DISASTER MANAGEMENT
| KATRINA LESSONS IN JOINT INCIDENT COMMAND —Kenneth L. Mattox, MD, Professor and Vice Chair of
Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, and Chief of Staff and Chief of Surgery,
Ben Taub General Hospital, Houston, TX
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| Introduction: strong evidence that 21 “dirty” bombs crossed border in Texas, New Mexico, and Arizona during last
24 mo and distributed to 21 cities across country; 21 bombs intended to go off simultaneously in future; disaster drills
proved worthless in September 11 disaster in New York City
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| Hurricane Katrina: only 18 hr elapsed from time Katrina became category 4 hurricane until it struck east of New Orleans,
LA; evacuation impossible; New Orleans lost all infrastructure because of broken levees; speaker’s experience—
speaker one of several people asked to bring evacuees from New Orleans Superdome to Houston, build shelter, develop
exit strategy, and take care of health problems; speaker believes disaster plans of governmental agencies and hospitals
mostly worthless; must empower team to perform job and depoliticize issue; joint incident command formed with 6
branches (speaker in medical branch); area emergency departments (EDs) protected; clinics built near shelter; predicted
epidemics (gastrointestinal, mental health, and pneumonia) and developed strategies; goal to close clinics in 10 days and
shelter in 14 days; mission data-driven and tracked trends; “denominator” determined (25,000 people in Superdome);
10% rule—in any disaster, only 10% of people who survive initial event have health problems, and only 10% of people
who come to clinics have major problems; number determines work force and needs; establishing order—potential
concerns determined, and each concern assigned to one individual who gathered data; professionals (eg, doctors, nurses)
not “owned” by any government agency but associated with medical societies, schools, private practice, and hospitals in
region; take advantage of personalities in region (eg, operating room nurses are “take charge” individuals); must have
shift leader in clinical areas; do not have too many doctors and nurses for first 3 days; do not allow outsiders; catalog every
person who responds and control environment with discipline; credential outside individuals; need local solutions to
local problems (decisions or solutions offered from outside state usually economically, personally, or politically motivated);
develop collaborative integrated network; top-down management not effective; patients must be driving force;
problem that every group thinks their group most important, and political process becomes driving force (local, county,
and federal public health officials want to be medical voice)
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| Disaster subunits: every government subdivision has disaster plan in emergency operating center, often funded from
same source; joint incident command required by federal regulations to organize all government agencies into one
unit; should have ultimate local authority to combine resouces; >500 “silos” (subunits) involved in disaster response
(>400 in Washington, DC); speaker believes Department of Homeland Security, Federal Emergency Management
Agency (FEMA), Centers for Disease Control and Prevention (CDC), and others worse than worthless during Katrina
(did not communicate and not helpful); quasi-government silos (eg, Red Cross, Salvation Army) have own set of
rules; management of volunteers essential (>60,000 volunteers during Katrina); other silos (eg, professional organizations,
medical schools) have own agendas and own set of rules; getting people to work together requires leadership
skills; most medical professionals believe that they and their hospital or trauma center are center of disaster (“nothing
could be further from the truth”; “you are an afterthought during the infrastructure formation”); for first 96 hr of disaster,
disaster area on its own, and outside agencies only come in after area already fixed or situation lost (won or lost in
first 48 hr); 200,000 evacuees from Louisiana in Houston; 25% to 35% had mental problems when they arrived; rescuers
provided food, shelter, and hygienic supplies to give hope (turn despair into hope); studies show posttraumatic
stress disorder (PTSD) rate of 24% among medical professionals after disaster; occurs with every disaster, and must
prepare for it from day 1; better for out-of-state volunteers to set up own shelter in own state to which evacuees can be
relocated (better use of resources); electronic medical records used; speaker states clinic could have closed by day 4
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| Final lessons: need new drills and joint commission; American College of Surgeons and others need to know about incident
command and silos and practice it; needs requirements should be data-driven; top-down management not effective
way to manage disaster; essence of success local leadership taking charge of local assets and “making it happen”;
develop sister-city programs with cities around area; outside help essential in face of total loss of infrastructure; preemptive
preventive security measures important; have preventive mental health programs in place; FEMA, Disaster
Medical Assistance Team (DMAT), National Disaster Medical System (NDMS), and CDC not available for first 96 hr
after disaster; communication among federal programs nonexistent (all politicized); understand that silos exist and
know their roles; inculcate one’s self into local incident command structure (programs need representation of medical
professionals and their insights on practicality); physicians and professional organizations currently not at political table
in disaster planning preparedness and response; statewide trauma systems one of best trauma responses; necessary
to bring silos together into integrated collaborative network
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| PEDIATRIC ASPECTS OF CHEMICAL/BIOLOGICAL TERRORISM —Michael Shannon, MD, MPH, Professor of
Pediatrics, and Chair, Division of Emergency Medicine, Children’s Hospital Boston, Harvard University Medical
School, Boston, MA
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| Introduction: goal of terrorist to produce fear, injury, revenge, publicity, reaction, and chaos; mantra of terrorist to
kill few, hurt hundreds, and scare thousands; examples sarin gas attack in 1995 and anthrax incident of 2001; in anthrax
incident, 22 people killed, but millions frightened; 4 major categories of terrorism include biologic, chemical,
nuclear, and thermomechanic
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 | Anthrax: easy to produce in large quantities; short incubation period; previously thought highly lethal, but only 40% to
50% of those who contracted inhalational anthrax in fall of 2001 died; characteristic clinical presentation fever,
malaise, and cough, with no rhinorrhea (to distinguish from influenza); not contagious; characteristic x-ray findings
include widening of mediastinum, with relative sparing of pulmonary parenchyma
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| Smallpox: eradicated in 1980; previously stored in 2 laboratories (one in former Soviet Union and another in United
States); presently, location unclear; vaccine previously given at 6 yr of age; no longer given as of 1972, unless in
military; those <36 yr of age susceptible if exposed, and because of waning immunity, 70% to 80% of those >36 yr
of age relatively susceptible; highly transmissible and contagious; fairly lengthy incubation period; not as lethal as
anthrax; clinical presentation headache, fever, rigors, and rash; relatively low mortality (but important); because of
combination of lengthy prodrome, low mortality, and high infectivity, considered greatest threat for worldwide
spread (only takes single individual on airplane traveling from one country to another to produce global spread)
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| Chemical weapons: 2 categories include built weapons and weapons of opportunity; built weapons—require organization,
money, time, people, and resources; weapons of opportunity—consist of agents found anywhere that, when
released, become chemical weapons (eg, rail car transporting ammonia, tank of chlorine); require no money, organization,
or planning
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| Sarin gas attack (1995): 80% of victims came to hospitals by taxi, car, or on foot; suggests inadequacy of emergency
medical services (EMS) in mass casualty event; victims came contaminated and unexpected in groups of hundreds
to whichever hospital nearby; number of health care workers sickened by taking care of victims; victims not
decontaminated; >400 health care workers sickened and unable to work; lessons learned— never manage contaminated
patient without personal protective equipment (PPE); never let contaminated patient inside health care facility
(fumes of sarin permeated hospital)
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| Children: have higher breathing rate and lower “personal cloud” where concentration of toxins at highest; at greater
risk for hypothermia (implications for showering as decontamination strategy); less fluid reserve; not communicative;
do not separate easily from parents; self-preservation acquired developmental milestone (not in place until 4 or 5 yr of
age [child 2 or 3 yr of age does not know how to run away from danger]); more likely to develop PTSD and other
mental health consequences after large-scale disaster of any type
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| Silos: after September 11, noted that groups of emergency/rescue personnel working in silos and not talking to each
other (eg, sarin authorities not talking to anthrax experts); inefficient and led to poor communication, redundancy, and
expense; all-hazards approach—planning for terrorist events should be done simultaneously with inevitable public
health emergencies; response plan for one emergency should work for others (eg, response plan developed for smallpox
could also be used for severe acute respiratory syndrome [SARS] or Avian flu); overt vs covert incidents—
terrorist events tend to be dramatic and extremely obvious; weapons of mass destruction (WMD) can be released covertly;
covert incidents—greatest public health threat because of ability to incite fear and to psychologically disable;
need to develop systems for recognition (same system good for public health [can help detect natural outbreak of disease
and disease clusters]); syndromic surveillance—building systems to identify covert incidents
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| Consequence management: no existing pediatric protocols for decontamination, drug administration, and vaccines;
management of pediatric casualties while wearing PPE; children accompanied by parents who will not leave them,
forcing management of adults; children unable to identify themselves, making tracking and reunification with parents
difficult; hospital campus—prepared hospital has sheltering within and lockdown protocols to keep personnel and
campus safe (contaminated victims and media kept outside, personnel kept safe inside); requires inventory of all entrances
and exits and mobilizing additional security forces; PPE—every hospital should have supplies; several
classes, ranging from class A (moon suit with self-contained breathing apparatus) to class D (universal protocols, eg,
gloves); class D PPE worthless for patients contaminated with chemical products; eg, sarin completely permeates
gloves and clothing; general recommendation, at least level C PPE for every hospital campus; keeping personnel safe
and healthy key; decontamination—must occur outside health care facility; 80% to 95% consists of removal of clothing
(bag and preserve clothing as potential evidence); water should be 100°F and contained if possible; surge
capacity—previously, hospital disaster plans capable of managing up to 50 casualties; after September 11, recommended
that hospitals should be prepared to respond to disaster involving as many as 500 casualties per million population;
in such instances, EMS systems ineffective; after mass casualty incidents, fairly predictable ratio of urgent/
walking wounded/worried well of 1:5:10 (ie, 10 times more patients coming to hospital not in need of medical attention
than in urgent need); ensure that those not in need do not come to hospital; requires identification of alternate remote
sites of care; “second wave” phenomenon—less sick patients (ie, those able to drive or walk) will be first to
arrive at hospital; more critically ill in field longer (EMS has to extricate, stabilize, manage airway, or possibly decontaminate
before transport); sickest patients arrive later; must keep in mind so resources not exhausted early; identify
alternate sites for walking wounded, and allocate resources carefully
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| Advance planning: every hospital should train sufficient core of staff to provide 24/7 response capability; training
should be accompanied by regular drills; paradigm shift in how hospitals and health care facilities perceive mission;
primary mission to protect personnel, and then patients; in mass casualty incident, especially if result of terrorism,
20% to 30% of health care workers will not show up for work; make sure workers know they are protected; stockpile
antibiotics; identify and inventory all isolation and reverse ventilation facilities in hospital; develop protocols for management
of critical incidents in manner that does not expose personnel; biodefense group—must be multidisciplinary;
requires political will and backing of hospital leadership; American Hospital Association (AHA) estimates
cost for good hospital plan $3 million
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| School planning: neighborhood health centers, physician offices, and schools overlooked in planning for emergency
preparedness; essential because children spend majority of waking hours (>60%) in school; with few exceptions,
school preparedness plans focus only on evacuation (fire drill) and crisis response; no national preparedness plans created;
schools specific targets of terrorism over last 10 yr; questions every school must answer—does school have
school-specific comprehensive crisis response manual? does it include evacuation and relocation plan? has it been
tested in all weather conditions? does plan include sheltering in? has it been practiced? is there emergency communication
plan (parents must be able to communicate with school, know whereabouts of child, and be assured of child’s
safety)? has effective communication between local and state emergency teams been established? challenges in developing
evacuation plan—temporary vs long-term evacuation; relocation sites should be preestablished and parents
should know them; need to designate person responsible for giving medications to students; decide how to keep children
warm and dry; relocation plan—establish multiple relocation sites, depending on size of student body; arrange
transportation of medication, communication lists, and other key information; establish school communication with
parents; create sheltering protocols for outdoor threats and lockdown protocols for threats within school
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| Summary: age of terrorism has brought new medical challenges, including new illnesses and injuries; all-hazards approach
appropriate not only for terrorist acts but for public health emergencies of all types; pediatricians and other clinicians,
as astute clinicians, have key role in syndromic surveillance and identifying sentinel events; new threats
forced paradigm shift in hospital’s mission from patient-centered to staff- and campus-centered; hospitals must create
response protocols, including surge protocols; unique needs of children, eg, being in school, require new protocols;
despite government assistance and regional collaboration, hospitals must develop own plans
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Suggested Reading
American Academy of Pediatrics Committee on Pediatric Emergency Medicine; American Academy
of Pediatrics Committee on Medical Liability; Task Force on Terrorism: The pediatrician and disaster preparedness.
Pediatrics 117:560, 2006; Autrey P et al: High-reliability teams and situation awareness: implementing a
hospital emergency incident command system. J Nurs Adm 36:67, 2006; Campos-Outcalt D: Disaster medical response:
maximizing your effectiveness. J Fam Pract 55:113, 2006; Cohen HW et al: The pitfalls of bioterrorism preparedness:
the anthrax and smallpox experiences. Am J Public Health 94:1667, 2004; Colias M: Hurricane Katrina. The
disaster after the disaster. Hosp Health Netw 79:36, 2005; Committee on Environmental Health; Committee on Infectious
Diseases et al: Chemical-biological terrorism and its impact on children. Pediatrics 118:1267, 2006; Cosgrove SE et al:
Ability of physicians to diagnose and manage illness due to category A bioterrorism agents. Arch Intern Med 165:2002,
2005; Devereaux A et al: Vesicants and nerve agents in chemical warfare. Decontamination and treatment strategies for
a changed world. Postgrad Med 112:90, 2002; Edwards D et al: First-receiver hospital decontamination: an 8-step approach
to a progressive and practical program. J Nurs Adm 37:122, 2007; Eggertson L: Katrina scars tens of thousands
psychologically. CMAJ 173:857, 2005; Eisenman DP et al: Disaster planning and risk communication with vulnerable
communities: lessons from Hurricane Katrina. Am J Public Health 97 Suppl 1:S109, 2007; Greenough PG et al: Hurricane
Katrina. Public health response--assessing needs. N Engl J Med 353:1544, 2005; Hadler JL: Learning from the
2001 anthrax attacks: immunological characteristics. J Infect Dis 195:163, 2007; Hull HF et al: Smallpox and bioterrorism:
public-health responses. J Lab Clin Med 142:221, 2003; Kapp C: Conference highlights bioterrorist threat. Lancet
362:1386, 2003; Lee EC: Clinical manifestations of sarin nerve gas exposure. JAMA 290:659, 2003; Marmagas SW et
al: Public health's response to a changed world: September 11, biological terrorism, and the development of an environmental
health tracking network. Am J Public Health 93:1226, 2003; Nelson C et al: Conceptualizing and defining public
health emergency preparedness. Am J Public Health 97 Suppl 1:S9, 2007; Parker CL et al: The Road Map to Preparedness:
a competency-based approach to all-hazards emergency readiness training for the public health workforce. Public
Health Rep 120:504, 2005
Educational Objectives
| The goal of this program is to improve disaster and emergency preparedness. After hearing and assimilating this program,
the clinician will be better able to:
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| 1. Make plans, based on the 10% rule, for any disaster.
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| 2. Describe the lessons learned in emergency preparedness from Hurricane Katrina.
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| 3. Recognize the differences between needs of children and needs of adults in disaster and emergency preparedness.
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| 4. Implement the all-hazards approach in emergency preparedness.
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| 5. Describe the measures that hospitals and schools can adopt to prepare for mass casualty incidents.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose relevant
financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified
conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business
or commercial interest. For this program, the faculty reported nothing to disclose.
Acknowledgements
Dr. Mattox was recorded at Detroit Trauma Symposium, held November 9-10, 2006, in Detroit, MI, and sponsored by
Wayne State University School of Medicine, Detroit Receiving Hospital and University Health Center. Dr. Shannon was
recorded at Pediatric Emergency Medicine 2007, held April 10-14, 2007, in Lake Buena Vista, FL, and sponsored by
Nemours. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production of
this program.
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