Drill Scenario by State of California Emergency Medical Services Authority

1
Drill Scenario byState of California Emergency
Medical Services Authority

• Amy Kaji, MD, MPH
• November 16th, 2005
• Acute Care College
• Medical Student Seminar

2
Background Scenario

• Politician to speak on controversial topic at a
  large public forum
• Nationally televised
• Pre-allocated resources
• First aid stations and onsite ALS and BLS
  ambulances
• Security and traffic control personnel
• Designated media area
• Shuttle buses
• On/off site parking areas with attendants
• 730 a.m. Opening commentary
• 800 a.m. Speech to begin

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800 a.m. The Exercise Begins

• Patients and hospital staff watch TV commentary
• 800 a.m. Speaker introduced
• As speaker reaches podium, explosion occurs
• Mass hysteria and panic ensue
• Number of casualties unknown
• ED anticipates arrival of victims
• Cellular and landline 9-1-1 calls begin flooding
  local dispatch centers

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Considerations and Decisions

• Should you consider implementing security
  measures at your facility?
• What are the triggers that implement HEICS in
  your facility?
• When, and who activates the high-census (surge)
  plan to free up or add patient beds to
  accommodate the anticipated influx of patients?

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802 a.m.

• At 802 a.m., a second explosion occurs in one of
  the on-site medical aid stations
• News reports estimate numerous casualties
• Hospital staff watch in horror

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Considerations and Decisions

• Does the hospital have an emergency call-back
  procedure to increase ED and essential hospital
  staff?
• Does the hospital have a security of lockdown
  procedure to protect the hospital and staff?
• Will your hospital activate HEICS now?

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804 a.m.

• 804 a.m. A third explosion on a main
  thoroughfare to the event detonates
• Staff exhibits signs of distress at possibility
  of loved ones being casualties of event

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Considerations and Decisions

• How does your hospital deal with staff concerns
  at the possibility of family members being
  casualties of the event?
• How does the hospital allocate scarce resources
  when confronted by this potential mass casualty
  incident?
• How does the hospital procure additional
  resources?
• Additional staffing
• Blood, trauma, and burn supplies
• Body bags and morgue refrigeration units
• Inpatient beds, ED beds, OR beds

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810 a.m.

• 810 a.m. Law enforcement establishes secure
  perimeter around the auditorium
• Residents living within perimeter evacuated
• Fire and EMS crews arrive at staging areas
  outside auditorium
• News reporters surround area
• FAA contacted to declare area a no-fly zone

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815 a.m.

• 815 a.m. - EMS establishes nearby off-site
  staging areas
• During the panic, fleeing victims mob offsite
  staging area and demand medical aid
• Immediate EMS resources overwhelmed
• Patients arrive at ED and clinics with blast
  injuries, in shock and panic

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Considerations and Decisions (for on-scene first
responders)

• Are evidence preservation protocols in place?
• Does ambulance agency dispatch a medical
  supervisor to large scale incidents?
• Are potential communication contingency plans in
  place?
• Have designated egress routes been identified?
• Does the ambulance provider have an in-field
  re-supply plan?
• Does the ambulance provider have chain of command
  procedures?

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Considerations and Decisions

• Clinics may be just opening for business
• Is the hospitals emergency plan in place for
  obtaining additional staff?
• Does your hospital have a credentialing procedure
  for convergent volunteers?

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820 a.m.

• 820 a.m. Local Department Operations Center
  (DOC) and Operational Area EOC are activated
• Landline and cellular circuits overloaded
• Your hospital activates back-up communications
  system
• High census plans activated and in-patients
  assessed for early discharge or transfer
• Elective surgeries and procedures cancelled
• Hospital is short staffed
• Plans to augment staff are activated
• Calk-back of staff
• Implementation of 12-16 hour shifts

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850 a.m.

• 850 a.m. - Local health officer declares local
  medical emergency based on large and increasing
  number of patients and need for additional
  resources
• ED and corresponding clinics are impacted
• Physicians order blood products for patients

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Considerations and Decisions

• How does the clinic communicate with the hospital
  to alert them of incoming patients?
• What resources does the clinic require until EMS
  arrives to transport patients to the acute care
  hospital?
• Does the clinic use the ICS?
• Do clinics have procedures for dealing with
  mental health concerns?
• Does the clinic have procedures for canceling
  scheduled appointments?
• Does the clinic have a protocol for notifying the
  blood supplier?

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855 a.m.

• 855 a.m. - Mayors office receives a call from
  the Universal Adversary (a known terrorist
  organization) claiming responsibility
• Media demands information at hospitals, clinics,
  and the local health department
• Press conference is scheduled for 1100 a.m.

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Considerations and Decisions

• What information should be presented to the
  public?
• Does you hospital have pre-scripted risk
  communication messages?
• What steps have been taken to ensure a consistent
  message among the healthcare community and levels
  of government?
• What community or government agencies will
  participate in the press conferences?
• Who will represent the hospital at the press
  conference?
• Where will the press conferences be convened, and
  who decides on the location?
• Who is the lead agency for the press
  conference?

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905 a.m.

• 905 a.m. - The Operational Area reports
  Statistics
• Numbers of patients with blast injuries
• Number of patients waiting to be seen
• Number of persons that may require
  hospitalization
• Available beds, operating rooms, emergency
  department beds
• Number of patients being seen at clinics
• Number of clinic patients awaiting transport to
  the hospitals
• Number of deceased, capacity for refrigeration
  units in morgues
• Anticipated need for blood products
• Communications with California Health Alert
  Network (CAHAN) is lost
• Hospitals, clinics, EMS, and Operational area EOC
  unable to place/receive calls
• Bomb squad with K-9s arrive

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Considerations and Decisions

• What other redundant communications systems
  exist?
• What agencies can be contacted to provide
  additional security for the hospitals?
• What community resources can be utilized to
  assist, including with mental health issues?
• How is your hospital addressing the mental health
  concerns of the staff and the public?

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1000 a.m.

• 1000 a.m. - Bomb squad clears venue of other
  IEDs
• Medical Operational Coordinator requests a status
  update from hospitals
• Bed availability
• Estimated numbers of patients
• Equipment status and anticipated needs

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1015 a.m.

• 1015 a.m. - Hospital nearly depletes blood
  products as well as trauma and burn supplies
• Clinics call local hospitals for supplies (IV
  tubing, bandaging supplies, burn sheets)
• Hospitals lack spare supplies and a means to
  transport supplies to clinics
• Vendors contacted to provide supplies and
  equipment
• Blood center advised of needs
• ICU is at capacity with no additional beds
• ED us holding ____ patients awaiting inpatient
  beds (insert appropriate number of ED patients to
  increase strain on resources), including ICU,
  telemetry, and medical-surgical

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Considerations and Decisions

• Is there a plan to ration resources?
• What mechanisms are available to procure the
  needed supplies and equipment, and what agency is
  contacted to provide those resources?
• What non-medical resources may be needed
  (sanitation, water, transportation, security)?
• What is the internal plan for maintaining
  security and containing the influx of patients?
• Are agreements in place to provide additional
  security?

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1015 a.m. continued

• 1015 a.m. continued Influx of patients
  continues
• Resources are overwhelmed
• Insufficient staff (all levels of healthcare
  providers)
• Lack of ED space
• Depleted patient care equipment and supplies
• Gurneys, oximeters, ventilators
• Medications and medical-surgical supplies

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Considerations and Decisions

• What procedure does the hospital have to expand
  treatment areas?
• What is the procedure for exempting the facility
  from DHS licensing and certification for nurse
  staffing ratios during this emergency?
• What additional areas within or outside the
  hospital can be used to provide patient care?
• What is your procedure for notifying DHS
  Licensing and Certification about using alternate
  care sites?
• Have patient tracking procedures been adequate?

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1015 a.m. continued

• 1015 a.m. continued
• ____ patients (insert number to stress the
  facility and coroner system) have died and await
  coroner to investigate and remove bodies
• Hospital must identify a secure area to hold
  bodies
• Law enforcement and FBI demand access to medical
  records and to interview victims and family

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Considerations and Decisions

• What are your hospital policies on interacting
  with law enforcement, evidence collection, and
  protecting patient privacy?
• Where will you stage law enforcement officials to
  allow for interviews but not congest patient care
  areas?
• What is the backup plan to store bodies when the
  morgue is not of adequate size?
• Are the bodies considered evidence?

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1030 a.m.

• 1030 a.m. Many patients will need weeks to
  months of supportive care before recovery
• Scarce resources will be long-term issues for the
  facility and community
• Hospitals, clinics, and EMS will need to
  construct contingency plans to address shortages
• Vendors will need to be contacted to provide
  additional supplies and equipment

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Considerations and Decisions

• What are the extended care implications for your
  hospital?
• What recovery and mitigation efforts can you take
  now to reduce the impact of this event?
• Have you integrated long-term care facilities
  into your disaster plans?
• Do the nearby ancillary care facilities
  coordinate with hospitals to accommodate a surge
  of long-term care patients in the community?

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1045 a.m.

• 1045 a.m. FBI states they have received a
  credible threat that an IED was placed in the
  hospital (optional participation)
• What are the procedures for notifying law
  enforcement?
• Who is in charge until law enforcement arrives?
• What is your policy regarding the use of radios
  and pagers while searching for an IED?
• What recovery and mitigation efforts can you take
  now to reduce the impact of this event, should an
  IED detonate?

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1100 a.m.

• 1100 a.m. - Influx of patients presenting to the
  ED continues
• Mayors press conference is held
• Cause of IED is attributed to Universal Adversary
  terrorist group
• Public is asked to report all suspicious packages
  and behavior
• Status reports from hospitals, clinics, EMS
  compiled
• Regional EOC begins to receive resource requests
  which are relayed to the State Operations Center

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1200 p.m.

• 1200 p.m.
• The Exercise Ends!

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Reference

• www.emsa.org. 2005 Statewide Medical and Health
  Disaster Exercise Guidebook (accessed September
  25, 2005).