Disasters, Mass Casualty Incidents, and Complex Emergencies 2a

Surge capacity

has been defined as the ability of a healthcare system to "expand rapidly and to obtain adequate staff, beds, supplies, and equipment to provide sufficient care to meet the immediate needs of an influx of patients following a large-scale incident or disaster. Hospitals should have surge capacity plans in order to diffuse this imbalance of supply and demand.

No Advanced Warning Events

include earthquakes, building fires, tornadoes, and explosions. Decisions must often be made very quickly in the midst of the disaster or immediately afterward.

Level B PPE

provides the greatest level of respiratory protection but a lower level of skin protection than Level A. It differs from Level A in that the suit is not fully encapsulated and airtight, but it provides splash protection against liquids. This level should be selected when the *highest level of respiratory protection is necessary, but a lesser level of skin protection is needed.* Level B consists of an SCBA, nonencapsulated chemical-resistant garments, gloves, and boots.

Secondary blast injuries

refer to trauma caused by projectiles carried by the blast pressure wave penetrating any body part.

Clues to the detection of a chemical event

(1) a rapid onset of symptoms in patients; (2) large numbers of patients presenting with common symptoms; (3) low-lying clouds or vapors; (4) dying animals or insects; (5) unexplained odors; and (6) concentrations of dead, dying, or sick people at the scene.

Level C PPE

* provides the same skin protection as Level B but a lesser level of respiratory protection than Levels A and B.* Level C consists of a nonencapsulated chemical-resistant suit (splash protection), air-purifying respirator (APR), gloves, and boots. Level C is used when the type of airborne exposure is known to be guarded against adequately by an APR.

Disaster Supply Kit

1. Water for 3 to 5 days (remember water for pets also); a normal person needs 2 quarts of water per day 2. Cans of food 3. Food items such as nuts, dried fruit, and other packaged snacks 4. Blanket, small pillow 5. Inflatable bed (may be used as a float if needed) 6. Closable waterproof plastic bags 7. Backpack for carrying items 8. Battery-operated radio (change the batteries every 6 months) 9. Medications to sustain 14 days 10. Personal hygiene items 11. Extra eyeglasses 12. Manual can opener 13. Flashlight with extra batteries 14. Face masks to protect from dust 15. Traffic flares 16. Duct tape and scissors 17. Whistle 18. Plastic sheeting 19. Work gloves 20. One complete change of cloths 21. Heavy duty plastic garbage bags and ties—for personal sanitation uses—and toilet paper 22. Compass 23. Waterproof matches 24.* Waterproof markers (used to write a young child's name, address, phone number, and next of kin number on children's feet)* 25. Over-the-counter medications for diarrhea, headache, nausea, and vomiting 26. Basic first aid kit 27. Cell phone charger 28. Water purifier kit 29. Sunscreen and insect repellent 30. Cash Home 1. Draw a floor plan of your home. Mark two escape routes from each room. 2. Make sure everyone in the household knows how to shut off water, gas, and electricity at the main switches. 3. Post emergency phone numbers by the telephones. Teach children how and when to call 911. 4. Identify two meeting places: The first should be near your home in case of fire; the second should be away from your neighborhood in case you cannot return home 5. Keep car gas tank filled. Documents* 1. Birth certificates 2. Immunization records 3. Homeowners insurance policy with contact information 4. Health records 5. Driver license copy 6. Complete list of medications 7. Copies of health insurance cards 8. All emergency phone numbers for family 9. List of all credit card numbers Other 1. Consider ways to help neighbors who may need special assistance, such as the elderly or the disabled 2. Make arrangements for pets. Most pets are not allowed in public shelters 3. Identify an out-of-state family member or friend so all your family members have a single point of contact.

Debriefing

A postevent disaster debriefing should be held within 24 hours of the disaster response. This debriefing should include all participants in the disaster response. The purpose of the debriefing is to critically analyze all aspects of the response and to identify strengths and areas that need to be improved. Additionally, this debriefing allows hospital leadership to begin to identify staff who may need assistance recovering from the disaster response.

Hospital Evacuation

Evacuations may be necessary due to fire or damage from a natural disaster such as a hurricane, earthquake or flood. The decision to evacuate a hospital should be based on the ability of the hospital to meet the medical needs of the patients. Hospitals should have in place plans for either a full or partial evacuation and those plans should be consistent with regulatory requirements. A full evacuation of a hospital should generally be considered a last resort. There are two types of hospital evacuations: "advanced warning events" and "no advanced warning events."

Hospital Preparedness

Disaster plans should address the following: • Staff safety/personal protective equipment • Decontamination equipment and processes • Surge capacity • Mental health • Lockdown procedures • Mass fatality management • Evacuation • Altered standards of care • Allocation of scarce resources • Mass employee medication prophylaxis • Internal utility failure • Workplace violence including active shooters • Bomb threats • Civil unrest

Explosions and Blast Events

Explosions occur when a solid or liquid material is rapidly transformed into a gas, and energy is released. The gas expands outward in a high-pressure blast wave that exceeds the speed of sound. Air is highly compressed on the leading edge of the wave, creating a shock or blast front. The body of the wave and the associated mass outward movement of ambient air, the blast wind, follows the front. Blast trauma from explosives varies greatly depending on the environment (indoors or outdoors), the structural characteristics of the building or vehicle, the presence of reflecting surfaces, and the distance from the blast. Primary blast injury is a result of barotrauma, unique to explosions, which causes damage to air-filled organs—the lungs (hemothorax, pneumothorax), gastrointestinal tract (bowel perforation), and auditory system (tympanic membrane rupture). Secondary blast injuries refer to trauma caused by projectiles carried by the blast pressure wave penetrating any body part. Tertiary blast injuries are caused by the individual being propelled by the blast wave and thrown into an object or when a structure collapses and causes injury. quaternary injuries, include exacerbations or complications of preexisting illnesses or injuries as a result of the blast such as burns.

HOSPITAL RESPONSE TO A DISASTER

For disasters such as hurricanes and floods, hospitals are likely to receive advanced warning and are able to activate their disaster plan before the event. For disasters such as earthquakes, tsunamis, chemical plant explosions, industrial accidents, building collapses, and acts of terrorism, there is no advanced warning system. Regardless of the warning, all disaster scenarios carry with them the possibility of many injured patients. The overall response to a disaster used to focus just on rescuing victims at the scene of the disaster and delivering these victims to the hospital. It was assumed hospitals would always be there, ready to receive all victims. However, the events of September 11, 2001, the anthrax incidents in 2001, and the 2002/2003 SARS cases changed the rules that defined hospital disaster preparedness and response. Following Hurricane Katrina in 2005 and the 2009 H1N1 pandemic, the rules changed again. Currently, disaster preparedness in hospitals is shifting yet again to include internal workplace violence concerns, active shooters, and strategies surrounding Emerging Infectious Diseases. Hospitals need to be accessible, prepared, and functioning at maximum capacity so that they are ready to respond to both external and internal events.

maintaining readiness

Hospitals and other healthcare organizations must be prepared to handle a large influx of patients with any level of acuity from any disaster event. Disaster drills or disaster exercises are an integral element of preparedness and should be conducted twice yearly. A disaster drill or exercise is a controlled, scenario-driven experience designed to demonstrate and evaluate an organization's capability to execute its Emergency Operations Plan (EOP). The goal during an exercise is to assess disaster processes and staff performance when systems are stressed during a simulated emergency. During the exercise, performance should be critiqued to identify deficiencies and opportunities for improvement facilitating modifications/improvements of the EOP. Disaster drills and exercises should test every aspect of the EOP including: • Setting up the incident command center • Receiving casualties • Triage • Testing communications systems, both internal and external, with response to agencies, including other healthcare organizations • Evacuating and transporting patients • Requesting and receiving emergency supplies • Staff roles and responsibilities • Utility management • Safety and security • Resources and assets, including the following equipment: decontamination, PPE, transportation, communication, and emergency supplies

Emergency Management Assistance Compact (EMAC)

If needed, a state can request outside assistance from other states through the _________________________. If they are available, the assisting states can provide resources such as National Guard or medical personnel.

quaternary injuries,

Other injuries, include exacerbations or complications of preexisting illnesses or injuries as a result of the blast such as burns.

Evacuation

Regardless of the warning, successful hospital evacuation requires the symphonic coordination of personnel, transportation, communication and the tracking of patients and materials. Additional considerations during an evacuation include: • Sequences of the evacuation: The most medically fragile and resource-intensive patients are usually evacuated first, as soon as appropriate transportation and staff are available. However, in cases in which all patients are in immediate danger and evacuation must be conducted as quickly as possible, some suggest that the most mobile patients should be evacuated first. • Urgency of the evacuation: It is important to distinguish between an orderly and planned evacuation, in which there is time to move patients in a manner that maximizes safety for all, and a "drop-everything-and-go" evacuation, in which patients and staff are in immediate danger and must exit the unit and/or hospital as quickly as possible. Optimal procedures for safely moving patients may be abandoned in favor of the fastest possible egress. • Extent of the evacuation: A hospital evacuation will be planned differently depending on whether the entire area/community is being evacuated or just one hospital. If just one hospital is being evacuated (e.g., because of a fire), patients can be more easily dispersed among nearby hospitals. In most metro areas, the transport would be for a distance of less than 10 miles, and ambulances could cycle back and forth moving patients. • Condition of hospital infrastructure: Although unlikely to be a problem during an "orderly and planned" evacuation, egress from a hospital may be severely constrained during a "drop-everything-and-go" evacuation. Stairwells or exits may be obscured by smoke or unavailable because of fire. Stairwells may be dark if backup power has failed. Elevators can also be out of service, lengthening the time required to move all patients out of the hospital. • Types of patients: Highly complex patients—especially intensive care unit and other specialty-care patients—may be difficult to place in the surrounding community. • Road conditions: In a disaster where a community and more than one hospital are affected, evacuating transport destinations may be far away. Traffic-choked highways and the lack of refueling stations preventing ambulances from quickly cycling back for repeated evacuation trips could slow the evacuation process. • Transportation resources: Transportation resources include not only the vehicles but also the staff, equipment, and supplies that must accompany the patient in the vehicle.

Assessing Risk and Vulnerability

The first step in disaster planning is the development of a hazard vulnerability analysis (HVA) and risk assessment. The HVA is an assessment of the risks and consequences of a disaster or critical event occurring in the community. A list of all potential hazards and threats in the region is compiled. The list may be quite lengthy and will vary depending on the location. Factors that should be considered when developing the list include historical records, input from local emergency managers and healthcare providers, and the presence of high-risk local industries, rail lines, stadiums, and airports. Communities should pay special attention to targets of high value to terrorists, including historical monuments. Each hazard is then given a ranking of low, medium, or high probability of occurrence. Next, the potential consequences of the event are evaluated and rated as high, medium, or low consequence. Things to consider include potential injuries, loss of life, disruption of services, loss of community trust, and business continuity issues. The data can then be put into a matrix that defines the probable events and consequences as high, medium, or low. Disaster planners will then use this grid for planning purposes.

drill safety tip

To maximize the effectiveness of the drill, inject as much "reality" into the exercise as possible such as volunteer moulaged patients (using makeup to simulate injuries), donning PPE, and testing communication devices and messaging. It is also essential to ensure safety for all participants during the drill. To do this, two key elements must be in place: 1. All communications during the drill should start and end with "This is a drill." 2. A safety officer with the sole responsibility to monitor and respond to any unsafe situations should be identified.

Tertiary blast injuries

are caused by the individual being propelled by the blast wave and thrown into an object or when a structure collapses and causes injury.

Improvised explosive devices (IEDs)

are conventional explosive devices deployed in an unconventional fashion such as a suicide bombing.

Infectious disease disasters

are events that involve the dissemination of a biological agent or disease that results in mass causalities.Humans are in a delicate balance with the microbial coinhabitants of the earth. There will always be emerging pathogens that may cause the next big infectious disease disaster. Emerging infections can be considered an MCI if large numbers of people are affected. Recent examples include Ebola and the Zika virus.

Mass Shooting Events/Active Shooters

are man-made disasters. "an individual actively engaged in killing or attempting to kill people in a confined and populated area." In most cases, active shooters use firearms, and there is no pattern or method to their selection of victims. The definition above does not include shootings tied to gang disputes or robberies that went awry, and it does not include shootings that took place in private homes. In an active shooter event, the people who are killed come from every race, religion and socioeconomic background. Their ages range from the unborn to the elderly. Shootings occur without warning in the most mundane places. Most of the victims are chosen not for what they have done but simply for where they happen to be. Mass shootings in America appear to be getting deadlier and happening more frequently (Box 71.6). Some have said "it feels like they've taken hold like a virus."

Recovery

begins almost concurrently with response activities and is directed at restoring essential services and resuming normal operations. This phase may require a large amount of time, money, and resources. --getting back to normal life

Level D PPE

consists of a surgical gown, mask, and gloves. It provides no additional protection for respiratory or splash hazards, only minimal protection for nuisance contamination

Response

covers the period during and immediately following a disaster. During this phase, emergency responders and public officials provide emergency assistance to victims of the event and try to reduce the likelihood of further damage.

MitigatioN

includes activities that eliminate or reduce the chance of occurrence or the effects of an event if it occurs. Disaster mitigation programs have shown that communities can do a lot to prevent major emergencies or disasters from affecting them negatively. If communities cannot prevent disasters, they can at least reduce the damaging impact, for example, requiring roof reinforcements to reduce damage from hurricane winds or passing legislation that prevents new construction in floodplains. --activities that eliminate or reduce the chance of occurrence or the effects of an event if it occurs.

Zika virus

is a mosquito-borne flavivirus. Zika primarily spreads through infected mosquitoes, but it can also be transmitted through sexual intercourse and can be passed from a pregnant woman to her fetus. Zika virus infection during pregnancy is a cause of congenital brain abnormalities, including microcephaly, and it can also be a trigger of Guillain-Barré syndrome.

Ebola virus disease (EVD)

is a rare and deadly disease caused by the Ebola virus.spreads to people through direct contact with the body fluids of a person who is sick with or has died from EVD. The virus can also spread to people through direct contact with the blood, body fluids, and tissues of infected fruit bats or primates. Symptoms may appear anywhere from 2 to 21 days after contact with the virus, with an average of 8 to 10 days.

Primary blast injury

is a result of barotrauma, unique to explosions, which causes damage to air-filled organs—the lungs (hemothorax, pneumothorax), gastrointestinal tract (bowel perforation), and auditory system (tympanic membrane rupture). LUNGS,EARS,STOMACH (L.E.S.)

Acute radiation syndrome (ARS)

is an acute illness caused by irradiation of the whole body (or a significant portion of it).The initial clinical manifestations are nonspecific and may be indistinguishable from those of other illnesses. They include nausea, vomiting, anorexia, diarrhea, fever, and possible mild skin erythema. These symptoms will start within minutes to days after the exposure, will last for minutes to several days, and may come and go. The person usually looks and feels healthy for a short time, after which he or she will become sick again with loss of appetite, fatigue, fever, nausea, vomiting, diarrhea, and possibly even seizures and coma. This seriously ill stage may last from a few hours to several months followed by recovery or death. Each phase of the illness varies in length relative to the radiation dose received. Early onset of anorexia, nausea, vomiting, and malaise is an indication of a high dose of exposure. skin damage includes swelling, itching, and redness of the skin (like a bad sunburn). There also can be hair loss. complete healing of the skin may take from several weeks to a few years depending on the radiation dose the person's skin received. Two major aims are to prevent neutropenia and sepsis. Most people who do not recover from ARS will die within several months of exposure. The cause of death in most cases is the destruction of the bone marrow, which results in infections and internal bleeding.

The incident command system (ICS)

is an organizational tool that is used to provide the management infrastructure to support any disaster response. The structure is the same regardless of the nature of the disaster. Fig. 71.7 illustrates the hierarchical structure of the ICS. The ICS is modular and can be expanded or contracted according to the changing needs of the disaster response. The structure is built around five major management activities/functions required in a disaster setting regardless of size or type. The functions are command, operations, planning, logistics, and finance/administration. For some terrorist incidents, a sixth role, intelligence gathering, may be added. Each function is headed by a section chief, and the overall response is led by an incident commander. The ideal span of control is three people, and the maximum is seven persons. Additional functions that aid in the response include liaison, public information, and safety/security. Table 71.6 explains the ICS's roles and responsibilities.

dirty bomb

is any explosive device that intentionally releases a secondary agent. The secondary agent can be any hazardous (chemical, radiological) or infectious (biological) agent.

intentional chemical disaster

is defined as the intentional release or spill of toxic chemicals to harm people and/or the environment (Box 71.5). Some of these compounds can be potential WMDs if used by terrorists.

• A Tornado Warning

is issued when a tornado has actually been sighted or picked up on radar

• A Tornado Watch

is issued when, although a tornado has not been seen, conditions are very favorable for one to occur at any moment

Level A PPE

is the highest level of respiratory, eye, mucous membrane, and skin protection. This level provides protection against gas, vapor, liquid, and oxygen-deficient atmospheres. It includes a totally encapsulating chemical protective suit, often called a "moon suit," with a self-contained breathing apparatus (SCBA), gloves, and boots. This level should be selected when the hazards are unknown or unquantifiable or when the greatest level of protection is required. It provides full protection against liquids and vapors. Generally, this level is not appropriate for hospital staff.

Bioterrorism (also known as biological terrorism)

is the intentional use of a biological agent or derivative to inflict harm or death onto a civilian population. Biological warfare differs from bioterrorism in that the target of the attack is military personnel. Bioterrorism has the potential to result in high morbidity and mortality. Organisms and toxins that can be used as biological weapons have been categorized by the CDC into three categories. Agents classified as Category A are easily disseminated or transmitted. They can result in high mortality rates, have the potential for a major public health impact, may cause public panic and social disruption, and may require special action by public health officials. Category B and C agents, although still concerning, are less easily disseminated and result in lower morbidity and mortality rates. A renewed sense of appreciation of the potential of biological weapons came following the anthrax-contaminated letters sent in the United States in late 2001.

Decontamination

is the reduction or removal of contaminating material from a person or equipment by water and mechanical processes. All hospitals must have the capability to provide some form of patient decontamination. Eliminating contaminants from a patient's skin and clothing is important because it reduces the risk for further absorption or inhalation and helps to prevent others from becoming secondarily exposed or contaminated. During the decontamination procedure, the patient must be monitored for signs of decomposition. Antidotes or other medications may need to be given. There are three goals for patient decontamination. First, hospitals must not allow contaminated patients to enter the facility. Hospital security staff needs to lock down the entrances and exits in order to protect patients and staff. Ideally, when medically appropriate, patients should be decontaminated at the incident scene. However, complete on-incident scene decontamination may not be possible because of the medical condition of the patient as well as weather conditions and equipment availability. This may require that decontamination sites and triage station be set up immediately outside the hospital ED. If needed, decontamination is carried out prior to triage. This arrangement is essential for security and safety reasons. Second, hospitals should decontaminate patients as rapidly as possible. This means the decontamination equipment must be easily deployable and the staff trained to set it up. Third, hospitals must plan to protect the decontamination team from secondary exposure and injury. This includes having enough decontamination suits, respirators, boots, and gloves on hand to sustain the facility for at least 24 hours with a cadre of staff rotating through the process.

Nonintentional chemical incidents

leading to an MCI can occur during the manufacture, storage, or transport of chemical agents (Box 71.4). An

Disaster Phases

mitigation, preparedness, response, recovery

PPE (personal protective equipment)

the hospital emergency planner or safety officer should evaluate the potential hazardous exposure of employees and provide the appropriate PPE. The selection of the appropriate PPE is a complex process and is based on a hazard assessment that (1) identifies the hazards or suspected hazards; (2) identifies the routes of entry of the potential hazard (inhalation, skin absorption, ingestion, and eye or skin contact); and (3) defines the performance of the PPE materials in providing a barrier to these hazards. The potential exposure of hospital staff is usually a result of proximity to or contact with a patient whose skin and/or clothing may be contaminated with a hazardous substance.

PreparednesS

the next phase, is planning how to respond when an emergency or disaster occurs. This step builds an organization's capacity to manage the effects of an event should it occur. These activities help to save lives and minimize damage by preparing people to respond appropriately. Examples include disaster drills, evacuation plans, and fire drills.

Chemical incident

usually involves the release of a vapor or liquid. The type and volume of the agent released is important in determining the type and volume of injuries. An outdoor vapor cloud release is quickly dissipated by the wind and may result in a small number of casualties at the release site. An agent dispersed indoors does not dissipate as easily and can lead to a greater number of casualties. Temperature, humidity, and the type of terrain can also affect the dispersal and the number of casualties

Patient decontamination includes the following procedures:

• Remove the patient's clothing. In general, removing and bagging a patient's clothing eliminates 60% to 90% of the contaminants. • Wet the patient's skin and wash with soap and water for 5 to 10 minutes. Gentle cleaning of the skin with soap and a soft cloth removes any remaining contaminants. • Pay special attention to hair, face, hands, and other areas that were exposed but were not covered by clothing. • Follow washing by a copious rinsing of the patient with tepid water. Additional elements of decontamination include: • Determining the level of PPE required for staff to wear. • Controlling access to the decontamination site as well as the hospital. • Having a container ready to receive contaminated clothing, valuables, and contaminated supplies. • Ensuring screens are available for patient privacy. • Ensuring a collection system for water runoff is available if needed. The degree of decontamination performed depends on the situation. Anyone suspected of being acutely exposed to or contaminated by a toxic material—whether it is chemical, biological, or radiological—should be provided adequate decontamination.

Principles for minimizing exposure to radiation

• Stay as far away from the source as is practical • Use appropriate shielding • Limit exposure time