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Thu, 07 Feb 2002 16:54:46 -0600

I think we're getting to see what the problem is.=20

Nobody is looking at the process. its just by facility.

but, not all facilities are going to get patients in a mass casualty =
event.=20

we need to stage additional equipment and resources so it can quickly be =
moved. say a transportable decon unit in a major city that can be sent to =
some triage site that hospitals get patients from.=20

problems: go to the National Guard 4077 MASH at 5th and Main. you'll be =
taken after initial decon to an appropriate facility free of charge. show =
up on your own, you're sent to 5th and Main. have that staging area send =
cases after stabilization to an appropriate center.=20

you're going to need somebody being incharge of all EMS and hospitals =
under certain conditions. I'm staying out of that turf battle.

every hosptial can't be everything to everybody. not all can do decon. =
plus be a hospital. plus take on a mass casualty event that will be hard =
enough to deal with.

I'm thinking a lot of the funds are going to be wasted.=20

there needs to be serious thinking up front of who what and where.

I'd argue after a while things will sort themselves out. the problem is =
between the event and this initial stabilization. that's the process that =
is going to get hairy. how and where to augment people, move appropriate =
supplies, this is what is known as a command post exercise.

there needs to be a way to establish EMS / rescue / fire staging areas =
outside the emergency zone. maybe a standard grid reference in a community.=
 say large open areas.

then deal with facilities.

the problem is, if its a real WMD, there won't be a 911 system to respond. =
it'll be that big. you'll be going into a real large destroyed area. I =
don't think this is something those outside of the military can grasp.

I think if we're thinking WMD scenarios, we need to scale up the destructio=
n.=20

>>> pbjorn@emh.org 2/7/02 4:24:18 PM >>>
Greg,

 " You are absolutely incorrect.  St. Lukes Hospital in Toyko was
contaminated because they were not prepared.  In Tokyo, 688 people were
transported via EMS, however over 4,000 sought emergency care.  Their =
first
error was in failing to recognize contaminated patients.  Unless your plan
involves having HazMat teams screen patients 24/7, this responsibility =
falls
upon the ED staff, and requires training.   Massive self triage is a =
common
characteristic of these types of incidents and must be planned for.   =20
=20
Answer me objectively: what constitutes adequate preparation for large-scal=
e
toxic exposure?  Are you comfortable blaming Japanese nurses for not being
day-to-day experts in chemical weaponry? =20
=20
Consider that in America, adequate preparation by your standards involves
something in excess of five thousand hospitals, employing (on average)
probably 50 or more ED staff who'll require thorough training and regular
review.  Then add equipment, plus expansion or new construction to allow =
for
a safe decontamination area (pretty dangerous to shower victims in our ED
parking lot this time of year).  How much do you want to spend?  I'd
estimating a domestic expenditure of something between fifty and a hundred
million dollars annually.  Considering the actual impact of large-scale
hazmat incidents in this country each year, I have to suggest that the
cost-benefit analysis ain't flattering.  The terrorists have already =
bruised
up our economy enough for my liking.  Fifty million dollars would buy a =
hell
of a lot of free bike helmets and car seats.
=20
All this assumes that there's any predictable "benefit" to hazmat training
for clinical personnel who, like as not, will NEVER see practical =
experience
in the course of their careers.  Can we realistically expect all those
nurses and techs to retain training to sufficient to perfectly protect
themselves--much less the hospital--next week?  Next month?  Next =
September?
Recall that a single business-sized, tightly-sealed envelope carrying a =
few
grams of anthrax shut down a rather beefy federal office building for four
months...
=20
I think of "massive self triage" as less a clinical conundrum, more a =
threat
to my colleagues and my community.  I think of the hospital as a collateral=

target, not a clinical objective.  My response--especially in the case of
WMD--would be to lock down the facility until appropriate decontamination
can be assured.  If regional or community disaster resources were more
methodically assigned, under the more realistic assumption that hospitals
are thoroughly incapable of defending themselves, then the first National
Guard hazmat team would be headed for the Eastern Maine Medical Center.

" Based upon several exercises and critiques of actual incidents, we have
come to the conclusion that we can not depend on the local hazmat team to
perform at-hospital decon in every situation.  This is not a reflection on
their quality, but rather a realistic assessment of what our resources =
are.
Since we cannot be assured of outside decon resources, we are training our
own personnel.  Pret, your hospital emergency planners may have discovered
the same thing.  Are they idiots as Dr. Frykberg suggest, or have they
thought things through better? "=20
=20
I'm less inclined than some to assert that anybody's an idiot, besides me:
I prefer to work with established truths.  But let's not waste time =
chasing
down points of etiquette.  So far, each response has given me more =
insight,
and I'm grateful.
=20
The whole point of this thread is that I think your exercises and =
incidents
have suffered from a flawed response paradigm.  Hazmat cannot be depended
on, because it has not been properly tasked.  Reconsider your scenarios, =
but
imagine that a solid portion of the hazmat response is assigned downstream,=

to the bottom of the funnel: to the hospital.  Any of your exercises
structured that way?
=20
 " Those of you that live in areas with multiple HazMat teams, do you also
have multiple hospitals in the same jurisdiction?    If so, who gets the
HazMat team(s)?  When do you call them?  Your staff still must be trained =
in
awareness and recognition.  How long of a response time does the HazMat =
team
have?  Add this to the briefing and set-up time.  How long will contaminate=
d
patients be waiting?  Where will they wait?  How much more product will be
inhaled/absorbed in that time?  Will they wait that long? "
=20
Most of these questions are quite reasonable, and directly dependent on =
the
rational construction of a disaster management plan which acknowledges =
both
a) how little can be clinically accomplished at the scene, and b) how
vulnerable the hospital is to secondary catastrophe.
=20
As for the wait times for initial victims, call me a hard-hearted bastard,
but I think the first priority is to shut off the chain of exposure.  =
We're
not accomplishing much if, while rushing one victim to treatment, we =
expose
a doctor and three nurses and contaminate the trauma bay and the entrance =
to
the ED.
=20
 " Bottom line, just like trauma, there is not one right way to plan for a
WMD incident.  It depends on your resources.  If an outside team is
available, will be there when you need them, and the logistics are
satisfactory, great.  If not, you better have another plan."
=20
No argument, except to assert that only the methodology must be flexible.
The objectives must remain fixed: ensure the safety of the rescuers, THEN
rescue the victims.

 " Greg  "
=20
Pret=20

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