DISASTER PLANNING
Educational Objectives
| The goal of this program is to improve disaster planning. After hearing and assimilating this program, the clinician
will be better able to:
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 | 1. Explain the psychology of risk.
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| 2. Review the lessons learned from Hurricane Katrina.
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| 3. Describe the necessary components of a disaster plan.
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| 4. Discuss the common difficulties in planning for disaster preparedness.
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| 5. Discuss the barriers to optimal preparedness in disaster planning.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty and members of the
planning committee to disclose relevant financial relationships within the past 12 months that might create any personal
conflicts of interest. Any identified conflicts were resolved to ensure that this educational activity promotes
quality in health care and not a proprietary business or commercial interest. For this program, the faculty and planning
committee reported nothing to disclose.
Acknowledgements
Mr. Pixley was recorded at Managing Medical Emergencies, held May 12, 2008, in Lebanon, NH, and sponsored by
the Dartmouth-Hitchcock Medical Center. Dr. Richards was recorded at Emergency Medicine Symposium, held April
12, 2008, in Albuquerque, NM, and sponsored by the University of New Mexico, School of Medicine, Department of
Emergency Medicine, Office of Continuing Education, and the New Mexico Chapter of the American College of
Emergency Physicians. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in
the production of this program.
| HOW DISASTER PLANS SUPPORT CLINICAL CARE IN ROUTINE AND ADVERSE SITUATIONS —
Stephen Pixley, RN, Emergency Management Coordinator, Dartmouth-Hitchcock Medical Center, Lebanon,
NH
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| Plan for multiple trauma: example of head-on collision with 4 major trauma victims; components—include
communications (eg, calling in extra physician and nursing staff, dealing with public and media); resources
(eg, enough trauma dressings, gauze, saline?); safety and security (eg, rivalries among victims’ social groups);
staff responsibilities (eg, enough nurses to take care of new and existing patients and to handle admissions?);
patient clinical and support activities (eg, enough registrars, enough beds in-house?); now seeing shift in responsibility
from federal and state level to local community or hospital level
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| Common difficulties in planning: details must be planned out; previous plans—silos (stand-alone plan for each
threat); rarely used and seldom exercised; rarely addressed exact situations encountered; many plans all-or-nothing;
9-11 terrorist attacks and Hurricane Katrina changed disaster planning; National Incident Management System
(NIMS)—established by 2003 Presidential directive; idea to form comprehensive management network that
integrates all members; achieves standardization and addresses all situations; mandatory incident command approach;
from Hurricane Katrina, clear that hospitals must be able to stand alone for extended period; Joint Commission
(JC) forcing compliance through reimbursement
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| New plans: based on actual risk; use incident command system and all-hazards approach; JC requires that core
processes in central plan used for all situations; hazard vulnerability analysis—emphasized; used for planning
and developing exercises; hospital incident command system (HICS)—uses command structure; supports necessary
activities; leaves physicians free for clinical activities; all-hazards approach—advantage frequent use and
fluency; based on existing systems wherever possible; used to preplan events and for low-level activations, eg,
blizzards and ice storms when staff cannot get to work; exercises; results in smoother core processes and better
commanders and leaders
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| NIMS element 7: necessary to have plan, ie, emergency operations plan and standard operating procedures that
incorporate NIMS principles, including planning, training, response, exercises, equipment, evaluation, and corrective
actions; 6 necessary elements in plan—communications; resources and assets; safety and security; staff responsibilities;
utilities management; patient clinical and support activities (eg, effective medical surge capacity)
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| Darthmouth–Hitchcock Medical Center plan: 6 JC requirements plus—activation of ICS; staffing; patient
flow, capacity, and surge (rapid discharge plan being developed); decontamination and evacuation; incident-
specific plans—severe weather; very important person (VIP) visit; Motorcycle Week; pandemic flu; information
services (IS) and information technology (IT) failure; business continuity; surges in need for bone marrow
transplantation after radiation injury
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| Benefits of planning: enhanced awareness of communications; facilitation of staffing augmentation; enhanced
awareness of census conditions; facilitation of surge capacity; potential for smoothing of supply chain
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| WHAT IT TAKES TO BE PREPARED: LESSONS LEARNED FROM DISASTERS —Michael E. Richards, MD,
Associate Professor and Chair, Department of Emergency Medicine, University of New Mexico School of Medicine,
Albuquerque
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| Hurricane Katrina: material from popular media before Hurricane Katrina—2001 article in Popular Mechanics
stated that New Orleans sinking and foregone conclusion that New Orleans would someday be hit by big
storm; 2001 article in Scientific American described what would happen in New Orleans after catastrophic
hurricane (large number of dead bodies found as water receded); 2002 article (5-part series) in major New
Orleans newspaper detailed effects of major hurricane to New Orleans; concluded that major hurricane
would decimate region; real threat flooding that could occur from just moderate hurricane; also stated that
just matter of time; 2003 civil engineering journal discussed levee system and that large storm with heavy
rainfall enough to cause failure of levees and flooding; 2004 Hurricane Ivan near-miss; prototype and
scripted disaster
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| Barriers to optimal preparedness: 4 areas; lack of goals and accountability—instead of system of disaster response
and preparedness, pieces or random acts of preparedness put together; failure of imagination—ability to
foresee how event will happen; challenges and barriers to be faced; often result of inadequate information; not
thinking problem through; missing or misplaced leadership—highest elected officials responsible; ensure that
officials have tools and knowledge necessary; strange psychology of preparedness—people have difficult time
understanding and perceiving risk; national culture of underpreparedness; people diehard optimists and believe
it will not happen or will not happen to them
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| Exponential increase in hydrometerologic natural disasters since 1942: reason has 2 components; 1)
idea of natural hazard or naturally occurring hazard with potential to affect humans; 2) idea of disaster; disaster
does not occur until humans put themselves in way of naturally occurring geologic or meteorologic
phenomena; catastrophic earthquake in San Francisco Bay area—prototypic natural disaster; 300 yr ago, earthquake
would not have been natural disaster because no one living there; decision to live there sets stage for
natural disaster; as population increases, interface of humans in areas with naturally occurring hazards also
increases; “occurrence of disaster is a political accomplishment”; risk sum of hazard and vulnerability; vulnerability
includes things people can do to change population’s risk or alter influence of hazard on people;
people do not have clear understanding of risk; extremes of weather (heat and cold) greatest natural hazard
threat in United States; heat wave in Chicago in 1995 caused 739 excess deaths
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| Psychology of risk: study published in Science; people want government to intervene on things people afraid of
or do not know about (huge implications for disaster preparedness and public response, eg, anthrax); things that
create some of the greatest threats those that people familiar with and generally not afraid of (creates huge barrier
to preparedness); lesson learned not always lesson remembered; large catastrophic events do not occur often,
and memory short; over time, degradation of learning occurs; high frequency of events prevents
degradation of learning; disasters not “equal opportunity” killers; those with resources better able to survive disasters
and care for themselves than those without (on international level and within affluent country); people
harmed by disasters those with least capacity to care for themselves
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| Lessons learned: local response essential—necessary to have everyone engaged in disaster preparedness (not
just small groups of professional disaster responders); bias present in disaster response community about utilization
of volunteers, but, in reality, volunteer nonprofessional disaster responders essential; in speaker’s experience
at field hospital in aftermath of Hurricane Katrina, almost all patient care provided by lay responders
or by medical professionals not affiliated with disaster response team; system failures—known; more complex
the system, the more likely to fail; communication system always fails, and failure should be built into disaster
preparedness plan; plan includes splitting hospital workforce into 3 groups; group A at hospital 24 hr before
storm expected to make landfall and stays until winds decrease to <35 miles/hr; group B comes in when
winds <35 miles/hr and safe to travel (group A sent home); group C comes in 24 hr after group A sent home;
right people for right job—people running disaster preparedness plan should have particular skills and abilities
to do so; in incident command system, default command position almost always goes to highest trained medical
person; need to be careful, because this means removing medical provider from most important role of direct
patient care; must understand and identify which person should respond to such events; returning to
basics—becomes more important the larger the event (eg, food, water, shelter); must understand epidemiology;
usually end up caring for vulnerable populations that become sick when medical infrastructure disrupted
during disasters, eg, diabetic without insulin or proper diet, patient with chronic obstructive pulmonary disease
who runs out of oxygen, patient with congestive heart failure who runs out of medication; trauma often
not problem
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| Tsunami preparedness in Mie prefecture: fishing village of 700 people in Japan; biggest concern simultaneous
earthquake along 3 fault lines, creating tsunami; have 7 min from first earthquake until 6-m wave enters
village; projected to happen within next 30 yr; leadership of town accepts that one of main responsibilities
protecting citizens of town and being prepared for event; culture of preparedness present; volunteer disaster
prevention associations formed (93% of all households participate); everyone has disaster response kit; every
child in village knows “one quake run”; throughout town, streets and walls marked with number of meters
above sea level; all pathways of evacuation have lighting not dependent on intact electrical system; done as
entire system of response, not individual elements; all cinderblock walls removed on escape pathways (wall
could fall during first quake and block pathway); everyone in village with mobility disorder identified, and
neighbors assigned to evacuate them
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| Pandemic influenza: one of 15 scripted disasters included in national disaster planning process; described by
New York Times in 2005 as “public enemy number one”; most likely to happen and most deadly; inevitable and
will occur with little warning; Centers for Disease Control and Prevention (CDC) has alarming estimates (eg,
2 million people infected, 300,000 excess deaths); reasons for difficulty in preparing for disaster events—numbers
overwhelming; by its very nature, overwhelming task barrier to progress; “park bench paradox”; disasters situations
in which resources outstripped by demands; goal to perform best job with available resources (measure
of success); first responders and local response key (cannot rely solely on professional disaster
responders)
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Suggested Reading
American College of Emergency Physicians: Disaster medical response. Ann Emerg Med 48:645, 2006; Auf
der Heide E: The importance of evidence-based disaster planning. Ann Emerg Med 47:34, 2006; Brown TR:
Emergency preparedness plan crucial for physicians and patients. Am Fam Physician 76:769, 2007; Campos-
Outcalt D: Disaster medical response: maximizing your effectiveness. J Fam Pract 55:113, 2006; Currier M
et al: A Katrina experience: lessons learned. Am J Med 119:986, 2006; Eastman AL et al: Alternate site surge
capacity in times of public health disaster maintains trauma center and emergency department integrity: Hurricane
Katrina. J Trauma 63:253, 2007; Eisenman DP et al: Disaster planning and risk communication with vulnerable
communities: lessons from Hurricane Katrina. Am J Public Health 97 Suppl 1:S109, 2007; Epub 2007
Apr 5. Fry DE: Disaster planning for unconventional acts of civilian terrorism. Curr Probl Surg 43:253, 2006;
Gavagan TF et al: Hurricane Katrina: response at the Houston Astrodome. South Med J 100:926, 2007; Larkin
H: 12-step disaster plan. Hosp Health Netw 80:46, 2006; Levin PJ et al: Can the health-care system meet
the challenge of pandemic flu? Planning, ethical, and workforce considerations. Public Health Rep 122:573,
2007; Mattox K et al: Integrated, collaborative disaster response networks. South Med J 99:1321, 2006; Moore
GS et al: Using blended learning in training the public health workforce in emergency preparedness. Public
Health Rep 121:217, 2006; Nelson C et al: Conceptualizing and defining public health emergency preparedness.
Am J Public Health 97 Suppl 1:S9, 2007; Nusbaum NJ: What physicians need to know when catastrophe
strikes. South Med J 100:1151, 2007; Pou AM: Hurricane Katrina and disaster preparedness. N Engl J Med
358:1524, 2008; Rosenbaum S et al: State laws extending comprehensive legal liability protections for professional
health-care volunteers during public health emergencies. Public Health Rep 123:238, 2008; White C:
Use military and private sector to cope with disasters, aid agencies told. BMJ 335:1233, 2007; Wingate MS et
al: Identifying and protecting vulnerable populations in public health emergencies: addressing gaps in education
and training. Public Health Rep 122:422, 2007.
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