drill scenario by state of california emergency medical services authority amy kaji, md, mph...

Drill Scenario byDrill Scenario byState of California State of California

Emergency Medical Services Emergency Medical Services

AuthorityAuthority Amy Kaji, MD, MPHAmy Kaji, MD, MPHNovember 16November 16thth, 2005, 2005Acute Care CollegeAcute Care College

Medical Student SeminarMedical Student Seminar

Background Scenario Background Scenario

• Politician to speak on controversial Politician to speak on controversial topic at a large public forumtopic at a large public forum– Nationally televisedNationally televised

• Pre-allocated resourcesPre-allocated resources– First aid stations and onsite ALS and BLS First aid stations and onsite ALS and BLS

ambulancesambulances– Security and traffic control personnelSecurity and traffic control personnel– Designated media areaDesignated media area– Shuttle busesShuttle buses– On/off site parking areas with attendantsOn/off site parking areas with attendants

• 7:30 a.m. Opening commentary7:30 a.m. Opening commentary• 8:00 a.m. Speech to begin 8:00 a.m. Speech to begin

8:00 a.m. The Exercise 8:00 a.m. The Exercise BeginsBegins

• Patients and hospital staff watch TV Patients and hospital staff watch TV commentarycommentary

• 8:00 a.m. – Speaker introduced8:00 a.m. – Speaker introduced• As speaker reaches podium, explosion As speaker reaches podium, explosion

occursoccurs• Mass hysteria and panic ensueMass hysteria and panic ensue• Number of casualties unknownNumber of casualties unknown• ED anticipates arrival of victimsED anticipates arrival of victims• Cellular and landline 9-1-1 calls begin Cellular and landline 9-1-1 calls begin

flooding local dispatch centers flooding local dispatch centers

Considerations and Considerations and DecisionsDecisions

• Should you consider Should you consider implementing security measures implementing security measures at your facility?at your facility?

• What are the triggers that What are the triggers that implement HEICS in your facility?implement HEICS in your facility?

• When, and who activates the high-When, and who activates the high-census (surge) plan to free up or census (surge) plan to free up or add patient beds to accommodate add patient beds to accommodate the anticipated influx of patients?the anticipated influx of patients?

8:02 a.m. 8:02 a.m.

• At 8:02 a.m., a second explosion At 8:02 a.m., a second explosion occurs in one of the on-site occurs in one of the on-site medical aid stationsmedical aid stations

• News reports estimate numerous News reports estimate numerous casualtiescasualties

• Hospital staff watch in horrorHospital staff watch in horror


• Does the hospital have an Does the hospital have an emergency call-back procedure to emergency call-back procedure to increase ED and essential hospital increase ED and essential hospital staff?staff?

• Does the hospital have a security Does the hospital have a security of lockdown procedure to protect of lockdown procedure to protect the hospital and staff?the hospital and staff?

• Will your hospital activate HEICS Will your hospital activate HEICS now? now?

8:04 a.m. 8:04 a.m.

• 8:04 a.m. – A third explosion on a 8:04 a.m. – A third explosion on a main thoroughfare to the event main thoroughfare to the event detonatesdetonates

• Staff exhibits signs of distress at Staff exhibits signs of distress at possibility of loved ones being possibility of loved ones being casualties of eventcasualties of event


• How does your hospital deal with staff How does your hospital deal with staff concerns at the possibility of family concerns at the possibility of family members being casualties of the event?members being casualties of the event?

• How does the hospital allocate scarce How does the hospital allocate scarce resources when confronted by this resources when confronted by this potential mass casualty incident?potential mass casualty incident?

• How does the hospital procure How does the hospital procure additional resources?additional resources?– Additional staffingAdditional staffing– Blood, trauma, and burn suppliesBlood, trauma, and burn supplies– Body bags and morgue refrigeration units Body bags and morgue refrigeration units – Inpatient beds, ED beds, OR bedsInpatient beds, ED beds, OR beds

8:10 a.m. 8:10 a.m.

• 8:10 a.m. – Law enforcement 8:10 a.m. – Law enforcement establishes secure perimeter around establishes secure perimeter around the auditoriumthe auditorium

• Residents living within perimeter Residents living within perimeter evacuatedevacuated

• Fire and EMS crews arrive at staging Fire and EMS crews arrive at staging areas outside auditoriumareas outside auditorium

• News reporters surround areaNews reporters surround area• FAA contacted to declare area a no-fly FAA contacted to declare area a no-fly

zonezone

8:15 a.m.8:15 a.m.

• 8:15 a.m. - EMS establishes nearby 8:15 a.m. - EMS establishes nearby off-site staging areas off-site staging areas

• During the panic, fleeing victims During the panic, fleeing victims mob offsite staging area and demand mob offsite staging area and demand medical aidmedical aid

• Immediate EMS resources Immediate EMS resources overwhelmedoverwhelmed

• Patients arrive at ED and clinics with Patients arrive at ED and clinics with blast injuries, in shock and panicblast injuries, in shock and panic

Considerations and Considerations and Decisions (for on-scene first Decisions (for on-scene first

responders)responders)• Are evidence preservation protocols in place?Are evidence preservation protocols in place?• Does ambulance agency dispatch a medical Does ambulance agency dispatch a medical

supervisor to large scale incidents?supervisor to large scale incidents?• Are potential communication contingency Are potential communication contingency

plans in place?plans in place?• Have designated egress routes been Have designated egress routes been

identified?identified?• Does the ambulance provider have an in-field Does the ambulance provider have an in-field

re-supply plan?re-supply plan?• Does the ambulance provider have chain of Does the ambulance provider have chain of

command procedures? command procedures?

Considerations and Considerations and Decisions Decisions

• Clinics may be just opening for Clinics may be just opening for business business

• Is the hospital’s emergency plan Is the hospital’s emergency plan in place for obtaining additional in place for obtaining additional staff?staff?

• Does your hospital have a Does your hospital have a credentialing procedure for credentialing procedure for convergent volunteers?convergent volunteers?

8:20 a.m. 8:20 a.m. • 8:20 a.m. – Local Department Operations 8:20 a.m. – Local Department Operations

Center (DOC) and Operational Area EOC are Center (DOC) and Operational Area EOC are activatedactivated

• Landline and cellular circuits overloadedLandline and cellular circuits overloaded• Your hospital activates back-up Your hospital activates back-up

communications system communications system • High census plans activated and in-patients High census plans activated and in-patients

assessed for early discharge or transferassessed for early discharge or transfer• Elective surgeries and procedures cancelled Elective surgeries and procedures cancelled • Hospital is short staffed Hospital is short staffed • Plans to augment staff are activated Plans to augment staff are activated

– Calk-back of staffCalk-back of staff– Implementation of 12-16 hour shiftsImplementation of 12-16 hour shifts

8:50 a.m. 8:50 a.m.

• 8:50 a.m. - Local health officer 8:50 a.m. - Local health officer declares local medical emergency declares local medical emergency based on large and increasing based on large and increasing number of patients and need for number of patients and need for additional resourcesadditional resources

• ED and corresponding clinics are ED and corresponding clinics are impactedimpacted

• Physicians order blood products Physicians order blood products for patientsfor patients


• How does the clinic communicate with the How does the clinic communicate with the hospital to alert them of incoming patients? hospital to alert them of incoming patients?

• What resources does the clinic require until What resources does the clinic require until EMS arrives to transport patients to the EMS arrives to transport patients to the acute care hospital? acute care hospital?

• Does the clinic use the ICS?Does the clinic use the ICS?• Do clinics have procedures for dealing with Do clinics have procedures for dealing with

mental health concerns?mental health concerns?• Does the clinic have procedures for Does the clinic have procedures for

canceling scheduled appointments?canceling scheduled appointments?• Does the clinic have a protocol for notifying Does the clinic have a protocol for notifying

the blood supplier? the blood supplier?

8:55 a.m. 8:55 a.m.

• 8:55 a.m. - Mayor’s office receives 8:55 a.m. - Mayor’s office receives a call from the Universal Adversary a call from the Universal Adversary (a known terrorist organization) (a known terrorist organization) claiming responsibility claiming responsibility

• Media demands information at Media demands information at hospitals, clinics, and the local hospitals, clinics, and the local health department health department

• Press conference is scheduled for Press conference is scheduled for 11:00 a.m. 11:00 a.m.


• What information should be presented to the What information should be presented to the public?public?

• Does you hospital have pre-scripted risk Does you hospital have pre-scripted risk communication messages? communication messages?

• What steps have been taken to ensure a consistent What steps have been taken to ensure a consistent message among the healthcare community and message among the healthcare community and levels of government? levels of government?

• What community or government agencies will What community or government agencies will participate in the press conferences? participate in the press conferences?

• Who will represent the hospital at the press Who will represent the hospital at the press conference? conference?

• Where will the press conferences be convened, and Where will the press conferences be convened, and who decides on the location?who decides on the location?

• Who is the “lead” agency for the press conference? Who is the “lead” agency for the press conference?

9:05 a.m. 9:05 a.m. • 9:05 a.m. - The Operational Area reports Statistics9:05 a.m. - The Operational Area reports Statistics

– Numbers of patients with blast injuriesNumbers of patients with blast injuries– Number of patients waiting to be seenNumber of patients waiting to be seen– Number of persons that may require hospitalizationNumber of persons that may require hospitalization– Available beds, operating rooms, emergency department Available beds, operating rooms, emergency department

bedsbeds– Number of patients being seen at clinicsNumber of patients being seen at clinics– Number of clinic patients awaiting transport to the Number of clinic patients awaiting transport to the

hospitalshospitals– Number of deceased, capacity for refrigeration units in Number of deceased, capacity for refrigeration units in

morguesmorgues– Anticipated need for blood products Anticipated need for blood products

• Communications with California Health Alert Communications with California Health Alert Network (CAHAN) is lostNetwork (CAHAN) is lost– Hospitals, clinics, EMS, and Operational area EOC unable Hospitals, clinics, EMS, and Operational area EOC unable

to place/receive callsto place/receive calls• Bomb squad with K-9s arriveBomb squad with K-9s arrive


• What other redundant What other redundant communications systems exist?communications systems exist?

• What agencies can be contacted to What agencies can be contacted to provide additional security for the provide additional security for the hospitals? hospitals?

• What community resources can be What community resources can be utilized to assist, including with utilized to assist, including with mental health issues? mental health issues?

• How is your hospital addressing the How is your hospital addressing the mental health concerns of the staff mental health concerns of the staff and the public? and the public?

10:00 a.m. 10:00 a.m.

• 10:00 a.m. - Bomb squad clears 10:00 a.m. - Bomb squad clears venue of other IEDsvenue of other IEDs

• Medical Operational Coordinator Medical Operational Coordinator requests a status update from requests a status update from hospitalshospitals– Bed availabilityBed availability– Estimated numbers of patientsEstimated numbers of patients– Equipment status and anticipated Equipment status and anticipated

needsneeds

10:15 a.m. 10:15 a.m. • 10:15 a.m. - Hospital nearly depletes blood 10:15 a.m. - Hospital nearly depletes blood

products as well as trauma and burn supplies products as well as trauma and burn supplies • Clinics call local hospitals for supplies (IV tubing, Clinics call local hospitals for supplies (IV tubing,

bandaging supplies, & burn sheets)bandaging supplies, & burn sheets)• Hospitals lack spare supplies and a means to Hospitals lack spare supplies and a means to

transport supplies to clinicstransport supplies to clinics• Vendors contacted to provide supplies and Vendors contacted to provide supplies and

equipmentequipment• Blood center advised of needs Blood center advised of needs • ICU is at capacity with no additional bedsICU is at capacity with no additional beds• ED us holding ____ patients awaiting inpatient beds ED us holding ____ patients awaiting inpatient beds

(insert appropriate number of ED patients to (insert appropriate number of ED patients to increase strain on resources), including ICU, increase strain on resources), including ICU, telemetry, and medical-surgical telemetry, and medical-surgical


• Is there a plan to ration resources?Is there a plan to ration resources?• What mechanisms are available to procure What mechanisms are available to procure

the needed supplies and equipment, and the needed supplies and equipment, and what agency is contacted to provide those what agency is contacted to provide those resources? resources?

• What non-medical resources may be needed What non-medical resources may be needed (sanitation, water, transportation, security)? (sanitation, water, transportation, security)?

• What is the internal plan for maintaining What is the internal plan for maintaining security and containing the influx of security and containing the influx of patients?patients?

• Are agreements in place to provide Are agreements in place to provide additional security?additional security?

10:15 a.m. continued…10:15 a.m. continued…

• 10:15 a.m. continued… Influx of 10:15 a.m. continued… Influx of patients continuespatients continues

• Resources are overwhelmedResources are overwhelmed– Insufficient staff (all levels of Insufficient staff (all levels of

healthcare providers)healthcare providers)– Lack of ED spaceLack of ED space– Depleted patient care equipment and Depleted patient care equipment and

suppliessupplies• Gurneys, oximeters, ventilatorsGurneys, oximeters, ventilators• Medications and medical-surgical supplies Medications and medical-surgical supplies


• What procedure does the hospital have to What procedure does the hospital have to expand treatment areas?expand treatment areas?

• What is the procedure for exempting the What is the procedure for exempting the facility from DHS licensing and facility from DHS licensing and certification for nurse staffing ratios certification for nurse staffing ratios during this emergency?during this emergency?

• What additional areas within or outside What additional areas within or outside the hospital can be used to provide patient the hospital can be used to provide patient care?care?

• What is your procedure for notifying DHS What is your procedure for notifying DHS Licensing and Certification about using Licensing and Certification about using alternate care sites? alternate care sites?

• Have patient tracking procedures been Have patient tracking procedures been adequate? adequate?

10:15 a.m. continued…10:15 a.m. continued…

• 10:15 a.m. continued…10:15 a.m. continued…• ____ patients (insert number to stress ____ patients (insert number to stress

the facility and coroner system) have the facility and coroner system) have died and await coroner to investigate died and await coroner to investigate and remove bodiesand remove bodies

• Hospital must identify a secure area Hospital must identify a secure area to hold bodiesto hold bodies

• Law enforcement and FBI demand Law enforcement and FBI demand access to medical records and to access to medical records and to interview victims and familyinterview victims and family


• What are your hospital policies on What are your hospital policies on interacting with law enforcement, interacting with law enforcement, evidence collection, and protecting evidence collection, and protecting patient privacy? patient privacy?

• Where will you stage law enforcement Where will you stage law enforcement officials to allow for interviews but not officials to allow for interviews but not congest patient care areas? congest patient care areas?

• What is the backup plan to store What is the backup plan to store bodies when the morgue is not of bodies when the morgue is not of adequate size?adequate size?

• Are the bodies considered “evidence”? Are the bodies considered “evidence”?

10:30 a.m. 10:30 a.m.

• 10:30 a.m. – Many patients will need 10:30 a.m. – Many patients will need weeks to months of supportive care weeks to months of supportive care before recoverybefore recovery

• Scarce resources will be long-term Scarce resources will be long-term issues for the facility and communityissues for the facility and community

• Hospitals, clinics, and EMS will need Hospitals, clinics, and EMS will need to construct contingency plans to to construct contingency plans to address shortagesaddress shortages

• Vendors will need to be contacted to Vendors will need to be contacted to provide additional supplies and provide additional supplies and equipmentequipment


• What are the extended care implications What are the extended care implications for your hospital? for your hospital?

• What recovery and mitigation efforts can What recovery and mitigation efforts can you take now to reduce the impact of this you take now to reduce the impact of this event?event?

• Have you integrated long-term care Have you integrated long-term care facilities into your disaster plans?facilities into your disaster plans?

• Do the nearby ancillary care facilities Do the nearby ancillary care facilities coordinate with hospitals to accommodate coordinate with hospitals to accommodate a surge of long-term care patients in the a surge of long-term care patients in the community? community?

10:45 a.m. 10:45 a.m. • 10:45 a.m. – FBI states they have received 10:45 a.m. – FBI states they have received

a credible threat that an IED was placed a credible threat that an IED was placed in the hospital (optional participation)in the hospital (optional participation)

• What are the procedures for notifying law What are the procedures for notifying law enforcement? enforcement?

• Who is in charge until law enforcement Who is in charge until law enforcement arrives? arrives?

• What is your policy regarding the use of What is your policy regarding the use of radios and pagers while searching for an radios and pagers while searching for an IED? IED?

• What recovery and mitigation efforts can What recovery and mitigation efforts can you take now to reduce the impact of this you take now to reduce the impact of this event, should an IED detonate?event, should an IED detonate?

11:00 a.m. 11:00 a.m.

• 11:00 a.m. - Influx of patients 11:00 a.m. - Influx of patients presenting to the ED continuespresenting to the ED continues

• Mayor’s press conference is held Mayor’s press conference is held – Cause of IED is attributed to Universal Cause of IED is attributed to Universal

Adversary terrorist groupAdversary terrorist group– Public is asked to report all suspicious Public is asked to report all suspicious

packages and behaviorpackages and behavior• Status reports from hospitals, clinics, Status reports from hospitals, clinics,

& EMS compiled & EMS compiled • Regional EOC begins to receive Regional EOC begins to receive

resource requests which are relayed resource requests which are relayed to the State Operations Centerto the State Operations Center

12:00 p.m. 12:00 p.m.

• 12:00 p.m. 12:00 p.m. – The Exercise Ends! The Exercise Ends!

Reference Reference

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

drill scenario by state of california emergency medical services authority amy kaji, md, mph...

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