[BLANK_AUDIO]. Preparedness on a Larger Scale. In this lecture, we're going to talk about support structures like hospitals and other institutions. We will explore how they need to prepare and how the disaster may limit what they can do for you, the victim. So hospitals and other institutions as well as local and national governments, at least in the US, are required to have disaster plans, just like you should. They all have the same parts, just on a much, much larger scale. They will need to have food and water available for all their patients, all the staff and possibly, the staff's family if that's a part of the disaster plan. In short, everyone who is either there already or who will come to the hospital. They will need to have supplies and pharmaceuticals, the drugs they need to treat the patients and the victims, for the same group. Even the small hospital will have a large number of people it will need to prepare for. They will need to have security plans and protocols in place for the protection of patients and staff, as well as traffic and the patients' family movement through the hospital and to the hospital. They will need communication plans just as you do to get information in and information out. They will need an, an authority structure to make sure that the decisions can be made and made effectively. Finally, they will need to test the plans and train the staff and administrators so that when a disaster occurs, they will know what to do. Alright. Let's talk about this stuff. Institutions still need to gather stuff, just as you do. Food and water will need to be stockpiled for patients. People already being treated, those with the normal problems which would send them to the hospital, whether there is a disaster or not. The victims of the disaster, those with everything from very minor concerns to major concerns. The staff, staff's family, possibly even their pets and those displaced and seeking shelter. Patient supplies, normal pharmaceuticals and those specific to the needs of trauma victims. The linens, the bandages and such, cleaning supplies, all the stuff needed for relatively normal operation in spite of the disaster will need to be stockpiled. There will be a need for extra equipment, such as respirators, monitors, and such, for the increased patient load. and that will need to be stored someplace. All of this for the same three plus days that you need to prepare for. Let's talk a little bit about electrical power. Hospitals and large essential institutions will still need to function if the utilities go out. So if the power's down, they still need to run lifesaving and life-sustaining equipment. Most hospitals have larger industrial generators and fuel supplies, which start up automatically when there is a power outage. These will not run everything in the hospital but will take care of the essentials. But there needs to be a backup system for this backup system, or it needs to be reasonably well-protected from anything the disaster or other things could bring. There have been problems with what can be considered reasonable plans for backup power. Many times generators, fuel tanks, and power services are located at ground level or in the basement of the institution. This may seem reasonable, but this makes them susceptible to flooding. Possibly, even if they are located at the top of a hill outside of a flood plain. There may not be a river or a stream running near there but there are water mains that serve the hospital and other institutions [COUGH] may be nearby. These are very, very large systems which carry large amounts of water to and around the building to other institutions. [COUGH] If they burst during severe weather or other disasters which has knocked out the power, they could flood the generator that's located in the basement or on the ground floor. And the hospital will have no power. This happened to a major US hospital during the summer of 2012. The hospital is high atop a hill, well, well away from the river or seemingly any other flood, flooding concerns. A major water main broke after a severe storm [UNKNOWN] knocked out power. And the flooding from the water main break knocked out the emergency power source. Fortunately, their sister university is located close by and was able to provide backup power. Hospitals need to have a backup plan or, as melodramatic as this may sound, people will die who may not need to die. [COUGH] While this section [UNKNOWN] specifically talks about electrical power, the concept applies to all utilities within the institution, including water for things like drinking. But beyond that, sanitation and cleaning natural gas, anything required for as close to normal operation as possible. Security will need to be closely involved with the development of the institution's plan. They will need to develop a traffic and patient flow patterns and then see that those are followed when the disaster occurs. Keeping order during event, which by nature is disorderly is another function of them. Keeping patients, families, and staff safe throughout the event. Unfortunately, bad guys are still bad during a disaster. And emotions do run high. So even non-bad guys can overreact or act very inappropriately. While this may be understandable, it only makes the situation worse and can be dangerous. Housekeeping is in charge of preparing the decontamination area should there be a need to decontaminate victims from the disaster. They are also responsible for caring and decontamination of large areas after the incident. Areas which were used for patient treatment which may not have been originally intended for that. They are responsible for keeping areas clean during the disasters. Disasters are messy, they will be difficult to keep up with the mess of multiple traumas and such. Everyone, physicians, physician assistants, nurse practitioners, nurses, aids, respiratory therapists, everybody, all will be expected to do more than what they normally do. They may even be asked to work beyond their normal scope of practice, certainly beyond what their normal day-to-day practice may be. Physicians, nurse practitioners, and physician assistants will need to step up beyond their normal practice levels and make diagnostic and treatment decisions with very limited information about the victim. The circumstances and how they were injured the normal testing that we used to, that we do everyday to make and generate this diagnostic information that we generally have. [COUGH] Nurses will be asked to operate under protocols and standing orders and may be required to make decisions they normally would not make without consulting a physician, a practitioner or a PA, physician assistant. All of this affects the standard of care you receive. It can not be helped. It is a disaster. So what can you expect as a patient or victim? In a disaster, things are different. Waves of victims, potentially far more than a normal day, will present to the hospital or to clinics. Besides these, there will be the normal patients who seek treatment as they would with or without the dis, the disaster. All of this will potentially overwhelm the hospital. There may be far more patients than victims that can be treated under the normal standards of care we are used to working under and being treated by, on a day to day basis. Some degree of privacy may be maintained but there will probably be patients and victims on gurneys in the hallways. While those who need to be seen by a physician, a physician assistant, or a nurse practitioner will be, not all patients will be seen by them. Some patients and victims will absolutely believe that they need to be seen by a physician or practitioner but may not be able to. It will be our judgement with, which makes the call. It will be just impossible to see everybody. Normal treatment may not be the norm. You may or may not get the X-ray that you would under normal circumstances. If we believe your arm is broken and does not require immediate surgery, we will splint it and send you home. Other similar diagnostic and treatment decisions will be made without the normal labs and tests. Nurses may need to act beyond their scope and make some diagnostic and treatment decisions, hopefully based on additional training and protocols established long before the disaster. Unfortunately, there are no real legal protections for health care providers who need to deviate beyond the normal standards of care. This is a problem. And while there is usually not a backlash against folks who do the best they can in a disaster, there can be problems involving abandonment, usual care, comfort care for those who we cannot save, and other very real concerns. It's important to note that good Samaritan laws in the United States and similar laws in other countries do not apply in this situation. So organizing the hospital scene. [COUGH] The hospital scene will seem very confused and crowded. The folks from the hospital will hopefully have an attitude of calm decisiveness. And you should as well. But keep in mind that the norm, what you normally expect, may not be possible. Holding areas will be established for minor and delayed victims. You may be classified as minor or delayed. While I'm sure that you would not think that what happened to you was minor, you do need to trust the judgment of those who know and are trained. Nurses may be the folks who manage these areas with protocols and a fair degree of independence. There will be treatment areas for specific patients. The ER is for resuscitation and stabilization. The OR is for treatment for those who require immediate surgery. Labs and radiology will be utilized only for those whom testing and radiology will change or direct their treatment. If it's obvious, we will treat and will not test. There may be an enlarged morgue. Hopefully there will be treatment protocols in [UNKNOWN] in place to protect patients and medical staff. Hospitals will organize as much as possible beforehand. But know then in a true disaster, by definition, the organization will be overwhelmed. You and the hospital need to be flexible. So let's talk about outside aid beyond the hospital. In a disaster, there is an ever expanding circle of aid, starting with self rescue, you rescuing yourself. Then neighbors helping neighbors. Then broader neighborhoods and then beyond. Local resources will respond. An Incident Command Post will be set up, which will direct Emergency Medical Services, Fire, Rescue, and Law Enforcement. Medical Reserve corps, volunteers will be called into the hospitals and clinics to staff the treatment areas. County will follow. County wide Emergency Management Office kicks in and sets up a larger Incident Command Post for a larger area. State level responses and resources will kick in beyond this. Road crews, law enforcement will provide support to the local response. The governor may then ask for a disaster declaration. This will open up Federal resources. The Federal resources is called in after this disaster declaration is made. However, if the disaster is big enough, the Federal response can come in even before that disaster declaration is made. Some federal resources which can be provided include things like the strategic stockpile. This is [COUGH] a stockpile of pharmaceuticals, airway and respiratory equipment that the Federal Government holds in reserve. In case of a disaster, if they are needed and requested, this large packet of supplies and equipment is sent to the closest military base. And then they are distributed by local and state authorities. As I said, they contain airway and pharmaceutical supplies. It also contains an assessment team. This team, then, performs an analysis of the needs created by the disaster. So [UNKNOWN] subsequent shipments will match the specific needs of the response. Health and human services, another aspect of the federal government, can also be called in. They can send in various teams to aid the local response. They usually only respond within the U, the borders of the United States. But in 2010, for the first time and so far the only time, they responded to the earthquake in Haiti. DMAT or Disaster Medical Assistance Teams, can set up an independent hospital for treatment of local victims, or backfill local hospitals to decompress them and allow a more effective patient care. DMORT, or Disaster Mortuary Teams, can respond and assist with staffing of morgues, body identification and, of course, care of the dead. DVET teams, Disaster Veterinary Teams, are teams of vet, veterinarians who come it and care for animals that are injured or displaced in the disaster. Each will have logistics teams and other support which follow them. The Federal Emergency Management Agency, or FEMA, can send in search and rescue teams to help. These rescue teams rescue victims from collapsed structures, search areas for victims trapped in homes or other buildings by the disaster. Homeland Security can also assist by providing law enforcement and other services. The Center for Disease Control or the CDC can provide laboratory assistance and expertise in diagnosis and management of healthcare related incidents. They also have stockpiles of medications for unusual injuries and illnesses. This is not an exhaustive list, at least for the United States. For instance, although there are some legal concerns in the US the military has responded and provided aid in disasters in the United States. They have also responded outside to the United States such as in the 2010 earthquake in Haiti. So the bottom line, be prepared, be flexible. You need to know that normal services will not, may not, probably won't be available. You need to know that, that the folks that are trying to help you are trying to help as many people as they can. Everyone needs to be flexible and everyone needs to be prepared.
