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HISTORY: BEST TOOL FOR DISASTER PLANNING
• 1920 BROAD STREET BOMBING (CULPRITS NEVER FOUND: ACCIDENT??)
• LED TO FOUNDING OF BEEKMAN HOSPITAL IN 1924
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THE TWO GOALS OF DISASTER PLANNING:
1)EVACUATION2) TREATING CASUALTIES
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9/11
99% OF PEOPLE BELOW IMPACT FLOORS SURVIVED
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EVACUATION
EVACUATION
EVACUATION
EVACUATION100:1
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WHICH REQUIRES:
COMMUNICATION
COMMUNICATION
COMMUNICATION
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TREATINGCASUALTIES:
ARE HOSPITALS ENOUGH?
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1) WHAT ROLE FIELD TRIAGE?
2) WHAT ROLE OUTSIDE HELP?
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TRIAGE:SPEED VS.
ACCURACY
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HOW FAST IS FIELD TRIAGE?
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WASTING TIME
• “ The captain wanted us to take their names before we transported. A woman with 90% burns, screaming. How are you supposed to take names?”
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TRIAGE DELAYS:
HISTORICAL PRECEDENTS
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TOKYO, MARCH 1995:SARIN GAS ATTACK IN
SUBWAY
• ST. LUKE’S HOSPITAL: 498 PTS.
• 99 TRANSPORTED BY AMBULANCE OR OFFICIAL CAR
• BY FOOT: 174
• TAXI: 120
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TOKYO: DANGERS OF DELAY
• PATIENTS DETERIORATED ENROUTE.
• GOOD THING THEY WEREN’T HELD AT THE SCENE
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OKLAHOMA CITY APRIL 1995:
ALFRED P. MURRAH FEDERAL BUILDING
BOMBED• 272 PATIENTS WITH KNOWN MODE
OF TRANSPORTATION
• CAR: 152
• WALKING: 27
• EMS: 90
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MEDIAN TRANSPORT TIME:
90 MINUTES
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FIVE HOSPITALS WITHIN 1.5 MILE-
RADIUS
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WHAT DELAYS PATIENT TRANSPORT?
EMS WANTS TO “CONTROL THE
SCENE.”TRIAGE CENTERS
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WEST WARWICK, R.I.FEBRUARY 20, 2003:
THE STATION NIGHTCLUB FIRE.
• 98 DEAD
• 186 TRANSPORTED IN ONE HOUR:
• 40 ALS RIGS, 26 ALS AND BLS PRIVATE AMBULANCES
• 40 CRITICAL
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CAPT. PETER GINAITT
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“WE HAD GREAT PROTOCOLS. EVERYTHING
FAILED.”
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“I TOOK MY TRAUMA TAGS AND PUT THEM ON A
BENCH.I ASSESSED AIRWAYS AND
MOVED ON. IT WASTOUGH KEEPING PEOPLE IN
ONE PLACE
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“I HAD TO SEND TWO WALKING
WOUNDED WITH EVERY CRITICAL. I
DIDN’T KNOW IF THEY WOULD
DETERIORATE.”
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HOW ACCURATE IS FIELD TRIAGE?
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• FIELD TRIAGE MISSES 30% OF LIFE-THREATENING INJURIES
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RULES TO LIVE BY:
1) SPEED BETTER THAN ACCURACY: CLEAR THE SCENE.
2) NO IDLING AMBULANCES
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BUT CAN THE HOSPITAL HANDLE
IT?
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NYU DOWNTOWN HOSPITAL
• 170 BED, LEVEL-II TRAUMA CENTER
• 6 OPERATING ROOMS
• ED: 29,000 VISITS/YEAR
• 4 BLOCKS FROM WTC
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1993: 250 patients. NO SYSTEMS
FAILURES
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DISASTER DRILL JULY 30, 2001
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SEPTEMBER 11, 2001
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THE FIRST HOUR:9AM-10AM
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CHRONOLOGY
• 8:46 AM: NORTH TOWER HIT
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CHRONOLOGY
• 9:02 AM: SOUTH TOWER HIT
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INITIAL SETUP
• 10 MINUTES TO PREPARE
• ASSEMBLE SUPPLIES/CENTRAL
• ED ATTENDING TO TRIAGE AREA
• NURSE MANAGER TO MAIN ED
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RESOURCES IN ED• 1 ED ATTENDING
• CHARGE NURSE (MARY LYKE, RN)
• 6 ED RNs
• SURGERY: 8 SURGEONS/5 HOUSESTAFF
• MEDICINE: 14 ATTENDINGS/30 HOUSESTAFF
• OB/GYN: 4 ATTENDINGS/16 HOUSESTAFF
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CONSTRAINTS: 12 OVERNIGHT ADMISSION
HOLDOVERS
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HOW DID WE ORGANIZE?1) INCIDENT
COMMAND SYSTEM2) STAGING AREAS
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IMMEDIATE EFFECT ON STAFF
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CRITICAL CASES
• 12 SEVERE MULTI-SYSTEM TRAUMAS/BURNS/CARDIAC ARRESTS.
• MANY LONG-BONES FRACTURES, VASCULAR INJURIES, DEEP LACERATIONS.
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BY 10AM: 200 PATIENTS SEEN
3 CASES TO O.R.
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HOSPITAL TRIAGE: MAXIMIZE
“SURFACE AREA” OF PERSONNEL TO
PATIENTS
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LATER ORGANIZATION:
CAFETERIA OPENED, SUCCESSIVE FLOORS
STAGED. COMMUNICATION BY
TWO-WAY RADIOS
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LESSONS: THE FIRST HOUR
• ONE-TO-ONE ESCORTS/TRIAGE
• SUPPLY OFFICERS/RUNNERS
• CLEAR LINES OF AUTHORITY--AT LEAST TWO LEVELS OF TRAUMA DECISION-MAKING
• STAGING AREAS FOR STAFF (ESPECIALLY OUTSIDE DOCS)
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ABOVE ALL:1) FAMILIAR
FACES IN CHARGE2) TAKE YOUR
TIME3) NO DISASTER-
MODE
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THE SECOND HOUR:10AM-11AM
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CHRONOLOGY
• 10:00 AM SOUTH TOWER COLLAPSES
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ADDITIONAL MECHANISMS: CRUSH,
INHALATION, OPHTHO, TRAMPLING
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CHRONOLOGY
• 10:28: NORTH TOWER COLLAPSES
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SYSTEMS FAILURES
• CON ED CUTS OFF STEAM AND GAS TO LOWER MANHATTAN
• CANNOT STERILIZE O.R. INSTRUMENTS• HVAC SYSTEM SHUT DOWN DUE TO
DUST CLOUD• TELEPHONES ALMOST USELESS• CITY’S OFFICE OF EMERGENCY
MANAGEMENT ON FIRE
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BY 11AM:
350 PATIENTS
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HIGH-VOLUME SOLUTION
• ONE-ON-ONE ASSIGNMENT: RECYCLE DOCS AS TRANSPORTERS: GET MORE HISTORY ON THE WAY, FIND APPROPRIATE CONSULT, NO ABANDONED PATIENTS
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ADDITIONAL 450 BYPASS FORMAL TRIAGE AREAS
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FALLBACK PHASE
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WHAT’S GOING ON UPSTAIRS??
• STABILIZED, CRITICAL PATIENTS TO ICU. INITIALLY STAFFED BY 1 MEDICINE RESIDENT AND 2 INTERNS. ATTENDINGS EVENTUALLY MAKE THEIR WAY UPSTAIRS.
• OUTPATIENT CLINIC OPENED ON 4TH FLOOR: 150 PATIENTS SEEN
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LESSON
• CLINICIANS WORK BEST IN THEIR OWN ENVIRONMENT
• GET DOCS (NOT NURSES) OUT OF THE ED
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LESSONS: THE SECOND HOUR
• INTER-HOSPITAL COORDINATION
• HOSPITAL MUST BE SELF-SUFFICIENT: POWER, STEAM, WATER.
• NEED SINGLE, RELIABLE CHANNEL OF COMMUNICATION WITH CITY/FIRE/EMS
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WHAT WORKED WELL?
• STAFF HAD LONG EXPERIENCE WITH EACH OTHER--LOTS OF TRUST
• HOUSEKEEPING VERY EFFICIENT• DOCS AND NURSES SELF-ORGANIZED• SUCCESSIVE AREAS OPENED UP
SMOOTHLY• RAPID DISCHARGE
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SELF-ORGANIZTION
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DOES OUTSIDE HELP WELL, HELP?
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9/11, 1 PM EMS SETS UP TRIAGE CENTERS AT PACE U.,
CHELSEA PIERS AND SOUTH FERRY
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NEVER COORDINATED WITH NYUDH: ED CLEARED
LESSON:COMMUNICATIONCOMMUNICATIONCOMMUNICATION
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BY 2PM: ALL PATIENTS TREATED AND ED CLEARED
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LESSON: YOU HAVE NO IDEA HOW FAST YOU CAN
MOVE, OR HOW WELL PEOPLE WILL RISE TO THE
OCCASION
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OKLAHOMA CITY, 1995: 388 PATIENTS TO 13 HOSPITALS
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NYU DOWNTOWN HOSPITAL ON 9/11
1)OVER 500 PATIENTS TREATED
2) SHELTERED ANOTHER 500
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ONE OF MANHATTAN’S
SMALLEST HOSPITALS
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RAN THE LARGEST DISASTER
RESPONSE IN CIVILIAN
AMERICAN HISTORY
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NO PATIENT MISSED
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CONCLUSIONS:
1) EVACUATION ABOVE ALL
2) FIELD TRIAGE: GET THEE TO A HOSPITAL3) TRUST SELF-ORGANIZATION
4) RELIABLE COMMUNICATION
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FINAL LESSON:
HOSPITALS MAKE NATURAL COMMAND
POSTS.WHY?
YOU CAN’T ABANDON THEM
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AFTERMATH
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I WISH I’D SPENT MORE TIME WITH
THEM”
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THE “I DIDN’T DO ANYTHING
SYNDROME.”