DMAT at the New Orleans Airport: DMAT at the New Orleans Airport: Triage and Command and Control in Triage and Command and Control in

the Austere Environmentthe Austere Environment  

Richard V. King, PhDRichard V. King, PhD

Kelly R. Klein, MDKelly R. Klein, MD

Section on EMS, Disaster Medicine and Homeland SecuritySection on EMS, Disaster Medicine and Homeland Security

University of Texas Southwestern Medical Center at DallasUniversity of Texas Southwestern Medical Center at Dallas

2007 NDMS Conference, Nashville, Tennessee, March 20, 2007

Disaster DefinitionDisaster Definition WikipediaWikipedia: A disaster (from Greek meaning, "bad : A disaster (from Greek meaning, "bad

star") is a natural or man-made event that star") is a natural or man-made event that negatively affects life, property, livelihood or negatively affects life, property, livelihood or industry often resulting in permanent changes to industry often resulting in permanent changes to human societies, ecosystems and environment. human societies, ecosystems and environment.

UNUN: Situation or event, which overwhelms local : Situation or event, which overwhelms local capacity, necessitating a request to national or capacity, necessitating a request to national or international level for external assistance; an international level for external assistance; an unforeseen and often sudden event that causes unforeseen and often sudden event that causes great damage, destruction and human sufferinggreat damage, destruction and human suffering

MedicalMedical: a situation with an imbalance between the : a situation with an imbalance between the acute needs and the locally available resources acute needs and the locally available resources

Regardless, it is when Regardless, it is when your system is your system is

overwhelmed to the overwhelmed to the point that you need point that you need outside assistance.outside assistance.

Katrina DisasterKatrina Disaster

Hurricane Katrina caused the evacuation Hurricane Katrina caused the evacuation of a major U.S. city including >250,000 of a major U.S. city including >250,000 people after the hurricane hit.people after the hurricane hit.

One of the evacuation centers for the One of the evacuation centers for the people trapped was the Louis Armstrong people trapped was the Louis Armstrong International Airport, initially staffed by 3 International Airport, initially staffed by 3 DMATs. DMATs.

DMAT StaffingDMAT Staffing

Physicians (any kind)Physicians (any kind) Nurses (any kind)Nurses (any kind) Nurse practitionersNurse practitioners Physician assistantsPhysician assistants Pharmacists (commercial to hospital based)Pharmacists (commercial to hospital based) Paramedics and EMTsParamedics and EMTs Other health professionalsOther health professionals Support staffSupport staff

What does a DMAT do?What does a DMAT do? Patient Triage/Treatment Site (PTS)Patient Triage/Treatment Site (PTS) Regional Evacuation Point (REP)Regional Evacuation Point (REP) Patient Reception Point (PRP)Patient Reception Point (PRP) Hospital augmentationHospital augmentation Hospital evacuationHospital evacuation Shelter care, standard or special-needs Shelter care, standard or special-needs Mass gatherings and special security eventsMass gatherings and special security events Medical support of other response Medical support of other response

teams/Fed Agenciesteams/Fed Agencies Mass prophylaxis or immunization programsMass prophylaxis or immunization programs

But where is the But where is the science to support science to support

what we do?what we do?

Medical responders have had to adapt Medical responders have had to adapt their practices for the austere medical their practices for the austere medical

environmentenvironment

No food or potable waterNo food or potable water No electricityNo electricity No communicationsNo communications No transportationNo transportation No higher level of care immediately No higher level of care immediately

availableavailable

Do we know how to operate Do we know how to operate safely in this environment?safely in this environment?

Do we know how to get people Do we know how to get people safely on and off a helicopter?safely on and off a helicopter?

TriageTriage Developed by the French military Developed by the French military

under Napoleon it is trauma based.under Napoleon it is trauma based. The most good for the largest The most good for the largest

number of patients regardless of number of patients regardless of rank or status.rank or status.

It was originally based onIt was originally based on• Patient's severityPatient's severity• Resources availableResources available• Transportation availabilityTransportation availability

How do we triage nursing home residents, How do we triage nursing home residents, diabetics, and people with fractured hips?diabetics, and people with fractured hips?

How do we triage people who are How do we triage people who are dehydrated, or stroke patients?dehydrated, or stroke patients?

How do you triage when there is no way How do you triage when there is no way to transport, and too few personnel?to transport, and too few personnel?

Need for researchNeed for research

Much of what we do is based on Much of what we do is based on case studies and anecdotes.case studies and anecdotes.

Training and response practices Training and response practices often have limited scientific often have limited scientific basis.basis.

Need for researchNeed for research

There is a paucity in the medical literature There is a paucity in the medical literature of published research on disasters that is of published research on disasters that is not anecdotal.not anecdotal.

Trauma triage is different from medical Trauma triage is different from medical triage, and it is not widely understood.triage, and it is not widely understood.

Although command and control is Although command and control is encouraged in federal response, in encouraged in federal response, in standard practice it does not seem to work standard practice it does not seem to work well.well.

Purpose of our researchPurpose of our research

Conduct an exploratory, Conduct an exploratory, pilotpilot study: study: Formulate key questionsFormulate key questions Generate hypotheses and Generate hypotheses and

suggestions for further researchsuggestions for further research

Study questions: Study questions: TriageTriage Is there a relationship between the Is there a relationship between the

number of deployments a person has number of deployments a person has been on and how they perform triage?been on and how they perform triage?

Are the majority of patients triaged Are the majority of patients triaged classified as classified as immediateimmediate??

Does level of medical education affect Does level of medical education affect the triage method used?the triage method used?

Is START the prevailing triage Is START the prevailing triage method?method?

Study questions: Study questions: Command & ControlCommand & Control

How well does the command and How well does the command and control function given large groups control function given large groups who do not regularly train and work who do not regularly train and work together?together?

Will perceptions of command and Will perceptions of command and control vary with the number of control vary with the number of deployments team members have deployments team members have experienced?experienced?

MethodMethod

An IRB-approved questionnaire was An IRB-approved questionnaire was provided to >100 DMAT team provided to >100 DMAT team members who had been at the New members who had been at the New Orleans airport during medical triage Orleans airport during medical triage operations.operations.

Results were summarized from the 16 Results were summarized from the 16 questionnaires returned.questionnaires returned.

ResultsResults

Who were our 16 DMAT Who were our 16 DMAT respondents?respondents?

Median age: 45 (Range: 37-59)Median age: 45 (Range: 37-59) 11 Male; 5 Female11 Male; 5 Female 12 practice healthcare in civilian life12 practice healthcare in civilian life 12 received triage training in past12 received triage training in past 10 practiced triage in past10 practiced triage in past 10 performed triage at the New Orleans Airport10 performed triage at the New Orleans Airport

Roles of the DMAT membersRoles of the DMAT members

MedicalMedical

NursesNurses 55

ParamedicsParamedics 5 5

PhysiciansPhysicians 22

EMTEMT 11

PAPA 11

Other Team MembersOther Team Members

CommunicationCommunication 33

LogisticsLogistics 22

SecuritySecurity 11

LeaderLeader 11

Other-UnspecifiedOther-Unspecified 22

Note: Several DMAT members played multiple roles.

Triage Training Type by Education LevelTriage Training Type by Education Level

Education LevelEducation Level STARTSTART SAVSAVEE

MilitarMilitaryy

TotaTotall

PhysicianPhysician 11 22 00 33

NurseNurse 44 11 11 66

ParamedicParamedic 55 22 22 99

EMTEMT 11 00 00 11

PAPA 00 00 11 11

CommunicationCommunication 22 00 11 33

LogisticsLogistics 11 00 00 11

Other/UnspecifiedOther/Unspecified 11 00 00 11

TOTALTOTAL 1515 55 55

Triage methods used at the Triage methods used at the New Orleans AirportNew Orleans Airport

Of the 16 respondents, 10 performed Of the 16 respondents, 10 performed triage, using the following methods: triage, using the following methods:

STARTSTART 55

SAVESAVE 11

MilitaryMilitary 00

OtherOther 33

Did not specifyDid not specify 77

Number of deployments and triage method usedNumber of deployments and triage method used

# of Deployments# of Deployments STARTSTART SAVESAVE MilitarMilitaryy

Other Other or or

BlankBlank

11 22

2-52-5 33 22

6-96-9 11 22

10-1310-13 22

>13>13 33

TOTALTOTAL 55 11 00 99

Where was triage performedWhere was triage performed

AreaArea nn

Flight line and baggage area (staging) 14 Flight line and baggage area (staging) 14

(Staffed by 1 DMAT w/augmentation)(Staffed by 1 DMAT w/augmentation)

Departure area (medical treatment)Departure area (medical treatment) 10 10

(Staffed by 2 DMATs)(Staffed by 2 DMATs)

The majority of patients triaged The majority of patients triaged were labeled were labeled minimalminimal——

not not immediateimmediate

ImmediateImmediate 13% 13%

DelayedDelayed 13%13%

MinimalMinimal 64% 64%

Expectant Expectant 1%  1% 

Adequacy of Command and ControlAdequacy of Command and Control

Was command and control adequate?Was command and control adequate?• YesYes 2 2• NoNo 1313

During the deployment the command and During the deployment the command and control structure:control structure:• ImprovedImproved 4 4• Stayed the sameStayed the same 4 4   • WorsenedWorsened 2 2

Number of deployments and perceptions of the Number of deployments and perceptions of the adequacy of command and controladequacy of command and control

 

# of# of

DeploymentDeploymentss

AdequatAdequatee

NotNot

AdequatAdequatee

ImprovedImproved WorseneWorsenedd

NoNo

ChangChangee

11 33 11

2-52-5 55 11 11 11

6-96-9 11 11 11

10-1310-13 11 11 22

>13>13 33 11 22

TOTALTOTAL 22 1313 44 22 44

Challenges of doing research Challenges of doing research during a disasterduring a disaster

QuestionnairesQuestionnaires• What are the important questions to ask?What are the important questions to ask?• How do you write a questionnaire that answers How do you write a questionnaire that answers

important questions without making it long and important questions without making it long and cumbersome?cumbersome?

• How can you create reliable and valid instruments?How can you create reliable and valid instruments?• How do you minimize bias in the questions you ask How do you minimize bias in the questions you ask

and how you ask them?and how you ask them?• When should you ask the questions?When should you ask the questions?• How do you get a sufficient number of responses?How do you get a sufficient number of responses?• What statistical tests are appropriate?What statistical tests are appropriate?

Challenges of doing research Challenges of doing research during a disasterduring a disaster

Patient carePatient care• How do you do patient care and How do you do patient care and

research at the same time?research at the same time? IRBIRB

• Adequate protection of human subjectsAdequate protection of human subjects• Timely approvalTimely approval

Suggestions for further researchSuggestions for further research

How does triage occur in actual disasters?How does triage occur in actual disasters? How can we incorporate How can we incorporate resourcesresources and and transporttransport into triage models and algorithms? into triage models and algorithms?

Does command and control work, and how Does command and control work, and how can it be improved?can it be improved?

What is the “right stuff” that differentiates an What is the “right stuff” that differentiates an effective disaster responder or leader?effective disaster responder or leader?

Do people have the skills and abilities they Do people have the skills and abilities they need to make decisions in the early part of a need to make decisions in the early part of a disaster?disaster?

Other suggestions for Other suggestions for research?research?