Transcript No Slide Title

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
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Erik Auf der Heide, MD, MPH, FACEP
Disaster Planning & Training Specialist
Agency for Toxic Substances and Disease Registry
U.S. Department of Health & Human Services
[email protected] (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.
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Agency for Toxic Substances
and 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.
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• 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.
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Importance of
Evidence-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.
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Examples of Common
Planning Assumptions Will Be Given
• Compared with research findings.
• Implications for disaster planning
Discussed.
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Typical Planning
Assumptions
• 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.
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Assumption: First Unit on Site
Will Assume Command
• Reality
– Most initial disaster response is carried out by
the survivors (e.g., family, friends, neighbors, coworkers).
– A large part of this activity is outside the control
of local authorities.
– Overall command & control rarely occurs early
in disasters.
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Search & Rescue by Survivors
50%
50%
Tornado, 1978
Lake Pomona, KS
Tornado, 1979
Cheyenne, WY
29%
Tornado, 1979
Wichita Falls, TX
40%
67%
Flash Floods
TX, 1978
0%
50%
100%
Drabek TE. 1981. Managing multiorganizational emergency responses. Boulder (CO):
Natural Hazards Research and Applications Information Center, University of Colorado,
pp.53,119
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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.
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Mexico City
Earthquake, 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.
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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 of
Search & 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 Survivors
Uncoordinated Search & Rescue:
The “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 Survivors
Lack of Information to Hospitals
• Hospitals need advance warning to prepare for
casualties.
• <1/3 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.
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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 Survivors
Nonambulance 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.
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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.
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Percentage of Casualties
Transported by Ambulance
100
90
World Trade Center
9/11/2001
20
0
Tokyo Sarin
Attack, 1995
10
6.8%
50
40
30
36%
7%
60
San Francisco
Earthquake, 1989
70
23%
20
Oklahoma City
Bombing, 1995
80
Consequences of Search & Rescue by Survivors
Bypass 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.
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Consequences of Search & Rescue by Survivors
Failure 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.
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Study of 29 U.S. Disasters
• In 75% of cases, >1/2 casualties taken to closest
hospital.
• In 46% of cases, >3/4 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.
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Treated & Released
40
Admitted
Number of Casualties Received
35
Casualty
Distribution
30
25
Hyatt Hotel Skywalk
Collapse, Kansas City, 1981
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15
16 of 26
Metro Hospitals
Received Patients
10
5
0
0-1
1-3
3-6
>6
Miles From Scene
Hyatt Disaster Medical Assessment. 1981. Kansas City (MO): Kansas City Health Department.
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120
110
100
Treated & Released
Hospitalized
Died
Casualty Distribution Among 28
Hospitals
90
(Revised figures, 11/2002)
70
60
50
40
30
20
10
0
0.68
0.69
1.7
2
2.2
2.2
4.4
6
7.4
8.9
9
9.2
9.2
15
15.7
20
37
>50
>50
Number of Casualties
80
Oklahoma City
Bombing
Miles From Scene
Shariat S. 2002. Personal Communication. Data from Injury Prevention Service, Oklahoma City
(OK): Oklahoma State Health Department.
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Consequences of Search & Rescue by Survivors
Least-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):169–77.
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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.
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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-tohospital 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.
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