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Prevention and Treatment of Injuries Following Hurricanes and Tornadoes

Moderator:Leticia R. Davila

Presenters:Dr. David Sugerman, MD, MPH, FACEP and Dr. John Armstrong, MD, FACS

Date/Time:July 11, 2013 2:00 pm ET

NOTE:This transcript has not been reviewed by the presenter and is made available solely for your convenience. A final version of the transcript will be posted as soon as the presenter’s review is complete. If you have any questions concerning this transcript please send an email to coca@cdc.gov

Coordinator:
Welcome and thank you for standing by. At this time all participants will be in a listen-only mode. During the question and answer session please press Star 1 on your touch-tone phone and please record your name clearly when prompted. Your name will be required to introduce your question and when recording your name please make sure your phone is off mute. Today’s conference is being recorded. If you have any objections at this time you may disconnect. And now I would like to turn the meeting over to your host Ms. Leticia Davila. Ms. Davila, you may begin ma’am. Thank you.

Leticia Davila:
Thank you (Rico). Good afternoon I am Leticia Davila and I represent in the Clinician Outreach and Communication Activity, COCA with the Emergency Communications System at the Centers for Disease Control and Prevention.

I am delighted to welcome you to today’s COCA Webinar, Prevention and Treatment of Injuries Following Hurricanes and Tornadoes. We are pleased to have with us today Dr. David Sugerman from the Centers for Disease Control and Prevention and Dr. John Armstrong from the Florida Department of Health. They will discuss the current state of science and epidemiology and state level response for the prevention and treatment of injuries following hurricanes and tornadoes.

You may participate in today’s presentation by audio only via Webinar or you may download the slides if you are unable to access the Webinar. The PowerPoint slides set and the Webinar link can be found on our COCA Web site at emergency.cdc.gov/coca. Click on COCA Calls; the Webinar link and slides set will be found under the call in number and call passcode.

At the conclusion of today’s session the participant will be able to describe the major challenges supervision of pre-hospital care, discuss the patterns of injury seen after hurricanes and tornadoes including appropriate initial management, and review appropriate emergency risk communication messages and the importance of data collection to improve messaging and response efforts.

In compliance with continuing education requirements all presenters must disclose any financial or other associations with the manufacturers of commercial products, suppliers of commercial services, or commercial supporters as well as any use of an unlabeled product or products under investigational use. CDC our planners and the presenters for this presentation do not have financial or other associations with the manufactures of commercial products, suppliers of commercial services, or commercial supporters. This presentation does not involve the unlabeled use of a product or products under investigational use. There was no commercial support for this activity.

At the end of the presentation you will have the opportunity to ask the presenters questions on the phone dialing *1 will put you in the queue for questions. You may submit questions through the Webinar system at any time during the presentation by selecting the Q&A tab at the top of the webinar screen and typing in your question.

Our first presenter Dr. John Armstrong is the Surgeon General and Secretary of the Florida Department of Health. Dr. Armstrong oversees the Emergency Support Function ESF-8, the public health and medical services, for 19.2 million Floridians and 89 million visitors annually. He is a graduate of Princeton University and the University of Virginia School of Medicine and performed his surgical residency at Tripler Army Medical Center, his trauma critical care Fellowship at the University of Miami/Jackson Memorial Hospital and his Master Educator in Medical Education Fellowship at the University of Florida at Gainesville.

Our second presenter Dr. David Sugerman is the Health Systems Team Lead in the Division of Unintentional Injury Prevention, National Center for Injury Prevention and Control at the CDC. In 2007 he joined the CDC Epidemic Intelligence Service as a Medical Officer in San Diego County followed by a position in the Division of Injury Response which focused on traumatic brain injury, pre-hospital triage of injured patients, and the health system strengthening. In addition to currently serving as the Health Systems Team Lead he works clinically at the Emory University Hospital Emergency Department. Dr. Sugerman is a graduate of Thomas Jefferson Medical College. He completed a Masters of Public Health at the Johns Hopkins School of Public Health and his residency in Emergency Medicine at the Johns Hopkins Hospital in 2007.

Again the PowerPoint slide set and Webinar link are available from our COCA Webpage at emergency.cdc.gov/coca. At this time please welcome our first presenter Dr. John Armstrong.

Dr. John Armstrong:
Thank you Leticia and good afternoon everyone. I’m delighted that you all are on this call. We will begin with a focus on injuries from hurricanes.

And this is an important reminder that every year our nation faces six months of hurricane threats. We in Florida, with 1,200 miles of coastline, face this threat perhaps to a greater degree than most other states and thus have gained a great deal of experience in readiness and management of the events surrounding hurricanes.

Here you see pictured four hurricanes from 2004 that crossed our state. And in the 2004-2005 hurricane seasons, we faced nine storms that included a tropical storm as well.

So this conversation, though focused on hurricanes, should also be relevant when it comes to tropical storms. As I look at this slide, I am reminded of my own personal experience in South Florida where I was for the 2004-2005 hurricane seasons. So I gained personal experience as well as professional endeavors in navigating these hurricanes in South Florida.

The objectives of this part of the program: (1) at the end of this you should be able to describe injury epidemiology associated with hurricanes, and (2) you should be able to discuss management of public health issues associated with hurricanes.

First a bit about hurricane mechanics: often when we hear about hurricanes, we hear them described in terms of the Saffir-Simpson system, which grades them from categories one through five and really is focused on the first bullet, wind speed.

I have not included the Saffir-Simpson grading scheme in this presentation because focusing only on wind speed misses a variety of other elements relevant in damage caused by hurricanes. This includes the forward speed of the hurricane and the direction, so forward speed and vector. It also includes the storm surge. The surge occurs because of the activity of wind on water and is a major source of flooding in coastal regions.

Rain also must be accounted for and is particularly responsible for flooding in inland regions. And then heat is an element that we often don’t describe with hurricanes and yet we must include as hurricanes occur at a very inconvenient time in the seasons. They occur typically when it is very hot, and that can lead to a variety of health issues during and after the hurricane event.

So as one reflects on injuries that occur as a result of hurricanes, it’s important to include all five of these mechanics in your mind, with resulting injuries. Now we’re going to look at the experience of Florida prominently in 2004 – 2005, where Florida did a great job in collecting data and was privileged to present this through the MMWR and through other publications.

In this chart you see the listing of deaths in Hurricane Charley, which was famous in Florida for doing a right hook south of Tampa Bay and catching a community in the Punta Gorda region of Florida somewhat off-guard.

What this shows first is taking a long view on health and injury issues coming out of a hurricane: as you see listed across the top of the slide, the dates through August on into September, when deaths occurred. Into the left side, you see the cause of death.

The number one cause of death was trauma, which accounted for over half of the deaths. And another important reality coming out of these events was exacerbation of a medical condition that led to death.

When we look at Hurricane Katrina in Florida, we see similar patterns. This table presents with greater granularity some of the causes of death. And note: hit by falling tree limb, car collision, and fall from ladder. Again traumatic injury accounted for the greatest numbers of deaths coming out of Hurricane Katrina.

Now some might be wondering why Katrina is listed for Florida when the prominent effect of Katrina seemed to be in the Gulf Coast in Louisiana and Mississippi?

Well, Katrina formed as a tropical storm initially just off the east coast of South Florida in the Bahamas, and within 24 hours was a category one hurricane and moved very quickly across South Florida and caused $386 million in damage.

I won’t forget hearing the weather reporter at the time declare that hurricane Katrina was “just a category one hurricane”. I would caution that any tropical storm and any hurricane demands respect and can inflict significant injury and environmental harm.

Well as we think about populations at risk for mortality and morbidity in the aftermath of a hurricane, it’s not just the populations in communities it’s also the responders. And Fayard and colleagues did a nice review of deaths related to response to hurricanes.

And in this chart you see what was responsible for 72 deaths in a review of hurricane deaths over a period of 15 years in first responders.

And you’ll see that it’s debris from the hurricane, it’s vehicular trauma, it is the use of machinery to recover, and then you get into issues of [drowning from] fishing boats, falls from roofs, and generators prominently [producing] carbon monoxide.

But what this really shows is again the relevance of traumatic injury when it comes to death and disability in the aftermath of hurricanes.

Now Ragan and colleagues looked at all hurricanes that struck Florida in 2004 - 2005 and recognized 213 deaths.

This chart shows in which phase of the hurricane death occurred, and has significant importance in recognizing that it is the post-impact phase where most deaths occur.

Typically we think about deaths occurring more when the hurricane strikes with the force of winds but the reality is that most deaths occur and most injuries occur in the recovery phase after impact of the hurricane.

Looking at the same data set of the 213 deaths, three quarters were men. Almost 80% were greater than 40 years of age. And in fact the median age of death was 58 in the state. This reflects the older population that exists in Florida. Florida has 17% of its population that is 65 years of age and older.

And again note that trauma accounted for half of the deaths. Non-accidental deaths refers to exacerbation of medical illnesses that led to deaths. So this includes prominently antecedent cardiovascular disease.

Fayard also looked at activities that were associated with death in responders following hurricanes, and in the 72 deaths recognized that it was performance of duties that was implicated more than the hazardous environment itself as the cause of death.

So as one thinks about risk communication messages to various populations, to include the responder community, it’s important to emphasize that environment is hazardous and yet it’s decisions related to rescue activities and recovery activities that lead to death more commonly.

Looking at the consequences of four storms in Florida from 2004 to 2005, recognize that the deaths do not sum to 213 because they don’t include all of the hurricanes.

But this gives you a sense of the scale of mortality as well as the economic cost from these storms: economic cost seen in the far right and column in billions of dollars.

Well, let’s shift gears a bit and look at the specific hazards during the storm and then move to hazards in the recovery phase and how it is we navigate the various health and trauma issues that emerge.

Well during the storm, there can be issues with structural collapse, and windborne debris, and falling trees, and downed power lines, and all of these relate to the wind component typically of a hurricane.

Now the surge component obviously can be responsible for loss of foundations and structures that are close to the shoreline, and similarly large amounts of pooled rain can pose a challenge for structures inland, particularly where the rainwater can collect on roofs.

And hazards after the storm relate to flooded roads. And typically people try to use vehicles through these flooded roads, and they can be readily picked up by current. There are utilities that are exposed. These include gas lines and electrical wires.

There are issues with insects and animals. The insects that challenge us in Florida include mosquitoes and fire ants, fire ants being displaced. And the animals that challenge us in Florida relate to snakes and rodents who are displaced from their natural environments, and they can float to other areas.

Potable water remains a challenge after the storm and particularly the lack of reliability with tap water initially.

And then carbon monoxide poisoning - carbon monoxide poisoning is an injury that results from the operation of gas generators.

And again, you’re getting a sense of where the risk communication messages need to be if we are going to reduce injuries and promote health coming out of hurricanes. Public health consequences relate to death, challenges with water and food shortages, and environmental hazards that we’ve articulated.

Loss of power: I had intimated earlier that it’s important to remember when it is that hurricanes occur. They occur typically in the summer into early fall, and it is very hot.

What made Florida habitable was the introduction of air conditioning. And loss of air conditioning is a very big deal in the post-storm phase and can lead to a variety of dehydration states and heat injury.

Infrastructure is damaged, and this can include the health and healthcare infrastructure.

We had just this past hurricane season a tropical storm, Debbie that hit the Panhandle. Didn’t make a lot of national press, but completely flooded several of our counties, to include the county health department, which was a major provider not only of health but of primary health care. And we found opportunities to improve the readiness plan there.

Population gets displaced as well, and it gets displaced because homes are lost, livelihoods are lost, and the education infrastructure is temporarily or more permanently lost (and that then results in kids who are not able to go to school).

And where the displaced populations can go can create its own public health challenge in terms of maintaining existing health and preventing chronic diseases from becoming acute diseases.

The classic example of the challenges with the displaced population relates to Hurricane Katrina in New Orleans.

Well, the health challenges that then emerge coming out of hurricanes relate to traumatic injury, heat injury, mosquitoes, the exacerbations of chronic disease, and the one that we typically do not plan as well for across the nation and that relates to the psychosocial effects.

So it is very important in planning, to plan for how to help communities gain resiliency with the consequences of wind and rain storms.

Looking at impact on a healthcare system following a hurricane, this is an example from Hurricane Wilma, which ripped across South Florida in 2004.

This was an interesting study that looked at presentation of patients to a community hospital following Hurricane Wilma.

And what you can see here interestingly enough is less an issue with trauma and more an issue with managing people with chronic diseases. And in this case, those with end-stage renal disease who require dialysis - and you can see that with a loss of existing dialysis centers, the presentation of patients to the emergency department increased during this time.

So part of the messaging for the population in general is to ensure that those with special medical needs have a contingency plan, and that the community response plan feeds into contingencies for management of some of these chronic diseases.

The injuries from hurricanes really relate to lacerations, puncture wounds, and blunt trauma, and these occur typically in the recovery phase.

Lacerations and puncture wounds occur prominently on the feet and on the upper extremities in those are engaging an environment that is more hostile with sharp objects.

So one of the key messages is wearing shoes and also being very careful with climbing ladders and with debris removal.

Blunt trauma relates to recovery phase with motor vehicle crashes because motor vehicles are moving in areas where they typically aren’t accustomed to being, and as well, to issues of debris removal and occasionally structural collapse.

A prominent part of our message is to reflect on wound care carefully and recognize that coming out of hurricanes that the wounds are not the same as wounds in everyday emergency care.

These wounds typically are much dirtier. So the message is wash them out: so irrigate, debride them of devitalized tissue, use wet to dry gauze dressings and don’t close them initially.

If you close them initially, chances are very good that they will get infected. These are tetanus prone wounds, so verify the tetanus status of individuals with wounds is essential.

And there is no need to use IV antibiotics. The overwhelming management technique is essential wound care that avoids primary closure.

The other issue that I’ve shared is related to carbon monoxide poisoning, again with generators. So the key risk message is to make sure people know how to use their generators and importantly that they do not operate them inside a house.

Here you see across four hurricanes in Florida in 2004, the presentation of patients to emergency departments with carbon monoxide poisoning, and recognize that carbon monoxide poisoning not only occurred on the front end but could occur on the backend in recovery as people use their generators. And carbon monoxide poisoning can be fatal.

This is a nice graph that highlights the symptoms. And the message here is be alert to these symptoms in emergency departments so that you can make the diagnosis of carbon monoxide poisoning and then provide appropriate treatment.

Note that most treatment can be done in the emergency department only or with some hyperbaric oxygen.

Looking at the volume in emergency departments after hurricanes, people like to think that when the hurricane strikes, that’s when they’re going to be busy; and the reality is that when the hurricane strikes, that’s when there’s a dip in activity in emergency departments because patients can simply not get there.

So that does mean that there will be a spike post-hurricane not only related to injuries coming out of a hurricane but importantly to the collection of non-hurricane related diseases that now can present to the emergency department.

Messages for risk communication are absolutely essential to share with the community: the risks with generators and carbon monoxide poisoning; issues of heat exhaustion and ensuring adequate hydration; preventing illness; avoiding floodwaters; being very careful with debris removal and climbing up ladders and using chainsaws; and obviously preventing mosquito borne illnesses by draining any standing water and wearing cover and insect repellent.

Obviously in the hot season, it can be difficult to wear long sleeved shirts and long pants: mosquito repellent then becomes essential as a practical measure.

You monitor following hurricanes for the injuries, the outbreaks, and regular health maintenance. And data collection is absolutely essential to identify lessons and apply them to the plan for the next disaster.

Well in summary traumatic injuries are most relevant in storm recovery, and risk communication is essential during all storm phases to mitigate injury.

Dr. David Sugerman:
Thanks John. This is David Sugerman I’m going to join and talk about tornado injuries. I’m going to talk about recent epidemiology, known risk, and preventive factors, common clinical presentations, and important treatment considerations.

First by way of definition the Enhanced Fujita scale or EF scale rates the strength of tornadoes in the United States based on damage they cause.

Wind speeds of tornadoes range from 65 miles per hour up to more than 200 miles per hour with those over 200 miles per hour being the most violent or so called EF-5 tornadoes.

Of the note the strength of a specific tornado is assessed retrospectively based on the damage caused to trees and structures.

The recent tornadoes that struck Oklahoma City this year and Joplin and Alabama in 2011 were EF-4 to 5.

This is a graph of the number of Enhanced Fujita (EF)-3 plus U.S. tornadoes seen as purple bars overlaid with the number of deaths represented by the yellow line.

Despite few intense tornadoes in 1953 there was a high number of tornado deaths leading to the implementation of a ground based radar warning system that allowed local weather forecasters to track storms across regions.

Since 1953 US tornado deaths have been correlated with a number of intense tornadoes and the population density along their destructive path including 2011 with the most deaths from the Alabama and Joplin, Missouri tornadoes.

Primary prevention is a public health goal, with enough lead time people may be able to avoid the predicted tornado path sheltering at work, school, or with friends and family.

However the federal tornado warning lead time is only 13 minutes due to forecasting limitations. This often only gives people enough time to seek nearby emergency shelter.

By far the best option is to shelter underground in a basement or storm shelter however in many parts of the country public and private underground structures are rare due to high water tables, shifting soil, high construction costs and rocky terrain.

As a last resort people should shelter in the lowest interior windowless room in a sturdy building. And if driving park their vehicle and stay belted.

A case series out of Alabama on three children published in Pediatric Emergency Care in 2012 showed that a nine year old with a baseball helmet and two and nine week olds in infant car seat carriers survived and EF-4 tornado with minimal to no injuries; however larger studies will be needed to determine if head protection is truly protective.

Further recommendations on tornado preparedness can be found on the CDC, American Red Cross, and National Weather Service Web sites.

Throughout the remainder of the presentation I’ll be mentioning an investigation our CDC team did along with the Alabama Department of Public Health conducted in Alabama following the April 27, 2011 tornadoes that resulted in over 1,500 injuries and 250 deaths.

In this investigation we performed chart abstraction at 39 hospitals throughout the state finding 1,398 injuries.

This was followed by interviews with 98 cases and 200 uninjured controls with similar exposure based on distance from the tornado path.

On this map you can see the cases, orange triangles, and controls, blue boxes, along tornado paths seen as black lines.

Let me switch back to national data. Form 1985 to 2010 nearly 2/3 of tornado deaths have occurred in mobile homes though only 6% of US population live in a mobile home. Data was unavailable from 1996 to 1999.

In an attempt to address deaths in mobile homes the Federal Tornado Shelter Act was signed into law in 2003.

It allocated community development block grant funds to construct storm shelters in mobile home parks.

However following the 2011 tornadoes deaths in permanent homes far exceeded those in mobile homes, highlighting the need for additional protection for those living in permanent homes.

Our Alabama investigation showed that a majority of injuries were in permanent homes though persons in mobile homes were 11 times more likely to severely injured.

No injuries were noted among persons in public or commercial buildings or storm shelters.

While we should always strive to prevent injury from occurring lives can still be saved from post injury care this includes the actions of bystanders in extricating those trapped under debris and provision of basic first aid, the immediate dispatch of emergency medical services, and triage of injured patients to the appropriate level of care, and the rapid treatment of injuries in field or standing hospitals.

In Alabama community members arrived on scene with pickup trucks and chainsaws helping remove victims from debris before ambulances could arrive with 40% of total injuries arriving by private vehicle.

During tornadoes wind speeds of up to 250 miles per hour pull up organic and inorganic matter, housing material, including glass, siding, and framing as well as the bark of trees, shrubs, and soil circulate creating a large debris storm that rips through homes and penetrates bodies like shrapnel.

As a result victims have poly traumatic injuries including amongst others complex contaminated wounds at risk for infection, crush injuries, and traumatic brain injuries from falling debris and walls.

From an analysis of injuries at St. Michael Community Hospital in Oklahoma City following the 1999 tornado you can see that a majority of injuries are wounds, abrasions, lacerations, and punctures from falling debris.

While uncommon significant injuries can occur from head, chest, or abdominal trauma including spinal cord injuries.

Data from our investigation in Alabama showed that 64% of total injuries were due to extremity trauma, predominantly minor wounds, while chest and head trauma constituted a majority of severe injuries (injury severity scored greater than 15) injuries.

Furthermore head injuries resulted in most ICU admissions, 56% and deaths, 71%. We also found that 22% of the 298 surveyed individuals screened positive for PTSD six months following; noting the death of a close person, loss of one’s home, and psychiatric history increasing the odds of developing PTSD.

Mental health services are extremely important in the days, weeks, and even month following natural disasters with a large number of casualties.

In examining patients with wounds and possible fractures many require plain films while those with chest abdominal and/or head trauma will often require CT scans. Imaging is often a bottleneck in treating a patient surge made more challenging if running on a generator power due to storm damage.

While most patients only require irrigation and basic dressings a large number will require sutures. At Tuscaloosa General Hospital where they treated nearly a 1000 patients in a six hour window, using a closed cafeteria as an alternate treatment site to suture wounds, helped decompress the emergency department.

Other patients will require IV fluids and antibiotics as well as casting or splinting of fractures. Still others will require emergent operations for intracranial hemorrhage, intra-abdominal trauma or complex orthopedic repairs or washouts.

Tornado wounds are often contaminated with soil from the environment leading to polymicrobial infections with aerobic gram-negative bacilli.

Infections due to Clostridium perfringens have become quite rare due to improved treatment as John had mentioned due to delayed closure and early washout.

Fungal infection should still be considered as demonstrated by the 13 Mucormycosis cases in Joplin, five of which died.

Prior tornado studies have seldom identified Nosocomial sources.

For patients with contaminated wounds initial treatment with broad spectrum antibiotics should only be considered but predominantly as John also mentioned the focus should be on immediate irrigation, and wide debridement, and removal of foreign bodies as well as tetanus prophylaxis.

The key to wound management is copious irrigation under pressure at the bedside and/or the operating room for severe injuries. This is followed by debridement of foreign bodies, delayed wound closure, antibiotic prophylaxis if needed and tetanus immunizations.

In Joplin wound treatment was delayed by severe damage to St. John’s emergency department, a possible risk factor for the fungal infections that followed.

So not as common as in earthquakes, tornadoes can lead to building collapse causing crush syndrome. Typically lower extremities are involved with pressure on muscles causing myocytes and nerves to die leading to kidney damage and possible failure, hyperkalemia, and hypercalcemia, and death, 1/3 develop renal failure and 1/2 of those can die. Five [mucormycosis] cases in Joplin had rhabdomyolysis at admission.

Treatment for crush injuries should be initiated in the prehospital setting with intravenous fluids prior to removing the crushing object.

After removing the object IV hydration should continue into the hospital along with diuretics, swollen limbs should be assessed for compartment syndrome.

Post disaster surveillance for personal risk factors is quite complicated. When homes are destroyed it can be very difficult to determine individual addresses for patient interviews.

Furthermore individuals will often not be present for interviews as they may have evacuated before the disaster or relocated after their home was destroyed and won’t - most won’t have call forwarding enabled.

Some persons will return to sift through debris for valuables one to two weeks following the disaster while some won’t.

In nearly all states, injury is not a reportable condition and is seldom made so during disasters limiting medical record abstraction or contacting patients due to HIPAA concerns at hospitals.

These limitations hamper a more complete understanding of risk factors for primary prevention and clinical care.

Of note on April 30, 2013 the Department of Homeland Security included a new provision the Disaster Recovery Assistant File System of Record.

This provision allows FEMA to share private data with federal, state, tribal, and local government agencies to contact individual and household program applicants that receive resources from FEMA to identify ways to improve community preparedness. This provision will enable a more detailed understanding of risk factors for injuries. Thank you.

Leticia Davila:
Thank you Dr. Armstrong and Dr. Sugerman for providing our COCA audience with such a wealth of information. We will now open up the lines for the question and answer session. And also remember you can submit your questions through the Webinar system. Operator?

Coordinator:
Thank you. And for those on the phone at this time if you’d like to ask an audio question please press * 1 on your touch-tone phone.

Please record your name clearly when prompted. When you’re recording your name please make sure your phone is off mute.

Once again *1. Please record your name clearly when prompted and please make sure your phone is off mute. One moment as we wait for our first questions.

Leticia Davila:
While we’re waiting, operator, I do have a question that has come through the Webinar system. The question is how can clinicians be better prepared for disasters?

Dr. John Armstrong:
I think the first step in clinical readiness is ensuring personal and family readiness. And that means having an individual plan; having the kit, so including plenty of water, plenty of food, personal medications; and then ensuring that you’re listening to the various warnings that are coming from a variety of sources before a hurricane strikes in this particular example.

The difference between a hurricane and a tornado in terms of readiness to a degree is that one can see hurricanes coming. You don’t always know precisely where they’re going to land. Tornadoes really are much less predictable.

Principles of readiness still apply across the settings, but that having been said, the reaction time is significantly less with tornadoes.

And then clinicians need to ensure they’re integrated in the readiness plans of their healthcare facilities, so particularly hospital-based clinicians, but also in the readiness plans across communities in general.

Dr. David Sugerman:
And I would just add to what John said by mentioning the importance of drilling tabletop exercises within hospitals. And then actually more live exercises where you actually go on auxiliary power. Several hospitals in Alabama lost power. They were unable to have enough power to generate their Electronic Health Record, air-conditioning in a hospital.

They also lost water pressure as two water tanks were destroyed by the tornado and weren’t able to sterilize instruments, so kind of thinking about contingency plans when several things around the hospital are destroyed as well as essentially portions of the hospital. And in spite that you’re going still receive large numbers of patients. So drilling and preparedness for contingency plans is really important. Alternative treatment sites can help converting flat space, all available flat space. I had mentioned the cafeteria but auditoriums angiography suites, et cetera, reverse triage can really help get people out of the hospital that don’t really need to be there and provide more space for treating patients as well as having locations for those that are worried well that are going to come because you’re the only light on the hill as was described in Tuscaloosa.

They had 1000 persons just seeking shelter as their homes were destroyed and they were concerned about oncoming storms. So you’re seeing a surge of injured patients as well as worried well that you have to manage.

Dr. John Armstrong:
This is John Armstrong. I think David’s point is so important - I’m just going to reemphasize it.

Having realistic drills is essential and for a good readiness posture.

And that means that you can actually drill within your homes for your own personal readiness and importantly drill in your clinical practices and in your hospitals and make them as realistic as possible.

The worst time to figure things out is “on the job” when a disaster strikes.

Another element of readiness is gaining insights from programs such as this. There are a variety of courses that are available for disaster readiness clinically, and what would include the National Disaster Life Support series of courses as well as courses from professional societies like the American College of Surgeons Disaster Management and Emergency Preparedness Course.

Coordinator:
And once again for those parties on the phone at this time if you would like to ask an audio question please press *1 and please record your name clearly when prompted.

Leticia Davila:
We do have another question from the Webinar system. What about care of vaccines during an event?

Dr. David Sugerman:
Care of - could you repeat that question, care of vaccines?

Leticia Davila:
Yes the care of vaccines during an event?

Dr. David Sugerman:
Oh when you’ve lost (cold chain). Is that the idea during a loss of power?

Leticia Davila:
Yes I’m assuming so. If there is a person by the name of (Patrick) on the line you can go ahead and chime in. But that’s the question that came through.

Coordinator:
If - (Patrick) needs to *1 on his touch-tone phone to get this line opened up.

Leticia Davila: Thank you.

Coordinator:
(Patrick) if you’re out there sir - hold on one moment. He did Star 1. One moment.

(Patrick McGary):
>Hello?

Coordinator:
(Patrick) your line is open.

(Patrick McGary):
Hello. This is (Pat McGary) from AAFP. And it is a big concern of many of our doctors what to do with vaccines in the event of a tornado. I’m in Kansas so we get a lot of those. But now where to find a secure power supply and refrigeration? And this is true with all other supplies that require that.

Dr. David Sugerman:
I would think one of the options that you’re talking about for folks that are primary care providers outside of the hospital system.

But hospitals should really have backup generator power and would be able to hopefully store some of those vaccines. I would think that partnerships with different large companies like Wal- Mart might be helpful, but those are just some suggestions.

(Patrick McGary):
That’s helpful. I didn’t think about the retail aspect.

Coordinator:
And at this time we have no other questions in the queue.

Leticia Davila:
Thank you. We do have some from the Webinar system. Do current studies support the recommendation to include helmets for tornado head injury protection?

Dr. David Sugerman:
Thanks for that question. Right now there have been a number of studies showing that people injured during tornados often have severe injuries and often die from head injuries. There was the case series as I mentioned out of Alabama with three children, two infants, showing some benefit from wearing helmets. But at this point there are no large cohort or case control studies to really demonstrate the effectiveness or animal or human model simulation studies.

There’s certainly no negative to wearing a helmet. But the true benefit of wearing head protection is not known. And beyond that the types of helmets that may portend a benefit are not yet known between motorcycle helmets that are quite substantial to a bicycle helmet or a baseball helmet, you know, et cetera.

So I think the types of helmets that may afford protection is unknown and the degree of protection is also unknown.

Dr. John Armstrong:
This is John Armstrong following up on what David has shared. Importantly not only is there no real evidence about the utility of helmets with tornados, trying to find a helmet when a tornado is bearing down on you is a distraction when the focus needs to be on shelter.

Dr. David Sugerman:
Right.

Leticia Davila:
Thank you. We have another question. I know that you spoke a little bit about alternate care sites. And the question is are there any recommendations for alternative care sites if a hospital is hit or must be evacuated?

Is there another - is another hospital the only choice?

Dr. John Armstrong:
This is John Armstrong. There are many choices for alternate care sites, and it’s important to identify these before disaster strikes and to drill inclusive of alternate care sites.

So examples include schools and churches and community centers and even parking garages and large malls.

When you consider alternate care sites it’s important to reflect on activities that already exist in those sites to make sure that there would actually be availability.

So for example planning to use a school when a school is in session may not be the best choice for an alternate care site.

But again the real issue here is making sure you identify proactively and that you drill inclusive of alternate care sites. And that means including set-up and staff for those sites.

Dr. David Sugerman:
Right and then I would also just include I think you should drill to have an alternative care site in front of the hospital to take out some of the surge of patients that are going to be entering with minor injuries and if they can be treated outside of your emergency department in addition to some of flat spaced conversion I had mentioned, that’s going to help out.

Dr. John Armstrong:
David raises an important point. If you can establish wound care stations outside of your facility, that will then enable movement of critically injured casualties into the healthcare facility where there can be a concentration of resources to improve outcomes.

Leticia Davila:
Perfect. Thank you so much. Operator are there any questions on the line?

Coordinator:
And we have no questions in queue at this time.

Leticia Davila:
And I do have one additional question. What additional challenges might hospitals face in caring for tornado injuries?

Dr. David Sugerman:
So thanks for that question. I had mentioned a few of those. Beyond loss of power, loss of water pressure there can certainly be loss of communication. [Limiting] capability [when] towers and when cell phone towers are out.

Social media can often be effective between patients and family and even providers in getting additional staff in. And radio, so Southern Link Radio in Alabama was very effective in communicating between emergency management and providers in the hospital.

The loss of the ability to control security doors should be considered and looting in hospitals. So security becomes very important to consider during hurricanes and tornados. So those are some of the additional problems. And John you may have some more related to the natural disasters.

Dr. John Armstrong:
What we have learned consistently when it comes to storms with flooding is that you’ve got to be very sensitive where you put your generators.

And we continue to see examples where generators and even emergency operation centers in facilities are located in the basement, and they get flooded and thus they’re lost.

We’ve seen other examples where generators have been placed on higher floors without reflecting on how to get fuel to the generators. There’s some examples of this coming out of Super Storm Sandy in the Greater New York area.

Leticia Davila:
Thank you. We do have another question that has come through the system.

What strategies can be used to address the psychosocial issues at the community level?

Dr. John Armstrong:
This is John Armstrong.

Dr. David Sugerman:
One, I think that you need to have mental health services immediately following these types of events.

In Alabama they had Project Rebound which is a community based counseling service that can screen and refer persons that need it (without cost) to a mental health services for further treatment. But it definitely should be considered that these are traumatic events. And many people following will have severe depression, anxiety including post-traumatic stress disorder.

Dr. John Armstrong:
This is John Armstrong following on what David has shared. The first essential step is to include psycho-social services in the plan.

Unfortunately too often recovery is not part of the plan, and that means that the opportunity to really intervene with psychosocial services is delayed. And that has consequences across the community and can lead to long term individual and community issues.

I think the second way to address psychosocial issues is with effective risk communication because it’s the uncertainty coming out of the events that really can promote greater stress. And so good risk communication, pre-storm, during the storm and after the storm, can really work to get thinking redirected to hope and recovery.

The third element is making sure that as efforts are made to promote community healing, that the needs of first responders and hospital receivers are considered and that there are a variety of debriefing opportunities.

I think debriefing actually works across a variety of community groups as well, and so getting community leaders involved in conversations is a great way to reduce some of the stress and the psychosocial consequences coming out of various disasters.

Leticia Davila:
Thank you. Operator do we have any questions on the line?

Coordinator:
No we have no questions in the queue at this time.

Leticia Davila:
Okay thank you. On behalf of COCA I would like to thank everyone for joining us today with a special thank you to our presenters Dr. Armstrong and Dr. Sugerman.

We invite you to communicate to our presenters after the Webinar. If you have additional questions for today’s presenters please email us at coca@cdc.gov. Put July 11 COCA Call in the subject line of your email and we will ensure that your question is forwarded to them for a response. Again that email address is C-O-C-A@cdc.gov. The recording of this call and the transcript will be posted to the COCA Web site at emergency.cdc.gov/coca within the next few days. Free continuing education is available for this call.

Those who participated in today’s COCA conference call and would like to receive continuing education should complete the online evaluation by August 12, 2013 using Course Code EC1648. That is E as in Echo, C as in Charlie and the numbers 1648. For those who will complete the online evaluation between August 13, 2013 and July 10, 2014 use course code WD1648.

All continuing education credits and contact hours for COCA conference calls are issued online through TCE Online, the CDC Training and continuing education online system at www2a.cdc.gov/TCEOnline/. To receive information about upcoming COCA calls subscribe to COCA by sending an email to coca@cdc.gov and write “Subscribe” in the subject line.

Please join us for our next COCA call on July 23, Understanding the Public’s Response to a Possible Scenario Involving Inhalation Anthrax. Also CDC launched a Facebook page for HealthPartners. Like our page at facebook.com/cdchealthpartnersoutreach to receive COCA updates. Thank you again for being a part of today’s COCA Webinar. Have a great day.

Coordinator:
Thank you. And at this time your call has concluded. You may disconnect at this time. Once again your call has concluded. You may disconnect at this time. Thank you and have a great day.

END

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