Disaster Response And Respiratory Care

Objectives

Understand the universal characteristics of disasters and the components of an all hazards approach to disaster management involving healthcare practitioners.

Demonstrate understanding of the role of Respiratory Therapists in disaster response and emergency management; and, describe the role of Respiratory Therapists as volunteers for disaster response.

Objectives

Explain the various levels of equipment and support Respiratory Therapists will utilize in responding to mass casualty incidents and disasters.

Discuss the implication of Pandemic Influenza as it relates to planning and response capability and capacity.

Describe the impact of Bioterrorism and man-made disasters to health care systems, providers, and disaster preparedness plans.

What’s The Fuss?

How Do We Respond To This…

So We Don’t Feel Like This…

Disaster Characteristics

Increased death, injury, illness that can’t be managed

Coordination public, government, and private organizations

Equal triage distribution Notification of family Evacuation/Sheltering

of evacuees

Disaster Characteristics

Media attention Heightened security;

crime scene Immediate and long

term emotional support

Significant property damage

Impact of Disasters

In the past 20 years “Although the yearly death totals from disaster declined by approximately 30%, the number of people affected by disaster increased 59%”

(AARC Times. 2006. p. 8)

Consequence Management

The objective of consequence management is:Provide supportSave livesRelieve sufferingMitigate further harm

Preparedness Cycle

Plan

Train

Equip

Exe

rcis

e

Health systems will be prepared through a continuous cycle of planning, equipping, training and exercising.

P.E.T.E.

PlanPublic Health Preparedness Strategic Plan

EquipVentilators, PPE, Pharmaceuticals, etc…

TrainOSHA, DHS, Other

ExerciseLocal, Regional, Statewide, Interstate,

National

Surge Surge CapacitCapacit

yy

County Health Departments

Pre-hospital

Outpatient Services

Hospitals

Pharmacies

Laboratories

Mortuary Services

Public Health Response

Health Care System

Domestic Security Regions

Region 1 Region 2 Region 3 Region 4 Region 5 Region 6 Region 7

Integrated Plans Federal

National Response Framework (NRF) Supported by National Incident Management

System (NIMS) and the National Disaster Medical System (NDMS)

Comprehensive Emergency Management Plan (CEMP)

Provides guidance Integrated and coordinated response Emergency Support Functions (ESF-8) Follows NRF

Integrated Plans State

Florida Department of Health Bomb, Blast, Burn (B3) Biological (B4) Pandemic Influenza Public Health and Medical Preparedness

Strategic Plan 2007-2010

County CEMP PlansHospital CEMP Plans

Goal of Surge Thinking

Maximize survival for all players!

Minimize morbidity!Maximize resource

utilization!Will require new thinking!

Natural Disasters

Natural Disasters

Tornadoes Forest Fires Floods Blizzards Cyclones/Typhoon Hurricanes Heatwave

Tsunami Volcanic Eruption Earthquakes Mudslides Limnic Eruption Draught/Famine Hail

Natural Disasters - Florida

Hurricanes Tornadoes Forest Fires Flooding Freezing Sinkholes Drought Heatwave Hail

Natural Disasters - Florida 2004

July 31 to December 3 9 Hurricanes; 5 Tropical

Storms Charley, Frances,

Jeanne, Ivan

2005 June 8 to January 6 15 Hurricanes; 12

Tropical Storms Katrina, Rita

Cost – 2004 Hurricane Season

Florida’s hospitals incurred $163.2 million in unexpected costs

Expenses related to facility modifications to reduce damage from future storms would exceed $48 million

Average hospital impact of more than $1 million

Total impact on hospitals > $200 million

Lessons Learned

Preparation Facility Planning

Power, Medical Gases, Water, Etc. Flood zone Material Resources

Communication Redundancy Contingency plans Incident Command!

Lessons Learned

Workforce issuesAdequate staff

Hospital Planning Incident CommandEducation/Training

Special Needs Behavior Health

Patient & Employee

Lessons Learned

Hospital Security Facility support Protective measures

Patient Safety Mutual Aid

Public and private partners

Medivac

Man-Made Disasters

Unintentional / Accidental

Engineering Failures Bridges, Buildings, Dams

Transportation Planes, Trains, Automobiles,

Shipping Environmental

Oil spills, pollution, waste runoff

Explosions Mine disasters Industrial accidents War Fire

Terrorism

Poking skunks is dangerous!

Terrorism

The goals of terrorists are to: Create confusion, fear,

chaos, and mistrust. Break down the

physical and political infrastructure.

Intimidate, subjugate, and weaken authority.

HOW WILL OUR ENEMIES FIGHT US?

UNCLASSIFIED

CChemicalhemical

BBiologicaliological

RRadiologicaladiological

NNuclearuclear

EEnergetics / nergetics / ExplosivesExplosives

CChemicalhemical

BBiologicaliological

RRadiologicaladiological

NNuclearuclear

EEnergetics / nergetics / ExplosivesExplosives

A Weapon of Mass Destruction is a device or material specifically designed to produce casualties or terror. CBRNE incidents may result from industrial accidents, acts of war, or acts of terrorism.

Chemical Agents

Mustard gas Sarin Phosgene Cyanide Chlorine

Chemical Agents

Industrial Chemicals

Choking Agents Blood Agents

Warfare Agents

Blister Agents Nerve Agents

Routes of exposure Inhalation, skin contact, ingestion, injection

Effect depends on doseLarger dose: earlier and more severe effectsEffects may be immediate or delayed

Individual susceptibility variesAge, chronic illness, medications

Exposure To Chemicals

Biological Agents: Undetectable by human senses +

Prolonged incubation period +

Limited surveillance capability = Unrecognized exposure

Bio-threats

Biological agents may be: Bacteria Viruses Toxins

They are naturally occurring and / or can be bioengineered as Weapons of Mass Destruction.

Routes of Transmission

Absorption: Skin and mucus membranes

Inhalation Respiratory through air droplets

Ingestion Gastrointestinal through consumption of food or

drink Injection

From needle or other object

Vectors

Letters / packages Insects / animals Contaminated food /

water Contaminated

clothing Air via aerosol

dissemination device

Anthrax (Bacillus anthracis) Botulism (Clostridium botulinum toxin) Plague (Yersinia pestis) Smallpox (Variola major) Tularemia (Francisella tularensis) Viral Hemorrhagic Fevers (Filoviruses

[e.g., Ebola, Marburg] and Arenaviruses [e.g., Lassa, Machupo])

CDC Category A Agents

Nuclear / Radiological Agents

Any source that emits radiation

Radiation Exposure

External – deposited on skin Internal – inhaled, swallowed, absorbed

through skin, or introduced through wounds Incorporation of radioactive materials –

uptake by body cells, tissues, or organs such as kidney, liver, and bone

Symptoms of Radiation Exposure

Nausea Vomiting Diarrhea Changes in mental

status

Early Detection

Is your key to limiting potential exposure.

Time is a huge factor in how much exposure one could receive.

Image Source http://www.awe.co.uk/Image Source http://www.awe.co.uk/

Beta Beta - - bbAlpha Alpha - aaAlpha Alpha - aa Gamma Gamma - gg Neutron Neutron - n

Radiation PenetrationRadiation Penetration

Dirty Bomb vs. Atomic Bomb

The atomic explosions that occurred in Hiroshima and Nagasaki were conventional nuclear weapons involving a fission reaction.

A dirty bomb is designed to spread radioactive material and contaminate a small area.

Terrorist Attacks

So called suicide attacks Unfortunate experience and expertise from

Israel Use of explosives and shrapnel (bolts, nails,

nuts) Predominate injury is lung injury (blast injury) 50% of patients who survive to hospitalization

develop ARDS and require mechanical ventilation

Terrorist Attacks 20 attacks > 10

wounded Total of 1475

wounded, 92 ICU admissions, 80 patients requiring MV

52% of patients had acute lung injury

Blast injury is the major mechanism

Aschkenasy-Steuer et al Crit Care 2005;9:1186

Terrorist Attacks 1983-2004 all multiple casualty events 875 patients from 31 events in Jerusalem Average of 28 patients per event ICU admission 5% (n=43) - of these70%

had blast lung injury 73% of patients required mechanical

ventilation

Avidan V, J Trauma. 2007 May;62(5):1234-9.

Plausible Scenarios

Trauma – natural or man-made Nerve agents – sarin, tabun, VX, soman Pulmonary Irritants – phosgene,

ammonia Biologic Agents – plague, tularemia,

anthrax, botulism Radiologic Events – nuclear weapon,

dirty bomb

Plausible Scenarios

SCENARIO TIME TO MVDURATION

OF MVVICTIMS NEED FOR MV

TraumaImmediate Days to weeks < 100

Hemo – pneumothorax, blast injury, burns smoke inhalation

Nerve Agent Immediate Hours Up to 1000Paralysis, bronchospasm,

bronchorrhea

PulmonaryIrritants

Hours Days to weeks Up to 1000ARDS, pulmonary edema, airway injury

Biologics Hours to days Days to weeks 1000ARDS, hemorrhagic

pulmonary edema

Radiologic Days to weeks Days to weeks HundredsTraumatic lung injury,

sepsis,

Rubinson L, Biosecur Bioterror. 2006;4(2):183-94.

Vulnerabilities

Hard Targets Military instillations Government buildings Secure Areas

Soft Targets Hospitals Schools Churches

Prevention Efforts

Rely on:Federal, State, & Local Law Enforcement

AgenciesHospital Hazard Vulnerability AssessmentsAccreditation and Regulatory AuthoritiesDiligence, Observation, ReportingSafety Committees >>> Performance

Improvement

Probability vs. Impact

POTENTIALIMPACT

PROBABILITY/LIKELIHOOD

NUCLEARWEAPON

IMPROVISEDNUCLEAR

DEVICE

RADIOACTIVEMATERIAL

CHEMICAL AGENTOR TOXIC

INDUSTRIALCHEMICAL

BIOLOGICALAGENT

Pandemic Influenza

Is it here yet?

Natural Biologic Threat

What is a pandemic?The spread of disease

over a wide geographic area affecting much of the population

Natural Biologic Threat

Pandemic Influenza Increased morbidity

(sickness) and mortality (death)

Social disruptionEconomic disruption

Seasonal vs. Pandemic Flu

Seasonal Yearly Familiar virus Mild/Moderate

Symptoms Very young, very old;

Health problems Vaccine available

Pandemic Rarely New virus Severe symptoms Healthy people No vaccine

Influenza Disease Characteristics Inflammation of the respiratory system Headache Fever Chills Cough Muscle aches Several days sick, several weeks

recovering

Pan Flu Stats Pandemic Influenza

History 1918 50 – 100 million deaths 1957 2 million deaths 1968 1 million deaths

Frequency ~ every 35 yearsDuration 1 – 3 yearsWorldwide 6 – 9 months, 3 months?Waves 1 – 3, 4 – 8 weeks/wave

National Strategy

1. Stop, slow or otherwise limit the spread of a pandemic to the United States

2. Limit the domestic spread of a pandemic, and mitigate disease, suffering and death

3. Sustain infrastructure and mitigate impact to the economy and the functioning of society

U.S. Planning Assumptions

Attack rate 35% of populationTreatment rate 25% of population

~75% of casesHospitalization rate 10% of casesCase fatality rate 2% (2% - 50%)Pre/asymptomatic 30% - 50% (?)

transmission Incubation period 2 days (1 – 8 days)

Florida Planning Assumptions

1st Wave/2nd Wave Total Cases 3.2 million 6.4 million

Hospitalized (10%) 320,000 640,000 Surge Beds (130%) 65,000

ICU 48,000 ICU Ventilator 24,000 Surge Ventilators 5,000

Dead (2%) 64,000 128,000

Florida population: 18.3 million

Plan Components

Rapid Response Isolation &

Quarantine Social Distancing Non-Pharmaceutical

Interventions Pharmaceutical

Interventions

On-going Planning Issues

Community Interventions Hospital Planning Support Alternate Medical Treatment Sites Mass care with limited supplies and resources

Current Situation

Human Deaths* 353 cases, 221 deaths (62.2% Mortality) 14 countries

Bird Deaths 150 – 200 million bird deaths >50 countries (Asia, Europe, Africa)

*WHO, 24 January 2008*WHO, 24 January 2008

Respiratory Care

Your Role In A Disaster

Healthcare Considerations

Adequate bed space ICU Capability and

Capacity Workforce reduction

Options Pharmaceutical

stockpiles Material resource

utilization

Continuity of quality Standard of Care

Command & Control / Security Plan

Infection Control Employee and

Community Education Financial Challenge

Healthcare Considerations

External Influences Social & Economic Disruption Mutual aid difficulties School and Child Welfare issues

Internal Influences Employee Issues

Single parent families Both parents work in health care Children sick, parent / employee(s) not working

Hospital Issues

Patient Volume High-volume demand for

medical attention Competition for scarce

medical resources Impact on caregivers Need for psychological

support Need for security

Material Resource Management

IV Tubing Lab Resources Pharmaceutical

IV Fluids Antibiotics Antiviral Vaccine

Mechanical Ventilators

Medical Gas supply Food Services Environmental

Service supplies Linens

The Gas Source Issue

The Gas Source Issue What is the best source of oxygen?

What about home health agencies and their patients?

Power is an issue!

Necessary Ventilator Features for Each Scenario? Where will mechanical ventilation be

performed? Who will perform mechanical ventilation? Where will the gas supply come form? How long will it last? Does the ventilator’s capabilities match the

needs of the patient, skill of the operator?

Necessary Ventilator Features for Each Scenario? Most mass casualty injuries result in ARDS All scenarios except nerve agent exposure

require constant volume delivery, control of airway pressures, monitoring, alarms, and control of PEEP and FIO2

When nerve agents result in paralysis – airway control and short term ventilation – “good air in – bad air out” may be all that is necessary

Ventilator Characteristics

FDA approved for adults/peds

Ability to operate without compressed gas

Battery life 4 hrs Volume control CMV and IMV PEEP to 20 cm H2O

Utilize both high and low pressure O2 sources

Control of RR, PEEP, VT, Flow or I:E

Monitor Paw and VT Alarms

Disconnect, apnea, high/low pressure, high pressure source gas disconnect

Ventilator Characteristics

Rugged Light weight (<10kg) Easy to use Gas consumption -

low Battery life - long Easy to trigger

< $10 K Vendor support and

longevity Maintenance Training

Critical Factors

In a MCI – many patients will need ventilation exceeding not only equipment but staff capabilities

Likely that critical care RRT will supervise non-critical care RRT and others in care of the ventilated patients

The ventilator must have adequate alarms and monitoring

The ventilator must have a simple interface and be easy to use

Specific Devices

Concerns

Education and training

Universal response Decentralization of

supplies and equipment

Operability in MCI environments

Safety Age capability Compensation Legal protection Communications Vulnerable

Populations Volunteerism

FEHVR

Florida Emergency Health Volunteer Registry, the Florida Department of Health online system for health care providers and other private volunteers.

https://www.servfl.com/

Medical Reserve Corps

Mission: To augment local community health and medical services with pre-identified, trained and credentialed volunteers during emergency medical operations and vital public health activities.

Purpose: The Florida Medical Reserve Corps (MRC) Network was established for the purpose of effectively facilitating the use of health professional volunteers in local, state, and federal emergency responses in every county within Florida.

Licensure Renewal Statement

If you are renewing to active status, would you be available to provide health care services in special needs shelters or to help staff disaster medical assistance teams during times of emergency or major disaster? □ Yes

Other Issues

Disaster Implications

Communities Food, Water, Shelter Power Economic and Social

Disruption Child Safety Domestic Animals Personal Property

Damage

Disaster Implications

Patient Populations Food, Water, Shelter Power for medical

equipment Medications Renal Dialysis Increase hospital

surge!

Healthcare Impacts

Road Closures Hospital Closures /

Evacuation Workforce Shortage Resource

Management HVAC Water, Food Sanitation

Supplies Management

Surrounding IssuesJust-In-Time InventoryAccess

Equipment & SuppliesVent CircuitsAerosol and Humidity MedicationsOxygen SuppliesOther Medical Supplies

Infrastructure Support

Mutual Aid AgreementsVendor AgreementsHospital AgreementsGovernment Agreements

Local (i.e. – City, Municipality, County) Regional State / Inter-State Federal

Infrastructure Support

Workforce & Staffing Personal Plan PPE

Plant Facilities Security Plans Facility Safety

Communication Devices

Phones: cell, satellite, land based

800 mgHz / MED Radios Pagers Overhead paging

systems Dispatcher Email HAM Radio

Special Populations

This is an everyday issue for hospitals on a small scale. We need to plan to support large numbers of persons who are hard to reach or have disabilities.

Deadly Misconceptions

“It won’t happen here”

It won’t happen to me”

“Someone else will take care of it”

Q & A?

Thank You!

AcknowledgementsThe 2008-2009 Florida State Working Group Ventilator Capability Team members are:

John Wilgis, MBA, RRT - Florida State Working Group Ventilator Capability Team Chair, Director, Emergency Management Services, Florida Hospital Association

Melanie McDonough, MSHS, RRT - Florida State Working Group Ventilator Capability Team, Education Sub-Group Chair, Director of Clinical Education, Cardiopulmonary Sciences, University of Central Florida

Scott Kirley, RRT - State Working Group Ventilator Capability Team, Equipment Sub-Group Chair, West Centrak Florida Disaster Services, Inc.

Mary Martinasek, MPH, RRT-NPS, RPFT, AE-C - Florida State Working Group Ventilator Capability Team, Response Sub-Group Chair, American Public Health Student Assembly- Secretary

Kris-Tena Albers, ARNP, CNM, MN - Florida State Working Group Ventilator Capability Team Liaison, Public Health Preparedness Hospital Liaison, Florida Department of Health

Dr. Jennifer Bencie Fairburn, MD, MSA, Director, Division of Emergency Medical Operations, Florida Department of Health

Dr. David V. Shatz, MD, FACS - Professor of Surgery, Trauma Surgery/Surgical Critical Care, University of Miami Paul Stephan, MPS, RRT - Program Director, Respiratory Care, Santa Fe Community College Randy De Kler, MS, RRT - Program Director, Respiratory Care, Miami Dade College Phil Khan, RRT - Florida Society for Respiratory Care Sandra J. Barker, MS, RRT - Director, Cardiopulmonary Services, Largo Medical Center Timothy J. Coons - Director, Cardio-Pulmonary Services, Shands Hospital at the University of Florida Bill Cunningham, BS, RRT - Adult Critical Coordinator, Cardiopulmonary Services, Shands Hospital at the University

of Florida Joseph Albino, BS, RRT - Manager, Respiratory Care, Mease Dunedin Hospital Kelly Sebree, RRT, NPS - Director, Respiratory Care, Lawnwood Regional Medical Center

References:Anonymous. (2006). Ventilation for Life – Mechanical ventilators in Mass

Casualty Incidents. AARC Times. 30(3), 8-11.Anonymous. (2007). List of Disasters. Wikipedia. The Free encyclopedia.

Retrieved 8/14/07 from: http://en.wikipedia.org/wiki/List_of_disastersBarnett, D.J., Balicer, R.D., Blodgett, D. Fews, A.L., Parker, C.L., Links, J.M.

(2005). The Application of the Haddon Matrix to Public Health Readiness and Response Planning. Environmental Health Perspectives. 113(5), 561-566.Branson, R. (2007). Augmenting Positive Pressure Ventilation Capacity. AARC

Summer Forum Journal Conference Presenation. Bunch, D. (2006). Are We Ready for the Worst? AARC Times. 30(3), 36-44.

Committee Working Document. (May 2005). Florida HRSA National Hospital Bioterrorism Preparedness Program FY05 Projects.

Carlton, P.K. (May 30, 2007). A Culture of Preparedness. Texas A&M University. Health Science Center. Retrieved June 30, 2007 from: www.tamhsc.edu/homeland/

References:Florida Hospital Association. (May. 2005). Eye of the Storm: Impact of the 2004

Hurricane Season on Florida Hospitals. Retrieved 6/30/07 from: http://www.fha.org/protected/hospitalpreparedness.html

Hall, B. (2007). Dirty Bombs. Eastern Shore (VA) Health District. Retrieved from personal email.

Rubinson, L., O’Toole, T.O. (2005). Critical care during epidemics. Critical Care. Vol. 9. BioMed Central Ltd. Published on-line 4/27/2005 at

http://ccforum.com/inpress/cc3533Rubinson, L., Nuzzo, J., Talmor, D., O’Toole, T., Kramer, B., Inglesby, T.

(2005). Augmentation of hospital critical care capacity after bioterrorist attacks or epidemics: Recommendations for the Working Group on Emergency Mass Critical Care. Critical Care Medicine. 33(10), E1-13.

State of Florida, Department of Health, Division of Emergency Medical Operations. Office of Public Health Preparedness (2007). Working Together for a Safe and Secure Future: Florida Public Health and Medical Preparedness Strategic Plan 2007 – 2010. Retrieved June 30, 2007 from Florida Department of Health.

References:State of Florida, Division of Emergency Management. (2007). Public Information. Retrieved June 30, 2007 from: www.floridadisaster.org Tynan, B. (2007). Pandemic Influenza: Healthcare Planning. Florida Department

of Health. Retrieved through personal email.U.S. Department of Health and Human Services. (2007). Federal Planning &

Response Activities. Retrieved 7/1/07 from: http://www.pandemicflu.gov/plan/federal/index.htmlU.S. Department of Health and Human Services. (2007). State and Local

Government Planning & Response Activities. Retrieved 7/1/07 from: http://www.pandemicflu.gov/plan/states/index.html

U.S. Department of Homeland Security, Federal Emergency Management Agency (2007). Introduction to Incident Command System. Emergency Management Institute. Retrieved 6/30/2007 from:

http://emilms.fema.gov/