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Drill Scenario by State of California Emergency Medical Services Authority. Amy Kaji, MD, MPH November 16 th , 2005 Acute Care College Medical Student Seminar. Background Scenario . Politician to speak on controversial topic at a large public forum Nationally televised

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drill scenario by state of california emergency medical services authority

Drill Scenario byState of California Emergency Medical Services Authority

Amy Kaji, MD, MPH

November 16th, 2005

Acute Care College

Medical Student Seminar

background scenario
Background Scenario
  • Politician to speak on controversial topic at a large public forum
    • Nationally televised
  • Pre-allocated resources
    • First aid stations and onsite ALS and BLS ambulances
    • Security and traffic control personnel
    • Designated media area
    • Shuttle buses
    • On/off site parking areas with attendants
  • 7:30 a.m. Opening commentary
  • 8:00 a.m. Speech to begin
8 00 a m the exercise begins
8:00 a.m. The Exercise Begins
  • Patients and hospital staff watch TV commentary
  • 8:00 a.m. – Speaker introduced
  • As speaker reaches podium, explosion occurs
  • Mass hysteria and panic ensue
  • Number of casualties unknown
  • ED anticipates arrival of victims
  • Cellular and landline 9-1-1 calls begin flooding local dispatch centers
considerations and decisions
Considerations and Decisions
  • Should you consider implementing security measures at your facility?
  • What are the triggers that implement HEICS in your facility?
  • When, and who activates the high-census (surge) plan to free up or add patient beds to accommodate the anticipated influx of patients?
8 02 a m
8:02 a.m.
  • At 8:02 a.m., a second explosion occurs in one of the on-site medical aid stations
  • News reports estimate numerous casualties
  • Hospital staff watch in horror
considerations and decisions1
Considerations and Decisions
  • Does the hospital have an emergency call-back procedure to increase ED and essential hospital staff?
  • Does the hospital have a security of lockdown procedure to protect the hospital and staff?
  • Will your hospital activate HEICS now?
8 04 a m
8:04 a.m.
  • 8:04 a.m. – A third explosion on a main thoroughfare to the event detonates
  • Staff exhibits signs of distress at possibility of loved ones being casualties of event
considerations and decisions2
Considerations and Decisions
  • How does your hospital deal with staff concerns at the possibility of family members being casualties of the event?
  • How does the hospital allocate scarce resources when confronted by this potential mass casualty incident?
  • How does the hospital procure additional resources?
    • Additional staffing
    • Blood, trauma, and burn supplies
    • Body bags and morgue refrigeration units
    • Inpatient beds, ED beds, OR beds
8 10 a m
8:10 a.m.
  • 8:10 a.m. – Law enforcement establishes secure perimeter around the auditorium
  • Residents living within perimeter evacuated
  • Fire and EMS crews arrive at staging areas outside auditorium
  • News reporters surround area
  • FAA contacted to declare area a no-fly zone
8 15 a m
8:15 a.m.
  • 8:15 a.m. - EMS establishes nearby off-site staging areas
  • During the panic, fleeing victims mob offsite staging area and demand medical aid
  • Immediate EMS resources overwhelmed
  • Patients arrive at ED and clinics with blast injuries, in shock and panic
considerations and decisions for on scene first responders
Considerations and Decisions (for on-scene first responders)
  • Are evidence preservation protocols in place?
  • Does ambulance agency dispatch a medical supervisor to large scale incidents?
  • Are potential communication contingency plans in place?
  • Have designated egress routes been identified?
  • Does the ambulance provider have an in-field re-supply plan?
  • Does the ambulance provider have chain of command procedures?
considerations and decisions3
Considerations and Decisions
  • Clinics may be just opening for business
  • Is the hospital’s emergency plan in place for obtaining additional staff?
  • Does your hospital have a credentialing procedure for convergent volunteers?
8 20 a m
8:20 a.m.
  • 8:20 a.m. – Local Department Operations Center (DOC) and Operational Area EOC are activated
  • Landline and cellular circuits overloaded
  • Your hospital activates back-up communications system
  • High census plans activated and in-patients assessed for early discharge or transfer
  • Elective surgeries and procedures cancelled
  • Hospital is short staffed
  • Plans to augment staff are activated
    • Calk-back of staff
    • Implementation of 12-16 hour shifts
8 50 a m
8:50 a.m.
  • 8:50 a.m. - Local health officer declares local medical emergency based on large and increasing number of patients and need for additional resources
  • ED and corresponding clinics are impacted
  • Physicians order blood products for patients
considerations and decisions4
Considerations and Decisions
  • How does the clinic communicate with the hospital to alert them of incoming patients?
  • What resources does the clinic require until EMS arrives to transport patients to the acute care hospital?
  • Does the clinic use the ICS?
  • Do clinics have procedures for dealing with mental health concerns?
  • Does the clinic have procedures for canceling scheduled appointments?
  • Does the clinic have a protocol for notifying the blood supplier?
8 55 a m
8:55 a.m.
  • 8:55 a.m. - Mayor’s office receives a call from the Universal Adversary (a known terrorist organization) claiming responsibility
  • Media demands information at hospitals, clinics, and the local health department
  • Press conference is scheduled for 11:00 a.m.
considerations and decisions5
Considerations and Decisions
  • What information should be presented to the public?
  • Does you hospital have pre-scripted risk communication messages?
  • What steps have been taken to ensure a consistent message among the healthcare community and levels of government?
  • What community or government agencies will participate in the press conferences?
  • Who will represent the hospital at the press conference?
  • Where will the press conferences be convened, and who decides on the location?
  • Who is the “lead” agency for the press conference?
9 05 a m
9:05 a.m.
  • 9:05 a.m. - The Operational Area reports Statistics
    • Numbers of patients with blast injuries
    • Number of patients waiting to be seen
    • Number of persons that may require hospitalization
    • Available beds, operating rooms, emergency department beds
    • Number of patients being seen at clinics
    • Number of clinic patients awaiting transport to the hospitals
    • Number of deceased, capacity for refrigeration units in morgues
    • Anticipated need for blood products
  • Communications with California Health Alert Network (CAHAN) is lost
    • Hospitals, clinics, EMS, and Operational area EOC unable to place/receive calls
  • Bomb squad with K-9s arrive
considerations and decisions6
Considerations and Decisions
  • What other redundant communications systems exist?
  • What agencies can be contacted to provide additional security for the hospitals?
  • What community resources can be utilized to assist, including with mental health issues?
  • How is your hospital addressing the mental health concerns of the staff and the public?
10 00 a m
10:00 a.m.
  • 10:00 a.m. - Bomb squad clears venue of other IEDs
  • Medical Operational Coordinator requests a status update from hospitals
    • Bed availability
    • Estimated numbers of patients
    • Equipment status and anticipated needs
10 15 a m
10:15 a.m.
  • 10:15 a.m. - Hospital nearly depletes blood products as well as trauma and burn supplies
  • Clinics call local hospitals for supplies (IV tubing, bandaging supplies, & burn sheets)
  • Hospitals lack spare supplies and a means to transport supplies to clinics
  • Vendors contacted to provide supplies and equipment
  • Blood center advised of needs
  • ICU is at capacity with no additional beds
  • ED us holding ____ patients awaiting inpatient beds (insert appropriate number of ED patients to increase strain on resources), including ICU, telemetry, and medical-surgical
considerations and decisions7
Considerations and Decisions
  • Is there a plan to ration resources?
  • What mechanisms are available to procure the needed supplies and equipment, and what agency is contacted to provide those resources?
  • What non-medical resources may be needed (sanitation, water, transportation, security)?
  • What is the internal plan for maintaining security and containing the influx of patients?
  • Are agreements in place to provide additional security?
10 15 a m continued
10:15 a.m. continued…
  • 10:15 a.m. continued… Influx of patients continues
  • Resources are overwhelmed
    • Insufficient staff (all levels of healthcare providers)
    • Lack of ED space
    • Depleted patient care equipment and supplies
      • Gurneys, oximeters, ventilators
      • Medications and medical-surgical supplies
considerations and decisions8
Considerations and Decisions
  • What procedure does the hospital have to expand treatment areas?
  • What is the procedure for exempting the facility from DHS licensing and certification for nurse staffing ratios during this emergency?
  • What additional areas within or outside the hospital can be used to provide patient care?
  • What is your procedure for notifying DHS Licensing and Certification about using alternate care sites?
  • Have patient tracking procedures been adequate?
10 15 a m continued1
10:15 a.m. continued…
  • 10:15 a.m. continued…
  • ____ patients (insert number to stress the facility and coroner system) have died and await coroner to investigate and remove bodies
  • Hospital must identify a secure area to hold bodies
  • Law enforcement and FBI demand access to medical records and to interview victims and family
considerations and decisions9
Considerations and Decisions
  • What are your hospital policies on interacting with law enforcement, evidence collection, and protecting patient privacy?
  • Where will you stage law enforcement officials to allow for interviews but not congest patient care areas?
  • What is the backup plan to store bodies when the morgue is not of adequate size?
  • Are the bodies considered “evidence”?
10 30 a m
10:30 a.m.
  • 10:30 a.m. – Many patients will need weeks to months of supportive care before recovery
  • Scarce resources will be long-term issues for the facility and community
  • Hospitals, clinics, and EMS will need to construct contingency plans to address shortages
  • Vendors will need to be contacted to provide additional supplies and equipment
considerations and decisions10
Considerations and Decisions
  • What are the extended care implications for your hospital?
  • What recovery and mitigation efforts can you take now to reduce the impact of this event?
  • Have you integrated long-term care facilities into your disaster plans?
  • Do the nearby ancillary care facilities coordinate with hospitals to accommodate a surge of long-term care patients in the community?
10 45 a m
10:45 a.m.
  • 10:45 a.m. – FBI states they have received a credible threat that an IED was placed in the hospital (optional participation)
  • What are the procedures for notifying law enforcement?
  • Who is in charge until law enforcement arrives?
  • What is your policy regarding the use of radios and pagers while searching for an IED?
  • What recovery and mitigation efforts can you take now to reduce the impact of this event, should an IED detonate?
11 00 a m
11:00 a.m.
  • 11:00 a.m. - Influx of patients presenting to the ED continues
  • Mayor’s press conference is held
    • Cause of IED is attributed to Universal Adversary terrorist group
    • Public is asked to report all suspicious packages and behavior
  • Status reports from hospitals, clinics, & EMS compiled
  • Regional EOC begins to receive resource requests which are relayed to the State Operations Center
12 00 p m
12:00 p.m.
  • 12:00 p.m.
    • The Exercise Ends!
  • www.emsa.org. 2005 Statewide Medical and Health Disaster Exercise Guidebook (accessed September 25, 2005).