UMass Disaster Medicine

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I am excited to post that John Broach and I published our Disaster Medicine book! It's been a long road and we couldn't have done it without all the amazing authors that contributed to the book and the people at Cambridge University Press. We both hope that this adds to the growth and professionalization of disaster medicine!

"Cases in Simulated Disaster Medicine"
The book contains a series of 44 ready to go medical cases in the setting of disasters. Think a crush injury case that has occurred because an earthquake caused a building collapse. These are complete ready-to-teach cases that educators can use for a wide range of learners ... nursing students, medical students, prehospital providers, residents, fellows and more. Core disaster medicine principles are included with each case. The cases are scalable and customizable to any learning environment, from low-resource teaching settings to high-fidelity simulation labs.

We couldn't have done this without the authors:
Alexander Hart, Ameer Ibrahim, C. Clare Charbonnet, MD, Cassandra Mackey, Christopher Hayden, Cody Johnson, Colleen Donovan, MD, Daniel Saltzman, David Ruby, Denise Fernandez, Emerson Franke, MD, FACEP, FAAEM, FAEMS, Emily Marx, Guy Carmelli, Jim Aiken MD MHA FACEP, James Phillips, MD, Jennifer Carey, Jennifer E. Geller, MD, Jonathan Gammel, Jordan Hitchens, Jorge Yarzebski, Ziad Kazzi, Kyle Herbert, Larissa Unruh, Lauren Bacon, MD, MBA, Lekha Reddy, Liam Porter, Mary McGoldrick, Matthew Carlisle, Matthew Tovar, MD, Meghan Maslanka, Michael De Luca, MD, MS, Michael Weiner, MD, Morgan Ritz, Natalie Moore, Natalie Sullivan, Paul Andrew Baker, Rashed Al Remeithi, Ritu Sarin, MD, Romeo Fairley, Sukhi Atti.

Our amazing book reviewers: Paul Biddinger and Selim Suner MD, MS, FACEP. The folks at Cambridge University Press including Jessica Papworth. And of course, all the support from UMass Emergency Medicine Residency UMass Chan Medical School

https://lnkd.in/ernzBhUP

BTW - the pictures on the cover are all from simulation courses or drills at UMass!

Medical Problems and Concerns with Temporary Evacuation Shelters after Great Earthquake Disasters in Japan: A Systematic Review

Summary by Zilmarie Díaz Pacheco, MD
UMass Disaster Medicine Fellow

This study reviews the literature on the medical problems and concerns that were encountered in evacuation shelters after earthquakes in Japan.

They focused on sanitation, food and nutrition, and medication.

Sanitation = they found that most shelters were poorly ventilated in the winter months and that, due to limited space, it was hard to implement droplet precautions. This led to an increased incidence of acute respiratory infections, tuberculosis, and waterborne diarrheal illnesses. The authors also mention that in most cases, there was no running water, gas, or electricity shortly after earthquakes. The lack of running water affected hygienic handling of food and perpetuated the use of latrines. Latrines were often insufficient, unsanitary, and unsafe.

Food = The food offered in evacuation shelters was not nutritionally balanced, and there was an excessive consumption of sodium by evacuees. The distribution of food between shelters was also imbalanced.

Medications = for chronic conditions were limited in quantity and variety. Many diabetic patients were unable to keep good glycemic control due to their living environment, inadequate nutrition, and lack of their chronic medications. Natural disasters have also been linked to exacerbations of peptic ulcers, COPD, physical disability, sleep disturbances, and cognitive dysfunction.

The authors recommended that health care professionals be dispatched to shelters, one for every 50 evacuees. They also emphasized the importance of providing education about hand hygiene during food preparation and after latrine use.

Tokumaru O, Fujita M, Nagai S, Minamikawa Y, Kumatani J. Medical Problems and Concerns with Temporary Evacuation Shelters after Great Earthquake Disasters in Japan: A Systematic Review. Disaster Med Public Health Prep. 2022 Aug;16(4):1645-1652. doi: 10.1017/dmp.2021.99. Epub 2021 Jun 9. PMID: 34103106.

UMass Emergency Medicine Residency UMass Memorial Medical Center UMass Chan Medical School

Hospital surge capacity preparedness in disasters and emergencies: a systematic review

Publich Health, 2023

Summary by Zilmarie Díaz Pacheco, MD
UMass Disaster Medicine Fellow

Hospital surge capacity is defined as the capability to deal with the sudden influx of patients beyond the usual resulting from a disaster or emergency. It compromises four components: staff, stuff, space, and system.

In this systematic review, authors evaluated the existing evidence on surge capacity by reviewing studies from 2016-2022.

When it comes to “staff”, they found that increasing hospital workforce is the most important way to improve surge capacity. This could be done by using on-call staff, local healthcare providers and volunteers, calling in stand-by or off-duty staff, and hiring staff from other facilities. Hospitals could also expand staff capacity training specialized and non-specialized staff in disaster preparedness.

In the “stuff” and “space” domain, hospitals could stockpile pharmaceuticals and medical supplies, create additional ICUs and ORs, and triage or reallocate scarce supplies. Additional beds could be provided through safe early patient discharge, reverse triage, and cancelling elective surgeries. In the article, authors highlight the need for healthcare coalitions and collaborations strategies to reallocate and distribute the necessary supplies.

In developing surge planning or “systems”, hospitals should examine their existing preparedness and identify possible problems and gaps. This could be done with web-based simulation tools, such as the one proposed by Toerper et al. This tool enables emergency planners to estimate the hospital surge capacity proactively. Authors identified different barriers to surge capacity preparedness in developing and developed countries.

In developing countries, barriers depend on the countries’ health systems and socio-economic conditions and are mostly due to lack of sufficient staff and stuff. In developed countries, most barriers are due to lack of standardized and systemic metrics or models for assessing surge capacity, among other factors.

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Assessment of active shooter preparedness in US hospital systems

American Journal of Disaster Medicine, 2023

Summary by Zilmarie Díaz Pacheco, MD
UMass Disaster Medicine Fellow

This study aims to gain insights regarding standard policies and practices currently used in response to active shooter events by surveying American healthcare leaders. It particularly focuses on insight regarding policies related to managing critically ill or otherwise immobile patients.

A total of 294 active hospital systems were asked to complete the survey, out of which representatives from 60 of these organizations answered. The hospitals were a mix of community and academic sites, both small and large. One third had experience with active shooter events. These institutions were most likely to perform drills.

Over 98% of all institutions had enacted an active shooter protocol. Of these, 24% had a dedicated plan to ensure continuity of care for patients who are critically ill or otherwise immobile.

Some had a “run-hide-fight” approach and others had a “secure-preserve-defend” approach. Authors identified that some well-prepared areas were the fact that most of these institutions had a protocol.

Half of the hospital systems routinely run drills. Most respondents indicated that their institution also has a plan to provide mental health after an event. They recognized areas of improvement such as stocking life-saving supplies and training staff on hemorrhage control.

A great part of the health systems do not have plans to manage critically ill or otherwise immobile patients. This is particularly important because the possibility of evacuating these patients during an active shooter crisis is largely infeasible and could jeopardize staff and patients.

These protocols need to be disseminated and practiced prior to events. Still, it is an ethical dilemma because at the end of the day, choosing to stay behind with patients is “not a moral obligation; it is a moral option”

UMass Emergency Medicine Residency UMass Memorial Medical Center UMass Memorial LifeFlight Brown Disaster Medicine and Emergency Preparedness

Adapting Standards of Care Under Extreme Conditions

Summary by Zilmarie Díaz Pacheco, MD
UMass Disaster Medicine Fellow

Clinical decisions made during disasters and extreme conditions tend to shift to a utilitarian framework where the goal is to achieve the greatest good for the greatest number of individuals. In these events, the clinicians’ focus is on maintaining worker and patient safety, maintaining airway, breathing, and circulation, and establishing or maintaining infection control.

Although the context changes in a disaster, no emergency should change the basic standards of practice, code of ethics, competence, or values of a professional.

This report stems from wanting to understand some of the legal issues and ethical-social expectations in advance of an emergency or disaster, while coming to terms with the fact that there can be no absolute, predetermined answers to many specific questions that arise in emergencies.

The Incident Command System should provide guidance at the moment to these particular dilemmas. Several themes that are discussed are the ability to maintain a safe environment, patient education, ensuring continuity of care, managing information, and communicating effectively during these extreme emergencies.

These and other aspects of emergency care may be affected by loss of essential services, loss of infrastructure, shortage of workers, sudden increase in number of patients or acuity, and relocation to alternate care sites.

The article concludes by recommending that health professionals should consider the ethics and issues in advance, participate in planning and practice, remain committed to delivering the best care possible under the circumstances, and evaluate the response to emergencies for continuous quality improvement.

HHS Administration for Strategic Preparedness and Response UMass Emergency Medicine Residency UMass Memorial LifeFlight UMass Memorial Medical Center

Adapting Standards of Care under Extreme Conditions Guidance for Professionals during Disasters Pandemics and Other Extreme Emergencies | Technical Resources Search the ASPR TRACIE Resource Library and view tailored Topic Collections comprised of current healthcare system preparedness resources.

We are very excited that Dr. Pacheco has joined our EMS/DM team at UMass. Zilmarie has already become an integral part of the group. She is an Emergency Medicine physician and was Academic Chief Resident at the University of Puerto Rico. Dr. Pacheco has won multiple awards, was the resident member to the hospital's executive committee, taught many classes to medical students and resident and was involved in the Medical Student Pride Alliance. We are very happy that she is here for 2 years as a DM fellow pursuing a Masters degree at the same time. And Zilmarie recently passed her written ABEM boards. congrats!

UMass Emergency Medicine Residency UMass Memorial Medical Center UMass Memorial LifeFlight

https://md.rcm.upr.edu/emp/

Here's an article we published. A survey of what disaster medicine doctors actually do ... how much they are paid, how much buy down time they get, what training they have and more!

UMass Emergency Medicine Residency UMass Memorial Medical Center ACEP Disaster Medicine Section

Engaging Active Bystanders in Mass Casualty Events and Other Life-Threatening Emergencies: A Pilot Training Course Demonstration

Summary by Zilmarie Díaz Pacheco, MD
UMass Disaster Medicine Fellow

Disaster Medicine and Public Health Preparedness. 2016

Active bystanders act immediately in the scene of mass casualty events. They can provide initial notification about the event, relay key information to professional responders, and may even supplement emergency responders’ capabilities.

This may result in improved outcomes for victims. This article describes the “Becoming an Active Bystander” training course created by the CDC and FEMA in collaboration with the ASPR’s Division of the Civilian Volunteer Medical Reserve Corps.

Several studies have shown that after training programs, participants are more likely to recognize the needs of, and provide initial care for victims; understand the sequence of actions to be performed; and know how to prioritize the information provided to 911.

In the USA, no broad-based initiative existed at the moment of the study to educate the population on keeping themselves safe in a mass casualty event, help with rescue and evacuation, basic first aid and notifying officials, and interaction and collaboration with emergency responders.

The course was provided to 6 Medical Reserve Corps groups composed of civilians, high school age and above with no prior medical training. They underwent pre- and post- test questionnaires and a course satisfaction survey. Improvement in pre and post test scores were seen among participants, and most found the course to be excellent.

UMass Emergency Medicine Residency UMass Memorial Medical Center UMass Memorial LifeFlight FEMA Federal Emergency Management Agency CDC UMass Chan Medical School Medical Reserve Corps

Mass Casualty Incident Management for Resource-Limited Settings: Lessons From Central Haiti (2021)

Summary by Zilmarie Díaz Pacheco
UMass Disaster Medicine Fellow

This article highlights low-tech, low-cost solutions to facilitate a systematic response to MCIs in resource-limited environments, such as this 300-bed academic hospital in central Haiti.
Some of the solutions implemented were the following:

1) The physician leader of each shift has an assigned cell phone for with nearby MCI alert
2) Chats via Whatsapp are established for ED chair, hospital leadership, department chairs, nursing, and ancillary services to communicate MCI alert.
3) Existing patients are quickly assessed for discharge, transfer of stable patients, and transfer from PACU to inpatient beds
4) Scene triage is not feasible in this setting- “quick look triage” is performed by an experienced ED provider on patient arrival, assigning them to predetermined zones.
5) A response leader is designated, along with triage officer and zone teams, and three groups of mobile personnel to assist in overall evaluation and triage
6) Prelabeled patient stickers are used for identification and documenting of vital signs, orders, and ultrasound results
7) Backup mass casualty carts were created for extra supplies and medications, along with on-call staff for planned events
8) Regular MCI protocol training for ED staff and other hospital staff on ID stickers, supply carts, and notification procedures

UMass Emergency Medicine Residency
UMass Memorial LifeFlight

Lessons Learned From the Evacuation of an Urban Teaching Hospital (2002)

This case report provides lessons learned from the evacuation of a 150-bed adult and 150-bed children’s teaching hospital due to flooding, after tropical storm Allison in 2001 in Texas. The decision to begin evacuating patients was made at 10:30AM, and in 31 hours, 169 patients were discharged and 406 patients were transferred to 29 other facilities. All of this was done without power, water, or telephone service in an actively flooding hospital.

In my opinion, some of the most important lessons learned from this internal disaster:
1) Electrical power outages are not always temporary- assess the cause and begin evacuation early on.
2) Appoint a triage officer to coordinate evacuation, along with a central command center to coordinate communication.
3) Have a reliable in-house communication system and a reliable telephone system for contacting outside facilities.
4) Have flashlights for all caregivers and at least 1 per patient
5) Maintain a paper record of all patients and their transfers/discharges.
6) Do not overwhelm an accepting facility by sending multiple patients at a time.
7) Send staff and equipment over with patients, if necessary, at the receiving facilities
8) Backup batteries should be available for ventilators and pumps.
9) Locate electrical panels high enough to avoid flood damage.
10) Only services that are not critical to patient care should be in the lower levels of a hospital if it is prone to flooding.

Summary by Zilmarie Díaz Pacheco
UMass Disaster Medicine

UMass Emergency Medicine Residency
UMass Chan Medical School