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Florida Hurricanes 2004 Models of Integration Between FL-1 DMAT and Local Hospitals. David GC McCann MD Chief Medical Officer FL-1 DMAT Fort Walton Beach, Florida. To understand methods of integrating a DMAT with local EDs during disaster response

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florida hurricanes 2004 models of integration between fl 1 dmat and local hospitals

Florida Hurricanes 2004Models of Integration Between FL-1 DMAT and Local Hospitals

David GC McCann MD

Chief Medical Officer


Fort Walton Beach, Florida

To understand methods of integrating a DMAT with local EDs during disaster response

To appreciate the differing challenges facing DMATs attempting to integrate with local EDs:

1. When the DMAT is “first out”

2. When the DMAT is relieving another team already on-site

To appreciate the advantages and disadvantages of various integration scenarios

To make recommendations for integration in future disaster deployments

florida hurricanes 2004
Four major hurricanes hit Florida in 2004:





A record number of landfalls and tremendous damage

Florida Hurricanes 2004
florida hurricanes 20047
Hurricane Charley

Landfall Friday, August 13 at Charlotte Harbor in SW Florida at 3:45 PM EDT

Wind speed=150 mph (Cat 4)

Damage to insured property=$14 billion

Direct Fatalities: 10

Hurricane Frances

Landfall Sunday, Sept 5 at Sewall’s Point, Stuart in South Florida at 1 AM EDT

Wind speed=105 mph (Cat 2)

Damage to insured property=$8.9 billion

Direct Fatalities: 23

Florida Hurricanes 2004
florida hurricanes 200410
Hurricane Ivan

Landfall Thursday, September 16 at Gulf Shores, AL at 3 AM EDT

Wind speed=130 mph (Cat 3)

Damage to insured property=$13 billion

Direct Fatalities: 25 in Florida

Hurricane Jeanne

Landfall Saturday, Sept 25 at North Hutchison Island, Stuart in South Florida at 11:50 PM EDT

Wind speed= 120 mph (Cat 3)

Damage to insured property=$6.5 billion

Direct Fatalities: 12

Florida Hurricanes 2004
disaster response principles
Better too much than too little…

Push resources toward affected area prior to eventwhen safe!

A quick, overwhelming response is better than a slow, well-planned response

If you wait until you have all the facts, it will be harder to change the outcome.

Disaster Response Principles
starter versus reliever
There are advantages and disadvantages to being “first out” versus relieving another team already on-site

Knowing the upside and downside of each scenario helps you prepare to meet challenges

Starter versus Reliever?
first out team pros
Set up physical plant the way you wantdo it so patient flow is under your control and optimized

Initial contact with local hospital “get off on the right foot”communication!

All team members psycheddisaster has just occurredLet’s roll…

First Out TeamPros
first out team cons
No pharmacy cache available until some time after set up on-site (usually)

Possibly difficult getting to deployment site due to downed trees, power lines etc.

Rapid Needs Assessment (RAN) still ongoingmission may not be completely elucidated when you deploy”waiting game”

First Out TeamCons
relieving team pros
RAN is completemission is certain and needs well determined

Pharmacy cache, air-conditioned tents on-site

Properly done handover allows continuity of careno need to reinvent the wheel

Relieving TeamPros
relieving team cons
Set up of physical plant is pre-determined if problems, now yours!

Any communication or interpersonal problems between previous team and local hospital you have to smooth over

Can be problem disengaging “we like having a DMAT, you can’t leave!”

Relieving TeamCons
dmat triage
Set up physical plant so patient flow controlled by DMAT

At Hurricane Charley we did this set up right in ED entrance worked very well

At Hurricane Jeanne, set up was across roadway inefficient and decreased numbers seen by DMAT as ED did triage and kept more patients.

DMAT Triage
disaster principle
In a study of 29 major disasters, only 10-15% of casualties were injured seriously enough to require overnight admission to hospital; only 6% of affected hospitals suffered supply shortages, and only 2% had personnel shortages.Disaster Principle
so what do disaster victims need in healthcare
Custodial care (e.g. if Nursing Homes damaged/destroyed)

Basic medical care

Mental Health care

Prescription medications/refills

Treatment for chronic illnesses (e.g. diabetes, asthma/COPD, CAD, etc.)

Oxygen for people on chronic oxygen

So What Do Disaster Victims Need in Healthcare?
healthcare visits to dmats
Study by Nufer & Wilson-Ramirez (2004) looked at NM-1 DMAT experience

Commonest Chief Complaints to DMAT:


Musculoskeletal Pain

Med refill



Abdominal complaints (pain, vomiting/diarrhea)

Healthcare Visits to DMATs
nufer wilson ramirez
Commonest Treatments Provided:

Tetanus vaccination

Wound care


Pain reliever

Medication refills

Nufer & Wilson-Ramirez
nufer wilson ramirez33
Triage Categories:

Green 80%

Yellow 16%

Red 4%

Patient Disposition:

Home 91%

Hospital 6%

Left AMA 3%

Nufer & Wilson-Ramirez
prescriptions refills
We found sending a letter by fax to all local pharmacies with doctors’ DEA numbers and FEMA credentials decreased call backs for verification

Do this as soon as DMAT set up

Obtain list daily of open pharmacies and local doctors’ offices to communicate to patients—try to arrange follow-up with their own physician if possible

Prescriptions & Refills
prescriptions refills35
DMATs need pharm cache sufficient to at least partially fill majority of scripts

Pre-printed prescription pads with doctor’s DEA and FEMA information—or at least a stamp with this info

Narcotic abuse is rampantdon’t write drugs of abusesend into ED where “regulars” well-known

Prescriptions & Refills
ca mrsa
Community-acquired MRSA is now a fact of life

“Spider-bites” and abscesses may be CA-MRSAculture then treat

We used Clindamycin as outpatient treatment of skin infections—recent reports also found TMP-SMX works on CA-MRSA

BUT, clindamycin-inducible CA-MRSA resistance commonthere is a test for this through lab

breaking up is hard to do
Disengagement—work closely with emergency managers and hospital admin

Implement demobilization incrementally

Chart call volume, peak times and duration watch trends especially in relation to expected post-disaster historical trends

Systematically reduce local dependence on DMAT

Breaking Up Is Hard To Do…
things not to say
“We’re from FEMA—we are federalizing this ED and taking over….”

“We’ll stay as long as you feel we are needed.” (That might be a long time…)

Telling patients: “Everything is free, you won’t have to pay for anything!”

Things Not to Say
nims and disaster research
According to FEMA IS-700 course on NIMS:

“The NIMS Integration Center will also develop a national database for incident reports”

Excellent idea to do it we need a system of uniform data entry/capture across all incident types and missions

NIMS and Disaster Research
disaster research data capture
We need uniform capture of data across all DMAT/IMSURT Missions:

Design an MS Access/Excel Program which all patient encounters would use for registration (mandatory field entry)

Print out Patient Encounter forms with entered data

Field codes to be saved in Access database

Disaster Research & Data Capture
disaster uniform data entry system dudes
Ideal program would log following fields:





Disaster Category

Classification (patient)

Disaster Related Activity

Chief Complaint

Co morbidities


ICD-9 Code


Triage Category

Disaster Uniform Data Entry System (DUDES)
disaster research data capture44
DUDES data should be kept in central server repository (NIMS Integration Center) make available for disaster researchers with appropriate clearance

Disasters occur infrequently let’s not miss opportunity to collect and store data!

Use Utstein template to internationally rationalize Disaster Research

Disaster Research & Data Capture
disaster response permutations47
After a disaster either there is a hospital to serve the injured/sick or not

Depending on the situation, either DMATs, IMSURTs or other portable medical assets may need deployment

Let us look at the possible permutations…

Disaster Response Permutations
maintaining local infrastructure
After hurricanes, hospitals, clinics & doctors’ offices may be damaged or destroyed

How can we (FEMA/DMATs) help prevent further loss of infrastructure due to economic impact?

Don’t want local docs and surgeons packing up & leaving for good

Maintaining Local Infrastructure
competing interests
Damaged hospitals need to get “up & running” ASAP to decrease lost revenue which threatens long-term viability

DMATs must use proper hospital order forms so tests run will be reimbursed

DMAT Triage vs Hospital ED triagepros and cons both ways

Competing Interests
portable hospital assets52
Federal Medical Contingency Station (FMCS)—part of Strategic National Stockpile

HHS developing 20 mobile medical facilitiesno OR, no ICU, no isolation but otherwise operational hospital

250 beds each with enough supplies for 3 days

$170,000-300,000 apiece

Portable Hospital Assets
portable hospital assets53
HHS also plans 2 more sophisticated units

Everything for a full-fledged hospital

$5 million each

HHS 2006 budgetmoney set aside to create voluntary national database of doctors, nurses, and emergency personnel who could be called upon in event of national disaster

Portable Hospital Assets
portable hospital assets54
Future Medical Shelter System (FMSS)

Developed at Y-12 Oak Ridge Labs and now delivered to Ft Detrick (military)

With 24 volt battery and push of green buttonbox morphs into 8’x8’x20’ OR with protection from biological & chemical weapons

Portable Hospital Assets
DMAT should always do triage but send in business to keep hospital viable this worked well after Hurricane Charley

FEMA should have portable buildings available to move in post-disaster so docs can begin seeing patients even if their offices are damaged

IMSURT may have to be sent in if OR damaged/destroyed

Deploy longer term OR/hospital assets that could be left on-site for up to a year post-disaster (a portable replacement hospital such as FMCS & FMSS)

Need to allow local docs to work in DMAT tents until portable buildings available

Let local surgeons work in IMSURTs until longer-term OR set up

Forward deploying DMATs toward area of expected hurricane cuts response time e.g. send FL-1 to Ocala (when safe) and then can get anywhere in S Florida quickly

You are being watched attend to sterile technique, HIPAA confidentiality, no off color humorBe professional at all times

Know your limits send to ED anything which might be beyond your abilities

things we wish we had
Single Phase Air-conditioned tents

temperatures in Florida in August/September 90-100+ F

Pharmacy cache going out the door

Always arrives late and we need meds en route to treat team members if necessary not to mention patients once set up

Things We Wish We Had
things we wish we had59
A standardized patient encounter form for all DMATs

Standardized data entry software for patient encounters in MS Access/Excel format with permanent database

Properly labeled cache/equipment by all DMATs so mixing of resources doesn’t cause inadvertent misdirection of resources

Things We Wish We Had
Good communication essential

Pharmacy cache should deploy with team

DMAT setup in front of ED if possible

DMAT should do all triage

Treat wounds as if CA-MRSA present

Allow local docs and surgeons to use our tent facilities if necessary

IMSURT may need deployment as bridge if OR damaged and no other hospital nearby

FEMA should provide portable buildings and have “portable hospital” available to prevent loss of infrastructure post-disaster

Disengagement incremental in close consultation with local admin

Need Database Program with Disaster Uniform Data Entry System (DUDES)

Keep DUDES in central data server for research NIMS Integration Center