Evolving a strategy for emergency response to natural disaster

Emergency Response to
Natural Disaster:
Floods, Winds, and
Earthquakes
Nicholas E. Kman, MD FACEP
Medical Team Manager, Ohio Task Force 1
The Ohio State University
Department of Emergency Medicine
Twitter @drnickkman

Disclosures
 Ohio Task Force 1: FEMA Urban Search and
Rescue
2

September 11th
, 2001
http://www.dispatch.com/content/graphics/2015/01/07/meiling-
hall.jpg

March 2011, Japan Earthquake and
Tsunami

Objectives
 Provide a background on Emergency Preparedness
and Disaster Response since 9/11/01.
 Analyze the Disaster Response Paradigm.
 Discuss Natural Disasters as they relate to
Preparedness.
 Define the injury patterns from Collapsed Buildings:
crush injury, compartment syndrome, and crush
syndrome
 Define the injury patterns from Wind Disasters.
 Describe flooding dangers.
14

What we will not cover!
 Ebola
 Bomb and Blast
 Infectious Agents of Bioterrorism
 Chemical Agents of Terrorism
15

Disaster Defined
 The United Nations Disaster Management Training
Program defines Disaster as:
 A serious disruption of the functioning of society,
causing widespread human, material, or
environmental losses which exceed the ability of
affected society to cope using only its own resources.
Bonnett et al. Surge Capacity: A proposed conceptual framework.
Amer J of Emerg Med 2007; 25: 297-306.
Dominique Faget—AFP/Getty Images

A Disaster: more simply…
 Any event that threatens or overwhelms the normal
operational capacities of the local healthcare system
and emergency medical services (EMS).
University of Wisconsin Cooperative Institute
for Meteorological Satellite Studies

Preparation
 Getting people and equipment ready to quickly and
effectively respond to a disaster.
 Conduct a Hazard Assessment
 Actual and potential hazards
 Develop a simple disaster plan (EOP)
 Failing to plan is planning to fail!
 Train all hospital staff in its application
 Awareness
 Technicians
 Patient care
American College of Surgeons, 2008, Advanced Trauma Life Support for Doctors, American College of Surgeons. Eighth Edition.
American Medical Association, 2012, Basic Disaster Life Support, Course Manual. V. 3.0.

Preparation and JCAHO
 6 focus areas for hospitals in disaster planning:
o Communications –internal and external to
community care partners, state/federal agencies
o Supplies
o Security – Enabling normal hospital operations and
protection of staff and property
o Staff – Roles and Responsibilities within a standard
Hospital Incident Command Structure
o Utilities – Enabling self-sufficiency for goal of 96
hours
o Clinical Activity – Maintaining care, supporting
vulnerable populations, alternate standards of care
26 http://www.jointcommission.org/emergency_management.aspx

Mitigation
Sustained actions taken to reduce or eliminate
long-term risk to people and property from
hazards.
Reducing effects before the event
Have an Incident Command System
 HICS (Hospital Incident Command System):
organizational structure that provides direction for
management of disaster response within hospital.
Train all staff in its application and use
 Plan in advance to ensure a coordinated response

National Disaster Medical System

Ohio Task Force-1
 1 of 28 Urban Search and Rescue (US&R) teams in
National US&R Response System managed by
FEMA.
 OH-TF1 also State of Ohio rescue response asset.
 MA-TF1 Urban Search & Rescue Structural Collapse Tra

Ropes Training
Camp Ravenna Joint Military Training CenterFlorida State Fire College
Camp Atterbury, Muscatatuck Urban Training Center

National Incident Management System
34

Incident Command System (ICS)
 Set of personnel, policies, procedures, facilities,
and equipment, integrated into common
organizational structure designed to improve
emergency response operations of all types.
 May be used for planned events, natural
disasters, and acts of terrorism.
 Is a key feature of the National Incident
Management System (NIMS 2004).

Incident Command System (ICS)
 Based upon changeable, scalable response
organization providing hierarchy within which people
can work together effectively.
 “First-on-scene" structure: First responder to scene
has charge until incident has been declared resolved
or more qualified responder arrives and receives
command.
 Used by all levels of government—Federal, State,
local, and tribal—as well as by many private-sector
and nongovernmental organizations.
http://emilms.fema.gov/IS200b/ICS0102summary.htm

ICS
 Structured to facilitate activities in 5 major
functional areas:
 Command
 Operations
 Planning
 Logistics
 Finance and administration.
37 http://emilms.fema.gov/IS200b/ICS0102summary.htm

Response: Prehospital and Inhospital
Care
 Saving life and property during and immediately
after a disaster.
 Implement the planned response quickly
 Decontaminate every patient
 Avoid contamination of facility, quarantine
 Disaster triage scheme (SALT)
 Effective surge capability
 Expect patient volume increased 20%
 Don’t expect outside help for at least 24 hours

Response: SALT Triage
Image adapted from: “SALT mass casualty triage: concept endorsed by the American College of Emergency Physicians, American College of Surgeons Committee on Trauma,
American Trauma Society, National Association of EMS Physicians, National Disaster Life Support Education Consortium, and State and Territorial Injury Prevention Directors
Association.” Disaster medicine and public health preparedness, v. 2 issue 4, 2008, p. 245-6.

Response: Surge Capacity
 If a mass casualty incident occurs, a healthcare
system may be suddenly faced with significant
increase of patients (Surge generating event).

Response: Surge Capacity
 Surge capacity is the ability of healthcare facility or
system to expand operations to safely treat an
abnormally large influx of patients.
 Surge Generating Event
 Contained
 Geographically Defined (tornado, flood, bombing)
 Population Based
 Infectious Diseases and Bioterrorism
http://buckeyextra.dispatch.com/

Inherent Response Problems
 Sudden and unpredictable onset
 Chaos
 Loss of services
 Disruption of gov’t
 Loss of infrastructure
 Transportation
 Communications
 Utilities
http://blogs.sacbee.com/photos/2010/08/hurricane-katrina-five-years-l.html

Inherent Response Problems (continued)
 Variable mitigation and preparation for response
at local level
 Loss of basic physiological necessities
 Shelter
 Food/water
 Sanitation
 Secondary hazards
 Further structural
damage
 Hazardous materials

Medical Response Obstacles
 Medical system overwhelmed
 Non-selective victim process
 Unusual medical problems
 Victims with previous problems
 Delay in treatment
 High risks to rescue personnel
http://video.foxnews.com/v/2674051681001/oklahoma-city-bombing-
missing-videos/?#sp=show-clips

Recovery
 Putting a community back together after a disaster.
50

Prevention
 Similar to Mitigation.
53

Natural Disaster
Crash Course
Photo: NASA GOES Project

Natural Disasters
Natural Disasters
 Earthquakes
 Landslides and Mudslides
 Tsunamis
 Volcanoes
 Wildfires
Weather Emergencies
 Extreme Heat
 Floods
 Hurricanes
 Tornadoes
 Tsunamis
 Lightning
 Winter Weather
An event of nature that
overwhelms local resources and
threatens the function and
safety of the community.

Wind Disasters
56
Marchigiani R, Gordy S, Cipolla J, et al. Wind disasters: A comprehensive review of
current management strategies. International Journal of Critical Illness and Injury
Science. 2013;3(2):130-142. doi:10.4103/2229-5151.114273.

Hurricanes
 Most mortality originates from secondary disasters
(storm surges, flash flooding, and tornados)
triggered by original event.
 In coastal regions, level of hurricane’s storm surge is
strong predictor of mortality.
 Winds are 2nd deadliest aspect.
 Most common non fatal traumatic injury pattern in a‑
hurricane consists of superficial lacerations from
airborne glass and/or other debris.
57

Tornados
 Tornados usually develop during intense “supercell
thunderstorms”.
 Result from updrafts created by solar warming of
earth’s surface. Updrafts then develop into vortex
with strong rotary winds and violent pressure
changes.
 Due to brief or absent warning, community has little
time to prepare or seek shelter, and morbidity and
mortality is proportionally higher compared to other
WDs.
58

Tornado Associated Injuries
 Most tornado fatalities die at scene and tend to be
either in exposed areas or in mobile homes.
 Risk factors for injury and death during a tornado
include:
 Poor building anchorage
 Occupant location other than a basement
 Age over 70 years
 High wind strength
59

Earthquake Injuries
60 Haiti Earthquake 2010 US&R LA County

Crush Injury
 Lactic acid produced
 Myoglobin, Potassium and other electrolytes
released
 Other toxins created/released (superoxides, O2 free
radicals)
 Capillary leak
 Thromboxane, prostaglandins, and other immune
system substances generated
 Muscle cell enzymes released

Crush Injury
 Effects are LOCAL ONLY until pressure released
and tissue reperfused
 Reason that patients survive entrapment despite
severe crush injury
 Adverse processes begin immediately upon
pressure release

Effects of Releasing Compressed Tissue
 Immediate:
 Capillary leak
 Hypovolemia/Hypotension
 Shock
 Severe metabolic acidosis: dysrhythmias, V-fib
 High serum potassium: cardiac dysrhythmia or arrest
 Delayed:
 Myoglobin/uric acid/renal toxins: kidney failure
 Other toxins: lung/liver/renal injuries

Cause of Death
 Major
 Hypovolemia
 Dysrhythmia
 Renal failure
 Other
 Adult Respiratory Distress Syndrome (ARDS)
 Sepsis
 Other electrolyte disturbances
 Ischemic tissue infection (gangrene)

EKG Abnormalities
 Related to
 Potassium levels and rate of rise
 Acidosis
 Other electrolyte abnormalities
 Other injuries
 Peaked T-waves, AV blocks, widened QRS, sine wave
 Responds rapidly to effective intervention

Strategies to Prevent Renal Injury
 Maximize renal perfusion
 IV normal saline
 Diuresis (brisk urine flow)
 Careful alkalinization of urine (pH > 6.5)
 Sodium bicarbonate
 Monitor urine flow and pH (Bladder catheterization if
possible)

Initial Management “in the Rubble”
 Maintain ABCs
 Protect airway
 Assess for crush injury potential
 Provide psychological support

Initial Management “in the Rubble” (continued)
 If crush potential is identified
 Establish IV access
 Fluid resuscitation prior to extrication
 Pre-release alkalinization
 Cardiac monitor (run baseline strip)
 Be prepared during extrication to treat
 Hypovolemia
 Acidosis
 Hyperkalemia

Floods-Preparedness
 Recognize Flood Risk
 Identify flood-prone or landslide-prone areas near
you.
 Know your community’s warning signals, evacuation
routes, and emergency shelter locations.
 Know flood evacuation routes near you.
69
www.dispatch.com

Floods-Response
 Unplug appliances to prevent electrical shock when
power comes back on.
 Gather emergency supplies and follow local radio or
TV updates.
 Do NOT drive or walk across flooded roads.
 Cars and people can be swept away
70 www.cdc.gov

Floods-Response and Recovery
 Practice safe hygiene
 Wash hands with soap and water to prevent germs.
 Listen for information from local officials on how to
safely use water to drink, cook, or clean.
 Use fans, air conditioning units, and dehumidifiers
for drying.
 For cleanup, wear rubber boots and plastic gloves.
Clean walls, hard floors, and other surfaces with
soap and water. Use mixture of 1 cup bleach and 5
gallons water to disinfect.
71 http://emergency.cdc.gov/disasters/floods/readiness.asp

Disaster Management Cycle Review
72

Disaster Management Cycle Review
73
Emergency Preparedness
Disaster Management

Final Pearls
 Have a straightforward disaster plan and
educate everyone in its use.
 Have an incident command structure and drill
often.
 Have a disaster triage scheme, and mobilize
surge resources as needed.
 Have a traffic control system and communication
system.
74

Final Pearls
 Communications-Cell Phones Go Down!
 Redundant modes / systems / equipment
 Supplies-Bring your own
 Ample supply stores / reliable supply chains
 Security
 Control traffic flow / patient, staff safety
 Volunteers
 Physician role is hospital-based patient care
75

What can you do?
 Be Informed: Learn your Emergency Operations
Plan (EOP) and exercise it.
 Find out where you would report in a disaster.
 Make a Plan: Prepare yourself and your family (
www.ready.gov).
 Build a kit.
76
http://www.costco.com/American-
Preparedness-Emergency-Backpack-
Kit.product.11100551.html

What can you do?
 Get Involved: Join your Emergency Preparedness
Committee.
 Go Regional, then National!
77

References
 FEMA Medical Team Training Student Reference CD (2/2009)
 FEMA WMD for Medical Specialist Training CD
 Franco et al. The National Disaster Medical System: Past, Present, and Suggestions
for the Future. Biosecurity and Bioterrorism: Biodefense Strategy, Practice, Science
2007; 5: 319-325.
 Bonnett et al. Surge Capacity: A proposed conceptual framework. Amer J of Emerg
Med 2007; 25: 297-306.
 ATLS 8th
Edition.
 Kman NE, Bachmann D. “Biosurveillance: A review and Update.” In Special issue:
Advances in Development of Countermeasures for Potential Biothreat Agents.
Advances in preventive medicine, v. 2012, 2012, p. 301408.
 Kman N, Rund D. “Disaster Preparedness 10 years after 9/11: The Experts Weigh In”.
Emergency Medicine. Emerg Med 2011; 43(9): 12-13. (September)
www.emedmag.com.
 Marchigiani R, Gordy S, Cipolla J, et al. Wind disasters: A comprehensive review of
current management strategies. International Journal of Critical Illness and Injury
Science. 2013;3(2):130-142. doi:10.4103/2229-5151.114273

References
 www.fema.gov
 www.cdc.gov
 http://phil.cdc.gov/phil/home.asp
 Marchigiani R, Gordy S, Cipolla J, Kman NE, Stawicki S, et al. "Wind disasters: A
comprehensive review of current management strategies." International journal of
critical illness and injury science. Vol. 3, no. 2. (Apr 2013): 130-142.
 Kman N, Bachmann D, Folley A, Adams J, Greer M. Emergency Preparedness
Simulation Cases for Medical Students: Crush and Organophosphate Exposure.
MedEdPORTAL; 2013. Available from: http://www.mededportal.org/publication/9330.
 Yuri Rojavin, Mark J Seamon, Ravi S Tripathi, Thomas J Papadimos, Sagar
Galwankar, Nicholas Kman, James Cipolla, Michael D Grossman, Raffaele
Marchigiani, Stanislaw P A Stawicki. “Civilian nuclear incidents: An overview of
historical, medical, and scientific aspects.” Journal of emergencies, trauma and shock,
v. 4 issue 2, 2011, p. 260-72.
 Kman NE, Nelson R. Infectious Agents of Bioterrorism: A Review for Emergency
Physicians. Emerg Med Clin N Am 2008; 26: 517-547.

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