Disaster, Crisis
Management and
Innovation in a Chilean
Mine
J.D. Polk, DO, MS, MMM, CPE, FACOEP
Deputy Chief Medical Officer
Chief, Space Medicine
NASA
Date
UNCLASSIFIED
3/17/2011
UNCLASSIFIED
2
Overview
• You are the medical consultant….
• 33 men are trapped in a mine 2,400 feet below
solid rock.
• Ages range from 19 to 62
• Known medical conditions in some of the
miners are Type 2 diabetes, Silicosis,
Hypertension, Coronary Disease, COPD.
3/17/2011
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3/17/2011
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Benchmarking
3/17/2011
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Leadership
FLAT, EMPOWERED Leadership chain
Daily Briefings
Crisis Management Team
3/17/2011
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Recommendations by Phase
Initial Incident
Survival
Sustain
UNCLASSIFIED
Rescue
Recovery/Reintegration
7
What are the initial concerns?
• 600,000 tons of rock
collapsed into the
mine.
• What two things kill
the majority of victims
in mine accidents?
3/17/2011
• Trauma
• Asphyxiation
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Phase 1- Initial Incident
• Trauma
• Blast pressure
– Air Filled spaces
•
•
•
•
Asphyxia
Explosion/ignition
Lethal gases
Air Sampling
performed
• Fresh air pumped
in
2/4/2011
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Blast Injury
• Patients with blast injury
can develop pulmonary
contusions and ruptured
hollow viscous injuries.
These can manifest hours
later with severe
shortness of breath or
abdominal pain.
• What simple method can
be used to triage and
identify patients rapidly?
3/17/2011
• Check to see if the
patient has difficulty
hearing. The middle ear
is also a hollow viscous
and is sensitive to rapid
changes in pressure.
• Decreased hearing and
hemotympanum are
clues that the patient may
crash soon.
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Masters of their Own Fate
• 17 days before
being found
• Dug wells
• Divided up the
rations
3/17/2011
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Survival
• The miners had one
teaspoon, one quarter of
a peach, and a teaspoon
of milk every other day.
• You finally have a paloma
that has reached them.
• You are about to send
food down. What is your
initial concern?
3/17/2011
• Refeeding syndrome
• Liver glycogen has
been used up.
• Down-regulation of
insulin.
• Brain switches to
ketones.
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Refeeding Syndrome
• What is the main
electrolyte
disturbance in
refeeding syndrome?
• What other
electrolytes are
effected?
• What vitamin is of
concern?
3/17/2011
• Phosphorus
(hypophosphatemia)
• Potassium and
magnesium
(hypokalemia and
hyomagnesemia)
• Thiamine (B1)
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Phase 2- Survival
Re-feeding Syndrome
• Impaired carbohydrate
utilization
• Increased insulin release with
decreased ability to use free
fatty acids
• Increased CO2 production
• Profound hypophosphatemia
and hypokalemia
• Gradually increase calories
• Keep the RQ (respiratory
quotient) as close to 0.85 as
possible.
• Supplement with
phosphorus, potassium, and
magnesium.
• Water soluble vitamins
Harris- Benedict Equation on caloric need based on basal metabolic rate
Protein requirements in catabolic states
1.4gm/Kg/day
2/24/2011
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Phase 2- Survival
Re-feeding Syndrome
Ensure plus and Supportan:
thiamine, phosphate,
potassium, and protein
and “going low and slow” (1020 kcal/kg initially) allowed the
liver stores to regenerate
without causing intracellular
shifts. This prevented lifethreatening complications from
the re-feeding.
Aug 2010
•
•
•
•
•
•
Hypophosphatemia
Hypokalemia
Hypomagnesium
Cardiac dysrhythmias
Cardiac failure
Cardiac arrest
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Courtesy Scott Smith, PhD and team
3/17/2011
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Why would the space program be
experts in this area?
3/17/2011
Classification
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Courtesy of Dr. Doug Hamilton and Team
1 gram of glucose + 0.74L of Oxygen yields 0.74 L of CO2 + 3.75 kcal
Polk-Aug 2010
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Who else gets refeeding
syndrome?
• Neurosurgical
patients
• Greater than 5-7
days of
malnourishment
• TPN without
adequate
phosphate.
3/17/2011
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Starvation and Dehydration
• The mine is 90 degrees
and 90 percent humidity
• The miners were sleeping
on hot rocks, vehicles,
and just about anywhere
• What could be the
consequences?
• What test would you use?
3/17/2011
•
Urine dipstick test was
one of first sent down.
• 50% of the miners were
positive for myoglobin.
• Rhabdomyolysis and
acute tubular necrosis
• Those miners targeted for
consumption of 5 liters of
water.
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Innovation
3/17/2011
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Competition
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Brainstorming Meetings
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Phase 3- Sustain
Contingency Re-supply and Stocking
• Contingency Supply
– Send medical, water, and food supplies sufficient for
enough time to re-establish supply chains, in the
event of a contingency cave-in or the miners are
again cut off from the surface.
2/24/2011
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Treatment of Chronic
Conditions
• The patient with Type
2 diabetes was on
metformin prior to the
accident.
• Should you begin
sending that down?
• What is the
physiologic concern
with metformin under
these circumstances?
3/17/2011
• Consider him diet
controlled until his
calorie count is over
1800 calories and he
is no longer spilling
ketones.
• Ketoacidosis is the
concern.
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Skin
• Linoleic Acid deficiency could
develop due to the initial poor
nutrition. This may result in an
eczema-like rash with
neutropenia and
thrombocytopenia. If a miner
has a resistant rash that is
unresponsive to steroids or antifungals, consider linoleic acid
deficiency as the etiology. This
is easily treated with linoleic
acid capsules and
supplementation or safflower oil
15cc/day.
3/17/2011
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Latent Virus Activation
• Herpes Virus family
– EBV
3/17/2011
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Immunization
• Vaccination for
tetanus (in the form of
diphtheria/tetanus
toxoid),
pneumococcal, and
meningococcal
strains
• Influenza
• Debate
3/17/2011
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Phase 3- Sustain
Common Medical Maladies Seen in Long Duration
•
•
•
•
•
•
Vitamin D deficiency
Epstein Barr/Herpes Latent Virus Reactivation
Constipation
Respiratory Infections
Skin Infections/Irritations
Dental caries and peridontal disease
Aug 2010
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Alcohol and Tobacco
• Medical versus psych
recommendations
• Concerns for
nutritional status and
unknown Thiamine
status
• Assumption of intake
upon rescue
3/17/2011
• Lung disease versus
second hand smoke
• Potential for revolt
due to need for
control
• Choosing the battles
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Psych Recommendations
• Alter thinking of miners, rescuers, families and country to longduration pace
– Marathon message to all groups from all managers and
caregivers
– Tangible changes such as:
• More permanent structures, for example family meeting site,
communications building, etc.
– Topside and in mine
• For key positions that are one-deep, begin on-site orientation
for trusted alternates
– Permits sufficient rest for key personnel and teams
3/4/2011
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Psychological Support Cont.
• Circadian and sleep-wake cycles
– Regular cycles of light/dark, exercise and eating in community
area (eating, social, etc)
• Regular time each day for each miner for these things.
Preserve an individual’s 24h cycle.
– Since miners work in 3 shifts, organized 3 distinct lighting areas
in mine:
• Sleeping area
• Community social area
• Mining work areas
Polk-Aug 2010
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Phase 4- Rescue
Decompression Risk
•
The pressure at about 775
meters in a cave is about 1.1
times the pressure at the
mine entrance. If we assume
the mine is at sea level
(worse-case), then the
miners would be saturated at
an air depth of about 3.3
FSW given that 1 ATA = 33
FSW and 1.1 times 33 FSW
is 36.3 FSW. Since the
miners are saturated at 3.3
FSW and the most
conservative limit for safe
direct ascent is 17 FSW, it is
unlikely that DCS is a
problem
2/24/2011
Tan et al. 2008, Courtesy of Johnny Conkin
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We know a thing or two about
Boyle’s Law
3/17/2011
Classification
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The Rescue
• The miners are well
nourished, and you have
been successful in
treating their chronic
medical conditions.
• It is time to contemplate
the rescue.
• They will have to be
upright for the duration of
the rescue. What
physiologic complications
could occur?
3/17/2011
• Orthostatic
hypotension
• Hypoxia
• Hypercarbia
• Anxiety reaction
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How would you combat the
physiologic consequences?
• Compression
garment
• Salt tablets
• Fluid load
• Sunglasses for UV
protection
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Fluid Loading Protocol
3/17/2011
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The “NASA Diet”
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What requirements would you
write for the escape pod?
3/17/2011
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3/17/2011
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Phase 4- Rescue
Suggested Triage Tent
•
•
•
Close to extraction point, but not so
close that it becomes a hindrance or
distraction. Preferably out of the wind.
Far enough away from helipad to avoid
rotor-wash
Treatment capabilities
– Prepare for and treat “Let down
syndrome”
– Airway, intravenous, basic trauma
care
– Save the specialists for the
hospital…do not allow them to grow
“roots”.
– Same plan for everyone; EVAC,
despite if they “look fine”.
2/24/2011
UNCLASSIFIED
Short distance from
extraction point
In route to helipad
Alaska Shelter or similar type, with
equipment for resuscitation
41
Suggested features and location of Helipad
Staging Area
Sloping Terrain allows “Ground Effect” for take-off in changing
temperatures and weights
N
Polk-Aug 2009
UNCLASSIFIED
Prev
Winds
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Six Sigma
Why did each
miner get placed
on a cot and
taken to the
triage tent when
they looked so
good coming out?
3/17/2011
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Phase 5- Convalescence,
Recovery, Reintegration
• Reintegration planning to minimize life damage
& increase chances of life success
– Planned training for both miner and family given at
least twice within 4 weeks of expected extraction
• Align expectations, family reintegration, children reactions,
major decisions, fame/money, stability
– Optional support 2X length of confinement
• Telephone call to each, may visit behavioral team
2/24/2011
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Phase 5- Convalescence,
Recovery, Reintegration
• The miners are being
followed for a period of
months for respiratory,
skin, and viral
syndromes.
• Why?
2/24/2011
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Conclusions
• Innovation, leadership, and mindset of the Chilean
government, medical and mining personnel were
paramount to the success.
• Lessons from Spaceflight were directly applicable to
the ground.
• Spaceflight has a tangible value that is difficult to
quantify.
3/17/2011
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Questions?
Polk-Aug 2009
Slide courtesy of USAF
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3/17/2011
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