SCCM Resource Library-Disaster Management With Limited Resources

Video Transcription

Good morning, everybody. We want to thank you for joining us today for this session on disaster management with limited resources. I'm Marilyn Bullock.  I'll be one of your moderators along with Jeremy Pamplin today for this session. We have three exciting speakers. We're really interested in hearing what they have  to tell us, and we're going to start with Antonio. He's going to tell us that we can't be his guest.  Good morning. Thank you for being here. So you can't be our guest. We are all physicians, so we cannot say you can't be our guest, but there are some exceptions.  I have no disclosures. When we think about intensive care, we always think about having access to advanced medical resources. We have more than the rest of the hospital or even more  than the rest of the places, but what happens when that's not the normal thing? When we think about intensive care, we think about fancy machines.  We think about fancy places, but that's the reality of tier one, very advanced countries, and that's not the reality even for all the Europe countries.  So it's different than usual sometimes when we have limited resources, and we have other different realities when we have operational environments.  When we'll have high tech, we can have some evacuation, some support, or even telemedicine, but in low resources countries, we don't have anything. We don't have whom we can call.  We don't have telemedicine, and sometimes we don't have the basic as evacuation. We don't have other hospitals to evacuate, or we don't even have roads to do it.  So the limited resources, that's more the reality of it. This ICU in Mozambique is not a ward. It's not anything. It's an ICU.  That's the hand point of a major hospital in Mozambique, and Mozambique, it's a huge country in Africa, and that's what they have. Their beds like this, and we're speaking  about not having sheets, not having anything, and that's not, that's their working beds where they put patients and intensive care patients. Sometimes they have donations.  Everybody donates. Some countries like to donate. They give beds. As you can see, in the upper left corner, that's Angus. So sometimes they have stuff. They have hand point things.  ICP, for example, but the thing is, do they know how to work it? They don't have neurosurgery. Why should they even try to assess it? So they sometimes have beds,  but all you can see, there's no sheets. In some realities, it's the relatives that take the medicine to the hospital and take food because in reality, they don't have anything.  They just have the walls and sometimes some fancy beds, and they could have some serum, for example, but nothing else. They don't have monitors, or at least they don't know  when they have to work with the monitors. So there you go, some tech, as you can see, but see the distance between the beds.  See the cleaning of the thing, and sometimes we're speaking about basic things that they don't know how to do, and we're not speaking of normal words.  We're speaking intensive care medicine and basic things like washing hands. But when sometimes we offer fancy things and they have it,  they don't touch it because they don't want to ruin it. They don't have how to arrange it. They don't have, for example, other truquillas.  They don't have how to replace things when they're using it. So it's better for them not to use it, and they keep it closed and they don't touch it.  So intensive care, that depends a lot of many things. It depends on the place you are, the country you are, and the reality you are in. And when we think that we have problems,  the problems there, it's everything. Education, sometimes it's very basic. It's very important to have things, but if you don't know how to use it, you don't know how  to assess the patients, you don't know how to recognize when you have a problem. So we need to educate. Material, everything. Maintenance, I have a monitor that doesn't work.  I have a pump that stops working. I have a ventilator that got dirty, something. There's no way they are able to arrange it. There's no way they have money or the knowledge  to put things to work. And even drugs. When you have countries or hospitals that the only thing they have is paracetamol or aspirin,  it's possible to speak or tell them they have to ventilate or they have to give Raucoron or something. You can give them some samples,  but the thing is they don't have means to maintain the level of care or to have it working as a regular basis. So what to do? Of course we should donate, we should try to help,  but donate without education? Doesn't seem very correct. And donate without coordination. The thing is if everybody gives without speaking  between each other, probably you can be giving repeated things or things that they don't need. Sometimes we have excess in our hospitals and we try to send  to other countries or other hospitals, but who knows they need it or not. Perhaps they don't need a fancy monitor or a fancy ventilator  and they just need some, I don't know, antibiotics. But which antibiotics? The ones that are more correct for us? Doesn't mean they are the more correct to use in Africa  or in Asia or Latin American or other countries. Can it get worse? Yes, it can. Imagine in Mozambique we had the cyclone Idai. So if you had a low resources country,  after Idai you didn't have anything, for example. So the things they got, got destroyed. So that's the ice you wore. This water, because it was raining inside the world  because the roof flew. You can see this was the visit four or five days after the Idai, so it got like this. And as you can see, roof is off.  So when we are speaking about the response in these countries, it's completely different. Also, it's true that they are able to survive the same way.  Of course, the expectancy of life in those countries are around 40 years, half in a developed country as U.S. But the thing is, if this would happen in our countries,  probably the way that we would deal with it would be very different because we're not used to having nothing. And for them, it's almost just another day. We just don't have roof.  But we didn't have much more than that. So it's almost business as usual. And it's the main hospital in Beira. That's a huge city. That's the main hospital in that region.  And it was like that. And they, two or three days after, started working and doing as, what they could as possible. So, different realities. Any questions?  No questions, go ahead. We're, thank you, Antonio. We're also going to save time at the end for questions as a whole. Our next speaker will be Chet, and he's going to talk to us  about there's a, it's a small world, and there's no way out. Thank you, Marilyn. Just for everybody, I'm Chet Morrison. Currently, I'm an Associate Professor  of Pharmacritical Care at Central Michigan University. But for a long time, I was an Army surgeon. I kind of missed my military days, as a matter of fact.  And so, perhaps because of this, some of this talk is going to have a bit of a military bias. But I'm sure you all mind that. And as Marilyn pointed out, it is a small world,  and there is no way out. And sometimes the water is rising, and the blizzard conditions are out there. And so, what I hope you all will get from this talk is  that there are things you can do. And that we don't panic. And that these situations happen. But again, there are things that can be done to handle it.  Here's where the world gets small. Again, with my title, military deployments. Military is very often fighting in hostile terrain, in battlefields that now are not static.  They stretch across hundreds of miles. And so, it brings up the problem of not just evacuating casualties. But you also have the problem of providing care to them  as far forward as possible. Which is something that we've been refining for, gosh, at least the past 20 years. And we continue to get better at it.  Nastral disasters have been mentioned. Those are all obviously prominent in our minds. And also, and you know, as an Army guy, I will do a hat tip to the Air Force.  We do have aircraft. Which is great. But the patients need to be taking care of them, as we'll see. When you are taking care of patients  and providing critical care in a austere environment, there's really three things to think about conceptually what you have to do. Incoming, which sometimes you have  to actually actively triage. And I'll say a few words about that at the end. The care principles of what you actually do when your patients are there.  And also, of course, foremost in everybody's minds, when they're in a small unit and they have a lot of patients, is getting them out. And getting them to upper echelons of care.  And this is where you have to leverage your evacuation capabilities. The framework can be thought of in this way. Here's a conventional. You can see this.  Here's a conventional way we think of intensive care units. I don't think I need to summarize the slide. But this is normal business. We have enough supplies.  We have enough staffing. We can actually expand to 20%. So if there's a run of patients, or we have like a modern motor vehicle accident, generally there's a 20% capacity.  Units usually have, and hospitals by now have contingency plans that, here's the point I want to focus, can expand in a goal of about 100%.  Okay? And that's when you have some things like train wrecks, minor disasters, things of that nature. And there's also, they tap on regional and state resources.  What sometimes happens, however, and these are fortunately rare, we have crisis situations where you have nontraditional areas. You have a lacking of supplies.  This is where you need to do your triage. And it would wish you are going to be drawing on natural resources, but they may take a long time to get there.  And the units are encouraged to have a goal of capacity of 200%. And that's what's going to be needed. That's our framework. Remember this picture? Remember what that is?  Let that sink in a minute. That's Hurricane Katrina, of course. These were the staff at the roof of the charity hospital where they were actually reduced to saying this.  And what was notable in here is this was a, in a sense, not just unplanned for situation of austere critical care. But this actually took some time to develop because the hurricane  that hit was a Category 3. It blew over. Things worked. The cell phone batteries were charged. And they, well, yeah, we'll just recover from this.  Except the water kept on rising, and the generators started going out, and the communications started going down. And so what was described here was actually a four  to five-day period where you had steadily diminishing supplies in which you had to contend with doing procedures sometimes in the dark.  Some of our medical brethren there had to handbag patients. But they did, and their survival rate was actually quite impressive.  And the other thing was there was a lack of communication, which wasn't very clear for the people working in the hospital that decisions were eventually being done  and help was eventually on its way. Plus the fact that there was civil unrest and breakdown of order. People had come to the hospital just to shelter from the storm and so forth.  And so this actually led to the guidelines being developed of not only what you do for patients, but also how you evacuate intensive care units. Fortunately, the triage that had  to be done on there was relatively rare. This, of course, is the interior of a C-17 plane. This has its own unique critical care challenges,  because although the planes work very well, they fly fast, and this particular aircraft can actually land on undeveloped airfields. But still, it's noisy like any other plane.  There's cabin depressurization. If you just think about it, you know, how much fun is it to fly an economy class when you're not hurt for eight hours?  Right? So think about the pain control that you would have to do. And we encourage pain control pleural catheters and frequent use of pain control measures in this.  One of the things that is notable is this one developed from experience. Conceptually put it this way, you're flying a patient. This actually happened in Bosnia.  Someone who has a severe electrical injury and polytrauma, and you're on a plane, you're flying him to regional Landstuhl, I think it was. You're in the air.  You're several hours out, and he goes into septic shock. Problem. However, you apply the principles of sepsis resuscitation to him. He gets fluid. He gets antibiotics.  His airway is secured, and he gets mechanical ventilation. And they actually said he got landed in better shape than when he took off. So with these principles,  you can actually make an improvement. And obviously, the patient survived. And this got the Air Force to thinking about, well, if it works for one isolated incident,  and there had been others, then we can make it work for the large number of patients that this is going to entail. A couple last anecdotes. This is ancient Babylon.  This was my stomping grounds back in 2004 when I was in the Iraq conflict. We had a tent, and we would get casualties such as this.  Now, the thing with here is besides the care that we have to do, the surgery, the debridement, and all this, how do we monitor a patient like this?  Well, I submit that in these austere surroundings, you not only have your stethoscope, you have your, you know, your wits about you, but remember,  you have things like just perfusion. You can monitor their extremity perfusion. You monitor their blood pressure. You monitor their color.  And in this context, though I don't reference it on the slide, we all remember the Andromeda shock trial that came out last year, which basically they got equivalent results  by the expedient depressing a glass slide on someone's index finger and seeing how long capillary refill took. Okay? Whoa, it wasn't any better than lactate.  Great. This is something that's very useful in austere settings. And this, of course, is a picture of something that happened to my armory buddy, Joseph DuBose,  when he was stationed out in the Middle East. Basically, a helicopter crash happened. There were survivors. There were seven of them, and they were promptly airlifted  to his joint surgical team. One, unfortunately, was declared dead on the staging area. Six were airlifted, and here's the impressive part about this.  Actually, there was a lot impressive. But in the interest of time, I'll say a couple things. One is one patient actually had a thoracotomy, a long flight  in which he got open cardiac massage, vessel clamping, and he lived. And the second thing that was notable about it is that if you look at the patients who were there,  they're getting WFWB. That's walking fresh whole blood. They took 55 units off of the crew members of that ship. And it was actually the whole blood that saved their lives.  In fact, it was actually used to treat acidosis. One patient, the one who had the thoracotomy, naturally was profoundly acidotic. He improved with whole blood.  This is obviously a pitch for whole blood, but it also tells you that with some planning, again, they survived, and it tells you with some planning  with whole blood, and with basically keeping your wits about you, there are things you can do. Similarly, when you're in a rather cold spot of the world, this is Antarctica,  in which evacuation is going to travel thousands of miles, and you think, well, who on earth would come to Antarctica? Well, actually, cruise ships come to Antarctica,  and they come more, and in fact, while researching this talk, I sort of looked up the trivia point of what's the southernmost city in the world.  It's actually in Tierra del Fuego, Argentina, and it's where the cruise ships sail out of. There's not much there, but it is where the cruise ships sail out of.  And once again, you think about the evacuation that has to happen, and the coordination. But again, it's basic principles, and one of the other things is, of course,  don't expose your fellow team members to austere environmental conditions, and you also have to think of the dangers. Because one of the other things  that happened here is a head injury that was minor, but could have been major, which faced the medic, again, one of my former military friends, with the decision  of do you evacuate him here, or do you evacuate him, excuse me, over a long period of time, because of something that might happen?  But if you guess wrong, it's going to be very long. Personally, my recommendation is you play the odds. If you think the odds are that this is not going  to require intervention, I think you're very justified in playing it, particularly because you don't want to expose other people to the hazards of evacuation.  One last little anecdote. This is midway at all, and it brings up a point I really wanted to mention, which is that when you are doing critical care in austere situations,  it may not just be battle casualties, or hurricane casualties, or pandemics. You also get people with underlying medical diseases  that come here, and this happened with one of my colleagues who was treating someone with cirrhosis, a lot of ascites, who normally took diuretics,  but they didn't have spironolactone. They had Lasix. So what they did is they gave him Lasix, and he had to climb up the coconut trees, because coconut water, it turns out,  is a source of potassium. And I'll spare you the video, but he sent me one of him fashioning a rope harness, and shimmying up the coconut tree, and getting the footer,  and coming back down. It worked. The patient had a significant improvement in his ascites, and was treated that way. And again, it kind of brings up the principle  that you use your resources that you have. Other examples have happened in Turkey, Armenia. You get the point. These things happen periodically,  and that's where basically intelligent planning, since we know they're going to happen, as well as personnel resources and training are very helpful.  And again, a way of thinking about this, notice that when you get your crisis, again, that 200% figure, that's when your standard of care starts to drop.  But in between that, there's a lot you can do. There's a lot of standard of care things. One thing I will leave you with, I really want you to get out of this talk, is that a lot  of this information is not only online, it's free. These are the joint trauma service guidelines that were created in these situations. Again, it's on the internet. It's available.  Jts.amid.army.mil, austere, and it's right there. In fact, in a way, anyone can give this talk. Just go online and read the guidelines, you know.  And basically, with limited resources and staffing, you have to kind of plan ahead what you're going to do. And one of the things is rapid triage, initial resuscitation  with blood products, control of hemorrhage. This is nothing fancy. You're getting them bleeding stopped. And this brings up the other point that's very,  very helpful in any austere situation, is ultrasound. I personally, every time I go there, I get some manufacturer who's shrinking ultrasound probes  and it attaches to an iPhone or an iPad or anything like that. And the quality of images gets better. So, ultrasound is very much something that can help you in this situation.  And in fact, it's actually in the guidelines. You don't need to put in central lines, okay. But everyone should know how to put in peripheral lines, IOs,  and then rapid infusion catheters are very helpful. They can be put in peripherally. And because they're wide, you can get an awful lot of volume in.  You don't have to put in central lines. And in fact, in these situations, it's probably better not to. Your walking blood bank I've mentioned. Again, there's guidelines for this.  And that's something that should be thought about. Whole blood works very well in these situations. And you have to give them a reliable system.  Because obviously, you want to transfer type-specific blood. You're not going to want transfusion reactions here. Damage control surgery is a part of it. It's all damage control.  You're not doing anything fancy. And notice the documentation here, which is not fancy, but understandable and requires no EMR.  And in fact, this is a picture from Hurricane Katrina, where the documentation was just paper written around, you know, putting in envelopes and just strung around the patients.  No EMR. Oh, well. We have pens and paper available to us. Anesthetic ones. Intravenous or intraosseous medication is preferred. Don't get tempted to give people intramuscular.  The absorption is unreliable. And it won't work. You're better off just giving them small doses of intravenous medication. Your goal is obviously to keep the casualty alive  and get adequate perfusion. And we mentioned, it doesn't take sophisticated monitors in this setting to monitor perfusion. Okay? It does take a clinician who's saying, hmm,  I think I want to make sure that my patient is adequately perfused. Maintain safety. You don't want your patients agitated and also stopping awareness.  Again, it's right on the guidelines. Equipment. You have your universal machines, and most units are deploying within, which can double as anesthesia machines and ventilators.  The ventilators usually are your rate-limiting step, because there's usually not a lot of them. And in fact, in disaster planning, that's often what disaster planners come down.  How many ventilators do we have? There are adjuncts, as I mentioned, and that can be very useful. And they've done elective surgeries on them.  Notice that in this case, and this was written up about the earthquake in Haiti, they used an austere cocktail of anesthesia. Just acetaminophen, dexbitamidine,  and succinylcholine worked. Because of this, you have to be very careful of the ventilators. This is basically right out of the guidelines for disaster management.  And the message I want to get out of this slide is you have to conserve, reuse when you absolutely have to, and when you get overwhelming patient resources,  your last, or overwhelming patients, your last step is reallocation. Oxygen you have to also be careful about. This is a good slide to point out that my Army buddy,  Steve Venticink and Kurt Grathwald wrote this all down in the critical care medicine supplement, and it's 12 years old. And you know what? That article does not date.  It's still very, very relevant here, because oxygen is always going to be a consideration. Ketamine has been very useful for pain control.  And in fact, just hot off the press, there's a meta-analysis that was done recently about just giving people ketamine, and they found that it worked very well.  Notice that these are in a lot of military conflicts, but there's no reason that they can't be applied to civilian areas as well, particularly since this is a medication  that has a very favorable hemodynamic profile. And of course, like medications, it's relatively portable. You may not have x-rays, but as I said,  you do have your ultrasound, and that's very important. And that also should be used liberally. And one of the things that I think people should learn is  using it for the abdomen and the chest. It's useful to use in the chest, and it's not always intuitive of what a pneumothorax looks like in ultrasound,  but it's a good point to have in your brain. And in fact, this has been written about in the aforementioned Haitian earthquake. When using ultrasound in a field hospital,  they felt it influenced care in 70%. Seventy percent of people, which I must say, looking at the data on fast, was a very refreshing change of pace.  There's a lot of people who denigrate fast as it doesn't influence care in a lot of people. Well, in a disaster setting, it does. Okay? Future crises, I don't need to dwell  on the Wuhan coronavirus, the SARS-2 coronavirus, as it's now officially called. And notice that it sort of sits in the middle of epidemics  between deadliness and spread, sort of right in the middle, which means that, you know, I sure hope we don't get any more boxes out here, but they could.  A few last bit of points about traumatic brain injury, and then I promise I'll wrap up. The lack of appropriate training and experience makes operative therapy more dangerous  than medical management. So unless you're a neurosurgeon or being coached by them, I would strongly recommend medical management for traumatic brain injury.  And you can actually do a lot of good that way. Because, you know, what's the two things that kill brain injured patients? Hypoxia and hypotension. Right? I know what to do.  I know what to do with those. Or at least I know interventions I can do. And I'm not a neurosurgeon, and I've never done some heroic, you know, burr hole drilling.  And frankly, I hope I never have to. There are infectious issues because it's a very dirty environment. Hand washing and basic antisepsis.  A high percentage of people will be infected. And hey, guess what? They come infected with nasty pathogens. Not the usual benign, you know, pan-sensitive staph and strep  that we get here in the United States. This is from another one of these mass casualty disasters. This was the tsunami that hit Southeast Asia in 2004. Some of the injuries.  And what was the point of this is that they all had a lot of very nasty pathogens. Acinetobacters and pseudomonads and all those dirt bugs  that actually, if you think about, kind of make a lot of sense with people who get exposed to dirty water and trauma. Few more basic principles.  And really, this is the point I would leave you with. That even in the austere situation, basic principles count. Basic vent management with head of bed elevation, oral care,  low tidal volume ventilation. You know, turn the tidal volume down. DVT prophylaxis, beta blockade, and tertiary surveys in which you're just reassessing patients.  You have your clinical skills with you. Manage your minds. Manage your team. Keep, you know, keep in the back of your mind that this is going  to be a traumatic experience for everybody. And that there's going to be a notable rate of PTSD. And get creative a little bit with the nutrition. People got to eat.  Last few words about triage, and I promise I'll wrap it up. Occasionally, there are people who you have to triage out. And these are the guidelines.  And generally, because these are people who have very low probability of survival. Basically, cardiac arrest, very high trauma injury severity  scores, and severe anoxic brain injuries. But as we said, these guidelines are a little bit fluid. And I get your attention back to Dr. DuBose's experience. They had six patients.  They had the capacity. They did something heroic, and it did work. So these are guidelines, but they're not absolutes. And of course, when the triage, and I put this slide in just  so that it's a dynamic process. You always reassess, and you always re-triage people. So these are my conclusions. Here's the takeaway, and I'll just leave you with this slide.  The preparation, make sure that your unit is prepared for the surge. If you're deploying, make sure that the equipment is there. Remain calm. Don't panic.  You know, the usual cliche about the Kipling poem, if you can keep your head while those about you are losing theirs, et cetera, et cetera, et cetera.  Clinical impression means a lot here. And basic principles of critical care, the basics never change. Basics are always the same. They're there for a reason.  Pull your personnel, and keep in mind that you always think transport. So coordinate with your Aravac, your people that will get them out of there, and make sure  that patients are prepared to go. And I think I will finish here. I do want to thank my colleagues at the East Military Committee who were very helpful in this, as well as my Army  buddies from my past life, my ex-Army buddies in my current life. And lastly, everybody who came here for your attention. Thank you, Chet.  I think many of us have unfortunately probably gone through some sort of mass casualty incident at our own practice. Or if you haven't, there's always the potential that you might.  And so with that, our last speaker, Laura Evans, is going to talk to us about maintaining preparedness at the national level.  Thanks.  Thanks, Marilyn. Thanks to SCCM for the opportunity to be here. I was asked to talk about maintaining preparedness at the national level, which I think  is sort of an interesting concept. Because I think you could have a very cogent argument as to whether we've actually achieved preparedness  at any national level, and are in the phase to maintain it. Or if we're really talking about arriving at a destination that we'll probably never get to,  but sort of continuously strive towards.  I don't have any financial conflicts of interest to disclose. I am part of a project that receives federal funding from the Assistant Secretary for Preparedness and Response  in CDC, called the National Ebola Training and Education Center, which is an effort geared towards facilitating health care and public health  preparedness for Ebola and other special pathogens. So for example, our novel coronavirus, COVID-19. I think the previous speakers have already covered this nicely.  These are just some photographic examples  from recent events within the last couple of years that many of our colleagues have been involved with in terms of preparedness and response to that, to events.  And I think we can expect these events to continue to rise in frequency, unfortunately. So there's clearly, this is data from The Economist,  but there's clearly a rise in the frequency of severe weather events. And I think many of us have experienced some of these.  Houston flooding recently, major hurricanes in the Caribbean. And I think we can expect those to continue in frequency. You can see the slope of this curve  is sort of rising nicely and continuously. This graph terminates in 2016. Similarly, the rise in frequency of human infectious disease outbreaks is climbing.  And this is different types of pathogens here. And I don't want to belabor the point, whether it's vector-borne or fungal or zoonoses. But I think we may be in the early stages  of the next major outbreak, depending on how the spread of COVID-19 moves from mainland China to the rest of the world. But we can expect that it's probably a matter of when  and not if we'll be in the throes of a major infectious disease outbreak. So as healthcare professionals and focused within the healthcare delivery system,  I think it's helpful to think about disasters in sort of two types of really three buckets. One is a sort of internal disaster. And you can think of that as something  that just affects your local healthcare delivery, so your ability to deliver care. And that could be something like power goes out and you're on backup power.  It could be a cyber attack and you lose, we're all I think sensitive to cyber crime and ransomware and whether you lose access to your medical records.  Or a fire that affects the operating room, so forth. So you can think about that as a confined scope, but it definitely affects your ability to deliver care within your facility.  You can also have external events that happen outside of your ability, where your ability, your infrastructure in your healthcare facility is preserved.  Your operating rooms are functional, your blood bank is functional, although you may be low on supply. So mass casualty incident flooding outside that.  Or commonly you may see mixed disasters that affect both the infrastructure ability of your healthcare delivery system, as well as the community around you.  And so one example of that would be pandemics. Because pandemics do affect our community. We're likely to have healthcare workers become infected,  not just through their work, but through the community. So you may have diminished staff availability in those settings. As well as natural disasters  that have both a combination of damage to the community, as well as damage to the facility. The example that Chet gave of Hurricane Katrina  is I think a really poignant example of that, where you're talking about a mixed disaster. It was a disaster both obviously in New Orleans as a whole,  but also within the individual healthcare systems there.  And so when we're thinking about these, our ability to prepare for disasters, we have to think about what type of event are we thinking about? And what are the different elements  that would go into being prepared for that? So Lee Bidison and Lewis Rubinson,  which I think many in the audience probably know, wrote a really lovely paper in 2011 that was published in Critical Care Medicine, sort of defining what preparedness looks like,  or what does it look like to be prepared. And I put air quotes around it on purpose. And they were specifically talking about ICUs, but I think you can generalize this  to other settings as well. So you have to understand what the hazards are. We can't prepare for everything, right? So you can't prepare for the zombie apocalypse,  because quite honestly, the zombie apocalypse probably isn't that likely to happen. But you should start thinking about what are the events that my community  and my institution and my ICU, or my emergency department are most at risk for? So you need to understand where your risk lies. And then after you understand where your risk lies,  potentially start thinking about what are your vulnerabilities to continuing to deliver care based on those risks. Use those steps then to start preparing  a written plan about what you would look like. Obviously, most written plans are gonna focus on the S's, right? Space, staff, stuff, or supplies.  You're gonna talk, as we heard about from chat already, something about allocations of resources under conditions of either relative or absolute scarcity.  Think about what you would do if you had to try to evacuate if that would be an option or not. And clearly thinking about how will you communicate with people?  And I would add as well that I think is an emerging area that we need to focus a lot more on is how will we get information in these settings to inform others of our response  and to help folks who may not yet be affected begin to prepare more accurately.  So for those, anybody in the room that does QI will recognize this. This looks a lot like any quality improvement cycle. You can substitute, you know, PDSA here if you wanted to.  But essentially, it's a quality improvement engagement where preparedness is one central component of emergency management, but it happens in a continuous cycle  of mitigating, preparing, responding, recovery, and using those processes iteratively to improve going forward.  So one example of a risk assessment, and this one is actually quite dated because I think the undertaking of doing this on a community level is quite extensive.  This is from New York City, and this is from the New York City Department of Public Health or Department of Health and Mental Hygiene from 2013.  And what they did was they did a comprehensive risk assessment of the New York City's risks. And then they plotted it by the likelihood of the event happening  versus the impact on New York City. And you can see where everything lies here. We have pandemic influenza, which would have a critical impact. And they put that probability in 2013  somewhere between a remote to occasional probability of occurrence.  An improvised explosive device had both sort of a mid-level impact and a mid-level probability. Flooding and coastal storm were both in the higher probabilities.  And I think this is a really good service to the community for a place like New York City to do to help us at the local level think about what we're most likely to face  and how we can begin to prepare for that.  You can also take this down to the facility level or the healthcare system level. And this is a tool that's freely available. It's a Kaiser tool for hazard vulnerability analysis.  And this is the example of one of the ones that we did as part of the New York City Public Hospital system, looking at what we thought our hospital-based risk was.  And again, it goes into the same concepts go into this. What's the probability of an event? And what's the impact? And the Kaiser tool breaks it down  by what the impact is on humans, property, business. And then it helps you prioritize what the risk is and how you would respond for that. So our hazard vulnerability analysis  in the New York City system, this is from a couple years ago now, had the three highest ones being explosion,  inclement weather, an infectious disease outbreak, and an IT system outage from that. And then we categorized them by first priority of risk score there.  So once you've sort of started with this concept of where do my risks lie, your best step in preparedness would be to try and fix those underlying risks, right?  It's not rocket science. So you would try and mitigate what those underlying risks might be. So if your institution says, we're at real vulnerability for flooding,  we live in a low-lying area, coastal storms are increasing in frequency, what can we do to mitigate the risk of flooding there? And whether that be flood barriers,  if you're in an earthquake zone, seismic retrofitting, and clearly even public health campaigns like influenza vaccination are a great mitigation strategy  to reduce the impact of an event on an organization.  Once you're, and again, this is all occurring as part of a continuous cycle, you're also going to prepare for the event beyond what you can mitigate from that.  And that's a continuous process of planning, organizing, training staff, making sure equipment is operational and present, exercising or testing our ability  to respond to simulated events,  using evaluation tools and basically writing improvement plans that we then follow up on to reduce our risk going forward. So you should be developing these plans  and then we need to test them. And so we need to test our capability through drills, simulations, and exercises. I wanna bring your attention to one effort  that's going on at the federal level. I'm not involved with this, but the Assistant Secretary for Preparedness and Response has funded four regional demonstration projects,  which I think is a great example of improving preparedness at the national level. So some of you may have heard of these regional disaster health response system pilot projects.  There are four of them. There are two adult focused projects and those are focused in the University of Nebraska and at Mass General Hospital and two pediatric projects,  one focused in Cincinnati and the other in San Francisco. And it's meant to bring together disparate types of resources because I think a lot of our preparedness efforts  typically happen in a more siloed fashion. So this is all about improving organization and coordination for a variety of threats.  So whether it be chemical, biologic, radiologic, nuclear, mass casualty incidents, trauma, you name it, it's trying to bring all these stakeholders and resources to the table  to think about how can we work better as a larger scale community to respond to an invention. So improving situational awareness as well, identifying and developing  highly specialized clinical capabilities. And this is particularly focused around things like burn or radiation exposure. I'm an increasing in the healthcare coalition model  to do that because the healthcare coalition does span the continuity of care. It's not just about the emergency department. It's not just about the ICU.  It's also about long-term care, nursing homes, so the entire healthcare delivery system writ large, which is all would be effective in a large scale event.  As part of our preparedness efforts, we also want to think, as I mentioned earlier, about what our research preparedness looks like. And there are a lot of ongoing efforts  to build our capacity for research infrastructure to ensure we learn from events. And I'm personally most familiar with the research capability infrastructure  building around preparedness for biologic events, but these are multinational efforts. So European Union has an effort. Australia has the APPRISE group, which you may be aware of.  And within the US, within the SCCM, we have Discovery Prep or the Resilience Intelligence Network, which was sort of founded and spearheaded by Dr. Perrin Cobb  with the NETEC, Special Pathogens Research Network, and the National Institute of Environmental Health is forming a disaster research response or DR2 planning project to ensure  that we are building the research infrastructure to be able to make sure that when an event happens, that we can learn as much as we can  and that we can disseminate that information effectively  and in a timely fashion. There's clearly, this needs to be part of preparedness efforts because once an event is happening, it's way too late to build a system to collect the data  from that and to report it and disseminate it in a timely fashion. I think the keys to all of this, and this is something we'll come back to,  is communication, collaboration, and coordination. And quite honestly, it does need funding.  Response, I think we heard from Antonio and from Chad already about some of the principles of response for mobilizing to an external or internal event.  We're using those plans that we made. The plans that we make are clearly going to be resource specific. So if I'm preparing in a highly resourced environment,  I'm preparing for a situation in a disaster where I become resource limited.  If I'm resource limited to start, like the example Antonio gave in Mozambique, my ability to plan for that surge capacity and implement crisis standards of care  is probably going to be limited because functionally I'm already operating in near that environment.  We're gonna use an incident command system, obviously, to respond to this, and then we're going to hopefully learn from this in a continuous and iterative process  and disseminate that data. Recovery is clearly the most protracted state of any event in that it's the hardest to return an affected area to its previous state,  and many places that have experienced events are still recovering. I think if you ask residents of New Orleans, where Katrina was in 2005,  I think they would say they are still recovering from that event.  And the recovery efforts sort of shift focus from immediate needs to rebuilding, to reemployment, to repairing an existing infrastructure and reopening of essential services.  And Chet mentioned earlier some of the mental health considerations that I think are a particularly prominent component of recovery. If we are preparing effectively,  if we engage in these processes, which do take time, they take effort, and they do take some diligence to paying attention to it,  and it's hard to do in a world of competing priorities. We all have immediate problems. And so it's hard to sort of sit down and find the time and find the engagement  for people to go down these sort of what if pathways. But the goal is if we do this and do it effectively, we will be in more resilient organizations.  And so we'll be more prepared to absorb and recover from and adapt to adverse events that functionally are inevitable. The scale may vary,  but we will all be in some sort of adverse event at some point in our professional careers. And this is a really nice document I would just carol your attention to  that it goes through many pages of that, but it defines some characteristics, much like Lee Bidison and Lou Rubinson define some characteristics of what prepared ICUs look like.  They define some characteristics of what resilient communities look like. And I think these will sound thematically similar to some of what we've covered.  So resilient communities have assessed risks and have a plan. They work together, they anticipate change, they have stakeholder engagement, they have clear goals.  And I think this probably the last bullet point probably should be up at the front when I remake this slide is to have leaders  who commit to improvement and accountability in a process.  If you take one thing home from this today, I hope you'll go back to your home institutions  and either do this yourself if you haven't done this or encourage the people that you work with to do this as well as to make a personal or family disaster plan from that.  We mentioned the zombie apocalypse earlier. If you actually Google CDC zombie apocalypse, it takes you to the personal disaster planning page on the CDC website from them.  But if you don't have a plan, we're less likely to be able to respond effectively. So I won't be able to concentrate on work, stay at work or really fulfill my job  if I'm worried about I don't have a plan for my kids or my family or my dogs, what would I do in those situations? And so there are some great tools out there  to help people develop a personal plan for what that would look like. So just to summarize, I think the keys to maintaining preparedness are very, very simple.  It's about communication, collaboration, coordination, building a plan, exercising or testing it and refining that plan. Put some resources up here on the next couple slides  right before I finish up that I think if you want more information are great places to start from that. The chest statement is terrific. There's a ESICM or European Society  of Intensive Care Medicine about pandemic planning, which is very useful. Some of the local or jurisdictional public health departments have done some terrific work around this.  Minnesota is a great example of that. WHO has resources and on the SCCM website, there's a great book, ebook that's called Preparing Your ICU for Disaster Response.  And with that, I'll stop and turn it back over to Marilyn. I want to thank each of our speakers. At this time, we have some time for questions from the audience.  We have one microphone that looks like over there. If anybody has a question, please feel free to approach the microphone. If not, I have a couple of questions.  But there is somebody. Okay, well, we're going to let the audience go first. It is. There could be lots of questions. This is a very good talk. Thank you very much.  My name is Debra Maka. I'm a PICU pharmacist here at Advent Health for Children. My question's for Antonio. It was very interesting of talking of the limited resources.  And here in this country, we tend to say, oh, we must help. Let's just randomly throw things at people. If we were trying to be the most helpful we can be,  are there some recommendations as general things that most areas would need to try to concentrate focus? Because you know people are going to try to help,  so you need to guide them in the best ways to do that. Thank you for the question. I think the most important is try to understand the needs of the place you're trying to help.  It's, I think it's of no interest to give things that people don't know how to work. Sometimes they just need some of our time to teach,  to have some education, and try to create education program, improvement program in those places. And then the things they know, the things they know how  to work with, to give them those things and establish someone there that you can speak to. We know in some of those countries, the corruption is very high.  It's normal to see trucks. If you give two trucks, one goes to the hospital, and the other one goes to somewhere else. So even that, I think there is a need, someone locally  that can coordinate things, and that doesn't steal that much. Because corruption is there, we won't stop it. So the thing is try to get the stuff we give  to the hospital to the right people. But assessing first through education, through knowledge, what to give. Beginning with education. Thank you. Can I add something?  Can I add something to that, too, if you don't mind, too? That's why I really emphasize integration with everybody as part of the team. Because if you're there rounding with us,  taking care of patients with us, you know what we need. Similarly, we have someone we can just turn to and say, you know, here in this situation,  what would you recommend, and how much of it do we have? You know, I mean, this crosses over to ordinary things here, too. I mean, I've taken care of patients whose kidneys got,  like, nicely, you know, sent to heaven because someone gave them vancomycin, and no one turned to the pharmacist or our other consultants and said, you know,  in this person who already has contrast AKI, perhaps we can do something else, give them something a little better. And they would have responded. You see what I mean?  With what I think was a preventable, you know, complication. So I can't resist emphasizing here about integration of everybody in the team.  And actually, you know, a point that I alluded to but didn't make explicit in my talk, but I'll make explicit now, is that it's the more you know  of everybody else's job on your team, the better. Because the more crosstalk you have and the more collaboration you get. Thank you very much. We have another question. Yeah.  Hi, I'm from Rochester. Thank you for a great talk. You talk a lot about, three of you talk a lot about preparedness from the national level,  from the organization level, professional level. Do you know any initiative from the patient side or community side? Because as you know, right now,  these days, everybody has cell phones. This is a really great channel, both ways. First, they can report some mechanism issues in the ground level, which you have not knowing.  Or the other way, actually, you can intervene some way, both ways. Do you know anybody where Amazon or Facebook has tried to get into space, really help engaging the public?  Because the reason I'm asking, because right now, I'm originally from China. I still have parents that live there. So right now, you know, a lot of millions of people  get quarantined, right? You know, each community have their own different guidelines to who is cooking in and out. Actually, there's a tech companies develop some QR code.  Eventually, have a blue, a red, a green, yellow, depends on your situation. But they get, like I said, like a pass, can add in and out for the community.  So it's kind of an innovation, because the large scale problem, you have to have some different solutions. Thank you. I'll let you take that one.  I'll take the first stab at that one, and then you guys can add in if you like. I think that's a terrific question. I don't know of private enterprise  that has engaged in that space, although there may be private enterprise engagement in that space. In the US side, there certainly has  been federal government engagement around that area. And so ASPR, for example, has run a series of workshops about recovery.  They have a huge group that works on community preparedness and engagement, and have involved all kinds of community organization groups, from either faith-based traditions  to other community groups, to exactly figure out what you're getting at, which is how to both receive information rapidly  from an affected community, how to process that information, and how to get good, high quality, accurate information back out to a community in a timely fashion  to facilitate, to mitigate the impacts in an event. But I think it's a great question about the private enterprise piece. Yeah, I would only add to that another anecdote  that I come up with. When they had the mass shooting at Las Vegas, most of the people who arrived to the three level traumas, the three trauma centers that were in Vegas,  there was a level one, there was a level two that actually got more patients than the level one, because it was closer, and there was a level three.  Most of them actually did not come in by ambulance. And there was no, oh, OK, this is EMS. We've got four people with gunshot wounds. No, they actually came in by private vehicle,  because it was very difficult for the ambulances to get in. But it was a very crowded place, so everybody started loading people onto cars, hailing taxis, hailing Ubers.  People were coming in the backs of the pickup trucks and everything like that. And so there was very little, so there wasn't really a lot of knowledge about how much was coming.  And I was struck by the fact that that's another frontier, that with a social network, you could at least get some of that information  and take whatever you can to prepare with that. Because when you hear it, they had no idea what was coming. It was really true. Wow.  Looks like we have another question from the audience. Hi, that's a great segue into my question, actually. So I come from the neuro world, so I'm not  coming from an emergency medicine or a military background. So I just wondered if you had recommendations for those of us without those backgrounds but that are in medicine to be  better prepared to handle a mass casualty incident,  like Las Vegas, for instance, when we're in the field or when they arrive to our hospital. Yeah. First of all, you need a plan. And parts of the plan, you know that what  happened in Las Vegas is what happens all the time. You have the less wounded normally that go walking and are the first getting to the hospital.  So parts of the mass casualty plan in your hospital must be triage. And you have to have a plan for the triage at the door of the hospital.  And you need another plan of triage at the door of your ICU. That will be different. For example, you have the example now of coronavirus. You have 5,000 persons that need ICU,  but you only have 500 ventilators. The level, the type of triage that you're going to do is a different one, even for ICU. So you need to get a plan, get the triage system working.  And that's the only way you can do it. Things will be different. The number of physicians for each patient will be different.  The number of nurses for each patient will be different. But put up a plan, and that's the only way. You cannot plan everything, but you  can plan for mass casualty, whatever it is, at least that. I would add to that. I teach ATLS, and that's actually a little part of our ATLS course as well.  Remember, we teach ATLS to everybody. And we teach it now to our APs, our advanced providers. We're teaching it to medical students. It's a language that everyone can do.  And one of the things that we teach is triage. And the principle is you triage people along the lines of ABC, just like you triage what to do on each individual trauma patient.  Do you know what I mean? And I think you use those principles, regardless whether it's a mass shooting, an earthquake, or something like that.  You're not going to be able to give neurosurgery in the field. But you can correct airway problems first. And you can oxygenate people so that they breathe OK.  And then you can do what you can for circulation and stop the bleed, which is really going to help them. So I would say ATLS is applied to triage principles  with a plan that my colleague said. And I think you might actually find yourself in the position where you can do a lot of good.  Well, everybody, we're going to have to conclude our talk today because there is another session after this. If you have any further questions for our speakers,  I invite you to continue the conversation outside the room here today. And thank you for attending. And have a wonderful rest of your Congress.

Video Summary

The session on disaster management with limited resources discussed the challenges of providing intensive care in low resource settings. Antonio highlighted the reality of limited resources in countries like Mozambique, where even basic necessities like sheets and monitors are lacking. He emphasized the importance of education and coordination in donation efforts, as well as the need for sustainable solutions, not just random donations. Chet discussed the concept of disasters as internal, external, or mixed, and stressed the need for preparedness at the national, organizational, and professional levels. He recommended a continuous cycle of mitigating risks, preparing plans, testing and refining those plans, and learning from events. Laura discussed the characteristics of resilient communities, including risk assessment, mitigation, planning, communication, and coordination. She also highlighted the importance of personal disaster planning and the need for engagement from private enterprises and patients. Overall, the session emphasized the importance of preparedness, education, coordination, and communication in effectively managing disasters and providing care in low resource settings.

Asset Subtitle

Crisis Management, 2020

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2020 Critical Care Congress held February 16-19, 2020, in Orlando, Florida, USA.

Learning Objectives

Describe the impact of insufficient surge capacity, staff and resource shortages, and other internal barriers on the delivery of critical care
Discuss patient care transport in a resource-limited setting following a natural or man-made disaster
Recognize barriers to patient transport and critical care in a resource-limited setting

You Can't Be Our Guest

Antonio J. Gandra D'Almeida

It Is a Very Small World and There Is No Way Out

Chet A. Morrison

Maintaining Preparedness on a National Level

Laura E. Evans

Meta Tag

Content Type Presentation

Knowledge Area Crisis Management

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Membership Level Professional

Membership Level Associate

Tag Resource Allocation

Tag Facilities Management

Year 2020

Keywords

disaster management

limited resources

intensive care

low resource settings

education

coordination

sustainable solutions

preparedness

resilient communities

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