Disaster myths

1
The Importance of Evidence-based Disaster
Planning
Erik Auf der Heide, MD, MPH, FACEP
The Second Mediterranean Emergency Medicine
Congress Sitges/Barcelona, Spain, September 16,
2003
8-28-03 Version
2
Erik Auf der Heide, MD, MPH, FACEPDisaster
Planning Training SpecialistAgency for Toxic
Substances and Disease RegistryU.S. Department
of Health Human Serviceseaa9_at_cdc.gov (404)
498-0291

• This presentation represents the opinions and
  observations of the lecturer and does not
  necessarily represent the policies or positions
  of
• the Agency for Toxic Substances and Disease
  Registry
• or the U.S. Department of Health and Human
  Services.

3
Agency for Toxic Substancesand Disease Registry
U.S. Department of Health and Human Services
The mission of ATSDR is to serve the public by
using the best science, taking responsive public
health actions, and providing trusted health
information to prevent harmful exposures and
disease related to toxic substances.
4

• Most of the data used in this presentation is
• from nonmilitary disasters in the U.S.A.
• Observations in other countries may differ
  because of economic, social, political, and other
  factors.

5
Importance ofEvidence-based Planning

• Many of the assumptions used in disaster planning
  have been disproven by systematic, field disaster
  research studies.
• Knowledge about these study findings helps avoid
  common response pitfalls.

6
Examples of Common Planning Assumptions Will Be
Given

• Compared with research findings.
• Implications for disaster planning Discussed.

7
Typical PlanningAssumptions

• Trained police, fire, and/or ambulance personnel
  on site will assume command.
• Firefighters and/or Emergency Medical Technitions
  will carry out search rescue.
• Patients will be
• Triaged
• Stabilized
• Distributed.

Olympic Centennial Park Bombing, Atlanta, 1996
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Realities

• Most initial care from survivors.
• Little stabilizing first aid given in the field.
• Most patients not triaged.
• Most transport not by ambulance.
• Closest hospitals get most patients.

Quarantelli EL. 1983. Delivery of emergency
medical services in disasters assumptions and
realities. New York Irvington. p. 67 and 91.
9
Assumption First Unit on Site Will Assume
Command

• Reality
• Most initial disaster response is carried out by
  the survivors (e.g., family, friends, neighbors,
  co-workers).
• A large part of this activity is outside the
  control of local authorities.
• Overall command control rarely occurs early in
  disasters.

10
Search Rescue by Survivors
50
Tornado, 1978 Lake Pomona, KS
50
Tornado, 1979 Cheyenne, WY
29
Tornado, 1979 Wichita Falls, TX
40
Flash Floods TX, 1978
67
Drabek TE. 1981. Managing multiorganizational
emergency responses. Boulder (CO) Natural
Hazards Research and Applications Information
Center, University of Colorado, pp.53,119
11
San Francisco Bay Area Earthquake, 1989
A study of 2 of the 6 Impacted Counties
Showed More Than 31,000 Survivors Involved
in Search Rescue
O'Brien PW and Mileti DS. 1993. Citizen
participation in emergency response. In Bolton
PA, editor. The Loma Prieta, California,
earthquake of October 17, 1989 societal
response. Washington (DC). US Government Printing
Office, p. B23-30.
12
Mexico CityEarthquake, 1985

• Over 1.2 million
• survivors involved
• in search rescue.

Dynes RR., Quarantelli EL, Wenger D. 1990.
Individual and organizational response to the
1985 earthquake in Mexico City, Mexico. Newark
(DE) Disaster Research Center, University of
Delaware. p. 84-6. Book and Monograph Series 24.
13
Tangshan, China,Earthquake, 1976

• 250,000 deaths.
• 200,000 to 300,000 rescued themselves,
• Then rescued 80 of others.

Yong, C. 1988. The Great Tangshan earthquake of
1976 an anatomy of disaster. Oxford Pergamon
Press. p. 59.
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Consequences ofSearch Rescue by Survivors

• Search rescue uncoordinated.
• Little field triage or first aid.
• Lack of hospital notification.
• Most casualties are transported to closest
  hospitals, while those further away wait for
  casualties that never arrive.
• The least serious casualties are the first to
  arrive at hospitals

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Consequences of Search Rescue by
SurvivorsUncoordinated Search RescueThe
Informal Mass Assault

• Large numbers of unskilled people.
• Tackling the first obvious problem.
• Overcoming it by sheer numbers.
• Then moving on to the next problem.
• No attention to the big picture.
• Lack of overall coordination.

Rosow R. 1977. Authority in emergencies four
tornado communities in 1953. Newark (DE)
Disaster Research Center, University of Delaware.
p. 16.
Form WH, Nosow S. 1958. Community in disaster.
New York Harper Bros. p. 59.
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Consequences of Search Rescue by SurvivorsLack
of Information to Hospitals

• Hospitals need advance warning to prepare for
  casualties.
• lt1/3 of cases involved contact between the
  disaster site any hospital.
• Of 19 communities, only 2 had interhospital radio
  net.
• Most information from first-arriving casualties
  or the news media.

Quarantelli EL. 1983. Delivery of emergency
medical services in disasters assumptions and
realities. New York Irvington. p. 67 and 91.
17
San Francisco Bay Area Earthquake, 1989

• 41 of 49 hospitals received inadequate
  information from field.
• TV broadcast radio the only sources of
  information for most hospitals.

Martchenke J. 1994. Hospital disaster operations
during the 1989 Loma Prieta earthquake. Prehosp
Disast Med 9(3)146-53.
California Association of Hospitals and Health
Systems. Hospital earthquake preparedness issues
for action. 1990. Sacramento (CA) p. 13.
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Consequences of Search Rescue by
SurvivorsNonambulance Transport

• To the lay public, the best medical care is
  transport to the closest hospital as quickly as
  possible.
• If a sufficient number of ambulances is not
  promptly available, the most expedient means is
  used to transport victims (e.g., private
  vehicles).
• Thus, most casualties completely bypass the field
  emergency medical services system.

Quarantelli EL. 1983. Delivery of emergency
medical services in disasters assumptions and
realities. New York Irvington. p. 67 and 91.
19
Arrival Means of Initial Disaster Casualties at
75 Hospitals
Helicopter 5
Police Car 6
Bus/Taxi 5
On Foot 4
Unknown 10
Private Car 16
Ambulance 54
Quarantelli EL. 1983. Delivery of emergency
medical services in disasters assumptions and
realities. New York Irvington. p. 70.
20
Percentage of Casualties Transported by Ambulance
Oklahoma City Bombing, 1995
San Francisco Earthquake, 1989
World Trade Center 9/11/2001
Tokyo Sarin Attack, 1995
36
23
7
6.8
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Consequences of Search Rescue by
SurvivorsBypass of Field First Aid Triage

• Unaware of existence or location.
• First aid considered inferior care.

Quarantelli EL. 1983. Delivery of emergency
medical services in disasters assumptions and
realities. New York Irvington. p. 67 and 91.
22
Consequences of Search Rescue by
SurvivorsFailure to Make Maximum Use of
Available Hospital Capacity

• Hundreds of survivors transport casualties to the
  closest hospitals.
• Hospitals further away receive few or no
  casualties.

23
Study of 29 U.S. Disasters

• In 75 of cases, gt1/2 casualties taken to closest
  hospital.
• In 46 of cases, gt3/4 casualties taken to closest
  hospital.
• Unused hospitals had an average 20 vacancy rate.

Quarantelli EL. 1983. Delivery of emergency
medical services in disasters assumptions and
realities. New York Irvington. p. 79.
24
Casualty Distribution
Hyatt Hotel Skywalk Collapse, Kansas City, 1981
Number of Casualties Received
16 of 26 Metro Hospitals Received Patients
0-1
1-3
gt6
3-6
Miles From Scene
Hyatt Disaster Medical Assessment. 1981. Kansas
City (MO) Kansas City Health Department.
25
Oklahoma City Bombing
Casualty Distribution Among 28 Hospitals
(Revised figures, 11/2002)
Number of Casualties
Miles From Scene
Shariat S. 2002. Personal Communication. Data
from Injury Prevention Service, Oklahoma City
(OK) Oklahoma State Health Department.
26
Consequences of Search Rescue by
SurvivorsLeast-serious Casualties Arrive First

• Those not entrapped.
• Hospitals unaware of more serious cases yet to
  come.
• When seriously injured arrive, all emergency
  department beds occupied.

Golec JA. 1977. The problem of needs assessment
in the delivery of EMS. Mass Emerg 2(3)16977.
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Planning Implications?
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Planning Implications

• Need to train firefighters and police how to
• coordinate search rescue by survivors.
• Assign responsibility for overall coordination.
  Example 1953 Waco, TX, Tornado
• Have bystander teams work with each officer.
• Assign each team to sectors.
• Coordinate with EMS for triage, treatment,
  transport.
• Realize that the ability to coordinate will be
  limited.

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Implications for Planning

• For those casualties that are transported by
  ambulance, avoid the closest hospitals.
• Survivors transporting casualties should be given
  directions to more distant hospitals and be
  advised that patient waiting times will be
  shorter there.

30
Implications for Planning

• Set up triage areas at hospitals or on major
  routes to hospitals.
• Then direct casualties to hospitals according to
  the severity and nature of medical condition.
• Importance of interhospital and
  ambulance-to-hospital radio networks for
  assessing hospitals ability to receive patients.

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Summary

• Although planners often talk about controlling or
  commanding the disaster response, many activities
  are not amenable to control.
• However, activities often can be influenced or
  planned around by
• Making officers with radios available help
  coordinate search rescue by survivors.
• Not sending ambulances to closest hospital.

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Summary (Continued)

• It is important to
• Become familiar with findings of disaster
  research studies, otherwise
• you might end up not planning for the right
  things.
• your plans might create a false sense of
  security.
• Assure that disaster drills test common response
  problems identified by disaster research.