WARNING: Contains graphic/disturbing images.
“Between 1981-1990 Canada experienced 167 declared disasters, approximately 1.4 per month. In 1991-1997, 100 disasters were declared, approximately 1.2 per month.”
(1998 Montreal, Quebec Ice Storm)
As if day to day activities in a paramedic’s life are not enough. What happens when disaster strikes and emergency services are suddenly faced with a mass casualty incident? Who is in charge? Where do the extra resources come from, and who is responsible for organizing them? Each departments’ levels of service and priorities change, which suddenly needs to be coordinated more closely with other emergency departments they may have not usually collaborate with. It is the responsibility of each service and its personnel members to become knowledgeable in disaster management. It is impossible to discuss all the various protocols as it varies from district to district. Here are just some of the things to think about when the unthinkable happens…
An MCI is defined as an incident that overcomes emergency personnels’ capabilities within the first fifteen minutes of response. Whether local or international, an MCI is quickly capable of overwhelming available resources including manpower, materials, vehicles, medication and access to facilities. Paramedics, somewhat unlike firefighters and police, have the unique position of being front line workers coupled with the responsibility as acting liaison to definitive care. For example, during the 2010 disaster in Haiti, EMS1 reported,
“Tens of thousands of people are feared trapped or dead following the magnitude-7 earthquake Tuesday. The Red Cross said Haiti’s disaster relief teams were “completely overwhelmed. “Severe damage to at least eight hospitals is making it nearly impossible to treat the tens of thousands of injured in the capital of Port-au-Prince or prevent outbreaks of disease,” said Paul Garwood, spokesman for the World Health Organization, and hotels are being converted into makeshift treatment centers.”1
(2010 Haiti Earthquake)
Haiti rescue workers were forced into a make-do mentality that would never be seen in the daily activities of emergency service work. Paramedics are forced to think outside the box, which may feel unnatural considering the rules and regulations they are usually confined by. However during a disaster creativity and improvisation can become life saving. For example,
“Local-based responders [in Haiti] were improvising to help victims by turning pickup trucks into ambulances and using door as stretchers. However, CBS reported the efforts were often to no avail because there are few areas in which to then get medical help.”2
Evacuation and temporary shelter become first priorities during this magnitude of disaster. Chances of survival are within the first few days, says EMS1. Triage becomes gristly business as chances of survival must be determined according to the low level of care available at the time. After the evacuation following an earthquake in China in 2008 the focus shifted from transport to the need for supplies, food, and water. The first Canadian Medical Assessment Team, directed by Kelly Prime, discovered that China had the medical personnel resources but,
“They just didn’t have the supplies. They needed medical supplies, because they were going through them so fast. People needed shelter, because they were displaced from their homes. So (CMAT’s) focus shifted (from medical aid) to providing medical supplies, shelter, and any type of food they could use.”3 Thriftiness is so important during an MCI along with effective triage in order to limit the consumption of precious resources. Paramedics’ are faced with the difficult task of deciding who gets what. In Canada strict adherence to the CTAS (Canadian Triage Acuity Scale) is underscored. Patients are evaluated on the basis of CTAS outlines, and not in comparison to the other victims around them.
(Example of Triage Tag)
Beyond the immediate scene a tiered response is activated when a disaster becomes apparent. It is important for first responders to immediately evaluate and request the need for more resources. During a disaster the magnitude of Haiti, decision making power is forced up into the hands of top government officials under the advisement of the most senior and qualified personnel of each emergency service. Within Canada three basic systems could be used to manage disasters. These systems include the Incident Command System (ICS), British Columbia Emergency Response Management System (BCERMS) and Emergency Site Management System (ESM). These systems are implemented because they afford the quickest access to the most resources, as well as facilitate multi-unit organization.
“Disaster response in Canada is the responsibility of elected officials at municipal level. They are mandated by law to prepare for and respond to disasters, which might affect their public (EPC, 1992). Within that broad jurisdiction are elements of various other jurisdictions: fire, police, emergency medical services, health officials, dangerous good specialists, members of local industry and public officials from provincial and federal government departments. However, the ultimate responsibility for disaster response lies with elected officials, not of the Fire Chief, EMS personnel or Police Chief as many assume.”4 A list of local and international disaster management agencies are available on the Canadian government’s website: http://www.publicsafety.gc.ca/prg/em /cemc/res_organization-eng.aspx.
Operations such as Global Medic, created by Toronto paramedic Rahul Singh, are innovators in disaster relief. Singh is critical of other emergency responses to disaster relief and the lack of practice implemented at the government level. He is an adamant supporter of having a thorough plan in place as a preemptive measure that is reviewed according during and after the disaster. Every community should have an emergency response plan that is reviewed at least annually by all members involved. It should be available to the public and kept in a place easily accessible. Having a plan is key to stabilizing the situation within the first 72 hours and reducing “clipboard time.” Singh says,
“Every other agency comes in with a clipboard [to do assessments before sending aid]. We don’t come in with a clipboard; we come in with a solution right away — and then we add to that solution. [Y]es, it’s important to get people hygiene items and to get other non-food items distributed, but in that first 48 to 72 hour period if you don’t get people clean drinking water they die. They get sick; they die. They overwhelm hospitals; they overwhelm facilities and you get outbreaks of disease. So that’s the critical time.”5
The F3 tornado at Pine Lake, Alberta, on July 14, 2000, demonstrated the importance of disaster planning and the critical role played by the EM community. The first response and role of paramedics in EM community at Pine Lake incident cannot be paraphrased. It is the details that make such a massive operation run smoothly and efficiently.
“First responders included the RCMP and EMS. When the magnitude of the destruction became apparent, calls for help were made to surrounding EMS agencies; this activated prearranged mutual-aid agreements. Paramedics on the scene rapidly notified the Shock Trauma Air Rescue Society (STARS) LINK centre and the Red Deer Regional Hospital, where casualties were already arriving by private vehicle. The STARS LINK centre, an aeromedical communications base, immediately dispatched its 2 medical helicopters and enacted its disaster plan, updating the RDRH and the larger Alberta referral hospitals in Edmonton and Calgary.
(2000 Pine Lake, Alberta Tornado)
As darkness fell, the rain and wind picked up. Victims made their way to a casualty collection post (CCP), which had been established near the impact site. First responders set up a triage centre, a helipad and a morgue, and police cordoned off the area to establish an inner and outer perimeter. The RCMP secured the road leading to the campsite; traffic control was imperative to maintain emergency vehicle access to the CCP. Fire, rescue and EMS vehicles began arriving from nearby Innisfail and Red Deer; later, they came from as far away as Calgary. As the search-and-rescue effort grew, a long line of ambulances accumulated along the lake access road.
Many patients were sent by ambulance bus to local hospitals. Those with more severe injuries were transported to the RDRH. Stable “green” patients were taken to a local community centre and evaluated by EMS personnel. The Red Cross was activated to provide shelter and comfort. Most important, they took over the difficult task of accounting for survivors and answering information requests from family members.” 6
According to the Canadian Journal of Emergeny Medicine, the Pine Lake disaster has been heralded as an impetus for the Canadian emergency medicine community to review their disaster plans and prepare for potential events in their own region. Communication is of paramount importance during a large disaster, and yet it is often a victim of the disaster itself. Communications systems may need to be improvised as towers become overwhelmed or destroyed. During the Pine Lake incident information was relayed through airborne helicopters to the STARS LINK centre, which could teleconference with multiple sites, as needed. Unfortunately, while the STARS LINK centre was instrumental in disseminating information, not everyone recognized that it had accurate scene information; hence, most waited for other confirmation before taking action. Communications must be scheduled frequently, on a frequency that has been agreed upon by all members, spoken in plain English and well detailed. Codes are not to be used that are not universal to all services. EMS1 suggests, “Designat[ing] a person outside the expected disaster area as a common calling point- it may be easier to call out of the area, rather than within, during a disaster.”7
The institute for Catastrophic Loss reduction suggests these main principles be upheld by all responders during disaster management:
Appropriate response to unique situations
Flexibility and adaptability
Cooperation across organizations and jurisdictions
Traditional supremacy of elected officials maintained
Provincial and federal governments “in support”
Coordination of planning and response efforts
Enhancement of the flow and distribution of information
An Emergency Operation Center (EOC) must be functional and
Disaster site management through team effort
A part of paramedics’ responsibilities in disaster management is their ability to educate the public in advance. It is a topic less talked about because it is not as exciting or flashy as the gritty work on the front lines. However, involving the public in disaster education and basic emergency care can save a lot of time, not to mention lives. Global Medic encourages locals to participate in securing their own short- and long-term solutions. They suggest public planning and organization of resources are “key in stabilizing disaster situations to allow relief and development agencies to take over.”8 17 million people in N. America are exposed annually to disaster & trauma (1995, Michenbaum). Involving the public spares trained personnel from minor needs and allows them to focus on the most serious cases. Websites such as http://72hours.org/ and http://www.redcross.ca/ are excellent resources for general education on disaster response.
It is also important in paramedic care to provide patients, and often co-workers, with resources for dealing with the after math of disaster and trauma. 25-30% of individuals exposed to traumatic events develop chronic PTSD or some other psychiatric disorder (Yehuda et al, 1994). The Traumatology Institute provides training and debriefing sessions for professionals. http://www.psychink.com/insite.htm
If you would like to volunteer/donate/get information see the TAC (Trauma Association of Canada) website>>>http://www.traumacanada.org/Default.aspx?pageId=987826
Now for some pictures of International Disasters and the Aftermath:
(2004 Indian Ocean Tsunami)
(2010 Pakistan Flood)
(2005 Hurricane Katrina)
(1981-84 African Drought- 20 nations)
(1975 China, Banqiao Damn Failure)
(2011 Philippine Cyclone)
(2009 Australia Wildfire)
(1,593 times China, Yellow River Flooding-)
Take care of each other out there!
Tornado at Pine Lake Alberta 2001