Comprehensive Notes on Disaster Management and Triage

Dimensions of Disaster Risk and Predictability

• Disaster risk assessment involves identifying specific geographical regions prone to certain hazards.
• Examples of localized risk include:
  • Tornado Alley: Prone to tornado activity.
  • Florida: High risk for hurricanes.
  • California: High risk for wildfires.
• Natural disasters, while biologically infrequent, are increasing in frequency and problematic nature due to factors such as climate change.
• Man-made disasters lack predictability and frequency. For instance, mass shootings are unpredictable because they occur whenever a person decides to act, leaving no time for a priori risk assessment.

Mitigation and Controllability Efforts

• Mitigation is the phase of disaster planning focused on minimizing pain, harm, suffering, and damage.
• Controllability examples include:
  • Implementation of building codes and standardized construction to withstand regional threats.
  • In Florida, the use of shutters to cover glass windows preventing hurricane-force winds from blowing out glass.
  • In California, evacuation orders are issued during drought conditions when fires spread.
  • Individual actions include spraying homes with water or clearing brush and kindling around property to prevent fire spread.
• Warning time varies; the amount of lead time available significantly influences the success of mitigation and evacuation efforts.

Vulnerability and Social Impacts of Disasters

• The severity of a disaster depends on its impact on society and the environment, specifically the vulnerability of the population.
• Most vulnerable populations include:
  • People physically unable to help themselves, such as the physically disabled or handicapped.
  • Hospitalized patients who are intubated, sedated, and require mechanical assistance for evacuation.
  • Mentally challenged individuals and confused older adults.
  • Young children who cannot navigate a disaster independently.
• Nurses carry the responsibility for evacuating dependent patients during hospital emergencies.
• Social and Physical Factors:
  • Physical: Time of occurrence, weather, and availability of food, water, and utilities (electricity and telephone service).
  • Chemical: Leaks into the air, soil, or groundwater affecting the food and water supply.
  • Biological: Contamination from waste disposal, pests, rodents, and lack of refrigeration for food storage.
  • Social: Loss of family members, friends, pets, and loved ones.
  • Psychological/Spiritual: Victims may question religious beliefs and faith when facing massive destruction.

Government Agencies and Resource Management

• Federal Emergency Management Agency (FEMA): The overarching agency responsible for disaster preparedness at the national level.
• Centers for Disease Control and Prevention (CDC):
  • Laboratory Response Network: Established in the late $1990s$; a surveillance system involving local, national, and international public health labs for early detection of threats.
• Strategic National Stockpile:
  • Established in the late $1990s$ as a reserve of critical medications (antivirals, antibiotics), equipment ($PPE$, ventilators), and emergency supplies.
  • Utilized during $COVID$ for distributing masks and redeploying ventilators for patients in respiratory failure.
• Occupational Safety and Health Administration (OSHA): Responsible for ensuring the safety of recovery and response workers.
• Community Resource Disparity:
  • High-resource communities: Possess infrastructure, funding, and established mitigation plans. They bounce back and return to normal quickly.
  • Low-resource communities: Often lack emergency planning and access to notification systems. They are frequently the last to receive help and struggle to secure rebuilding funds.

State and Local Emergency Infrastructure

• State Government Roles:
  • Emergency Operations Plan (EOP): A document describing how people and property are protected, detailing roles, equipment, and facility use.
  • Governor's Power: Can open the Emergency Operations Center (EOC), declare a state of emergency, and request that the President declare a disaster to unlock federal recovery funds.
  • State Stockpiles: Independent reserves of medications and supplies that localized states use (e.g., performance differences noted during $COVID$).
• Local Government Roles:
  • Focuses on the immediate community including fire departments, police, hospitals, and local public health departments.
  • Voluntary organizations like the American Red Cross operate at this level.
  • Contingency plans are tailored to specific local threats such as mass shootings, infectious disease, or tornadoes.
• Hospital Planning:
  • Hospitals must develop independent plans and conduct internal drills separate from community drills.
  • Coordination between regional hospitals is essential for managing mass casualty incidents (MCIs) and distributing victims.

Case Study: Disaster Management in Infectious Disease Outbreaks

• Mitigation Strategy:
  • Surveillance: Early identification of pathogens and monitoring symptoms.
  • Vaccination Clinics: Increasing herd immunity through campaigns (e.g., flu season).
  • Environmental Controls: Use of negative pressure rooms. One example mentioned a $12$ floor hospital tower where every floor could be flipped to negative pressure.
• Preparedness Strategy:
  • Training personnel on screening and triage.
  • Establishing incident command structures with assigned roles (Incident Commander, Logistics Chief, Communication Officer).
  • Stockpiling $PPE$, antivirals, and test kits.
  • Continuity of Operations Plan: Ensuring the hospital can function during the disaster.
• Response Strategy:
  • Putting the plan into action (crisis mode) and sharing real-time information with the community via websites.
• Recovery Strategy:
  • Debriefing and lessons learned. Example: During a Monkeypox outbreak, hospitals burned curtains to prevent spread but failed to prepare replacements, leaving patients exposed during exams.

Emergency Severity Index (ESI) Triage in the ED

• The $ESI$ is a five-level triage system used in the Emergency Department to determine the urgency of care based on severity and resource needs.
• Level $1$: Immediate life-saving intervention required (e.g., patient is about to die).
• Level $2$: High-risk situation, confused/lethargic, or in severe pain; requires rapid assessment.
• Levels $3, 4, 5$: Distinguished by the number of resources the patient is predicted to need.
• Goal: To prioritize patients so that those most at risk are seen before those who are stable, regardless of arrival time.

Simple Triage and Rapid Treatment (START) System

• Developed for mass casualty incidents where assessments must be completed in under $1$ minute (ideally $30$ seconds).
• Objective: Help the most people in the shortest amount of time.
• Color-Tagging System:
  • Green (Minor): "Walking wounded." Victims can follow commands to walk toward the triage officer.
  • Yellow (Delayed): Serious but stable injuries; treatment can wait approximately $2$ hours (e.g., stable fractures, controlled medical emergencies).
  • Red (Immediate): Life-threatening injuries requiring treatment within $60$ minutes (e.g., internal bleeding, airway obstruction, large-scale burns).
  • Black (Deceased/Unsalvageable): No respirations after one airway repositioning, agonal breaths, or injuries incompatible with life (e.g., exposed brain matter).
• 32-Can-Do Mnemonic:
  • $30$: Respirations. If over $30$ per minute, tag Red.
  • $2$: Perfusion. Check radial pulse or capillary refill. If cap refill is over $2$ seconds or radial pulse is absent, tag Red.
  • Can Do: Mental Status. If the patient cannot follow simple commands, tag Red.

Pediatric Triage: The JumpStart System

• Used for children, generally aged $1-8$ years old.
• Differences from adult START Triage:
  • Respiratory Rate: Limits are set at $15$ and $45$. If RR is below $15$ or above $45$, tag Red.
  • Rescue Breaths: If a child is not breathing, the airway is opened. If no spontaneous breath appears but a pulse is present, the nurse provides $5$ rescue breaths. If breathing resumes, tag Red. If not, tag Black.
  • Mental Status: Uses the AVPU scale (Alert, Verbal, Pain, Unresponsive) instead of specific commands.
  • Painful Stimuli: Techniques like the clavicle pinch (using a pointer finger and thumb to pinch the bone) are used to assess response.

Casualty Collection Points (CCP) and Operational Flow

• Station 1: Contact Triage. Occurs at the site of the disaster to assign initial color tags.
• Station 2: Casualty Collection Point (CCP). Victims are moved here and organized by color (all Reds together, all Yellows together). The morgue (Black tags) is kept separate from the living.
• Station 3: Field Hospital. Used for prolonged disasters to provide continued care when transport to a permanent facility is delayed.
• Logistics: Requires clear paths for ambulances and designated landing zones for helicopters to avoid traffic jams and overlap.
• Reassessment: Tags can be updated (e.g., Green to Red) as a patient's condition deteriorates, except for Black tags which are final to prevent family members from attempting to re-prioritize the deceased.

Questions & Discussion

• Question on ESI: A student asked about the placement of appendicitis in triage.
• Response: Without labs or ultrasound in the field, appendicitis presents simply as abdominal pain. Presence of danger vitals (elevated heart rate, low oxygen, vomiting) would escalate the $ESI$ level; otherwise, it remains a lower priority based on visible stability.
• Discussion on Emotional Toll: The instructor emphasized that tagging a living person as Black (unsalvageable) is one of the most traumatic experiences for healthcare providers, as it requires walking away from a life to save others.
• Activity Briefing: The class participated in a simulation involving triage nurses and patients. Participation was optional due to the potential psychological stress of simulating a mass casualty event where classmates might be "black-tagged."