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 support  Save lives  Relieve suffering  Mitigate further harm

Preparedness Cycle

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

Plan Train

P.E.T.E.

 Plan  Public Health Preparedness Strategic Plan  Equip  Ventilators, PPE, Pharmaceuticals, etc…  Train  OSHA, DHS, Other  Exercise  Local, Regional, Statewide, Interstate, National

Public Health Response

County Health Departments Pre-hospital Outpatient Services Hospitals Pharmacies Laboratories Mortuary Services Health Care System

Surge Capacity

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 Plans  Hospital CEMP Plans

Goal of Surge Thinking



Maximize

survival

players!

for all



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 issues  Adequate staff  Hospital Planning  Incident Command  Education/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

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.

C hemical B iological R adiological N uclear E nergetics / Explosives

Chemical Agents

 Mustard gas  Sarin  Phosgene  Cyanide  Chlorine

Chemical Agents

Industrial Chemicals Warfare Agents  Choking Agents  Blood Agents  Blister Agents  Nerve Agents

Exposure To Chemicals

Routes of exposure  Inhalation, skin contact, ingestion, injection Effect depends on dose  Larger dose: earlier and more severe effects  Effects may be immediate or delayed Individual susceptibility varies  Age, chronic illness, medications

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

CDC Category

A

Agents



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])

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.

Radiation Penetration

Alpha

-

a Beta

-

b Gamma

-

g Neutron

- n

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

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

ammonia – phosgene, 

Biologic Agents

anthrax, botulism – plague, tularemia, 

Radiologic Events

– nuclear weapon, dirty bomb

Plausible Scenarios

SCENARIO Trauma Nerve Agent Pulmonary Irritants Biologics TIME TO MV

Immediate Immediate Hours Hours to days

DURATION OF MV VICTIMS NEED FOR MV

Days to weeks Hours Days to weeks < 100 Hemo – pneumothorax, blast injury, burns smoke inhalation Up to 1000 Paralysis, bronchospasm, bronchorrhea Up to 1000 ARDS, pulmonary edema, airway injury Days to weeks  1000 ARDS, hemorrhagic pulmonary edema

Radiologic

Days to weeks Days to weeks Hundreds Traumatic 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 Agencies  Hospital Hazard Vulnerability Assessments  Accreditation and Regulatory Authorities  Diligence, Observation, Reporting  Safety Committees >>> Performance Improvement

Probability vs. Impact

NUCLEAR WEAPON BIOLOGICAL AGENT POTENTIAL IMPACT IMPROVISED NUCLEAR DEVICE RADIOACTIVE MATERIAL CHEMICAL AGENT OR TOXIC INDUSTRIAL CHEMICAL PROBABILITY/LIKELIHOOD

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 disruption  Economic 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  1957  1968  Frequency  Duration  Worldwide  Waves 50 – 100 million deaths 2 million deaths 1 million deaths ~ every 35 years 1 – 3 years 6 – 9 months, 3 months?

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  Treatment rate  Hospitalization rate  Case fatality rate  Pre/asymptomatic transmission  Incubation period 35% of population 25% of population ~75% of cases 10% of cases 2% (2% - 50%) 30% - 50% (?) 2 days (1 – 8 days)

Florida Planning Assumptions

  Cases Hospitalized (10%) Surge Beds (130%) ICU ICU Ventilator Surge Ventilators  Dead (2%) 1st Wave/2nd Wave 3.2 million 320,000 65,000 48,000 24,000 5,000 64,000 Total 6.4 million 640,000 128,000 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

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 Issues  Just-In-Time Inventory  Access  Equipment & Supplies  Vent Circuits  Aerosol and Humidity  Medications  Oxygen Supplies  Other Medical Supplies

Infrastructure Support

 Mutual Aid Agreements  Vendor Agreements  Hospital Agreements  Government 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!

Acknowledgements

               The 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 Randy De Kler, MS, RRT -

Program Director, Respiratory Care, Santa Fe Community College Program Director, Respiratory Care, Miami Dade College

Phil Khan, RRT -

Florida Society for Respiratory Care

Sandra J. Barker, MS, RRT Timothy J. Coons -

Director, Cardiopulmonary Services, Largo Medical Center Director, Cardio-Pulmonary Services, Shands Hospital at the University of Florida

Bill Cunningham, BS, RRT -

University of Florida Adult Critical Coordinator, Cardiopulmonary Services, Shands Hospital at the

Joseph Albino, BS, RRT Kelly Sebree, RRT, NPS -

Manager, Respiratory Care, Mease Dunedin Hospital 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_disasters Barnett, 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/cc3533 Rubinson, 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.html

U.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/