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CEMEx 2011: Chennai Emergency Management Exercise

Abstract:

CEMEx 2011, which was a result of a multi-institutional public-private partnership designed to harness the strengths and capabilities of regional emergency responders, educational institutions, hospitals, humanitarian agencies and state agencies as they prepare to confront urban catastrophes, focused on humanitarian and medical response. Its unique feature was to incorporate capacity building that included table top planning exercises related to skill sets needed for large scale of operation in emergency management. This article discusses the events of CEMEx and the learning from the mock-drill for better understanding of the complex issues of disaster management and lessons learnt from them.

Key Words: Emergency Management Exercise, Disaster Preparedness, Disaster Drill

The Genesis of CEMEx 2011

This initiative was planned by the “SRMC Emergency Physicians Alumni Association” (SEPAA), in partnership with the National Disaster Management Authority (NDMA), Government of India along with technical support from the United Nations Disaster Management Team (UNDMT), India, Government of Tamil Nadu, the Chennai City Corporation and other state agencies.

The academic activities of the exercise were conducted at Sri Ramachandra University (SRU), Chennai and also at some leading Chennai based government and private hospitals and institutions like Sri Ramachandra Medical College & Research Institute, Rajiv Gandhi General Hospital, Kilpauk Medical College & Hospital, Stanley Medical College, Apollo Group of Hospitals, Sundaram Medical Foundation, Dr. Mehta's Hospital and the state government's PPP partner for EMS, GVK EMRI 108 Ambulance Services and many other institutes.

The Event

th thCEMEx was held from 4 to 8 of August 2011. The event was managed by Divitha LeoVijai, MSc (N) who was also a National Faculty for the Emergency Nursing track and Prof T V Ramakrishnan, Head of Department of Accident & Emergency Medicine at SRU (he also was the Track Leader for Comprehensive Trauma Life Support), both of whom were guided by Prof S Rangaswami, Vice Chancellor of SRU. More than a 100 support staff from various departments of the university ranging from associate professors to students were provided by the authorities; the students played various roles - co-ordinators, trouble-shooters and volunteers, all contributing to a seamless organisation of the exercise.

CEMEx was a rigorous 5 day long event. A total of 54 national faculties from various organisations like NDMA, National Civil Defence College, Nagpur, All India Disaster

M i t i g a t i o n I n s t i t u t e , Ahmedabad, Red R India, Pune, College of Nursing CMC, Vellore, ITACCS Society, SRU, GVK EMRI and Indian Institute of Emergency Medical Services (IIEMS), Kottayam imparted training to 980 odd participants with heterogeneous professional backgrounds from Southern India. Thirteen different parallel tracks were conducted during CEMEx 2011.

P a r t i c i p a n t s i n c l u d e d corporat ion off icials and administrators, police, fire services, coast guards, NDRF, school teachers and head masters, college professors, NGO representatives, social workers, engineers, college students, industrial safety officers and administrators, doctors, nurses, paramedics from government and private medical colleges and hospitals and railway hospital.

Ten international faculties, Robert Bristow, Heidie Cordii and Raymond Cordii from New York Presbyterian Hospital, Dario Gonzales , Medical Director of New York Fire Department, George Abraham, Robert McLafferty, Richard W Lippert and Verne E. Smith from Pennsylvania and Anne E Ryan and Denise Eggert from New York devoted their time contributing towards the training of participants during CEMEx 2011.

The inaugural ceremony held on ththe 4 August 2011 at 5.00 PM at

the SRU Main Auditorium was presided over by Sashidhar Reddy, Hon’ble Vice Chairman, NDMA who in his inaugural address stated that “NDMA is very happy to associate itself with Emergency Management Exercise in Chennai. The people of Chennai and Tamil Nadu will see the kind of efforts made through this exercise, to raise public awareness, to look at our capabilities and

He added that “It should not be a one off kind of exercise.

identify the gaps”.

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The NDMA needs to carry this forward. The states will have to play an important role, so also the urban local bodies like Chennai in CEMEx 2011.”

He further pointed out that “the World Bank and the UN have stated that 1 dollar invested in mitigation will save 20 dollars” and that “in 5 years India will have World Class preparedness to meet the Challenges.”

The Capacity Building Programs

During the first 3 ½ days, CEMEx 2011 focused on 13 parallel tracks for skill enhancement in basic areas to bring awareness about disaster management. Areas like disaster preparedness, EMS, trauma management, nursing care, triage in the field and within hospitals, disaster management and responses that require co-ordinated efforts and continuous honing of skills were stressed upon. All training programs focussed on didactic lectures and capacity building through fire, slum and HAZMAT drills, skill stations, innovative interactive programs, group discussions, hands on experience through SIM Man (simulated manikins), etc.

th thEmergency Medical Services was conducted from the 4 to 7 of August 2011 and was carefully designed to give the First Responders, EMT's or Paramedics, the confidence, skills and knowledge needed to provide the highest level of immediate care in a disaster setting. These included basic but critical skills of CPR, log-rolling and extrication. Participants also learnt the theory and physiological basis of life support, early trauma management and triage through certified International Trauma Life Support (ITLS) for pre-hospital care providers during the first 2 days of training; the remaining days were devoted to disaster management principles and EMS response during disaster, table top exercise and disaster drill.

The 175 participants consisted of EMTs, Emergency Trauma and Critical care Technician's (ETCT), Paramedics etc. Twenty-four faculties of New York Presbyterian Hospital, GVK EMRI 108 Ambulance Services, Chennai and IIEMS conducted this course.

thITLS ACCESS Course was conducted on 7 August 2011. ITLS ACCESS provided EMS crews, pilots and first responders the training they need to reach, stabilize and extricate trapped patients. The 8 hour course was built around the concept of using hand tools commonly carried in ambulances or first responder units. Pre and post tests were conducted for ITLS ACCESS provider certification.

Fifty pilots, ambulance drivers, paramedics and emergency physicians took part in this program. Four faculties of ITLS ACCESS and IIEMS conducted this course.

Emergency Nursing Care thwas conducted from the 4 to

th7 of August 2011. This course was carefully designed to give the nursing staff working in the ED, the confidence, skills and knowledge they need to provide the highest level of immediate care in a disaster setting in the Emergency Department. They also had h a n d s o n t r a i n i n g o n management of t rauma

The Chennai Emergency Management Exercise 2011 (CEMEx 2011) was the 'Brainchild' of the authors of this paper - Srihari Cattamanchi, Emergency Physician, Disaster Medicine Research Fellow, Harvard Affiliated Disaster Medicine Fellowship, Harvard Medical School, and Nishanth Hiremath, Consultant, Dept. of Emergency Medicine, Columbia Asia Hospital, Bangalore. Both attended the Mumbai Emergency Management Exercise – MEMEx II, in December 2010 and were inspired to take up the challenge of creating CEMEx 2011.

p a t i e n t s o n S I M M A N (Simulated Manikin) as part of their practical skill stations.

In all 101 participants from Government and p r iva te institutes, railway hospitals working in the emergency and critical care areas and those working in quality and safety control sectors took part in this training. Eight faculties from New York Presbyterian Hospital, College of Nursing, CMC Vellore and TACT Academy of Chennai conducted this course.

The Hospital Emergency Management program was aimed at improving the ability of hospital management to organize intra-hospital care during mass casualty events. While EMS and other first responders provide initial trauma care in the disaster settings, hospital is the ultimate destination for majority of survivors. With considerations of surge capacity and local p h y s i ca l co n d i t i o n s an d resources available at the forefront, the participants learnt to develop unique plans to coordinate the delivery of care at all levels and effectively assess and mobilize hospital resources.

Around 128 doctors, nurses, hospital administrators, hospital management students amongst others benefitted from this program. Four faculties from New York Presbyterian Hospital conducted this course.

Comprehensive Trauma Life Support was conducted for 2

thdays starting on the 5 of August 2011. CTLS

participating doctor was shown how to assess, resuscitate and deliver initial care in a systematic algorithmic manner to patients with major trauma. Pre and post tests were conducted and CTLS provider certificates were issued.

is an initiative of ITACCS India, supported by International Trauma Care. This course had case presentations, evidence based discussions and skill stations in a very interactive style. Each

A Class on Hospital Emergency Management

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All the 120 participants were drawn from amongst casualty medical officers, anaesthetists, orthopedicians, surgeons, emergency medical officers, interns and nurses. Twelve faculties from International Trauma Anaesthesia & Critical Care Society (ITACCS), Indian Chapter and SEPAA conducted this course.

Basic & Advanced Disaster Life Support track was a 3 day affair

thending on the 6 of August 2011. The course offered a more advanced practicum for those individuals who respond to disasters. This intensive course trained participants in mass casualty decontamination, use of personal protective equipment, essential skills and mass casualty incident information systems and technology applications. Using simulated all-hazards scenarios, interactive sessions and drills with high-fidelity manikins and volunteer patients, the course created a true-to-life, practical experience in treatment and response.

The program conducted at CEMEx was on the lines of an ideal course and included both classroom instruction and hands-on training. Pre and post tests were conducted and American Medical Association (AMA) BDLS and ADLS provider certificates were given to participants.

Sixty-two emergency physicians participated in this program.

It was a milestone in Disaster Medicine in India. The success of the course has emboldened SEPAA and IIEMS to develop a pool of national faculties to conduct future courses in India.

Humanitarian Response Track focusing on public health was held over 4 days, one of the longer tracks of CEMEx 2011. Emphasis was laid on interaction of hazards and vulnerability (material, organizational, attitudinal), SOPs and approaches for disaster response, public health approach to disaster management, application of minimum standards, Sphere & INEE, public health promotion and mass communication and interagency coordination.

Forty-seven participants consisting of social workers, NGO representatives, community nurses, engineers, school and college teachers and students pursuing subjects as varied as arts and management and medical and dental college students. Four faculties from RED R India, Pune conducted this course.

thA slum drill was conducted on the 7 in Dhidir Nagar, Saidapet, Chennai where the participants had to survey the slum, identify potential hazards that can precipitate disasters, find solutions and educate the slum dwellers on how to overcome the adverse situations facing them; this was followed by a small rally to reach out to those who did not attend the program.

It was a good learning experience for all the 47 participants and they had a wonderful time.

The First Responder Course was conducted as a 2 day event. In this, 114 participants from the Civil Defence, Police, Fire Service, Security Personnel, Red Cross, St. John's Ambulance Personnel, Coast Guards, etc. took part. Four faculties from RED R India conducted this course.

th thThe Public Health Assessment Track was held on the 5 & 6 of August 2011. This course was designed for senior level public health practitioners, community medicine post graduates and disaster management personnel for imparting the skills needed to evaluate disaster response systems. The course included an overview of various components of

disaster response and practical t o o l s t o e v a l u a t e t h e s e components.

Sixty-one participants, (public health personnel, community medicine doctors, nurses, emergency physicians amongst others) sat through the 2 day track conducted by 4 faculties from New York Presbyterian Hospital .

The Communication Workshop focused on aspects of inter-agency communication during d i s a s t e r s m a n a g e m e n t , i m p o r t a n c e o f e f f e c t i v e communication with the media and global advancement in communication technology.

The 39 participants who took part in this very important workshop came from varied stakeholder agencies like revenue department, municipal corporation, police, fire service, EMS and hospitals. This course again was conducted by New York Presbyterian Hospital and UNDMT.

The School Safety Centric Disaster Preparedness program was attended by 51 key movers and 2000 school children. This was a 2 day course that focused on school disaster preparedness, child safety and preparedness audits. Following the course,

ththere was a fire drill on 5 of August 2011 at the Corporation High School, Thiruvanmiyur, Chennai by the Chennai Fire Service, where 2000 school children were taught fire safety, evacuation protocols during fire, first aid and methodology of removal of victims from the site of injury, etc.

The 51 key movers were participants from government and private schools; the significant key of the exercise was the profile of these p a r t i c i p a n t s . T h e y w e r e principals and head mistresses and senior school teachers. This was an attempt to institutionalise school safety and disaster

preparedness in schools. Four faculties of the All India Disaster Mitigation Institute (AIDMI), Ahmedabad conducted the course.

thA separate track on Higher Education Disaster Preparedness was held on the 6 August 2011, which targeted college superintendents and administrators, NSS and NCC Division Heads; they were sensitised on issues related to disaster preparedness, students' safety and various aspects of disaster response and management.

The 31 participants were trained by 4 faculties from the AIDMI, Ahmedabad.

The last of the tracks was on Industrial & Chemical Disaster Preparedness and was th thattended by 30 trainees on the 5 and 6 of August 2011. Considering the fact that Chennai city

is surrounded by more than 100 hazardous chemical industries, any disaster would cause immense damage to life and property. Hence, a special 2 day course on disaster preparedness and safety audits for industries was conducted. This course targeted at administrators, industrial safety officers, hospital safety officers, EMS administrators and industrial doctors of various industries in Suburban Chennai.

This course was conducted by National Civil Defence College (NCDC), Nagpur. A special HAZMAT drill was conducted during this course at SRU by NCDC assisted by the Chennai

thFire Service on the 6 of August 2011.

The Table Top Exercise

Table top exercises are always an important component of any Emergency Management Exercise.

thOn 7 August 2011 at 2.00 PM, a table-top exercise was conducted at the Main Auditorium of SRU by Robert Bristow, Dario Gonzales and Srihari Cattamanchi, in which 600 participants took part. All participants, especially team leaders from various collaborating local agencies met to practice simulated scenarios to identify roadblocks in communication and execution with a focus on the drill scheduled for the following day.

It also brought together leaders of Chennai's response agencies: Fire, Police, NDRF and EMS, along with heads of hospitals, doctors, nurses, non-governmental organizations to walk through a simulated disaster, step by step. As the scenario unfolded, the facilitator stopped and asked each sub-group to propose their response strategy. This exercise revealed the strengths and gaps in inter-agency communication and discrepancies and overlapped response planning among the various stake holders.

Disaster Drill

thOn the 8 of August 2011, a major incident was simulated and a controlled drill was conducted at the Pattinapakkam Corporation ground on South Canal Road, Chennai. A scenario was enacted, that of a wall collapse during a football match leading to stampede causing multiple casualty incident. This scenario was, created and executed by Nishanth Hiremath and Srihari Cattamanchi along with SEPAA and the faculties from New York. This simulated exercise was carried out in co-ordination with Chennai City Corporation, Chennai Police Services, Chennai District Fire Service, NDRF, NDMA, UNDMT and 200 junior artists and 20 make up men from Film Employees Federation, Chennai. A total of 700 participants directly benefitted from this simulated exercise.

Incident Command: This brought together all the major responders, testing real-time inter-agency communication and coordination at all levels of these organizations, especially the Incident Command Structure within Chennai City Corporation limits at the Disaster Cell in Chennai Police Commissioner's office

and its various agencies, National Disaster Response force, the private sector and citizen groups.

This drill also pushed the medical response system into handling extreme scenarios and compelled the physicians and m e d i c a l s t a f f o f b o t h g o v e r n m e n t a n d p r i v a t e hospitals involved in the disaster drill to prioritize care to maximise the saving of life and limb under duress. The Public Health Assessment participants, who were trained in monitoring and evaluating disaster drills u s i n g s t a t e - o f - t h e - a r t international tools, lent us s i g n i f i c a n t s u p p o r t i n conducting the drill by providing feedback on it to help us organise better drills in future and make our disaster response system better prepared.

Hot Wash: The term “Hot wash” or “After Action Meet” refers to a short discussion about the drill immediately after it gets over. The highlight of a Hot Wash is that every organisation that participated in the drill would come forward to describe/make constructive criticisms about the whole event. This enables every participant to run through the event again and opens a forum for them to clarify their doubts with the experts. CEMEx 2011 Mock Drill concluded with a 2 hour “Hot Wash” at 4.00 pm, which was conducted in the Main Auditorium of SRU. Various groups of experts expressed their views about the event, areas of difficulties were discussed and solutions were reached. The drill evaluators from each hospital presented their views about how their hospitals were prepared to manage the mass causalities.

Learning from Disaster Drill during CEMEx 2011

There were numerous lessons learnt from CEMEx 2011; there were different dimensions to the learning in this event. It sounded very easy, wel l

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planned, all in control and all groups felt prepared while analysing and discussing the event at the table top.

However, the reality was very different!

On the day of the event it did not seem so; it took a lot of time to grasp the situation and respond. As the mock drill began, the command centre setup at the Police Commissioner's office along with 7 participating agencies were in control of the situation, updating all the participating agencies.

But at the incident site different participating agencies had different incident commanders, different objectives and different plans, acting initially on their own, with no unified command system, action plan and response. There was improper communication from the incident command centre to the participating hospitals. Many gaps were identified in inter agency co-ordination. There was no onsite incident command centre.

As soon as the NDRF arrived, they started announcing” all those who can walk, please walk out of the scene.” This caused many victims with broken legs walking over to green area giving rise to improper triaging. These victims were re-triaged and transferred to their appropriate area by EMS personnel. This also resulted in some of the mock drill victims leaving the scene giving rise to un-accountability issues.

After the bomb squad arrived and announced “safe zone”, the EMS commander took charge of the triaging. He, along with the incident commander and the organisers were able to sort out the initial glitches, which existed, discussing with all the participating agencies on the ground.

A good, systematic information system was set up by the EMS commander who kept a record of how many victims were transported to each of the hospitals, to ensure equal distribution of causalities. Each hospital was called and informed as soon as the ambulance was dispatched. Even with such preparations on the field there was some disparity in the distribution of victims to the hospitals. Some had received 60 patients and one didn't receive any patient at all. This was again a learning experience to enable us to have the maximum utilization of our resources at the hospitals.

As the ambulances were on the road, the Chennai traffic police did an excellent job

managing the traffic and making way for the ambulance to reach the hospitals on time. It was a well co-ordinated effort. As the causalities reached the hospitals, teams awaited at entrances to receive and manage the causalities. The hospital staff were well prepared and managed to run the show smoothly. They were able to deliver as per plans. A total of 60 mock drill victims were unaccounted for, giving rise to serious security and accountability issues.

The greatest learning from this drill was that every city needs a disaster plan, not only on paper but on ground also. Hence, it is essential to have periodic drills not only in order to be ready to face disasters but also to effectively and efficiently utilize the resources that we have.

Valedictory Ceremony

The Valedictory Ceremony of CEMEx 2011 was held immediately after the “Hot Wash” at 5.00 PM. Muzzafar Ahmed, Hon’ble Member of National Disaster Management Authority was the Chief Guest for this ceremony.

Delivering the valedictory address, he stated that CEMEx 2011 has been a great success. According to him, “the vision of NDMA along with UNDMT in CEMEx 2011 was to have a

leadership with reference to risk resilience in the urban cities in India, which are most vulnerable and most multi hazard prone. CEMEx achieved that goal.”

He expressed his happiness about the way various tracks were organised and voiced his satisfaction that CEMEx 2011 was able to create a resource of 1000 people. “CEMEx has added 1000 people to the resource database of Tamil Nadu and this resource pool will be helpful for the disaster p re v e n t i o n , m i t i g a t i o n , preparedness and response. CEMEx has truly exhibited the spirit of multi stakeholder partnership in collaboration with NDMA, UNDMT and SEPAA.”

Prof. Mahesh Mishra of JPN Apex Trauma Centre, New Delhi and Sanjeev Bhoi, Associate Professor, Dept. of Accident & Emergency Medicine, AIIMS, New Delhi, were present during the table top exercise, disaster drill and hot wash as observers from Government of India with the aim to evaluate and conclude the feasibility and utility of replicating similar training exercises all over India by NDMA in near future.

Lessons of CEMEx

Strengths

l One of the biggest disaster p r e p a r e d n e s s t r a i n i n g programs conducted in the country

l Thirteen academic activities were targeted at various stakeholders of the society

l Multi-institutional PPP with active participation of NDMA for the first time in s u c h e m e r g e n c y management exercise

l Active participation from different State Government a n d C h e n n a i C i t y Corporation institutions in the academic activities

l A total of 600 people a t t ended the t ab l e top

exercise making it one of the largest table top exercises conducted in the history of the country in formulating an urban centre disaster preparedness plan

l 2000 school children and 50 school headmasters / headmistress were taught about school fire safety and school evacuation during fire

l Created awareness amongst the officials of the municipal corporation and encouraged them in preparing a multi hazard disaster plan for city of Chennai

l Helped all the participating private hospitals to create a robust disaster preparedness plan or revising the existing disaster plan, testing the respective plans through individual drills and table top exercises, updating and executing them during the combined city wide disaster drill

l The disaster drill identified various loop holes in the disaster preparedness of the city of Chennai, giving the administrators the chance to rectify them and be better prepared for future disasters

l Created awareness amongst the first responders of various public and private agencies and encouraged them to improve their inter agency coordination, which is of great importance during disaster response.

l Also created awareness about the need of frequent multi-institutional public private disaster drills in the near future in order to make a more resilient Chennai, one that is better prepared to manage disasters

l Pool of Resources: A pool of 980 resource personnel has been created, a pool that can be activated at a short notice in the event of a multi-casualty incident. Data base of all resource personnel comprising of their contact details and their competencies and skill sets developed has been submitted by CEMEx 2011 organisers to the State Disaster Management Authority (SDMA) and the NDMA. In future urban catastrophes or disasters, resource personnel from the above database can be called on to serve and respond to disasters

l Future Plan: A detailed report of CEMEx 2011 based on the deliberations that took place during the 3 ½ days of training program, tabletop exercise, disaster drill and “Hot Wash”, along with recommendations will be submitted to the NDMA based on which a NEEDS ASSESSMENT Workshop will be conducted by NDMA, UNDMT and SEPAA along with the Government of Tamil Nadu, SDMA, Chennai City Corporation and Disaster Cell at Chennai Police Commissioner's Office

Weaknesses (where difficulties were encountered)

l Absence of effective incident command system and ICS protocols

l Different agencies had different objectives and different plans during the disaster drill, even though they were debriefed before the drill

l Absence of inter agency coordination

l Poor communication from incident command centre to govt and private hospitals

l Lack of disaster response training and common standards and guidelines for disaster response among various response agencies.

l Inadequate facilities at the drill site for the disaster responders safety and needs

Dr Srihari Cattamanchi,The Author is Disaster Medicine Research Fellow,Harvard Affiliated Disaster Medicine Fellowship,

Division of Emergency Medicine, Harvard Medical School,Department of Emergency Medicine, Beth Deaconess Medical Centre

Co-authored byDr Nishanth Hiremath,

Accident & Emergency Medicine,Consultant, Department of Emergency Medicine, Columbia Asia Hospital

EMS in Maharashtra

EMS of Maharashtra state, first talked about 5 years back after the serial blasts in 2006 and marked by incessant delays and controversies since then, seems to be finally on track. The proposal was cleared by the cabinet on October 15, 2008.

Maharashtra Emergency Medical Services (MEMS) will have a 24x7 call centre and a fleet of 937 life support ambulances to cater to the emergency medical needs of t h e r u r a l a n d u r b a n population. The system will have 374 ambulances in the first phase, 373 in the second phase and 190 in the third phase.

The Government unlike other states has not just asked for ambulances but an entire trauma management system.

The helpline will be a toll free number accessible from l a n d l i n e o r m o b i l e . Emergency help will reach on an average in 18 minutes, according to the State Health Minister, Suresh Shetty.

Initially, only the highways will be covered. The service will be extended to districts in the next phase and then talukas will be encompassed.

The state government has now roped in experts from AIIMS to provide technical support in the planning and design of the ambulances it proposes to roll out under the NHRM.

According to Suresh Shetty, “ s i n c e t h e 1 , 0 0 0 o d d ambulances will be deployed across the state, including remote areas, we did not want to leave any lacunae in the d e s i g n a n d t e c h n i c a l viability”.

Like other states, 108 will be the common access number.

Disaster Management Drill