Grand Rounds Recap - EMS Disaster Day 03.31.21
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DECONTAMINATION WITH GUEST LECTURER DR. JAMES AUGUSTINE
Hazmat is not simple
Usually it is contamination plus injuries and illnesses
Always have to assess decontamination versus medical care needs
First seconds to minutes count and can drastically change patient outcomes
National Poison Number 800-222-1222, Cincinnati (513-636-5111)
Contamination prep through the decades
50s,60s: radiation
70s: trauma, cardiac arrest, burn
80s: hazardous materials
90s: AIDs, hepatitis (bloodborne)
2000s: terrorism, airborne illnesses
Terrorism events: terrorist tools exhibit a continued increase in the level of sophistication and technical skills, with secondary devices present in more than 50%
2010s: active shooter, ebola, COVID
Case example: Sarin in Tokyo Subway (1995)
5500 people exposed
Essentially no victim decontamination and healthcare personnel got very sick
Physicians endorsed symptoms such as vision problems (73%), rhinorrhea (53%), dyspnea or chest tightness (27%)
Lesson learned that decontamination in the pre-hospital setting (removing clothes) can help significantly to limit spread of a contaminant
Lessons learned with civilian contamination
Every person who can extricate himself will do so
Every person who can decontaminate himself will do so
Wet and dry decontamination can be safely and successfully performed out of the hospital
Ambulatory patients present earliest and can overwhelm the hospital
Only 10-15% of patients present via EMS
ED preparedness burden
Run-off has to be collected and disposed of safely
Many EDs have a dedicated decontamination room with a separate entry to protect other patients and hospital staff
Decontamination of agents
Clean first, contain later
Dry decon required for biologic and radiologic agents
Wet decon required for radiation and nuclear agents
Contaminated wounds should be thoroughly irrigated and covered up (i.e. in plastic) to prevent further contaminant from soaking in
Volume of irrigation: Eyes require rapid and plentiful of decon, extremity requires ~8 gallons, full-body ~25 gallons
Irrigate eyes with any sterile solution, preferably one not containing glucose
Warm water is much preferred to prevent rapid cooling of the patient
After initial decon, cocoon victim to prevent secondary contamination and cooling
EMS boxes typically have some decon drugs - atropine, 2PAM, calcium, magnesium, etc.
Protecting the Rescuer
Structural firefighting gear protects for 15-30mins
Airway protection for the rescuer - breathing masks, appropriate PPE etc.
PREPARATION PLANNING AND RESPONSE WITH DR. MEL OTTEN
Disaster - a serious disruption of the functioning of society, causing widespread human material or environmental losses, that exceeds the local capacity to respond.
Natural disasters (tornados, hurricanes, floods) vs human caused disasters (HAZMAT, terrorism)
Why are disasters a public health problem?
Unexpected number of deaths, injuries and illnesses that exceed available health resources
May destroy local health infrastructure and emergency response capabilities
May cause adverse effects to the environment
May cause large populations to move
Human impact of Katrina
1464 fatalities in New Orleans
>1 million people evacuated: 800,000 people displaced, 300,000 in evacuation centers
100,000 remained that caused civil unrest, health hazards, and infrastructure failure
What do people need every day when there is no disaster?
3 min without o2
3 hours without warmth
3 days without water
3 weeks without food
Safety from injury or illness
Many priorities during non-disaster and disaster times: Medicine, food, water, clothing, safety, garbage pick-up, toilets, transportation, heat, electricity, shelter, communication, evacuation - everyone will prioritize these differently based on individual needs
Many factors influence a disaster: Geography, weather, time of year, population, building construction, EMS response, communication system, planning, fire and rescue, public transportation, power grid, water supply
Mitigation of disasters
Natural disasters will occur despite human efforts
Human disasters can be prevented through human efforts
All disasters can be mitigated through proper planning
Engineering factors
Site selection - flood plains, tidal areas, fire-prone areas, fault lines
Building construction
Bridge and road design
Material design - fireproof, safety glass
Safety and rescue considerations
Communication factors
Notify persons in the potential disaster area to take shelter, leave the area, or take preventive measures
Weather alert radios - activated from central location
Community sirens, radio, tv, internet alerts
Notify disaster response personnel
Disaster team pager, telephone activation
Disaster team communications - radio, satellite, cell phones, telemedicine, computers
Need to have redundancy to ensure communication is fail-safe
Planning for Response
Levels of planning
National, State, County, City, Hospital
Rules of disaster response
Basic needs are the same for everyone
Be an asset, not a liability
If you didn’t bring it, you won’t have it
Sleep when you can, eat what you have, and don’t waste water
Training must be realistic, ongoing, coordinated, documented, and evaluated
Components of the federal response plan - Emergency support functions (ESF)
Transportations
Communications
Public works and engineering
Firefighting
Information and planning
Mass care
Health and medical services
Urban search and rescue
Hazardous materials
Food
Energy
Common problems are still common
Many victims without chronic medications, oxygen, dialysis access
Major trauma is less likely after initial impact
Minor trauma is common during the clean up phase
Depending on type of disaster some problems are recurrent: CO poisoning, allergic dermatitis, asthma, water borne illness from contaminated water sources, food poisoning due to lack of ability to freeze/refrigerate foods
EBOLA UPDATE WITH DR. CALHOUN
There continue to be outbreaks in remote areas of Africa - Democratic Republic of the Congo and Guinea
All travelers are monitored daily for fever (as risk for transmission without fever is unlikely)
Refresher: Ebola is a viral hemorrhagic disease
Symptom onset 8-12 days (up to 21 days)
Viral prodrome followed by GI symptoms
Hemorrhagic symptoms NOT universal (only in 18% of patients)
Droplet precautions required at minimum (full coverage of all skin and mucous membranes)
airborne precautions for any aerosol-generating procedure at minimum
2 MAB treatments approved
OREGON HISTORIC DISTRICT SHOOTING WITH GUEST LECTURER DR. BRIAN SPRINGER
Oregon Historic District Shooting on August 4th, 2019 in Dayton, OH
Gunman killed 9 and wounded 17
Shooter was a young white male in his 20s with no adult criminal history
Unknown motive
Gunman killed by responding officers 32 seconds after first rounds fired
Occurred <1 day after shooting in El Paso, Texas
Oregon Historic District is a neighborhood in downtown Dayton - 12 square blocks
Architecture dating back to 1800s
Bars and restaurants
RADIATION INJURIES WITH DR. DUSTIN CALHOUN
Non-ionizing radiation: visible, infrared, microwave
Ionizing radiation: ultraviolet, X-ray, gamma ray
Irradiation - patient is not harmful to the healthcare worker
Contamination - clothing removal is 90% of the decon, and PPE can be work for spread prevention
Acute versus chronic dose - 2000mSv over a year may not be a problem, but 2000mSv today is a big problem
Acute dose has a threshold effect and it is non-linear
Applies to non-stochastic effects only
Acute radiation syndrome
Prodrome: nausea, vomiting, diarrhea, anorexia that starts in minutes to days and lasts for minutes to days
Higher dose leads to more rapid onset and shorter latent period
Latent stage: hours to weeks
Manifest illness: variable symptoms, lasts for hours to months
Recovery / death
Radiation burns
May take minutes to days to be evident
Exposure is not painful, unlike thermal burns
Care
PPE (to prevent spread)
Manage ABCs
Decon: undress, wash with soap and water, irrigate wounds
Stay indoors unless evacuation is ordered
Don’t introduce contamination into the body (i.e. ingestion)
Potassium iodide
Competitively inhibits I131 uptake
Reduces the risk of thyroid cancer
Must be given within 12 hours of I131 inhalation
Usually unnecessary if over 40 years of age based on function of thyroid
