Disaster School

After 9/11, in response to the lack of a standardized national training program for disaster management education, a quartet of educational and healthcare institutions set out to create a National Disaster Life Support (NDLS) curriculum. The Medical College of Georgia, University of Georgia, University of Texas Southwestern Medical Center and University of Texas Health Science Center School of Public Health, with sponsorship from the American Medical Association (AMA), created the courses, then created the National Disaster Life Support Foundation (NDLSF) with a primary mission of establishing and accrediting a national network of training centers.

The courses utilize an all-hazards approach and are patterned after the nationally recognized Advanced Cardiac Life Support and Advanced Trauma Life Support programs. The NDLS courses provide prehospital and hospital-based personnel a consistent, streamlined approach to multiple-casualty management and a consistent method of recognizing and responding to multiple-casualty incidents.

COURSE DESCRIPTIONS
Currently, there are four courses available for emergency-response personnel. The following descriptions come from the NDLSF website, www.bdls.com.

CORE DISASTER LIFE SUPPORT
Core Disaster Life Support (CDLS) is a four-hour awareness-level course focused on the medical first responder, but also useful for nonmedical providers.

The program is constructed around the DISASTER paradigm (see Three Key Mnemonics, page 61) and is designed to teach core concepts of disaster management. In addition, students are taught concepts that will allow them to be more effective in the recognition of and response to medical disasters. MASS triage is taught to allow these providers to more effectively assist in mitigation. Hospital administrators and emergency planners will gain useful information for planning for the medical consequences of disasters.

BASIC DISASTER LIFE SUPPORT
Basic Disaster Life Support (BDLS) is targeted to multiple disciplines, including EMS, hazmat and public health. Teaching to multiple disciplines simultaneously contributes to a commonality of approach and language that should improve care and coordination in an emergency.

BDLS is a daylong course approved for 7.5 hours of Category 1 PRA credit by the American Medical Association. The curriculum includes the DISASTER paradigm, natural and manmade disasters, traumatic and explosive events, nuclear and radiological attacks, biological events, chemical events, the public health system and the psychosocial aspects of disasters. Certification in BDLS requires course completion and a passing score on the competency exam. To maintain these credentials, renewal training is required every three years.

BDLS is the didactic component of the NDLS training. Those completing it can then progress to ADLS.

ADVANCED DISASTER LIFE SUPPORT
Advanced Disaster Life Support (ADLS) is an advanced practicum of the principles introduced in BDLS. ADLS includes lectures on MASS triage in detail; community and hospital disaster planning; media communications during disasters; and mass-fatality management. Small interactive group sessions allow students to work through a series of difficult disaster-management questions in a tabletop format.

Day 2 of ADLS is the "hands on" day of training. Four skills stations reinforce the previous day's learning:

• MASS triage--This station allows the students to practice the concepts of the DISASTER paradigm with an emphasis on patient triage. Simulated disaster victims must be triaged and treated correctly while participants manage a chaotic scene and request appropriate resources.
• PPE and decontamination--This station teaches important concepts about the use of personal protective equipment and decontamination techniques. Students wear PPE and participate in a simulated decon while attempting to render care.
• Disaster skills--This station imparts important information for the medical management of disasters. Students are familiarized with the Stategic National Stockpile and proper use of the Mark 1 kit. They also practice smallpox immunizations.
• Human patient simulator--Recognition of victims of chemical and biological disasters is of paramount importance. This station reinforces the detection and proper treatment of disaster conditions we don't often treat, including those involving chemical, biological and trauma victims. Using high-fidelity simulators allows the student to see, hear and feel information that would normally be provided by an instructor, providing a more realistic experience than normal manikins allow.

ADLS is a 16-hour course, with eight hours of classroom lectures and eight hours of hands-on exercises.

A Dark and Stormy Night: The Clearfield County Bus Accident
Mass-casualty incidents come in all shapes and sizes, and when they happen, things can often go wrong. The response to an MCI in Clearfield County, PA, last May provided a good example of how to minimize such problems. Around 3:30 a.m. on May 20, Clearfield EMS (a three-crew/24-hour-a-day service) and Clearfield Hospital were alerted to a tour bus accident on Interstate 80. The accident involved 34 patients, all of whom spoke mainly Chinese, though some could muster broken English. The weather was a mixture of rain and fog.

EMS Perspective
The initial call was dispatched as a tractor-trailer rollover with unknown injuries. Per policy, Clearfield EMS responded with two ALS crews. As the crews were preparing to respond, the incident was clarified to a tour bus accident with 34 patients. During this time Clearfield EMS had its third crew preparing to respond and asked for Clearfield 9-1-1 to page for manpower for its two remaining units, as well as its mass-casualty unit.

At the scene, the two crews found 30 patients out of the vehicle walking around, while two additional patients were fatalities. The crews immediately began triage and command setup and called for mutual aid, which brought the remaining Clearfield EMS crews and seven more ambulances from neighboring companies. It was determined that since all the patients spoke little to no English and no interpreter was yet available, it was best that all be transported to Clearfield Hospital, six miles from the scene.

As the third crew arrived, triage determined that one patient had a respiratory compromise severe enough to be flown to a trauma center. Clearfield EMS transported the patient to Clearfield Airport, where a crew from STAT MedEvac flew the patient to Altoona Hospital, the closest trauma center. Shortly thereafter, weather deteriorated, and no other patients were able to be flown from the scene. It was later determined at Clearfield Hospital that seven additional patients, ranging from spinal to chest and abdominal injuries, needed to be transported to Altoona Hospital as well. They were taken by Clearfield EMS ground crews.

Among the interesting aspects of the on-scene work:

• The fire chief in charge, Jas Catherman, was able to utilize a local tour bus to have seven "worried well" patients transported to Clearfield Hospital.
• Catherman assigned an on-scene "concierge" to follow deputy EMS director Tim Lumadue around and assist him as needed in aspects ranging from scribe to immobilization.
• Once responders realized communication would be an issue, they asked the 9-1-1 center if it had listings for interpreters. A concerned citizen who heard this exchange on a scanner called the 9-1-1 center and advised them of a Chinese-speaking person who lived nearby, but whose exact street address he did not know. Lawrence Township Police went to the area of the person's home and started checking license plates of cars parked on the street until they found the person's home. The person was advised of the situation and graciously agreed to help, and was taken to Clearfield Hospital to assist with communications.

Hospital Perspective
At Clearfield Hospital, the ED physician on duty, Dr. Ernest Jones, declared a disaster, and the hospital enacted its emergency plan. Nurse manager Monica Smith began calling staff in, starting with the nurses living closest to the hospital, while the on-duty nursing supervisor began calling additional physicians. Nurses who lived farther from the hospital were also called, but were used as backfill rather than primary responders. Over 30 minutes, six additional physicians and 10 additional nurses came in to assist with the surge.

As the patients started to arrive, the ED physician became the triage officer, and an RN assisted by assigning rooms. The language barrier made caring for and communicating with the patients challenging, and hospital staff had to function on their own until approximately 4:40 a.m., when the interpreter arrived. All patients were taken to the ambulance entrance, which, through prior planning, had been set up for such an emergency. The ED waiting room became a minor-care clinic for the 14 walking wounded, and care was administered by two Pas, an RN and an ED tech. A Facility Resource Emergency Database (FRED) alert was sent out to notify surrounding facilities of the mass-casualty incident. A total of 31 patients, with injuries ranging from the walking wounded to chest and abdominal injuries, were cared for before the end of the disaster was declared at 7:10 a.m.

Preplanning and After-Action Aspects
The Clearfield County I-80 incident was a great example of not only a coordinated effort between prehospital and hospital, but also of preplanning between organizations. All five ambulances from Clearfield EMS, as well as the service's mass-casualty unit, responded within 17 minutes. On scene, the use of unified command proved valuable, as all responders performed their respective duties without problems while coordinating efforts between all agencies. In addition, the use of other agencies, such as the Lawrence Township Police to locate an interpreter and the local bus company for transportation, demonstrated great examples of resource utilization. Clearfield Hospital had developed disaster patient triage charts that reflect sequential numbers, rather than names, and correspond to the manual patient status board in the ED. The charts were a great help in differentiating disaster patients from other patients coming in while the MCI response was going on.

During the after-action review, several problem areas were identified, and actions have been taken to correct them.

• Triage--Clearfield EMS uses the START system, and some responders were not familiar with it. All are now.
• Mutual aid/backfilling--This aspect is addressed in the disaster plans, but was overlooked during this incident. Luckily, no other ambulances were needed in the Clearfield area during the time of the incident, and the problem has now been resolved.
• Documentation--There wasn't any type of EMS log sheet at the hospital to determine which ambulance brought which patient; thus it took over two days for EMS to find out who the patients were and where they ended up. An EMS log sheet has now been added to the hospital's disaster chart.
• Hospital incident command--At the time of the incident, none of the hospital's administrative staff had training in the Hospital Emergency Incident Command System (HEICS), and during the incident there wasn't any type of incident command set up. Since the incident, arrangements have been made to train all of the hospital's administrative staff in HEICS. --TL

NDLS-DECON
Decontaminating a large number of victims from a chemical or radiological event will require training and equipping large numbers of personnel. Although healthcare providers in PPE will be needed to render immediate care and triage, the workforce providing actual decontamination in a disaster of this nature should be nonmedical or hospital-based. This program is designed to meet this need. After completing the awareness-level CDLS program, students complete an additional eight hours of instruction over two days. They also serve as "victims" on whom other students practice decontamination.

The components of the Decon program include an introductory lecture, donning and doffing PPE, ambulatory decon, litter decon, small group interactive sessions and a tabletop, then a full-scale decontamination practice.

Three Key Mnemonics
While some of the NDLS material, such as an emphasis on scene safety, may be old hat for some, the classes offer a unique approach through use of three mnemonics:

1. The DISASTER paradigm (Detection, Incident Command, Scene Safety and Security, Assess Hazards, Support, Triage and Treatment, Evacuation and Recovery) organizes the response to any type of disaster.
2. MASS (Move, Assess, Sort and Send) triage enables quick sorting of large numbers of casualties. Patients are categorized using ID-ME (Immediate, Delayed, Minimal and Expectant). These categories basically represent the familiar triage colors: Immediate = red, Delayed = yellow, Minimal = green and Expectant = black.

A benefit to this system is that it can be used by those who aren't medically trained. For example, a janitor at a school who's the first person at an incident scene can see all those moving, so he can move them to another location or out of harm's way.

BRINGING THE CLASS TO THE PEOPLE
Last February, the Disaster Management Center at the University of Pittsburgh Medical Center (UPMC) welcomed personnel from the Medical College of Georgia, who taught and presented both BDLS and ADLS to more than two dozen UPMC employees. In turn, the next month, Center staff and their Pittsburgh-area regional EMS council (the Emergency Medical Services Institute, or EMSI) hosted the first BDLS class for prehospital providers in western Pennsylvania at the annual EMSI EMS Update event.

CONCLUSION
The EMS community will benefit tremendously from the all-encompassing structure and streamlined approach of these classes. They put disasters into perspective, from incidents with only a few patients to those the size and scope of Katrina. The classes are not meant to undermine what EMS personnel have experienced in the field, but merely to capture those experiences and offer unique approaches to disaster management and patient triage and present them in a new, standardized format. An additional benefit for instructors and sponsoring facilities is that the classes can be adapted to each audience.

Terry Lonchena has over 20 years' experience in EMS/public safety. He is currently the Medical Operations Specialist in the Disaster Management Center at the University of Pittsburgh Medical Center. Contact him at 412/802-6210 or lonchenatw@upmc.edu.