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Title: Paul K. Carlton, Jr., MD, FACS Lt. Gen, USAF, Ret Director, Homeland Security The Texas A


1
Training Together First Responders and First
Receivers Playing the Same Game
Paul K. Carlton, Jr., MD, FACS Lt.
Gen, USAF, Ret Director,
Homeland Security The Texas AM University
System Health Science Center January 20, 2006
2
Preparation for the NationMaking the Pieces
Fit
First Preparers
First Receivers
Trauma Critical Care Pararescue Course
Public Health Course
Bio-Terrorism Course
Trauma Disaster Course
Mental Health Aspects Course
Mental Health Aspects Course
Trauma Critical Care Pararescue Course
WE
Trauma Disaster Course
Mental Health Aspects Course
Public Health Course
Eye Trauma Course
Critical Infectious Diseases Course
Bio-Terrorism Course
Critical Care Transport
First Responders
Public Health Course
Bio-Terrorism Course
Trauma Dusaster Course
3
Surge Discussion
4
Surge Protection
Protection from surges of electricity
5
Surge Protection
Surge Hospital
Protection for surges of patients from natural or
man made disasters
6
Surge Protection
Surge Hospital
Protect our most valuable asset PEOPLE
7
Surge Hospital Definition
TRATEGIC HARED
S
U
TILIZATION OF
R
ESOURCES FOR
G
EOGRAPHICAL
MERGENCIES EFFICIENCIES
E
8
Surge Hospital/ Facility
Definition A facility that can be used to
provide sufficient medical care when a primary
medical facility is -destroyed
-contaminated denied -overwhelmed
9
Criteria for Surge Hospital
10
Threats, Challenges and Viable Solutions
11
A Word on the Slides
  • You will see almost ---- slides today!
  • On average the slide will be up 6 seconds!
  • Each slide with information has the reference at
    the bottom right hand side of the slide
  • This is a visual presentation!
  • If you want it to review, it is available
  • What I want you to do is listen, reflect, and if
    you decide anything said is useful to you, THEN
    figure out how you WILL USE THE INFORMATION TO
    IMPROVE YOUR STATE OF PREPAREDNESS and the
    Nations!

12
Begin with the end in mind
FINISH
13
Criteria for Surge Hospital
14
Surge Hospitals
Hospitals become ICU other buildings become wards
15
Goal Solid Structure Addressing ALL Areas
Our House
  • People
  • Equipment
  • Training
  • Organization

E
O
Heretical Thinking!
ALL HAZARD ENVIRONMENT
16
The interface of standard of care and sufficiency
of care
Graceful Degradation of Care
GOLD STANDARD
Care Standards
Plan B Operations Results in more survivors
???
Demand
MORAL IMPERATIVE
17
Build a Solid Structure
Our House
Use 4 components to build a solid structure
18
Organization
Standard of Care/Sufficiency of Care
Move out of circle as needed Move back as
quickly as possible
Sophisticated care done in hospitals Less
sophisticated care done in surge hospitals
Sufficiency of Care
Sufficiency of Care
Standard of Care
19
Plan A
  • Standard of Care
  • What is currently used in USA today

20
BUT
  • If Plan A is denied because
  • Loss of hospital
  • Contaminated hospital
  • Numbers are overwhelming
  • THEN

21
Must move smoothly and quickly to Plan B, C, D
Operations
22
Then
1,000 Burn Patients If engaged 50
If engaged 100 at 84
at 84 420 survivors 840
survivors
23
SO
Plan B 84 survivors 1,000 burn patients
Standard Plan A 90 survivors 1,000 patients
only 100 engaged 90 survivors
If engaged 50 at 84
420 survivors


If engaged 100 at 84
840 survivors
466
933
A tremendous improvement
Source Journal of Burn Care and Rehabilitation
Volume 18, Number 3, 1997
24
Solve for rate limiting step!
25
The interface of standard of care and sufficiency
of care
Graceful Degradation of Care
GOLD STANDARD
Care Standards
???
Results in more survivors
Demand
MORAL IMPERATIVE
26
ITS ALL ABOUT PEOPLE Not about bricks or lumber
in a pile, not about concrete destroyed It is the
dead and injured.
Medical Must Be Considered
27
Overview
  • Threat
  • Solutions

28
If you believe the threat is real Then It demands
solutions now!
29
Disaster Preparedness
Its All About Me!
  • Three deadly misconceptions
  • It will not happen here!
  • It will not happen to me!
  • Someone else will be there to take care of the
    problem!

Jay A Johannigman Crit Care Med Vol 33, No1
30
Disaster Preparedness
Its All About Me!
  • Three deadly misconceptions
  • OUR REALIZATIONS!!
  • It will not happen here! IT DID!
  • It will not happen to me! IT DID!
  • Someone else will be there to take care of the
    problem! THEY WERE NOT!

Jay A Johannigman Crit Care Med Vol 33, No1
31
LEARNERS
In a time of drastic change it is the learners
who inherit the future. The learned usually find
themselves equipped to live in a world that no
longer exists!
Eric Hoffer
32
LEARNERS
ALL OF US MUST BE LEARNERS!
33
Dont be learned!
34
You may obtain a copy of this presentation at
www.tamhsc.edu/homeland/
35
America is in Danger!
36
Danger Always Present, Just
Beneath the Surface
37
Facing Reality is Difficult
None of us Want to Face What Lies Ahead of
Us We Must!
38
Change Is Hard
Every revolutionary idea evokes three stages of
reaction
  • Youre nuts!
  • It would work, but no reason to change!
  • You like it? It was MY idea!

39
Response Chain
40
  • LINKS
  • Prevention
  • Mitigation
  • Consequence Management
  • Recovery

41
All of these have some part of the response
chain-
  • Police
  • Fire
  • EMS
  • Medical

42
Weak Link
Medicine may be the Weakest Link!
43
It all comes to life or death!
44
ITS ALL ABOUT PEOPLE Not about bricks or lumber
in a pile, not about concrete destroyed It is the
dead and injured.
Medical Must Be Considered
45
Weak Link
We could see collapse of our health care system
in any bio event! Chuck
Ludlam, Chief of Staff
Senator Lieberman
15 April 05
46
Weak Link
We are totally unprepared medically! We have
none of the vaccines nor antibiotics that we
would need in a bio event. Defense Contract
model will not work in this situation.
Chuck
Ludlam, Chief of Staff
Senator Lieberman
15 April 05
47
Weak Link
Medicine is our weak link and that is where we
will break. Ed Eberhart
CINC NORTHCOM
May 3, 2004

48
These people could be wrong but I doubt it
49
Medical Response
Why?
Different worlds they do not understand each
other
50
Medical Response
Different worlds they do not understand each
other
51
Medical Response
  • NO OWNED ASSETS
  • ALL PRIVATE
  • REQUIRES BETTER COOPERATION and UNDERSTANDING
    THAN WE HAVE EVER SEEN!

52
Threats
Medicine, as we know it, is in danger of failing.
53
The Current Hospital Environment
  • Key component of consequence management is timely
    medical care for victims of mass casualty
    incidents
  • Incorrect assumptions made about existing
    medicalcapabilities to treat mass casualties
  • Hospital surge capacity has never been more
    restricted
  • Medical community struggling just to maintain
    everyday capacity
  • Majority of preparedness issues are financially
    (revenue vs cost) based
  • Without prompt action, the nation carries the
    risk thatvictims of a mass-casualty disaster
    might end up in ambulances to nowhere."

Source Barbera, Macintyre, and DeAtley Mar 2002
54
Ambulances to Nowhere
  • Funding shortfalls
  • Decline in government support for public and
    privatehospitals
  • Increasing number of expensive, unfunded, or
    under-funded regulatory mandates
  • Continued expectation that hospitals will
    maintain highlevels of charity medical care
  • National shortage of nurses for acute care
    hospitals, resulting in need for special
    compensation packages to attract personnel
  • Results -- closure, downsizing, consolidation,
    reconfiguration, and partnering
  • Abolition or downsizing of specialty services
    crucial todisaster preparedness!

Source Barbera, Macintyre, and DeAtley , Mar
2002
55
Ambulances to Nowhere
  • Delivery of acute medical care evolved beyond
    ordinary business relationship to "trust" with
    patients
  • Trust has extended to current threat
    environment
  • Move from individual patient to community as a
    whole
  • Financial support to hospitals by community
    create expectation hospitals will address
    community's health/medical needs, including
    disaster preparedness
  • Reasonable cost for hospital preparedness for
    mass casualtieswas assumed to be necessary cost
    of doing business
  • Financing costs
  • Old Medicare and fee for service
  • New Managed care payment system (capitation)
  • Bottom line Disconnect between expectations and
    funding!

Source Barbera, Macintyre, and DeAtley , Mar
2002
56
Troubled Medical System
  • Growing concern over projected shortage of
    healthcare providers in coming years
  • Other factors aging population, increased
    demand, and increased costs
  • Troubled specialties -- orthopedics, radiology,
    dermatology, cardiology, ophthalmology and
    anesthesiology
  • Bleak future forecast
  • Shortage of 200,000 doctors,
  • 157,000 pharmacists
  • 20 shortfall in nursing
  • requirements by 2020
  • Quality of life greatest deterrent

Kiplinger, Mar 05
57
A Strained System
  • Hospital capacity continues to be main limiting
    factor in disaster medical response
  • Critical care services and intensive care units
    most affected
  • Recent examples
  • Only 25 ICU beds usable for 27 patients in Madrid
    bombing
  • Only 12 ICU beds available for 20 patients in
    Bali bombing
  • 2001 Houston floods reduced ICU capacity by 75
  • More challenges
  • Toxic chemical scenario 1200 bed hospital could
    handle only two patients at one time
  • Poor staffing levels for critical care areas

Dara, Ashton Farmer, Feb 05
58
A Strained System
  • Possible surge solutions
  • Pre-emptive education Increased disaster
    response awareness, improved skill sets,
    comprehension of roles and responsibilities,
    alternate communication styles, and expertise in
    cooperation during chaos
  • Interfacility cooperation Creation of flexible
    plans for interchanging resources to supplement
    existing capacity of hospitals
  • Dual usage of resources Critical care units
    respond outside geographical locations merge
    training and education

Dara, Ashton Farmer, Feb 05
59
Trauma Center Problems
  • Trauma center experts announce facilities
    ill-prepared to handle disaster or epidemic
  • It's a struggle to meet the nightly demand of
    911 calls, but somehow we're supposed to deal
    with a terrorist bombing? Or a new strain of
    influenza? -- ER Physician
  • A losing battle
  • Trauma care is money loser serves many patients
    without health insurance
  • Expensive to maintain a round-the-clock staff
    and specialists
  • Atlanta ER expecting loss of 10M in 2005!

Miller, Dec 05
60
TEAM
61
Preparation for the NationMaking the Pieces
Fit
First Preparers
First Receivers
Trauma Critical Care Pararescue Course
Public Health Course
Bio-Terrorism Course
Trauma Disaster Course
Mental Health Aspects Course
Mental Health Aspects Course
Trauma Critical Care Pararescue Course
WE
Trauma Disaster Course
Mental Health Aspects Course
Public Health Course
Eye Trauma Course
Critical Infectious Diseases Course
Bio-Terrorism Course
Critical Care Transport
First Responders
Public Health Course
Bio-Terrorism Course
Trauma Dusaster Course
62
5 Ps
  • Prior
  • Planning
  • Prevents
  • Poor
  • Performance

63
ITS ALL ABOUT PEOPLE Not about bricks or lumber
in a pile, not about concrete destroyed It is the
dead and injured.
Medical Must Be Considered
64
Independent Missions
Independent Missions
Wartime Readiness
Peacetime Benefit
Military
USA
65
Interdependent Missions
Interdependent Missions
aaaaa
Peacetime Benefit
Wartime Readiness
Military
USA
Inherently Governmental!
66
  • Those with a military background have an
    obligation to share what we know with our
    civilian colleagues!
  • Our civilian colleagues do NOT have an obligation
    to listen- but it is at their and their patients
    peril!

67
Finding a Balance
Balanced Surge Capacity Scale
Efficient
Effective
68
Finding a Balance
Current Surge Capacity Scale
Not Balanced!
Effective
Efficient
69
Solutions
Dollars Do Matter!
70
Master Plan
Low hanging least expensive and everyone should
do it
71
Master Plan
Mid level more expensive highest risk targets
should do it
72
Master Plan
Top level most expensive only highest ??
Targets should do it Washington Hospital Center,
Houston, etc.
73
Goal Leak Proof Umbrella
P
E
T
O
ALL HAZARD ENVIRONMENT
74
Texas AM Conference
  • Texas AM Health Science Center plans to have a
    conference 4-5 April that will fill in these
    thoughts about what to do to properly prepare!
  • Most of the solutions are cheap and easy to
    apply!
  • The conference will be aimed at decision makers
    in the major health care systems.

75
Current Threats to the Medical System
Impact
Terrorism
Epidemics
Natural Disasters
Underinsured /uninsured
Baby Boomers
Probability of Occurrence
76
President George W. Bush October 1, 2003
  • On September 11, 2001
  • Enemies of freedom made our country a
    battleground
  • Used mass murder of innocent
  • Make Americans live in fear

We refuse to live in fear!
77
President George W. Bush
October 1, 2003
The best way to overcome fear and frustrate the
plans of our enemies is to be prepared and
resolute at home, and to take the offensive
abroad.
78
Closing the Gaps
  • U.S. still inadequately prepared to respond to
    natural disasters
  • No overall strategy for reducing lives lost and
    property destroyed for wildfires, earthquakes,
    floods, hurricanes, and tsunamis
  • Specific agencies focused on natural disasters
    must negotiate federal bureaucratic
    infrastructures!
  • Closing the gaps
  • Enhanced monitoring and detection systems.
  • Techniques for mitigating destruction from one
    hazard can be applied to other hazards

National Journal, Dec 05
79
Closing the Gaps
  • Improving preparedness through educating public
    and developing coordinated response strategies
    for federal, state, and local agencies
  • National Science and Technology Council Report
  • Right people need to be warned at right time
  • Scientists need to understand causes of disasters
  • Communities built to resist natural hazards
  • Vulnerability of critical infrastructure reduced
  • Communities must regularly assess resilience to
    disasters using standard methods.
  • Educate people about risks and disaster
    preparations

National Journal, Dec 05
80
Hospitals Still Unprepared
  • Hurricane Katrina revealed majority of U.S.
    hospitals unprepared for catastrophic disaster
  • Mandatory twice/year exercises ineffective
  • Vague planning guidelines little regulation
  • Unable to sustain contingency ops for long period
    of time
  • Tough decision
  • When and where to evacuate patients
  • Limited budgets and resources
  • Cooperating with competing organizations
  • Balance readiness vs normal operations

Market Watch, Nov 05
81
Lessons Learned
  • Recent natural disasters tested system
  • Many New Orleans hospitals closed for lost power
    and competing resources (patient helicopters)
  • Lapses in infrastructure (no power,
    communications, etc)
  • Must prepare for surge!
  • It's a calculated risk being taken (surge
    preparation) and if there isn't a disaster at
    your hospital, you win and if there is, then the
    victims lose. -- Dr Rob Sutter
  • Financial gaps
  • Disaster planning typically less than 1 or 2 of
    hospital's budget

Market Watch, Nov 05
82
Complaints without Solutions Whining
83
Whining
84
President George W. Bush
October 1, 2003
The best way to overcome fear and frustrate the
plans of our enemies is to be prepared and
resolute at home, and to take the offensive
abroad.
85
SOLUTIONS
Currently under way at AM Health Science Center
  • 1. Education and Training
  • 2. Menu Brief
  • 3. Medical Student Education
  • 4. Leadership Program for Disaster Response
  • 5. Master Plans
  • Plan B
  • Triage
  • 8. Mobile Solutions
  • 9. Surge Hospitals or Community Health Centers
  • 10. Veterinary School Surge Hospital
  • 11. VA Proposal

12. Incentives Carrot Credentials 13.
Medical Operations Center Proposal 14. Proposal
to Dr. Eduardo Sanchez Commissioner of
Health 15. NORTHCOM 16. Diabetic Retinopathy
Screening 17. Isolations Rooms 18.
Scancorder 19. Ventilators
7 April 05
86
Plan for Surge
  • Advance planning is key
  • Locate buildings of opportunity
  • Train staff
  • Equipment ready to set up

87
Surge Protection
Surge Hospital
Protect our most valuable asset PEOPLE
88
All Hazard
89
Forward Operation Base Marez Mosul, Iraq 24
December 04
90
Forward Operation Base Marez, Mosul, Iraq
1215 pm Explosion in dining facility
Evacuation begins 1225 pm 12
casualties arrive at medical facility
Medical Fights On To Save Lives
91
Forward Operation Base Marez, Mosul, Iraq
1225 pm Triage begins 1240 pm Mortar
attack hits hospital
Hospital hard and no casualties Full speed for
12 hours 1130 pm Breath 200 am
CCATTs arrive- medical tune up for flight
400 am CCATTs fly away 12 patients to
Germany
92
Statistics
9 OR cases 7 Open laparotomies 10 surgeries in
hallway 8 pts mechanical ventilation 14 chest
tubes placed 39 CT scans done 200 plain
radiographs 294 lab tests 40 units of blood
products 217 IV meds given
91 patients 18 DOA 4 DOW 69 left 20 to other
military hospitals 49 to treat
Great Job Army!
93
A Busy Day
  • Attack by suicide bomber on food tent in Forward
    Operating Base Marez created numerous casualties
  • 91 casualties in 11 hours
  • 22 died in attack 18 were American
  • 17 dead on arrival 5 with nonsurvivable wounds
  • A busy day for casualties
  • Highest number of casualties treated at military
    hospital in Iraq during war
  • 9 surgeries performed in OR 10 performed outside
    OR
  • Mortuary established in parking lot

NY Times, Dec 04
94
What can we learn from this?
95
Standard of Care/ Sufficiency of
Care
Sufficient care
Demands
Standard of Care

Care Capability
96
Standard of Care/ Sufficiency of
Care
Sufficient care
10 surgeries in hallway
Demands
Smooth transition
Standard of Care
7 Open laparotomies
9 operations in OR

Care Capability
97
The interface of standard of care and sufficiency
of care
Graceful Degradation of Care
GOLD STANDARD
Care Standards
???
Plan B Operations
Demand
MORAL IMPERATIVE
98
The interface of standard of care and sufficiency
of care
Graceful Degradation of Care
GOLD STANDARD
This plan stays within SOC
Care Standards
Double the numbers moves to Sufficient Care
???
Plan B Operations
Demand
MORAL IMPERATIVE
99
Standard of Care/Sufficiency of Care
Move out of circle as needed Move back as
quickly as possible
Sophisticated care done in hospitals Less
sophisticated care done in surge hospitals
Sufficiency of Care
Sufficiency of Care
Standard of Care
100
Lessons Learned
  • Triage needs work
  • Training saves lives
  • Resource allocation is critical!

101
Surge Protection
Surge Hospital
Protect our most valuable asset PEOPLE
102
Criteria for Surge Hospital
103
Criteria for Surge Hospital
104
Surge Hospitals
Hospitals become ICU other buildings become wards
105
Goal Solid Structure Addressing ALL Areas
Our House
  • People
  • Equipment
  • Training
  • Organization

E
O
Heretical Thinking!
ALL HAZARD ENVIRONMENT
106
The interface of standard of care and sufficiency
of care
Graceful Degradation of Care
GOLD STANDARD
Care Standards
Plan B Operations Results in more survivors
???
Demand
MORAL IMPERATIVE
107
Build a Solid Structure
Our House
Use 4 components to build a solid structure
108
Organization
Standard of Care/Sufficiency of Care
Move out of circle as needed Move back as
quickly as possible
Sophisticated care done in hospitals Less
sophisticated care done in surge hospitals
Sufficiency of Care
Sufficiency of Care
Standard of Care
109
Plan A
  • Standard of Care
  • What is currently used in USA today

110
BUT
  • If Plan A is denied because
  • Loss of hospital
  • Contaminated hospital
  • Numbers are overwhelming
  • THEN

111
Must move smoothly and quickly to Plan B, C, D
Operations
112
Rate Limiting Steps for Mass Casualties
P E
T O Burns Yes
Yes No No Chem
Yes Yes Yes
No Radiation Yes Yes
Yes No Bio Yes
Yes Yes No
113
For Example
  • Current burn therapy
  • Uses sulfamylon
  • Silver sulfadiazine
  • Other topicals
  • Heavily reliant on surgical wound care and skin
    grafting
  • Very labor intensive

Source Journal of Burn Care and Rehabilitation
Volume 18, Number 3, 1997
114
But
Burn Care
  • Mafenide hydrochloride
  • Mafenide acetate
  • Both Proven Effective

Sulfamylon
Source Journal of Burn Care and Rehabilitation
Volume 18, Number 3, 1997
115
Numbers
  • 1,000 burn patients- using mafenide acetate
    (sulfamylon) Plan A
  • only treat 100 conventionally
  • 90 survival of those treated
  • 90 survivors
  • Very labor intensive

Source Journal of Burn Care and Rehabilitation
Volume 18, Number 3, 1997
116
Solve for rate limiting step!
117
Numbers
Mafenide hydrochloride spray used in Viet Nam to
stabilize burn wounds Had 16 death rate (17 of
110) And much less labor intensive
Source Journal of Burn Care and Rehabilitation
Volume 18, Number 3, 1997
118
Numbers
  • 1,000 burn patients
  • Less labor intensive methods
  • Mafenide hydrochloride results in 84 survival
  • Less efficacious in small numbers
  • 6 less efficacious in preventing deaths on small
    scale

Source Journal of Burn Care and Rehabilitation
Volume 18, Number 3, 1997
119
But
Engage greater numbers because less wound
management required so solves people and
equipment problem
Source Journal of Burn Care and Rehabilitation
Volume 18, Number 3, 1997
120
Then
1,000 Burn Patients If engaged 50
If engaged 100 at 84
at 84 420 survivors 840
survivors
121
SO
Plan B 84 survivors 1,000 burn patients
Standard Plan A 90 survivors 1,000 patients
only 100 engaged 90 survivors
If engaged 50 at 84
420 survivors


If engaged 100 at 84
840 survivors
466
933
A tremendous improvement
Source Journal of Burn Care and Rehabilitation
Volume 18, Number 3, 1997
122
Solve for rate limiting step!
123
The interface of standard of care and sufficiency
of care
Graceful Degradation of Care
GOLD STANDARD
Care Standards
???
Results in more survivors
Demand
MORAL IMPERATIVE
124
Rate Limiting Steps for Mass Casualties
P E
T O Burns Yes
Yes No No Chem
Yes Yes Yes
No Radiation Yes Yes
Yes No Bio Yes
Yes Yes No
125
Rate Limiting Steps for Mass Casualties
Graceful Degradation of Care
Accept lower percent survival to affect a higher
survival depending on rate of limiting steps
Mafenide Acetate
90
Care Standards
Mafenide Hydrochlorine
84
Demand
MORAL IMPERATIVE
126
That is Plan B operations perhaps not optimal on
an individual basis But Far more survivors on a
large group basis depending on what is the rate
limiting step
Source Journal of Burn Care and Rehabilitation
Volume 18, Number 3, 1997
127
We need such thinking for
128
Plan A, Plan B, C, D
E
O
129
Criteria for Surge Hospital
Split Operation
Group inside cannot come out Group
outside cannot come in Two facilities Contamin
ated Facility Clean Facility
130
Contaminated facility mitigate with
Killer filter
Killer
M95 masks
Isolation technology

surge isolation Clean facility

Bare bones only emergent care
STOP all elective
surgeries
131
The interface of standard of care and sufficiency
of care
Graceful Degradation of Care
People and equipment are rate limiting steps
GOLD STANDARD
Care Standards
???
Results in more survivors
Demand
MORAL IMPERATIVE
132
Criteria for Surge Hospital
Most expensive option Most difficult option
Destroyed
133
Destroyed
  • Reconstitute a medical facility
  • alternative facility (large animal clinic)
  • Soft sided
  • Temporary hard sided
  • Modular building

134
Destroyed
P lose some of yours those on duty
reconstitute with those at home E must have
bare bones back up T in austere treatment O
must be flexible to accommodate change
135
Help will be on the way!
Local Infrastructure Baseline Capability
Units of Medical Capability
Time
136
ITS ALL ABOUT PEOPLE Not about bricks or lumber
in a pile, not about concrete destroyed It is the
dead and injured.
Medical Must Be Considered
137
Way Ahead
  • Planning for surge
  • Isolation issues
  • Present these concepts to VA Senior leadership!
  • Enter political arena with these thoughts!

138
Need of Triage
  • Evidence based
  • Reliably reproducible
  • Based on survival and deterioration rate
  • Scalable

139
Triage System
  • Started addressing fixes in 83
  • Dedicated resources and equipment in triage to
    redefine
  • 98 Ben Taub in Houston
  • Scalable
  • Factors to measure
  • Reproducible
  • Uses computers

140
Triage System
  • 750 now in database
  • Pulse ox not reliable indicator of survival
  • Respiratory rate
  • Motor responses
  • Pulse
  • Institute of Surgical Research
    is still accruing patients for database

still key
141
November 2003
  • Given SACCO brief
  • Evidence based
  • reproducible
  • Factored in survival and deterioration
  • Scalable

102,000 patients in Pennsylvania Trauma Registry
database
142
Not Reproducible
143
Evidence Based
144
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145
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146
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147
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148
Resource Allocation is Critical
149
Surge Examples
  • Surge in place
  • Austin

  • Surge into building of opportunity
  • Earl K. Long facility
  • PMac
  • Field House
  • K Mart
  • Surge into preplanned building of opportunity
  • Vet School

150
Surge in Place
Austin, Texas
151
Austin, Texas How to
Build a Surge Hospital for a Song
Austin, Texas August 2005
152
This Plan Protects
  • Staff
  • Patients
  • Victims of MCI
  • State Capitol
  • Football Stadium

153
Requirement by Department of State Health Services
112 Bed Surge Facility in place St.
Davids requirement from the DSHS as fair share
for Austin community
154
The Red Wedge Concept
Sufficient care
Plan B
At some point we will go to sufficient care ,
not standard of care
Demand
Soft sided solutions may apply
Standard of Care
Surge from outside sources
Peacetime Surge - within

Care Capability
155
The interface of standard of care and sufficiency
of care
Graceful Degradation of Care
GOLD STANDARD
This plan stays within SOC
Care Standards
Double the numbers moves to Sufficient Care
???
Plan B Operations
Demand
MORAL IMPERATIVE
156
Entry
Sequence 1.
Notification of MCI 2.
Decon and Triage prepared
3. Day surgery empties
4. Opens beds for MCI
Key
  • Control hospital
  • Not allowed into facility until decon is done
  • Allow time for preparation of day surgery for
    mass casualty incident (MCI)
  • Allows isolation from rest of facility
  • Central to downtown

Photo by Salvador Monastra-SeBasoc
St. Davids Safety Officer
157
Flow Pattern in Triage Area
Decontamination
Immediate
Sequence 1.
Notification of MCI 2.
Decon and Triage prepared
3. Day surgery empties
4. Opens beds for MCI
Minimal
Delayed
Expectant
Triage entirely dependent on resources and load
from MCI
158
Whole separate HVAC system protected by Isolate
Filter
Day surgery patients go straight to central
hospital
Sequence 1.
Notification of MCI 2. Decon and Triage prepared
3. Day
surgery empties
4. Opens beds for MCI
Immediate RX area
To OR
ICU
Holding beds
Photo by Salvador Monastra-SeBasoc
St. Davids Safety Officer
159
Summary
Gives them 127 Standard of Care beds by just
rearranging!
160
The Red Wedge Concept
Sufficient care
Plan B
At some point we will go to sufficient care ,
not standard of care
Demand
Soft sided solutions may apply
Standard of Care
Surge from outside sources
Peacetime Surge - within

Care Capability
161
The interface of standard of care and sufficiency
of care
Graceful Degradation of Care
GOLD STANDARD
Care Standards
Demand
MORAL IMPERATIVE
162
Recent Threats
Hurricanes Katrina and Rita
163
KATRINA A Rain of Terror
164
Medical Victory Due to
  • Ingenuity
  • Dedication to patient care
  • Volunteerism
  • Good planning by some!

165
Surge
  • Surge in place
  • Austin

  • Surge into building of opportunity
  • PMac
  • Earl K. Long Facility
  • Field House
  • K Mart
  • Surge into preplanned building of opportunity
  • Vet School

166
LSU Campus
Field House
Maravich Coliseum
167
Surge into Buildings of
opportunity Pete Maravich Coliseum
168
Board from Fall 04 College of Architecture
Semester Project
What idiot would build a hospital in a sports
facility?
Any idiot that needs to!
169
Maravich Coliseum
170
SURGE CONCEPTS
171
Standard of Care/Sufficiency of Care
Move out of circle as needed Move back as
quickly as possible
Sophisticated care done in hospitals Less
sophisticated care done in surge hospitals
Sufficiency of Care
Sufficiency of Care
Standard of Care
172
Standard of Care/Sufficiency of Care
Move out of circle as needed Move back as
quickly as possible
Sophisticated care done in hospitals Less
sophisticated care done in surge hospitals
Standard of Care
173
The interface of standard of care and sufficiency
of care
Graceful Degradation of Care
GOLD STANDARD
Care Standards
???
Plan B Operations
Demand
MORAL IMPERATIVE
174
Maravich Coliseum
Lab
Pharmacy
SIC U
MIC U
Dialysis
Wards
Surgical Ward
Peds
Isolation
Red to Yellow level patients
Registration
Entrance
175
Maravich Coliseum
Red to Yellow level patients
176
Maravich Coliseum
Red to Yellow level patients
177
Maravich Coliseum
Red to Yellow level patients
178
Surge
  • Surge in place
  • Austin

  • Surge into building of opportunity
  • Earl K. Long Facility
  • PMac
  • Field House
  • K Mart
  • Surge into preplanned building of opportunity
  • Vet School

179
Surge into Buildings of
opportunity Carl Maddox Field House
180
Field House (Special Needs)
Yellow to Green Level Patients
181
SURGE CONCEPTS
182
Standard of Care/Sufficiency of Care
Move out of circle as needed Move back as
quickly as possible
Sophisticated care done in hospitals Less
sophisticated care done in surge hospitals
Sufficiency of Care
Sufficiency of Care
Standard of Care
183
The interface of standard of care and sufficiency
of care
Graceful Degradation of Care
GOLD STANDARD
Care Standards
???
Plan B Operations
Demand
MORAL IMPERATIVE
184
Field House (Special Needs)
Yellow to Green Level Patients
185
Field House (Special Needs)
Yellow to Green Level Patients
186
Field House (Special Needs)
Yellow to Green Level Patients
187
Field House (Special Needs)
Yellow to Green Level Patients
188
Surge
  • Surge in place
  • Austin

  • Surge into building of opportunity
  • Earl K. Long Facility
  • PMac
  • Field House
  • K Mart
  • Surge into preplanned building of opportunity
  • Vet School

189
Surge into Buildings of
opportunity Vacant Building (Formerly
Kmart)
190
Surge Hospital/ Facility
Definition A facility that can be used to
provide sufficient medical care when a primary
medical facility is -destroyed
-contaminated and thus denied -overwhelmed
191
Hospital Requirements
  • Space
  • Ingenuity
  • Nice to have
  • AC
  • Power
  • Gases
  • Back up power

192
Empty Building (formerly Kmart)
  • No Power
  • No AC
  • Filthy

104,992 sq. ft.
193
Vacant Building Set Up
DECON
194
Vacant Building Set Up
DECON
195
Vacant Building Set Up
DECON
196
Vacant Building Set Up
DECON
197
Vacant Building Set Up
DECON
198
Vacant Building Set Up
DECON
199
Lessons Learned - Katrina
  • Start training
  • Volunteerism
  • Tabletops
  • Shorten mother may I loop
  • Senior mentors/strike force
  • Medical mosaic
  • Graceful degradation of care
  • Buildings of opportunities/surge hospital
  • Validate DLS family of courses
  • Communications must be fixed
  • Security is critical

200
Lessons Learned P.K.
Carlton, Jr., M.D.
  • 9. Validate DLS family of courses
  • 10. Communications must be fixed
  • 11. Security is critical
  • 12. Dialysis patients
  • 13. Pre-planning is critical
  • 14. Flexibility is key to every disaster
    response!
  • 15. Veterinary community
  • 16. Standards
  • Chain of Command Clear
  • Training - invaluable
  • Volunteerism
  • Tabletops
  • mother may I loop was proactive and extremely
    well done
  • Medical mosaic
  • Graceful degradation of care
  • Buildings of opportunities/surge hospital

I was on the way to debrief this slide in Baton
Rouge---then I received the telephone call!
201
Hurricane Rita
202
Worst Nightmare
Evacuated special needs population out of major
metropolitan area Galveston/ Houston
Lose whole local health care network!
Rita
203
Medical Victory Due to
  • Ingenuity
  • Dedication to patient care
  • Volunteerism
  • Good planning!
  • Rapid federal response
  • Unbelievable Vet School attitude

204
Lessons Learned - Rita
  • Chain of Command Clear
  • Training - invaluable
  • Volunteerism
  • Tabletops
  • mother may I loop was proactive and extremely
    well done
  • Medical mosaic
  • Graceful degradation of care
  • Buildings of opportunities/surge hospital
  • Validate DLS family of courses
  • Communications must be fixed
  • Security is critical
  • Dialysis patients
  • Pre-planning is critical
  • Flexibility is key to every disaster response!
  • Veterinary community
  • Standards

205
Good
  • Transportation evacuation early and reasonably
    orderly
  • Communication for medical capability
  • Surge
  • Regional and national plan
  • Thinking about this for long term
  • Exercises for last 4 years
  • Attitude
  • MOC up and functional early
  • Home of National Disaster Life Support (NDLS)
    consortium so well educated
  • Had a plan and executed plan

206
Bad
  • Transportation hung up with numbers so patients
    arrived without staff
  • Deaths
  • Overwhelming number
  • Highway congestion

207
Ugly
  • Bus fire

208
Worst Nightmare
Evacuated special needs population out of major
metropolitan area Galveston/ Houston
Lose whole local health care network!
Rita
209
SURGE CONCEPTS
210
Surge Hospital/ Facility
Definition A facility that can be used to
provide sufficient medical care when a primary
medical facility is -destroyed
-contaminated denied -overwhelmed
211
Surge Facility
212
Texas AM University College of Veterinary
Medicine Surge
Hospital
Model for the State
213
Surge
  • Surge in place
  • Austin

  • Surge into building of opportunity
  • Earl K. Long Facility
  • PMac
  • Field House
  • K Mart
  • Surge into preplanned building of opportunity
  • Vet School

214
The Concept
215
Begin with the end in mind
FINISH
216
Potential
  • Mortuary reception area for thousands

    -Forensic issue
  • Surge reception area
    -local
    events
    -over flow
    from State for current sick people
    to offload medical facilities who are
    primary receivers
  • Headquarters for Texas Medical Rangers training
  • Equipment

    -700 bed
    -Storage
    facility for
    -Vents, OR
    supplies, etc
  • Model for every College of Veterinary Medicine in
    the Nation
  • Answers some of national surge concerns

217
Surge Hospital
700 beds 24-32 ORs 64 ICU beds Full Decon Full
Mortuary Ready accessible to most vulnerable
sites in area
218
Total
Triage 100 patients Hallway
260 patients ICU 32-
45 Beds
(30-45 plumbed) PACU/ICU
32 beds-16 rooms (2 per) Surgical Ward 36
Beds Peds unit 250 patients
Total 710
219
Increments
1st 700 bed easily into Large Animal Hospital
This is the subject of the presentation
today 2nd 700 bed easily into Large Animal
Hospital 3rd 700 bed into Small Animal
Facility 4th 700 bed into Small Animal Facility
220
Way Ahead
  • Present concept to Dean and Executive Committee
    of Vet School 1 Sept and 5 Sept approved
  • Present concept to Emergency Management Planner
    approved 5 Sept
  • Present concept to local health care facilities
    20 Sept
  • Approve plan Texas AM University
  • Seek funding Texas AM System, Board of
    Regents, State
  • Present to State
  • Could be up to 2,800 beds!

221
From Concept to Reality 20 Sept 2005
222
Built of Units of Capabilities
223
Surge Hospital
224
Chain of Command
State Government
Texas AM
Gates
Dickey
Health Commissioner
Presidents
College of Veterinary Medicine
College of Medicine
County Health Officer
Colleges
Adams
Colenda
EPR Coordinator (Mike
Paulus)
Deans
Carlton Moyer
Medical Director (PK Carlton)
Directors
Volunteers
PHS
225
FLOW
Concept of Flow for a Health Care Facility How
to optimize your facility for casualty management!
226
Large Animal Facility Surge Flow
Registration
North
250 Beds
250 Beds
Large animal hospital
227
Large Animal Facility
Shriners/100
1
North
Wednesday night/Thursday morning
Large animal hospital
228
(No Transcript)
229
(No Transcript)
230
Large Animal Facility
Shriners/100
1
2
Special People
North
Wednesday night/Thursday morning
Large animal hospital
231
(No Transcript)
232
Large Animal Facility
Shriners/100
Special People
North
Thursday morning/Thursday afternoon-set up in
hours
1st 250 bed package
3
Large animal hospital
233
(No Transcript)
234
Large Animal Facility
Shriners/100
Special People
North
Friday morning/Friday afternoon- set up in hours
4
1st 250 bed package
2nd 250 bed package
Large animal hospital
235
CDC Push Pack
Days to set up Veterinary College did it in
hours! First deployment of equipment
236
(No Transcript)
237
(No Transcript)
238
CDC/PHS Arrival The Cavalry!
Full time staff
239
(No Transcript)
240
A Perfect Fit!
Uniformed Personnel plus Volunteers A
perfect fit!
241
Arrival of Patients
242
Patients Area
243
Patients Area
244
Patients Area
245
Patients Area
246
Large Animal Facility
Shriners/100
1
North
Wednesday night/Thursday morning
Large animal hospital
247
Patients Area
248
Patients Area
249
Large Animal Facility
Shriners/100
1
2
Special People
North
Wednesday night/Thursday morning
Large animal hospital
250
Patients Area
251
Patients Area
252
Patients Area
253
Patients Area
254
Patients Area
255
Patients Area
256
Patients Area
257
Patients Area
258
SURGE CONCEPTS
259
Standard of Care/Sufficiency of Care
Move out of circle as needed Move back as
quickly as possible
Sophisticated care done in hospitals Less
sophisticated care done in surge hospitals
Sufficiency of Care
Sufficiency of Care
Standard of Care
260
The interface of standard of care and sufficiency
of care
Graceful Degradation of Care
GOLD STANDARD
Care Standards
???
Plan B Operations
Demand
MORAL IMPERATIVE
261
Good
  • Transportation evacuation early and reasonably
    orderly
  • Communication for medical capability
  • Surge
  • Regional and national plan
  • Thinking about this for long term
  • Exercises for last 4 years
  • Attitude
  • MOC up and functional early
  • Home of National Disaster Life Support (NDLS)
    consortium so well educated
  • Had a plan and executed plan

262
Bad
  • Transportation
  • Deaths
  • Overwhelming numbers

263
Overwhelming Numbers
  • Actual numbers of special needs patients must be
    obtained
  • It is larger than we expected

264
Nursing Home
265
Ugly
  • Bus fatalities

266
UGLY Bus fires kills 20
Source Dallas Morning News 24
September 05
267
Lessons Learned P.K.
Carlton, Jr., M.D.
  • 9. Validate DLS family of courses
  • 10. Communications must be fixed
  • 11. Security is critical
  • 12. Dialysis patients
  • 13. Pre-planning is critical
  • 14. Flexibility is key to every disaster
    response!
  • 15. Veterinary community
  • 16. Standards
  • Chain of Command Clear
  • Training - invaluable
  • Volunteerism
  • Tabletops
  • mother may I loop was proactive and extremely
    well done
  • Medical mosaic
  • Graceful degradation of care
  • Buildings of opportunities/surge hospital

268
Chain of Command
State Government
Texas AM
269
CDC 22 Sept
We are here to help! What do you need?
270
Lessons Learned P.K.
Carlton, Jr., M.D.
  • 9. Validate DLS family of courses
  • 10. Communications must be fixed
  • 11. Security is critical
  • 12. Dialysis patients
  • 13. Pre-planning is critical
  • 14. Flexibility is key to every disaster
    response!
  • 15. Veterinary community
  • 16. Standards
  • Chain of Command Clear
  • Training - invaluable
  • Volunteerism
  • Tabletops
  • mother may I loop was proactive and extremely
    well done
  • Medical mosaic
  • Graceful degradation of care
  • Buildings of opportunities/surge hospital

271
Training
  • Full menu of courses must be available to train
    on these scenarios
  • Available today include the Disaster Life Support
    Family of Courses
  • Their importance was demonstrated clearly here in
    this disaster!

272
Disaster Life Support
  • Product of
  • University of Georgia
  • Louisiana State University
  • University of Texas Southwest
  • University of Texas Scott Lillibridge

273
Education Training Cardiac Life
Support
Education
In Hospital Care
ACLS
More Advanced
More Specialized
Pre-hospital life support
CPR
Training
274
Education Training
Advanced Trauma Life Support ATLS
Education
In Hospital Care
ATLS
More Advanced
More Specialized
PHTLS
First Aid
Training
275
Disaster Life Support Courses
Education
Instructor
Advanced
Basic
More Advanced
More Specialized
Core
Introduction
Training
276
Education Training
Our job is to fill in the Educational pyramid!
Our job fill in the blanks for this menu
Education
?
400
?
Advanced Disaster Life Support Course
?
300
More Advanced
More Specialized
Basic Disaster Life Support Course
?
?
?
200
Core Disaster Life
Complex Disasters
PHLS
CPR
100
Training
277
Education Training Disaster Life Support
FCC
Response to Radiological Terrorism
Hospital DLS
Education
More Specialized
Basic Disaster Life Support Course
Who will review? Who will certify? Who will
teach? What is the reward?
Mayo course
FDM
DIMO
Core Disaster Life Support Course
Harvard Course
Hopkins Course
CERT
Training
278
Disaster Life Support
A Advanced Life Support 2 day
First Receivers B Basic Life Support 8 hours
First Responders C Core 4 hours
Community/First
Preparers D Intro hour
Community awareness AMA
meeting December 2003 1st full course
New Product modeled after ACLS/ATLS
279
DLS Family of Courses
  • Disaster Life Support courses should be added to
    Veterinary Colleges curriculum
  • Study side by side with College of Medicine
    students
  • Set standard for Nation

280
Surge Discussion
281
Begin with the end in mind
FINISH
282
Criteria for Surge Hospital
283
Surge Hospitals
Hospitals become ICU other buildings become wards
284
Goal Solid Structure Addressing ALL Areas
Our House
  • People
  • Equipment
  • Training
  • Organization

E
O
Heretical Thinking!
ALL HAZARD ENVIRONMENT
285
The interface of standard of care and sufficiency
of care
Graceful Degrada
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