Infection Control Today - 09/2003: BIOTERRORISM

BIOTERRORISM, TRIAGE SITUATIONS GET ICPS IN HIGH GEAR

By John Roark

How adequately a community manages a mass casualty eventdepends on the integration of the emergency medical services, includingfirefighters, police, ambulance services, medical personnel and hospitals.

Simply put, triage is the sorting ofpatients based on their medical needs. A standardized method of triaging in amass casualty situation, called Simple Triage and Rapid Treatment (START), wasdeveloped by the Hoag Hospital and the Newport Beach, Calif. Fire Department tobe used in the event of a multiple casualty incident (MCI). Many large citiesuse this system, which allows emergency medical technicians (EMTs) andparamedics to triage a patient at an MCI in 60 seconds or less.

The plan is based on three basic observations: assessment of the patient in terms of their airway, circulatory and neurologic status.¹

The triage team must evaluate and place the patients into oneof four categories:

• Deceased (BLACK): Victim is dead/no care required

• Immediate (RED): Immediate care/life threatening

• Delayed (YELLOW): Urgentcare/can delay up to one hour

• Minor (GREEN): Delayed care/can delay up tothree hours

One of the principals of triage is you need to be doing thegreatest good for the greatest number of victims with the least depletion ofresources, says Roy Alson, PhD, MD, associate professor of emergencymedicine, Wake Forest Baptist Medical Center. During a disaster situation youmay have patients who on a day-to-day basis could be saved in an emergencydepartment. But during disaster, because you have many more victims andperhaps fewer resources, you might not be able to work on that patient.

You might have to bypass them and go to somebody who has abetter chance of survival, or a better outcome. Thats a difficult thing formedical personnel to actually do. It runs contrary to our natural instinct.

Teamwork

Weve been proactive in preparation for disaster responsefor a number of years, says Linda Williams, assistant chief of medicine,North Little Rock Campus, Central Arkansas Veterans Healthcare System. Whenwe drill during an exercise, its very important that we talk aboutinteraction with the people who are going to be bringing the victims to us, andwhat they will have done in the field as well as how we will respond to them.

But being prepared goes well beyond ones own facility. Oneof the things that hospitals often do as they develop and test their disasterplan is they dont involve the local emergency management personnel, localfire, EMTs, and all the other players, says Alson. And they may not eveninvolve the other hospitals in the community! Thats kind of foolish, because we dont operate in avacuum. Everybody has to work together. I think that the steps are being taken. Theres definitely recognition that there is a problem. Theyremaking great strides. But we have a ways to go.

Chemical Attack

In the event of a chemical attack or accidental chemicalrelease, hospitals must have a knowledge of decontamination procedures. Ifyou have contaminated patients, be it biological or chemical, intentional or accidental, they have to bedecontaminated, says Alson. As a medical facility, you cannot afford toallow a contaminated patient inside the door, because then you lose thefacility, and you lose the ability to treat the other patients. Decontaminationhas got to be an integral part of any kind of hazardous materials event. Peoplehave to train for that. You also have the security issues at your facility. Theydo continue even in an accident, because you dont want someone whoscontaminated to run through looking for help and contaminate your wholehospital.

There are specific decontamination protocols when chemicalsare involved, says Williams. For instance, our EMRT team is trained torespond for the release of chemical warfare agents. In our training we alsolearn how to deal with radiation events, industrial chemical events andbiological events. The decontamination sequence can differ, the antidotes useddiffer, the type of response in the triage area vs. the hospital ER area aftertheyve been decontaminated differs depending on the agent thats involved.

You can adjust your decontamination approaches to what isused and how the patients are presented to you, continues Williams. Forinstance, receiving decontamination victims at a hospital would be vastlydifferent than what you would do if you were going to the site in the field. 80percent plus of contaminants can be removed by removing the clothing of thevictim.

In dealing with the contaminated patient scenario, one ofthe things the hospital has to consider is being able to lock down, so that allaccess is through controlled areas, says Alson. And thats verydifficult to do because its contrary to the image we want to project asmedical facilities. But I believe it is absolutely necessary to do that toprotect the functioning of the facility, or else you may very well lose theability to care for any other patient, he reasons. The key issue ofdecontamination precludes all that, again bearing in mind that in an attack,your facility could very well become a target. In combat situations today,medics no longer wear the red crosses like they used to during the first WorldWar, because it made them a target. Enemies quickly realized that if you shootthe medic, more people die. If Im a terrorist and I want to kill a lot ofpeople, I set off a device and then I also do something to prevent the hospitalsfrom treating them, and multiply my mortality.

The Worst Case Scenario

The ultimate worst case scenario would be if transportationwere disrupted and you could not get available medical supplies and personnel tothe victims, and you could not get the victims out from the area for medicaltreatment, theorizes Williams. In fact, I think thats what happened ona limited scale when the Twin Towers came down. You really could not get thevictims, even the healthy ones, out in time. When you have limited egress orlimited ability to enter an area, the victims are left without access to themedical resources that are available.

The worst case scenario would be when you have everythingin place to be able to deliver the care, and theres no way to deliver it, continues Williams. Thats the worst case for a provider to know what to do, to have what you need to do it, and be unable to provideit. In fact, that can be one of the most psychologically devastating events fora provider. Because this is kind of the scenario: What if you gave a disaster and nobody came?

Having a large number of casualties and not having thesupplies needed for a medical person is a horrible thing because you feelpowerless, says Alson. But I would also argue that thats only part of thatequation thats only looking at medical care. Things happen in disastersthat are beyond just medicine, that can have significant impact on healthcare.For example, drinking water. If you have contaminated water you can have thespread of disease. It doesnt have to be a bioweapon, it can be infectiousdiarrhea. So the public health aspects of it are just as key. To me, the worstcase scenario would be a disaster where Im unable to provide adequate water,shelter and food for the victims because of the event, which is potentiallygoing to put in jeopardy their health and well-being. Even though they may notbe patients now, they may potentially be.

Lessons Learned

The reality of terrorism was made real for Americans as theevents of September 11 unfolded. It was a tremendous wakeup call, saysAlson. The events of that day made the response to terrorism very personalfor most Americans. Before that it was something they watched on TV. As a resultof it I think we will see sustained support on the part of the public.

Since 9/11, many of the communities and hospitals have beenstimulated to go back and examine their plans, says Williams. Many have conducted extensive reviews of their resourcesand liaison agreements. Many have done drills and have refined their proceduresand protocols. There definitely is a heightened awareness.

Quite frankly, there are very few places in the world thatcould mobilize the assets and resources immediately available that the city ofNew York can put on, says Alson. Were talking about a city that has15,000 fire fighters, 30,000 police officers. The amount of response personnelthat they can mobilize is incredible. They had obviously learned some lessonsfrom the first attack on the World Trade Center and they started to put theminto place, but one of the things for us as a country is that we tend to be alittle short-term. Disaster planning got very high for all of us right after thefirst attack.

Then other issues became more pressing. Some of the thingsthat we had planned to do never happened. Thats not pointing fingers atanybody, its the reality of the world we work in.

The fact that in a very short period of time local assetswere mobilized and moved, surrounding agencies came in to back the cities up,there was a lot of inter-agency support, federal assets were quickly moved its a reflection of the fact that the system that we have does work, Alsoncontinues. Can we improve upon it? Yes. There are extensive reports that have made the analyses of thelessons learned from 9/11, and all of us are starting to improve on ourresponse.

Perspective

As we are focusing as a nation on response to terroristevents, we should not to lose sight of the fact that natural disasters,transportation accidents, chemical accidents happen every day, says Alson.Were actually more at risk in any one community from one of those than weare a terrorist event. Our training for the terrorist event, the principals weuse for planning and training command, triage and the like, apply just as wellto natural disaster. You can have the best terrorist response plan in the worldfor dealing with chemical or biological weapons, but if youre attaching it toa very poor community disaster plan for everything else, its not going towork. The keys to managing these events are planning in advance,training and that involves all the players training together and taking ateam approach and realistically evaluating what you have done so that youuse the exercise as a tool to assess: this has worked, this hasnt, we need toimprove this, we forgot about this, and so forth. Then adjust what youre doing and train again. It takestime, it takes money and it takes commitment. And the worst part is youredoing all of this hoping that you never have to do it for real. The biggestthing I can do is to urge everybody to train and plan, taking an approach of notIF it happens here, but when.