Disaster Response And Respiratory Care

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Disaster Response And Respiratory Care
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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.

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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.

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Whats The Fuss?
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How Do We Respond To This
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So We Dont Feel Like This
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Disaster Characteristics

• Increased death, injury, illness that cant be
  managed
• Coordination public, government, and private
  organizations
• Equal triage distribution
• Notification of family
• Evacuation/Sheltering of evacuees

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Disaster Characteristics

• Media attention
• Heightened security crime scene
• Immediate and long term emotional support
• Significant property damage

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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)

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Consequence Management

• The objective of consequence management is
• Provide support
• Save lives
• Relieve suffering
• Mitigate further harm

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

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Public Health Response
County Health Departments
Pre-hospital Outpatient Services
Hospitals Pharmacies Laboratories
Mortuary Services
Surge Capacity
Health Care System
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Domestic Security Regions

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

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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

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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

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Goal of Surge Thinking

• Maximize survival for all players!
• Minimize morbidity!
• Maximize resource utilization!
• Will require new thinking!

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Natural Disasters
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Natural Disasters

• Tornadoes
• Forest Fires
• Floods
• Blizzards
• Cyclones/Typhoon
• Hurricanes
• Heatwave

• Tsunami
• Volcanic Eruption
• Earthquakes
• Mudslides
• Limnic Eruption
• Draught/Famine
• Hail

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Natural Disasters - Florida

• Hurricanes
• Tornadoes
• Forest Fires
• Flooding
• Freezing
• Sinkholes
• Drought
• Heatwave
• Hail

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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

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Cost 2004 Hurricane Season

• Floridas 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 gt 200 million

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Lessons Learned

• Preparation
• Facility Planning
• Power, Medical Gases, Water, Etc.
• Flood zone
• Material Resources
• Communication
• Redundancy
• Contingency plans
• Incident Command!

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Lessons Learned

• Workforce issues
• Adequate staff
• Hospital Planning
• Incident Command
• Education/Training
• Special Needs
• Behavior Health
• Patient Employee

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Lessons Learned

• Hospital Security
• Facility support
• Protective measures
• Patient Safety
• Mutual Aid
• Public and private partners
• Medivac

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Man-Made Disasters
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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

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Terrorism
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Poking skunks is dangerous!
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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.

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HOW WILL OUR ENEMIES FIGHT US?
UNCLASSIFIED
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CBRNE
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.
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Chemical Agents

• Mustard gas
• Sarin
• Phosgene
• Cyanide
• Chlorine

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Chemical Agents

• Industrial Chemicals
• Choking Agents
• Blood Agents

• Warfare Agents
• Blister Agents
• Nerve Agents

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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

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Biological Agents

• Undetectable by human senses
• Prolonged incubation period
• Limited surveillance capability
  
• Unrecognized exposure

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Bio-threats

• Biological agents may be
• Bacteria
• Viruses
• Toxins
• They are naturally occurring and / or can be
  bioengineered as Weapons of Mass Destruction.

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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

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Vectors

• Letters / packages
• Insects / animals
• Contaminated food / water
• Contaminated clothing
• Air via aerosol dissemination device

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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)

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Nuclear / Radiological Agents

• Any source that emits radiation

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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

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Symptoms of Radiation Exposure

• Nausea
• Vomiting
• Diarrhea
• Changes in mental status

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Early Detection

• Is your key to limiting potential exposure.
• Time is a huge factor in how much exposure one
  could receive.

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Radiation Penetration
Beta - b
Alpha - a
Gamma - g
Neutron - n
Image Source http//www.awe.co.uk/
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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.

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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

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Terrorist Attacks

• 20 attacks gt 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 200591186
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Terrorist Attacks

• 1983-2004 all multiple casualty events
• 875 patients from 31 events in Jerusalem
• Average of 28 patients per event
• ICU admission 5 (n43) - of these70 had blast
  lung injury
• 73 of patients required mechanical ventilation

Avidan V, J Trauma. 2007 May62(5)1234-9.
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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

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Plausible Scenarios
SCENARIO TIME TO MV DURATION OF MV VICTIMS NEED FOR MV
Trauma Immediate Days to weeks lt 100 Hemo pneumothorax, blast injury, burns smoke inhalation
Nerve Agent Immediate Hours Up to 1000 Paralysis, bronchospasm, bronchorrhea
Pulmonary Irritants Hours Days to weeks Up to 1000 ARDS, pulmonary edema, airway injury
Biologics Hours to days Days to weeks 1000 ARDS, hemorrhagic pulmonary edema
Radiologic Days to weeks Days to weeks Hundreds Traumatic lung injury, sepsis,
Rubinson L, Biosecur Bioterror. 20064(2)183-94.

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Vulnerabilities

• Hard Targets
• Military instillations
• Government buildings
• Secure Areas
• Soft Targets
• Hospitals
• Schools
• Churches

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Prevention Efforts

• Rely on
• Federal, State, Local Law Enforcement Agencies
• Hospital Hazard Vulnerability Assessments
• Accreditation and Regulatory Authorities
• Diligence, Observation, Reporting
• Safety Committees gtgtgt Performance Improvement

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Probability vs. Impact
NUCLEAR WEAPON
BIOLOGICAL AGENT
IMPROVISED NUCLEAR DEVICE
CHEMICAL AGENT OR TOXIC INDUSTRIAL CHEMICAL
POTENTIAL IMPACT
RADIOACTIVE MATERIAL
PROBABILITY/LIKELIHOOD
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Pandemic Influenza
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• Is it here yet?

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Natural Biologic Threat

• What is a pandemic?
• The spread of disease over a wide geographic area
  affecting much of the population

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Natural Biologic Threat

• Pandemic Influenza
• Increased morbidity (sickness) and mortality
  (death)
• Social disruption
• Economic disruption

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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

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Influenza Disease Characteristics

• Inflammation of the respiratory system
• Headache
• Fever
• Chills
• Cough
• Muscle aches
• Several days sick, several weeks recovering

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Pan Flu Stats

• Pandemic Influenza
• History
• 1918 50 100 million deaths
• 1957 2 million deaths
• 1968 1 million deaths
• Frequency every 35 years
• Duration 1 3 years
• Worldwide 6 9 months, 3 months?
• Waves 1 3, 4 8 weeks/wave

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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

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U.S. Planning Assumptions

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

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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

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Plan Components

• Rapid Response
• Isolation Quarantine
• Social Distancing
• Non-Pharmaceutical Interventions
• Pharmaceutical Interventions

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On-going Planning Issues

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

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Current Situation

• Human Deaths
• 353 cases, 221 deaths (62.2 Mortality)
• 14 countries
• Bird Deaths
• 150 200 million bird deaths
• gt50 countries (Asia, Europe, Africa)

WHO, 24 January 2008
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Respiratory Care

• Your Role In A Disaster

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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

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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

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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

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Material Resource Management

• IV Tubing
• Lab Resources
• Pharmaceutical
• IV Fluids
• Antibiotics
• Antiviral
• Vaccine

• Mechanical Ventilators
• Medical Gas supply
• Food Services
• Environmental Service supplies
• Linens

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The Gas Source Issue
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The Gas Source Issue

• What is the best source of oxygen?
• What about home health agencies and their
  patients?
• Power is an issue!

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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 ventilators capabilities match the
  needs of the patient, skill of the operator?

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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

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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 IE
• Monitor Paw and VT
• Alarms
• Disconnect, apnea, high/low pressure, high
  pressure source gas disconnect

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Ventilator Characteristics

• Rugged
• Light weight (lt10kg)
• Easy to use
• Gas consumption -low
• Battery life - long
• Easy to trigger

• lt 10 K
• Vendor support and longevity
• Maintenance
• Training

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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

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Specific Devices
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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

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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/

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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.

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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

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Other Issues
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Disaster Implications

• Communities
• Food, Water, Shelter
• Power
• Economic and Social Disruption
• Child Safety
• Domestic Animals
• Personal Property Damage

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Disaster Implications

• Patient Populations
• Food, Water, Shelter
• Power for medical equipment
• Medications
• Renal Dialysis
• Increase hospital surge!

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Healthcare Impacts

• Road Closures
• Hospital Closures / Evacuation
• Workforce Shortage
• Resource Management
• HVAC
• Water, Food
• Sanitation

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Supplies Management

• Surrounding Issues
• Just-In-Time Inventory
• Access
• Equipment Supplies
• Vent Circuits
• Aerosol and Humidity
• Medications
• Oxygen Supplies
• Other Medical Supplies

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Infrastructure Support

• Mutual Aid Agreements
• Vendor Agreements
• Hospital Agreements
• Government Agreements
• Local (i.e. City, Municipality, County)
• Regional
• State / Inter-State
• Federal

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Infrastructure Support

• Workforce Staffing
• Personal Plan
• PPE
• Plant Facilities
• Security Plans
• Facility Safety

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Communication Devices

• Phones cell, satellite, land based
• 800 mgHz / MED Radios
• Pagers
• Overhead paging systems
• Dispatcher
• Email
• HAM Radio

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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.

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Deadly Misconceptions

• It wont happen here
• It wont happen to me
• Someone else will take care of it

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Q A?

• Thank You!

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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 - 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

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References
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Mechanical ventilators in Mass Casualty
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A.L., Parker, C.L., Links, J.M. (2005). The
Application of the Haddon Matrix to Public Health
Readiness and Response Planning. Environmental
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R. (2007). Augmenting Positive Pressure
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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,
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101
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., OToole, 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 Ru
binson, L., Nuzzo, J., Talmor, D., OToole, 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.
102
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/