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Thu Aug 6 03:01:32 BST 2009

This is certainly an area of interest for me as an EMS manager (I'm
not a physician).  When I teach Disaster/MCI classes, I try to impress
upon the students the importance of the initial period (~5 minutes) of
an incident.  It's up to the initial responders to institute some form
of ICS and determine the scope/magnitude of the event.
Underestimating the scope/size will result in overburdened or
insufficient resources, whereas overestimating the scope will result
in too many people being "activated" which results in increased costs,
less care available to the "normal" patients/citizens, and additional
inefficiency in an already daily overburdened system.

Since this initial period is so important, its absolutely critical
that the worker bees of the system have the skills and knowledge of
Disaster Management.  Too many
systems fail to truly educate their staff members and erroneously rely
solely on the "senior managers" to run the incident.  It's great if
the senior managers of a hospital system, police dept, fire dept, etc
can all work together, but it means absolutely nothing if don't have
the field staff being able to work together.  Passing around a memo or
a "disaster policy" is not education or training.

My system focuses on initial management and cooperation among field
providers (medics, firefighters, police officers, dispatchers, ER
charge nurse) so that everyone knows their role and also how to help
other people in their role.  We also have a system in place where one
call to our MedCom dispatcher opens up a simultaneous radio patch to
all hospitals so that each hospital can get information directly from
the medical commander of the incident to manage their internal
preparations.  Relying on "whisper down the alley" almost always leads
to the "over activation" that Dr. Mattox referred to.

You can't be proficient in anything without practice.  As such, we
deploy these basic prinicipals to any multi-patient incident.  Our EMS
crews establish the EMS branch of ICS (EMS Group Supervisor for you
NIMS people) even for a 3 vehicle MVC with minor injuries.  If after
assessing the scope of the incident it is determined that the ICS
sytem isn't needed, it is simply terminated.  However, this gets all
the field providers in the habit of determining the scope and
establishing command.

I hope in the future that more systems have mechanisms and training in
place to adequately manage the initial period of these incidents.

Jon Hoerner, BS NREMT-P
Allentown, PA

On 8/5/09, Robert Smith <rfsmithmd at comcast.net> wrote:
> I know Dr. Schwab doesn't participate on this list but he would probably
> have some insight re: what happened.
>
> Rob Smith
>
> On Aug 5, 2009, at 12:17 PM, KMATTOX at aol.com wrote:
>
> > Thx. I will but since this did occur in Pittsburgh, and we are  discussing
> > Disaster System Principles to apply to our own communities, it is  best if
> > those OUTSIDE of Pittsburgh at this time be the discussants.
> >
> > k
> >
> >
> >
> >
> >
> > In a message dated 8/5/2009 11:14:34 A.M. Central Standard Time,
> > Krin135 at aol.com writes:
> >
> > Dr.  Mattox:
> >
> > You might want to contact Dave Crippen, MD direct as he  probably has
> > contacts at the facilities and could give you more  information directly.
> >
> > Also, I'm betting that this will be a hot topic  on the Critical Care
> > Mailing List (CCM-L.org), which Dr. Crippen  also heads.
> >
> > ck
> > Charles S. Krin
> >
> >
> > In a message dated  8/5/2009 10:09:42 Central Standard Time,
> > KMATTOX at aol.com
> > writes:
> >
> > I  have  been following this story since last evening.     This  time it
> > occurred in Pittsburgh, and involved a community  at the periphery of
> > Pittsburgh,
> > not downtown.     It is tragic as to what  happened,  and the victims
> > ranged
> > from  minor to critical.    They were taken to  three  hospitals.
> > This
> > is
> > just a  peripheral  observation as ANY community in the world could  and
> > will
> > face a SYSTEM mass  casualty or disaster  situation.   In this instance,
> it
> > appears  that this was no  greater than a  busy Friday night in anyone's
> > ER,
> > but it gained   national attention  because it was a single shooter in an
> > exercise  gym.     Now for some editorial comments  relating to  trauma
> > care,
> > disaster systems  etc.
> >
> > 1.    Pennsylvania trauma system is  governed by  the  Pennsylvania Trauma
> > Foundation.   I do not  know  if the disaster  systems response or mass
> > casualty
> > systems   approaches are under the PTF or  not.   I do know that  with
> > most
> > instances such as this, there are many  silos that  want to be  the boss
> > and
> > get
> > the credit.   When this  occurs,  the  system care is often jeopardized.
> > My
> > comments here are not   directed at Pittsburgh, but in  general.   I would
> > plea that  every  community have a  system approach for such an event
> which
> >
> > involves law   enforcement, the trauma system, the EMS system, public
> > health, and
> > Critical  Care.   I only know of ONE state  where this  is occurring and
> > all
> > work  together in an integrated  manner and  that is Connecticut.    Such
> > an
> > integration  must  be in place AHEAD of time or mass confusion and
> > posturing
> >
> > breaks out among the many silos.     I saw just a bit   of  that happening
> > here
> > on the very very late news last  night.
> >
> > 2.    During most disasters, and mass  casualty  situations,  after one
> > eliminates the dead, and  obviously those who  will soon be dead and  have
> > non
> > survivable injury etc, the 10% rule  exists.   That is  only  10% or less
> > of
> > those
> > involved need  to go to a  hospital, and of that group only  10% have
> > immediate life   threatening conditions (1% of the original  group).
> >
> > > From
> > >
> > my
> > calculations of the very little data I  obtained from  the Internet  and
> > news
> > reports from last night and this  morning,  these statistics  seemed to
> > hold
> > true
> > again.
> >
> > 3.    Even though  the 10% rule  and statistical papers  regarding surge
> > capacity have  been  widely published, the ERs of the receiving
> facilities
> > are
> > often  massively over loaded with far too many people.    I  am currently
> > attempting to get data from the Internet reports about  the  numbers  of
> > providers
> > in the three hospitals to which  the victims were   taken.   I would
> > suspect
> > that at  least 2 of the hospitals  activated  their disaster plans and had
> > far
> > too many doctors, nurses  , etc. when the  immediately  available data did
> > not
> > support disaster  plans activation, and  the  SURGE limitations are not in
> > the
> > location  where the  patients arrived (EC), but  the ORs and ICUs.    That
> >
> > is
> > why pre-planning for a system  approach with OR and ICU  persons on  the
> > planning committee is  essential.     We have learned  these lessons over
> > and over
> > again.
> >
> > 4.    This now  brings up my last point.     It  is key that the system
> > find
> >
> > the 1% of critical patients very  early and send them  to the right  place
> > quickly.     As one examines the disasters  which have  occurred in the
> > United
> > States during the last 20 years, including   911,  this often did not
> > happen.
> > In the Washington DC   area  following the Pentagon being hit, not one
> > patient was taken  to  a local or  regional verified Level I Trauma
> Center.
> >
> > Very
> > interesting.    In Pittsburgh last night,  it seems  that perhaps  two
> > patients were CRITICAL.    Those  individuals optimally would be  taken
> > immediately
> > to  a facility that  routinely during everyday operations would  have
> > received
> > such  critical patients, and that most often is NOT the  closest
> > facility.
> >
> > I have not yet determined  just who went where, but  I  suspect there was
> > an
> > element of  secondary triage and  transfer.   This  kind of delay is
> often
> > the
> > case during  disaster and mass casualty, when it  is  not for just another
> > busy  Friday night.   That is  because when a  disaster is declared,
> there
> > is
> > often a  group of people calling the EMS and  distribution  shots that are
> > not
> > involved in every day EMS  operations.    This gets  us back to the issue
> > of
> > pre planning using all  of the  right  people in a community
> >
> > The purpose of this post is for all of us   to optimally learn positive
> and
> >
> > negative lessons from sad  events  such as this.   I am point no fingers
> > at
> > all,  unless I am  pointing at myself and my own city and  state.   Let us
> > all
> > build on the lessons of the past.
> >
> > Kenneth L. Mattox,   MD
> > Houston
> >
> >
> >
> >
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> >
> >
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> >
> >
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> >
>
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