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Following a philosophy that the best way to train is through realism, the EMS and healthcare community in Memphis, Tenn., and the lead authors of this article created one of the most true-to-life educational programs for EMTs, paramedics, nurses and physicians to learn how to manage patients following detonation of terrorist IEDs.
Lt. J. Harold Logan, who heads up EMS consequence management and quality improvement for the Memphis Fire Department, is one of the creators of this interactive multidiscipline mass casualty training. In this role, Logan is immersed in disaster preparedness and terrorism on a daily basis.
As part of EMS special operations, and chairman of a federal grant for the MMRS, Logan is part of the MMRS steering committee charged with developing and executing emergency response for natural and man-made events for local responders and receivers.
The training model Logan and the other MMRS steering committee members devised was to bring emergency response agencies, private and public ambulance services, health departments, hospitals, law enforcement, and fire and rescue services together for day-long multi-casualty incident simulation exercises. Participants work together in a former television studio that is specially designed and equipped to simulate a disaster.
With scenarios based on federal target capabilities such as improvised explosive device detonation, the entire emergency response system is put to the test in a hands-on educational setting that employs high-tech, wireless Laerdal SimMan simulators—the latest triage and treatment devices in a real-world environment. The setting and its realistic visual and auditory effects make it a challenging and highly educational experience for the participants.
In the day-long experience, the Disaster Preparedness Exercise and Procedural Cadaver Lab program eliminate the time compression and focus on the incident command system, with particular attention to the medical branch functions for prehospital providers, and the Hospital Incident Command System for hospital responders.
Anatomy of the Program
The day begins with a 90-minute lecture by Logan, Memphis Fire Department and Shelby County Municipal Medical Director Joseph Holley, MD, and Methodist Healthcare Systems Corporate Safety and Emergency Preparedness Officer Andrea Merriweather, RN. The trio orients each class of approximately 100 students and the presents a variety of topics, including multi-casualty management, incident command systems, domestic and international terrorism and disaster preparedness.
Other guest speakers during the lecture portion have included bomb specialists, FBI personnel, and prehospital and hospital personnel with real-world disaster experience. This experience has included deployments to the largest man-made and natural disasters in recent U.S history: the Sept. 11, 2001, attack on the Pentagon and the Aug. 29, 2005, landfall of Hurricane Katrina near New Orleans.
Logan says, “We take the education that the EMTs, paramedics, nurses and physicians already have, but don’t get to practice every day, and give the important educational lectures, followed by scenarios and a highly structured, multi-station cadaver lab where they visualize anatomy, find and feel landmarks and organs and perform important procedures such as EZ-IO tibial and humeral IO insertion, advanced airway procedures and pleural decompressions.
“We also put squads through a complete simulation of a catastrophic event that combines all areas of emphasis, the explosion, debris field, complete darkness, moulaged nursing student actors/patients, rapid triage, packaging and removal to safety and emergency care procedures—all under the watchful eye of a team of simulation experts, instructors, safety officers, physician and educators. Hospital staff is given an extra rotation through an exact hospital ED facility in the training center, including a loading dock where ‘incoming’ are received by private vehicles after a simulated IED attack. We then critique each team with emphasis on educating on lessons learned from real-world experiences,” he says.
This interactive educational experience allows time for teaching, thinking, evaluating, and, most importantly, correcting mistakes. “A lot of times, when we do drills for mass casualty incidents, we only have an hour and a half to work together,” Logan says. “Here we are able to spend a well-focused day, make mistakes, stop, take a time out, or work through issues to make it a highly educational experience for the participants.
“Moving through a dark debris field and having to perform triage in the dark in a rapid fashion using only helmet-mounted lighting is an intense experience that the students enjoy. To make the experience even better, we form squads consisting of agency personnel who have never worked together before and have to select and follow a team leader. This reinforces the ICS system and gives participants an opportunity to show (or learn) leadership skills,” he says.
In the program scenario, an entire city block is impacted by an improvised explosive device. The building where the teams are deployed is totally destroyed. In the simulated environment, participants work in a lightless, noisy, debris-filled room, and utilize the START system to locate both live actors and high-fidelity simulators.
The program is brought to life by using some of the most advanced interactive computer-operated mannequins and theatrical techniques ever developed. Live and simulated victims are scattered throughout a large area in an upper floor of the facility and present to the crews with realistic visual injuries and illnesses, and signs and symptoms of blast injuries and burns. The teams are monitored by staff via a full wall window in an adjacent control room and via video cameras and audio monitoring.
To add to the realism, multiple visual and auditory distractions are used throughout the exercises. As teams work to locate and triage, they are challenged with near-complete darkness, dense smoke and the sound of rescue workers using heavy rescue tools like saws and jackhammers. Cries for help increase the stress level and add to the challenge. The high-fidelity simulators talk, cough, sweat, and have pulses and blood pressures.
“Students get so engaged that I’ve had to calm a couple of them down and to rapidly focus on the task and move on,” Logan says.
Once triaged, the simulators and actors are tagged for severity of injury into red, yellow, green and black triage categories and transported down multiple stairways to the treatment division in a safe and secure area for medical care. This is carried out under the guidance and control of each team’s medical group supervisor and reinforces several aspects of NIMS.
All of this must be completed under the added pressure of a secondary explosive device, which often is detonated and catches lagging responders off guard. This second explosion results in additional simulated casualties that must then be triage, treated and evacuated to safety for advanced care.
An important aspect of this part of the educational experience is that active critical care nurses, nursing students, and physicians serve as either participants, victims or observers in a safe location. This allows those not routinely in a role that would allow them to be first on the scene of such an incident to experience what it’s like to be faced with the challenges of prehospital care in an uncontrolled environment. These healthcare providers come away with a newfound understanding of the prehospital disaster/terrorism environment and respect and admiration of first response challenges that involve on-the-fly decision-making and adaptation in extreme circumstances.
Holley, who is cofounder of the program, notes that this experience is critical to improving the communication, workflow and understanding of the unique situations disasters present. “These situations are uncommon, and most responders will only experience one during their career. We bring lessons learned from our extensive experience in disaster medicine to make sure we provide students with the most realistic experience possible.
"Lessons learned are often forgotten, or never utilized due to the infrequency of such major events. This course brings those lessons to bear, and actually provides a situation as close to real as I’ve ever experienced,” he says.
Once in the safe confines of the treatment division, EMTs and paramedics, often still in full turnout gear and stressed and exhausted from their search, recovery, initial care and packaging, as well as extrication and transfer of patients down hot, dark stairways, must practice both basic and advanced airway management skills, vascular access (including EZ-IO insertions) and other high-risk skills.
Once the simulated patients leave the treatment division, they are transported across the street to a simulated emergency department where emergency department staff/students await their arrival. This is the realistic hospital element of the interactive educational experience. It allows emergency department and intensive care nurses to “receive” the patients from the mass casualty scene. The same victims associated with the bombing are delivered by wireless controlled simulation patients and the actual arrival of actors bringing moulaged patients from the bombed city block to the emergency department entrance in personal vehicles. The participating nurses and physicians are then challenged with secondary triage on a moment’s notice.
Electronic Tracking Systems
Both hospital and prehospital participants are taught how to use the electronic patient tracking system to triage, log and track multiple patients. This enables the patient to be electronically followed from the scene to the hospital in real time. Patient accountability has been given a much greater emphasis since Hurricane Katrina tore through the Mississippi Gulf Coast and New Orleans. Many families were separated and lost, adding insult to injury in this disaster. Responders thus learned the benefits of electronic patient tracking, which has been incorporated into this program.
The region has also deployed standardization of triage tags for all delivery models of EMS and the entire health care community. This effort has also improved on the federal target capabilities of interoperability and information sharing.
Optimal Environment & Simulators
The Medical Education Research Institute facility used for this complex medical simulation program is a state-of-the-art facility. The MERI provides fresh cadavers for a hands-on procedural cadaver lab, as well as providing the most realistic patient and scene simulators available.
As with the concurrent IED educational experience across the street and in the simulated emergency department, instruction is conducted with subject matter experts, including EMS educators, physicians, and nurses who educate students on high-risk, low-frequency procedures. This instills confidence and a comfort level to participants, making them more comfortable with those tools of the trade.
Physicians, nurses, EMTs and paramedics have critical decision-making skills put to the test as they are pressed into this intense experience. The focus is situational awareness and leadership combined with advanced procedure such as airways, chest tubes, and high-level venous access techniques. The lab features the newest technologies in emergency medicine.
The development of this course flowed from the passion for teaching derived from backgrounds of real-world rescuers deployed to multiple incidents across the U.S. as medical specialists, EMTs, paramedics, nurses and physicians—from the Pentagon on 9/11, to the first day during medical operations in New Orleans after Hurricane Katrina, where the first teams triaged 368 people on a partially submerged overpass.
The program's genesis also stems from a woman who was intubated on the hood of a car after having just been rescued from her home during Katrina, survived a boat ride to the overpass to the cooling station where she collapsed and then lapsed into cardiac arrest from dehydration and hypoglycemia due to lack of food and water, as well as the excessive heat.
Most responders don’t get the opportunity to experience this level of intensity, so the team decided to use patient and scene simulation and realism to enhance the educational experience. The realism, interactive learning, simulators and personal engagement have proved invaluable to the participants as well as the instructors involved.
This experience brings all cognitive, psychomotor and affective learning together for the ultimate experience in emergency preparedness. The environment in this educational experience challenges the students as they apply the new procedures and technologies perfected in the procedural cadaver and high-fidelity simulation labs in a realistic mass casualty incident. Combined with awareness overviews of the Hospital Incident Command System, the NIMS, and the medical branch of the incident command system allows the student to function at the tactical and strategic management levels as roles change during the disaster.
J. Harold Logan, BS, EMT-P – I/C, is a 28-year veteran of fire-based EMS and serves as a lieutenant firefighter/paramedic for the Memphis Fire Department in an EMS administration capacity, specializing in EMS consequence management, emergency preparedness, quality improvement and education. His national recognition for innovation in EMS education includes the EMS 10: Innovators in EMS award. Logan also holds a bachelor’s degree in health and safety. For more than a decade, he has also served as a rescue/medical specialist and a medical coordinator for FEMA’s Tennessee Task Force One Urban Search and Rescue Team. Contact him at email@example.com.
Joseph Holley, MD, is medical director for Memphis Fire, Shelby County Fire, and multiple municipalities in the area. He is medical director for FEMA’s Tennessee Task Force One Urban Search and Rescue Team, as well as the Tennessee EMS medical director.
A.J. Heightman, MPA, EMT-P, is editor-in-chief of JEMS and a recognized mass casualty incident management educator. Contact him at firstname.lastname@example.org.