DISASTER DRILLS
Help or Hindrance?
Jenny Atas MD FACEP
Department of Emergency Medicine
Wayne State University
March 4 , 2012
Emergencies in Medicine
Effective emergency management
takes into account an “all-hazard”
approach and includes 4 phases
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Mitigation
Preparedness
Response
Recovery
Mitigation
According to the Joint Commission on
Accreditation of Healthcare Organizations, those
activities a hospital undertakes to lessen the
impact and severity of a potential emergency.
Preparedness
Activities a hospital, healthcare facility or
agency undertakes to build capacity and
identity resources that may be used if an
emergency occurs, such as stockpiles of
supplies, personnel, communication tools, etc.
Preparedness
Effective emergency management and
incident response activities begin with a host
of preparedness activities conducted on an
ongoing basis, in advance of any potential
incident.
Preparedness
An integrated combination of assessment,
planning, procedures and protocols, training
and exercises, personnel qualifications,
licensure and certification equipment
certification, and evaluation and revision.
Response
Involves activation of emergency plans to deal
with the actual event .
Recovery
Activities designed to help facilities resume
normal operations and occurs at the conclusion
of the event.
Emergency Management Plans
Contingency plans designed to facilitate
response and based on a facility’s or agency’s
hazard vulnerability analysis (HVA).
Hazard Vulnerability Analysis
Purpose: To identify potential emergencies that
could affect the need of a facility’s services or
affect it’s ability to provide those services.
Elements of a HVA
• Define potential risks by developing list of
emergencies that may affect a facility’s ability
to function including surrounding variables
• List of potential internal and external risks
(power outages or fires)
• Should focus on naturally occurring or
manmade disasters, or terrorist or Hazmat
incidents
HVA cont.
• Assign a probability or likelihood of the event
• Rank the severity if the event were to occur
• Review the emergency plan to assess how well
the facility as well as the community is
prepared for a certain type of event
• This can be accomplished or rehearsed
through various types of drill or exercises
Drills and Exercises
• Simulated or based on possible real life
scenarios in order to improve response
• Based on weakness identified in the HVA
Types of Drills or Exercises
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Drill
Tabletop Exercise
Functional Exercise
Full Scale or Field Exercise
Drill
A supervised activity with a limited focus to test
a component of the emergency management
plan, such as an activation notification plan.
Tabletop Exercise
• Uses written and verbal scenarios to evaluate
the effectiveness of an organization’s
emergency management plan
• Also focuses on procedures to highlight issues
of coordination and assign responsibilities
Functional Exercise
• Simulates a disaster in a realistic manner
• Utilizes a carefully designed scenario with
timed messages between the players and
simulators
Full- Scale
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Real time
Real equipment
Real responses
Usually involves multiple agencies
Scenario 1
Unknown Illness from a Common Source
DAY 1
• Flight 3550 with 225 passengers on board
lands at your airport
• Among the passengers is a group of 100
returning from a 14 day tour of Europe
• 75 of the remaining 125 passengers
immediately took connecting flights to other
states
Scenario 1
Unknown Illness from a Common Source
DAY 3
• Four (4) members of the tour group began
feeling ill and presented to your Emergency
Department with high fever, chills, malaise,
hypotension and a productive cough.
• One (1) patient complains of severe nausea,
vomiting, abdominal pain.
Scenario 1
Unknown Illness from a Common Source
DAYS 4 & 5
• Six (6) more members of the tour group go to
area Emergency Departments presenting with
similar symptoms as the first group
Scenario 1
Unknown Illness from a Common Source
DISCUSSION ITEMS
• Which agencies exterior to the hospital, if any,
should be notified of the current situation, and who
is empowered to make that decision?
• At what point do you assess that these circumstances
may indicate an outbreak?
• What resources are available and needed to assist in
diagnosing or confirming the diagnosis of an illness?
• What are your hospital’s greatest concerns in
responding to this type of incident?
Scenario 2
Suicide Bomber
7:00 p.m.
• Lines at the local Theater Complex have begun filling for the
first showing of the evening, and people are beginning to pour
into a nearby restaurant adjacent to the theater. As the crowd
moves about, a lone man wearing a heavy jacket enters the
restaurant. He walks past the hostess and into the center of
the dining room where, without hesitating, he detonates a
powerful bomb that is hidden beneath his jacket. There is a
terrific explosion that demolishes the restaurant. Inside there
is momentary silence as debris settles from the collapsed roof.
Seconds later a few muffled cries for help can be heard from
within.
Scenario 2
Suicide Bomber
SCENARIO
7:00 p.m. (con’t)
• From outside, the front of the building simply disappears
behind a brief flash and a hail of smoke and debris. Glass,
metal and wood fragments from the restaurant fly through the
air injuring scores of people on the sidewalks and along the
street in front of the restaurant.
Scenario 2
Suicide Bomber
SCENARIO
7:01 p.m.
• There is pandemonium on the street as the more distant
pedestrians instinctively run from the damage. Dozens of
people are lying on the street, some injured, some merely
stunned.
• Moments later, other people run toward the damaged
restaurant in an effort to help. Sirens begin to sound in the
distance.
• The now darkened building and street front is littered with a
random mixture of motionless bodies, building materials,
human body parts, tables and chairs, and broken glass.
Scenario 2
Suicide Bomber
SCENARIO
7:05 p.m. to 7:10 p.m.
• All hospitals in the area are advised via MedCom radio that a
MCI has occurred and asked to activated their external disaster
plan.
• The hospital receives a call from the first responders on scene,
and is informed of the explosion, mass carnage, and that there
are approximately 30 Priority-1 victims.
• HEICS is initiated. Hospital Command Center is activated. Recall
of staff initiated.
Scenario 2
Suicide Bomber
SCENARIO
7:40 p.m.
• Ambulances are arriving at the hospital and the victims are
being transported into the ED.
7:45 p.m.
• A terrific explosion is felt in the hospital that shakes the walls
of the ED. From the main entrance of the hospital there are
sounds of panic and screaming. Smoke and dust begin to fill
the air. Word comes that a suicide bomber has detonated an
I.E.D. in the main visitor reception area and there is massive
damage to that area of the hospital and scores of people and
staff are injured, many fatally.
Scenario 2
Suicide Bomber
SCENARIO
7:45 p.m. to 8:15 p.m.
• The hospital ED is unable to receive victims and ambulances
are diverted to other area hospitals. Police and fire units have
secured and stabilized the scene at the hospital and initiated
SAR operations.
• Available staff begin moving the injured to the ED for triage
and treatment. ED staff are quickly overwhelmed and the ED
supervisor requests additional personnel.
• The ED supervisor advises the I.C. that eight (8) patients need
to be transferred to other facilities.
Scenario 2
Suicide Bomber
DISCUSSION ITEMS
• What immediate steps should you take to prepare
the Emergency Department Room and staff for this
influx of patients?
• On a “routine” Saturday night in early summer, what
capacity does your ED have to manage a sudden
casualty situation of this magnitude?
• Given the degree of trauma to these victims, what
steps do you need to take at this time of night to
ensure that adequate blood supplies are available?
Scenario 2
Suicide Bomber
DISCUSSION ITEMS
• What procedures or protocols exist for handling
injured victims who may be suffering from existing
medical conditions or diseases such as Hepatitis or
HIV/AIDS?
• How are large quantities of contaminated tissues,
fluids or body parts from mass casualty sites to be
handled at your facility?
Scenario 2
Suicide Bomber
DISCUSSION ITEMS
• What special precautions must be taken by EMS and
hospital personnel?
• What training has your facility’s personnel received
in cooperating with and supporting law-enforcement
personnel and investigating officers?
• What is the immediate responsibility of your ED staff
to the arriving victims from the primary terrorist
incident, and to those at your own facility?
ARE YOU PREPARED?
- - - - - SCENARIO 3 - - - - -
• It has been a routine peaceful Sunday in the
community and at your hospital.
• At 11:00 AM the NWS issues a severe
thunderstorm and tornado watch for your area,
effective from 2:00 PM until 10:00 PM.
• At 4:00 PM the NWS upgrades the severe
thunderstorm watch to a warning until 6:00 PM.
ARE YOU PREPARED?
------ SCENARIO ------
• At 5:00 PM a severe storm hits your
community.
• At 5:30 PM the NWS issues a tornado warning
for your area. The warning is broadcasted and
sirens are activated.
ARE YOU PREPARED?
------ SCENARIO ------
• At 5:42 PM a security guard yells, “take cover,
a tornado is about to hit the hospital”, and the
unthinkable happens…
Video Clip
Joplin, MO EF-5 Tornado
Sunday, May 22, 2011
ARE YOU PREPARED?
------ SCENARIO ------
• A minute later here is
what’s left of your
hospital…
ARE YOU PREPARED?
------ SCENARIO ------
• And your community…
ARE YOU PREPARED?
------ Initial Response Considerations ------
– Would the HICS be activated at this point? If so,
what is the activation process? Which positions
would currently be in play?
– Would the hospital consider evacuation or SIP at
this point? Who would make this decision and
based on what critical factors.
– What notifications, if any, would you make?
– Would you request additional resources at this
point? If so, what and from whom?
ARE YOU PREPARED?
------ Initial Response Considerations ------
– How will you handle incoming calls from patient
family members requesting a situation report?
– What other hospital plans, if any, would be
activated?
– Would your hospital go on diversion?
– How will you keep yourselves current regarding
the event?
– What other actions would you take at this point?
ARE YOU PREPARED?
------ SCENARIO UPDATE ------
• The Hospital IC has decided to evacuate the
entire hospital as soon as blocked roads are
reopened, but for now you are directed to SIP
and prepare for evacuation.
ARE YOU PREPARED?
------ Response Considerations ------
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What notifications will you make?
Would you call in any additional staff?
What security measures would you take now?
What HICS positions would you consider
activating now?
• How will you find destinations for your
evacuating patients?
• How will you coordinate internal patient
movement for transportation out of the hospital?
ARE YOU PREPARED?
------ Response Considerations ------
• How will you coordinate arriving external
transportation to your hospital campus?
• How will you track patients as they move
throughout your hospital and to the receiving
destination?
• How will you notify patient family members?
Who else needs to be notified?
• Will you request any additional resources? From
whom?
• How will you transfer medical information
regarding the patient to the receiving facility?
ARE YOU PREPARED?
------ Other Response Considerations ------
• How are you going to
handle contaminated
patients that self-present
to the ED?
• How would you surge
beyond your internal
morgue capacity?
ARE YOU PREPARED?
------ Other Response Considerations ------
• How you would get medical
supplies and pharmaceuticals
if (like Joplin) your internal
storage facilities were
destroyed?
• Do you have plenty of available
flashlights and fresh batteries
available? (In Joplin the electrical
utility went down and the
generators were destroyed)
ARE YOU PREPARED?
------ Other Response Considerations - Business Continuity ------
• Do you have local
access to a disaster field
hospital?
August 2, 2011 Medical Response
to Joplin Tornado May 22, 2011
Immediate Response Considerations
• Both incident command centers were destroyed and
emergency operations plans (EOP) lost in the debris. Hospitals
need deployable incident command centers rather than fixed.
• The national exercise occurred just weeks before. The Hospital
credits that exercise for the high survival rate and level of
preparedness. All presenters talked about the value of
exercises and the limited value of written plans.
• During your emergency planning process include everyone and
do not allow anyone to avoid the planning process, including
and especially your medical staff.
• Disaster planning and exercises is the key to survival – not the
disaster plan.
Special Immediate Concerns
• Be sure to have a representative in the
City/County EOC.
• Know your local, state, and federal response
partners and have an established relationship
with them prior to any event.
• Interoperable communications was an
immediate and continuing concern.
Special Immediate Concerns cont’
• Hospitals need to consider building bunkers on site to house
incident command documents, back up communication
resources and emergency supplies; they should be positioned
to avoid potential debris fields.
• The 96 hours of self-sustainability is a myth. The 96-hour cache
was consumed in less than 4 hours.
• Pre-event MOUs and MOAs are good to have in place;
however, it may be days before you can communicate with
vendors and many may be affected by the event.
• Your only means of communication for a period of time may be
EMS radios. While the hospital is attempting to save lives, EMS
crews are engaged in the same battle and may not be available
to assist with communications.
Special Immediate Concerns cont’
• Is hospital policy written to allow the public to shelter
in your facility? Rethink it and plan instead to lock
down the facility in the event of a disaster.
• In an event of this magnitude, the hospital will
require armed security.
• Security forces came in a variety of uniforms, no
common identification, and no common radio
frequency.
• Hospitals need the ability to install at least a 6’ steel
chain link fence around the perimeter as soon as
possible following the initial event.
Lessons Learned
• Interoperable communication is a must. Hospital and
response partners could not communicate effectively.
• Solar charging stations for cellular phones and radio
batteries.
• Texting/social media worked; all staff should have.
• Hospital telephone numbers were rolled to PBX system in
Springfield, which took 2,500 calls the first day.
• Long hours w/o relief results in poor decision-making.
Manage staff/provide support, including mental health
services.
• Security is critical; you have to protect your resources.
• Badges will be lost; have wallet identification cards.
Takeaways
• Know response partners: local, state, federal.
• Drill with community partners.
• Have a strong connection with hospital
associations.
• “As leadership goes so goes the staff.”
• Practice, Practice, Practice. When events
occur, EOP documents have very little value.
• Drill until you fail, then fix it.
• What you practice is what you do.
Jason Smith, director of EMS for Metropolitan
Emergency Transport System (METS) in Joplin
“. . . common training, policies, protocols, skills
labs, medical director, employees and most
important, past mutual aid scenes, including the
May 10, 2008 F-4 tornado in Newton County,
allowed us to complement each other naturally
and work effectively as one team. For the first
hour, that’s all we had.”
Get Fit or Get Hit
program sponsored by the
Department of Health and Human Services
“Exercises allow personnel, from first responders to senior
officials, to validate training and practice strategic and tactical
prevention, protection, response, and recovery capabilities in a
risk-reduced environment. Exercises are the primary tool for
assessing preparedness and identifying areas for improvement,
while demonstrating community resolve to prepare for major
incidents. Exercises aim to help entities within the community
gain objective assessments of their capabilities so that gaps,
deficiencies, and vulnerabilities are addressed prior to a real
incident.”