Disaster Facts and Myths
Amy H. Kaji, MD, MPH
November 16, 2005
Acute Care College
Medical Student Seminar
•The Disaster Facts…
Disaster Facts
• Disaster – defined as a natural or manmade
event that results in an imbalance between the
supply and demand for existing resources
• Natural
• Earthquakes, wildfires, hurricanes, floods, droughts,
tsunamis, etc.
• Manmade
• Terrorist incidents including chemical, biological,
radiological, nuclear, and explosive events
• Civil unrest and riots
September 11, 2001 and the
Dissemination of Anthrax
Disasters will Impact ALL
Physicians
• Emergency Physicians
• Will likely be the first to assess victims of disaster
• Anesthesiologists
• Victims will often require operative care
• Surgeons
• Traumatic injuries may warrant operative treatment
• Critical Care Specialists
• Victims may require intensive care unit and ventilatory management
• Primary Care
• Victims will need care of their chronic underlying medical conditions
• May be the first to see victims of a covert biological attack
• Psychiatry
• Victims may require supportive care and grief counseling
Disasters will Impact ALL
Physicians
• Teamwork will be critical
• Flexibility in roles may be warranted
• Surgeons and anesthesiologists may lend a
helping hand in the emergency department
March 11, 2004:
Madrid, Spain Train Bombings
How does disaster triage differ
from ordinary triage?
• Daily triage
• Involves providing highest intensity of care to the
most seriously ill patients
• These patients may have a low probability of survival
• Disaster triage
• Doing greatest good for greatest number
• Focus shifts on identifying victims who have a chance
of survival with immediate medical interventions
Disaster Triage Systems
• Red
• Critical injuries that can be cared for with minimal time or
resources
• Example: obstructed airway or tension pneumothorax
• Yellow
• Significant injuries that can tolerate a delay in care
• Example: femur fracture without neurovascular compromise
• Green
• Injuries that can wait for days to be treated
• Example: minor contusions, sprains, and abrasions
• Black
• Expectant patients who have minimal chance of survival even if
significant resources are expended
Triage Tag
Simple Triage and Rapid
Treatment (START)
• Assesses respiratory status, perfusion, and mental status
• All patients who can walk are asked to move away from
the incident
• Green
• Those remaining with RR>30, capillary refill >2 seconds,
or are unable to follow commands
• Red
• Those remaining with RR<30, capillary refill <2 seconds,
and are able to follow commands
• Yellow
Children vs. Adults
• Emergency Medical Services (EMS) will
not respect “children only” and “adults
only” emergency departments during
disasters
• Every facility must be able to care for and
stabilize both children and adults
Common problem during
disasters: Communications
• Communication modes and routes may be
destroyed mechanically by natural disasters
• Sudden increase in volume and need to
communicate with victims, responders, and
witnesses
• Landlines and cellular phone lines become saturated
• Radio frequencies may not be coordinated
Communication Difficulties
• People problems, not equipment
problems predominate
• What information needs to be collected?
• Who should collect it?
• How should the information be relayed
expeditiously and comprehensibly to those
that need it?
Importance of Redundant
Communications
• Many regions now enlist volunteer HAM
operators
The Media
• Lack of planning for interaction with the media
is common
• Planning with the media
• Maximize risk communications
• Precautions about heat illness, food and water safety, disease
transmission, etc.
• Source of education and support for community disaster
mitigation and planning
• Decrease disruptive aspects of their involvement
• Designate single point of information release
Hospital as Victim
• Structural and nonstructural damage
• Examples: ceiling, water, emergency generator power failure
• Prevention is critical
• Hospitals should not be built in areas of recurrent floods, or
near earthquake faults
• Adherence to hazard resistant building codes
• Is the hospital safe?
• Post-impact assessment by trained structural engineers
• Networking within the community
• Inter-organizational cooperation with other hospitals, EMS,
public health, and fire
Hospital as Victim
• US Geological Survey estimates that 25%
of hospital beds will be damaged and
unavailable in a major earthquake
• Northridge Earthquake, 1994
• 8/91 acute care hospitals required evacuation
(2500 beds lost)
• 4 hospitals condemned
Standardizing: Hospital Emergency
Incident Command System
(HEICS)
• Originated in CA by the EMS Authority
• Joint Commission of Accreditation of Hospital
Organizations (JCAHO) requirement
• Common terminology
• Predictable chain of management
• Flexible organization chart
• Prioritized response checklists
HEICS
HEICS
• Incident Command (IC)
• Overall responsibility for incident management
• Role often fulfilled by Hospital Administrator
• Planning
• Continually evaluates the event by developing action
plans and conducting strategic meetings during the
event.
• Finance and Administration
• Responsible for the payment, contracting, or
implementation of other agreements required to
obtain needed resources as identified by the IC.
HEICS
• Logistics
• Responsible for providing services, facilities, and materials
needed to support the event.
• May include communication equipment, information systems,
food, clean water, medical supplies, and facilities construction.
• Operations
• All other functions of the ICS are performed to support the
operations component.
• Responsible for medical direction and communication required
to accomplish the management, triage, treatment, and
disposition of victims.
Hazard Vulnerability Analysis
(HVA)
• Joint Commission on Accreditation of
Healthcare Organizations (JCAHO) definition
of Hazard Vulnerability Analysis (HVA) –
• “Identification of hazards and the direct and indirect
effect these hazards may have on the hospital…
• Hazards that have occurred or could occur must be
balanced against the population at risk to determine
vulnerability.”
Hazard Vulnerability Analysis
(HVA)
• HVA based on an “all hazards approach”
• Begin with list of all disasters, regardless of
their likelihood, geographic impact, or
potential outcome
• List should be as comprehensive as possible
• Typical categories of potential hazards
considered include natural hazards,
technological hazards, and human events
• Note possible overlap between categories
Hazard Vulnerability Analysis
(HVA)
• Prioritization Process due to limited resources
• Evaluate each hazard for:
• Probability of occurrence
• Risk to organization
• Organization’s current level of preparedness.
• Disaster are not predictable with any degree of accuracy
• Familiarity with geographic area, common sense, and research
will help identify hazards
• Important to consider likely and unlikely scenarios
• Establishing probability of event is only part objective
and statistical
• Remainder is considered intuitive or highly subjective
Probability of Hazard
• Evaluate each hazard for its probability of
occurrence
• Factors to consider:
• Known risk
• Historical Data
• Manufacturer/vendor statistics
• Tool presented here uses qualitative terms: high,
medium, low, or no probability of occurrence
Risk of Hazard
• Risk is potential impact hazard may have on
organization, and issues to consider include:
•
•
•
•
•
•
Threat to life and/or health
Property damage – seismic activity
Disruption of services from systems failure
Economic loss - adverse financial impact
Loss of community trust/goodwill
Legal ramifications
Current Level of Preparedness
• A final issue in HVA is hospital’s current
level of preparedness, including:
• Community resources -- hospital does not
respond in a vacuum
• Current status of emergency plans and
training status of staff
• Availability of insurance coverage or backup
systems
The HVA Tool
• Each potential hazard is evaluated and scored in
areas of probability, risk, and preparedness
• Factors are multiplied for overall total score for
each hazard
• Ordering total scores prioritize hazards in need
of the attention and resources
• Determine a score below which no action is
necessary, and focus on hazards of higher
priority
Example of the HVA Tool
Event
Probability Risk
3=high
2=med
1=low
0=none
Hurricane
Ice Storm
Earthquake
5=life threat
4=health safety
3=high disruption
2=mod disruption
1=low disruption
Preparednes
s
3=poor
2=fair
1=good
Total
July 29, 2003:
Hospital Structural Damage from
an Earthquake in Tokyo, Japan
Myth #1
• “I was told that hospitals do not need to
prepare for disaster, since disasters are
similar to daily emergencies on a large
scale. Isn’t that true?”
The Truth
• Fact: Disasters pose problems that require
unique strategies, since disasters tend to
disrupt normal communications systems,
transportation routes, and normal
response facilities.
Severe Drought
•What other myths
plague disaster medicine?
Myth #2
• Physicians and nurses should be sent to
the field to help at the actual disaster site.
The Truth
• Physicians and nurses depend upon monitors and
equipment, not available in the field
• On-site chaos of disaster may prove disabling
• Goal of disaster medical response planners is to assign
personnel to roles that are as familiar as possible and to
enhance flexibility of response to extraordinary
circumstances
• Only physicians and nurses specially trained to work
in the field environment should do so
• Only if physicians are in surplus in the hospital/clinic
environment should they be sent to the field as care
providers
October 2003:
California Wildfires
Myth #3
• A disaster plan is required for hospital
accreditation. Thus, the existence of a
written disaster plan is assurance that the
hospital is indeed prepared.
The Truth
• Written disaster plans
• Can cause an illusion of preparedness
• The “paper plan syndrome”
• Often massive documents that are cumbersome
• A disaster plan is only useful, if it is:
• Based upon a valid hazard vulnerability analysis
• Integrated with local and regional plans
• Accompanied by resources necessary to carry out the
plan
• Associated with an effective training program
Avoiding the Paper Plan
Myth #4
• The EMS Agency will disperse and
distribute the patients to various facilities
so as to not inordinately impact one
hospital.
The Truth
• Closest hospital will be the one most
significantly impacted
• Laypersons assisting non-ambulatory patients
will transport them to nearest facility
• Many victims will go to closest facility out of
loyalty or financial reasons
March 28, 1979:
Three Mile Island
Myth #5
• Timely and appropriate information will
be received from the disaster site, and
responders will be able to prioritize the use
of available resources.
The Truth
• Communications from the disaster site
occur in less than one-third of major
incidents
• Hospitals learn about disaster from mass
media, first arriving casualties and
ambulances, rather than from personnel at
the actual site
• Radio equipment and telephone lines may be
damaged or overloaded
Water, water, everywhere…
Myth #6
• Most of the initial emergency response is
carried out by well trained pre-hospital
healthcare personnel.
The Truth
• Most initial care provided by civilian
bystanders
• Majority of casualties not transported by
ambulance
• Field and first aid triage stations bypassed
• Hospitals do not receive adequate
information to guide response
Myth #7
• All patients will be transported to
hospitals only after they have received
adequate medical care in the pre-hospital
setting.
The Truth
• Casualties arrive to ED in two waves
• First wave – within the first 30 minutes
• Walking wounded and self-transporters
• Second wave – after 30-90 minutes
• More critically ill patients needing extrication and
ambulance transportation
• Up to 80% of victims will seek medical care on
their own, by foot or by private automobile
• During HAZMAT incidents, 64% are transported
to the hospital for decontamination
Tokyo, Japan: March 20, 1995 Sarin in the Subway System
Ambulance Transport in less
than 20%
Myth #8
• Primary medical need will be to deal with
large numbers of victims suffering from
multiple trauma.
The Truth
• Most disaster injuries requiring medical
care are minor
• Only 20% of victims are admitted
• Many injuries occur during the clean-up
period
• Many have lost access to routine care and
medications and follow-up of chronic
medical conditions
Minor Injuries Predominate
Attention to Chronic Medical
Conditions
Myth #9
• Disasters bring out the worst in human nature
and behavior
• There is a great deal of looting in the aftermath of a
disaster (This used to be a myth until Hurricane
Katrina!!!)
• This myth likely becomes a truth when there is a
disaster of catastrophic proportions with thousands of
displaced persons, famine, and death
• There are very few donations in the setting of a
disaster
• All types of supplies, medications, and blood are needed
• Any supply of drug is better than none
The Truth
• Looting is seldom a major problem after any
major disaster (unless disaster is of catastrophic
proportions)
• Helping response after a disaster is impressive
• Massive donation programs often cause a second
disaster
• Staffing and resources must be diverted to manage the
donations
• Problems with massive quantities of improperly labeled,
packaged, expired, and unsorted pharmaceuticals
• World Health Organization (WHO) guidelines for
pharmaceutical donations
Unfortunately, looting after a
disaster may not be as mythical as
once thought…
The Helping Response:
December 26, 2004 and the
Tsunami
Donations for Indonesia after
the Tsunami
Myth #10
• All disasters are catastrophic and involve
hundreds of thousands of victims.
The Truth
• Very few disasters in the US have resulted
in > 1,000 casualties
• Only 10-15 disasters per year result in > 40
casualties
• World Trade Center (WTC) attack on
9/11/01 was only the 8th peacetime disaster in
US history resulting in more than 1,000
fatalities
Transportation Disasters
Myth #11
• Massive epidemics will result from
disasters, particularly if there are many
dead victims at the site. Thus, mass
vaccination programs should be instituted,
and corpses should be disposed of rapidly.
The Truth
• Dead bodies rarely cause mass epidemics of disease
• There is time to respect the dead and observe a proper burial
• Non-endemic diseases will not pose a problem unless
brought into disaster area
• Public health efforts should concentrate on pathogens
endemic to the region
• Immunizations should be administered judiciously
• Increased disease transmission is greater risk than risk of
epidemic outbreaks
Myth #12
• The disaster-stricken region is helplessly
waiting for external (state, federal, or
international) help.
The Truth
• All disasters are local
• Indigenous population will have performed
much of the disaster response and recovery
before external help arrives
• Rescue teams responding to large-scale disasters
involving trapped victims will have little impact
unless they arrive within 1-2 days
• Federal and state aid will not arrive for 24 to 48
hours
April 19, 1995:
Oklahoma City Bombing
Myth #13
• Critical Incident Stress Debriefing (CISD),
where disaster victims and responders are
encouraged to express and voice their
feelings and emotions, is a necessary and
important component of acute disaster
recovery and response.
The Truth
• No evidence that CISD in the acute phase
is helpful in decreasing rate of posttraumatic stress disorder (PTSD)
• Single-session debriefing
• Victims encouraged to relive traumatic event
shortly after incident
• Controversial and may be harmful
Myth #14
• Most of the recovery will be performed
within the first few days, and things will
return to “normal” relatively quickly.
The Truth
• Recovery process occurs over months and
years
• Media attention dwindles
• Aid becomes sparse
• Example: Northridge Earthquake in 1994 –
recovery is still ongoing
• Retrofitting of buildings to meet earthquake
standards still not complete
April 29, 1992:
Rodney King Riots
July 7, 2005: London Terror
Bombings
August 29,2005:
Hurricane Katrina –
Estimated Damage: > $200 Billion
AL, LA, & MS
Hurricane Katrina –
Estimated Damage: > $200 Billion
• “Probably the worst natural disaster in the
United States”…
• Catastrophic, with over 50,000 evacuees
and refugees (displaced persons)
• All hospitals evacuated
Lessons from Katrina?
• Poor coordination of local, state, and federal resources
• Who should have taken control?
• Years prior to Katrina, the State knew that they were
only prepared for a Category Three storm
• What is the role of mandatory evacuation?
• Were security measures in place at the Superdome and the
convention center?
• Were they prepared to shelter evacuees for longer than 2 days?
• Did they have mutual agreements in place with other states?
• The hospitals had less than 3 days worth of supplies. Why?
Hospital Disaster Preparedness
• Hospital disaster preparedness requires:
• Improving physician knowledge and
understanding of all types of disasters,
including chemical, biological, and
radiological events
• Improving daily surge and disaster surge
capacity
• Drills
Hospital Disaster Preparedness
• Community involvement and cooperation
• Communication and cooperation with Public
Health
• Communication and cooperation with law
enforcement
• Communication and cooperation with fire
department and EMS
Hope this presentation has helped
dispel some disaster myths…
• Questions?
Selected References
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Braun BI, Darcy L, Divi C, Robertson J, Fishbeck J. Hospital bioterrorism preparedness
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2002, Albany, NY: Delmar Learning Service.
Cone DC, Weir SD, Bogucki S. Convergent Volunteerism. Annals of Emergency
Medicine. 2003; 41:457-62.
Currance PL. Medical Response to Weapons of Mass Destruction. 2005, St. Louis,
MO: Elsevier Mosby Inc.
Geiger H. Terrorism, Biological Weapons, and Bonanzas: Assessing the Real Threat to
Public Health. Am J of Pub Health 2001;91:708-709.
Ghilarducci DP, Pirrallo RG, Hegmann KT. Hazardous materials readiness in the
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Greenberg MO, Jurgens SM, Gracely EJ. Emergency Department preparedness for the
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instrument based on the Mass Casualty Disaster Plan checklist: results of a statewide
survey. Am J Infect Control. 2004 Oct; 32(6):327-32.
Selected References
• Hogan DE and Burstein JL. Disaster Medicine. 2002, Philadelphia, PA:
Lippincott Rven Press.
• Hsu EB, Jenckes MW, Catlett CL, Robinson KA, Feuerstein C, Cosgrove SE,
Green GB, Bass EB. Effectiveness of hospital staff mass-casualty incident
training methods: a systematic literature review. Prehospital Disaster Med.
2004 Jul-Sep; 19(3): 191-9.
• Keim ME, Pesik N, Twum-danso NA. Lack of hospital preparedness for
chemical terrorism in a major US city: 1996-2000. Prehospital Disaster
Med. 2003; 18: 193-9.
• Khan AS, Ashford DA, Craven RB, et al. Biological and Chemical Terrorism:
strategic plan for preparedness and response. Recommendations of the CDC
strategic planning workgroup. MMWR 2000; 49:1-14.
• Kortepeter M, Vhristopher G, Cieslak T et al, eds. Medical management if
biological casualties handbook, 4th ed. Frederick, MD: United States Army
Medical Research Institute of Infectious Diseases, 2001.
• Murphy JK. After 9/11: Priority focus areas for bioterrorism preparedness in
hospitals. J Healthc Manag. 2004 Jul-Aug; 49(4):227-35.
Selected References
• Novick LG, Marr JS. Public Health Issues in Disaster Preparedness, Focus on
Bioterrrorism. 2001, Gaithersburg, Maryland: An Aspen Publication.
• Ridge T. The critical role of hospitals involved in national bioterrorism
preparedness. J Healthcare Prot Manage. 2002 Summer;18(2):39-48.
• Schultz CH, Koenig KL, Noji EK. A medical disaster response to reduce
immediate mortality after an earthquake. The New England Journal of
Medicine. 1996; 334; 438- 444.
• Schultz CH, Koenig KL, Lewis RJ. Implications of hospital evacuation after
the Northridge, California Earthquake. The New England Journal of
Medicine. 2003; 348:1349-55.
• Schultz CH, Mothershead JL, Field M. Bioterrorism preparedness. I: The
emergency department and hospital. Emerg Med Clin North Am. 2002
May; 20 (2):437-55.
• Schur CL, Berk ML, Mueller CD. Perspectives of rural hospitals on
bioterrorism preparedness planning. Policy Anal Brief W Ser. 2004; 4: 1-6.
Selected References
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Simon R, Teperman S. The World Trade Center Attack. Lessons for Disaster
Management. Critical Care 2001;5:318-320.
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preparedness for weapons of mass destruction incidents: an initial assessment. Ann
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Waeckerle J. Disaster Planning and Response. N Eng J Med 1991;324:815-821.
House, H. Graber M. Scheckel S. Is your emergency department ready for a terrorist
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Wetter D, Daniell W, Treser C. Hospital Preparedness for Victims of Chemical or
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