Mass Casualty Incident (MCI) Medical Response A Simulation

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					Mass Casualty Incident (MCI)
    Medical Response:
 A Simulation Opportunity
    Jay J. Schnitzer, M.D., Ph.D.
               CIMIT
    Massachusetts General Hospital
       Harvard Medical School
     Concepts and Issues
• Communication
• Command and control
   – Incident command system
   – Clash of cultures
• Response time - “golden hour”
• Media
• Surge capacity
• “New” ideas
• Things that keep me awake at night
  Why is it important to have a
  federalized medical response?
Accountability
Reliability
Quality control
Proper documentation
Correct integration with other
rescue efforts
Scene security
Ensures full spectrum of medical care
(MD, RN, Medics, EMT’s) with personal
protective gear, credentials, and
renewable medical supplies
Ideal Characteristics of Rapid
       Response Team
•   Truly rapid (wheels up 4-6 hours)
•   Independent operation
•   Flexible (variable mission profile)
•   Task-organized
•   Direct link(s) to higher echelons
•   Multiple (parallel) capabilities
    – Assessment
    – Triage
    – Treatment
      Ideal Characteristics of Rapid
             Response Team

•   Priority of support to team
•   Clear mission guidelines
•   Appropriate pre-deployment
•   Capable of joint (operations in relief) of
    rapid response military (active/reserve)
     Key Requirements
• Administrative
  – Credentialing for personnel
  – System for federal appointment
  – Draw on local talent
    • Local MD’s, RN’s, technical personnel
  – Funding
  – Limited/hardened IS
  – Documentation for patients
        Key Requirements

• Operational
  – Appropriate recruitment and training
  – Independent and integrated operational
    capabilities
  – Experienced personnel in key leadership
    positions
  – Simple / reliable communications
  – Security is essential
        Key Requirements

• Logistics
  – Minimal lift requirements
  – Minimal deployments (2-3 days)
  – Common equipment (to DoD and USPHS)
  – Interoperability with higher echelon(s)
Communication at Ground Zero
• Each shift, face-to-
  face greeting
  mandatory with EMS
  100 yds away
• FDNY leadership
  trained in integrated
  incident command
  were all dead
   Bam Iran: Response Time Line
26 December 2003; 5:28 am
Magnitude 6.5; Centered in
Bam, Kerman Province
White House allocated the
IMSuRT team under the
direction of the State
Department
Diplomatic issues were sorted
out during the day of 12/26
Official activation at ~2 am
12/27
Team assembled at MGH at
7:00 am ready to leave
   Bam Iran: Response Time Line
“Wheels up” from Westover
AFB at approx 5:30 pm
Rhein-Main, Germany
Mid-air Refuel to Kerman, Iran
Transport Kerman to Bam
Assignment of space
Set-up
Operations begin evening of
December 31, 2003
     Bam Iran: Clinical Response
727 Patients Seen
7 OR cases
6 Births
• (2 c-sections)
Emergency Room Capability
ICU Capability
Acute Men’s / Women’s
Tents
Pedi Tent
Logistics alone can ensure failure
    MCI Hypothetical Scenario
• On September 11,
  2006, a tanker laden
  with 33 million
  gallons of LNG enters
  Boston inner harbor
• At 8:46 am, a small
  craft loaded with
  explosives collides
  with tanker
                     Pool Fire
• intentional breach of
  two tanks with
  puncture holes
  approximately 5 m
  each in diameter
• 572 m diameter pool
  fire that burns for 8.1
  minutes
        LNG pool fire details

• LNG fire cannot be      • 3-tank breach would
  extinguished by           extend thermal heat
  conventional fire-        zones up to 37.5
  fighting techniques       kW/m2 or 12,000 Btu
• LNG fires can burn at     to a radius of 630 m
  temperatures of 3,000     (2,066 ft), and up to 5
  degrees Fahrenheit
                            kW/m2 or 1,600 Btu to
• emissive power can        a radius of 2,118 m
  reach 265 kW/m2 or
                            (6,947 ft)
  84,000 Btu/hr/ft2
                        Zones
• Typical danger zone from
  an LNG spill and pool fire
  in Boston harbor
• The black rectangle is the
  vessel outline
• Inner solid red line is the
  maximum extent of the
  pool fire
• Outer dashed line is the
  outer edge of the thermal
  radiation zone (5 kW/m2)
        Expected casualties

• Depends on location of tanker at time of
  incident, weather, wind, time of day, etc.
• Several thousand dead
• Tens of thousands injured, many (?most)
  with severe life threatening burns
• Hundreds of thousands of walking
  wounded and worried well
          Boston response

• 911, EMS, other first responders activated,
  respond
• Disaster plans activated
• Disaster command center operational
• Hospitals notified, activate individual plans
• Chaos, panic
            MGH Response

• Hospital disaster plan activated
• HEICS
• MGH at 81% occupancy
  – 23 adult ICU beds available
  – 24 stepdown beds available
  – 80 general care beds available
                                                                                                               Incident Commander
                                                                                                                   A. Prestipino                          BUL 225A
                                                                                                                     P. Slavin                            6-8619



          EMERGENCY MANAGEMENT                                                        Public Information Officer
                                                                                                                                        Liaison Officer                                                  Biological Agent Advisor
                                                                                                                                            A. Conn
          INCIDENT COMMAND ORGANIZATION                                                       P. Slasman                                                                                                      S. Calderwood
                                                                                                                                          C. Cochran                                                            D. Hooper

                                                                                              Safety Officer                            Medical Officer                   BUL 207
                                                                                               R. Castaldo                               B. Nicholson                      4-9085                         Nuclear Agent Advisor
                                                                                                                                                                                                              R. Woodleigh
                                                                                             Security Officer                         Compliance Officer
                                                                                              B. Michelman                               M. Spicer
                                                                                                                                                                           Chiefs of Services
                                                                                                                                                                                                         Chemical Agent Advisor
                                                                                           Senior EM Advisor                                                                                                  R. Castaldo
                                                                                               M. Hughes                            Emergency Management
BUL 222                       BUL 240C                             BUL 380D                                                              Coordinator
                                6-7630                               4-0574
                                                                                               J. Sinclair
 6-7629                                                                                                                                  C. Cochran                                       BUL 225B
                                                                                                                                                                                          6-5017


  Logistics Chief                 Planning Chief                         Finance Chief                                                                ELL 218                Operations Chief                  BUL 350         BUL 360B
     J. Elrick                      T. Gallivan                         S. Mason Boemer                               BUL 225B                        6-6670                  J. Ives Erickson                 6-3823          6-2214
                                    J. Schnitzer
                                                                                                                      6-5017

  Facility Unit Leader          Situation-Status Unit                   Time Unit Leader                                Medical Care Director                                                         Psychological
       G. MacNeil                      Leader                              T. Sheehan                                                                                      Ancillary Services                                 Human Services
                                                                                                                               L. Mort                                                               Support Director
                                      S. Dodge                                                                                                                                  Director                                         Director
                                                                                                                            J. Somerville                                                               A. Daniels
                                     G. Reardon                                                                                                                               D. Palumbo                                         J. Davis
    Damage Assessment &                                                                                                                                                                                 J. Herman
                                                                        Claims Unit Leader
       Control Officer
                                                                           M. McMahon               Inpatient Area                                                                                   Family Support Unit
         J. Dimeglio           Labor Pool Unit Leader                                                                             Treatment Area          Peri-Ops area
                                                                                                      Supervisor                                                                                           Leader                 Dependent Care
                                     S. Taranto                                                                                     Supervisor             Supervisor        Laboratory Unit
                                                                                                       D. Burke                                                                                          P. Gauthier                Unit Leader
Environmental Services                                             Cost/Procurement Unit                                            P. Biddinger            D. Tenney            Leader
                                                                                                       L. Ronan                                                                                            J. Park                    J. Sapir
        Officer                                                           Leader                                                    M. Hughes                P. Dunn          D. MacMillian
     B. Banchiere                   Volunteer Services                                                                                                                                                    G. Leslie
                                                                          C. Aiena
                                         Officer                                                    Adult Inpatient                                                                                                                 Staff Support
                                                                                                                                 Triage Unit Leader                                                    Patient Support
Telecomm Unit Leader                    P. Rowell                                                       Care                                                                  Radiology Unit                                         Unit Leader
                                                                                                                                         ED                                                             Unit Leader
      J. Candito                                                                                     A. Kennedy                                                                   Leader                                              B. Welch
                                                                                                                                                                                                           T. Mian
                                                                                                                                                                             K. Tabor McEwan
                                                                                                                                                                                                            L. Park
 Materials Supply Unit         Medical Staff Unit Leader                                                                         Critical Treatment
        Leader                         G. Meyer                                                                                     Unit Leader                              Pharmacy Unit
                                                                                                    Maternal-Child                                                                                      Employee
       E. Raeke                      L. Weinstein                                                                                         ED                                    Leader
                                                                                                     Unit Leader                                                                                      Assistance Unit
                                                                                                                                                                               M. Clapp
                                                                                                      J. Newell                                                                                           Leader
     Transportation Officer                                                                                                                                                                             A. Stidsen
          B. Viscomi             Nursing Unit Leader                                                                              Urgent Treatment
                                    Nursing Sups.                                                                                                                            Respiratory Unit
                                                                                                   Critical Care Unit               Unit Leader
                                                                                                                                                                                  Leader
                                                                                                         Leader                          ED                                                           Support Facility
                                                                                                                                                                               B. Kacmarek
 Biomedical Engineering                                                                                  S. Tully                                                                                        Manager
       P. Volpe                           Patient Tracking Officer                                                                                                                                     M. Ditomassi
                                                                                                                                  Minor Treatment
                                                N. Connery
                                                                                                         Case                       Unit Leader
   Information Systems                                                                             Management Unit                   N. Bryant
         J. Noga                                                                                       Leader                       N. Gagliano
                                             Patient Information
                                                                                                      N. Sullivan
                                                   K. Ford
    Nutritional Supply                                                                                                             Discharge Unit
     S. Barraclough                                                                                                                    Leader
                                         Interpreter Services Officer                                                                S. Bouvier
                                                   P. Rowell
   Utilities Engineering                                                                                                                                                                                  MGH Emergency Management Plan
          T. Srisirikul                                                                                                          Morgue Unit Leader                                                           Updated: August 2006
                                                                                                                                     B. Hynes
 Degradation of MGH Response
• Rhode Island nightclub fire February 2003
  – 13 patients total to MGH and SBH
  – 5 patients to SICU; brought unit to a standstill
• ~1200 burn ICU beds nationwide
  – ~800 occupied
Things that keep me awake at night

 •   Triage in MCI
 •   Catastrophic MCI - surge nightmare
 •   Leadership - command and control
 •   Communication
 •   Degradation of hospital services with time
            “New” Ideas
• Combined mobile response team
  – Military and civilian partnership
• Convening “in the trenches” expertise
• Surge capacity personnel
• New technology
  – Simulation for MCI training
    MCI Simulation Requirements
•   Complex scenario
•   Multiple agencies
•   Real time, simultaneous participation
•   Emphasis on command and control,
    incident command, communication