6353. Accessed August 25, 2008. 4. Report of the Virgiia Tech Review Pael. August 2007. Available at: http://www.goveror.virgiia.gov/temp- Cotet/techPaelReport.cfm. Accessed August 25, 2008. 5. Bush George W. Homelad Security Presidetial Directive/HSPD-8. December 17, 2003. 6. West Virgiia EMS Coucil. Mass Casualty Icidet Pla: Ems Mutual Aid Respose Guide. 2006. 7. Motgomery Regioal Hospital. Motgomery Regioal Hospital VT Icidet Debriefig. April 23, 2007. 8. Heil J. et al. Report to the Virgiia Tech Review Pael. Psychological Itervetio with the Virgiia Tech Mass Casualty: Lessos Leared i the Hospital Settig. 2007. The Surgical Techologist OCtOber 2008 454 Associatio of Surgical Techologists For reprit permissio: publicatios@ast.org
Pademic disease: The ext great disaster? Tom Borak Perhaps the greatest atural disaster threat is that of pademic disease. While it may ot cause collateral damage o the scale of a terrorist attack or a category 5 hurricae, this silet killer has a much greater reach ad the destructive power to devastate ay city i ay coutry aroud the world. These biological agets kow o boudaries ad ca travel as fast as the hosts that carry them, which i today s fast-paced world ca mea global impact i just a few weeks time. I November 2002, severe acute respiratory sydrome (SARS) broke out i the Guagdog Provice of Chia. O November 27, Caada s Global Public Health Itelligece Network, a electroic warig system that is part of the World Health Orgaizatio s (WHO) Global Outbreak ad Alert Respose Network, picked up reports of what was beig called a flu outbreak, ad otified the WHO. 1 Public awareess, particularly i the Uited States, did ot escalate util February 2003, whe a America busiessma cotracted the disease o a flight from Chia to Sigapore. He was take to a hospital i Haoi, Vietam, where several of the staff that treated him also cotracted the disease, despite followig hospital protocol. The patiet evetually died. The WHO issued a global alert o March 12, 2003, followed by a health alert by the US Ceters for Disease Cotrol ad Prevetio (CDC). SARS was idetified i 29 separate geographic areas. While it was cocetrated maily i Chia, cases were diagosed across Wester Europe, Caada ad the Uited States. From November 2002 to July 2003, 8,096 cases were diagosed, leadig to 774 deaths. (Sice July 11, 2003, 325 cases have bee dismissed i Taiwa, Chia. Laboratory iformatio was isufficiet or icomplete for 135 of those cases, of which 101 died.) 2 While SARS was ultimately cotaied, the speed with which it spread is a importat idicator of how fast future pademics may travel. It is critical that the Uited States health care system is prepared for such a catastrophic evet. ARE WE READy? It is highly likely that hospitals ad other health care facilities will be overwhelmed by the sheer volume of patiets at the oset of a pademic. Accordig to Nacy Doega, r, director of ifectio cotrol at the Washigto Health Ceter i Washigto, DC, hospitals ca icrease their patiet care capacity i relatively short periods of time by surgig i place, which ivolves rapidly dischargig existig patiets, cacellig scheduled elective procedures, ad takig steps to icrease the umber of patiet-care staff i the facility i order to make additioal staffed hospital beds available for icomig disaster evet Free Press ewsboys do protective masks durig the 1918 pademic. While widely used, the masks had o protective effect agaist the virus. Wiipeg Free Press Archive Associatio of Surgical Techologists For reprit permissio: publicatios@ast.org OCtOber 2008 The Surgical Techologist 455
patiets. 3 However, most hospitals operate at or ear full capacity, which meas they have a very limited ability to rapidly icrease the workforce. While this strategy ca provide a temporary ability to icrease patiet care capacity, most hospitals caot sustai such a surge for exteded periods of time. Idividual facilities will quickly become overwhelmed if the disaster ivolves large umbers of victims presetig over a prologed period of time ad most projectios estimate that a pademic will last at least a few moths. Oe of the most sigificat reasos for this is isufficiet fudig. Accordig to the America Hospital Associatio, approximately oethird of hospitals lose moey o operatios with Medicare ad Medicaid uder-fudig beig a key driver. Aother oe-third of hospitals operate at or ear the break-eve poit. This meas that two out of three hospitals are ot able to ivest sigificatly i surge capacity preparatio. 3 By the same toke, fiacial costraits have forced may hospitals to adopt just-i-time supply chais for their equipmet, which meas that ew shipmets are scheduled to arrive just as the supply is beig exhausted. Therefore, i a sustaied surge, as ca be expected durig a pademic, hospitals will face a almost immediate shortage of critical supplies, icludig vetilators, persoal protective equipmet for staff, drugs ad other supplies. 3 Sice most hospitals are operatig o the just-i-time model, medical suppliers will be uable to keep up with icreased demad from all of their cliets simultaeously, which will result i a shortage, ad supply ratioig. Accordig to the Ceter for Biosecurity at the Uiversity of Pittsburgh Medical Ceter, the estimated cost of readiess for a severe (1918-like) pademic is $1 millio per average-sized hospital (164 beds). The estimated costs iclude: Develop specific pademic pla: $200,000 Staff educatio/traiig: $160,000 1918 Iflueza pademic Margaret Sterlig cst, lp, m a Iflueza, or simply the flu, ca be traced through writte records as far back as 412 B.C. 1 Sice the, there have bee umerous outbreaks that have varied i severity. Noe, however, has impacted the world with the severity of the pademic outbreak i 1918-19. Dubbed the Spaish Flu, the disease ifected betwee 20-40 percet of the world s populatio ad killed more tha 20 millio people worldwide i less tha a year 500,000 i the Uited States aloe. 2 The US outbreak bega at a Army base ear Bosto i September 1918. While it was idetified as iflueza, the characteristics of the strai were uique. The majority of deaths were due to bacterial peumoia, a secodary ifectio caused by iflueza. The virus also killed people directly, causig massive hemorrhages ad edema i the lugs. 3 The oset of the 1918 flu was very sudde. A victim could go from good health to beig uable to walk withi a few hours. Symptoms icluded geeral weakess, severe aches i muscles, backs, joits ad heads. This was ofte accompaied by a fever that could reach 105 degrees, causig overwhelmig bouts of delirium. Whe the fever broke, may survivors suffered from post-iflueza depressio. 4 The impact o the Easter seaboard was almost immediate. The Bosto stock market was closed, a state-wide order i Pesylvaia shut dow every place of public amusemet icludig saloos, ad the Ketucky Board of Health prohibited public gatherigs of ay kid, icludig fuerals. The dead piled up faster tha they could be buried, resultig i piles of bodies i the streets ad mass graves. The medical commuity was overwhelmed. By the time the pademic had made its way across the coutry, ad evetually faded completely, the atio had bee devastated. Refereces 1. Marti P. Marti-Grael E. 2,500-year Evolutio of the Term Epidemic. Emergig Ifectious Diseases. 2006. 2. Ceters for Disease Cotrol ad Prevetio. Pademic Iflueza. February 12, 2004. Available at: http://www.hhs.gov/vpo/pa demics/flu3.htm#8. Accessed September 3, 2008. 3. Taubeberger J. Mores D. 1918 Iflueza: The Mother of all Pademics. Emergig Ifectious Diseases. 2006. 4. Crosby A W. America s Forgotte Pademic. Cambridge Uiversity Press. 1989 The Surgical Techologist OCtOber 2008 456 Associatio of Surgical Techologists For reprit permissio: publicatios@ast.org
Stockpile miimal persoal protective equipmet: $400,000 Stockpile basic supplies: $240,000 Total: $1 millio 3 O top of that, the ceter estimates that aual costs to maitai a state of readiess could reach approximately $200,000 per year. Based o these umbers, the total for the atio s 5,000 geeral acute care hospitals for iitial pademic preparedess ot icludig aual maiteace costs is about $5 billio. 3 The US govermet s Natioal Bioterrorism Hospital Preparedess Program has recogized the problem ad is workig to icrease the cash flow to the hospital system, although it is a very slow process: Prelimiary estimates i 2002 suggested that hospitals would require approximately $11 billio to obtai a basic level of all hazard preparedess. Sice the, Cogress has appropriated about $500 millio per year for the program ad the fiscal year 2007 request is $487 millio. This amouts to $2.1 billio over five years, or about $100,000 per hospital per year to fud preparedess. However, the amout that hospitals have actually received is sigificatly less due to dollars allotted for the federal govermet s admiistratio of the program ad overhead fuds that the state gratees have retaied. 3 The other sigificat factor is ma power. While there are atioal plas to improve hospital staffig umbers durig a surge by expadig the Medical Reserve Corps ad the Public Health Service Commissioed Corps, it becomes a moot poit whe the call for help simultaeously arises from hospitals across wide geographic areas. I additio, sice the Medical Reserve Corps ad other advaced registratio programs for voluteers ofte recruit their medical voluteers from hospital staff, it is ulikely that the voluteers home hospital would permit them to deploy elsewhere if there is a expectatio that they will be eeded i their ow hospitals, 3 which, i the case of a pademic, is exactly the sceario that would likely occur. Aother cosideratio is that just because hospital staff work i a medical eviromet, it does ot make them immue to the pademic. Staff will be exposed to the disease both iside ad outside of work. Some will likely become ifected themselves. Others may choose ot to show up for work at all, istead optig to stay home with family. Util the severity of the pademic is uderstood, there is o way to kow exactly how it will impact the workforce ad hospitals ability to serve. Despite these shortcomigs, it is critical that all hospitals ad health care providers maitai a state of readiess for a potetial pademic outbreak. It is advisable for facilities to follow the three pillars of the Natioal Implemetatio Pla wheever possible: 1) preparedess ad commuicatio, 2) surveillace ad detectio, ad 3) respose ad cotaimet. 3 For more i-depth research ad additioal details o the atioal strategy, the Natioal Strategy for Pademic Iflueza Implemetatio Pla ca be foud at http://www.whitehouse. gov/homelad/spi_implemetatio.pdf. Refereces 1. Mawudeku A. Blech M. Global Public Health Itelligece Network. mt-archive. 2005. 2. World Health Orgaizatio. Summary of probable SARS cases with oset of illess from 1 November 2002 to 31 July 2003. 3. Doega Nacy. Testimoy of the America Hospital Associatio before the US Seate Special Committee o Agig. Preparig for Pademic Flu. May 25, 2006. Available at http://www.ucop.edu/riskmgt/documets/aha_ paflu_testimoy.pdf. Accessed July 7, 2008. Associatio of Surgical Techologists For reprit permissio: publicatios@ast.org OCtOber 2008 The Surgical Techologist 457
CEExam 298 OCtOber 2008 3 Ce Credits Disasters Ear CE credits at home You will be awarded cotiuig educatio (CE) credit(s) for recertificatio after readig the desigated article ad completig the exam with a score of 70% or better. If you are a curret AST member ad are certified, credit eared through completio of the CE exam will automatically be recorded i your file you do ot have to submit a CE reportig form. A pritout of all the CE credits you have eared, icludig Joural CE credits, will be mailed to you i the first quarter followig the ed of the caledar year. You may check the status of your CE record with AST at ay time. If you are ot a AST member or are ot certified, you will be otified by mail whe Joural credits are submitted, but your credits will ot be recorded i AST s files. Detach or photocopy the aswer block, iclude your check or moey order made payable to AST, ad sed it to Member Services, AST, 6 West Dry Creek Circle, Suite 200, Littleto, CO 80120-8031. Note this exam awards three cotiuig educatio credits. Members: $18, omembers: $30 1. What is the easiest way to desigate a patiet s status at a disaster scee? a. A simple spreadsheet b. Move patiets to screeig areas c. Triage tags d. Mobile rescue uits 2. The cetral focus of disaster triage is: a. Stabilize patiets that caot walk b. Fid ad tag patiets that require immediate care c. Providig defiitive care d. Stabilizig critically ijured patiets 3. medical care improves the casualty s coditio. a. Expert c. Defiitive b. Specialized d. Geeral 4. Casualty collectio sites should ot be located: a. O hospital property b. Dowwid from hazards c. Dowhill from cotamiated areas d. All of the above 5. Decompressig a disaster scee meas: a. Evacuatig seriously-ijured casualties b. Dismissig excess medical staff c. Expadig the search parameters for survivors d. Frequetly re-triagig patiets 6. The simplifies commuicatio amog disaster respoders: a. Emergecy Respose System b. Icidet Commad System c. Emergecy Respose Network d. Disaster Preparedess System 7. Usig the START method, triage evaluatio should take: a. 15 secods c. Oe miute b. 30 secods d. Up to two miutes 8. Durig disaster triage, if a patiet does ot start breathig after simple airway maeuvers: a. Immediately move patiet to secodary care facility b. Tag as red/immediate ad move o c. Tag as black/dead ad move o d. Call for assistace 9. Which sceario has the greatest casualty potetial? a. A terrorist attack o a major city b. A atural disaster c. A uclear power plat meltdow d. A pademic disease outbreak 10. What was the greatest pademic i US history? a. Spaish Flu c. West Nile Virus b. Avia (Bird) Flu d. SARS 298 OCtOber 2008 3 Ce Credits part 1 OF 3 Disasters Certified Member Certified Nomember My address has chaged. The address below is the ew address. Certificatio No. Name Address City State ZIP a b c d a b c d 1 6 2 7 3 8 4 9 5 10 Telephoe The Surgical Techologist OCtOber 2008 458 Mark oe box ext to each umber. Oly oe correct or best aswer ca be selected for each questio.
11. What is a hospital s first respose to a disaster sceario? a. Surge i place b. Cacel all elective surgeries c. Divert all icomig o-disaster patiets d. Place the hospital uder secure lockdow 12. Surgig i place does ot ivolve a. Rapidly discharge existig patiets b. Cacelig scheduled elective procedures c. Hirig more support persoel d. Icreasig the umber of patiet-care staff 13. A key reaso for hospitals losig moey is: a. Icreasig cost of eergy b. Uderfudig of Medicare ad Medicaid c. High costs of updatig equipmet d. Persoel salaries 14. The Natioal Implemetatio Pla does ot iclude: a. Preparedess ad commuicatio b. Iitiatig a emergecy respose alert c. Surveillace ad detectio d. Respose ad cotaimet 15. Natural disasters do ot iclude: a. Hurricaes b. Mie cave-is c. Floods d. Earthquakes 16. A mass casualty evet is defied as: a. A icidet that produces a sufficiet umber of casualties to disrupt ormal fuctios b. A evet that affects more tha oe millio people c. A occurrece that is the result of terrorism d. A evet that ivolves oly fatalities 17. The most importat missio i a disaster respose sceario is: a. Commuicatig the locatio b. Alertig the atioal guard c. Triage d. Alertig evacuatio teams 18. Disaster triage excludes: a. Providig the greatest good for the patiet b. Respose teams prioritizig the casualties c. Orderly treatmet d. Best use of equipmet 19. idetifies a patiet who will ot survive without immediate treatmet. a. Black b. Red c. Yellow d. Gree 20. After the critically ijured are treated, the tagged patiets are see. a. Yellow b. Gree c. White d. Orage 298 OCtOber 2008 part 2 OF 3 Disasters a b c d a b c d 11 16 12 17 13 18 14 19 15 20 Mark oe box ext to each umber. Oly oe correct or best aswer ca be selected for each questio. OCtOber 2008 The Surgical Techologist 459
21. provides a commo orgaizatioal structure ad laguage to simplify commuicatio. a. START method b. Icidet Commad System c. Emergecy Medical Respose d. Decompressig 22. Small aircraft evacuatio ca be characterized by: a. Simple ad geerally available b. More efficiet c. High cost ad complexity d. Removal of critical resources 23. More patiets lives ca be saved through: a. Temporizig damage-cotrol surgery b. Defiitive surgery c. Log-lastig surgical itervetio d. Use of sophisticated techology 24. ICS is built aroud: a. Commad/Operatios b. Plaig/Logistics c. Admiistratio/Fiacial d. All of the above 25. is whe hospitals icorporate the ICS ito their emergecy preparedess plas: a. Triage c. Defiitive medical care b. HEICS d. SARS 26. Defiitive medical care is provided i: a. A existig hospital b. Mobile facility c. A ad B d. Noe of the above 27. determies the orgaizatioal hierarchy of the ICS: a. Job titles b. Seiority c. Academic degree d. Fuctioal requiremets 28. ifected 20-40 percet of the world s populatio. a. SARS b. Sara c. Spaish Flu d. Buboic Plague 29. The Spaish Flu caused death by: a. Bacterial peumoia b. Massive hemorrhages c. Edema i the lugs d. All of the above 30. A pademic outbreak ca result i: a. Ecoomic dowtur b. Mass quaratie c. Overwhelmed medical commuity d. All of the above Disasters 298 OCtOber 2008 part 3 OF 3 a b c d a b c d 21 26 22 27 23 28 24 29 25 30 Mark oe box ext to each umber. Oly oe correct or best aswer ca be selected for each questio. The Surgical Techologist OCtOber 2008 460