James Smith, PhD
Associate Director for Radiation
Division of Environmental Hazards and Health Effects (EHHE)
National Center for Environmental Health (NCEH)
Centers for Disease Control and Prevention (CDC)
A national response plan exists for disasters, including terrorist events, that describes how the federal government will coordinate operations. It outlines the procedures, and the roles and responsibilities for federal agencies. It also defines resources most likely needed during an incident.
But remember, all emergencies are local. Federal resources will require many hours, to days, before arriving.
An example of a significant national resource is CDCs Strategic National Stockpile. Its mission is to maintain a national repository of life-saving pharmaceuticals and medical materiel that could be delivered to the site of a terrorist event to supplement local resources. A federal plan, however, cannot substitute for a community emergency plan. This type of planning involves a large network of partners, including not only the area hospitals and clinics, but also fire, police, EMS, health departments, the news media, and many other organizations.
Let’s look at some of the immediate response issues: facility preparation, surge capacity, health care provider safety, patient decontamination, triage and the medical management of life threatening injuries. With regard to facility preparation, first, activate the hospital disaster plan. In addition, obtain radiation survey meters and personal dosimeters for staff.
Contact, the radiation safety officer and in-house radiation Professionals, for example, the staff in nuclear medicine and radiation oncology. Establish triage and decontamination areas with warm and cold zones. Establish areas for patient treatment with a system for patient transportation. And it is important to establish a crowd control plan with adequate security.
In planning for triage, let’s consider how victims would arrive at the hospital. In the Oklahoma City bombing of 1995 we found that more than half of those who arrived at the local area hospitals came by private vehicles.
In the sarin attack in Tokyo of the same year far more of those that arrived at the local hospitals came as walk-ins, by private vehicle, or were delivered by taxi.
A review of the disaster literature indicates that a majority of patients seeking care in the immediate post event time period are self referrals. People will most likely go directly to the closest or most familiar hospitals and most who seek care will be ambulatory and minimally injured as well as those who are not hurt but understandably concerned about possible health effects. This is a natural response to mass causality incidents.
An important strategy for triage is categorizing the risk. The medium to high risk group would include those with severe physical trauma, significant exposure or internal contamination. They should be referred to the emergency department as their condition requires.
The low risk group would include those with limited trauma, exposure and contamination. They should be decontaminated, treated and observed. The negligible risk group includes those with minimal or no trauma, exposure, or contamination. They may require decontamination, but will certainly require information and reassurance.
An exceptionally important triage strategy is that of establishing a secondary assessment center physically separate from the hospital. This is a basic step toward protecting the hospital from becoming overwhelmed. It is also useful for pre-clinical screening, assessing exposure and contamination, and conducting triage and decontamination as well as reuniting families.
The secondary assessment center should be established in the planning stages by working with communities and local and state agencies. These centers could be community facilities, such as schools and churches, and they could involve non-traditional personnel such as allied health professionals, retired health care workers, and community nurses.
Let’s summarize: Remember, all emergencies are local. The initial hours of response will be managed by the local emergency response system and the local hospitals.
The majority of patients seeking care in the immediate post-event time period are self-referrals.
In addition to clinical personnel, have available radiation experts, radiation survey meters and personal dosimeters.
And finally, plan for establishing secondary assessment centers, physically separate from the hospital.