Disaster medicine

[Veneficus]

So I was commenting in the BDLS thread. Rather than hijack it further, I figured we should discuss it here.

In what is defined as "refugee conditions" in the early event, war, natural disaster, etc. trauma is the major cause of morbidity and mortality.

Later in the event, destruction/uninhabitable environment overtakes trauma as the leading cause.

US EMS education brings almost no useful skills or knowledge to a large or long term disaster.

I would like to discuss that here.

So, what are you or your agency prepairing to do before help arrives?

What do you plan to do when it leaves if the conditions persist?

What knowledge or skills do you think would be important?

 

[DrParasite]

http://www.nj1dmat.org/

 

[Rettsani]

Federal Office of Civil Protection and Disaster Assistance

 

[Melclin]

I don't know that your post really reflects the generally accepted stages of disaster management. You seem to be talking about how EMS systems transition from helping during the response phase of a disaster to helping during the recovery phase. Or maybe just the latter half of a big disaster's response phase. Could you specify?

What do you mean before help arrives? We are the help. I don't of course just mean your standard ambulance crews but the emergency management infrastructure that stands behind them as part of the greater ambulance service. Not to mention where that all fits into the state health emergency response plan. Maybe I'm missing the point for the following reasons, or maybe its one of those many situations where I've missed the point because its US specific.

As usual, I've just quickly skimmed EMTlife after coming home from a night out and found a topic that I'd really like to comment on meaningfully but am too drunk to do so. Sigh.

I'll see you in 24 hrs.

 

[Veneficus]

Talking about a larger scale, above response. Go have a few more beers mate, you are still sober enough to be typing here.

 

[shfd739]

For us we are on mandatory recall and must present to work before the event (if possible such as with a hurricane) with 5 days worth of uniforms, personal items, snacks/food etc.

Company has a cooking team that will pre-position with a portable kitchen so that as soon as possible they can move in and provide us with 2 hot meals. Breakfast will cereals, pastries etc. They will also set up temporary showers for hygeine needs. By the point that 5 days of uniforms are running out a laundry will be set up.

For a non-plannable event such as a tornado the onduty crews will be held and off duty personnel called in. Size of area impacted will determine how the aftermath is handled but we can ramp up to after type hurricane response pretty quickly using local resources.

If after an event is still too much for the local resources then contracts are in place with other services to send people to help as long as needed.

This was put to use on the Miss. coast after Katrina. We had set up with Superior Ambulance out of Illinois to provide crews and they wound up rotating thru for 2-3 months after the storm. As people began going into cleanup/recovery/rebuild mode our call volume jumped due to injuries and exacerbation of illnesses due to the conditions.

 

[Veneficus]

For us we are on mandatory recall and must present to work before the event (if possible such as with a hurricane) with 5 days worth of uniforms, personal items, snacks/food etc.

Company has a cooking team that will pre-position with a portable kitchen so that as soon as possible they can move in and provide us with 2 hot meals. Breakfast will cereals, pastries etc. They will also set up temporary showers for hygeine needs. By the point that 5 days of uniforms are running out a laundry will be set up.

For a non-plannable event such as a tornado the onduty crews will be held and off duty personnel called in. Size of area impacted will determine how the aftermath is handled but we can ramp up to after type hurricane response pretty quickly using local resources.

If after an event is still too much for the local resources then contracts are in place with other services to send people to help as long as needed.

This was put to use on the Miss. coast after Katrina. We had set up with Superior Ambulance out of Illinois to provide crews and they wound up rotating thru for 2-3 months after the storm. As people began going into cleanup/recovery/rebuild mode our call volume jumped due to injuries and exacerbation of illnesses due to the conditions.

Is there a plan for your family?

 

[shfd739]

Is there a plan for your family?

Yep...Wifey will be at work like me...and the dog will either hang around the office or chill at home...which happens to be a mile from the office...and will prob become a crash pad for employees.

 

[Veneficus]

Yep...Wifey will be at work like me...and the dog will either hang around the office or chill at home...which happens to be a mile from the office...and will prob become a crash pad for employees.

I meant does the company have a formal plan, so you don't have people abandoning jobs for family.

 

[shfd739]

I meant does the company have a formal plan, so you don't have people abandoning jobs for family.

Not so much a formal plan but our policies have suggestions on how to care for your family, to make pre-plans and to move your family out of harms way when possible. Time is given for family movement. The ones that stay wind up helping each other and supporting the employed family members. Like a big work family.

In over 8 years I can count on 1 hand how many instances Ive heard of jobs being abandoned. For the non-plannable events it appears our folks have made decent preparations for their families and the famiies understand that they need to be self sustaining minus the family member that is working.

For us when we lived on the coast, we went into work before a storm with the house made as ready as possibile, important papers/items etc were left at a relatives house along with our pets. I figured whatever happened to our stuff happened. I was 45mins away with more important things to handle.

 

[mycrofft]

Plans, training and cutting out organizational choke points.

I heard at a conference in 2005 this was a big factor in the Katrina disaster. Not only because sustainability of ops was chopped by severed infrastructure, but key people could not or did not respond to their posts. And some disaster plans weren't like "The facility commander or his assistant will issue keys", but more like "Bubba Gump will unlock the key locker"; in the event, BG is under water, fled with his family, has died or moved since the plan was drawn, was never told he had the mission, or changed his phone number.

FEMA is starting to waffle on their "72 hrs" preparedness standard. Many people I've heard have said "10 days"....and good luck with that.

 

[shfd739]

I heard at a conference in 2005 this was a big factor in the Katrina disaster. Not only because sustainability of ops was chopped by severed infrastructure, but key people could not or did not respond to their posts. And some disaster plans weren't like "The facility commander or his assistant will issue keys", but more like "Bubba Gump will unlock the key locker"; in the event, BG is under water, fled with his family, has died or moved since the plan was drawn, was never told he had the mission, or changed his phone number.

FEMA is starting to waffle on their "72 hrs" preparedness standard. Many people I've heard have said "10 days"....and good luck with that.

This^^^^ is agency failures.

We always had a staff meeting right at the beginning of hurricane season that was to the effect of "your job and community depend on you to be present- make it happen that you will be here and if you need our help to prepare we will help you."

Missing or bailing out for a storm was unacceptable except for extreme circumstances.

 

[mycrofft]

As usual, undermining paradigms...

1. HOSPITALS IN DANGER ZONES: Before you build, get a threat analysis. Then either DON'T build there, or make concessions like elevating the building, not building a glass tower in hurricane and tornado country, making seismic reinforcement integral in earthquake zones, and always have ample and redundant, frequently tested alternative infrastructure like water cistern or purification, generators, emergency radio communications, emergency lighting and equipment circuits, oxygen supply, and capacity to support staff for at least a little while.

2. EMERGENCY SERVICES: locally, get the threat assessment, then train and equip and plan to meet it. Make the system resilient and redundant. See above for facilities, but also be prepared to "go mobile" and send out communication nodes. Set up mutual aid with non-contiguous agencies (less likely to be mutually affected by same disaster). Make this include MOU's for emergency staples like water, food, fuel, batteries, and include delivery and storage.

3. INDIVIDUALS: get trained, get equipped, but do it reasonably. NOT everyone will have an earthquake or hurricane despite FEMA's plans and training.

 

[shfd739]

1. HOSPITALS IN DANGER ZONES: Before you build, get a threat analysis. Then either DON'T build there, or make concessions like elevating the building, not building a glass tower in hurricane and tornado country, making seismic reinforcement integral in earthquake zones, and always have ample and redundant, frequently tested alternative infrastructure like water cistern or purification, generators, emergency radio communications, emergency lighting and equipment circuits, oxygen supply, and capacity to support staff for at least a little while.

This one continues to amaze me where hospitals are built.

I know of one specialty care hospital on the Miss. coast that is no longer there due to Katrina. Huge 2 story building across the street from the gulf that was wiped out. The only remaining clue it was there is the concrete sign still in the ground. This facility only had beach and road in front of it so it caught a full on water hit.

Another coastal hospital had flooding due to only being 3-4 blocks from the water. These folks had to carry on in crap conditions with backup power and decresed water service.

Contrast that with the 2 hospitals in my former county that are off the waterfront, have massive powerplants to generate their power and large ponds that were used to provide water into the hospital's water treatment system. It was like a storm never happened and business as usual for them.

I realize that storms like Katrina are very infrequent but when they happen the local community is depending on the hospitals to be there for them. Putting facilities so close to the beach provides for great views but can hamper operations.

 

[mycrofft]

Beachside real estate is a great investment for the hospital. They can use it to leverage building loans.

 

[bstone]

I spent 3 months in the Gulf Coast after Katrina. It was hell on wheels. The local hospital was destroyed, thousands and thousands of displaced people, people dead, dying, and sick. It was really hell. The heat was 110F on a good day. I never want to go through that heat again. It was hell.

The government was nowhere. Help was given by people who got in their cars packed full of supplies. Occasionally there was an MD, RN, EMT, etc who showed up. We ended up putting together a huge free kitchen and a tent-based medical clinic.

It was hell. We did a lot of good, but it was hell.

 

[Jambi]

Why yes, I am bumping this thread!

I'm kinda bummed that the thread stopped and ended with FEMA guidelines...

One of my professional interests is the utilization of EMS during all phases of disaster management. I say this as I finish up the last three classes for my BA in emergency and disaster management (EDMG)...

My entire degree program had one course dedicated to EMS titled Special Operations in EMS. It was a public health course and it dealt with neither public health or EMS. It was horrible. EMS was touched on in that it was made known that EMS are those people that go get patients and bring them to hospitals...

Thus "Disaster" EMS is severely underrepresented in the disaster community. Also compounding the issue is the nearly complete lack of public health education EMS personnel receive during initial training.

The EDMG community and mode of thought is, and has been, in severe flux with all portions evolving at a rapid pace while also trying to find its own identity (sound familiar?). It is not surprising that EMS has no solidified place in EDMG.

Public health is important because after initial response immediately post-disaster, everything essentially becomes a Public Health response while also trying to maintain traditional services...

So I have aspirations to change this...a little at a time at least.

P.S. If anyone is curious, all EDMG is is public policy and social sciences.

 

[Veneficus]

One of my professional interests is the utilization of EMS during all phases of disaster management..

A dream.

It was horrible. EMS was touched on in that it was made known that EMS are those people that go get patients and bring them to hospitals....

It is true

Thus "Disaster" EMS is severely underrepresented in the disaster community. Also compounding the issue is the nearly complete lack of public health education EMS personnel receive during initial training.

Because US EMS were never designed for disaster response.

They are just slapped on like a band aid.

The current US EMS curriculum and model is completely worthless in a major disaster. When drive to the hospital is not an option, the whole system collapses.

It is one of the many reason international dsaster relief has no use for EMS providers with out other skills like technical rescue disciplines.

The EDMG community and mode of thought is, and has been, in severe flux with all portions evolving at a rapid pace while also trying to find its own identity (sound familiar?). It is not surprising that EMS has no solidified place in EDMG..

Probably because there are not many jobs in it?

Perhaps because experience outside policy making is helpful?

Public health is important because after initial response immediately post-disaster, everything essentially becomes a Public Health response while also trying to maintain traditional services...

Ummm... is that what they told you?

Because it is a little oversimplified.

Trauma, public health, and destruction of the environment contribute to what a Harvard researcher on the topic labled "refugee conditions" as she observed that disasters followed the same patten. (probably why she is a Harvard professor)

Trauma and basic health concerns alternate over time as the primary cause of morbidity and mortality in refugee conditions because of environmental insuitability and human efforts to try and make it sustainable.

US EMS provides definitive care neither for trauma nor for public health.

Ergo, on a large scale it is useless except to drive people to the hospital. Granted some small individuals or small groups will benefit from the equipment found with EMS providers and in some cases even their abilities.

But local EMS is simply too small to have an impact on health and is best assigned to its designed role of transport.

Whether in an austere environment, during a disaster, 3rd world country, refugee conditions, etc. It all comes down to logistics.

The public policy of disaster response is rather simplistic.

"We need money to prepare and respond..."

"We don't want to give you the money..."

Ask any professional fire offcer how the "management by disaster" game plays out.


So I have aspirations to change this...a little at a time at least.

P.S. If anyone is curious, all EDMG is is public policy and social sciences.[/QUOTE]

 

[Jambi]

Short Version:

The heart of the matter with EMS and utilization within EDMG is not in how it can operate and provide definitive care and outcomes, because no single profession is capable of such things, but with how it can be integrated into the larger health system and become part of the process. EMS is an interface of sorts that can be used to fulfill both care and logistical component. This can only be done trough an actual education process that encompasses a much broader scope of subjects than is currently provided in the current model of vocational training.

A dream.



It is true



Because US EMS were never designed for disaster response.

They are just slapped on like a band aid.

The current US EMS curriculum and model is completely worthless in a major disaster. When drive to the hospital is not an option, the whole system collapses.

It is one of the many reason international dsaster relief has no use for EMS providers with out other skills like technical rescue disciplines.

You seem to have a very fatalistic view of EMS in general and what it stands to be made into with the right amount of progress. You also seem to be referring to the response phase of EDMG, which is the smallest portion of the pie. albeit the most visible.

So in the response phase, EMS' role is best kept to what it does, medical transportation. What I am referring to is utilization of EMS in the largest phase of EDMG - recovery. Depending on the disaster, the recovery phase begins 3-7 days after initial impact

Recovery is where EMS stands to be made the most use of. This will require a large shift from what we know EMS responders as of today. Yes, this requires change is curriculum. EMS must move away from a vocational training model to an actual education model, which doesn't exist except from is small pockets across the U.S.

Probably because there are not many jobs in it?

No, there are plenty of job. They're just filled with wholly under and unqualified persons that walked into the positions because of a particular association with certain vocations like fire and LE.

Perhaps because experience outside policy making is helpful?

EDMG is not focused on policy making, but rather apply policy and developing mitigation and recovery strategies. Again, the whole experience thing seems to go back to the idea that EDMG is primarily response. The response phase with what happens when all the other phases have failed.

Ummm... is that what they told you?

Because it is a little oversimplified.

Trauma, public health, and destruction of the environment contribute to what a Harvard researcher on the topic labled "refugee conditions" as she observed that disasters followed the same patten. (probably why she is a Harvard professor)

Trauma and basic health concerns alternate over time as the primary cause of morbidity and mortality in refugee conditions because of environmental insuitability and human efforts to try and make it sustainable.

It was meant to be oversimplified. The caring for masses of people during the recovery phase is a logistical public health issue. Acute injuries, while it would be nice to address if possible, end up being a small issue to the larger picture of getting the "world" started back up to some sort of normalcy. Refugee camps, as you mentioned from what I assume to be a rather unimaginative Harvard researcher, are public health issues. In this regard, there is no profession prepared to care for such issues as currently trained except for those public health trained persons that tacked it on after initial education (DR, RN, PA, etc).

US EMS provides definitive care neither for trauma nor for public health.

I agree, but there is no one profession capable of solely providing definitive care in acute or long-term public health settings. It requires a system filled with many individuals with different skills to so such.

The heart of the matter with EMS and utilization within EDMG is not in how it can operate and provide definitive care and outcomes, because no single profession is capable of such things, but with how it can be integrated into the larger health system and become part of the process. EMS is an interface of sorts that can be used to fulfill both care and logistical component. This can only be done trough an actual education process that encompasses a much broader scope of subjects than is currently provided in the current model of vocational training.

Ergo, on a large scale it is useless except to drive people to the hospital. Granted some small individuals or small groups will benefit from the equipment found with EMS providers and in some cases even their abilities.

During the very short response phase this is true. This can be changed during the recovery phase, which is the real "meat" of the whole process.

But local EMS is simply too small to have an impact on health and is best assigned to its designed role of transport.

During the response phase, yes.

Whether in an austere environment, during a disaster, 3rd world country, refugee conditions, etc. It all comes down to logistics.

I agree, thus it seems like insanity to not use resources available.

The public policy of disaster response is rather simplistic.

"We need money to prepare and respond..."

"We don't want to give you the money..."

Ask any professional fire offcer how the "management by disaster" game plays out.

Hence the genesis of EDMG as a distinct academic and professional discipline. It's needed because the key to any discipline is in its education. What is also why EMS continues to have so many problems with identity, utilization, scope, etc.

 

[Veneficus]

You seem to have a very fatalistic view of EMS in general and what it stands to be made into with the right amount of progress..

I have been in the EMS game a long time.

EMS as it standstoday cannot meet the day to day demands placed on it. Even it's very mission of intervention in acute pathology is outdated.

The only 2 acute pathologies are trauma and toxins.

The rest of the modern pathology requires years and decades to create an acute event, it also takes years to manage or reverse. (when possible at all)

In my whole career of trying to advance EMS, the resistance to education has been absolute and constant over time.

If EMS is not willing to increase education for what it does every day, how do you propose to actually get them to focus on things outside the mission?

How are you going to pay?

Who will pay and why?

With all due respect, I am not interested in dreams of what EMS can or could be doing.

I am interested in how to actually effect the change. What is your plan?

You also seem to be referring to the response phase of EDMG, which is the smallest portion of the pie. albeit the most visible...

Not really, the whole thing.

Disaster pre-planning is not new to the world, nor is what is basically termed "recovery" which is not only getting things "back to normal" for society, but for very base level things like restoring an inhabitable environment.

What I am referring to is utilization of EMS in the largest phase of EDMG - recovery. Depending on the disaster, the recovery phase begins 3-7 days after initial impact

and can take decades...With a host of professions and vocations already more suited to it than EMS.

Why pay to retrain EMS providers when only a relatively handful of them will ever see or be a part of a disaster?

Recovery is where EMS stands to be made the most use of. This will require a large shift from what we know EMS responders as of today. Yes, this requires change is curriculum. EMS must move away from a vocational training model to an actual education model, which doesn't exist except from is small pockets across the U.S.

To what end?

Are you planning to use only the local EMS providers?

If you are planning to use them as a continued part of a recovery, who is paying?

Who is getting paid?

Who is covering the cost of OT and shift coverage from their initial location?

Who is traning them to use the equipment at the location?

Who is going to replace local assets if they bring equipment with them? At what rate? How will the local area cope with the loss of local assets?

Do you think anyone is really going to pay for "surge" effect equipment?

If they were why aren't they doing it now for even day to day surge?

No, there are plenty of job. They're just filled with wholly under and unqualified persons that walked into the positions because of a particular association with certain vocations like fire and LE.

Agreed, so do you plan to replace them by walking into their employer and telling them to clear out your desk?

Do you plan to go through the same experience path they took hoping they move on, retire, or die before you retire and open up a promotion?

Do you plan to somehow reverse the inevitable federal, state, and local budget cuts to supply money for disaster preparedness?

How?

EDMG is not focused on policy making, but rather apply policy and developing mitigation and recovery strategies. Again, the whole experience thing seems to go back to the idea that EDMG is primarily response. The response phase with what happens when all the other phases have failed.

In the first lecture I ever attended on rescue, the instructor said "The book tells you how to rescue somebody in the ideal situation... If the situation was ideal, nobody would need rescued."

Especially in the US, where it is much more the culture to clean up than prevent, there will always be a response phase.

To suggest with the best planning and preparation dsaster of any scale can be prevented is simply wishful thinking.

It was meant to be oversimplified. The caring for masses of people during the recovery phase is a logistical public health issue. Acute injuries, while it would be nice to address if possible, end up being a small issue to the larger picture of getting the "world" started back up to some sort of normalcy..

I don't think you undersand the scope of trauma and acute injuries in recovery.

The purpose of healthcare is to maintain wealth. Not only must people not be sick, they must be able to work. Trauma is the number 1 pathology that reduces productive life years. Whether those injuries happen during the disaster or after the disaster during recovery it doe snot matter in the practical sense, the goal of trauma care is to return people to productivity.

People who disable themselves rebuilding do not really see the difference in whether or not initial event injury or post event rebuilding. All they know is they are not functioning how they did. Which strains their ability to survive and prosper.

Refugee camps, as you mentioned from what I assume to be a rather unimaginative Harvard researcher, are public health issues. In this regard, there is no profession prepared to care for such issues as currently trained except for those public health trained persons that tacked it on after initial education (DR, RN, PA, etc).

Firstly, I did not say refugee camps. I said refugee conditions. Which unlike the buzzwords (like recovery) of lesser capable people to describe post event requirements, encompasses a much more accurate depiction of what is is actually occuring.

Whether it is a refugee camp, a war zone, or even post nuclear accident, refugee conditions, describe the challenges of having an inhabitable stable environment become and uninhabitable environment, and the challenges of providing basic necessities of life. It then moves into economic development, more encompassing public health issues like provision of long term healthcare, and finally infrastructure and social contracts of modern 1st world society.

It is fundamental building of a destroyed society, not returning a stricken part of a 1st world nation back to normal function. However, in my experience, I have found that many of the same lessons and challenges are applicable in isolated incidents in modern nations.

(I think the observation of rebuilding war torn Kosovo and how to appl that to large ans small disasters all over the world is a bit more imaginitive than trying to figure out rebuild part of the US from a tornado or flood.)

Secondly, if it takes doctors and nurses + extra education to rebuild (PA excluded as it is unique to a small amount of societies and doesn't cross borders as easily as doctors and nurses) you plan to retool US EMS training to meet this demand?

To do what? Give immunizations?

Let me point something out...

If I need to somehow supply, whether with imported or establishing local capability, (lets use conservative easy numbers) 3000 calories of food per day +10 liters of water for each inhabitant of a disaster area, is it better for me to add an extra responder that also requires those resouces or to use the minimal level of training possible to train a already stricken inhabitant, who I am already providing those resources for.

What about fuel and other transport costs? I have to get these providers there.

Not to mention pay them.

But I could give a local a meager job and a skill which will not only benefit him and the community in the future, while providing intangible local buy-in and knowledge, but it reduces the over all resources required at every level.

Which lends to maintaining these skills at a vocational level not an educational one.

but there is no one profession capable of solely providing definitive care in acute or long-term public health settings. It requires a system filled with many individuals with different skills to so such..

True, but it also doesn't help to pay for education and mobilization of resources which are simply not needed in order to give somebody extra contract income or protect their choice of undergrad.

The heart of the matter with EMS and utilization within EDMG is not in how it can operate and provide definitive care and outcomes, because no single profession is capable of such things, but with how it can be integrated into the larger health system and become part of the process. EMS is an interface of sorts that can be used to fulfill both care and logistical component. This can only be done trough an actual education process that encompasses a much broader scope of subjects than is currently provided in the current model of vocational training.

So what you are really saying is you want to retool EMS in the imagine of disaster response despite the fact a large percentage will never be involved in one to perform a function that is already being done by already greater educated people?

Sounds a bit more self serving to me than altruistic.

During the very short response phase this is true. This can be changed during the recovery phase, which is the real "meat" of the whole process.

So tell me what they are going to provide to justify the cost and resources they use that cannot already be done better or for less?

Hence the genesis of EDMG as a distinct academic and professional discipline. It's needed because the key to any discipline is in its education. What is also why EMS continues to have so many problems with identity, utilization, scope, etc.

There is what I think is the meat. You are trying to justify your value by changing EMS into a wasteful disaster response unit under the guise of advancing education.