The State Of Emergency Preparedness on 9/11/14: Are We Ready?

The State of Emergency Preparedness on 9/11/14:Are We Ready?

Nicholas E. Kman, MD FACEPMedical Team Manager, Ohio Task Force 1The Ohio State University Department of Emergency MedicineTwitter @drnickkman

Disclosures

None

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September 11th, 2001



October of 2001

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2005 Hurricane Season

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March 2011, Japan Earthquake and Tsunami

Hurricane Sandy 10/25/12

Hurricane Sandy

Boston 4/15/13

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2014 Ebola Outbreak

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2014 Ebola Outbreak

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Objectives

Provide a background on Emergency Preparedness and Disaster Medicine since 9/11/01.

Analyze the Disaster Response Paradigm. Describe the resources and stakeholders in the

region. Outline methods by which community agencies (law

enforcement, public health, emergency medical services, schools, etc.) interact to coordinate disaster response.

Review WMD and CBRNE Agents

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Disaster Defined

The United Nations Disaster Management Training Program defines Disaster as: A serious disruption of the functioning of society,

causing widespread human, material, or environmental losses which exceed the ability of affected society to cope using only its own resources.

Bonnett et al. Surge Capacity: A proposed conceptual framework. Amer J of Emerg Med 2007; 25: 297-306.

Dominique Faget—AFP/Getty Images

A Disaster: more simply…

Any event that threatens or overwhelms the normal operational capacities of the local healthcare system and emergency medical services (EMS).

University of Wisconsin Cooperative Institute for Meteorological Satellite Studies

National Preparedness

National Disaster Medical System


Supplement an integrated National medical response capability for assisting State and local authorities in dealing with the medical impacts of major peacetime disasters

To provide support to military and the Department of Veterans Affairs medical systems in caring for casualties evacuated back to the U.S. from overseas armed conventional conflicts.

NDMS also interfaces with state/local Departments of Health & private hospitals.

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How did I get involved?

NC Disaster Response (SORT) SORT provides advanced life support medical teams

for mass crowd gatherings such as college graduations, special awards ceremonies, sporting events, and VIP visits.

How did I get involved?

NC Disaster Response (SORT) SORT provides advanced life support medical teams

for mass crowd gatherings such as college graduations, special awards ceremonies, sporting events, and VIP visits.

Ohio Task Force-1

1 of 28 Urban Search and Rescue (US&R) teams in National US&R Response System managed by FEMA.

OH-TF1 also State of Ohio rescue response asset.

Urban Search & Rescue

The science of responding, locating, reaching, medically treating, and safely extricating victims entrapped by collapsed structures

Ohio Task Force-1

Fire, law enforcement, emergency medical and hospital personnel, structural engineers, and other professionals.

When requested by FEMA, Ohio Task Force One is deployed to scene of disaster in 1 of 2 configurations:

Type I (heavy) or Type III (light).

OH-TF1 Mission

Location and extrication of victims entombed by structural collapse.

Specialized expertise needed in emergency medicine, hazardous materials, and structural engineering.

Even food, shelter, transportation, and communications must be provided.

OH-TF1 Post 9/11 Mission

The core mission of the team expanded to include ability to perform search and rescue operations in a Weapons of Mass Destruction environment.

OH-TF1 Medical Team Manager

Has overall responsibility for management and supervision of medical function of task force during incident operations.

The Medical Team Manager reports directly to the Task Force Leader.

Directing medical care delivery to task force personnel, search dogs, and victims

Ropes TrainingCamp Ravenna Joint Military Training Center

Florida State Fire College

Camp Atterbury, Muscatatuck Urban Training Center


Disaster Response: DMAT’s

DMATs (OH1, OH5, OH6) Disaster Medical Assistance Team (DMAT) is

response unit of National Disaster Medical System composed of professional and paraprofessional medical personnel

Designed to provide emergency medical care during a disaster or other event.

Franco et al. The National Disaster Medical System: Past, Present, and Suggestions for the Future. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, Science 2007; 5: 319-325.

National Incident Management System

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Incident Command System (ICS)

Set of personnel, policies, procedures, facilities, and equipment, integrated into common organizational structure designed to improve emergency response operations of all types.

May be used for planned events, natural disasters, and acts of terrorism.

Is a key feature of the National Incident Management System (NIMS 2004).


An ICS is based upon a changeable, scalable response organization providing hierarchy within which people can work together effectively.

“First-on-scene" structure: First responder to scene has charge until incident has been declared resolved or a more qualified responder arrives and receives command.

Used by all levels of government—Federal, State, local, and tribal—as well as by many private-sector and nongovernmental organizations.

http://emilms.fema.gov/IS200b/ICS0102summary.htm

ICS

Structured to facilitate activities in 5 major functional areas: Command Operations Planning Logistics Finance and administration.

34 http://emilms.fema.gov/IS200b/ICS0102summary.htm


Regional Emergency Preparedness

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Fenzl, Mark (09/2008). "Chemical exposure preparedness for emergency departments in a Midwestern city". American journal of disaster medicine (1932-149X), 3 (5), p. 273.


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Ohio EMA

Coordinates activities to mitigate, prepare for, respond to and recover from disasters.

Interfaces with local, state and federal agencies in effort to bring resources of recovery and support to Ohioans impacted by disaster.

Also: education, training, planning and preparedness - strengthening Ohio's first responder capabilities and improving communication.

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CMMRS

CMMRS mission is to enhance the existing emergency preparedness system within the Columbus and surrounding Metropolitan areas

To effectively respond to public health/medical emergencies or events involving CBRNE, in order to minimize loss of life, disability, and suffering.

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CMMRS

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52nd WMD-CST AD8 Aerospace Medicine Squadron Alcohol Drug & Mental Health Board of Franklin Co American Red Cross Disaster Services Armada Battelle Memorial Institute BOMA Columbus Siemens Industry Bucyrus Community Hospital Capital Square Review & Advisory Board Central Ohio Amateur Radio Emergency Service Central Ohio Amateur Radio Emergency Service Central Ohio Area Agency on Aging Central Ohio Poison Center Central Ohio Trauma System CEPAC Civil Air Patrol Columbus Dept of Safety and Occ. Health Columbus City Schools Columbus Division of Fire Columbus Division of Police Columbus Public Health Columbus Neighborhood Health Center Columbus Regional Airport Authority Columbus State Community College Crawford County EMA Crawford County Health Department Delaware County General Health District Delaware Health Doctors Hospital Dublin Methodist Hospital Fairfield County Health Department Fayette County Fayette County Memorial Hospital Federal Bureau of Investigation Franklin County EMA and HS Franklin County Public Health Franklin County Comm. Emer. Response Team Franklin County Coroner's Offi ce Franklin County Engineer's Offi ce Franklin County Sheriff's Office Franklin Co. Offi ce Of Homeland Security & Justice Fusion Center Galion City Health Department Grandview Heights Fire Department Hands On Central Ohio Hilliard Police and Fire Huntington National Bank Kenton-Hardin Local

Knox County Licking County/Newark City Logan County Health District Madison County Emergency Management Agency Madison County - London City Health District Madison County - London City Health District Marion County Health Department Medflight Mid-Ohio Regional Planning Commission (MORPC) Morrow County Nationwide Children's Hospital Norwich Fire Department Ohio Air National Guard Ohio Department of Health Ohio Dept of Health Bureau of Radiation Protection Ohio Department of Public Safety Ohio Department of Homeland Security Ohio Department of Mental Health Ohio Emergency Management Agency Ohio Environmental Protection Agency Ohio Health Ohio Expo Center The Ohio State University OSU Medical Center OSU Department of Public Safety Park National Bank Pickaway County General Plain Township Fire Union County General Union County Health Department Union County MRC Upper Arlington United States Postal Service United Way of Central Ohio Whitehall Fire Department Worthington Fire Department Worthington Wyandot County General Wyandot County Health Department


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Central Ohio Poison Center

Marcel Casavant: Pre-Incident: Ongoing Planning with CMMRS Ongoing Preparedness Activities Ongoing Response Activities Actual Incident: Responsibilities

24-Hour Toxico-epidemiologic consultation Calls from Medical Professionals Calls from Public

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COTS

501(c)(3) private non-profit organization that coordinates trauma care, emergency care, and disaster preparedness systems throughout 15 counties in central Ohio.

COTS manages and distributes Federal preparedness funds to 29 partnering hospitals and community healthcare partners in Region 4.

Supports prevention, education, data collection and research initiatives.

46http://www.goodhealthcolumbus.org/cots.html

COTS and COHC


COTS Hospital Incident Liaison (HIL)

Response to 9/11 terrorist attacks. COTS established HIL role to support central Ohio

hospitals and partnering agencies in disaster. HIL serves as conduit for situational awareness and

information sharing, assists with regional resource allocation, and facilitates the coordination of response activities for 29 trauma and acute care hospitals throughout central Ohio.

Staffed 24/7 by 10 trained personnel.







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Nationwide Children’s EP Committee

2 part-time roles dedicated to EP, an Emergency Preparedness Coordinator (Darlene Radel) and an Emergency Preparedness Educator (Kathy Wareham).

EP Committee meets monthly 25 individuals, including our Trauma Medical Director

(Dr. Jon Groner), an Emergency Physician (Dr. Ellen McManus), and Central Ohio Poison Center leadership (Dr. Marcel Casavant and Rick Spiller).

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Nationwide Children’s EP Committee

Offsite EP Committee: offsite NICUs, Urgent Care Centers, Close to Home Centers, Labs, Behavioral Health Clinics, etc.

RISK Assessment Team (RAT): Small group of individuals activated for potential disaster to determine scope of NCH response and need to activate EOP.

Work closely with community partners via COTS, OHA, EMS for Children, CMMRS and the Franklin County Healthcare Coalition.

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4 Phases of Public Health Disaster Paradigm

Emergency Preparedness

● Phase 1: Preparation

● Phase 2: Mitigation

Disaster Management

● Phase 3: Response

Prehospital and Inhospital Care

Pathophysiology and Patterns of Injury

● Phase 4: Recovery

American College of Surgeons, 2008, Advanced Trauma Life Support for Doctors, American College of Surgeons. Eighth Edition.





Disaster Management






“Do the greatest good for the greatest number”

Preparation

Conduct a Hazard Assessment Actual and potential hazards

Develop a simple disaster plan (EOP) Failing to plan is planning to fail!

Train all hospital staff in its application Awareness Technicians Patient care

American College of Surgeons, 2008, Advanced Trauma Life Support for Doctors, American College of Surgeons. Eighth Edition.American Medical Association, 2012, Basic Disaster Life Support, Course Manual. V. 3.0.

Preparation and Education

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Preparation and Education

https://www.dropbox.com/s/arlvoylmyypa96b/Edited%20Disaster%20Drill.avi

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Mitigation

Have an Incident Command System HICS (Hospital Incident Command System):

organizational structure that provides direction for management of disaster response within hospital.

Train all staff in its application and use Plan in advance to ensure a coordinated response


Response: Prehospital and Inhospital Care

Implement the planned response quickly Decontaminate every patient

Avoid contamination of facility, quarantine

Disaster triage scheme (SALT) Immediate, delayed, minor, [expectant], dead

Effective surge capability Expect patient volume increased 20%

Don’t expect outside help for at least 24 hours


Disaster Crash Course

Photo: NASA GOES Project

Natural Disasters

Natural Disasters Earthquakes Landslides and Mudslides Tsunamis Volcanoes Wildfires

Weather Emergencies Extreme Heat Floods Hurricanes Tornadoes Tsunamis Lightning Winter Weather

Haiti Earthquake 2010 US&R LA County

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Weapons of Mass Destruction (CBRNE)

Weapon Types: CBRNE

Chemical

Biological

Radiological

Nuclear

Explosive

Day 5 Bacillus anthracis infection involving left eye.www.phil.cdc.gov/phil. Image part of public domain

“CBRNE” = Chemical, Biological, Radiological, Nuclear, Explosive & Incendiary

Classification of Chemical Agents

Toxic agents: producing injury or death Lung damaging agents (choking agents)

Chlorine (CL), phosgene (CG), smokes, vesicants, TICs

Nerve agents – anticholinesterases Tabun (GA), sarin (GB), soman (GD), GF, VX

Blister agents – vesicants Mustard (H), Lewisite (L), phosgene oxime (CX), riot

control agents, T-2 mycotoxins

“Blood” agents – cyanogens AC and CK

CBRNE: Chemical

Nerve agents: atropine, pralidoxime, ± benzodiazepine (Mark I or Duodote Autoinjector)

Blood agents: hydroxocobalamin (or sodium nitrite + sodium thiosulfate)

Choking agents: supportive care Blister agents: careful decontamination, wound care All chemical agents require decontamination (should

be done at scene or outside hospital)

CBRNE: Radiological

“Dirty Bombs” “Low-level” industrial / medical radioactive waste

Treat radioactive contaminants as “dirt” Harmless to properly garbed providers All radiological agents require decontamination Decontamination should not delay necessary care

Resuscitation before decontamination in extremis


CBRNE: Nuclear

Reactor meltdown Highly radioactive products of fission reactions

Alpha radiation: no penetration – extremely dangerous if inhaled or ingested

Beta radiation: skin burns >100 rad (>1Sv) X-ray and gamma radiation: acute radiation

syndrome >200 rad (>2Sv) Perform needed operations within first 3 days –

hematopoietic failure impedes wound healing


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Columbus and Metropolitan Medical Response System

(CMMRS)

Columbus, Ohio

GUIDELINES FOR THE MEDICAL MANAGEMENT OF

RADIATION CASUALTIES Produced by the: Medical Management Workgroup, CMMRS Radiological Sub-Committee Marcel J. Casavant MD, Workgroup Chair Caitlin Spontelli, MPH Coordinator January 23, 2012

CBRNE: Explosive & Incendiary

Blast Effects 1°: overpressure injuries from blast wind 2°: penetrating injuries from fragments 3°: blunt injuries from impact 4°: other injuries (including burns)


Biological Warfare (BW) is intentional use of biological (bacterial, viral, fungal) agents or toxins to cause death or disease among personnel, plants, or animals, or to deteriorate material.

Biological Weapons

Anthrax eschar on the neck.http:phil.cdc.gov/phil. Image in public domain and free to use

Agent categories: Bacteria: microorganisms capable of living & reproducing

outside body & not dependent upon host, provided proper environmental conditions exist.

Toxins: chemical compounds produced by living organisms. Toxins are chemical compounds rather than living organisms & cannot reproduce themselves or be transmitted person-to-person.

Viruses: organisms that require living cells to replicate.

Biological Weapons

Infectivity Contamination Virulence Incubation period Transmissibility Lethality

Biological Agent Characteristics

http:phil.cdc.gov/philImage in public domain and free to use

Anthrax Smallpox Plague Botulism Hemorrhagic Fever Viruses Tularemia

Category A Diseases/Agents

The Cities Readiness Initiative is federally funded effort to prepare major U.S. cities and metropolitan areas to effectively respond to a large scale bioterrorist event by dispensing antibiotics to population within 48 hours.

Since 2004, the CDC has provided funding for CRI through the Public Health Emergency Preparedness Cooperative Agreement.

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Ebola HF in the Acute Care Setting

Objectives for acute presentation of Ebola HF (Hemorrhagic Fever)1. Identification & Recognition2. Isolation3. Medical Treatment

Identification of Ebola HF Patients

Education of staff Increased awareness levels at portals of entry

Clinics Urgent care centers Emergency departments

Public health awareness Patient self-selection Signage & outreach


Screening criteria for Ebola HF in the ED: Any of the following symptoms:

Fever >101.5F Headache Joint / muscle aches Weakness Vomiting Diarrhea


Ask about travel to high-risk areas <21days: Guinea Liberia Nigeria Sierra Leone

Concerning symptoms PLUS high risk travel requires immediate isolation!

Isolation of Ebola HF Patients

Place a mask on the patient Initiate contact, droplet, & airborne precautions

Staff personal protective equipment includes: Gown Gloves Mask Eye protection


Outpatient setting Arrange transfer to ED (via ambulance with PPE)

Emergency Department Place patient in private room with bathroom Negative airflow not required Contact, Droplet & Airborne isolation precautions Dedicated medical equipment should be disposable

when possible


Notifications: ED Attending Critical Events Officer Infectious Disease Team Public Health Department (via the CE Officer)

This notification chain is institution dependent

Initiation of laboratory testing

Acute Medical Treatment of Ebola HF

Supportive therapy: Fluids and electrolytes Blood pressure and oxygen status Treatment of complicating infections

Initial management of complications Admission to the inpatient setting

Level of care depends on acuity of illness





Disaster Management






Final Pearls

Communications-Cell Phones Go Down! Redundant modes / systems / equipment

Supplies-Bring your own Ample supply stores / reliable supply chains

Security Control traffic flow / patient, staff safety

Volunteers Physician role is hospital-based patient care

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Final Pearls

Have a straightforward disaster plan and educate everyone in its use.

Have an incident command structure and drill often. Have a disaster triage scheme, and mobilize surge

resources as needed. Have a traffic control system and communication

system.

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What can you do?

Be Informed: Learn your Emergency Operations Plan (EOP) and exercise it.

Find out where you would report in a disaster. Make a Plan: Prepare yourself and your family (

www.ready.gov). Build a kit. Get Involved: Join your Emergency Preparedness

Committee. Go Regional, then National!

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References

FEMA Medical Team Training Student Reference CD (2/2009)

FEMA WMD for Medical Specialist Training CD

Franco et al. The National Disaster Medical System: Past, Present, and Suggestions for the Future. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, Science 2007; 5: 319-325.

Bonnett et al. Surge Capacity: A proposed conceptual framework. Amer J of Emerg Med 2007; 25: 297-306.

ATLS 8th Edition.

www.ready.gov

Kman NE, Bachmann D. “Biosurveillance: A review and Update.” In Special issue: Advances in Development of Countermeasures for Potential Biothreat Agents. Advances in preventive medicine, v. 2012, 2012, p. 301408.

Kman N, Rund D. “Disaster Preparedness 10 years after 9/11: The Experts Weigh In”. Emergency Medicine. Emerg Med 2011; 43(9): 12-13. (September) www.emedmag.com.

References

www.fema.gov

www.cdc.gov

http://phil.cdc.gov/phil/home.asp

Marchigiani R, Gordy S, Cipolla J, Kman NE, Stawicki S, et al. "Wind disasters: A comprehensive review of current management strategies." International journal of critical illness and injury science. Vol. 3, no. 2. (Apr 2013): 130-142.

Kman N, Bachmann D, Folley A, Adams J, Greer M. Emergency Preparedness Simulation Cases for Medical Students: Crush and Organophosphate Exposure. MedEdPORTAL; 2013. Available from: http://www.mededportal.org/publication/9330.

Yuri Rojavin, Mark J Seamon, Ravi S Tripathi, Thomas J Papadimos, Sagar Galwankar, Nicholas Kman, James Cipolla, Michael D Grossman, Raffaele Marchigiani, Stanislaw P A Stawicki. “Civilian nuclear incidents: An overview of historical, medical, and scientific aspects.” Journal of emergencies, trauma and shock, v. 4 issue 2, 2011, p. 260-72.

Kman NE, Nelson R. Infectious Agents of Bioterrorism: A Review for Emergency Physicians. Emerg Med Clin N Am 2008; 26: 517-547.

Questions

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